Page 122 - HIV/AIDS Guidelines

HIV-Infected Adolescents and Young Adults (Last updated January 10, 2011; last reviewed
January 10, 2011)

Older children and adolescents now make up the largest percentage of HIV-infected children cared for at
pediatric HIV clinics in the United States. The Centers for Disease Control and Prevention (CDC) estimates
that 15% of the 35,314 new HIV diagnoses reported among the 33 states that participated in confidential,
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name-based HIV infection reporting in 2006 were among youth 13–24 years of age. Recent trends in HIV
prevalence reveal that the disproportionate burden of HIV/AIDS among racial minorities is even greater
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among youth 13–19 years of age than among young adults 20–24 years of age. Furthermore, trends for all
HIV/AIDS diagnoses in 33 states from 2001 to 2006 decreased for all transmission categories except among
men who have sex with men (MSM). Notably, among all black MSM, the largest increase in HIV/AIDS
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diagnoses occurred among youth 13–24 years of age. HIV-infected adolescents represent a heterogeneous
group in terms of sociodemographics, mode of HIV infection, sexual and substance abuse history, clinical
and immunologic status, psychosocial development, and readiness to adhere to medications. Many of these
factors may influence decisions concerning when to start antiretroviral therapy (ART) and what antiretroviral
(ARV) medications should be used.

Most adolescents who acquire HIV are infected through high-risk behaviors. Many of them are recently
infected and unaware of their HIV infection status. Thus, many are in an early stage of HIV infection, which
makes them ideal candidates for early interventions, such as prevention counseling, linkage, and engagement
to care. A recent study among HIV-infected adolescents and young adults presenting for care identified
primary genotypic resistance mutations to ARV medications in up to 18% of the evaluable sample of recently
infected youth, as determined by the detuned antibody testing assay strategy that defined recent infection as
occurring within 180 days of testing. This transmission dynamic reflects that a substantial proportion of
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youth’s sexual partners are likely older and may be more ART experienced; thus, awareness of the
importance of baseline resistance testing among recently infected youth naive to ART is imperative.

A limited but increasing number of HIV-infected adolescents are long-term survivors of HIV infection acquired
perinatally or in infancy through blood products. Such adolescents are usually heavily ART experienced and
may have a unique clinical course that differs from that of adolescents infected later in life. If these heavily
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ART-experienced adolescents harbor resistant virus, optimal ARV regimens should be based on the same
guiding principles as for heavily ART-experienced adults. (See Virologic and Immunogic Failure.)

Adolescents are developmentally at a difficult crossroad. Their needs for autonomy and independence and
their evolving decisional capacity intersect and compete with concrete thinking processes, risk-taking
behaviors, preoccupation with self-image, and the need to “fit in” with their peers. This makes it challenging
to attract and sustain adolescents’ focus on maintaining their health, particularly for those with chronic
illnesses. These challenges are not specific to any particular transmission mode or stage of disease. Thus,
irrespective of disease duration or mode of HIV transmission, every effort must be made to engage them in
care so they can improve and maintain their health for the long term.

Antiretroviral Therapy Considerations in Adolescents
Adult guidelines for ART are usually appropriate for postpubertal adolescents, because the clinical course of
HIV-infected adolescents who were infected sexually or through injection drug use during adolescence is
more similar to that of adults than to that of children. Adult guidelines can also be useful for postpubertal
youth who were perinatally infected because these patients often have treatment challenges associated with
the use of long-term ART that mirror those of ART-experienced adults, such as extensive resistance, complex
regimens, and adverse drug effects.

Dosage of medications for HIV infection and opportunistic infections should be prescribed according to
Tanner staging of puberty and not solely on the basis of age. 6-7 Adolescents in early puberty (i.e., Tanner

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-6

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