Page 123 - HIV/AIDS Guidelines

Stages I and II) should be administered doses on pediatric schedules, whereas those in late puberty (i.e.,
Tanner Stage V) should follow adult dosing schedules. However, Tanner stage and age are not necessarily
directly predictive of drug pharmacokinetics. Because puberty may be delayed in children who were infected
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with HIV perinatally, continued use of pediatric doses in puberty-delayed adolescents can result in
medication doses that are higher than the usual adult doses. Because data are not available to predict optimal
medication doses for each ARV medication for this group of children, issues such as toxicity, pill or liquid
volume burden, adherence, and virologic and immunologic parameters should be considered in determining
when to transition from pediatric to adult doses. Youth who are in their growth spurt period (i.e., Tanner
Stage III in females and Tanner Stage IV in males) and following adult or pediatric dosing guidelines and
adolescents who have transitioned from pediatric to adult doses should be closely monitored for medication
efficacy and toxicity. Therapeutic drug monitoring can be considered in selected circumstances to help guide
therapy decisions in this context. Pharmacokinetic studies of drugs in youth are needed to better define
appropriate dosing. For a more detailed discussion, see Guidelines for the Use of Antiretroviral Agents in
Pediatric HIV Infection. 9

Adherence Concerns in Adolescents

HIV-infected adolescents are especially vulnerable to specific adherence problems based on their
psychosocial and cognitive developmental trajectory. Comprehensive systems of care are required to serve
both the medical and psychosocial needs of HIV-infected adolescents, who are frequently inexperienced with
health care systems and who lack health insurance. Many HIV-infected adolescents face challenges in
adhering to medical regimens for reasons that include:

• denial and fear of their HIV infection;
• misinformation;
• distrust of the medical establishment;
• fear and lack of belief in the effectiveness of medications;

• low self-esteem;
• unstructured and chaotic lifestyles;
• mood disorders and other mental illness;
• lack of familial and social support;
• absence of or inconsistent access to care or health insurance; and
• incumbent risk of inadvertent parental disclosure of the youth’s HIV infection status if parental health
insurance is used.

In selecting treatment regimens for adolescents, clinicians must balance the goal of prescribing a maximally
potent ART regimen with realistic assessment of existing and potential support systems to facilitate
adherence. Adolescents benefit from reminder systems (e.g., beepers, timers, and pill boxes) that are stylish
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and inconspicuous. It is important to make medication adherence as user friendly and as little stigmatizing
as possible for the older child or adolescent. The concrete thought processes of adolescents make it difficult
for them to take medications when they are asymptomatic, particularly if the medications have side effects.
Adherence to complex regimens is particularly challenging at a time of life when adolescents do not want to
be different from their peers. 11-13 Directly observed therapy might be considered for selected HIV-infected
adolescents such as those with mental illness. 14-18

Difficult Adherence Problems
Because adolescence is characterized by rapid changes in physical maturation, cognitive processes, and life
style, predicting long-term adherence in an adolescent can be very challenging. The ability of youth to adhere

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-7

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