Page 124 - HIV/AIDS Guidelines

to therapy needs to be included as part of therapeutic decision making concerning the risks and benefits of
starting treatment. Erratic adherence may result in the loss of future regimens because of the development of
resistance mutations. Clinicians who care for HIV-infected adolescents frequently manage youth who, while
needing therapy, pose significant concerns regarding their ability to adhere to therapy. In these cases,
alternative considerations to initiation of therapy can be the following: (1) a short-term deferral of treatment
until adherence is more likely or while adherence-related problems are aggressively addressed; (2) an
adherence testing period in which a placebo (e.g., vitamin pill) is administered; and (3) the avoidance of any
regimens with low genetic resistance barriers. Such decisions are ideally individualized to each patient and
should be made carefully in context with the individual’s clinical status. For a more detailed discussion on
specific therapy and adherence issues for HIV-infected adolescents, see Guidelines for Use of Antiretroviral
Agents in Pediatric HIV Infection. 9

Special Considerations in Adolescents
Sexually transmitted infections (STIs), in particular human papilloma virus (HPV), should also be addressed
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in all adolescents. For a more detailed discussion on STIs, see the most recent CDC guidelines and the
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pediatric opportunistic infection treatment guidelines on HPV among HIV-infected adolescents. Family
planning counseling, including a discussion of the risks of perinatal transmission of HIV and methods to
reduce risks, should be provided to all youth. Providing gynecologic care for the HIV-infected female
adolescent is especially important. Contraception, including the interaction of specific ARV drugs on
hormonal contraceptives, and the potential for pregnancy also may alter choices of ART. As an example,
efavirenz (EFV) should be used with caution in females of childbearing age and should only be prescribed
after intensive counseling and education about the potential effects on the fetus, the need for close
monitoring—including periodic pregnancy testing—and a commitment on the part of the teen to use
effective contraception. For a more detailed discussion, see HIV-Infected Women and the Perinatal
Guidelines. 21

Transitioning Care
Given lifelong infection with HIV and the need for treatment through several stages of growth and
development, HIV care programs and providers need flexibility to appropriately transition care for HIV-
infected children, adolescents, and young adults. A successful transition requires an awareness of some
fundamental differences between many adolescent and adult HIV care models. In most adolescent HIV
clinics, care is more “teen-centered” and multidisciplinary, with primary care being highly integrated into
HIV care. Teen services, such as sexual and reproductive health, substance abuse treatment, mental health,
treatment education, and adherence counseling are all found in one clinic setting. In contrast, some adult HIV
clinics may rely more on referral of the patient to separate subspecialty care settings, such as gynecology.
Transitioning the care of an emerging young adult includes considerations of areas such as medical
insurance, independence, autonomy, decisional capacity, confidentiality, and consent. Also, adult clinic
settings tend to be larger and can easily intimidate younger, less motivated patients. As an additional
complication to this transition, HIV-infected adolescents belong to two epidemiologically distinct subgroups:
(1) those perinatally infected—who would likely have more disease burden history, complications, and
chronicity; less functional autonomy; greater need for ART; and higher mortality risk; and (2) those more
recently infected due to high-risk behaviors. Thus, these subgroups have unique biomedical and psychosocial
considerations and needs.

To maximize the likelihood of a successful transition, facilitators to successful transitioning are best
implemented early on. These include the following: (1) optimizing provider communication between
adolescent and adult clinics; (2) addressing patient/family resistance caused by lack of information, stigma or
disclosure concerns, and differences in practice styles; (3) preparing youth for life skills development,
including counseling them on the appropriate use of a primary care provider and appointment management,

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-8

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