While the incidence rate of HIV in adolescents and young adults is the second highest in the United States, the uptake rate of pre-exposure prophylaxis (PrEP) for HIV prevention has remained low, especially among at-risk adolescents, according to a review published in the JAMA Pediatrics.
In 2018, adolescents and young adults aged 12 to 24 years accounted for 21% of new HIV diagnoses (N=37,377); of these, 1707 diagnoses occurred in adolescents aged 13 to 19 years. Yet, data on PrEP initiation from the manufacturer (Gilead Sciences Inc) indicated that < 5% of individuals receiving new PrEP in 2012 were adolescents. Although the total number of prescriptions has since increase, the percentage of total prescriptions provided to adolescents progressively declined to < 0.6% in 2018.
Despite recommendations for routine HIV testing by the Centers for Disease Control and Prevention and the US Preventive Services Task Force, most adolescent specialist and generalist care clinicians do not routinely offer HIV testing. Thus, improving PrEP uptake will require training and retraining of generalist health care professionals on adolescent PrEP guidelines.
Staying abreast of the laws and the nuances between adolescent and adult PrEP guidelines will improve clinicians’ confidence in prescribing PrEP. Use of HIV risk prediction tools for identifying adolescents at risk for HIV will further help in active screening and subsequent PrEP initiation. In addition, clinicians should become comfortable with routine HIV risk history taking, since “taking a comprehensive, inclusive, nonjudgmental social and sexual history builds rapport, establishes trust, and informs education, counseling, risk stratifications, and risk reduction strategies, including PrEP,” stated the researchers.
Leveraging social media may also help improve PrEP uptake; social media, gaming apps, and ubiquitous internet access have been used successfully in PrEP campaigns. In particular, educational content presented by social influencers or celebrities into entertainment pieces on social media can be very effective.
Furthermore, access to youth-friendly health services in schools and at the community level may influence the health of adolescents. Community-focused interventions can facilitate communal participation and promote a sense of ownership in one’s health. Open communication between parents/guardians and adolescents can further increase awareness and willingness to enroll for PrEP. “Open conversations are particularly pertinent in [gay, bisexual, and other men who have sex with men] and transgender women of color, who despite their greater need for support, face rejection and violence as a result of their sexual identity,” stressed the researchers.
Additional barriers to PrEP prescription include legal concerns about confidentiality and consent in unaccompanied adolescents thus there needs to be a harmonization of consent laws across the United States and guaranteed confidentiality to minors when desired. Moreover, adolescents are vulnerable to financial barriers that limit access to PrEP services and so, there needs to be incorporation of comprehensive PrEP services into Title X programs, added the researchers.
In the future, lifestyle-congruent PrEP formulations and strategies such as on-demand strategies, and long-acting oral, injectable, and implantable modalities may be needed given the low uptake of PrEP witnessed to date. “In the meantime, the continued use of tenofovir disoproxil fumarate with emtricitabine must be carefully considered and the benefits of HIV prevention weighed against the risk of toxic effects when prescribing for adolescents until such a time when safer alternatives become routinely available,” concluded the researchers.
Disclosure: Errol Fields, MD, PhD, MPH, and Allison L. Agwu, MD, ScM, declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of their disclosures.
Yusuf H, Fields E, Arrington-Sanders R, Griffith D, Agwu AL. HIV preexposure prophylaxis among adolescents in the US: a review [published online May 11, 2020]. JAMA Pediatr. doi:10.1001/jamapediatrics.2020.0824