Reasons for testing and clinical and demographic profile of adolescents with non-perinatally acquired HIV infection

What affects timely linkage to HIV Care for Young Men of Color who have sex with Men? Young Men's Experiences Accessing HIV Care after Seroconverting

The HIV care continuum provides intervention points that should be addressed to optimally identify, engage, and retain populations in HIV care. This study addressed the lack of research into barriers and facilitators of linkage to care for HIV-positive young men who have sex with men (YMSM) of color. Data were collected using a qualitative timeline follow-back interview approach with YMSM who had seroconverted in the last 6 months. Interviews were conducted with 15 YMSM from April 2017 to April 2018. This study provides important information about what can delay linkage to care for YMSM of color. These delays include fractured referrals to care providers via mobile HIV testing vans, adapting to an HIV diagnosis and integrating it into their lives, and finding caring and competent providers that offer wraparound services, specifically mental health services, as soon as possible after an HIV diagnosis. Addressing these issues is imperative to optimize YMSM's engagement in the HIV care continuum and work toward ending the epidemic.

Adolescents and Young Adults: The Pediatrician's Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis

Most sexually active youth in the United States do not believe that they are at risk for contracting HIV and have never been tested. Creating safe environments that promote confidentiality and respect, obtaining an accurate sexual and reproductive health assessment, and providing nonstigmatizing risk counseling are key components of any youth encounters. Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing and prophylaxis to adolescent and young adult (youth) patients. In light of persistently high numbers of people living with HIV in the United States and documented missed opportunities for HIV testing, the Centers for Disease Control and Prevention and the US Preventive Services Task Force recommend universal and routine HIV screening among US populations, including youth. Recent advances in HIV diagnostics, treatment, and prevention help support this recommendation. This clinical report reviews epidemiological data and recommends that routine HIV screening be offered to all youth 15 years or older, at least once, in health care settings. After initial screening, youth at increased risk, including those who are sexually active, should be rescreened at least annually, and potentially as frequently as every 3 to 6 months if at high risk (male youth reporting male sexual contact, active injection drug users, transgender youth; youth having sexual partners who are HIV-infected, of both genders, or injection drug users; youth exchanging sex for drugs or money; or youth who have had a diagnosis of or have requested testing for other sexually transmitted infections). Youth at substantial risk for HIV acquisition should be routinely offered HIV preexposure prophylaxis, and HIV postexposure prophylaxis is also indicated after high-risk exposures. This clinical report also addresses consent, confidentiality, and coverage issues that pediatricians face in promoting routine HIV testing and HIV prophylaxis for their patients.

Facilitators, Barriers, and Outcomes of Self-Initiated HIV Testing: An Integrative Literature Review

BACKGROUND AND PURPOSE

HIV testing is an essential tool for identifying people at risk for HIV infection and linking those who are infected to care. Despite the recommendation for routine HIV testing for people who are vulnerable to HIV infection, healthcare professionals experience difficulties initiating discussions related to sexual health and recommending HIV testing. Healthcare professionals not offering HIV testing is a frequently reported reason for delays in testing. Self-initiated HIV testing is understudied and vital to improving HIV testing rates, treatment, and the process of HIV prevention. The main aim of this integrative literature review is to identify facilitators, barriers, and outcomes of self-initiated HIV testing.

METHOD

A search of PubMed, CINAHL, PsycINFO, EBSCO host, and Google Scholar, revealed 31 studies that met the inclusion criteria.

RESULTS

Self-initiated HIV testing is voluntarily requested and completed by individuals either using self-testing kits or in a setting that provides HIV testing. Perception of susceptibility to HIV infection, privacy, access to HIV testing sites or self-testing kits, and knowledge related to HIV infection and testing, were some of the salient facilitators and barriers to self-initiated HIV testing. Findings from our review indicate several benefits to self-initiated HIV testing, including early identification of acute HIV infection, increased likelihood for the uptake of HIV prevention interventions, and a reduction in sexual risk behaviors.

IMPLICATION FOR PRACTICE

Nursing initiatives geared toward promoting self-initiated HIV testing will lead to prompt diagnoses and linkages to treatment which will further improve nursing care and a variety of health outcomes.

Factors Associated With HIV Testing in Youth in the United States: An Integrative Review

We used an integrative review to synthesize existing literature on the factors associated with HIV testing by youth ages 13 to 24 years in the United States. PubMed, CINAHL, PsycINFO, and Google Scholar were systematically searched and 44 original research studies met our criteria. A directed qualitative content analysis was conducted to integrate findings according to the personal, relationship, community, and society levels of the social-ecological model. Female gender, African American race, age, and physical illness were some of the factors more consistently associated with HIV testing. Modifiable factors such as fear, drug use, poor condom use, partner communication, and multiple sexual partners were also noted as influencing HIV testing in youth. Our integrative review revealed gaps in the literature that need further exploration, particularly in the area of community and society influences on HIV testing for youth. Implications for research, practice, and policy are discussed.

Integrating Routine HIV Testing into Family Planning Clinics That Treat Adolescents and Young Adults

OBJECTIVE

Adolescents and young adults remain at high risk for new HIV infections and for unknowingly transmitting the virus to others. Yet, they have demonstrated low rates of testing due to barriers such as stigma and difficulty accessing testing services. Few existing programs have successfully integrated family planning and HIV care services to improve testing and diagnosis rates among young adults and adolescents, particularly those of minority groups. This study describes the process of implementing HIV services into family planning clinics and how to train staff in routine, opt-out testing.

METHODS

This study used HIV screening data from 10 family planning clinics serving adolescents and young adults in Houston, Texas. A total of 34,299 patients were tested for HIV during a 48-month study period, from January 2010 through December 2014.

RESULTS

Patients tested included minors <18 years of age (25.5%), males (22.8%), and individuals who had missed opportunities for HIV testing at other health-care settings. From the opt-in period (2006-2007) to the routine, opt-out period (2008-2010), the yearly average number of tests administered more than doubled; the yearly average increased again by 50% from the routine, opt-out period to the routine, rapid period (2011-2014). Eighty-eight (0.3%) patients were diagnosed with HIV, a higher seropositivity rate than CDC's recommended threshold of 0.1% for settings where routine screening is warranted.

CONCLUSION

Routine, opt-out HIV testing integrated into family planning clinics increased rates of testing acceptance, receipt of test results, and HIV-positive diagnoses among adolescents and young adults.

Practices, Beliefs, and Perceived Barriers to Adolescent Human Immunodeficiency Virus Screening in the Emergency Department

OBJECTIVE

Limited data exist regarding knowledge of and compliance to the Centers for Disease Control and Prevention's universal adolescent human immunodeficiency virus (HIV) screening recommendations. Our objective was to assess current guideline knowledge, practice, and perceived barriers to emergency department (ED)-based adolescent HIV screening.

METHODS

We administered an anonymous Web-based cross-sectional survey from May 1, 2012, to June 30, 2012, to 1073 physicians from the American Academy of Pediatrics Section on Emergency Medicine LISTSERV. Survey participants were included if they (1) practiced as attending-level physicians, (2) practiced primarily in pediatric emergency medicine or general emergency medicine, and (3) provided clinical care for patients younger than the age of 21 years. The survey examined respondent demographics, knowledge, attitudes, beliefs, practices, and barriers to ED-based HIV screening. Standard descriptive statistics and comparative analyses were performed.

RESULTS

A total of 220 responses were obtained; 29 responses were excluded and 191 responses were included in the study. Most of the participants were from urban, free-standing children's hospitals and had an annual ED volume of more than 61,000 patient visits. Respondent knowledge of the Centers for Disease Control and Prevention guidelines was low; less than 40% of the respondents identified correct consent requirements. Only 15.4% of the respondents reported screening for HIV more than 10 times for the prior 6 months. Most frequently cited barriers included concerns for privacy (67.4%), follow-up (67%), and cost-effectiveness (65.4%). Human immunodeficiency virus screening facilitators included availability of health educators (83%), established follow-up (74.7%), and rapid HIV tests (65.2%).

CONCLUSIONS

Emergency department clinicians exhibit poor knowledge of adolescent HIV screening recommendations. Current universal screening practices remain low; barriers to screening are numerous. Future efforts should disseminate guideline knowledge, increase rapid HIV testing and health educator availability, as well as reduce adolescent-specific barriers.

Factors affecting linkage to care and engagement in care for newly diagnosed HIV-positive adolescents within fifteen adolescent medicine clinics in the United States

Early linkage to care and engagement in care are critical for initiation of medical interventions. However, over 50 % of newly diagnosed persons do not receive HIV-related care within 6 months of diagnosis. We evaluated a linkage to care and engagement in care initiative for HIV-positive adolescents in 15 U.S.-based clinics. Structural and client-level factors (e.g. demographic and behavioral characteristics, clinic staff and location) were evaluated as predictors of successful linkage and engagement. Within 32 months, 1,172/1,679 (69.8 %) of adolescents were linked to care of which 1,043/1,172 (89 %) were engaged in care. Only 62.1 % (1,043/1,679) of adolescents were linked and engaged in care. Linkage to care failure was attributed to adolescent, provider, and clinic-specific factors. Many adolescents provided incomplete data during the linkage process or failed to attend appointments, both associated with failure to linkage to care. Additional improvements in HIV care will require creative approaches to coordinated data sharing, as well as continued outreach services to support newly diagnosed adolescents.

Implementing routine HIV screening in an urban pediatric emergency department

OBJECTIVE

In 2006, the Centers for Disease Control and Prevention recommended that all outpatient health care settings offer routine, opt-out HIV screening for patients aged 13 to 64 years, except where the prevalence of undiagnosed HIV infection is known to be less than 0.1%. Most emergency departments (EDs) lack routine HIV screening. The objective of this investigation was to describe the results of the implementation of routine, nontargeted opt-in HIV screening for patients aged 13 to 20 years in an urban pediatric ED (PED) in a city in which 1 of 30 residents has HIV/AIDS.

METHODS

This was a retrospective chart review from an urban, academic PED. The implementation of routine HIV screening in the ED was funded by the New Jersey Department of Health and Senior Services and planned independently of the study investigator. Patients aged 13 to 64 years were offered HIV screening by nursing staff, physicians, and/or HIV counselors. Patients who accepted were screened with rapid HIV fingerstick testing performed via Clearview HIV 1/2 STAT-PAK by HIV counselors as per the New Jersey Department of Health and Senior Services protocol. Data collected by the study investigator were done by chart review from October through December 2009, the first 3 months after implementation of routine HIV screening. Data were collected from patients aged 13 to 20 years presenting to the PED. Primary outcomes measured included the proportion of patients offered and accepted screening, newly diagnosed HIV cases, and the rate of linking newly diagnosed HIV patients to treatment. Demographic data collected included patient age, sex, and ethnicity. Results from the first 3 months of routine, nontargeted screening were compared with the HIV screening results of October through December 2008, during which time rapid HIV screening was provided to patients in the ED based on clinical indication. Patients who were not offered testing or who refused testing were measured by forms that were placed in every chart and collected by physicians. Emergency department census data were queried to identify the total number of patients seen in the ED within age range and time frame studied.

RESULTS

Three hundred (11%) of the 2645 patients aged 13 to 20 years were offered routine HIV screening in the PED from October through December 2009. Two hundred twenty-four patients (74%) accepted HIV testing. No new cases of HIV were identified. There was an increase in acceptance of HIV testing that correlated with increasing age (P < 0.05). There was no significant difference between male and female acceptance rates (P < 0.05). Eleven (4.9%) of the patients accepting testing did not have testing performed because of unavailability of the counselor and/or the patient could not wait. Review of HIV testing performed in the PED from October through December 2008 showed 39 patients aged 13 to 20 years were tested. Routine testing increased the number of patients tested by 446%.

CONCLUSIONS

Pediatric patients in this urban setting are very accepting of HIV testing. HIV screening is increased when routine screening is offered.

Adolescents’ agreement to test for HIV when different testing methods are offered

Offering rapid HIV testing improves rates of testing in adults, but little is known about whether offering adolescents a choice of testing methods increases rates of testing. The aims of the study were to determine rates of HIV testing in adolescents when different testing methods were offered and explore factors associated with agreement to be tested for HIV. Participants ( n= 200, sexually experienced 13–22 year olds) were recruited from an urban adolescent clinic, completed a 99-item theory-based survey and were offered their choice of venipuncture, rapid fingerstick or rapid oral fluid HIV testing. Approximately half (49.5%) agreed to HIV testing. Male gender, parental completion of high school, intention to test for HIV if offered by clinician and higher perceived likelihood of current HIV infection were independently associated with agreement to test. Combining new strategies, such as opt-out testing, with routine testing may be needed to improve rates of adolescent HIV testing.

Adolescents and HIV infection: the pediatrician's role in promoting routine testing

Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing to adolescent and young adult patients. Most sexually active youth do not feel that they are at risk of contracting HIV and have never been tested. Obtaining a sexual history and creating an atmosphere that promotes nonjudgmental risk counseling is a key component of the adolescent visit. In light of increasing numbers of people with HIV/AIDS and missed opportunities for HIV testing, the Centers for Disease Control and Prevention recommends universal and routine HIV testing for all patients seen in health care settings who are 13 to 64 years of age. There are advances in diagnostics and treatment that help support this recommendation. This policy statement reviews the epidemiologic data and recommends that routine screening be offered to all adolescents at least once by 16 to 18 years of age in health care settings when the prevalence of HIV in the patient population is more than 0.1%. In areas of lower community HIV prevalence, routine HIV testing is encouraged for all sexually active adolescents and those with other risk factors for HIV. This statement addresses many of the real and perceived barriers that pediatricians face in promoting routine HIV testing for their patients.

Gender, sexual orientation, and adolescent HIV testing: a qualitative analysis

Using qualitative data, this article explored the circumstances leading to HIV testing among 59 HIV-infected adolescents recruited from New York City HIV clinics. Results showed differences between the heterosexual women and the gay and bisexual men. Most of the young women were tested during routine health care or self-initiated tests, and most were asymptomatic when they tested positive. Their testing decisions were sometimes based on assessments of their boyfriends' risk behaviors rather than their own. Many young men were experiencing symptoms of illness when they tested positive, and about half of them recognized their symptoms as related to HIV and sought tests. Some young men expressed fear of learning about positive test results, which delayed their testing, and some providers did not initially recommend HIV testing for young men who presented with symptoms. The article concludes that consideration of these gender and sexual orientation-related concerns can facilitate HIV testing among adolescents.

Relationships between perceived STD-related stigma, STD-related shame and STD screening among a household sample of adolescents

CONTEXT

Important barriers to STD testing may include individuals' perceptions of STD-related stigma (negative societal attitudes toward STD infection) and expectations of STD-related shame (negative personal feelings) that would result from a positive STD test. Obtaining a clear understanding of the relationship between STD-related stigma, STD-related shame and STD testing may help inform programs and policies aimed at reducing STD transmission.

METHODS

Measures derived from previously published scales were used to assess perceived STD-related stigma, anticipated STD-related shame and receipt of an STD test in the past year in an urban, household sample of 594 sexually active 15-24-year-olds interviewed in 2004-2007. Logistic regression was used to examine associations between recent STD testing and perceived stigma, shame and other participant characteristics.

RESULTS

Thirty-seven percent of males and 70% of females reporting having had an STD test in the past year; the largest proportions of tests (42% among males and 59% among females) had occurred in the context of a routine health care visit, not because adolescents had had disease symptoms or were concerned about exposure to infection. For both males and females, the level of STD-related stigma was negatively associated with the odds of having been tested (odds ratio, 0.5 for each). STD-related shame was not related to STD testing.

CONCLUSIONS

Adolescents who view STDs as stigmatizing have a reduced likelihood of being screened, but it is unclear whether this relationship reflects their care seeking or providers' practice of offering STD screening at a routine health visit.

Adolescents and HIV: prevention and clinical care

The incidence of HIV infection has increased to alarming proportions among minority youth, in particular among young men who have sex with men and among teenage girls. The unique socioeconomic, behavioral, and emotional vulnerability of adolescents for sexually transmitted diseases, including HIV, requires early identification of HIV infection for linkage to care. Differences in the clinical and psychosocial presentations of youth with perinatally versus behavioral acquired HIV infection are important and influence the acceptance of illness, self-efficacy, and antiretroviral treatment adherence. The ideal multidisciplinary team approach of culturally sensitive services for youth integrates clinical care, psychosocial and peer support interventions, transition planning, primary and secondary prevention, as well as comprehensive reproductive adolescent health services.

HIV testing and care in Canadian Aboriginal youth: a community based mixed methods study

Background

HIV infection is a serious concern in the Canadian Aboriginal population, particularly among youth; however, there is limited attention to this issue in research literature. The purpose of this national study was to explore HIV testing and care decisions of Canadian Aboriginal youth.

Methods

A community-based mixed-method design incorporating the Aboriginal research principles of Ownership, Control, Access and Possession (OCAP) was used. Data were collected through surveys (n = 413) and qualitative interviews (n = 28). Eleven community-based organizations including urban Aboriginal AIDS service organizations and health and friendship centres in seven provinces and one territory assisted with the recruitment of youth (15 to 30 years).

Results

Average age of survey participants was 21.5 years (median = 21.0 years) and qualitative interview participants was 24.4 years (median = 24.0). Fifty-one percent of the survey respondents (210 of 413 youth) and 25 of 28 interview participants had been tested for HIV. The most common reason to seek testing was having sex without a condom (43.6%) or pregnancy (35.4%) while common reasons for not testing were the perception of being low HIV risk (45.3%) or not having had sex with an infected person (34.5%). Among interviewees, a contributing reason for not testing was feeling invulnerable. Most surveyed youth tested in the community in which they lived (86.5%) and 34.1% visited a physician for the test. The majority of surveyed youth (60.0%) had tested once or twice in the previous 2 years, however, about one-quarter had tested more than twice. Among the 26 surveyed youth who reported that they were HIV-positive, 6 (23.1%) had AIDS at the time of diagnosis. Delays in care-seeking after diagnosis varied from a few months to seven years from time of test.

Conclusion

It is encouraging that many youth who had tested for HIV did so based on a realistic self-assessment of HIV risk behaviours; however, for others, a feeling of invulnerability was a barrier to testing. For those who tested positive, there was often a delay in accessing health services.

Young, seropositive, and pregnant: epidemiologic and psychosocial perspectives on pregnant adolescents with human immunodeficiency virus infection

The objective of the study was to characterize human immunodeficiency virus (HIV)-seropositive pregnant adolescents according to maternal reproductive, behavioral, and psychosocial characteristics. Data were derived from the national HIV/AIDS Reporting System (HARS, 2001-2004) and the Perinatal Guidelines Evaluation Project (PGEP, 1997-1999). Births to HIV-seropositive 13- to 21-year-olds reported to HARS via pediatric case report forms, and HIV-seropositive pregnant adolescents (aged 13- 21 years) who participated in PGEP were identified and characterized. In the 28 states with confidential, name-based perinatal HIV exposure reporting, 1183 live births occurred to 1090 seropositive adolescents. Fifteen births were to perinatally HIV-infected adolescents. HIV serostatus was known before the index pregnancy in half the cases (52.6% and 49.2% in HARS and PGEP, respectively). Of seropositive PGEP adolescents, 67% were previously pregnant; most pregnancies (83.3%) were unplanned. Many HIV-seropositive pregnant adolescents were aware of their serostatus when they became pregnant. Pregnancy and transmission risk reduction interventions targeting young seropositive females are needed.

A one-session human immunodeficiency virus risk-reduction intervention in adolescents with psychiatric and substance use disorders

OBJECTIVE

To explore change in human immunodeficiency virus (HIV) risk among teens in outpatient treatment for substance use disorders (SUDs).

METHOD

From December 2002 to August 2004, 50 adolescents (13-19 years) with major depressive disorder, conduct disorder, and one or more non-nicotine SUD completed the Teen Health Survey (THS) at the beginning and end of 16 weeks of outpatient cognitive behavioral SUD treatment, which included a one-session HIV intervention. Changes in THS scale scores and specific item responses targeted by the intervention were assessed with paired t tests and Wilcoxon signed rank tests.

RESULTS

Pre/post mean THS scores significantly improved for two subscales: Measures of HIV Information (14.8-17.6; p < .001) and Beliefs about Condom Use (17.6-18.5; p < .05). Analyses of specific items showed trends for improvement in intentions to carry condoms and in the number of teens who obtained condoms. Not all of the risks targeted by the intervention showed significant change, but no change was observed in any area that was not specifically targeted.

CONCLUSIONS

Results from this preliminary study are consistent with the need for specific assessment and targeted intervention to reduce HIV risk in outpatient adolescent SUD treatment.