HIV preexposure prophylaxis underused by U.S. adolescents

NEW YORK (Reuters Health) - Greater education and attention are needed to address the underuse of HIV preexposure prophylaxis (PrEP) by U.S. adolescents, according to a review.

“I would like for providers to be aware that PrEP exists and that more likely than not they are encountering youth that could benefit from it,” Dr. Allison L. Agwu from Johns Hopkins University School of Medicine, Baltimore, Maryland, told Reuters Health by email. “They can prescribe it instead of creating additional hurdles for youth by referring them out to get it.”

Adolescents and young adults accounted for 21% of new HIV diagnoses made in 2018 and, therefore, remain a high-priority population in need of HIV prevention.

Dr. Agwu and colleagues review the current status of HIV PrEP uptake among at-risk adolescents aged 13 to 19 years and recommendations for improving PrEP access, uptake, and future needed directions in their online report in JAMA Pediatrics.

An estimated 86% of New York adolescents eligible for PrEP had never been informed about PrEP by their health care professionals, yet awareness is a well-recognized step toward PrEP uptake. Only about 1.5% of adolescents younger than 18 who are at risk for HIV are receiving PrEP.

Both the Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force recommend routine HIV testing of persons ages 13 to 64, yet most adolescent specialists and general clinicians do not routinely offer HIV testing out of a lack of awareness or failure to see the need.

Among the hurdles to adolescent PrEP are issues of consent, confidentiality, and the rights of a minor, but the vulnerability of adolescents to financial barriers also limits access to PrEP services.

Social media campaigns, patient education, and integration of PrEP into school health programs could enhance knowledge and awareness of PrEP among adolescents.

Provision of youth-friendly PrEP, messaging by celebrities or other influencers, and integration of PrEP services into primary or general adolescent healthcare are among the approaches that could increase the acceptability of PrEP.

Harmonization of consent laws across states and guarantee of confidentiality to minors when desired are additional strategies for improving PrEP uptake among adolescents.

Financial limitations could be addressed by expansion of medication assistance programs, incorporation of comprehensive PrEP services into Title X programs, and subsidization of transportation and related costs.

Health care professionals should be trained on adolescent PrEP guidelines and should be encouraged to include routine HIV risk assessment in primary care adolescent visits. HIV risk prediction tools can be used to identify adolescents at risk for HIV.

While tenofovir disoproxil fumarate with emtricitabine-based PrEP has been the main combination for preventing HIV transmission in adolescents, its use has been associated with renal and bone toxicity, so more acceptable, safer, and lifestyle-congruent formulations and strategies are needed.

“PrEP is being under-utilized despite evidence that it could decrease HIV risk for adolescents,” Dr. Agwu said. “Providers are key to overcoming the barriers.”

“Providers should not assume, but ask, identify those youth that may be at risk, test for sexually transmitted infections (STIs) and HIV, and then include PrEP in their package of things they offer adolescents to keep them safe,” she said.

“Normalizing sexual activity is important,” Dr. Agwu concluded. “Having PrEP be part of the conversation is one more tool to help our youth minimize their risk.”

Dr. Sybil Hosek from John Stroger Hospital of Cook County, Chicago, Illinois, who has researched various aspects of PrEP for adolescents, told Reuters Health by email, “For me, the most pressing issues are the role of the health care providers and the low rates of PrEP uptake, which are related. Too many pediatric and family practitioners continue to express discomfort with PrEP specifically, but also with sexual and reproductive health of youth in general.”

“For example,” she said, “only about 13% of U.S. high school seniors have had an HIV test (yet 57% have had sexual intercourse), but an HIV test is the gateway to PrEP. Adolescents, and their families, need trusted providers - as well as other trusted sources of information - to proactively address the sexual health needs of youth.”

“Adolescents have a complicated relationship with medications for many developmentally sound reasons, and the barriers around PrEP adherence and persistence need to be addressed as well,” Dr. Hosek said. “However, more effort must be devoted to introducing adolescents, families, and communities to PrEP as a highly efficacious HIV prevention strategy - otherwise uptake will remain low and infections will continue.”

SOURCE: JAMA Pediatrics, online May 11, 2020.