Adolescent Health Care: A Practical Guide

Chapter 31

Human Immunodeficiency Virus Infections and Acquired Immunodeficiency Syndrome

Marvin E. Belzer

Miguel Martinez

Lawrence S. Neinstein

Acquired immunodeficiency syndrome (AIDS) is one of the largest pandemics to hit modern society and the focal point of intense national and international debate. The last decade has seen a dramatic reduction in the mortality due to AIDS in developed countries. When taken correctly, combinations of antiretroviral medications called highly active antiretroviral therapy (HAART) enable most infected patients to have long healthy lives. The greatest challenges for care providers of adolescents with human immunodeficiency virus (HIV) infection involve identifying infected youth, engaging them in care, and assisting them with long-term adherence to these medications. Unfortunately, in only a fraction of the estimated 20,000 annual new cases of HIV infection in 13- to 25-year olds in the United States does the patient have access to care while still an adolescent or young adult. Internationally, the impact on youth is even higher, with an estimated 50% of new HIV infections occurring in youth. Developing countries have very limited access to the life-saving medications now routinely available in the United States.

Special issues are important to consider in relation to the adolescent population and infection with HIV, including a host of legal and ethical dilemmas regarding testing, disclosure of information, and consent for treatment in research protocols. For HIV-infected adolescents there is also the problem of availability of age-appropriate services.

Adolescents are in danger of contracting HIV because of their risky sexual behaviors, drug use, or both. Because most adolescents are not yet infected but may be involved in high-risk behaviors, they are a high-priority target group for HIV preventive measures.

Information about HIV infection is developing rapidly. Several thousand articles are published yearly with information that often becomes quickly outdated. The treatment of HIV has become so complex that recommendations have been made that all HIV-infected persons should be treated by physicians with expertise in HIV medications, their side effects and interactions, as well the psychosocial interventions required to maintain adherence. This chapter includes an overview of HIV and AIDS, with a focus on considerations that are important in the adolescent. It is essential for the practicing physician to keep up to date through the literature or continuing medical education on the many aspects of HIV infection, including HIV prevention, psychosocial issues, legal issues, diagnosis, evaluation, and treatment.

Etiology, Pathogenesis, and Natural History

The causative agent of AIDS is HIV, a single-stranded RNA retrovirus. This virus was isolated at the Pasteur Institute in Paris in 1983. HIV-1 is the cause of most cases of AIDS in the world. HIV-2, another retrovirus related to HIV-1, is found primarily in Central Africa. HIV-2 generally has a much slower progression (20 years versus 5–10 years with HIV-1) but a similar spectrum of disease.

HIV-1 infects and leads to the destruction of CD4⁺ T lymphocytes. A flu-like illness occurs in most patients 2 to 6 weeks after infection. The illness typically lasts 1 to 2 weeks and typically causes fever, fatigue, myalgias, lymphadenopathy, and sore throat (Table 31.1). The phase of illness after the acute infection was once characterized as one of latency, but it is now clear that viral production is steady at an estimated 10 billion virions daily. T-cell production and destruction remain precariously balanced. A slow but steady depletion of CD4⁺ T cells occurs in all but a small percentage of patients, who are referred to as long-term nonprogressors. Most patients develop AIDS (severe immune deficiency), without treatment, over a period of 8 to 10 years. Approximately 10% of individuals will rapidly progress to an AIDS diagnosis within 4 years. Both host factors like human leukocyte antigen (HLA) type and other genetic factors and host immune response to HIV-1 have been correlated with disease progression. Viral factors like HIV-fitness and ability to be “syncytium-inducing” have also been associated with disease progression. Numerous studies indicate that HAART can suppress the viral load to undetectable levels in most patients. Viral suppression is associated with a steady immune reconstitution in most patients. Even patients with severe depletion of their immune systems can often return to excellent health after months to years of successful treatment. Preliminary studies of adolescents indicate that their “thymic reserve” may allow for even better immune restoration than in adults.

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TABLE 31.1 Characteristics of 25 Individuals with Acute Primary Human Immunodeficiency Virus Infection at the Johns Hopkins Hospital, 1993–1995a

Characteristic No. of Individuals (%) aAll patients were diagnosed by a p24 antigen level >30 pg/mL. All had a negative or indeterminate Western blot test with later evidence of seroconversion. From Quinn TC. Acute primary HIV infection. JAMA 1997;278:58, with permission. Sex Male 15 (60) Female 10 (40) Risk exposure Injection drug use 11 (44) Heterosexual 9 (36) Homosexual/bisexual 3 (12) Undetermined 2 (8) Symptoms Fever 24 (96) Fatigue 23 (92) Myalgia or arthralgia 18 (72) Adenopathy 16 (64) Pharyngitis 16 (64) Diarrhea 12 (48) Headache 11 (44) Rash 10 (40) Weight loss 9 (36) Nausea or vomiting 8 (32) Mucocutaneous ulcerations 5 (20) Thrush 3 (12)

Unfortunately, even when the best therapy is strictly adhered to for several years, patients have been unable to eliminate HIV from their body (i.e., a cure is not currently possible). Reservoirs of latent virus are effectively hidden from the effects of the potent antiretrovirals. Patients, who go off HAART after several years of treatment, usually develop viremia within a couple weeks. Current research is focused on whether some type of immune modulation with medication or vaccines can nullify the inevitable rebound in HIV viremia.

Although the natural history of HIV has changed from a lethal illness to that of a chronic disease, it is unclear whether lifelong viral suppression is feasible. Many adolescents are unable to adhere to or tolerate complex medication regimens. Some patients develop resistance to medications due to nonadherence, and some patients are being infected with HIV that has extensive resistance to many medications (studies in recent seroconverters indicate that many regions in the United States have 10% to 15% with baseline resistance to at least one antiretroviral medication). Patients with multiple drug resistance can eventually have immune depletion and succumb to the opportunistic infections and neoplasms that were so prevalent before the advent of HAART.

Epidemiology

1. Number of cases
2. Total cases: As of December 2004, 944,306 cases of AIDS have been reported to the Centers for Disease Control and Prevention (CDC). Also, by the end of 2003, an estimated 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS.
3. Annual cases: The number of AIDS cases reported annually has increased each year for teens aged 13 to 19 between 1998 and 2003 but dropped in 2004 (Fig. 31.1). For those aged 20 to 24 there has been an increase every year from 2000 to 2004 (Fig. 31.2). In 2004, for all age-groups there were 38,730 cases of HIV/AIDS diagnosed in the 33 states and Guam and U.S. Virgin Islands (with long-term, confidential name-based HIV reported). CDC estimates that 40,000 persons become infected with HIV each year. The estimated rate of AIDS cases in the United States in 2004 was 14.1 per 100,000.
4. Age: In all years through 2004, an estimated 40,049 youth aged 13 to 24 or 4% of the total number of cases received an AIDS diagnosis. With a median incubation period of 7 to 10 years from HIV infection to AIDS, most of the cases in young adults aged 25 to 29 (11.4%) were also acquired as adolescents. In 2004, approximately 1% of cases of AIDS were in ages 13 to 19 and 4.2% in those aged 20 to 24. From 2001 through 2004, the estimated number of HIV/AIDS cases decreased in children younger than 13 years, and in 30 to 34, 13 to 14, 30 to 34, 35 to 39, 40 to 44, and 45 to 49 age-groups. Cases increased in the age-groups 15 to 19, 20 to 24, and in those older than 50. Cases remained stable in those young adults aged 25 to 29.
5. Ethnicity: African-Americans are dramatically overrepresented, making up 70% of all cases of HIV/AIDS in youth aged 13 to 19 years (Fig. 31.3) and 50% of adolescents and adults diagnosed during 2004.
6. Gender: Figures 31.4 and 31.5 show that numbers of reported HIV and AIDS cases are higher in males than females but that the difference increases with age. For all adults 25 and older, 74% were males with diagnosed HIV/AIDS in 2004.
7. Transmission: Figure 31.6 shows the common routes of transmission for males and females diagnosed with HIV/AIDS from 2001 to 2004. Although youth with Hemophilia made up 25% of 13- to 19-year olds diagnosed with AIDS in the past, these cases are no longer occurring. Most new cases in males are in men-who-have-sex-with men and/or injection drug users. Figure 31.7 illustrates how heterosexual contact is the main reported mode of transmission in female youth.

Human Immunodeficiency Virus Staging

In 1993, the Centers for Disease Control and Prevention (1992) expanded their AIDS definition criteria and changed their staging system (Table 31.2). The system uses the lowest-ever CD4⁺ T-cell count (rows 1 through 3) in combination with clinical staging (columns A through C in Table 31.2) based on symptoms. The problem with this current system is that it reflects the most advanced stage a

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patient has reached but not the patient's current condition. A patient who once had advanced AIDS with life-threatening infections but who then successfully starts HAART and is asymptomatic with a CD4⁺ T-cell count higher than 500/mL will still be staged as a 3C (the mostly severely ill stage).

FIGURE 31.1 Reported AIDS cases among adolescents 13 to 19 years of age, by sex, 1985 to 2004—United States (N = 5,593). (From Centers for Disease Control and Prevention.Adolescents and HIV. Slide set at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed 2006.)

FIGURE 31.2 Reported AIDS cases among young adults 20 to 24 years of age, by sex, 1985 to 2004—United States (N = 32,757). (From Centers for Disease Control and Prevention.Adolescents and HIV. Slide set at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed 2006.)

FIGURE 31.3 Proportion of HIV/AIDS cases and population among adolescents 13 to 19 years of age by race/ethnicity, diagnosed in 2004—33 states. (From Centers for Disease Control and Prevention. Adolescents and HIV. Slide set at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed 2006.)

Transmission

HIV can be transmitted only by the exchange of body fluids. Blood, semen, vaginal secretions, and breast milk are the only fluids documented to be associated with HIV infection. Although HIV is found in saliva, tears, urine, and sweat, no case has been documented that implicates these fluids as agents of infection.

FIGURE 31.4 Proportion of HIV/AIDS cases among adults and adolescents by sex and age-group diagnosed in 2004—33 states. (From Centers for Disease Control and Prevention.Adolescents and HIV. Slide set at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed 2006.)

HIV is easily transmitted by the sharing of needles. The Centers for Disease Control and Prevention (2005) has provided guidelines for reducing the spread of HIV and hepatitis through the sharing of needles (http://www.cdc.gov/ncidod/dhqp/bphiv.html).

• The best way for you to prevent HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) transmission is to NOT inject drugs.
• Starting substance abuse treatment can help you reduce or stop injecting. This will lower your chances of infection.
• Get vaccinated against hepatitis A and hepatitis B. You can prevent these kinds of viral hepatitis if you get vaccinated.

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• If you cannot or will not stop injecting, you should:
• –Use a new, sterile syringe obtained from a reliable source to prepare and divide drugs for each injection.
• –Never reuse or share syringes, water, cookers, or cottons.
• –Use sterile water to prepare drugs each time, or at least clean water from a reliable source.
• –Keep everything as clean as possiblewhen injecting.
• If you can't use a new, sterile syringe and clean equipment each time, then disinfecting with bleach may be better than doing nothing at all:
• –Fill the syringe with clean water and shake or tap.
• –Squirt out the water and throw it away. Repeat until you don't see any blood in the syringe.
• –Completely fill the syringe with fresh, full-strength household bleach.
• –Keep it in the syringe for 30 seconds or more.
• –Squirt it out and throw the bleach away.
• –Fill the syringe with clean water and shake or tap.
• –Squirt out the water and throw it away.
• If you don't have any bleach, use clean water to vigorously flush out the syringe:
• –Fill the syringe with water and shake or tap it.
• –Squirt out the water and throw it away.
• –Do this several times.

TABLE 31.2 1993 Revised Classification System for Human Immunodeficiency Virus (HIV) Infection and Expanded Acquired Immunodeficiency Syndrome (AIDS) Surveillance Case Definition for Adolescents and Adults

Clinical Categories CD4+ T-cell Categories (A) Asymptomatic, Acute (Primary) HIV or PGL (B) Symptomatic, not (A) or (C) Conditions (C) AIDS-Indicator Conditionsa PGL, persistent generalized lymphadenopathy. aConditions included in the 1993 AIDS Surveillance Case Definition (AIDS indicator conditions) are: · Candidiasis of bronchi, trachea, or lungs · Candidiasis, esophageal · Cervical cancer, invasive · Coccidioidomycosis, disseminated or extrapulmonary · Cryptococcosis, extrapulmonary · Cryptosporidiosis, chronic intestinal (>1 month's duration) · Cytomegalovirus disease (other than liver, spleen, or nodes) · Cytomegalovirus retinitis (with loss of vision) · Encephalopathy, HIV-related or extrapulmonary · Herpes simplex chronic ulcer(s) (>1 month's duration); or bronchitis, pneumonitis, or esophagitis · Histoplasmosis, disseminated or extrapulmonary · Isosporiasis, chronic intestinal (>1 month's duration) · Kaposi sarcoma · Lymphoma, Burkitt (or equivalent term) · Lymphoma, immunoblastic (or equivalent term) · Lymphoma, primary, of brain · Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary) · Pneumocystis carinii pneumonia · Mycobacterium tuberculosis,any site · Mycobacterium, other species or (pulmonary or extrapulmonary) unidentified species, disseminated or extrapulomonary · Pneumonia, recurrent · Progressive multifocal leukoencephalopathy · Salmonella septicemia, recurrent · Toxoplasmosis of brain · Wasting syndrome due to HIV infection 1. ≥500/µL A1 B1 C1 2. 200–400/µL A2 B2 C2 3. <200/µL AIDS-indicator T-cell count A3 B3 C3

FIGURE 31.5 Proportion of AIDS cases among adults and adolescents by sex and age-group, reported in 2004—United States. (From Centers for Disease Control and Prevention.Adolescents and HIV. Slide set at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed 2006.)

FIGURE 31.6 HIV/AIDS cases among male adolescents and young adults by transmission category from 2001 to 2004—33 states. (From Centers for Disease Control and Prevention.Adolescents and HIV. Slide set at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed 2006.)

FIGURE 31.7 HIV/AIDS cases among female adolescents and young adults by transmission category from 2001 to 2004—33 states. (From Centers for Disease Control and Prevention. Adolescents and HIV. Slide set at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed 2006.)

Because of the unreliability and frequent unacceptance of needle bleaching and unacceptance or inaccessibility of drug treatment, almost all public health organizations support needle exchange. At these sites, injection drug users can turn in dirty needles for clean ones while at the same time gaining access to condoms, bleach, and referral resources. Programs in San Francisco, California, and New Haven, Connecticut, as well as others in the United States and Europe, have shown that injection drug use does not increase in the community or in an individual user when needle exchange is available. Moreover, HIV and other blood-borne disease transmissions (e.g., Hepatitis) are markedly reduced with the availability of needle exchange programs.

Sexual transmission of HIV is thought to have a hierarchy of relative risk. Within this hierarchy, receptive anal intercourse without condoms is riskiest, followed by insertive anal intercourse and vaginal intercourse. Oral sex is categorized as less risky in this model but has been shown to transmit HIV. Studies have shown that the proper and consistent use of latex condoms or dental dams can markedly reduce the risk for HIV transmission during sex.

The risk to health professionals of infection caused by needle sticks from HIV-infected patients is estimated to be 1 in 200 to 1 in 500. Injuries involving injection of blood are much riskier than simple pricks. In a preliminary study from the Centers for Disease Control and Prevention (1995), zidovudine (AZT) was found to be possibly helpful in reducing the risk of HIV infection to health care workers after accidental needle stick with needles contaminated with an

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infected patient's blood. For the health care workers in this study, the use of AZT decreased the risk 79%. Current CDC recommendations include consideration of rapid treatment within hours, with multiple medications, after the occurrence of a needle stick from a known HIV-infected patient (referred to as postexposure prophylaxis) (http://www.ucsf.edu/hivcntr/PEPline/index.html). Other considerations include whether the patient has been receiving effective HIV therapy and whether there is any known drug-resistant virus in the patient involved. The availability of clinicians with expertise in HIV transmission is essential to assist health care personnel exposed to a needle-stick injury to make complicated decisions regarding the risks and benefits of treatment. Information on occupational exposures and postexposure prophylaxis is available from the CDC and other Web sites (included at the end of this chapter) as well as the postexposure prophylaxis hotline (888-448-4911).

Nonoccupational exposure including sexual exposure prophylaxis: Antiretroviral postexposure prophylaxis after injection drug use, sexual, or other nonoccupational exposure to HIV is recommended when persons seeking care within 72 hours of exposure to blood, genital secretions, or other potentially infectious body fluids of a person known to be infected with HIV and the exposure represents a substantial risk for transmission. Treatment with HAART for 28 days is recommended but seeking expert guidance (see phone number in the preceding text or Web sites at the end of this chapter) to help practitioners determine if the exposure represents substantial risk is strongly advised. It is unknown if treatment for exposures after 72 hours provide any reduction in HIV risk and the U.S. Department of Health and Human Services (DHHS) does not take a stance on this. For exposures from persons of unknown HIV status DHHS does not make a recommendation other than recommending consideration of treatment on a case-by-case basis if the exposure is less that 72 hours old.

Developmental Issues Related to HIV Infections in Adolescents

Although most youth do not undergo extreme turmoil and distress in their teenage years, adolescence provides many opportunities for risk for youth with regard to HIV infection. These additional opportunities for risk can be categorized in the following areas as outlined in the subsequent text: (a) cognitive and emotional development; (b) social, behavioral, and physiological development; and (c) family relationships.

Cognitive and Emotional Development

Cognitive and emotional development factors that put teens at increased risk for AIDS include:

1. Greater experimentation and greater degree of influence by peer behaviors
2. Naïveté and lack of good judgment
3. Feelings of immortality and invulnerability
4. Ignorance of modes of AIDS transmission and prevention
5. Denial of personal risk
6. Identification with moral codes (i.e., those of peers) other than those of their parents

Social, Behavioral, and Physiological Development

Adolescent behaviors that increase teens' risk for HIV infection include the following:

1. Sexual activity: A high percentage of adolescents engage in sexual intercourse, often without a barrier contraceptive or any contraceptive. In 2005, 46.8% of high school students reported that they had had sexual intercourse (Centers for Disease Control and Prevention, 2006), http://www.cdc.gov/HealthyYouth/yrbs/index.htm). Teens in urban areas, and particularly inner-city teens and those in group homes and detention centers, seem to have the earliest onset of sexual activity. Many adolescent males (17% to 37%) report having had at least one same-sex experience. A 1994–1998 CDC-sponsored study of urban young men (age 16–22) who have had sex with men reported that 41% had engaged in unprotected anal sex in the preceding 6 months (7% were HIV infected). Although, reported condom use at last sex in high school students has increased from 46.2% in 1991 to 62.8% in 2005, this still leaves many youth at risk for HIV infection through unprotected intercourse (Centers for Disease Control and Prevention, 2006).
2. Sexually transmitted diseases (STDs): The high prevalence of STDs in adolescents is an indicator of both high-risk behavior among teenagers and the lack of condom use. One in four sexually experienced teens contracts STD, annually.
3. Illicit drug use: Although there are no adequate national statistics on injection drug use among teenagers, estimates are that 1 in 50 high school juniors and seniors have injected drugs. Youth who have dropped out of school or are homeless have even higher rates. Millions of youth have used cocaine, stimulants, or opiates, all of which can be used intravenously. Teens may also be sharing needles in other ways, such as piercing ears, tattooing, or using steroids (i.e., athletes). Crack cocaine users appear to have an especially high rate of HIV infection. In addition, any drug use impairs a youth's ability to make good decisions concerning sexuality. In 2005, 23.3% of high school students reported use of alcohol or drugs before their last sexual activity (Centers for Disease Control and Prevention, 2006).
4. Runaway behavior: Approximately 1 million teenagers run away each year, and many of these are involved in high-risk behaviors, including injection drug use and survival sex (sex for money, food, or a place to stay). AIDS-related risks are high but are often ignored in the context of the immediate crises of survival (i.e., housing, food, and clothing).
5. Physiological factors: Adolescent girls may be at increased risk of HIV infection because of several physiological features, including:
6. Differences in the cervix of adolescents (more columnar epithelium)
7. Alterations of the vaginal pH as compared with adults
8. Differences in menstrual patterns (less ovulation, less progesterone, and therefore less thick cervical mucus).

Family Relationships

Unresolved issues can lead to powerful conflicts between parents and adolescents. Sometimes the dysfunctional

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nature of the teen's family significantly increases the chances of the teen's involvement in high-risk behavior.

Human Immunodeficiency Virus Testing

Most laboratories offer enzyme immunosorbent assay (EIA) screening with a confirmatory Western blot analysis for any blood specimen with two consecutive positive EIA test results. A positive EIA test result should never be reported to a patient as a positive test result for HIV. A positive Western blot has almost 100% specificity. Western blot tests can be indeterminate. This is common for patients in the window phase between acute infection and seroconversion. However, many patients with indeterminate tests will later test HIV negative by EIA or Western blot. It is recommended that testing be repeated until a definitive positive or negative result occurs. This can be performed after 1, 3, and 6 months for an indeterminate Western blot. The time delay from HIV infection to positive Western blot averages 21 days with newer test reagents. Rare cases of prolonged seroconversion (6 months or longer) have been reported. False-positive serology results may occur in 1 of 200,000 cases. Factitious reporting of HIV infection has been reported as well. In confusing cases, including indeterminate results, false reporting, and patients who are potentially in the window period, HIV DNA or RNA determination by polymerase chain reaction (PCR) may be helpful in clarifying serostatus.

The technology for HIV testing has expanded greatly. In addition to blood tests, tests of oral secretions and urine are approved by the U.S. Food and Drug Administration (FDA). Oral secretion tests have sensitivity and specificity similar to blood whereas urine tests are slightly less sensitive. In the United States, there are four rapid HIV tests currently licensed that can be used on serum, whole blood, and oral secretions. Positive test results must be confirmed like other screening tests and this must be incorporated into pretest counseling. The Centers for Disease Control and Prevention (2004a) Web site (http://www.cdc.gov/hiv/rapid/URL/testing/) has extensive information on the use of rapid HIV testing, including specific recommendation for providers regarding the Clinical Laboratory Improvement Amendments (CLIA) program, counseling, and quality assurance guidelines. Rapid test technology can change frequently, so health care providers should check the CDC Web site for updates. However, as of 2006, the current tests included:

• OraQuick Advance Rapid HIV-1/2 Antibody test (Oral fluid, whole blood, or plasma)
• Reveal G-2 Rapid HIV-1 Antibody test (serum or plasma)
• Uni-Gold Recombigen HIV test (Whole blood, serum, or plasma)
• Multispot HIV-1/HIV-2 Rapid test (serum or plasma)

All of these tests had sensitivities in the 99% to 100% range and specificities in the 98.6% to 99.9% range. One benefit to rapid testing is that it nearly eliminates the problem of youth not returning for their results. Most rapid tests have CLIA waivers and clinicians can perform these in their offices, although some states may have additional regulations.

Consent and Confidentiality

Health care practitioners must balance the protection of adolescents' rights against the amount of information needed to deliver proper care.

1. Individuals older than 18 years who are competent: These individuals must make an informed consent for HIV testing, which involves a dialogue concerning the risks and benefits of the test, the implications of the test, and alternatives to the test. However, the CDC has recommended that patients in all health care settings get HIV testing after being informed and given a chance to opt-out. They recommend that separate informed consent (from the general medical consent) not be done and that prevention counseling should not be required for HIV diagnostic testing or as part of HIV screening programs.
2. Individuals between 12 and 17 years: The laws vary widely from state to state. In most states, the adolescent can and must give his or her own consent; however, as with any informed consent, the individual must be considered by the practitioner as competent to give an informed consent.
3. Individuals younger than 12 years and incompetent adolescents: For these individuals, a third party (parent or guardian) authorizes the testing. However, this authorization may be restricted by state laws.

An increasing number of states have statutes governing HIV testing. Without such a statute, general laws regarding minors apply. In most states, adolescents can give their own consent for diagnosis and treatment of STDs or contagious diseases. It is not clear whether HIV testing would fall under this category in states that do not declare AIDS to be an STD. In some states, adolescents are authorized and must give their own consent. Generally, those adolescents who are judged to have the right to consent are also considered to have the right to refuse testing and the right of confidentiality.

The physician should be aware of the current local laws regarding the following:

1. Consent for testing: Who can consent? What is the required informed consent? Are pretest and posttest counseling available?
2. Who can get the results of these tests?
3. Where can the test results be recorded?
4. Can results be disclosed to other involved individuals and under what circumstances?
5. What can be written in the chart regarding testing and test results?

To Whom Should Human Immunodeficiency Virus Testing Be Offered?

In 2006, as indicated in the preceding text, the CDC modified its recommendations to advise that HIV testing be routinized for all sexually active adolescents and adults younger than 64 years when they access health care. Youth should be advised that they will be tested and given the option to decline. Once initially tested, persons at high risk should be screened annually. Separate written consent is no longer recommended by the CDC but many states have laws requiring written informed consent. Prevention counseling is not required but does continue to offer benefit

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for health care systems that have the ability to provide this service. The following groups are at high risk and should have repeat testing at least annually:

1. Men who have sex with other men regardless of sexual orientation (as many youth in this group may not self-identify as gay or bisexual)
2. Youth who share needles (including tattooing, ear piercing, steroid injection, and recreational drugs)
3. Youth with partners from the above two groups
4. Youth who have had intercourse or shared needles with HIV-infected persons
5. Youth with STDs
6. Sexually active youth from inner city or economically disadvantaged areas or areas of known high seroprevalence
7. Youth with multiple sexual partners

Who Should Have Human Immunodeficiency Virus Testing Deferred?

1. Suicidal teens and those who seriously state they would be suicidal if HIV positive
2. Intoxicated and drug-withdrawing youth
3. Severely mentally ill youth who cannot provide consent for testing

When Should Testing Be Repeated for Youth with Positive Confirmatory Human Immunodeficiency Virus Test Results?

Testing should be repeated for the following persons:

1. Any youth who desires a second test
2. Any youth who is claiming to be HIV positive but has unreliable documentation
3. Youth who are at extremely low risk and have a single positive test result
4. Youth with normal CD4⁺T cells and undetectable viral load, who are not taking antiretroviral medications and have had only a single positive test result in the past

Methods for Human Immunodeficiency Virus Testing

1. Anonymous testing: Patients are not identified by name but are given a number. Many adolescents prefer this method because of confidentiality issues, but it may lower the rate of return for posttest counseling or the rate of follow-up for medical care if the adolescent is found to be HIV positive.
2. Confidential testing: Pretest and posttest counseling are done, and the results are part of the medical record. Normal laws regarding patient confidentiality still protect clients. Because the counselor or physician probably knows the patient's name and address, he or she can follow-up with HIV-positive clients to ensure they receive adequate care.
3. Youth-specific testing: Many testing sites now have counselors (including peers) who are specifically trained to work with adolescents. These testing sites may therefore be perceived as youth friendly. The counselors may have more time for complete evaluations of risky behaviors and have knowledge of how to help youth change unhealthy behaviors. Often, these sites are located where other services or activities are available for teens (e.g., homeless shelters, free clinics, schools, recreational centers, mobile testing vans). Youth-specific testing should be recommended whenever possible, because it can be an effective component of prevention education.

Human Immunodeficiency Virus Counseling and Testing

The primary goals of HIV testing include identifying patients who are infected with HIV and linkage to appropriate health care and supportive services. The CDC is moving in a direction of increasing the ability and frequency of detecting HIV and avoiding prevention counseling as a possible impediment to HIV testing. Clinicians must weigh the need for HIV testing and HIV prevention counseling for patients. Although HIV prevention counseling is no longer required for HIV testing, Donna Futterman has developed the ACTS (Assess, Consent, Test, Support) system to assist practitioners with brief HIV counseling and testing (Table 31.3) (http://www.adolescentaids.org/healthcare/acts.html). This instrument was specifically designed with adolescents in mind. For some adolescents, the screening test may be a highly “teachable” moment and risk behavior assessment and counseling may be appropriate.

Posttest Counseling for Positive Test Results

Posttest counseling should be given in person and should include the following:

1. Provide the results of the test: This should be done in a direct manner at the beginning of the posttest session.
2. Allow the adolescent time to express feelings and reactions: It is important to give the adolescent hope by reiterating the advances in medical treatment discussed during the pretest session. As discussed in the preceding text, if rapid testing has been employed youth should be reminded that a second test must be conducted for confirmation.
3. Assess the adolescent's understanding of the result: This is best assessed by asking the teen directly what the test result means to him or her. The teen should be supported in identifying behavior change goals to reduce their risk of transmitting the virus to others. The teen should also understand that although the virus is probably present for life, a positive antibody test does not mean one has AIDS. Antibody-positive adolescents should be advised as follows:
4. Do not donate blood, semen, or body organs.
5. Employ safer sex practices.
6. Inform physicians and dentists of HIV status.
7. Encourage sexual partners, children, and needle contacts to seek evaluation and testing (many counties have anonymous partner notification programs).
8. No evidence exists that HIV is transmitted to family household members or to close contacts by routes other than sexual intercourse, exposure to infected blood, and perinatal transmission.
9. Household items may be shared by HIV-infected individuals and household members. Dishes and eating utensils should be routinely washed in hot water and a detergent. Personal hygiene items (i.e., razors and toothbrushes) should not be shared.

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1. The HIV-seropositive individual's blood and other body fluids should be handled with care. Soiled clothes or linen should be washed with a detergent or bleach.
2. Bathroom facilities may be used by all household members.
3. Refer the patient to an HIV specialist who is experienced with adolescents. Ideally, the clinic will have a multidisciplinary team that includes a physician, social worker, nurse, and other caregivers to assist the patient with treatment and in coping with the illness.

TABLE 31.3 ACTS: A Rapid System for HIV Counseling and Testing

HIV, human immunodeficiency virus. From Futterman DC. HIV and AIDS in adolescents. Adolesc Med Clin 2004;15:369 with permission. Assess need for HIV testing, care, or prevention counseling · Explain benefits of testing for patient's health and prevention. · Discuss modes of HIV transmission (e.g., sex, needles, perinatal). · Review risk assessment form or explain to patient that HIV testing is advisable if the patient has: (a) ever had sex, (b) has had intercourse without a condom, (c) has ever used recreational drugs intravenously, or (d) shared intravenous syringes and works. · Recommend testing, discuss HIV prevention, and provide referrals as appropriate. Counsel and obtain consent · Clarify the meaning of positive and negative results and explore patient's potential reactions. · Assess readiness for immediate testing, including patient's social support network. · Review health department requirements, such as the difference between confidential and anonymous testing and names reporting, partner notification, and domestic violence screening. · Obtain consent. Test · Describe/provide HIV test (e.g., blood, oral, urine, rapid). · Make appointment to deliver results in person, by phone, or have patient wait for rapid results. Support during testing and afterward HIV-negative patients · Clarify need to retest in 3 months (e.g., window period, based on risk assessment). · Provide prevention strategies and referrals; HIV testing alone is not prevention. HIV-positive patients · Provide support and link to care and prevention. · Review HIV reporting, partner notification, and domestic/partner violence issues. Complete ACTS training materials are available at http://www.adolescentaids.org.

Management of Human Immunodeficiency Virus Infection in Adolescents

Initial Assessment

History and Physical Examination

The history and physical examination should stress the following:

1. Prior exposure to diseases that are likely to reactivate in individuals with HIV, including tuberculosis (TB), syphilis, herpes genitalis, herpes zoster, and cytomegalovirus (CMV) infections
2. Number of children, their ages, and their health status
3. Injection drug-use history and history of alcohol and other drug use
4. Travel history to find out about possible exposure to fungal infections that are endemic in certain areas, such as histoplasmosis, coccidioidomycosis, or blastomycosis
5. Sexual history, including sexually transmitted infections
6. Prior immunizations
7. A review of systems, focusing particularly on the following:
8. Systemic: Anorexia, weight loss, fevers, night sweats
9. Skin: Pruritis, rashes, pigmented lesions
10. Lymphatic: Increased size of lymph nodes
11. Head, eyes, ears, nose, and throat: Headache, change in vision, sinus congestion
12. Cardiopulmonary: Cough, dyspnea
13. Gastrointestinal: Dysphagia, abdominal pain, and diarrhea
14. Musculoskeletal: Myalgias, arthralgias
15. Neurological: Memory loss, neuralgias, motor weakness, depression, and headache
16. Genitourinary: Bumps, ulcers, burning, or discharge
17. Careful measurement of weight at each visit

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9. Careful examination particularly focusing on the following:
10. Skin: Seborrhea, folliculitis, Kaposi sarcoma (KS) lesions, psoriasis, tinea, herpetic lesions, and molluscum contagiosum
11. Eye: Visual acuity and fields, cotton-wool and hemorrhagic exudates on funduscopic examination
12. Mouth: Periodontal disease (gingivitis), oral hairy leukoplakia (white plaques along lateral aspect of tongue), thrush, oral ulcers, and KS lesions
13. Lymphatic: Asymmetrical, tender, enlarged nodes, particularly posterior cervical, axillary, and epitrochlear nodes
14. Cardiopulmonary: Rales, murmurs (in injection drug users)
15. Gastrointestinal: Hepatosplenomegaly
16. Genitourinary: Herpetic lesions, warts, and penile discharge in males; cervical or vaginal discharge in females
17. Rectal: Perianal herpes, condyloma, fissures, and proctitis
18. Neurological: Focal findings, altered mental status

Laboratory Evaluation

Initial assessment should include the following:

1. Complete blood count, looking for anemia, leukopenia, or pancytopenia
2. Platelet count
3. Chemistry panel, looking for hypergammaglobulinemia, hypoalbuminemia, hypocholesterolemia, increased liver enzymes, or decreased renal function
4. Urinalysis
5. CD4⁺T-cell count and percentage
6. Viral load (HIV RNA by PCR)
7. Consider HIV resistance testing (genotyping is less expensive than phenotyping) in patients with acute or recent seroconversion
8. Purified protein derivative (PPD) of tuberculin skin test
9. Serology for syphilis, hepatitis A, B, and C, toxoplasmosis, and varicella if previous infection or immunization status is not known
10. Chest radiograph
11. Tests for gonorrhea and chlamydia infections if sexually experienced
12. Papanicolaou test (Pap smear) in women

Vaccinations

1. Hepatitis A: Recommended for all at-risk individuals.
2. Hepatitis B: Recommended for all patients without evidence of hepatitis B immunity or chronic infection. Retrospective studies demonstrate that many youth with HIV do not develop antibodies to hepatitis B after three immunizations. Physicians can consider a fourth immunization or repeating the series after the patient begins HAART.
3. Human papillomavirus (HPV): HIV infection is not a contraindication (it is not a live vaccine), and in the HIV-infected population, it could be a real positive. However, it is not clear if the efficacy in the immune suppressed population will be as high as that in the nonimmunosuppressed population. Although HPV vaccine is currently FDA approved only for females aged 9 to 26, the significant morbidity and even mortality associated with HPV-related disease in men-who-have-sex-with men argues for its early adoption into clinical practice.
4. Influenza: Should be offered annually in October or November to all HIV-infected individuals. In patients not receiving HAART, the viral load may increase transiently after vaccination, but it returns to baseline in approximately 1 month. Intranasal vaccination is contraindicated.
5. Measles-mumps-rubella (MMR): All patients should have received two MMR vaccinations in their lifetime. MMR is considered safe in patients with HIV but should not be used if severe immunosuppression is present. (Severe immunosuppression is not defined but one might use a CD4⁺below 200 in this setting.)
6. Meningococcal vaccination: Persons with HIV are likely at increased risk for meningococcal disease. They may elect to receive the conjugate quadrivalent vaccine although its efficacy in this population is unknown.
7. Pertussis (acellular pertussis): Adolescents and young adults are being recommended to be revaccinated with Tdap. HIV is not a contraindication (it is not a live virus) but the response in those immunosuppressed might be suboptimal.
8. Pneumococcal: Should be given once to previously unimmunized individuals.
9. Polio: Patients requiring primary or booster immunizations should receive the inactive form, inactivated poliovirus (IPV), not the oral poliovirus vaccine (OPV).
10. Tetanus-diphtheria: Same as if uninfected.
11. Varicella (chickenpox): The vaccine for prevention of varicella (varivax—live attenuated varicella virus vaccine) is NOTadvised for use in those with acquired or primary immunodeficiencies. Research using this vaccine in persons previously infected with varicella is in progress. Currently, the new vaccine Zostavax (live attenuated varicella/zoster vaccine) for prevention of shingles is approved only for individuals older than 60 and is contraindicated in those with immunosuppressive diseases including AIDS.

Follow-up

Patients should have their medical and social needs assessed at least every 3 months. Most patients on HAART should be seen monthly, because adherence issues frequently arise. These appointments should focus on signs and symptoms of disease progression, coping skills, and secondary prevention education. Antiretroviral management is reviewed later in this chapter. Secondary prevention focuses on preventing the spread of HIV to others but also in preventing unplanned pregnancy and STDs that are commonly seen in youth. Follow-up should include the following:

1. Complete blood count with platelet count and CD4⁺T-cell count every 3 months
2. HIV RNA by PCR every 3 months
3. PPD yearly
4. Venereal disease research laboratory (VDRL) or a rapid plasma reagin (RPR) test for syphilis, yearly. These tests should be conducted more frequently for young-men-who-have-sex-with men in high prevalence regions.
5. Pap smear annually in sexually experienced women
6. Regular discussion of safer sex and family planning

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7. Discussion of disclosure including options for partner notification
8. Discussion of nutrition, exercise, disease progression, medication options, and potential clinical trials
9. Regular evaluation of emotional status
10. Focused interval history and physical examination, concentrating on illnesses common for the patient's stage of HIV disease

Early Manifestations of Human Immunodeficiency Virus Infection

Early manifestations of HIV disease may include the following:

Chronic lymphadenopathy Pruritic papular eruptions Unexplained weight loss Oral hairy leukoplakia Xerosis Frequent tinea Severe molluscum contagiosum Leukopenia Seborrheic dermatitis Exacerbations of psoriasis Isolated thrombocytopenia Fatigue and malaise

Opportunistic diseases, including infections and neoplasms, typically occur after immune suppression reaches a certain level. Table 31.4 lists some common diseases and the corresponding CD4⁺ T-cell count associated with these illnesses.

TABLE 31.4 Opportunistic Diseases

CD4+ T-cell Count (per mm3) Condition AIDS, acquired immunodeficiency syndrome. From Phari JP, Murphy RL. Contemporary diagnosis and management of HIV/AIDS infections. Newton, PA: Handbooks in Health Care, 1999 with permission. 200–500 Thrush Kaposi sarcoma Tuberculosis reactivation Herpes zoster Bacterial sinusitis/pneumonia Herpes simplex 100–200 Pneumocystis carinii pneumonia All of the above 50–100 Systemic fungal infections Primary tuberculosis Cryptosporidiosis Cerebral toxoplasmosis Progressive multifocal leukoencephalopathy Peripheral neuropathy Cervical carcinoma 0–50 Cytomegalovirus disease Disseminated Mycobacterium avium complex Non-Hodgkin lymphoma Central nervous system lymphoma AIDS dementia complex

The management of conditions associated with HIV is beyond the scope of this chapter, changes frequently, and is frequently left to HIV specialists. Updated treatment information is available on several Web sites listed at the end of this chapter.

Management of Sexually Transmitted Infections

1. Uncomplicated chlamydia, gonorrhea, trichomonas, and syphilis are generally treated in the same manner as in adolescents without HIV.
2. Pelvic inflammatory disease can be more difficult to treat in women with HIV, especially if immune dysfunction is pronounced (low CD4⁺T-cell count). In general, the CDC treatment guidelines (http://www.cdc.gov/STD/treatment/) are followed, but the threshold for hospitalization for administration of intravenous antibiotics is reduced.
3. Cervical dysplasia has been shown to be very prevalent in women with HIV. High-risk serotypes such as HPV-16 seem to be more common, and spontaneous regression appears to be less common. Still, annual screening after initiating sexual activity (rather than delaying for 3 years as now recommended for HIV-negative patients) and referral for colposcopy for both low-grade and high-grade squamous intraepithelial lesions or recurrent atypical results on Pap smears are recommended. Treatment and follow-up recommendations for abnormal findings on colposcopic biopsies are generally the same as in

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women not infected with HIV. Whenever possible, refer adolescents with HIV and abnormal Pap smear results to care providers with HIV experience.

Management of Family Planning

Risk of Maternal-Child Transmission

With the marked improvements in prevention of maternal-child transmission of HIV, family planning has changed. Many youth now acknowledge their interest in having children despite having HIV. Physicians should be honest about the risks of maternal-child transmission. The risk of maternal-child transmission of HIV is approximately 23% without antiretroviral treatment. The current standard of care is to treat infected women who desire pregnancy, with HAART (minimum of three antiretrovirals). The risk of transmission has been shown to be <4% for women taking HAART, and it is probably <1% when a patient conceives while following an effective HAART regimen (i.e., viral load is undetectable) and maintains the program during pregnancy. The CDC has developed specific guidelines on the prevention of maternal-child transmission; these are available on their Web site (http://www.cdc.gov/mmwr/PDF/rr/rr5118.pdf).

Contraception

Although the prevention of maternal fetal transmission of HIV is no longer the primary reason for birth control, the typical issues of adolescence and being prepared for parenting are still critical. Unplanned pregnancies can disrupt an already complex situation for youth infected with HIV. Providing contraceptive counseling in these youth is complicated by the competing desires to prevent transmission of HIV to sexual partners by using condoms and to prevent unplanned pregnancy (usually with a more effective hormonal method). Studies of adult women with HIV have shown that patients using hormonal methods of contraception were less likely to use condoms. However, those using condoms frequently reported using them irregularly. Data from a cohort of HIV-infected adolescents indicated that most adolescents reported condoms as their main method of contraception (Belzer et al., 2001). Unfortunately, the rate of conception was >20% during the first year in the study, and it was high in those reporting contraception use as well. Contraception needs to be addressed frequently and adherence to the method of choice discussed. Contraceptives utilizing estrogen may be less effective in patients using protease inhibitors (which increase estrogen metabolism), and contraceptive pill use adds to the pill burden in patients taking other medications.

Common Psychosocial Problems

Common psychosocial problems in HIV-infected adolescents include, but are not limited to, the following:

1. Depression and suicidal ideation
2. Substance use
3. Self-blame
4. Social isolation, including family and peers
5. Unsafe sex
6. Distress/negative reactions regarding sexual identity
7. Homelessness
8. Survival sex
9. Denial
10. Unplanned pregnancy
11. HIV disclosure

The cornerstone to good care is the availability of a strong health care team, including physicians, nurses, social workers, psychologists or psychiatrists, nutritionists, substance abuse counselors, and medical subspecialists as needed. Coordinating the team to focus on the patient's identified needs improves compliance and facilitates normal adolescent development.

Travel

Visiting regions outside one's normal community can expose an individual to many pathogens. In developing countries, opportunities for exposure to enteric pathogens, includingCryptosporidium and Isospora, increase. Risk for certain respiratory infections such as coccidioidomycosis, histoplasmosis, and TB also increases in many developing countries and in certain geographic regions of the United States. The CDC offers an international travelers' hotline (telephone 877-FYI-TRIP) and a Web site http://www.cdc.gov/travel/. Patients planning significant travel should discuss preventive strategies with their physician.

1. Avoid contaminated food and drink (i.e., tap water).
2. Receive appropriate immunizations.
3. Extended travel should be accompanied by appropriate medications and telephone numbers for emergency care.
4. Seek medical attention promptly if fever, diarrhea, or other illness occurs during or after travel.

Sports Participation

When Ervin “Magic” Johnson announced that he was infected with HIV, many questions surrounding the advisability of vigorous exercise occurred. To date there have been no studies documenting a positive or negative impact of exercise on HIV. Currently, we recommend using common sense in guiding infected youth on sports participation.

There have been no documented cases of HIV transmission during athletic participation. We would not withhold a youth from competitive sports (even full-contact sports like wrestling or football) solely on the basis of HIV-positive status. The principal risks athletes have for acquiring HIV are related to off-the-field settings (Mast et al., 1995). However, all participants, whether infected with HIV or uninfected, should not compete with open wounds, and universal precautions should always be followed when bleeding occurs.

Evaluation of Specific Syndromes

Pulmonary (Cough or Shortness of Breath)

1. If the CD4⁺T-cell count is 200/mL or less or the percentage of CD4⁺ T cells is 14% or less, the patient requires the following:
2. Chest radiographic examination: Look for interstitial or other infiltrates
3. Pulse oximetry or arterial blood gas determination for hypoxemia
4. Consider induced sputum for Pneumocystis cariniipneumonia (PCP)
5. Consider bronchoscopy for PCP evaluation
6. In patients with a CD4⁺T-cell count higher than 200/mL and a percentage higher than 14%, it is unlikely to be PCP. These patients require the following:
7. Consider evaluation for bronchitis, sinusitis, TB, and bacterial pneumonia

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1. Chest radiographic examination or sinus films
2. Subsequent PPD
3. Sputum for culture and sensitivity, acid-fast bacillus

Fever

Evaluation in patients who have severe immunosuppression (CD4⁺ T-cell count <200/mL) but lack of specific organ system signs or symptoms should include the following:

1. Chest radiographic examination: Interstitial infiltrates are consistent with PCP, infection with Mycobacterium aviumcomplex (MAC) or CMV; focal infiltrates are consistent with TB or bacterial pneumonia
2. Complete blood count: Anemia is common in MAC
3. Chemistry panel: Elevated lactate dehydrogenase is common in PCP; elevated alkaline phosphatase is common in MAC
4. Blood cultures for bacteria, virus (CMV), fungus, and acid-fast bacillus
5. Serum cryptococcal antigen

If fever persists and above tests are inconclusive, consider the following:

1. Lumbar puncture: May pick up cryptococcal infection
2. Bone marrow biopsy: May pick up disseminated MAC, CMV, or fungus
3. Ophthalmology consultation: Looking for CMV
4. Body computed tomography (CT): Looking for lymphoma
5. Sinus films

In patients with mild immunosuppression (CD4⁺ Tcell count 200–500/mL), look for common illnesses (viral or bacterial) and consider looking for TB, sinusitis, and pneumonia.

In patients with minimal immune suppression (CD4⁺ T-cell count >500/mL), avoid costly work-ups unless conservative evaluation fails.

Diarrhea

Always assess whether this could be medication related. In patients with severe immunodeficiency (CD4⁺ T-cell count <200/mL):

1. If diarrhea is mild, consider empiric treatment with diphenoxylate (Lomotil) or loperamide (Imodium).
2. If diarrhea is severe, check stool for ova and parasites, culture and sensitivity, Cryptosporidium, Cyclospora, or Isosporainfection.
3. If these tests are inconclusive, consider colonoscopy looking for CMV, MAC, Microsporidia,and Isospora.

In patients without severe immunodeficiency:

1. Diarrhea is usually self-limited, and costly evaluations should be avoided.
2. Consider stool ova and parasites, stool for Clostridium difficiletoxin, and bacterial culture and sensitivity if the patient is sexually active, is homeless, or has traveled abroad recently.

Neurological (New Headaches, Seizures, Focal Neurological Signs)

In patients with severe immunodeficiency (CD4⁺ T-cell count <200/mL):

1. Emergency CT or magnetic resonance imaging (MRI) of head: Multiple enhancing ring lesions are usually indicative of toxoplasmosis; primary central nervous system lymphoma is also common.
2. Lumbar puncture for cell count, protein, cryptococcal antigen, Gram stain, routine acid-fast bacillus and fungal cultures, and VDRL.

Dysphagia

In patients with severe immunodeficiency (CD4⁺ T-cell count <200/mL):

1. If oral thrush is present, consider empiric treatment for Candidaorganisms with fluconazole or ketoconazole.
2. If there is no oral thrush or empiric treatment fails, try endoscopy with evaluations for fungus, CMV, and herpes simplex virus.

Prophylaxis

Prophylaxis is one of the most important ways that patients with severe immunosuppression can maintain their health. Patients who have severe immune suppression but are not ready for HAART should still be encouraged to use prophylaxis.

Primary Prophylaxis

The CDC frequently publishes updated guidelines for primary prophylaxis and can be found on their Web site (http://aidsinfo.nih.gov/ContentFiles/OIpreventionGL.pdf).

1. Pneumocystis: Initiate when the CD4⁺T-cell count is 200/mL or less. Patients who start HAART and in whom the CD4⁺ T-cell count rises above 200/mL for 3 to 6 months may safely discontinue prophylaxis.
2. Drug of choice: Trimethoprim-sulfamethoxazole double-strength tablet, daily or three times weekly (patients with allergies to sulfa can usually be desensitized).
3. Alternatives: Dapsone 100 mg/day orally (check for glucose-6-phosphate dehydrogenase [G6PD] deficiency before using); nebulized pentamidine 300 mg every 4 weeks through Respirgard II nebulizer (may be the method of choice in noncompliant youth); Atovaquone 1,500 mg orally a day with meals.
4. Tuberculosis: Initiate in teens who are PPD positive (>5 mm), have recent TB exposure, or have a history of inadequately treated TB that healed.
5. Drug of choice: Isoniazid 300 mg plus pyridoxine 50 mg daily or Isoniazid 900 mg plus pyridoxine 100 mg twice a week for 9 months.
6. Alternative: Rifampin 600 mg plus pyrazinamide 15 to 20 mg/kg daily for 60 doses (rifampin is contraindicated in patients taking protease inhibitors).
7. Mycobacterium avium complex: Initiate when the CD4⁺T-cell count is 50/mL or less. Prophylaxis can probably be discontinued if the cell count rises above 100/mL for 3 to 6 months after initiation of HAART.
8. Drug of choice: Clarithromycin 500 mg twice daily or azithromycin 1,200 mg orally once a week.
9. Alternative: Rifabutin 300 mg orally once a day.
10. Toxoplasma gondii risk: Initiate when the CD4⁺T-cell count is <100/mL and serology results are positive for T. gondii immunoglobulin G.
11. Drug of choice: Trimethoprim-sulfamethoxazole, one double-strength tablet/day.
12. Alternative: Dapsone 50 mg orally once a day plus pyrimethamine 50 mg/week plus leucovorin 25 mg/week.

Antiretroviral Therapy

The CDC regularly updates guidelines on the use of antiretrovirals for adolescents and adults (http://aidsinfo.nih.gov/ContentFiles/

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AdultandAdolescentGL.pdf) and should be consulted with the assistance of an HIV specialist in determining whether a patient should be treated with HAART. In addition, the Health Resources and Service Administration has published a report titled, Helping Adolescents with HIV Adhere to HAART (available through the National AIDS Clearinghouse http://www.cdc.gov/mmwr/preview/mmwrhtml/00001789.htm). Although a full discussion of the use of antiretrovirals is beyond the scope of this chapter, some basic principles pertaining to youth are important.

Initiating Highly Active Antiretroviral Therapy

Although the United States Department of Health Services publishes guidelines for the initiation of HAART in adolescents and adults, which are based primarily on a patient's immune status (CD4⁺ T-cell count) and risk for disease progression (viral load, HIV RNA), there has been considerable attention to the issue of a patient's ability to adhere strictly to a regimen for many years and perhaps for the rest of the patient's life. Decisions to initiate therapy must be made jointly by a well-informed patient and his or her health care providers. Empowering patients through education on their ability to control HIV through the proper use of medications, while at the same time helping them develop a realistic time frame and plan for initiating therapy, is the key to eventual adherence and the reaching of mutual agreement on treatment.

There are currently 22 FDA-approved antiretroviral drugs that belong to one of four classes based on their mode of preventing HIV replication. New medications in each class are currently in development, and new classes are also being researched. There are also an increasing number of medication formulations that allow 2 to 3 different medications to be placed into one single pill or fewer pills per medication. These have allowed for considerable simplification of antiretroviral regimens.

1. Nucleoside/nucleotide reverse transcriptase inhibitors
2. Zidovudine (Retrovir or AZT)
3. Didanosine (Videx or DDI)
4. Stavudine (Zerit or D4T)
5. Lamivudine (Epivir or 3TC)
6. Abacavir (Ziagen)
7. Zalcitabine (Hivid or DDC)
8. Emtricitabine (Emtriva or FTC)
9. Tenofovir (Viread)
10. Combivir, a combination pill with both zidovudine and lamivudine
11. Trizivir, a combination of zidovudine, lamivudine, and abacavir
12. Epzicom, a combination of abacavir and lamivudine
13. Truvada, a combination of tenofovir and emtricitabine
14. Nonnucleoside reverse transcriptase inhibitors
15. Nevirapine (Viramune)
16. Efavirenz (Sustiva)
17. Delavirdine (Rescriptor)
18. Protease inhibitors
19. Ritonavir (Norvir)
20. Saquinavir (Fortovase)
21. Indinavir (Crixivan)
22. Nelfinavir (Viracept)
23. Fosamprenavir (Lexiva)
24. Lopinavir/ritonavir (Kaletra)
25. Atazanavir (Reyataz)
26. Tipranavir (Aptivus)
27. Darunavir (Prezista)
28. Entry (fusion) inhibitors
29. Enfuvirtide (Fuzeon)

The general principles of HAART therapy are listed in Table 31.5. The primary aim is to initiate a regimen (frequently described to patients as a cocktail) containing a minimum of three antiretroviral medications with the goal of reducing the patient's viral load to an undetectable level on a highly sensitive assay for HIV RNA. Incomplete suppression, through either inadequate medication or nonadherence, can lead to the development of HIV strains that are resistant to the antiretrovirals. Because of potential cross-resistance, second- and third-line treatment is often more complex, more toxic, and less effective. An increasing number of persons newly infected with HIV are being infected with strains that are already resistant to one or more antiretroviral medications. Physicians should consult their local health departments to determine if assaying for baseline antiretroviral resistance is cost effective for any particular region.

The patient's need for HAART must be balanced with the ability to adhere to the drug regimen. Research has indicated that physicians are notoriously poor at predicting how likely a patient is to take his or her medication. Table 31.6 reviews some factors that may influence patients' decisions to start taking medication. Table 31.7 reviews some basic concepts about adolescents and adherence to HAART. Predictors of poor adherence include psychosocial problems such as poor support, mental health problems (depression was shown to be a predictor of nonadherence in adolescents with HIV in one study), substance abuse, and homelessness. In addition, factors such as patients' trust in their health care providers or concerns that taking medication might inadvertently disclose their HIV status to family, friends, roommates, or coworkers must be considered. Also critical are medication-inherent factors such as the number of pills, the frequency of dosing, the size or taste of pills, potential side effects (many youth fear rashes because they might disclose their HIV status), and food and timing requirements. In general, one would try to keep regimens as simple and tolerable as possible. Regimens as simple as one pill daily or one pill twice daily are available. Because studies have demonstrated that adolescent adherence to antiretroviral therapy is often poor, it is important to choose regimens such that, if resistance develops, options can still be maintained for the future. Close monitoring for nonadherence by multiple providers including psychosocial support staff is critical and monthly follow-up appointments are needed for most patients. The use of pill boxes, alarms, or pagers can help youth stay organized although these methods have yet to be studied in randomized trials. As stated earlier, helping patients to prepare for HAART and to maintain it once begun is a challenging task and one that should be reserved as much as possible for physicians with expertise in HIV and adolescent care. Many adolescent-HIV specialists have adapted the stages of change model developed by Prochaska and DiClemente (1983). Table 31.8reviews the stages from precontemplation through maintenance and provides the goals for health practitioners and the key objectives for each stage.

In summary, the need for HAART in HIV-infected adolescents must be balanced against the potential for benefit from the medications and the potential for harm

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from the development of resistance due to nonadherence. It is not unreasonable to initiate a short trial of practice medication for 1 to 4 weeks. If the patient cannot take the medication regularly or even follow-through with the next appointment, the initiation of medication can be delayed while more preparation can occur. It is very reasonable to hold off on HAART, even for patients with highly advanced AIDS, if the patient and physician conclude that adherence is unlikely. Medication has been demonstrated in many cases to produce immune reconstitution in even the most damaged immune systems as long as the virus is sensitive to the medication and the patient has not developed a terminal or untreatable complication.

TABLE 31.5 Summary of the Principles of Therapy of Human Immunodeficiency Virus (HIV) Infection

AIDS, acquired immunodeficiency syndrome; HAART, highly active antiretroviral therapy. Adapted from U.S. Department of Health and Human Services. Report of the NIH panel to define principles of therapy of HIV infection. MMWR Morb Mortal Wkly Rep 1998;47(R-55):1. 1. HIV replication results in immune system damage and progression to AIDS. HIV infection is always harmful. Regular, periodic measurement of HIV RNA levels (viral load measurements) 1. Determines the risk for HIV disease progression 2. Guides decisions to initiate and change antiretroviral treatment regimens (HAART) Measurement of CD4+ T-cell counts monitors the extent of immune dysfunction 2. Treatment decisions are individualized based on both viral load levels and CD4+ T-cell counts 3. The goal of HAART is maximum achievable suppression of HIV replication to below the levels of detection by sensitive viral load assays. The most effective means of maximizing suppression of HIV replication is through treatment with simultaneous initiation of combinations of antiretroviral drugs that 1. The patient has not received before 2. Are not cross-resistant with drugs the patient has received 4. Each antiretroviral drug used in combination therapy should always be used according to optimum schedules and dosages 5. Any changes in therapy reduce future treatment options because the number of drugs is limited and cross-resistance occurs 6. Women should receive optimal antiretroviral therapy regardless of pregnancy status 7. These principles apply to HIV-infected children, adolescents, and adults, although the treatment of HIV-infected children involves unique pharmacological, virological, and immunological considerations 8. Persons identified with acute primary HIV infection should also be treated with combination antiretroviral therapy to achieve viral load levels below detectable levels with sensitive plasma HIV RNA assays 9. HIV-infected persons should be considered infectious even with undetectable viral load levels, and should be counseled to avoid sexual or drug-use behaviors that would transmit HIV or other infectious pathogens

Human Immunodeficiency Virus Prevention

Primary

Until a vaccine is found, behavioral interventions, comprehensive school-based health education, blood supply screening, postexposure prophylaxis, and access to sterile needles are the main tools to reduce the risk of infection. Current primary prevention efforts include the use of counseling, HIV testing and referral, increasing the proportion of individuals with known HIV status, and the referral of individuals at high risk of HIV infection into appropriate prevention programs, including evidenced-based interventions.

Appropriate educational interventional goals for HIV-negative adolescents include the following:

1. Reducing misinformation and prejudice against HIV-infected persons
2. Helping to reduce high-risk behavior, including recommendations to decrease sexual activity, numbers of sexual partners, and experimentation with drugs
3. Supporting adolescents who choose abstinence
4. Increasing the use of condoms in adolescents who are having intercourse
5. Encouraging adolescents in sexual relationships to get HIV tested with their partners and to maintain monogamy

HIV/AIDS prevention education needs to be conducted at schools, religious organizations, youth organizations, medical facilities, and meetings with parents. Media (television, radio, magazines) are powerful methods to impart information that may change adolescents' attitudes. Meeting youngsters, where they congregate, by outreach workers can be an especially effective method of reaching high-risk populations such as homeless youth, gang youth, or out-of-school youth. Topics for HIV prevention include the following:

1. Epidemiology of HIV/AIDS and myths about AIDS
2. Sexual transmission and prevention, including abstinence, safer sex, and condom use
3. Transmission through needles, drug use prevention
4. HIV and pregnancy
5. Testing and counseling

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6. Biology of HIV/AIDS
7. Medical aspects of HIV/AIDS
8. Peer pressure and dating skills
9. Community resources

TABLE 31.6 Medication Adherence Assessmenta

HIV, human immunodeficiency virus. aThis assessment was developed in 1998 by Alice Myerson, MSN, PNP of the Adolescent AIDS Program at the Montefiore Medical Center in New York. Factors that may influence decision to take medication Client perception of health status 1. What is the meaning of the HIV infection to the patient? 2. What is his or her perception of his or her level of wellness and illness? 3. What does taking medicine mean to the patient? 1. Does he or she believe medicine will help him or her? 2. What are his or her past experiences with medicines, including those taken by family members? Social support network 1. Who is the most significant person in the patient's life? 2. Is this person aware of the patient's diagnosis? Is this person involved in the patient's care? 3. With whom does the patient live? 4. Who in the patient's home knows the diagnosis? 5. Who doesn't know? 6. What is the patient's relationship with the clinic team? Living arrangements and financial situation 1. Housing 1. Does the patient have stable housing? 2. Does the patient have a space he or she calls his or her own? 3. Does the patient have access to a refrigerator and a secure place to store his or her medications? 2. Health insurance 1. Does the patient have health insurance that will pay for his or her medications? Presence of psychopathology and problems with substance use 1. Does the patient have an active psychiatric diagnosis (e.g., manic depressive disorder, poor impulse control, major depression, suicidality)? 2. Is the patient an active substance user (e.g., marijuana, alcohol, crack, cocaine, heroin, Valium, Xanax)? Developmental level 1. What is the patient's developmental stage? 2. What are the patient's developmental goals? Factors that may influence ability to perform the work of taking medications Time orientation and organization 1. Ability to remember recent past 2. Ability to organize self toward immediate future 3. Routine organization of activities of daily living both during the week and on the weekend 1. What time does the patient awake? 2. What does he or she do on awakening? 3. Meal schedule, etc. 4. Future plans and goals Physical abilities 1. Visual acuity 2. Reading ability 3. Ability to open bottles 4. Ability to take out correct number of pills 5. Ability to take pills at the correct time of day 6. Ability to put pills in mouth 7. Ability to swallow pills 8. Ability to follow directions 9. Ability to prepare medications in advance Ability to recognize and tolerate side effects 1. Ability to distinguish between major and minor sides 2. Ability to tolerate discomforts of individual medications Medical regimen complexity 1. Number of pills 2. Number of doses 3. Additional directions for dosing 4. Mechanical actions necessary for preparation (e.g., crushing pills, mixing powder with liquid)

TABLE 31.7 Barriers to Adherence

HIV, human immunodeficiency virus; HAART, highly active antiretroviral therapy; AIDS, acquired immunodeficiency syndrome. Barriers for the general patient population 1. Complexity of medical regimen 2. Lack of social support 3. Adverse effects of treatment 4. Distrust of health providers 5. Lack of understanding about the medication 6. Difficulty coming to terms with a life-threatening illness Additional barriers for adolescents The developmental capacities of adolescence can create barriers to adherence 1. Early adolescence 1. Concrete, not yet abstract, thinking (undeveloped problem-solving skills) 2. Preoccupation with self and questions about pubertal changes 2. Middle adolescence 1. Need for acceptance from peers (desire not to appear different) 2. Present-orientation (decreased ability to plan for future doses and future implications of disease) 3. Busy, unstructured lives (difficulty remembering to take pills) 3. Late adolescence 1. Establishment of independence (the need to challenge authority figures and restructure regimens) 2. Feelings of immortality (disbelief that HIV can hurt them) Additional barriers for adolescents with HIV 1. For most, fear of disclosure of their HIV status to family and friends 2. For many, lack of adult or peer support to reinforce their adherence 3. For youth establishing independence, the conflict between needing to challenge authority figures and needing to depend on adult providers for support in taking HAART 4. For asymptomatic adolescents, difficulty accepting the implications of a serious illness when they still feel well 5. For some who still think concretely, difficulty grasping the concept that there is a connection between strict adherence to HAART and prevention of disease progression 6. For youth who live in the inner city, fear that they will die from violence, not AIDS 7. For homeless and transient youth, lack of refrigeration or a place to store medicines and lack of a daily routine

It is important to offer HIV/AIDS education in a language that the adolescent can understand. The information must be simple, accurate, and direct. In recent years, the federal government has put a lot of resources into abstinence only prevention education. Unfortunately, there has never been any research documenting the long-term benefit from abstinence-only prevention education. In fact, in one study abstinence-only education was shown to increase the level of sexual activity in youth. Abstinence-based education, which also provides information on how to reduce risk if sexually active, has been shown to delay the onset of sexual activity in some studies. The CDC (http://www.cdc.gov/hiv/pubs/hivcompendium/hivcompendium.htm) posts information on their Web site, including “Programs that Work” and a “Compendium of Effective Interventions to Reduce HIV.” They include only strategies that have been documented in the peer-reviewed literature as effective.

Kirby et al. (1994) reviewed the characteristics of school-based sexuality education programs. Effective programs were those that reflected the following key aspects:

• Used social learning theory as a foundation for program development.
• Included a narrow focus on reducing sexual risk-taking behaviors that may lead to HIV, STDs, or pregnancy.
• Provided basic, accurate information about the risks of unprotected intercourse and methods of avoiding unprotected intercourse through experiential activities designed to personalize this information.
• Included activities that address social or media influences on sexual behavior.
• Reinforced clear and appropriate values to strengthen individual values and group norms against unprotected sex.
• Provided modeling and practice in communication and negotiation skills.

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TABLE 31.8 Stages of Behavioral Change

Stage Definition Goal Objectives HAART, highly active antiretroviral therapy. Precontemplation Not thinking about starting HAART To shift the decisional balance regarding taking HAART from negative to positive To assist youth to · Become aware of the HIV disease process and the potential value of HAART · Understand their personal reluctance to taking HAART · Consider the possibility of taking HAART Contemplation Thinking about starting HAART in the next 6 months To complete the shift of decisional balance regarding taking HAART from negative to positive To enable adolescents to · Assess their psychosocial and behavioral readiness to begin HAART · Enhance their self-esteem · Overcome their misgivings about their ability to adhere to HAART Preparation Planning to begin HAART in next 30 days or has made a recent attempt to begin To maximize readiness to initiate HAART To assist adolescents to · Overcome the barriers and strengthen the supports in their lives for adherence to HAART · Enhance their capacity for adherence · Build skills for taking medicines successfully Action Has been taking HAART for less than 6 months To maintain successful adherence to HAART To assist teens to · Maintain the therapeutic alliance · Continue to solicit the support they need in their lives to remain adherent · Determine and monitor progress toward shared therapeutic goals Maintenance Has been taking HAART for 6 months or more To continue to maintain successful adherence to HAART To continue to assist teens to · Maintain the therapeutic alliance · Continue to solicit the support they need in their lives to remain adherent · Determine and monitor progress toward shared therapeutic goals

Many youths are not at school and are therefore not reachable through school programs. Street youth service workers who have regular contact with these teens may be effective AIDS educators. Involving peers in the education process can also be helpful. Principles of youth development have shown promise in the prevention of a variety of adolescent high-risk behaviors. These programs:

• Build competencies and self-efficacy (the belief that trying will result in success).
• Help families and communities send consistent messages about standards for positive behavior.
• Expand opportunities and recognition for youth who engage in positive behavior and activities.
• Provide structure and consistency in program activities.
• Last a minimum of 9 months.
• Offer opportunities for engagement of youth in the development and implementation of services.

Secondary

Since the onset of the HIV epidemic, prevention efforts in the United States have largely targeted persons at risk for becoming infected with HIV and have been aimed at reducing sexual and drug-using risk behaviors. Although efforts continue to include primary prevention of HIV transmission, new efforts have also been initiated that target HIV-positive individuals as targets of HIV prevention. Launched in 2003, the CDC's new initiative, Advancing HIV Prevention: New Strategies for a Changing Epidemic, aims to reduce barriers to early diagnosis of HIV infection and increase access to quality medical care, treatment, and ongoing prevention services for those diagnosed with HIV. Advancing HIV Prevention includes four main areas:

1. Incorporating HIV testing as a routine part of care in traditional medical settings

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2. Implementing new models for diagnosing HIV infections outside medical settings (e.g., rapid testing)
3. Preventing new infections by working with people diagnosed with HIV and their partners
4. Further decreasing mother-to-child HIV transmission

For physicians working with HIV-positive youth, it is important to assess, monitor, and attempt to influence potential risk behaviors while building a trusting provider/patient relationship in order to influence behavior change. The following key steps have been identified:

• Be persistent in efforts to engage and retain youth in services.
• Conduct a comprehensive interview at intake and update every 6 months (or as needed).
• Ask HIV-positive adolescents about their social life at every visit.
• Ask the same question in a variety of ways.
• Talk to youth about your concerns regarding their health.
• Explore the reasons for risky behavior and discuss common issues preventing youth from changing their behavior and disclosing their status (from Developing Responsive Prevention Programs Targeting Youth living with HIV: A Guide for Medical Providers).

Recommendations for Primary Care Physicians

Primary care practitioners should:

1. Obtain a sexual history and perform counseling on safer sexual behaviors.
2. Be able to perform pretest and posttest HIV antibody counseling.
3. Be able to co-manage individuals with HIV infections with HIV specialists (especially if the HIV care provider is not familiar with youth issues).
4. Know how to initiate the evaluation of common AIDS-related symptoms such as fever, lymphadenopathy, headache, and diarrhea.
5. Be familiar with community resources for adolescents in need of more intensive HIV prevention interventions.

Controlling Transmission

Blood and body fluid precautions should be consistently used for all patients, because medical history and examination cannot reliably identify all patients who are infected with HIV.

Web Sites

General Resources

http://AIDSinfo.nih.gov. DHHS HIV treatment guideline for Adolescents and Adults (Oct 2004), Use of antiretrovirals in pregnancy (June 2004).

http://www.ucsf.edu/hivcntr/Clinical_Resources/.

http://www.cdc.gov/hiv/pubs/hivcompendium/hivcompendium.htm. Information on HIV prevention: “Programs that Work”.

http://www.cdcnpin.org. National Prevention Information Network–Provides in-depth information about HIV/AIDS and STDs.

http://www.cdc.gov/HealthyYouth/YRBS/. Information on youth risk behaviors in 2005.

Information on Human Immunodeficiency Virus Counseling and Testing

http://www.cdc.gov/hiv. Guidelines for counseling and testing.

http://www.fda.gov/cber/products/testkits.htm. Licensed/approved HIV tests. Information on rapid testing including guidelines, sample consents, quality assurance, and CLIA application information. Consumer-oriented Treatment Information.

http://www.projinf.org/. Project Inform, with numerous articles on many aspects of HIV and AIDS.

http://www.thebody.com. The Body–An HIV and AIDS education site.

Occupational Exposure Issues and Information on Prevention of Human Immunodeficiency Virus and Other Occupational Needle-Stick Exposures

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm. CDC information on Postexposure prophylaxis.htm. CDC information on Postexposure prophylaxis.

http://www.cdc.gov/hiv/resources/guidelines/index.htm#occupational. Information on exposure to blood, preventing needlestick injuries, universal precautions.

http://www.cdc.gov/niosh/bbppg.html. Bloodborne Infectious Diseases, HIV/AIDS, Hepatitis B Virus, and Hepatitis CVirus.

http://www.cdc.gov/niosh/2000-108.html. Preventing Needlestick Injuries in Health Care Settings.

Information on Human Immunodeficiency Virus and Other Bloodborne Pathogens in Health Care Workers

http://www.cdc.gov/niosh/. Overview of State Needlestick Legislation (June, 2002).

Postexposure Prophylaxis

http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis.

http://www.cdc.gov/hiv/resources/guidelines/index.htm#occupational/. HIV postexposure prophylaxis registry.

National clinicians 24-hour hotline on postexposure prophylaxis (PEP)—telephone 1-888-HIV-4911, 1-888-448-4911 (project of the University of California at San Francisco).

Selected National Human Immunodeficiency Virus Resources

National Pediatric and Family HIV Resource Center, 30 Bergen Street, ADNC #4, Newark, NJ 07103, telephone 973-972 0410, fax 1-973-972-0399.

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Magic Johnson Foundation, 6167 Bristol Parkway, Suite 450, Culver City, CA 90230, telephone 1-310-338-8110, fax 1-310-338-8563.

AIDS Alliance for Children, Youth and Families, 1600 K St. NW Suite 200, Washington, DC 20006, telephone 1-202-785-3564, fax 1-202-785-3579.

Advocates for Youth Media Project, telephone 310-234-0454, fax 310-441-6553, website-http://www.themedia-project.com. Advocates for Youth–National Office, 2000 M St. NW Suite 750 Washington, DC 20036, telephone 1-202-419-3420. Website www.advocatesforyouth.org

AIDS Hotline, United States Public Health Service, telephone 1-800-342-2437 or 1-800-344-7432 in Spanish or 1-800-243-7889 for hearing-impaired persons. National Center for Youth Law–Adolescent Health Care Project, 405 14th Street, Suite 1500, Oakland, CA 94612, telephone 1-510-835-8098, fax 1-510-835-8099. Website www.youthlaw.org. AIDS Hotline, United States Public Health Service, telephone 1-800-342-2437 or 1-800-344-7432 in Spanish or 1-800-243-7889 for hearing-impaired persons. National Center for Youth Law–Adolescent Health Care Project, 405 14th Street, Suite 1500, Oakland, CA 94612, telephone 1-510-835-8098, fax 1-510-835-8099. Website www.youthlaw.org

CDC AIDS Prevention Information Clearinghouse, telephone 1-800-458-5231. CDC AIDS Prevention Information Clearinghouse, telephone 1-800-458-5231.

Pacific AIDS Education–Training Center: For help with a clinical HIV problem, telephone 1-800-933-3413.

World Health Organization, Appropriate Health Resources and Technologies Action Group–Essential AIDS Information Resources: For catalog, write to CH 1211 Geneva 27, Switzerland or telephone +41-22-791-4652.

Educational Resources

ETR Associates: Has comprehensive Health Education Resources for grades K-12. Includes HIV or AIDS, STDs, Drugs, Family Life Education, and Reproductive Health. Telephone 1-800-321-4407. Web site www.etr.org.

Project SNAPP–Skills and Knowledge for AIDS and Pregnancy Prevention: An 8-session curriculum and video for middle school students. From Division of Adolescent Medicine, Children's Hospital Los Angeles; published by ETR Associates, telephone 1-800-321-4407.

CDC AIDS Prevention Clearinghouse: Has lists of HIV or AIDS materials. Telephone 1-800-458-5231.

Advocates for Youth: Has fact sheets on youth sexuality including HIV or AIDS and many educational materials. Telephone 1-202-419-3420. Web site http://www.advocatesforyouth.org.

Alfred Higgins Production, Inc. (video): Teens At Risk: Breaking the Immortality Myth. Telephone 1-310-440-3232.

San Francisco Study Center (video): Between Friends. Telephone 1-415-626-1650.

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