Left Behind: Adolescents at Risk and Living with HIV

Transcription

1 Left Behind: Adolescents at Risk and Living with HIV The 2018 National Latino HIV and Hepatitis C Conference San Antonio, Texas May 20 th, 2018 Vincent Guilamo-Ramos, PhD, MPH, LCSW, RN, ANP-BC Professor, New York University Director, Center for Latino Adolescent and Family Health Core-Director, Center for Drug Use and HIV Research The Adolescent AIDS Program (AAP), Children s Hospital at Montefiore (CHAM)

2 Objectives I. Making a Case for Adolescent and Young Adult Health III. The HIV/AIDS Prevention and Treatment Continuum: Adolescents and Young Adults No Financial Disclosures to Report

3 I. Making a Case for Adolescent and Young Adult Health

4 Defining Adolescence and Young Adulthood Adolescence Early Adolescence Late Adolescence Ages 10 to 14 years Ages 15 to 19 years Young People YoungAdulthood Young Adulthood Ages 20 to 24 years Sawyer, S. M. et al. (2012). Adolescence: a foundation for future health. The Lancet, 379(9826),

5 Global Distribution of Young People (Age 10-24) 1.8 Billion Year Olds Worldwide 25% of Global Population Nearly 90% of Youth live in Low-Middle Income Countries U.S. 65.4mil year olds Pakistan 58.6mil China 278.6mil UNFPA. (2014). The State of World Population 2014: The Power of 1.8 Billion Adolescents, Youth and the Transformation of the Future. Brazil 50.9mil Sub- Saharan Africa 296mil India 355.3mil

6 Young People in the U.S. U.S million year olds 20% of Population UNFPA. (2014). The State of World Population 2014: The Power of 1.8 Billion Adolescents, Youth and the Transformation of the Future. Map from U.S. Census Bureau, Census Data Mapper. Median Age 44.2 to to to to to 36.4 Note: Overall U.S. Population million

7 Adolescents in the U.S. In 2014: 46% of adolescents were minorities and 1 in 5 Hispanic/Latino In 2050: 60% of adolescents are projected to be minorities and 1 in 3 Hispanic/Latino Department of Health and Human Services. (2018). The Changing Face of America's Adolescents.

8 Over Half of Latinos in the U.S. are Younger than 25 Years Age (years) Latino Age (years) U.S.-Born Latino Males Females Males Females Percent Percent Pew Research Center. Age and Gender Distribution for Race, Ethnicity and Nativity Groups: 2013.

9 Adolescence as a Developmental Period Social Adolescence is an important developmental period with implications for immediate and longterm outcomes in health and wellbeing. Cognitive Moral Identity Behavioral Emotional McNeely, C., & Blanchard, J. (2009). The Teen Years Explained: A Guide to Healthy Adolescent Development. WHO. (2018). Maternal, newborn, child and adolescent health: Adolescent development. Biological

10 Adolescent Health & Well-Being: A Life-Course Perspective Adolescence: a critical period of human development Complex interaction of different processes impact onset of heath behaviors to shape young people s future health and country social/economic welfare. I Early Life Disadvantage III Morbidity and Mortality IV Economic and Social Impact II Adolescent Health Problems and Risk Patton, G. C., et al. (2016). Our future: A Lancet commission on adolescent health and wellbeing. The Lancet, 387(10036),

11 Early Life Disadvantage: Adverse Childhood Experiences (ACEs) ACEs include temporary and chronic early experiences of trauma, neglect, and instability in the household Research suggests that the impact of adverse childhood experiences can be offset by experiences during adolescence Moore, K. A., & Ramirez, A. N. (2016). Adverse childhood experience and adolescent well-being: Do protective factors matter?. Child Indicators Research, 9(2), Robert Wood Johnson Foundation. (2013). The Truth About ACEs Infographic.

12 Adolescent Health Problems and Risk Mental Health Unintended Injuries and Violence Physical Activity/Sedentary Lifestyle Adolescent Factors in Adult Death & Disability Alcohol, Tobacco and Drug Use Nutrition/Obesity Sexual Behaviors i.e. unplanned pregnancy, STIs and HIV CDC. (2016). Youth Risk Behavior Surveillance United States, Office of Adolescent Health. (2018). A Picture of Adolescent Health.

13 Globally, nearly 70% of premature adult mortality are associated with processes that initiate in adolescence. Adult Mortality Sawyer, S. M. et al. (2012). Adolescence: a foundation for future health. The Lancet, 379(9826),

14 Economic and Social Impact Disengaged Youth Individuals who are not actively engaged in school or the workforce. In the U.S. approximately 6.7 million disengaged youth. 6.7 million disengaged youth represent a total social burden of $4.7 trillion over their lifetime. RootCause. (2012). Social Issue Report: Youth Career Development. Bureau of Labor Statistics, U.S. Department of Labor. (2018). Economic News Release: Table A-10. Selected unemployment indicators, seasonally adjusted.

15 Making a Compelling Case for Adolescent Health and Social Welfare I. Adolescence is a critical period for health and overall wellbeing II. Adolescence offers opportunities to correct early life disadvantage III.Adolescent health shapes adult morbidity and mortality IV.Adolescence has long-term economic and social impacts

16 II. Adolescent and Young Adult Sexual and Reproductive Health

17 Adolescents are Sexually Active Comprehensive Sex Education and Prevention Delay Sexual Debut Guttmacher Institute. (2017). Adolescent Sexual and Reproductive Health in the United States. Fact Sheet.

18 Sexual Partners During Adolescence 19% 20% 15% 9% 13% 10% 5% 5% 0% 9th 10th 11th 12th Had Sex with 4+ CDC. (2016). Youth Risk Behavior Surveillance United States, Morbidity and Mortality Weekly Report,65(6),

19 Record High of Youth STIs STI incidence among youth aged has hit a record high in 2016, rising for the 3 rd year in a row. CDC. (2016). Youth Risk Behavior Surveillance United States, Morbidity and Mortality Weekly Report,65(6),

20 Youth Bear Disproportionate Burden of STIs Youth ages make up roughly 25% of the sexually active population Youth account for 50% of the 20 million new reportable STIs in the U.S each year CDC. (2017). HIV Surveillance Report, 2016; vol. 28. CDC. (2013). Sexually Transmitted Infections Among Young Americans.

21 Prevalence of STIs CDC. (2016). CDC Fact Sheet: Reported STDs in the United States national data for Chlamydia, Gonorrhea, and Syphilis. Washington, DC: CDC.

22 Adolescents contract HIV: 1) Perinat ally or 2) Behaviorally Global Distribution of Adolescents Living with HIV In the United States, most adolescent HIV infections occur behaviorally Globally, the majority of adolescents were infected through perinatal transmission ~2.1 million Adolescents (10-19) living with HIV worldwide Number of Adolescents Living with HIV UNICEF. (2016). For Every Child End AIDs. Seventh Stocktaking Report, New York, NY: UNICEF. UNICEF. (2017). Children and AIDS: Statistical Update. UNICEF. (2018). Current Status + Progress. AIDS Info. (2018). HIV and Adolescents.

23 Global HIV Incidence among Youth There are 380,000 new HIV infections yearly in youth (15-24) Young people, ages 15-24, account for approximately 37% of new HIV infections Every hour, 26 new HIV infections occur among adolescents (ages 10-19) Sources: UNAIDS. (2017) Core Epidemiology Slides [Powerpoint slides]. UNICEF. (2016). Adolescents Living with HIV: Developing and Strengthening Care and Support Services. Image: 2009 outline-world-map.com

24 Gender Differences Globally, females make up two thirds of new infections in adolescents years old CDC. (HIV Surveillance Report, 2015; vol. 27. UNICEF (2018). Statistical Tables. In the U.S., more than 85% of new infections in adolescents years are males

25 Change in AIDS Mortality Between , By Age Group UNICEF. (2016). Adolescents Living with HIV: Developing and Strengthening Care and Support Services. UNICEF. (2016). Press Release. AIDS-related deaths have declined among all age groups except adolescents (aged years) AIDS is the #1 cause of death for adolescents (10-19) in Africa and the #2 cause of death for youth worldwide *Estimated

26 Youth Living with HIV in the U.S. An ESTIMATED 60,300 youth (13-24 years) are living with HIV 36,492 adolescents and young adults (aged 13-24) are living with diagnosed HIV in the U.S. Sources: CDC. HIV Surveillance Report, 2016; vol. 28. Map From AIDSVu.

27 New Diagnoses in the U.S. in 2016 N= 39,782 9,000 The median time between infection and diagnosis is roughly 3 years 7,964 8,000 6,776 7,000 5,701 6,000 5,000 4,242 4,000 3,334 3,156 3,000 2,000 Youth aged account for more than 20% of new HIV diagnoses 2,959 1,923 1,652 1,089 1, < Age at Diagnosis (years) Source: CDC. (2017). HIV Surveillance Report, 2016 (Vol. 28). Dailey A.F., et al (2017). Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays United States. MMWR. 66(47):

28 Youth Living with HIV in the U.S. AIDSVu. (2018). National Youth HIV/AIDS Awareness Day Data source: Centers for Disease Control.

29 HIV Diagnoses Among Youth in the U.S., by Race/Ethnicity and Sex, 2016 Young of colo overrep males r are resente d * CDC. (2018). Fact Sheet: HIV and Youth. *From 2011 to 2015

30 Incidence of HIV Diagnoses among MSM Youth of Color Men Who Have Sex With Men (MSM) accounted for 81% of youth newly diagnosed with HIV in 2016 Of those, 79% were Young Men of Color, primarily in the South 81% CDC. (2018). Fact Sheet: HIV and Youth. CDC. (2017). Fact Sheet: HIV Surveillance Report.

31 Multipurpose Prevention Technologies (MPTs) STIs HIV Sexual & Reproductive Health Family Planning Male & Female Condoms Topical vaginal gels HIV, HSV, pregnancy Chlamydia, gonorrhea, HIV, HPV, HSV, pregnancy HIV, HSV HIV, BV, HSV HIV, HPV, HSV Chlamydia, HIV, HSV HIV, BV, HSV Rectal gels Chlamydia, HIV, HSV Existing MPTs MPTs in Development Diaphragm + gel HIV, HPV, HSV, pregnancy Intravaginal Rings HIV, HPV, HSV HIV, pregnancy HIV, HSV, pregnancy HIV, HSV Chlamydia, gonorrhea, HIV, HSV, pregnancy Vaginal pills BV, gonorrhea, pregnancy HIV, HPV, HSV HIV, HSV Vaginal film HIV, HSV Guilamo-Ramos, V., Reading, M., Bowman, A.S., Perlman, D.C., & Barrett, S. (2018). Multipurpose Prevention Technologies: A Global Sexual and Reproductive Health Priority. Journal of the Association of Nurses in AIDS Care, 29(1), 6-9.

32 Summary of Adolescent SRH I. Majority of youth are sexually active-particularly as they age. II. STI rates among adolescents are disproportionately high. III. Youth represent a significant portion of new HIV infections globally and in the U.S. IV. Young Black and Latino MSM are particularly at risk for HIV V. Disparities are concentrated in specific geographic areas: South + States with high concentration of Latinos

33 III. The HIV/AIDS Prevention and Treatment Continuum: Adolescents and Young Adults

34 The Integrated Youth HIV/AIDS Prevention and Treatment Continuum HIV HIV + NYC Health. (2015). The Power of Quality Improvement [Powerpoint slides]. Horn, T. et al. (2016). Towards an integrated primary and secondary HIV prevention continuum for the United States: a cyclical process model. Journal of the International AIDS Society, 19(1), Smith, D.K., & Beltrami, J. (2013). A Proposed Framework to Monitor Daily Oral Antiretroviral Pre-Exposure Prophylaxis in the U.S. American Journal of Preventive Medicine, 44(1), S141-S146 HIV Testing

35 The HIV/AIDS Prevention Continuum HIV HIV + NYC Health. (2015). The Power of Quality Improvement [Powerpoint slides]. Horn, T. et al. (2016). Towards an integrated primary and secondary HIV prevention continuum for the United States: a cyclical process model. Journal of the International AIDS Society, 19(1), Smith, D.K., & Beltrami, J. (2013). A Proposed Framework to Monitor Daily Oral Antiretroviral Pre-Exposure Prophylaxis in the U.S. American Journal of Preventive Medicine, 44(1), S141-S146 HIV Testing

36 HIV Testing & Diagnoses Among Young People ~44% of youth aged living with HIV don t know they are infected. 10% 90% Nationwide (United States) Ever Tested Adolescents in High School (2015) 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 44.4% 55.6% Young people with HIV Diagnosed Undiagnosed CDC. (2016). Youth Risk Behavior Surveillance United States, Morbidity and Mortality Weekly Report,65(6), CDC. (2017). Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data United States and 6 dependent areas, HIV Surveillance Report. 22 (2), 1-63.

37 HIV Testing Guidelines for Adolescents and Young Adults The American Academy of Pediatrics Guidelines Indicate that HIV Testing Should Be Offered: At least once between years of age To sexually active adolescents To adolescents at high risk for HIV B. F. P. S. Workgroup & Committee on Practice and Ambulatory Medicine. (2017) recommendations for preventive pediatric health care. Pediatrics, e Moyer, V. A. (2013). Screening for HIV: US preventive services task force recommendation statement. Annals of internal medicine, 159(1),

38 The Power of Routine Testing for Youth Prolongs Life HIV treatment can improve quality of life and increase survival by many years/normal life span Reduces HIV Transmission HIV+ people who know their status reduce high-risk sex Lower viral loads from ARV also reduces transmission Can identify those needing Prep Preserves Resources Successful ARV reduces overall care costs for HIV+

39 Screening for HIV Risk Episode of unprotected anal or vaginal sex Injection Drug Use STI history High Risk Partners (HIV+) Risk Screening Network Risk HIV screening and prevention has historically been based on behavioral risk. There has been less focus on the context of an adolescent s sexual and drug network risk. Campbell, E.M. et al. (2017). Detailed Transmission Network Analysis of a Large Opiate- Driven Outbreak of HIV Infection in the United States. The Journal of Infectious Diseases, 216(9),

40 Social/Sexual Networks HIV adolescent in low risk network HIV Acute HIV + Established HIV + HIV adolescent in high risk network France, A.M. et al. (2018). Rapidly Growing HIV Transmission Clusters in the United States, [Powerpoint slides]. Oster, A. M. et al. (2018). Molecular epidemiology and the transformation of hiv prevention. JAMA, 319(16),

41 HIV Transmission Rates: National Average vs High Transmission Clusters HIV Transmission Rate in the United States HIV Transmission Rate in High Transmission Clusters Transmission rates in High Transmission Clusters are up to 33 times the national average Source: France, A.M. et al. (2018). Rapidly Growing HIV Transmission Clusters in the United States, [Powerpoint slides].

42 High Risk Social/Sexual Networks 27 Molecular HIV Surveillance Jurisdictions The CDC identified 60 rapidly growing transmission clusters ( 5 new diagnoses in the last 12 months) Clusters are located in 20 geographic locations throughout the U.S. Sources: France, A.M. et al. (2018). Rapidly Growing HIV Transmission Clusters in the United States, [Powerpoint slides]. Oster, A. M. et al. (2018). Molecular epidemiology and the transformation of hiv prevention. JAMA, 319(16), Texas Health and Human Services. (2017). Health Advisory: Rapidly Growing Clusters of Ongoing HIV Transmission in Texas. Bridger, C.M., San Antonio Metropolitan District. (2017). There are 16 clusters in Texas and 6 in San Antonio alone

43 Disparities in High Transmission Clusters Race/ Ethnicity Rapid Growth Clusters Slower Growing Clusters Latino 38% 27% White Black Other 26% 31% 31% 25% 41% 32% Age Rapid Growth Clusters Slower Growing Clusters <30 years 30 years 70% 58% 30% 42% Transmission Category Rapid Growth Clusters Slower Growing Clusters 59% MSM 83% Heterosexual 15% Other/ Unidentified 4% 12% 23% Source: France, A.M. et al. (2018). Rapidly Growing HIV Transmission Clusters in the United States, [Powerpoint slides].

44 Adolescent Trials Network ATN Study Sites Montefiore Medical Center (NY) The Fenway Institute (MA) Children s Hospital of Philadelphia (PA) Johns Hopkins University (MD) Children s National Medical Center (DC) Cook County Hospital (IL) Wayne State University (MI) Children s Hospital of Los Angeles (CA) University of California, San Francisco (CA) University of Colorado Denver (CO) St. Jude s Research Hospital (TN) Tulane Medical Center (LA) University of South Florida (FL) University of Miami (FL) Baylor College of Medicine (TX) Purpose: to conduct multi-site research on HIV-infected and HIV-at-risk youth Adolescent Trial Network (ATN). (n.d.). Publication.

45 PrEP Efficacy, Safety, and Adherence for Youth ATN 110 (N=200) Young MSM seroconversions through week 48 ATN 113 (N=79) Young MSM seroconversions through week 48 No drug resistance found Adherence was good overall but varied by race/ethnicity (e.g.. AA) PrEP was well tolerated with minimal safety concern Substantial drop-outs: need for ongoing retention/engagement strategies Adherence dropped across both studies after week 12 indicating a need to address longterm prevention adherence among youth Hosek, S. et al. (2016) An HIV Pre-Exposure Prophylaxis Demonstration Project and Safety Study for Adolescent MSM ages in the US (ATN 113). AIDS ST International AIDS Conferences. Hosek, S. et al. (2017). An HIV Preexposure Prophylaxis Demonstration Project and Safety Study for Young Men who HaveSex with Men in the United States. J Acquir Immune Defic Syndr, 7491),

46 Disparities in PrEP Uptake: Youth ~700,000 youth in the U.S. could benefit from PrEP Over 20% of new HIV diagnoses in 2016 were among Youth, yet only 11% of all PrEP users were younger than 25 years. AIDSVu. (2018). National Youth HIV/AIDS Awareness Day CDC. (2017). HIVin the United States: At A Glance. Allen, E. (2018). SAHM Annual Meeting: Abstracts of Platform Research Presentations (1-34): Estimated Prevalence of Adolescents and Young Adults with Indications for HIV Pre-exposure Prophylaxis in the United States, Journal of Adolescent Health, 62, 1-19.

47 PrEP Use by Race/Ethnicity There were over 145,000 PrEP users in the U.S. in 2017 Total PrEP Use by Race/Ethnicity September 2016 Estimated New HIV Infections by Race/Ethnicity 2015 PrEP use among African Americans and Hispanics is disproportionately low relative to the rate of new HIV infections Mera Giler, R., Magnuson, D., Trevor, H., Bush, S., Rawlings, K., & McCallister, S. (2017). Changes in truvada (TVD) for HIV pre-exposure prophylaxis (PrEP) utilization in the United States: ( ). [PowerPoint Slides].

48 FDA Approval for Truvada for Youth Based on ATN Trial 113 Gilead Sciences. (2018). Press Release: U.S. Food and Drug Administration Approves Expanded Indication for Truvada (Emtricitabine and Tenofovir Disopeoxil Fumarate) for Reducing the Risk of Acquiring HIV-1 in Adolescents.

49 PrEP + Condoms + Adherence/Retention Support Condoms PrEP Adherence/Retention Support Young people need comprehensive individualized wrap around services to cover all facets of their HIV prevention and adherence needs

50 97% of sexually active adolescents (15-19 years) report ever using a condom, but only 43% of high school students used a condom the last time they had sex Condoms 1 2 Abma, J., Martinez, G., Division of Vital Statistics. (2017). Sexual Activity and Contraceptive Use Among Teenagers in the United States, National Health Statistics Report, CDC. (2016). Youth Risk Behavior Surveillance United States, Morbidity and Mortality Weekly Report,65(6), CDC (2016). Fact Sheet: It s Your Future. You Can Protect It. Effective as protection against HIV if youth: Use condoms correctly every time they have sex Have the knowledge and skills to handle commonly occurring condom use problems and errors Such as: Incorrect use, premature removal or delayed use

51 Comprehensive Prevention for Youth Barrier Methods/Condoms Social Determinants Youth Friendly Health Services Stigma Reduction Horn, T. et al. (2016). Towards an integrated primary and secondary HIV prevention continuum for the United States: a cyclical process model. Journal of the International AIDS Society, 19(1), Sexual & Reproductive Health Services Substance Use Services/Harm Reduction Mental Health/Behavioral Health CDC. (2018). Comprehensive HIV Prevention Services. Centers for Disease CDC. (2014). Fact Sheet: Preexposure Prophylaxis (PrEP) for HIVPrevention.

52 The Youth HIV/AIDS Treatment Continuum HIV HIV + NYC Health. (2015). The Power of Quality Improvement [Powerpoint slides]. Horn, T. et al. (2016). Towards an integrated primary and secondary HIV prevention continuum for the United States: a cyclical process model. Journal of the International AIDS Society, 19(1), Smith, D.K., & Beltrami, J. (2013). A Proposed Framework to Monitor Daily Oral Antiretroviral Pre-Exposure Prophylaxis in the U.S. American Journal of Preventive Medicine, 44(1), S141-S146 HIV Testing

53 Youth HIV/AIDS Care Continuum: Data Sources Estimates National Surveillance Convenience Sampling Zanoni, B.C, & Mayer K.H. (2014). The Adolescent and Young Adult HIV Cascade of Care in the United States: Exaggerated Health Disparities. Aids Patient Care and STDs, 28(3), CDC. (2017). Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data United States and 6 dependent areas, HIV Surveillance Report. 22 (2), Lally, M. A. et al. (2018). HIV Continuum of Care for Youth in the United States. JAIDS Journal of Acquired Immune Deficiency Syndromes, 77(1),

54 Estimated Youth HIV Care Cascade 78,949 (100%) Youth Aged ,979 (40%) 19,824 (25%) 8,723 (11%) 4,449 (6%) Zanoni, B.C, & Mayer K.H. (2014). The Adolescent and Young Adult HIV Cascade of Care in the United States: Exaggerated Health Disparities. Aids Patient Care and STDs, 28(3),

55 CDC HIV Surveillance Reports care cascade data for youth (13-24 years old) CDC. (2017). Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data United States and 6 dependent areas, HIV Surveillance Report. 22 (2), 1-63.

56 CDC HIV Care Continuum Surveillance CDC. (2017). Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data United States and 6 dependent areas, HIV Surveillance Report. 22 (2), Slide taken from Futterman, D., Adolescent AIDS Program. (2018). Undetectable=Untransmittable: Opportunities & Challenges [PowerPoint slides].

57 HIV Continuum of Care for Youth in the U.S. Michelle A. Lally; Jacob J. van den Berg; Andrew O. Westfall; Bret J. Rudy; Sybil G. Hosek; J. Dennis Fortenberry; Dina Monte; Mary R. Tanney; Elizabeth J. McFarland; Jiahong Xu; Bill G. Kapogiannis; Craig M. Wilson The Adolescent Medicine Trials Network forhiv/aids Interventions (ATN) Purpose: To evaluate the effectiveness of primary and ongoing treatment for HIV infected young people at various ATN sites across the U.S. Methods Dates: February February 2016 Study site: 14 ATN clinics across the U.S. Inclusion Criteria: Behaviorally Infected with HIV Receiving or planning to receive care at any participating ATN site English Speakers Lally, M. A. et al. (2018). HIV Continuum of Care for Youth in the United States. JAIDS Journal of Acquired Immune Deficiency Syndromes, 77(1),

58 Sample Demographics Age 3.0% 12.6% N= 467 Gender Race/Ethnicity 3.4% 7.3% 1.3% 20.6% 17.3% 57.4% 26.8% 79.4% 70.7% Male Female Black White Did Not Identity Hispanic Other Lally, M. A. et al. (2018). HIV Continuum of Care for Youth in the United States. JAIDS Journal of Acquired Immune Deficiency Syndromes, 77(1),

59 Adolescent Trials Network: HIV Continuum of Care for Youth 86% Engaged in Care 98% prescribed ART Viral Load Among Engaged Youth 81% 89% 59% VL <200 VL <200 VL <200 50% of 100% of Time Time Sustained Viral Suppression Lally, M. A. et al. (2018). HIV Continuum of Care for Youth in the United States. JAIDS Journal of Acquired Immune Deficiency Syndromes, 77(1),

60 Viral Load of Youth Seen at AAP Slide taken from Futterman, D. Adolescent AIDS Program. (2018). Undetectable=Untransmittable: Opportunities & Challenges [PowerPoint slides].

61 Differentiated Care for Youth Adapted from Differentiated Care. (2018). Accessed online at:

62 Final Thoughts: Clinical Issues in Caring for HIV+ Youth

63 Treatment Issues Adherence/Viral Load Suppression Disclosure Ongoing Risk of Transmission Reproductive Health Behavioral Health and Substance Abuse Transition to Adult Care

64 Youth Transitioning In/Out of Adolescent Care Facilitate transition from supportive to increasingly independent Responsibilities from parent/provider to patient Promote growth, self-expression and personal decision making Choose adult clinic with multidisciplinary services Can be challenging for youth to leave trusted providers Potential for discomfort in the presence of adult patients Consider phased transition (case manager, specialty appointments)

65 LGBT Youth Same developmental tasks as all youth and most grow to be healthy adults Must develop healthy, integrated identity amidst negative stereotypes/prejudice, often without family support More susceptible to emotional distress, psychiatric morbidity, multiple disparities, stigma, abuse, violence, isolation

66 Slide from Futterman, D., Adolescent AIDS Program. (2018). HIV and Adolescents [PowerPoint slides]. You can t be gay, you ll shame the family

67 Challenges for Transgender Individuals/Youth Increased Risks for Transgender Youth: Social rejection, stigma, and violence Discrimination from others- including, health and social service providers Invisible status - Difficulty accessing prevention, education, employment, and housing Sharing needles for hormone treatment or body modification CDC. (2018). HIV and Transgender People. WHO. (2015). HIV and Young Transgender People. Clark, H. et al. (2017). Diagnosed HIV Infection in Transgender Adults and Adolescents: Results from the National HIV Surveillance System, AIDS and behavior, 21(9),

68 Slide from Futterman, D., Adolescent AIDS Program. (2018). HIV and Adolescents [PowerPoint slides].

69 Thank You! Vincent Guilamo-Ramos, PhD, MPH, LCSW, RN, ANP-BC