Adolescents with HIV require careful, full-spectrum examination and care
In each issue, POZ publishes a different standard of care, a guide by which people with HIV and their care providers can make personal choices about health care regimes. HIV standards of care differ by region, treatment philosophy and patient population. The following guide to medical care for adolescents was prepared for POZ by Donna Futterman, M.D., director of the Adolescent AIDS Program (the nation's largest) at Montefiore Medical Center in Bronx, New York.
Adolescents represent a growing proportion of those newly infected with HIV. Recent studies have shown that a quarter of people with HIV in the U.S. were infected before age 22, and one to two teenagers become positive each hour. (In this group, people of color are twice their proportion of the overall population.) Yet adolescent HIV providers nationally report that few of these youth are receiving care since most remain untested and thus unaware of their diagnosis.
Adolescents' reactions to learning of HIV infection vary, depending on their stage of illness, developmental level, emotional maturity and life history. Caregivers can best help the newly diagnosed teenager by correcting misconceptions, alleviating guilt and providing emotional support. Establishing rapport with the teenager is key and can be promoted by addressing issues of confidentiality and when and if to disclose to parents, partners and friends.
Medical care alone is inadequate for most youths with HIV. It is important to formulate with the client a coordinated plan including medical treatment, psychosocial care and support, nutrition, recreation, work and school life and financial support. At Montefiore, our "one-stop shopping" setup (multidisciplinary staff plus specialist consultants to maximize services) is very helpful for adolescents, who find negotiating the medical/social-service system difficult and intimidating. Where such an approach is not possible, the primary care provider should carefully coordinate the client's medical treatment with other care programs.
Adolescents (even without HIV) are not well-served by the current U.S. health care system: Many teens have to rely on hospital emergency rooms for care, and nearly half of adolescent visits with doctors last less than 10 minutes -- inadequate time for good care, let alone risk-reduction education. For those youth with HIV, research on the ways their disease patterns and treatment responses differ from adults has only just begun; a federally funded study is enrolling in 10 cities. Hopefully, more care providers will incorporate adolescent-specific HIV prevention, screening and direct medical care for HIV positive youth into their practices.
Medical history and review of systems
Include questions about possible seroconversion illness (a flulike syndrome), fatigue, fever, night sweats, sinusitis, lymph node enlargements, skin lesions or rashes, weight loss or failure to gain during the pubertal growth spurt, and past or present illnesses, including sexually transmitted diseases (STDs), recurrent pneumonia and tuberculosis. Ask females about vaginal candidiasis, menstrual and pregnancy history. If the teen might have been infected perinatally, include history of parents' drug use, HIV-related risk behavior or known HIV infection.
Explore the teen's current living situation, work and school circumstances and psychological status (history of past or present depression, anxiety, suicidal thoughts or attempts, hospitalizations or treatments). Ask sexual questions carefully and clearly, using common terms and distinguishing sexual behaviors from orientation -- ask about the gender and number of sexual partners, rather than "Are you gay?" Ascertain safer sex practices, HIV disclosure and reproductive desires and plans. A complete drug history should deal with the full range of licit and illicit substances (including alcohol) and needle-sharing..
Physical exam should assess growth, nutritional status, vision, head, eyes, ears, nose, mouth, heart, lungs, abdomen and lymph nodes. Determine Tanner stage of sexual maturity, perform a rectal inspection and exam, do a pelvic exam on females who have had intercourse or are over 18 and a genital exam on all males. Perform standard exams of neurological function, mental status and abstract thinking; determine patient's level of cognitive understanding to facilitate treatment planning. Have lab tests done for immune function (but note the absence of normal values for HIV negative pubertal youth) and viral load measures, complete blood count, chemistry, as well as standard urinalysis, TB tests and STD screens (for syphilis, gonorrhea, chlamydia, hepatitis, trichomoniasis, vaginosis and candida). Pregnancy test if needed.
Pneumococcal vaccine, annual influenza shots (if condition allows), age-appropriate DT (diptheria and tetanus), MMR (measles, mumps and rubella) and HIB immunization, and hepatitis B vaccine for those without immunity.
Use HIV infection staging system of Centers for Disease Control and Prevention (CDC) to assess immune function and degree of symptomology, but recognize that the course of infection in adolescents has not yet been determined. Because adolescents need more support than adults, schedule more frequent appointments: Stage one (few or no symptoms, CD4 count above 500), every three months; stage two (mild symptoms, CD4 count 200?500), every one to three months -- more frequently when starting new treatments; stage three (symptomatic, CD4 counts under 200), at least monthly plus acute care as needed. Measure viral load per current adult guidelines. Staff should phone patients to remind them of appointments, and for referrals, give clear directions, travel fare or even send a staff person with them on the first appointment.
Use standard, dose-adjusted protocols for antiretroviral and prophylactic medication. Adolescents in Tanner Stages I and II should receive pediatric dose schedules; in Stages IV and V, adult dose schedules, regardless of age; and in Stage III, adult dose schedules with more careful monitoring. Enhance treatment adherence via simple instructions for taking medications and assistance in integrating medications into daily routine.
All youth with HIV need support: Encourage client to attend group sessions for support and coping ideas. Help client enroll in any needed entitlement programs and social services, including substance abuse treatment and psychotherapy. Runaway and homeless youth may need basic food and shelter. Provide careful education about the importance of safer sex and, if relevant, clean needle use.
Source: Donna Futterman, M.D., Director, Adolescent AIDS Program, Montefiore Medical Center, Bronx, New York, 1996.