Teens taking antiretroviral meds share with adults all the problems of keeping HIV in check long-term—sweating out side effects and adhering to a precise pill-popping schedule they must stick with day in and day out for the long haul. But for many adolescents, yet another trouble is the real biggie: Being different from their friends.

Among teenagers, anything that makes you unlike your buddies is a bad thing. So gulping gobs of pills several times a day—which will certainly make someone stand out from the crowd—is tough. And that may also out you as HIV positive—even tougher.

The alternative—hiding HIV status and the meds that go with it—is also more difficult for teenagers. Neal Hoffman, MD, medical director of the Adolescent AIDS Program at Montefiore Medical Center in New York City, says: “Their worlds are smaller. Try to figure out how to incorporate meds into the life of a kid who’s on the bus at 7:30 am and doesn’t get home until evening because of after-school activities.”

In the end, it seems like a lot of teens can’t figure it out. Hoffman says that even the kids who are willing to try the meds often fail to sustain their regimens for more than a few weeks. The key, he believes, is careful preparation: “Day One is not telling these teens that they have to start taking drugs now. Instead, it’s the beginning of a series of sessions teaching them what the meds may do for them, what they look like, how taking them can be integrated into their lives, and so on.”

Hoffman notes that such preparation is particularly important for younger teens who may find it very difficult to do an accurate risk/benefit analysis. “It’s hard for them to see that taking meds now—with all the side effects and problems that may come with them—is worth it because of the possible future benefit of avoiding disease progression and illness. And some feel that not taking the pills will magically mean that they don’t really have the disease.”

The high rate of  teen nonadherence has taught Hoffman and his colleagues that what’s key is helping adolescents gain skills and confidence in life management and self-care. With that often comes a belief in their ability to stick to their drug regimens. So support groups and buddy systems are an integral part of the Montefiore program. For teens, seeing how their friends do it and getting that crucial peer support may be a big boost toward success—and, as with adult groups, a great way to deliver the latest info on AIDS care.