The Food and Drug Administration (FDA) recently expanded the approval of Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis (PrEP) against HIV for use in at-risk adolescents. This is an exciting milestone that sets a global precedent for increasing adolescents’ access to this critical HIV preventive measure. Hopefully, it will also guide other countries’ decision-making to introduce PrEP to this highly vulnerable population and spur increased focus on improving quality of care among adolescents.
Globally, HIV preventive efforts has been increasingly focused on adolescents due to high rates of HIV in this group; in 2015, an estimated 29 adolescents acquired HIV every hour and adolescents are the only age group in which AIDS-related deaths have not decreased. Subgroups of adolescents—gay and bisexual men, male and female sex workers, and adolescent girls—bear an even greater burden of HIV.
Thanks to federally funded programs domestically (e.g., Secretary’s Minority AIDS Initiative Fund) and internationally (e.g., President’s Emergency Plan for AIDS Relief [PEPFAR]), we are now gaining a better understanding of what works to improve HIV services for young people. The FDA approval of PrEP for adolescents indicates an opportunity for increased investment in improving the quality of health care for adolescents to ensure they can actually access and adhere to PrEP.
Adolescents—both in the United States and the world over—are reluctant to access sexual and reproductive health and HIV preventive services due to perceived and experienced poor quality of care. For example, adolescents have reported experiencing stigma and discrimination (e.g., criticized for having sex or having a certain sexual orientation), poor provider-adolescent communication, no privacy and confidentiality, and other issues when seeking services. In fact, recent research shows that providers with negative attitudes toward adolescents engaging in sexual intercourse were not even willing to prescribe PrEP to them.
In the age of PrEP, we have an opportunity and obligation to improve services for adolescents in the United States and around the world. In looking at some of the latest research, where should we prioritize our efforts?
Engage adolescents to exercise their rights and assess their risks. Adolescents must be an equal partner in their health; they should be actively involved in designing the spaces where they seek care. Adolescents require comprehensive sexuality education and information about their rights to access sexual reproductive health services. Additionally, some of those most susceptible to HIV do not perceive themselves at risk for HIV, highlighting the need for tools that will help adolescents assess their personal risk for HIV and take the necessary steps to avert becoming infected.
Regularly train health staff, from administrators to providers, to provide adolescent-centered care. Adolescents are diverse in their sexual identity, preferences and behaviors. Everyone that an adolescent encounters during a clinical visit should receive stigma reduction and cultural competency training. Providers in particular must be equipped to tailor their services to the needs and preferences of each adolescent they serve. This includes designing and providing providers with appropriate PrEP counseling strategies for adolescents. The Population Council’s work in Bangladesh has shown that provider stigma reduction training can positively impact the quality of care provided to adolescents.
Reduce barriers for adolescents by integrating PrEP into general health and sexual and reproductive health services. Long waits, long distance to travel for services, and high costs keep adolescents from services. Early research on the introduction of PrEP in Tanzania shows that stigma associated with taking PrEP is a major concern for adolescents and that they would like to access PrEP where they typically seek care or in other safe places in their community. Therefore, all provider types, including primary care and specialty care providers, should be prepared to provide PrEP. Adolescent-only hours at clinics or adolescent clinics, school-based health centers and community-based organizations are ways to improve access to PrEP. Furthermore, some of the most vulnerable adolescents rely on the Children’s Health Insurance Program (CHIP) or Planned Parenthood to access HIV preventive services. Proposed funding cuts to or proposed restrictions on these programs would be detrimental to adolescents’ PrEP access.
Invest in high quality and practical research to identify strategies that increase uptake and adherence to PrEP among adolescents. Adherence is key for PrEP to work, but most PrEP trials to date show that adherence to daily PrEP is more challenging for younger populations. This underscores a critical need to identify more effective strategies to support adherence in adolescents.
The FDA’s decision to approve PrEP for adolescents is great, but it is just a start. Now it is time for adolescents, health care providers, researchers and community advocates to work together to ensure adolescents can actually access and adhere to PrEP in the United States, and around the world.
Nanlesta Pilgrim, PhD, MPH is an adolescent social and behavioral researcher at the Population Council. She conducts research on how to effectively introduce pre-exposure prophylaxis (PrEP) to populations at risk for HIV.