April 1997
SAN FRANCISCO – Because adolescents represent an increasing part of the population with HIV, physicians who treat adolescents should make risk assessment a part of their clinical interviews, said Donna Futterman, MD, at a recent Society for Adolescent Medicine meeting held here.
It is important for pediatricians working with adolescents and their families to develop skills to routinely incorporate HIV counseling and offer of testing with consent into their clinical interviews, as well as to be aware of how to conduct primary and secondary risk-reduction interventions and their relative efficacy. Pediatricians should also incorporate medical and psychosocial care for HIV-positive youth into their practice, said Futterman, director of the Adolescent AIDS Program at Montefiore Medical Center, Bronx, New York.
A complete and accurate risk-assessment interview establishes the parameters of confidentiality; uses a mixture of open-ended questions and specific questions; asks questions that acknowledge the range of sexual behaviors; asks adolescents to clarify unfamiliar language; and asks explicit questions, according to an article published in International Pediatrics, written by Brenda Chabon, PhD, department of pediatrics, Albert Einstein College of Medicine, and Futterman.
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Despite the epidemiological utility of grouping transmission categories and describing high-risk groups, at-risk adolescents may be missed if a physician relies solely on risk-behavior assessment, which makes these measurements important, Futterman said.
This is where knowing the distinction between sexual identity and sexual behavior plays an important part. "Some males who have sex with males may identify themselves as straight, gay or bisexual," she explained.
Normal behaviors of adolescents often place them at risk for HIV infection, but certain subgroups are at an even higher risk because of increased likelihood of exposure to the virus. These subgroups include adolescents who are gay, runaways and homeless, sexually abused, drug users and sexually active adolescent girls who live in high prevalence communities.
"Males who have sex with males are the second leading group of adolescents with AIDS, and the leading behavior for new cases of infection among males," Futterman said.
HIV counseling and testing for adolescents serves many purposes for the youths, and allows physicians a chance to play an important role in helping teenagers address their risk for and concerns about HIV.
Pretest counseling is designed to help adolescents make an informed decision about learning their HIV status and to provide an opportunity to identify psychological interventions that promote preventative health behaviors, whether or not the adolescent decides to be tested.
Risk assessment is also an integral part of counseling because it allows adolescents to understand their personal risk for HIV infection. If the adolescent's emotional or physical state is unstable, consider deferring the test until those issues are addressed, Futterman said.
To understand the issues related to risk reduction for a particular adolescent, it is important to know several facts including: age of first sexual intercourse, age and sex of initial and subsequent partners, sexual orientation, number of sexual partners and experience with survival sex – the exchange of sex for money, food, drugs or shelter.
Counseling before and after HIV/AIDS testing, regardless of the results, is important and can address several other issues present among gay youth. These issues may include violence at school or at home, "coming out" and peer pressure. An adolescent requesting an HIV test may also be seeking help for other issues such as breaking up a relationship, substance abuse or depression.
"Gay kids are prone to higher rates of suicide," said Miriam Kaufman, MD, division of adolescent medicine, Hospital for Sick Children, Toronto.
Negative results must be adequately explained. The patients commitment to protect themselves and others should be assessed, and patients must fully understand that negative results do not give them a license to continue risky behavior.
The adolescent should be encouraged to discuss HIV with their partner and to bring the partner in for counseling and testing.
Notification of positive results should be carefully handled. A supportive phrase describing the exact meaning of a positive test combined with treatment suggestions may help the adolescent feel more comfortable. Before the session is over, ensure the youth is emotionally stable and arrange for medical and psychosocial follow-up care.
A provider should understand that the adolescent's family, friends and others in the community may reject, stigmatize and discriminate against the patient.
Adolescents with AIDS have been reported from 45 states and territories, but most (54%) are in Florida, New York, California, Texas, New Jersey and Puerto Rico.
A complete and accurate risk assessment interview:
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