Lawrence J. D'Angelo

Health Care Transition for Youth Living With HIV/AIDS

There are ∼1 million people in the United States living with HIV/AIDS, and >50 000 new infections occur each year. With an estimated 13% of all new infections occurring among young people aged 13 to 24 years and an increasing number of perinatally infected youth surviving to adulthood, there is now an increasing need to transition both perinatally and behaviorally infected youth to the adult health care setting. Recently, pediatric providers and professional societies have prioritized the development of transition programs for adolescents with chronic disease to address the many challenges these youth face in the process. Although multiple position papers have called for continuous, coordinated, culturally appropriate, compassionate, family-centered transition programs for youth with special health care needs and have recognized the need for evidence-based models, few data exist on what strategies are most effective. To date, published data on health care transition for HIV-positive youth are limited and include only 2 studies, which considered behaviorally infected youth. In this state-of-the-art review, we discuss the unique transition challenges to consider for this population, including socioeconomic and health insurance status, the special role of the pediatric or adolescent provider as family, stigma and disclosure issues, cognitive development and mental health issues, medication adherence, and sexual, reproductive, and gender health concerns. Future research will need to include the experiences of transition in low-resource settings and examine clinical outcomes and factors that may predict success or failure of the transition process.

A STD/HIV prevention trial among adolescents in managed care

Objective. To determine if sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, risk assessment, and education tools provided as part of office-based primary care reduce adolescent risky sexual behaviors. Design. A randomized intervention trial with 3- and 9-month follow-up. Setting. Five staff-model managed care sites in Washington, DC (n = 19 pediatricians). Patients. Consecutive 12- to 15-year-olds receiving a general health examination; 81% minority. Participation rate = 215/432 (50%). Nine-month follow-up rate = 197/215 (92%). Intervention. Audiotaped STD risk assessment and education about staying safe (safer = condoms, safest = abstinence). Main Outcome Measures. Adolescent-reported sexual intercourse and condom use. Results. More intervention adolescents reported pediatrician discussion on 11/13 sexual topics. Although more vaginal intercourse (odds ratio [OR] = 2.46, 95% confidence interval [CI] = 1.04–5.84) was reported in the intervention group at 3 months, this was not true of overall sexual intercourse (OR = 1.55, 95% CI = .73–3.32). More sexually active adolescents reported condom use in the intervention group at 3 months (OR = 18.05, 95% CI = 1.27–256.03). At 9 months, there were no group differences in sexual behaviors; however, more signs of STD were reported by the control (7/103) than the intervention group (0/94). Conclusions. STD risk assessment and education tools administered in a single office visit facilitated STD/HIV prevention education. Any impact on sexual activity and condom use was short-lived. Further research is needed to develop brief, office-based sexual risk reduction for young adolescents.

Virologic and Immunologic Outcomes after 24 Weeks in HIV Type 1-Infected Adolescents Receiving Highly Active Antiretroviral Therapy

BACKGROUNDnAdolescents represent the fastest growing demographic group of new human immunodeficiency virus (HIV) infections in the United States. At present, there is little information available about their response to therapy.nnnMETHODSnWe studied 120 adolescents infected via high-risk behaviors who began receiving highly active antiretroviral therapy (HAART), to determine their virologic and immunologic response to therapy.nnnRESULTSnSubjects were enrolled at 28 sites of the Pediatric Acquired Immunodeficiency Syndrome Clinical Trials Group. After 16-24 weeks of HAART, 59% of subjects had reproducible undetectable virus loads, according to repeat measurements (virologic success). As enumerated by flow-cytometric analysis, increases in levels of CD4 helper cells (both naive and memory) and decreases in levels of CD8 suppressor cells were observed. Partial restoration of some immunologic parameters for patients who did not achieve virologic success was also observed, but to a more limited extent than for adolescents with virologic success. Adherence to HAART was the only predictor of achieving undetectable virus loads.nnnCONCLUSIONSnAdolescents have the capacity to improve their immunologic status with HAART. Lower than expected success in virologic control is related to lack of adherence, and efforts to improve treatment outcome must stress measures to assure adherence to medication.

A Family Group Approach to Increasing Adherence to Therapy in HIV-Infected Youths: Results of a Pilot Project

This paper describes the development of a novel, pilot program in which a combined family group and peer approach were used to increase adherence to antiretroviral therapy in HIV-infected youths. Twenty-three HIV-positive youths, 15-22 years of age and 23 family members or treatment buddies participated in one of three 12-week programs. The intervention had six biweekly family and youth education sessions and six biweekly youth-only education sessions. Devices to increase adherence to antiretroviral therapy such as pill boxes, calendars, and watch alarms were introduced at youth-only sessions. Eighteen of the 23 youths completed a group. Ninety-one percent of youths self-reported increased adherence to medications after completion of a group. Four participants experienced a one-log reduction in viral loads to undetectable levels during the intervention. Two participants continued to decline antiretroviral medications at the end of the intervention and demonstrated no decrease in viral load. Participants tested five devices and rated the multiple alarm watch as the best aid for improving adherence to medication. Family/treatment buddies rated the overall program as highly helpful, citing social support as most valuable. An unanticipated benefit was an increase in other health behaviors, including medical and dental appointments, hepatitis B and influenza immunizations, and referrals to mental health and substance abuse treatment.

Predictors of Antiretroviral Medication Adherence Among a Diverse Cohort of Adolescents With HIV

PURPOSEnTo compare prevalence and describe predictors of antiretroviral treatment adherence among adolescents with HIV acquired perinatally (PIY) or through risk behaviors (BIY).nnnMETHODSnData were obtained from the baseline assessment of Adolescent Impact, an intervention for HIV-infected adolescents receiving care in three U.S. cities. Patients self-reported missed medication doses as well as medication factors, HIV knowledge, disclosure, substance use, mental health, and social support through face-to-face or computer-assisted interviews.nnnRESULTSnOf 104 participants, 68 (65.4%) reported full adherence. Compared with BIY, PIY were younger, had greater HIV disease severity, and had more structural supports. Adjusting for transmission mode (PIY vs. BIY), nonadherence by self-report was associated with higher viral load (VL) (adjusted odds ratio [AOR] = 1.5, confidence interval [CI] = 1.03, 2.18). Nonadherent adolescents were significantly likely to have had AIDS, discussed HIV disease with providers, reported difficulty with medication routine, experienced internalizing behavior problems, and used drugs. In multivariate analyses, independent predictors of nonadherence included acquiring HIV behaviorally (AOR = 4.378, CI = 1.055, 18.165), ever having AIDS (AOR = 4.78, CI = 1.31, 17.49), perceiving difficult medication routine (AOR = 1.84, CI = 1.07, 3.16), discussing disease indicators with provider (AOR = 4.57, CI = 1.74, 11.98), and missing doses because of forgetting (AOR = 2.53, CI = 1.29, 4.96). Adjusting for transmission mode, detectable VL was associated with lower recent CD4(+) lymphocyte counts, discussing disease indicators with providers, and missing doses because of forgetting or being depressed. Low recent CD4(+) lymphocyte counts (AOR = .988, p = .024) but fewer HIV symptoms (AOR = .466, p = .032) and missing doses because of forgetting (AOR = 1.76, p = .05) were independently associated with detectable VL in multivariate analysis.nnnCONCLUSIONSnDespite differences between groups, nonadherence was associated with severity of illness, difficult medication routine, and forgetfulness. Beyond individual needs, both groups of adolescents had suboptimal adherence and would benefit from simplified medication routines and organizational skills.

A profile of human immunodeficiency virus—Infected adolescents receiving health care services at selected sites in the United States

OBJECTIVEnTo determine the demographic/clinical profile of human immunodeficiency virus (HIV)-infected adolescents in care at selected sites.nnnMETHODSnWe mailed surveys requesting prevalence data from physicians in government-funded HIV research and care programs on HIV-infected youth (10-21 years) receiving care.nnnRESULTSnA total of 49% responses yielded information on 978 subjects. Vertical, blood, and sexual were predominant transmission modes. Three-quarters were of an ethnic/racial minority; 50% were female. The earliest median CD4 count was 0.467 x 10(9)/liter (467/microliter). Percent asymptomatic varied by transmission: vertical (16%), blood products (40%), male-male sexual (67%) and female-male sexual (M:73%) (F:74%). Clinical indicated Pneumocystis carinii pneumonia prophylaxis was differentially prescribed: vertical (96%), blood (89%), and sexually (male-male-47%) (female-male: M: 36% and F: 56%). Of these youth 78% are not represented in national AIDS case data.nnnCONCLUSIONSnExamination of numerator data from selected sites indicates three transmission-driven adolescent HIV epidemics with different characteristics. Minority youth are disproportionately represented; many vertically infected infants are surviving to adolescence; sexual activity is a significant transmission avenue. HIV-infected youth appear to enter care with considerable immunosuppression. Clinical profiles and treatment patterns appear to differ by transmission mode. Further study is needed on adolescent HIV disease progression and determinants of access to care and treatment.

Guidelines for adolescent participation in research: current realities and possible resolutions.

morbidity in adolescents from drug abuse, preventable injury, violence, and unprotected sexual activity continues to increase. Moreover, with AIDS this generation of adolescents is threatened by an epidemic of potentially devastating proportions. This epidemic requires that the origins of risk-taking behaviors be understood in appropriate developmental and behavioral terms and that every opportunity be seized to learn what programs are effective in adolescent risk reduction and health mainte-

Atypical hemolytic uremic syndrome in human immunodeficiency virus-1-infected children

Abstract. We describe the clinical and pathological findings of the hemolytic uremic syndrome (HUS) in two children with human immunodeficiency virus (HIV) infection. Both patients presented with microangiopathic hemolytic anemia, thrombocytopenia, and subsequently developed renal failure. The diagnosis of HUS was confirmed by renal histopathology in both patients. None of these children presented with bloody diarrhea, evidence of circulating antibody response to Escherichia coli O157 lipopolysaccharide, or other known risk factors for HUS, except for the presence of HIV infection. Each patient was treated with intravenous plasma infusion and renal replacement therapy. Their clinical course was characterized by non-oliguria and lack of significant hypertension throughout the acute phase of the disease. Despite these favorable clinical parameters, both patients developed end-stage renal failure. The etiology of this atypical HUS characterized by poor renal survival remains unknown and the role of HIV infection in its pathogenesis, although possible, is unclear.

HIV infection and AIDS in adolescents: a position paper of the society for adolescent medicine

This article focuses on HIV infection and AIDS in adolescents and its prevention. It briefly reviews the epidemiology of AIDS and HIV infection in adolescents; the clinical profile medical care and access to services of HIV-infected adolescents in high-risk situations; and HIV counseling and testing. Also presented are substantial recommendations on prevention that are strategic to epidemiology clinical profile and medical care HIV counseling and testing special populations and research.

Identification of HIV-Infected 12- to 24-Year-Old Men and Women in 15 US Cities Through Venue-Based Testing

OBJECTIVEnTo test whether venue-based testing could identify human immunodeficiency virus (HIV) infection in US youth, 12 to 24 years of age, who were otherwise not aware of their infection. Racial and ethnic minority women and men who have sex with men (WSM and MSM) compose the majority of new HIV cases among adolescents and young adults.nnnDESIGNnCross-sectional study.nnnSETTINGnSelected venues in communities surrounding the 15 Adolescent Trials Network for HIV/AIDS Interventions (ATN) clinical sites over a 3-month period.nnnPARTICIPANTSnAt each venue, ATN sites recruited 20 to 30 English- or Spanish-speaking at-risk youth (12 to 24 years of age), resulting in a total of 1217 study participants, including 611 MSM and 606 WSM. Intervention Venue-based HIV testing with 2 components: an anonymous audio computer-assisted self-administered interview and an anonymous HIV antibody assay.nnnMAIN OUTCOME MEASUREnThe prevalence of HIV infection in MSM and WSM.nnnRESULTSnThe prevalence of HIV infection in MSM and WSM was 15.3% and 0.3%, respectively. Sixty percent of the MSM and 100% of the WSM claimed to not know of their infection.nnnCONCLUSIONnVenue-based testing may be an important strategy to identify HIV-infected younger MSM; however, other strategies are needed for WSM.