Lawrence J. D’Angelo

Sexually Transmitted Diseases Including Human Immunodeficiency Virus Infection

The risk of acquiring a sexually transmitted disease (STD) is one of the most significant and immediate risks to the health and well-being of adolescents. From an economic and social standpoint, these infections continue to exact a significant toll on adolescents and ultimately on society. This toll can be measured in terms of projected costs of certain infections, such as chlamydia infections (Washington, 1987), and in terms of health outcomes, such as the number of ectopic pregnancies (Chow, Darling, & Greenbert, 1987) and the rate of infertility (Westrom, 1980). The real concern, however, is that in an era when a sexually transmitted infection—human immunodeficiency virus (HIV) infection—can result in a fatal illness—acquired immunodeficiency syndrome (AIDS)—we have begun to measure the impact in terms of deaths of adolescents and young adults from AIDS. For this reason, the potential impact of STDs is all the more significant and prevention of these infections an even higher priority.

Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care – Washington, DC*

ABSTRACT One goal of the HIV care continuum is achieving viral suppression (VS), yet disparities in suppression exist among subpopulations of HIV-infected persons. We sought to identify disparities in both the ability to achieve and sustain VS among an urban cohort of HIV-infected persons in care. Data from HIV-infected persons enrolled at the 13 DC Cohort study clinical sites between January 2011 and June 2014 were analyzed. Univariate and multivariate logistic regression were conducted to identify factors associated with achieving VS (viral load < 200 copies/ml) at least once, and Kaplan–Meier (KM) curves and Cox proportional hazards models were used to identify factors associated with sustaining VS and time to virologic failure (VL ≥ 200 copies/ml after achievement of VS). Among the 4311 participants, 95.4% were either virally suppressed at study enrollment or able to achieve VS during the follow-up period. In multivariate analyses, achieving VS was significantly associated with age (aOR: 1.04; 95%CI: 1.03–1.06 per five-year increase) and having a higher CD4 (aOR: 1.05, 95% CI 1.04–1.06 per 100 cells/mm3). Patients infected through perinatal transmission were less likely to achieve VS compared to MSM patients (aOR: 0.63, 95% CI 0.51–0.79). Once achieved, most participants (74.4%) sustained VS during follow-up. Blacks and perinatally infected persons were less likely to have sustained VS in KM survival analysis (log rank chi-square p ≤ .001 for both) compared to other races and risk groups. Earlier time to failure was observed among females, Blacks, publically insured, perinatally infected, those with longer standing HIV infection, and those with diagnoses of mental health issues or depression. Among this HIV-infected cohort, most people achieved and maintained VS; however, disparities exist with regard to patient age, race, HIV transmission risk, and co-morbid conditions. Identifying populations with disparate outcomes allows for appropriate targeting of resources to improve outcomes along the care continuum.

Is it safe? Talking to teens with HIV/AIDS about death and dying: a 3-month evaluation of Family Centered Advance Care (FACE) planning – anxiety, depression, quality of life

Purpose To determine the safety of engaging HIV-positive (HIV+) adolescents in a Family Centered Advance Care (FACE) planning intervention. Patients and methods We conducted a 2-armed, randomized controlled clinical trial in 2 hospital-based outpatient clinics from 2006–2008 with HIV+ adolescents and their surrogates (n = 76). Three 60–90 minutes sessions were conducted weekly. FACE intervention groups received: Lyon FCACP Survey©, the Respecting Choices® interview, and completion of The Five Wishes©. The Healthy Living Control (HLC) received: Developmental History, Healthy Tips, Future Planning (vocational, school or vocational rehabilitation). Three-month post-intervention outcomes were: completion of advance directive (Five Wishes©); psychological adjustment (Beck Depression, Anxiety Inventories); quality of life (PedsQL™); and HIV symptoms (General Health Self-Assessment). Results Adolescents had a mean age, 16 years; 40% male; 92% African-American; 68% with perinatally acquired HIV, 29% had AIDS diagnosis. FACE participants completed advance directives more than controls, using time matched comparison (P < 0.001). Neither anxiety, nor depression, increased at clinically or statistically significant levels post-intervention. FACE adolescents maintained quality of life. FACE families perceived their adolescents as worsening in their school (P = 0.018) and emotional (P = 0.029) quality of life at 3 months, compared with controls. Conclusions Participating in advance care planning did not unduly distress HIV+ adolescents.

Adolescents' Perceptions of Transition Importance, Readiness, and Likelihood of Future Success: The Role of Anticipatory Guidance.

Expert consensus supports anticipatory guidance around health care transition (HCT), but little is known about its impact on adolescents’ perceptions of HCT. This study aimed to evaluate the frequency of HCT anticipatory guidance delivery and the effect it had on participants’ perceptions of HCT. Adolescents (n = 209) with special health care needs were administered National Survey for Children with Special Health Care Needs transition assessment questions, then reported perceptions of transition importance, readiness, and likely future success. Over half of the participants reported no history of discussion about transition to an adult provider (64%) or insurance needs (67%); just under half (43%) had not discussed their changing health care needs. In participants reporting receipt of anticipatory guidance, ratings of transition readiness and future success were significantly higher than those who received no anticipatory guidance, supporting that HCT anticipatory guidance has a significantly positive impact on adolescents’ perceptions of the HCT process.

“When Should I Tell?”: Perspectives on Disclosure to Their Children among Parents with Perinatally Acquired HIV

Adolescents and young adults (AYA) with perinatally acquired HIV (PHIV) engage in developmentally expected behaviors, such as establishing relationships and having children. Previous research has focused on pregnancy management/outcomes of AYA with PHIV. However, little research has focused on the parenting experiences of this emerging cohort and on their views of disclosure to their offspring. This article examines data from a pilot study of five AYA parents with PHIV on disclosure to their child(ren) (n = 7, 6 HIV-negative). Disclosure of their own HIV status to their children is on the minds of parents with PHIV. However, few currently have children old enough to understand the parent’s diagnosis. Three parents indicated they would disclose their HIV status when their child was “old enough to understand” so that their child would be knowledgeable about HIV. One father also noted that he currently had more pressing parenting responsibilities beyond disclosure. When discussing their perspectives on disclosure, many referenced their personal stories indicating a link between their decision to disclose/not disclose to their child and their own disclosure narrative. One mother cited she did not plan to reveal her diagnosis to her son because he was uninfected, while another mother explained she did not want to worry her child. The mother of the only infected child “did not want to wait like my mother did” and planned to tell her son at an earlier age than when she learned of her own diagnosis. Clinical implications related to disclosure will be discussed and future areas of research identified.

Growing up with HIV: the perinatal transmission survivors become teenagers

Conclusions: A growing number of HIV infected adolescents have acquired their infection in the perinatal period. Those who have survived to this point are likely to be reasonably healthy and have clinical profiles not unlike their behaviorally infected peers. As with many adolescents with chronic illness they will be forced to deal with issues common to all adolescents and make decisions concerning risk behaviors. Additional studies of this unique disease group should shed even more light on their psychosocial profile. (excerpt)

Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort

Abstract Background Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the leading mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission. Methods We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV-infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for incident STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk. Results Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5 months (4% chlamydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5–4.1); age 18–34 years, 10.8 (95% CI, 9.7–12.0); transgender women, 9.9 (95% CI, 6.9–14.0); Hispanics, 9.2 (95% CI, 7.2–11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1–8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL. Conclusions STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation.

Perceptions of Health Care Transition Care Coordination in Patients With Chronic Illness

With this study, we support the effectiveness of HCT CC by improved perceptions of chronic illness care quality. OBJECTIVES: Expert consensus jointly authored in 2011 by the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians supports the use of health care transition (HCT) care coordination (CC). Although gaps in care are addressed in these practice-based implementation recommendations, such recommendations have never undergone rigorous assessment. We assessed the effectiveness of implementation on quality of chronic illness care and CC during HCT for adolescents and young adults. METHODS: Adolescents and young adults with special health care needs were enrolled in a randomized HCT CC intervention. Intervention participants received HCT CC as outlined in the 2011 clinical report. Perceptions of chronic illness care quality and CC were assessed at 0, 6, and 12 months. RESULTS: Intervention participants had a Patient Assessment of Chronic Illness Care score at 12 months of 3.6 vs 3.3 compared with participants in the control group (P = .01). Intervention participants had higher average scores for patient activation (3.7 vs 3.4; P = .01), problem solving (3.8 vs 3.4; P = .02), and coordination/follow-up (3.0 vs 2.5; P < .01). The Client Perceptions of Coordination Questionnaire revealed that intervention participants had 2.5 times increased odds to endorse mostly or always receiving the services they thought they needed and had 2.4 times increased odds to have talked to their provider about future care (P < .01). CONCLUSIONS: Implementing recommended HCT CC practices improved patient or patient caregiver perception of quality of chronic illness care and CC especially among the most complex patients.

“Stranger in a Strange Land”: The Non-address of the 40th President (or Is it the First?) of the Society for Adolescent Health and Medicine

I have decided to depart from the usual tradition of the presidential address. I will not give this talk from the podium. I prefer towander around among you here on the floor. In fact, I do not plan on giving the traditional address at all and have officially designated this as a ‘‘presidential non-address.’’ I immediately need to apologize for the title of the nonaddress, which I have shamelessly borrowed from the title of Robert Heinlein’s 1961 novel about Valentine Michael Smith, an ‘‘earthling’’ raised onMarswho comes back to Earth to live among and assimilate with his human peers [1]. Since my time in Adolescent Health and Medicine has occasionally givenme the feeling of being on a slightly alien planet, the title seemed so right, for reasons that are obvious to some but will be known to all of you by the end of this brief sharing. Now there are several reasons I have decided to take a more informal approach to this important communication. First, I do not have a particularly compelling life story or lots of pictures of myself when I was a kid (like Abigail English’s address several years ago). Second, I have not traveled any place which is really interesting, and even if I had, I am not a particularly good photographer (like Mary-Ann Shafer who showed in her address last year). Third, I cannot sing (who could forget Larry Neinstein’s song at the conclusion of his address in 1999). Fourth, although my family has always been supportive of me and mywife Dee is here today, my kids are grown up and cannot come up on stage with me (likeMarty Fisher’s family did in 1998). In fact, my kidswere always uncomfortable whenever I used to talk and bring up their names. That is partly my fault, because as they got older and particularly while they were adolescents, I used to use experiences from their adolescence to illustrate points when I gave community talks. My daughter, Marisa, shrugged this sort of thing off. But her younger bother, Mike, was really upset about it. In fact, one Saturday, when I was going out to talk to his Boy Scout troop’s parents, he came running down the driveway to the car while I was backing out, reached inside, grabbed me by the shoulders, shook me and said, ‘‘Just remember, you are NOT funny.’’ I will try to remember this during the course of my remarks today. Fifth, podiums are dangerous, particularly for people like me. Whenever I get behind a podium I immediately become slightly bombastic. Why, if I were behind that