Sexual health: Preventing and treating HIV, STIs in adolescents and teens 

In the past three decades, prevention and treatment options for HIV (human immunodeficiency virus) have changed dramatically. Compared to the 1980s and 90s when HIV prognosis was unfavorable, today it is a manageable chronic illness. However, challenges with HIV remain, especially among young people. The Centers for Disease Control and Prevention (CDC) estimates that consistently one-fifth (21%) of newly diagnosed people with HIV in the U.S. annually are adolescents and young adults.

Pediatric clinicians play an important role in conversations with adolescents and teens about sexual health, sexually transmitted infections (STIs) like HIV, and prescribing pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). In the Talking Pediatrics episode, “What pediatric clinicians should know about PrEP,” host Dr. Angela Goepferd and Dr. Katy Miller, medical director of the adolescent health program at Children’s Minnesota, share their thoughts about how to educate young patients to prevent STIs and stay safe.

Manageable but still a health concern

There is no cure for HIV, but people with HIV who receive proper medical care can live long, healthy lives. Today’s HIV treatments can result in an undetectable viral load and prevent HIV-positive people from transmitting HIV to others.

“Many clinicians feel like HIV isn’t such a big deal anymore [because] it’s under better control,” said Dr. Miller. “[They think] we over-test for HIV and that’s absolutely not the case. Anyone who is sexually active and anyone who uses injection drugs is at risk of acquiring HIV. So that’s a fair number of teenagers.”

Factors that increase HIV risk

While anyone can be at risk for acquiring HIV, there are some behaviors that increase HIV exposure, including:

• Multiple sexual partners.
• Sex with someone who is known to have HIV.
• Insertive or receptive anal intercourse. The tissues involved in that kind of sexual activity are more likely to tear, creating a higher risk of HIV acquisition and transmission.
• No or infrequent use of condoms.
• Use of injected drugs.

Health disparities among certain groups also impact the risk of acquiring HIV and the ability to get adequate care, including African American and indigenous communities, resulting in higher rates of HIV. LGBTQ+ communities are also at a higher risk of HIV because of barriers to HIV testing and care, and health care generally. Individuals who are unhoused are more likely to have survival or transactional sex, which might mean multiple partners and/or no use of condoms.

Clinic visit checklist: Lessen stigma, encourage tests and condoms

The stigma around HIV that started 30 years ago remains today, and it still impacts testing and treatment. “I think a lot of people are terrified to get tested for HIV,” said Dr. Miller. “I’ve had plenty of teenagers say, ‘I don’t want the test. I’d rather not know and be able to live my life.’”

Pediatric clinicians can reduce HIV stigma and help normalize conversations about HIV and other STIs during clinic visits with adolescents and teens. Sex education curriculums in schools vary and tend to be aimed at cisgender heterosexual relationships, so a young person who identifies as gay or queer might not have received information about how to protect themselves from STIs.

Here’s a checklist of sexual health topics to cover during clinic visits with adolescents and teens:

• Talk about HIV and HIV testing as part of other conversations about sex. “I group [HIV testing] in with other conversations I’m having about how to have safe sex, how to protect yourself during sex, how to make sure that a sexual relationship is consensual and enjoyable for all involved,” said Dr. Miller. “I recommend [HIV and other STI] testing at least once a year once someone has started having sex. And that’s the language I’ll use with teenagers: ‘You know, once someone has started having sex, we recommend getting tested at least once a year, sometimes more than that if you’re having more than one partner, and that’s just part of your life from here on out.’”
• Use the “opt-out” strategy for STI tests. The common STI tests include chlamydia, gonorrhea, HIV, and syphilis. Testing is recommended annually, or more frequently if the person has increased risk factors. Tests for HSV (herpes) or trichomoniasis (trich) aren’t typically done unless there are symptoms. Dr. Miller likes to use an “opt-out” strategy when talking to adolescent and teen patients: “I’ll emphasize that this is the testing I recommend for everybody because it’s my job to know someone’s particular risk factors. So, I’ll phrase it as, ‘Here’s our standard set of [tests] we do. Does that sound okay to you today?’ An opt-out strategy decreases stigma. If we have HIV as an opt-in strategy, which used to be what we did; you had to sign a separate piece of paper to consent for testing for HIV. We know that increased stigma and decreased testing.” Dr. Miller then writes down the list of tests that were done and sends it with the teen so they’re clear about what they were (and weren’t) tested for.
• Condoms are still one of the best ways to prevent HIV infection, aside from abstinence. Latex condoms work best; polyurethane condoms are a good alternative for people with a latex allergy. Natural condoms, like lambskin, have tiny holes and are ineffective against HIV transmission. Condoms are less effective for other types of STIS that are spread by skin-to-skin contact, like herpes or syphilis.Dr. Miller emphasizes the consistency of condom use when talking to teens. “Instead of asking, ‘Do you use condoms, yes or no?’ [I prefer], ‘What percent of the time do you use condoms?’ Because most teenagers will probably give you a yes. If that is 10% of the time, that might still be a yes, but it’s relevant to know that they’re using condoms 10% of the time. And if someone’s using condoms 10% of the time, my answer will always be, ‘Oh, that’s great. I’m so glad you’re using condoms. What can we do to get you up to 80 or 90% of the time? What are some of the things that get in the way?’”Sometimes a motivational interviewing approach like this can segue the conversation to other important topics like being able to afford condoms, a partner doesn’t want to use condoms, what it means to be in a safe relationship, personal rights in a sexual relationship, etc.

Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)

There are now two types of safe, effective tools to prevent HIV transmission from sex or injection drug use: PrEP and PEP.

Pre-exposure prophylaxis (PrEP) is a helpful tool for people at risk of acquiring HIV. PrEP is a preventative medication in the form of a daily pill or an injection taken every two months to reduce the chance of getting HIV from sex or injection drug use. Good candidates for PrEP include a person who:

• Has multiple sexual partners and doesn’t know their HIV status and isn’t using condoms 100% of the time.
• Has a sexual partner who has other sexual partners.
• Has been treated for multiple STIs.
• Has a sexual partner with HIV but they are trying to conceive and need to have unprotected sex.
• Is engaging in survival sex. The primary goal is to get this person to a place where they don’t have to have survival sex, but PrEP could be a good option until that happens. Also, the person might be unable or unwilling to stop having survival sex so this can be a very complex situation.
• Has an injection drug partner with HIV and/or shares needles, syringes, or other injection drug equipment.

Dr. Miller discusses specific PrEP medications (e.g., Truvada, Descovy) during this podcast and her comments can be read in the transcript. PrEP medications are available at the Infectious Disease Clinic at Children’s Minnesota.

“[PrEP] is a safe medication,” said Dr. Miller. “We as pediatricians routinely prescribe less safe medications with comfort and regularity. So, I wouldn’t want [clinicians] to feel intimidated or like this is out of [their] scope of practice as a pediatrician. It’s a really powerful tool and one we should be willing to use when the right scenario comes up.”

Post-exposure prophylaxis (PEP) is a treatment taken within 72 hours after an exposure to HIV to prevent acquisition of HIV. The most common use of PEP is after a sexual assault when the perpetrator’s HIV status is or isn’t known. Other reasons to prescribe PEP for suspected HIV exposure after sexual activity or injection drug use include:

• A condom wasn’t used.
• A condom was used but it broke.
• The adolescent or teen is highly anxious about HIV exposure. There could be much more history than they are willing to share (e.g., abuse, coercion, etc.)
• Needles, syringes, or other injection drug equipment was shared.

“If someone seems to have a reasonable fear of an HIV exposure, I’ll talk through, ‘Here are the risks [and] benefits. It’s 28 to 30 days of treatment, usually twice a day. If that sounds okay, we can absolutely do that,’” said Dr. Miller.

Specific PEP medications (e.g., tenofovir, emtricitabine, raltegravir) and patient confidentiality are also discussed during this podcast. Listen to “What pediatric clinicians should know about PrEP” or read the transcript here.

About Children’s Minnesota’s infectious diseases and adolescent health programs

The infectious diseases department at Children’s Minnesota diagnoses and treats acute and chronic infectious diseases, in both hospitalized patients and outpatient/clinical settings. We’re known across the region for our Minnesota Perinatal and Pediatric HIV Program, which provides clinical care and support services to families affected by HIV.

The Adolescent Health Clinic is a multidisciplinary team of medical and mental health professionals focused on the needs of adolescents and teens. Clinical services include primary medical care, acute and chronic care, reproductive care, and mental health assessment and therapy. Our care teams bring together pediatric kid experts from a broad range of departments to assure each child receives the best care. Learn more about our programs and patient referrals here.