February 10, 2023
What do you know about preventing and treating HIV in teenagers? Did you know that 21% of all new HIV infections occur in adolescents? Join us for a conversation with our Adolescent Health Kid Expert, Dr. Katy Miller, to learn about how to talk to teenagers about sexual health, STIs and HIV, and how and to who we should prescribe Pre Exposure Prophylaxis (PrEP) as well as Post Exposure Prophylaxis (PEP). You might be surprised to learn who is at risk and how easy it is for us to keep kids safe in the primary care office.
Transcript
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the kid experts where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change how you care for kids. Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd.
What do pediatricians and other clinicians who care for kids and teenagers need to know about HIV? It’s estimated that 21% of all new HIV infections in the United States occur in teenagers and young adults. Despite this, most teenagers believe that HIV only happens to other people. And the most common way that HIV is passed among teenagers is through unprotected sex. Teens, however, are less likely to use a condom during intercourse than adults, which places them at higher risk. In addition to advocating for barrier methods in safer sex, another way to keep teens HIV negative is Pre-Exposure Prophylaxis, otherwise known as PrEP, and its cousin, Post-Exposure Prophylaxis, or PEP. Here to teach us what we need to know about PrEP and PEP and teenagers is our kid expert in all things adolescent health, Dr. Katy Miller, Medical Director of Children’s Adolescent Health Program. Katie, welcome back to Talking Pediatrics.
Dr. Katy Miller: Thanks for having me back.
Dr. Angela Kade Goepferd: All right. Let’s start with teenagers and HIV. What can you tell us about HIV risk in teenagers, both what we know and kind of based on your experience?
Dr. Katy Miller: We know that teenagers are at risk of HIV. And I think many clinicians feel like HIV isn’t such a big deal anymore, it’s under better control, maybe feel we over-test for HIV, and that’s absolutely not the case, right? Because we have good treatments for HIV; you can get an undetectable viral load. It prevents you from transmitting HIV and being contagious. But we’re not taking advantage of our testing and we’re not taking advantage of our treatments adequately. So teenagers are absolutely at risk.
Dr. Angela Kade Goepferd: And which teenagers are at higher risk?
Dr. Katy Miller: So we see a lot of health disparities come out in who is at risk of HIV in adolescence. 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. People who are in higher risk categories for acquiring HIV are people who fall into the category of what the CDC labels ‘men who have sex with men.’ I don’t love that terminology, but anyone engaging in insertive or receptive anal intercourse is at higher risk just because the tissues involved in that kind of sexual activity are more likely to tear, creating a higher risk of HIV acquisition and transmission. Anyone who has multiple sexual partners, someone who has a sexual partner who is known to have HIV, and then anyone who’s using any kind of survival sex or transactional sex; they might not be in a position where they can negotiate for condom use, for example. So that creates a higher risk.
Dr. Angela Kade Goepferd: One other category that you didn’t mention that I’ve read a lot about, and this is perhaps more global than here in the United States, but that young women are having increased numbers of HIV, not necessarily because of their high risk sexual practices, but sometimes the high risk behaviors of their partners that then transmit the HIV to them.
Dr. Katy Miller: Exactly. So I think there’s often a perception of safety within maybe a cishet relationship, but if anyone is having sex with anyone else, there’s absolutely a risk.
Dr. Angela Kade Goepferd: And then let’s talk a little bit too about health disparities. So we talked a little bit about risk factors for HIV, but we know that there are many health disparities that exist, particularly when it comes to race. Do we see health disparities for HIV, as well?
Dr. Katy Miller: Yes, we absolutely see disparities in race and ethnicity and HIV acquisition. That’s not because different races or ethnicities are having sex at different rates or engaging in higher risk activities. It’s really about access to care and testing and adequate medical treatment. So we know that, for example, African-American individuals are less likely to be able to access testing and treatment, so we do see higher rates in that community. We see higher rates in indigenous communities. We see higher rates in LGBTQ communities. So especially, again, the CDC’s description, ‘men who have sex with men.’ Trans women. Trans women of color, in particular, are at much, much higher risk of HIV.
Dr. Angela Kade Goepferd: And I would imagine that all of the social determinants of health that go into all of the other health disparities would also play in here. So one thing you mentioned earlier was survival sex. So anything that’s going to put you at increased risk of being unhoused will put you at increased risk of survival sex, will therefore put you at increased risk of HIV.
Dr. Katy Miller: Yeah. So I’ve done a lot of work in shelter systems and we know that LGBTQ kids are kicked out of the house at much higher rates; much more likely to end up on the streets trading sex for a place to stay and trading sex for food or even money. That increases your risk pretty dramatically.
Dr. Angela Kade Goepferd: You know, the other thing I always think of when I think of HIV is stigma. So when we first kind of had HIV come on the scene in the nineties and Magic Johnson made his big announcement about being HIV positive, there was a lot of stigma around HIV, and I think some of those big announcements were designed to sort of break down some of that stigma. Fast forward what I hate to say is now 30 years later, I still think we have stigma around HIV. Do you see that?
Dr. Katy Miller: Oh, totally. I think a lot of people are terrified to get tested for HIV. Like I’ve had plenty of teenagers say, “I don’t want the test. I don’t want to know. I’d rather not know and be able to live my life.” So we have a huge amount of stigma that really impacts testing and treatment, and it’s definitely still prevalent today.
Dr. Angela Kade Goepferd: And I think the more we can maybe talk about HIV as a sexually transmitted infection, as something as routine to test for, as something that we have treatments for, hopefully we can remove some of that stigma. But I do know it’s still out there even for adults.
Dr. Katy Miller: Hmm-mm. Absolutely. And it is a really manageable chronic illness now, right? You can get your viral load down to zero, you can be not contagious. So we have effective treatments, but there’s still a lot of stigma left over from the eighties and nineties when we didn’t have good treatments and it was considered a death sentence.
Dr. Angela Kade Goepferd: If we do want to reduce stigma, we’ve got to talk about HIV. Do you have some suggestions for how we can talk to kids or our patients about HIV? Do you have the sense that they’re learning about it in schools and elsewhere? What does the landscape look like?
Dr. Katy Miller: I think whether or not kids and teenagers are learning about it is really variable. You know, different school systems do different jobs with sex education. The public schools, I think especially in the state of Minnesota, are generally pretty good with sex education. But it might not be queer inclusive sex education, so you might have to go and do some extra education. If you have a kid who identifies as gay or queer, they might not have gotten any information about how to protect themselves. So sex ed curriculums are largely aimed towards cisgender heterosexual relationships.
Dr. Angela Kade Goepferd: So in the room with an adolescent, how would you approach the subject of HIV or HIV testing, or how would you provide some information about that?
Dr. Katy Miller: Yeah. So I would group it in with other conversations that 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. So I recommend 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.
Dr. Angela Kade Goepferd: Hmm-mm.
Dr. Katy Miller: And then I’ll explain the testing I recommend, which is usually a variation of chlamydia testing, gonorrhea testing, HIV once a year, or depending on risk factors, more often, plus or minus syphilis testing. And I’ll write these down for teenagers, because I think teenagers can often think, “Oh, I got tested for everything”, but maybe they didn’t, right? Like we don’t test for HPV, for example, routinely. We don’t test for Trich in many cases unless there’s symptoms or a specific risk factor. And we can’t test for HSVs, or herpes, if there’s no genital lesions. So I think sometimes that can lead to complications in the romantic lives of teenagers. If they said, “Well, I got tested for everything and it was negative”, and then maybe a partner gets herpes, and … I think it’s important for kids to know exactly what we’re testing for and what we’ve done and what we haven’t done.
Dr. Angela Kade Goepferd: And if a adolescent says to you, “I don’t need you to test me for HIV, I know I don’t have that,” how would you approach that conversation? Or how do you kind of destigmatize that a little bit for adolescents?
Dr. Katy Miller: I’ll emphasize that, “This is just the testing I recommend for everybody because it’s my job to know what someone’s particular risk factors are. I think this is something that everyone should have done once a year. Are you okay with that today?” So I’ll kind of phrase it as, “Here’s the normal what we do”, and kind of an opt-out strategy, because I do think that decreases stigma. Right? 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 that increased stigma and decreased testing. So having it be like, “Here’s our standard set of things we do. Does that sound okay to you today?”
Dr. Angela Kade Goepferd: So I do want to talk about some things that have changed, speaking of the nineties, and a couple of those things I mentioned in the intro, including PrEP and PEP. But one thing that has not changed is the use of barrier methods, or specifically condoms, to prevent against HIV and really any STI. I think there’s a lot of myths out there still about condom use, particularly among teenagers, but even among some adults. So I wanted to break those down a little bit so we can be sure we’re accurately talking to teenagers about barrier methods and condom use. So what would you think is important for us to know or to convey to adolescents about the use of condoms?
Dr. Katy Miller: Condoms are one of the best ways to prevent HIV infection, hands down. So aside from abstinence, which is not feasible for many people for a variety of reasons, condoms work really well for protecting against HIV. They work a little bit less for other types of sexually transmitted infections, things that are spread from skin to skin contact, like herpes or syphilis, but they’re pretty effective against HIV. So they’re a huge tool in the toolbox.
Dr. Angela Kade Goepferd: And are there certain types of condoms that we should recommend avoiding?
Dr. Katy Miller: Latex condoms work the best. So if someone doesn’t have a latex allergy or a sensitivity to latex, they are the most effective at preventing HIV, and they’re also the least likely to break. Polyurethane condoms are a good alternative for people who have latex allergies. Natural condoms, such as lambskin, those actually don’t protect against HIV because they have these tiny holes in them that don’t block viruses. So lambskin condoms are ineffective against HIV transmission.
Dr. Angela Kade Goepferd: What would be a best practice conversation for talking with teenagers about condom use? And I ask this because I was formerly in a relationship with someone who was a sex educator, and the things that I heard that teenagers would ask about condoms sort of blew my mind. One that sticks out is, “Well, if one is good, two is better”, which … Not.
Dr. Katy Miller: Two is not better.
Dr. Angela Kade Goepferd: Two is not better. Two is actually worse. So do you pull out a banana in the exam room? How do you have that conversation about using condoms and ensuring they’re being used correctly?
Dr. Katy Miller: I don’t actually have a banana in clinic, although maybe we should get one, but one of the most important things is just consistency of use. So instead of asking, “Do you use condoms? Yes or no?”, “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?”
Dr. Angela Kade Goepferd: Hmm-mm.
Dr. Katy Miller: So those motivational interviewing approaches. Sometimes it’s really easy. “I don’t know, they’re expensive.” “Great, here’s like 50.”
Dr. Angela Kade Goepferd: Right.
Dr. Katy Miller: “No, maybe not 50, but we’ll definitely give you 10 or 20.”
Dr. Angela Kade Goepferd: Right.
Dr. Katy Miller: “Take some here. We have more. Here are places where you can get them for free.2. Sometimes it’s that a partner doesn’t want them, and then you can get into conversations about negotiating condom use and feeling safe in a relationship and what someone’s rights in a sexual relationship are.
Dr. Angela Kade Goepferd: Some other things I’ve done is even talking through the basics of how to put a condom on correctly. Like there is an up and a down, and if you put it on incorrectly, you can’t just … Especially if you have an erect penis, you can’t just take it off and then put it back on the right way. So kind of talking through some of those logistical things; pre-ejaculate, what happens if it breaks…
Dr. Katy Miller: Hmm-mm. Yeah, exactly.
Dr. Angela Kade Goepferd: Teenagers-
Dr. Katy Miller: The logistics of it.
Dr. Angela Kade Goepferd: …Don’t just intuitively know how these things work.
Dr. Katy Miller: No. And no matter how much sex ed they get in school, there’s often a gap in the knowledge, right? Because there’s only so much information someone can take in. And you might have someone who’s not totally comfortable teaching condom use, or they might just skip over the practical demonstration.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: So I think we should have a banana in clinic that we physically unroll and look at, but usually I’ll talk through it with teenagers.
Dr. Angela Kade Goepferd: All right. So let’s move on to talking about PrEP. So what is PrEP?
Dr. Katy Miller: So PrEP stands for Pre-Exposure Prophylaxis. PrEP is a really amazing thing that has come out. It is a daily pill, or now an injection that can be taken every two months, that protects against HIV acquisition.
Dr. Angela Kade Goepferd: And who would be eligible for PrEP?
Dr. Katy Miller: Anyone at risk of HIV. So that’s a pretty broad category. If we think back to who is at higher risk of HIV; someone who has a sexual partner who’s known to have HIV, for example, especially if you’re trying to conceive and you need to have unprotected sex. If you know your partner has other partners, that could be a really good situation. If you have multiple partners yourself and you don’t know the HIV status of your other partners and aren’t using condoms 100% of the time, you’re probably a good candidate for PrEP. Things that would flag for me as a clinician would be someone who’s been treated for sexually transmitted infections, especially multiple sexually transmitted infections; kids who are engaging in survival sex. Obviously, the primary goal is to get them in a place where they don’t have to do that, but they might be a good candidate for PrEP while some of those things are being worked out or if that’s just a situation that they’re unable or unwilling to get out of.
Dr. Angela Kade Goepferd: And what medications are available? You mentioned a daily pill, but then you also mentioned an injection. And who can take what?
Dr. Katy Miller: So the injection is new, so that’s really exciting. And it’s wonderful that it’s every two months, because as you can imagine, adherence is a challenge for a lot of teenagers. So an every two month injection is kind of awesome and I’m super excited for it. That is available through the Infectious Disease Clinic at Children’s Minnesota. They have got a system set up to do that, which is pretty amazing. The daily pill is what I’ve used more often, just because that’s been around longer. There’s two brand names out. There’s TRUVADA and DESCOVY. They have similar versions of two antiviral medications that prevent replication of the virus in the body, and they work really, really well. They’re 99% effective against HIV when they’re taken as prescribed.
Dr. Angela Kade Goepferd: Hmm-mm.
Dr. Katy Miller: And even if you take them four or five out of seven days, they still give really good protection. That’s obviously not what I lead with teenagers.
Dr. Angela Kade Goepferd: Right.
Dr. Katy Miller: But I know that four to five days is still going to give you a really high level of protection.
Dr. Angela Kade Goepferd: And is there a reason that you would use one over the other?
Dr. Katy Miller: That’s a very good question and one that’s a little bit controversial.
Dr. Angela Kade Goepferd: Hmm-mm.
Dr. Katy Miller: I tend to use TRUVADA. It’s the older version, it’s what we have more data on. We know it works really well. It’s more affordable because it does come in generic formulations. DESCOVEY is advertised as not having the two side effects that TRUVADA has been criticized for, which is potentially lower bone density and potentially impacting your kidney function, which is monitored when someone is on TRUVADA. So DESCOVEY has the advantage of potentially having less of those effects, but because it’s newer, because there’s not a generic, because we have less data, I’ve stuck with TRUVADA so far.
Dr. Angela Kade Goepferd: Okay. And then the injection form, other than maybe being newer and hard to access, are there particular people, or … ?
Dr. Katy Miller: I think anyone who is struggling with daily adherence, the injection form is amazing. I haven’t done the injection myself because it is pretty new.
Dr. Angela Kade Goepferd: If I wanted to prescribe PrEP for a patient, so say I had someone that I felt met the risk criteria and I decided I wanted to prescribe this, what would I need to know as a prescriber in terms of how to talk about it with families and patients and what side effects to watch for, and things like that?
Dr. Katy Miller: Yeah. The first thing to know is that this is a safe medication. We as pediatricians routinely prescribe less safe medications with comfort and regularity. So I wouldn’t want you to feel intimidated or this is out of your scope of practice as a pediatrician.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: There are probably some logistical hurdles to work through; like getting coverage, figuring out confidentiality pieces, right? Like is an insurance policy holder going to be okay with an explanation of benefits that has some information about the medication? But it’s a really straightforward medication. There is testing that we recommend at the start of treatment and then every three months. So when you start TRUVADA, which is the one I’m going to talk about specifically, this also applies to DESCOVEY, we recommend testing for Hepatitis B because the medications in TRUVADA are also treatment for Hepatitis B. So you could have a flare of Hepatitis B infection if you took the medication away.
So it’s just relevant information. It’s not an absolute contraindication, but if someone has Hepatitis B, I want to know about it. Or if they didn’t convert the vaccine and they don’t have immunity to Hepatitis B, they should be re-immunized, which is also helpful because Hepatitis B can be spread through sexual activity. So you’re going to check for Hepatitis B; you’re going to get a baseline HIV test. And that should be a fourth generation antigen/antibody combo. That’s what we routinely use. Like if you type it into pretty much any electronical medical record at a big health center, we’re getting the fourth generation antibody/antigen combo.
Dr. Angela Kade Goepferd: Okay.
Dr. Katy Miller: That’s the most effective form of testing. You also want to get baseline kidney function. So getting a BMP, checking to make sure that their creatinine clearance is in the normal range. Because that would be a contraindication to taking TRUVADA, if they had abnormal kidney function. And then we recommend getting regular STI testing. So that’s going to include chlamydia, gonorrhea, plus HIV. For someone who is having any kind of insertive or receptive anal sex or oral sex, we recommend also checking a rectal and pharyngeal swab for chlamydia and gonorrhea because those are often missed. And there are some estimates that we’ll miss up to 60 to 70% of chlamydia and gonorrhea cases in the men who have sex with men category if we’re not getting those rectal and pharyngeal swabs.
Dr. Angela Kade Goepferd: And then in terms of ongoing monitoring for things like kidney function, how often do we need to be checking them?
Dr. Katy Miller: Yeah. So kidney function is every three to six months. You will check an HIV test every three months to make sure that someone hasn’t acquired HIV, because then they would need to switch to a treatment for HIV rather than the prevention. And then we recommend testing chlamydia, gonorrhea, again, in all three sites, rectum, pharyngeal and a urine sample, every three months. Because we know if someone is having condomless sex, they’re also at risk of other sexually transmitted infections. So we can treat and monitor those and make sure that someone isn’t having sequela from sexually transmitted infections and also spreading them.
Dr. Angela Kade Goepferd: And in your experience in prescribing for patients, is this something that they’re resistant to, they’re pretty open to? What has been your experience in explaining this as an option?
Dr. Katy Miller: It’s a little 50/50. Among older adolescents, especially college age adolescents and above, I’ve had many patients who have taken PrEP and had really good results and felt really comfortable, and it allowed them a little bit more comfort with their sexuality. Younger adolescents and some older adolescents have often felt, “Well, I don’t need this.” So I’ve had patients where I really felt they could benefit from PrEP. Like I’ve treated someone for multiple sexually transmitted infections, having six or seven partners a month, and they don’t perceive themselves at risk.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: So that is someone that I would have follow up just with as frequent STI testing as we can get and maybe encourage them to think about it for the future.
Dr. Angela Kade Goepferd: And most often, is this being done in a confidential setting where their parents are unaware or a parent is unaware? Or how has that gone?
Dr. Katy Miller: I have yet to have a patient tell their parent about this. So you could get into probably the weeds. I haven’t had this come up in as many patients who are under 18. I don’t know that this would technically fall under minor consent, although there is an argument for it because it’s the prevention of a sexually transmitted infection.
Dr. Angela Kade Goepferd: Sure.
Dr. Katy Miller: You could say it’s the treatment of a sexually transmitted infection. And I do know clinicians who say this falls under minor consent for that reason. Often the bigger issue is paying for it if parents are unaware.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: My patients who are 18 and older have either been on their own insurance or they’ve been able to get MFPP, which is Family Planning Funds, to pay for it. But I don’t think that the patients I’ve had have shared that information with their parents.
Dr. Angela Kade Goepferd: Yeah. Well, and I think we talked about this in our previous episode, about confidentiality, that when we are prescribing medications like this or we are doing confidential treatments with adolescents, we have to be really thoughtful about where information may show up. So you referenced the explanation of benefits, or even at the pharmacy if they get information about the medication, so …
Dr. Katy Miller: Yeah. So a parent might have their number listed for the pharmacy and they get a phone call, “The prescription’s ready”, or the policy holder could get a letter about, “Here’s information about your medication.” So warning young adults and teenagers that that’s a possibility.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: It’s a lot easier if they’re the policy holder or if they’re on Medicaid or state insurance. You’re able to assure confidentiality quite a bit better.
Dr. Angela Kade Goepferd: Anything else about PrEP that you think we should know before we move on to PEP?
Dr. Katy Miller: I would just say don’t be scared of it.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: It can be a really good tool. You can reach out to ID or Adolescent Medicine for more questions, but don’t be afraid of it. It’s a really powerful tool and one that we should be willing to use when the right scenario comes up.
Dr. Angela Kade Goepferd: Yeah, absolutely. And I think we often underestimate, likely when someone becomes a young adult, and particularly in pediatrics, we’ve been seeing them for a long time, we’re the trusted relationship. So I think it’s helpful sometimes for us to have that conversation, even with an 18, 19 year old, than them meeting someone for the first time and jumping into their sexual practices and keeping themselves safe.
Dr. Katy Miller: Totally. You’re the person the patient knows. And even setting the stage for future PrEP use. Like I tell pretty much all teenagers who are sexually active about it, even if they don’t have risk factors, because I want them to know what exists and tell their friends that exist if they do know someone who might benefit from PrEP.
Dr. Angela Kade Goepferd: Yeah. All right. Let’s talk about PEP. So what is PEP?
Dr. Katy Miller: PEP is Post-Exposure Prophylaxis. So that is someone who may have been exposed to HIV. And it is a treatment that lasts about 28 days and is taken after an exposure to try to prevent acquisition of HIV.
Dr. Angela Kade Goepferd: And so what I had mostly heard about with regard to PEP, because we work in healthcare, is like a needle stick or something like that where someone worries that they may have been exposed. But talk me through a situation in which you might consider a sexual exposure or something where you might be counseling an adolescent that you’d want them to do this.
Dr. Katy Miller: The most common scenario is going to be post-sexual assault. So if a patient comes to the emergency department or to clinic and discloses that they’ve been sexually assaulted and you’re within 72 hours of that sexual assault and you don’t know the perpetrator’s HIV status, this can be a really powerful tool. So in that scenario, you know, say we had an unknown perpetrator, you would be treating for chlamydia, gonorrhea, you would be testing for all of those things and HIV, but you could also offer Post-Exposure Prophylaxis to prevent an HIV infection if the person was potentially exposed.
Dr. Angela Kade Goepferd: And in a scenario where there was an exposure, but you know the person, the partner, they know the partner, the condom broke, they didn’t use a condom, something like that, would you go through a risk history to decide if this was something that would be warranted? Or how would you approach that situation?
Dr. Katy Miller: Yeah. The history can be really helpful. If you’ve got the partner there and the partner’s willing to be tested for HIV, that’s pretty straightforward; if the test is going to be delayed, if you can’t get it done within 72 hours. If there’s a high degree of anxiety from an adolescent, I would consider that a pretty reasonable indication to do PEP. I’m not really in the business of withholding it if someone asks for it or is concerned about an exposure, because there could be so much more history that an adolescent might not feel comfortable sharing. They could have an abuse history, there could be an element of coercion. There could be plenty of things that an adolescent might not feel safe coming forward with.
Dr. Angela Kade Goepferd: Hmm-mm.
Dr. Katy Miller: So if someone seems to have a reasonable fear of an HIV exposure, I’ll talk through, “Here are the risks, benefits. It’s 28 to 30 days of treatment, usually twice a day. If that sounds okay, we can absolutely do that.”
Dr. Angela Kade Goepferd: And what are the medications that we’re using for PEP?
Dr. Katy Miller: So the medications we use for PEP are different than the medications we use for PrEP. So the preferred regimen is Tenofovir, 300 milligrams, Emtricitabine, 200 milligrams, which comes usually in one pill, plus raltegravir twice daily. So it’s a little bit more involved, in that it’s twice daily medications and it’s for 28 days.
Dr. Angela Kade Goepferd: Is there anyone who we should not be prescribing these to or side effects that we should be watching for for prescribing PEP?
Dr. Katy Miller: So if someone is beyond the 72 hour window of exposure to HIV, it will probably be ineffective. So if you’re beyond 72 hours, you want to do an HIV test in four weeks and 12 weeks. If someone has significant creatinine function that’s impaired, that might be a contraindication. You also want to do testing before you’re starting PEP. So you’ll test for HIV, you’ll get a pregnancy test if that’s relevant, you’ll test liver function and kidney function. You will test Hepatitis B as well for PEP because it has similar medications that, again, could treat or then cause a flare of symptoms [inaudible 00:24:32] taken away Hepatitis B. And you’ll check Hep C antibody. In terms of side effects, sometimes some nausea and vomiting. It’s usually pretty well tolerated though.
Dr. Angela Kade Goepferd: Okay. So I want to close with talking a little bit about teenagers who are living with HIV. First, have you ever had to tell a teenager that they’re HIV positive, and how did it go if you did?
Dr. Katy Miller: I haven’t up until now.
Dr. Angela Kade Goepferd: And if you ever did have to tell a teenager that they were HIV positive, do you have a sense of how you might explain being HIV positive or what that might mean for them? You know, we talked earlier about it kind of being like living with a chronic disease. How might you go into that conversation?
Dr. Katy Miller: I would ask if they had a friend or a family member that they wanted to come sit with them. So I would share the information and then try to get some support on board for them. I would’ve absolutely called our ID team ahead of time to be able to get them in with a specialist who treats HIV, ideally the same day or the next day.
Dr. Angela Kade Goepferd: And so what would it look like for an adolescent to be diagnosed with HIV? You know, we’d start them on treatment. And then do you have a sense of what a trajectory would be like for them?
Dr. Katy Miller: Yeah. So I’ve cared for plenty of adolescents who have HIV and live healthy, happy lives. So adherence to treatment is one of the most important things, but you can have a very full regular life with meaningful relationships and healthy sexuality and sexual relationships and do exceptionally well. So that is the message I would really want to convey to young people. And that is some of the message that I convey when someone’s telling me they’re really afraid to be tested.
Dr. Angela Kade Goepferd: So tell me a little bit about the teenagers that you’ve taken care of who are on HIV medications. When medications first came up for HIV, I know they came sometimes with a lot of side effects and side effects that people did not want. My impression as someone who’s not an expert is that medications have improved and people are now living more comfortably taking their HIV medications regularly. What’s been your experience?
Dr. Katy Miller: You know, I wasn’t a doctor in the eighties and nineties, but I think absolutely the treatments are much more tolerable now. I have patients who do really well and don’t notice much. I have other patients who do have side effects and are working fairly closely with their ID physicians to manage those. But generally, I think you can have a really good quality of life. I don’t think it’s like when people had to take high doses of AZT multiple times a day. You can get down to a one pill a day regiment in many cases, and life is pretty tolerable and pretty well managed.
Dr. Angela Kade Goepferd: Yeah. And my understanding just from friends and community members who I know who have HIV is that many of them are living with undetectable levels of HIV, and as you mentioned, really having full, happy, healthy lives, including healthy sex lives and relationships and all of those things.
Dr. Katy Miller: Absolutely.
Dr. Angela Kade Goepferd: Thank you so much for joining me to talk about all of the acronyms, HIV and PrEP and PEP and all of those things. Appreciate you sharing all things adolescent with us. I’m sure there will be more to come, but I appreciate you coming back to talk about this with me.
Dr. Katy Miller: Thanks for having me.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.