This guideline includes recommendations for identifying HIV-infected adolescents; obtaining a baseline medical history; performing baseline and ongoing physical examinations, laboratory evaluations, and psychosocial interventions; and maximizing treatment adherence. This chapter discusses issues that may have particular diagnostic, preventive, or therapeutic implications for female adolescents, including epidemiology, pelvic examinations, reproductive health, contraception, and pregnancy.
Acquisition of HIV: The most common mode of female HIV acquisition is through heterosexual sex. In New York State, female adolescents aged 13 to 24 accounted for 42% of the adolescents living with HIV/AIDS in 2005 . Nationwide, it is estimated that 63% and 82% of new AIDS cases among younger (13 to 19 years) and older (20 to 24 years) adolescent females, respectively, are from heterosexual transmission .
Sexually active adolescent females may be particularly vulnerable to acquiring HIV infection for the following reasons :
- An adolescent’s immature cervix contains more single-layer columnar cells that may be more vulnerable to infection.
- Females are more likely than males to experience asymptomatic STIs, and the presence of STIs may enhance transmission of HIV infection.
- HIV infection is more easily transmitted from male to female than female to male because 1) the susceptible surface area of the female (cervical epithelium and the mucosal area of the vagina and rectum) is larger than that of the male (urethral meatus) and 2) semen can remain in the vagina, cervix, and rectum for hours to days after sexual intercourse, making the period of HIV exposure much longer for a female than a male.
Identifying a supportive adult: HIV infection and reproductive health issues are often difficult topics for many HIV-infected adolescents to discuss. Some adolescents are comfortable discussing these subjects with parents/guardians, while others are not. A supportive adult with whom the adolescent can comfortably discuss HIV-related information and reproductive health care should be identified. The medical team should encourage the adolescent to involve this person in discussions concerning her care. This person may or may not be a parent or legal guardian but should be someone with whom the adolescent feels comfortable sharing personal information.
- NYSDOH. NYS HIV/AIDS surveillance semiannual report for cases diagnosed through 2005. Available at: http://www.health.state.ny.us/diseases/aids/statistics/semiannual/2005/surveillance_semiannual_report_2005_june.pdf
- Kaiser Family Foundation. Women and HIV/AIDS in the United States. HIV/AIDS Policy Fact Sheet. February 2006. Available at: http://www.kff.org/hivaids/upload/6092-03.pdf
- Futterman D. HIV and AIDS in adolescents. Adolesc Med Clin 2004;15:369-391. Review.
In June 2006, the Food and Drug Administration (FDA) approved the release of a quadrivalent HPV vaccine (Gardasil) that protects against disease caused by HPV types 6, 11, 16, and 18. These HPV types are associated with 70% of cervical cancers (HPV 16 and 18) and 90% of genital warts (HPV 6 and 11) in non-HIV-infected women . The pivotal clinical trials showed that the vaccine prevented precancerous vulvar, vaginal, and cervical lesions caused by these HPV types for up to 36 months. Most studies have shown a high prevalence of HPV infections in HIV-infected individuals .
Administration: The vaccine is FDA-approved for administration to females between the ages of 9 and 26 years . It is administered as a three-dose regimen over a 6-month period (0, 2, and 6 months). The full regimen must be completed to confer protection. HPV vaccine has been demonstrated to provide high levels of neutralizing antibody for 5 years; the full length of its protection has not been established.
Vaccine is for prevention, not treatment: The HPV vaccine is preventive, but not therapeutic. Current studies demonstrate that the preventive efficacy of the HPV vaccine is greatest in women who are not yet sexually active and thus have not been exposed to HPV. However, HPV testing is not required before administration of the vaccine, and most women, regardless of sexual activity status, may benefit from vaccination. In the pivotal clinical trials, only 1 in a 1,000 women showed evidence of having been exposed to all four types of HPV prevented by the vaccine. Gardasil may also provide some cross-protection against HPV genotypes other than 6, 11, 16, and 18. However, additional data are required before the vaccine can be recommended for the prevention of cross-reactive HPV types.
Safety and efficacy: Most of the data regarding HPV vaccine safety and efficacy are derived from studies in non-HIV-infected females. HIV-infected women may have reduced antibody response to the immunization because women who are immune suppressed have an impaired ability to mount an immune response. Studies are currently underway to provide more extensive data regarding the safety and efficacy of the vaccine in the HIV-infected population. There currently are no recommendations to vaccinate males against HPV.
Ongoing cervical screening: Clinicians should continue to perform regular cervical screening with Pap tests and visual inspection of the vulva and vagina during annual pelvic examinations in women who have received the HPV vaccine because the vaccine does not protect against the 25% to 30% of lesions and genital cancers caused by other HPV types. Females who have not engaged in vaginal or anal penetrative sex but who have participated in sexual activity with direct genital contact should be evaluated for vulvar lesions because the virus can be passed through direct contact.
- Centers for Disease Control and Prevention. Quadrivalent Human Papillomavirus Vaccine – Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56:1-24. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr56e312a1.htm
- Clifford GL, Goncalves MA, Franceschi S for the HPV and HIV Study Group. Human papillomavirus types among women infected with HIV: a meta-analysis. AIDS 2006;20:2337-2344.
- Food and Drug Administration. Gardasil. Available at: http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM094042
Sexual Risk Assessment and Risk-Reduction Counseling
Sexuality and sexual practices should be addressed during the initial visit and during routine clinical visits. Adolescents may choose not to disclose all important personal information during the first visit. Some adolescents are comfortable discussing sexual activity and reproductive health with their providers with whom they have had a long-term relationship, in some cases since childhood; however, other adolescents may feel more comfortable discussing their sexual activity with a different provider or a same-sex provider. Clinicians who are nonjudgmental when interacting with patients may establish a trusting bond with the adolescent which will facilitate discussion of sensitive issues.
The purpose of the sexual history and risk behavior assessment is to enable the clinician to provide appropriate risk-reduction counseling. This counseling should include safer-sex practices, including strongly advising continued use of condoms to prevent superinfection with an HIV-infected partner or transmitting HIV/STIs to their sexual partners. Clinicians who are not comfortable discussing different sexual behaviors and ways to reduce the risk of sexually transmitting HIV should seek training to enhance their comfort level. Consultation with clinicians who have experience in risk-reduction counseling for adolescents may also be beneficial.
Elements of a Sexual Risk Assessment
- Is patient is sexually active or does she have plans to initiate sexual activity?
- Age at initiation of sexual intercourse
- Number of sexual partners
- Gender(s) and ages of partners and length of relationships
- Inquiring about the age of partners may be useful because it is often more difficult for younger women to be assertive regarding safe-sex practices with older partners.
- HIV and STI status of partners
- Disclosure to partner(s) of HIV status: If HIV status has not yet been disclosed to partner(s), the clinician should offer assistance.
- History of STIs and treatment
- Sexual practices (oral, anal, vaginal, digital, use of sex toys) with and without protection
- Contraceptive history and current practices, specifying frequency and condom use
- Self-assessment of safer-sex practices
- Pregnancy history
- Sexual abuse (personal or family)
- History of exchanging sex for housing, food, money, or drugs
- Drug or alcohol use
Substance use: Use of alcohol and marijuana is significant among HIV-infected adolescents. Although their use is not a direct risk for HIV transmission, they cause disinhibition which can result in sexual risk taking. Intoxication from these substances impairs the adolescent’s judgment and ability to negotiate condom use and sexual activities with partners. This not only increases the risk of pregnancy and other STIs, but also increases the risk of transmitting HIV infection. Referrals should be made for counseling for patients who indicate risky substance use.
For further information about female substance users, see Care of the HIV-Infected Substance-Using Woman.
Performing a Gynecologic Examination
Adolescent or young adult female patients who have not had a previous gynecologic examination, who have had previous “bad experiences” with pelvic examinations, or who are victims of past sexual assault may require extra time and explanation during their first examination. More than one visit may be necessary for these patients before a comprehensive gynecologic examination can be completed.
|New York State Law|
|Clinicians are required to report cases of suspected child abuse or neglect to the New York State Central Registry at 1-800-635-1522.|
If the clinician is performing the patient’s first pelvic examination, he/she should take time to explain the various steps and components involved in a pelvic examination, show the patient the instruments that will be used, and explain how the instruments function. Well-informed patients may feel more comfortable during examinations, which may then encourage the patient to be proactive in obtaining future routine pelvic examinations. The use of demonstration models or pictures can alleviate concerns about what to expect during a pelvic examination.
The smallest speculum available should be used for a first-time examination, even in sexually active adolescents. For some adolescents, a nasal speculum may be needed.
|Because adolescents may require additional time during clinical visits to become comfortable with the idea of receiving a pelvic examination, it may be necessary to schedule longer appointments.|
Laboratory Tests for Sexually Active Female Adolescents with HIV Infection
Cervical Pap test: Baseline; 6 months after baseline; then annually, as long as results are normal
- Colposcopy should be performed for all HIV-infected women with abnormal Pap tests. Follow-up would then vary on a case-by-case basis. Abnormal Pap tests should be repeated every 3 to 6 months thereafter until there have been two successive normal cervical Pap tests. Women with cervical HSIL also should be referred for high-resolution anoscopy and/or examination with biopsy of abnormal tissue.
- Annual anal cytology should be obtained from patients with a history of anogenital condyloma or abnormal cervical/vulvar histology.
Culture, nucleic acid amplification test (NAT), or urine test for gonorrhea: Baseline and every 6 months
- Urine screening should not preclude performing a pelvic examination because other visible STI lesions may be missed (HPV, HSV, etc.).
- Depending on the sexual behaviors reported or suspected, oral and anal cultures may be indicated as well as cervical or urethral cultures.
RPR or VDRL for syphilis: Baseline and at least annually
- Positive test verified by confirmatory FTA-Abs or MHA-TP. Immunofluorescence or DNA amplification test for chlamydia: Baseline and every 6 months
Urine testing for chlamydia: At 6-month evaluations when pelvic exam is not performed
Herpes simplex virus serology: Baseline
Herpes culture: When symptoms are present
Pregnancy test: Baseline and when: 1) upon patient request; 2) change in menses pattern or flow; 3) when timing of unprotected sex is of concern to patient or care provider; or 4) prior to initiation of teratogenic medication (e.g., efavirenz)
Rates of unintended pregnancy are higher among adolescent and young adult females than among older females; therefore, it is essential that clinicians clearly address reproductive health issues and contraception with HIV-infected adolescents.
Clinicians prescribing contraceptives should be cognizant of adolescent adherence patterns, which may be poor. Many adolescent healthcare clinicians offer younger patients contraception in the form of a shot (Depo-Provera), vaginal ring (Nuvaring), or patch (Ortho-Evra) to reduce inconsistent contraceptive use, which may be encountered with oral contraceptives. However, use of any hormonal contraception is often accompanied by a decrease in use of condoms during sex. Patients should be strongly advised to continue using condoms simultaneously with hormonal contraceptives to avoid superinfection with an HIV-infected partner or transmitting HIV/STIs to their sexual partners.
|Correct and consistent use of routine contraception may be challenging for adolescents. A reliable contraceptive method that does not require daily use may be more successful in this population.|
Injectable progesterone (depot medroxyprogesterone acetate, Depo-Provera) is an efficacious contraceptive; however, current data suggest that Depo-Provera can cause bone demineralization when used for prolonged periods. For this reason, the Food and Drug Administration recommends that providers limit the use of Depo-Provera to 2 continuous years followed by an interruption of its use . Recent data suggest that after 2 years of discontinued use of Depo-Provera, bone mineral density returns; however, these studies have not been performed in adolescents with or without HIV infection.
If efavirenz is used, or combination pills containing efavirenz, female adolescents should be informed of the possible risk to an unborn fetus and should be strongly advised to use effective birth control or choose an alternative medication. Many HIV providers prefer not to use efavirenz in this population because of teratogenicity concerns; efavirenz is contraindicated during the first trimester of pregnancy.
- Food and Drug Administration. Black Box Warning Added Concerning Long-Term Use of Depo-Provera Contraceptive Injection. November 17, 2004.
Reproductive Health Counseling
Upon learning of their HIV infection, many HIV-infected adolescents think that they may not live long enough to bear children or may never be able to bear non-HIV-infected children. Many young women view pregnancy as a “rite of passage” and may feel deprived of this “rite.” Perinatally infected female adolescents may develop strong desires to become pregnant in an effort to be connected to a family of their own or to be “normal.” Their motivations may be to be like their peers or, as a result of their fear of mortality; they may want to have children to leave behind in the event of their own premature death.
Clinicians providing HIV care to adolescents may be the only source of medical information for these patients. Female adolescents may not be as successful as older women in navigating the healthcare system to obtain reproductive health care and information. See Physicians for Reproductive Health: Teen Reproductive Health for additional information.
Clinicians providing HIV care to younger female patients need to proactively counsel patients about future reproductive options. Explicit guidance about how to increase the chances of delivering a healthy, non-HIV-infected infant when the patient is ready to become pregnant should be outlined during this counseling. Topics such as those shown below should be discussed. For patients who are already receiving ARV medications, adherence to the drug regimen should be emphasized. The clinician also should explain to the patient that a planned pregnancy which occurs when the patient is in her best physical condition is one that has the greatest chance of resulting in a healthy, non-HIV-infected infant and a healthy mother.
Elements of Reproductive Health Counseling
- Effect of HIV on pregnancy
- Effect of pregnancy on HIV
- Future reproductive concerns and options
- Routine contraception and use of dual contraceptive methods
- Emergency contraception
- Effect of antiretroviral drugs on oral contraceptive pills
- Potential for maternal and fetal/neonatal toxicity
- Effect on pregnancy outcome
- Role in preventing perinatal transmission
- Importance of adherence to the ARV regimen, especially for patients already receiving ARV medications
Routine prenatal care:
- Vitamin and folic acid supplementation
- Smoking cessation
- Healthy nutrition
Perinatal HIV transmission
- Risk of transmission and risk-prevention
- Mode of delivery (cesarean vs vaginal)
- Avoiding breastfeeding
- Housing and food
- Medical and pediatric care
- Continuing education
Providing Care for Pregnant Adolescents
Pregnancy is often the time when heterosexually infected females are identified as being HIV-infected. The recommendation for universal counseling with recommended testing of all pregnant women, either prenatally or through expedited perinatal testing, has facilitated the identification of HIV infection in adolescents who become pregnant.
Optimal care of HIV-infected pregnant adolescents includes ARV treatment to reduce mother-to-child HIV-1 transmission and maintenance of general health for the pregnant adolescent. Providers face the difficult task of maximally suppressing the virus while avoiding or minimizing potential toxicities to the mother and fetus. To prevent perinatal HIV transmission, a three-part zidovudine regimen is recommended for all HIV-infected pregnant women, regardless of whether or not they are receiving ART, unless a specific contraindication to zidovudine is known, such as a history of a severe adverse effect of zidovudine, severe anemia, or the need for an antagonistic medication such as stavudine. Factors associated with higher rates of transmission include ruptured membranes for more than 4 hours, advanced maternal disease, high maternal viral load, low maternal CD4 cell count, and concomitant infections, including hepatitis C. Cesarean delivery prior to the onset of labor and ruptured membranes can significantly reduce the risk of transmission. Guidelines for the use of ART during pregnancy, routine monitoring of HIV-infected pregnant women, and labor and newborn management are included in Management of HIV-Infected Pregnant Women Including Prevention of Perinatal HIV Transmission.
|Although HIV-infected pregnant adolescents will be referred to obstetrical care services that can provide care to HIV-infected pregnant women, the clinician may want to remain the primary care provider for the adolescent during the pregnancy.|
Clinicians should consider the likelihood of pregnancy when considering specific HAART medications, such as efavirenz or combination pills containing efavirenz, because some adolescent patients may be pregnant for a significant amount of time without informing their HIV providers. Devising prenatal ART regimens for pregnant, perinatally infected females is often difficult because the patients are frequently more advanced in their clinical disease state and may be resistant to many ARV medications. Clinicians should consult with an HIV Specialist when developing a prenatal ART regimen for this population. Treatment during adolescent pregnancy raises multiple issues and should be provided by a clinician experienced in caring for HIV-infected pregnant patients.
Pregnant adolescents may benefit from supportive services to help prepare them for parenthood. Adolescent patients should be referred to supportive services that are often provided at prenatal clinics that encourage a healthy outcome for adolescent patients during their pregnancy and delivery. Supportive services may include prenatal, postpartum, and infant development education; nutrition education for mother and child; parenting skills training; child care support; and counseling, whether group or individual.
|CDC Reproductive Health: Teen Pregnancy|
|ALL RECOMMENDATIONS: CARE OF FEMALE ADOLESCENTS WITH HIV INFECTION|
Identifying a Supportive Adult
Sexual Risk Assessment and Risk-Reduction Counseling
Sexually Active Patients
Reproductive Health Counseling