Identification of a Supportive Adult
Clinicians should identify a supportive adult to whom the adolescent can safely disclose human immunodeficiency virus (HIV)-related information and discuss reproductive health issues.
Human Papillomavirus Vaccine (HPV)
Clinicians should offer the HPV vaccine to HIV-infected females between the ages of 9 and 26 years.
Clinicians should continue to obtain cervical Pap tests on the recommended schedule in HIV-infected women who have been vaccinated with HPV vaccine (see the Table below). Vaginal and vulvar visual inspection should be continued at regularly scheduled pelvic examinations.
HPV typing prior to administering the vaccine is not recommended.
Sexual Risk Assessment and Risk-Reduction Counseling
Clinicians should obtain a sexual risk assessment during the baseline examination and during routine visits (see Table 1 in the original guideline document).
The clinician should routinely discuss sexuality, personal relationships, birth control, safe sex, and partner disclosure with patients. Clinicians should discuss partner disclosure prior to the onset of the adolescent's sexual activity.
Clinicians should inquire about physical and sexual abuse and sexual assault and should refer patients for counseling when indicated.
Clinicians should recommend consistent and correct use of latex condoms to prevent pregnancy, acquisition of sexually transmitted diseases (STDs), transmission of HIV/STDs, and superinfection. For patients with a latex allergy, clinicians should recommend polyurethane condoms. Clinicians should advise HIV-infected adolescents to avoid using lambskin condoms or condoms that are lubricated with nonoxynol-9. For adolescents with same-sex partners, the use of dental dams during oral sex and safe use of sex toys should be discussed to prevent disease transmission.
Clinicians should use a model to demonstrate to adolescents the correct way to use a condom.
Clinicians who are not comfortable discussing sexual practices with adolescents should consult with clinicians who have experience in risk-reduction counseling for adolescents or seek training to enhance their comfort level.
Performing Gynecologic Examinations
At baseline and as part of the annual comprehensive physical examination, clinicians should obtain a menstrual, gynecologic, and sexual history as well as examine the external genitalia, anus, perineal area, breasts, and axilla using the Tanner rating scale for sexual maturity.
The clinician should educate the patient about the importance of periodic pelvic examinations, STD screening, and Pap tests.
Clinicians should perform the first gynecologic examination when any of the following occur:
- The patient reports sexual activity
- The patient requests a pelvic examination
- The patient presents with any gynecologic symptom for which a pelvic examination would assist in a differential diagnosis (e.g., pelvic pain or new onset menstrual irregularity)
- The patient presents with symptoms of an STD or sexual activity
- The patient reaches age 14 -- however, if the inspection reveals an intact hymen or no likely sexual activity, the speculum examination and the Pap test should be deferred until age 18 or until the patient is sexually active, whichever occurs first
Before performing a first-time pelvic examination in a patient, the clinician should explain the various steps and components involved in the examination, including a review of basic genital anatomy, the instruments used for the examination, and the purpose of the examination.
Clinicians should use the smallest speculum available for a first-time examination, even in sexually active adolescents.
Patients should be asked if they would prefer having a female provider perform the examination. During the examination, an additional female member of the medical staff should be present as a chaperone.
Primary care clinicians who do not directly provide gynecologic care should obtain a menstrual, gynecologic, and sexual history and then refer the patients to gynecologic providers with experience providing examinations to adolescents.
Key Point:
Adolescents may require additional time during clinical visits to become comfortable with the idea of receiving a pelvic examination. Additional time may be needed when scheduling these appointments.
Evaluation for Sexually Active HIV-Infected Female Adolescents
At baseline and as part of the annual comprehensive physical examination, clinicians should examine the anogenital area, including the vulva and vagina, to assess for visible ulcerative lesions.
Clinicians should perform the laboratory tests listed in the Table below for HIV-infected females who are sexually active.
Table
Laboratory Tests for Sexually Active HIV-Infected Adolescent Females
|
| Test |
Frequency |
| Cervical Pap test |
Baseline, repeated at 6 months, and then annually, if the results are normal1,2 |
| Culture, deoxyribonucleic acid (DNA) amplification test, or urine test for gonorrhea3,4 |
Baseline and every 6 months |
| Rapid plasma regain (RPR) or Venereal Disease Research Laboratory (VDRL) for syphilis5 |
Baseline and at least annually |
| Immunofluorescence or DNA amplification test for chlamydia |
Baseline and every 6 months |
| Urine test for chlamydia |
At 6-month evaluation when a pelvic examination is not performed |
| Herpes simplex virus serology |
Baseline |
| Herpes cultures |
When symptoms are present |
| Pregnancy test |
Baseline and when: 1) the adolescent requests one, 2) menses change in pattern or flow, 3) timing of unprotected sex concerns the patient or provider, or 4) prior to starting teratogenic medications (e.g., efavirenz) |
1Women with abnormal Pap tests should be referred for colposcopy. Follow-up would then vary on a case-by-case basis. Abnormal Pap tests should be repeated every 3 to 6 months until there have been two successive normal cervical Pap tests. Women with cervical high-grade intraepithelial lesion (HSIL) should be referred for high-resolution anoscopy.
2Patients with a history of anogenital condyloma or abnormal cervical/vulvar histology should receive an annual anal Pap test.
3Urine screening should not preclude performing a pelvic examination because other visible STD lesions may be missed (HPV, herpes simplex virus [HSV], etc.)
4Depending on the sexual behaviors reported or suspected, oral and anal cultures may be indicated as well as cervical or urethral cultures.
5Positive test verified by confirmatory fluorescent treponemal antibody absorption test (FTA-Abs) or microhemagglutination-treponema pallidum (MHA-TP)
Contraception
Clinicians should counsel patients about contraceptive options. If necessary, patients should be referred to a family planning provider for contraceptive counseling.
Clinicians should recommend the simultaneous use of a condom and an additional method of contraception (dual method use) in the event of condom breakage or slippage.
When prescribing hormonal contraceptives, clinicians should consider, on a case-by-case basis, drug interactions between HIV-related medications and hormonal contraceptives, the patient's adherence patterns to medications, and the side effect profile of the hormonal contraceptives. Clinicians should also reinforce the importance of using condoms in addition to hormonal contraception.
Clinicians should counsel HIV-infected adolescents about the interactions between antiretroviral (ARV) medications and oral contraceptives, specifically lopinavir/ritonavir, nelfinavir, nevirapine, ritonavir, saquinavir, and tipranavir, because contraception protection may be reduced.
Clinicians should strongly recommend the use of contraception for HIV-infected adolescent females of childbearing age who are receiving efavirenz or combination pills containing efavirenz.
Key Point:
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.
Reproductive Health Counseling
Clinicians should provide reproductive health counseling to HIV-infected female adolescents (see table below). As part of reproductive health counseling, clinicians should educate female adolescents about the importance of maintaining their own health should they wish to become pregnant in the future.
Clinicians should recommend prenatal vitamins and folic acid for adolescents who wish to become pregnant or who are not taking action to prevent pregnancy.
For adolescents considering pregnancy, likely to become pregnant, or not actively using a method of contraception, clinicians should discuss the following concerning ARV medications:
- Efavirenz (including combination pills containing efavirenz)
- Efavirenz should be avoided because of teratogenicity concerns.
- If there are no alternatives for efavirenz, clinicians should strongly advise the use of effective contraception and should obtain a pregnancy test before initiation.
- For adolescents receiving efavirenz and expressing a desire to have children, efavirenz should be discontinued 2 months before stopping contraception.
- Hydroxyurea should be avoided.
- Liquid amprenavir and didanosine/stavudine in combination should be used with caution.
Key Point:
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.
Table
Elements of Reproductive Health Counseling for HIV-Infected Adolescent Females
|
| General Concerns |
- Effect of HIV on pregnancy
- Effect of pregnancy on HIV
- Future reproductive concerns and options
|
| Contraception |
- Routine contraception
- Use of dual contraceptive methods
- Emergency contraception
- Effect of ARV drugs on oral contraceptive pills
|
| ARV Medications |
- 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
|
| Parenting Responsibilities |
- Housing/food
- Childcare
- Medical care and pediatric care
- Continuing education
|
Providing Care for Pregnant Adolescents
Clinicians should consider the likelihood of pregnancy when selecting specific highly active antiretroviral therapy (HAART) medications for HIV-infected adolescents because some adolescents may not inform the clinician about a pregnancy for significant periods of time.
Clinicians should discuss options with patients who are making decisions about carrying pregnancy to term or terminating pregnancy. For adolescents who are not comfortable discussing pregnancy with their long-term provider, other trained professionals should be accessible.
Clinicians should educate pregnant adolescents who choose to carry pregnancy to term about the role of ARV therapy in optimizing maternal health and reducing the likelihood of perinatal transmission.
Clinicians should use the three-part zidovudine regimen for all HIV-infected pregnant adolescents, regardless of whether or not they are receiving HAART, 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.
The clinician should consult with an HIV Specialist to devise prenatal HAART regimens for perinatally infected adolescents.
Primary care clinicians should have referral agreements with obstetrical services that can provide care to HIV-infected females during pregnancy.
Clinicians should refer adolescent patients to supportive services available at prenatal clinics.
The adolescent's clinician should work in conjunction with the infant's pediatrician to provide the adolescent with access to training to improve parenting skills and other necessary services.
Key Point:
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.
