• New York State Department of Health. Identification and ambulatory care of HIV-exposed and -infected adolescents. New York (NY): New York State Department of Health; 2004 Nov. 22 p. [21 references]

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Identification and ambulatory care of HIV-exposed and -infected adolescents. New York (NY): New York State Department of Health; 2003. 21 p.

The quality of evidence (I-III) is defined at the end of the "Major Recommendations" field.

Identification of Human Immunodeficiency Virus (HIV) Infected Adolescents

• Clinicians should provide HIV counseling for all adolescents and recommend HIV testing to sexually active adolescents when they present for care. (III)
• Clinicians should obtain a sexual risk history at the annual physical examination. (III)
• Clinicians should assess risk issues, including sexual activity and substance use, as well as home environment, history of violence, involvement in foster care, family history, and school, for those in care or undergoing HIV pre- and post-test counseling. Questions regarding physical and sexual abuse, sexual assault, and suicidal ideation, gestures, or attempts should be asked. (III)
• An adolescent who exhibits symptoms of major depression or symptoms of other severe psychiatric disorders during the HIV counseling process should be referred immediately for mental health services. If there is an acute risk of suicidal behavior, HIV testing should be deferred until the risk has been appropriately addressed. (III)
• Clinicians should be knowledgeable about New York State laws pertaining to adolescent consent and confidentiality and should educate their patients about these laws. For more information on a minor's rights regarding consent and confidentiality, refer to Appendix A in the original guideline document. (III)
• Clinicians who care for HIV-infected youths should develop referral agreements with testing sites where youths are initially diagnosed with HIV disease. (III)
• The clinician should identify a supportive adult to whom the adolescent can safely disclose HIV-related information. (III)

Baseline Medical History of HIV Infected Adolescents

• During baseline visits, clinicians should obtain a complete medical history (refer to Table 1 below). (III)
• The sexual history of a sexually active adolescent patient should focus on risk assessment, including the number of recent sexual partners, whether the patient currently has any sexual partners, and, if so, whether or not there are multiple partners or one stable partner. Clinicians should offer assistance with partner notification if needed. (III)
• Youths should be informed of the New York State Partner Notification Law as it pertains to HIV-infected individuals during HIV counseling process and prior to obtaining consent for testing (see Appendix B in the original guideline document). Providers should also offer assistance in disclosing HIV status to sexual and needle-sharing partners. (III)

*In New York State, examples of when a minor might be considered emancipated are as follow: if he/she is married, he/she is in the armed forces; he/she has established a home and is financially independent.

**If HIV status has not yet been disclosed to partner(s), the clinician should offer assistance with partner disclosure.

Baseline Physical Examination for HIV-Infected Adolescents

• During baseline visits, the clinician should perform a full physical examination with emphasis on HIV-associated manifestations (refer to Table 2 below). The examination should include an external genital, breast, and axilla examination using the Tanner rating scale for sexual maturity and perianal inspection of male and female patients. A pelvic examination including sexually transmitted diseases (STD) screening is indicated for female patients who have had sexual intercourse, ask for a pelvic examination, or have an unexplained gynecologic problem. (III)
• A mental status examination should be performed, which includes assessment of general mood, depression, suicidal ideation and attempts, and an abbreviated examination for cognitive function. (See the New York State Department of Health AIDS Institute publication Mental Health Care for People With HIV Infection for further guidance.) (III)

Baseline Laboratory Evaluation

• When performing laboratory tests for HIV-infected adolescents, clinicians should follow guidelines for adults. (New York State Department of Health (NYSDOH) AIDS Institute, 2003; Department of Health and Human Services & Henry J. Kaiser Family Foundation, 2002) (III)
• Clinicians should perform baseline laboratory tests for HIV-infected adolescents which include immunologic and virologic assessment, evaluation for tuberculosis, STD screening, hepatitis antibody panels, and other baseline tests (refer to Table 3 below). (III)

*STD screening is equally important for both male and female adolescents.

**The NYSDOH AI recommends that Pap smears be performed at least annually in HIV-infected women as long as the results are normal. Women with abnormal Pap smears should receive more frequent follow-up, with repeated Pap smears every 3 to 6 months until there have been two successive normal Pap smears. The Centers for Disease Control and Prevention (CDC) and the Agency for Health Care Policy recommend that HIV-infected women receive a gynecological evaluation with pelvic examination and Pap smear, a repeat examination at 6 months, and then annually thereafter. The American College of Obstetrics and Gynecology (ACOG) recommends Pap smear every 6 months for HIV-infected women.

Ongoing Medical Evaluation

• Adolescents should receive a comprehensive annual examination including a complete physical examination. (III)
• Adolescents should be seen for routine visits at least every 3 months. An interim history of HIV-related symptoms, ongoing risk behaviors, and psychosocial issues should be obtained during each routine visit. (III)
• Laboratory evaluations should occur on a routine basis (refer to Table 4 below). (III)
• The clinician should regularly discuss birth control, safe sex, and partner disclosure with patients, and should offer to assist with partner disclosure.(III)
• When ARV therapy is indicated but the youth chooses not to accept it, each routine visit should be viewed as an opportunity to review treatment options. (III)

*The NYSDOH AI recommends that a Pap smear be performed at least annually in HIV-infected women, and those with a history of an abnormal Pap smear should receive more frequent follow-up, with repeated Pap smears at least every 6 months. The Centers for Disease Control and Prevention (CDC) and the Agency for Health Care Policy recommend that HIV-infected women receive a gynecological evaluation with pelvic examination and Pap smear, a repeat examination at 6 months, and then annually thereafter. The American College of Obstetrics and Gynecology (ACOG) recommends Pap smear every 6 months for HIV-infected women.

Ongoing Psychosocial Intervention

The clinician should play a central role in coordinating a multidisciplinary care approach for the HIV-infected adolescent. (III)

Ongoing assessments of the adolescent's housing situation, education, family, sexual partners, safe sex practices, drug use (if applicable), and the adolescent's parenting skills (if applicable) should be integrated into the adolescent's medical care. (III)

When making referrals to drug treatment programs, community-based organizations, and counseling and support programs, the clinician should try to identify agencies with adolescent-focused services. (III)

Clinicians should be familiar with New York State laws pertaining to an adolescent's right to consent for certain forms of health care. (Feierman, Lieberman, & Chu, 1998; English, 1998; New York State Public Health Law, #27850(5), 1993; New York State Public Health Law, #2504(4), 1993) (III)

Special Populations

• Clinicians working with HIV-infected youths should develop skills to work with adolescents with special needs, including perinatally infected adolescents, gay adolescents, transgender adolescents, pregnant adolescents, substance-using adolescents, and homeless adolescents. (III)

Perinatally Infected Adolescents

• Perinatally infected adolescents should be assessed for HIV transmission risk behaviors regardless of their developmental stage. The interventions employed for risk reduction should be individualized for the adolescent's developmental stage. (III)
• Perinatally infected adolescents have the capacity to understand the meaning of an HIV diagnosis and should be informed of their diagnosis if disclosure has not already occurred during childhood. (III)
• The clinician should begin to shift from discussing treatment with the family/caregivers to directly discussing treatment with the perinatally infected adolescent in an age-appropriate manner. (III)
• If an adolescent makes an educated informed decision to discontinue treatment the clinician should respect that decision. (III)
• Sexuality, contraception, substance use, gynecology, and adolescent treatment adherence patterns, should be discussed. (III)
• Pediatricians caring for perinatally infected adolescents should provide or refer for certain clinical services, including gynecologic examinations, contraception/family planning, STD screening, substance use assessment and treatment, and adolescent-focused mental health services. (III)

Gay Adolescents

• Clinicians should perform a comprehensive psychosocial assessment of gay adolescents and should facilitate referrals for mental health care when indicated. (Gionsiorek, 1989; Remafedi, 1994; Ryan & Futterman, 1998) (III)
• The clinician should be part of a support network for a gay adolescent who is more likely to experience feelings of alienation, rejection, and ostracism as compared to his/her same-age heterosexual peers. (III)
• The clinician should be able to counsel the gay adolescent about issues of disclosure of his/her sexuality as well as his/her HIV status. If necessary, the clinician should facilitate safe disclosure to parents and other family members. (III)
• Clinicians should be able to counsel gay youths on risk reduction in a manner that is non-judgmental and is consistent with the youth's sexuality. (III)
• Clinicians should screen gay youths for sexually transmitted diseases yearly and more often if necessary. (III)
• Clinicians should be able to detect the warning signs of adolescent suicide by directly asking questions about whether patients are feeling depressed or isolated, whether they have supportive individuals to whom they can turn, and whether they have had any recent suicidal ideation or gestures. (III)

Transgendered Adolescents

• Clinicians working with transgendered youths should be capable of addressing the specific issues associated with this population, such as mental health, gender identity, hormonal therapy, and sexuality needs. (III)
• Clinicians should obtain a gender identity assessment and inquire about hormone use in transgendered patients. (III)

Pregnant Adolescents and Adolescent Parents

• Clinicians should discuss options with patients who are making decisions about carrying pregnancy to term or terminating pregnancy. (III)
• Clinicians should advise pregnant adolescents who choose to carry pregnancy to term about the benefits of ARV therapy in reducing perinatal transmission. (Kurman et al., 1994; Public Health Service Task Force, 2002) (I)
• Clinicians should have referral agreements with obstetrical services that can provide care to HIV-infected women during pregnancy; however, the clinician may want to continue to be the primary care provider for the adolescent during the pregnancy (refer to the NYSDOH AIDS Institute's Management of HIV-Infected Pregnant Women Including Prevention of Perinatal HIV Transmission for further guidance). (III)

Adolescent Substance Users

• Clinicians should be familiar with programs that provide drug detoxification and maintenance as therapeutic modalities. (III)
• Clinicians should be able to detect alcohol and marijuana use and should be able to provide counseling as well as referral for treatment. (III)
• Clinicians should be familiar with both harm reduction-based and abstinence-based drug treatment programs for the purposes of referral. (III)
• Clinicians should be aware of drug interactions between HIV-related medications and illicit drugs. (III)

Homeless Adolescents

• Clinicians should work closely with case managers and social workers to help homeless youths find appropriate housing. (III)

Definitions:

Quality of Evidence for Recommendation

1. Evidence from one or more properly randomized, controlled trial
2. Evidence from one or more well-designed clinical trial without randomization; from cohort or case-controlled studies
3. Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees

None provided

The type of supporting evidence is classified for selected recommendations (see "Major Recommendations").

• New York State Department of Health. Identification and ambulatory care of HIV-exposed and -infected adolescents. New York (NY): New York State Department of Health; 2004 Nov. 22 p. [21 references]

Not applicable: The guideline was not adapted from another source.

2003 (revised 2004 Nov)

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Not stated

Not stated

Not stated

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Identification and ambulatory care of HIV-exposed and -infected adolescents. New York (NY): New York State Department of Health; 2003. 21 p.

None available

This NGC summary was completed by ECRI on February 3, 2005. This NGC summary was updated by ECRI Institute on September 19, 2007.