“HIV/AIDS: Adolescents and Youth”

1. “HIV/AIDS: Adolescents and Youth” Epidemiology, Outreach, Engagement and Treatment Issues of Significance for the HIV Health and Human Services Planning Council of New York Jeffrey M. Birnbaum, MD, MPH Assoc. Professor of Pediatrics & Preventive Medicine Director, HEAT & FACES Programs SUNY Downstate Medical Center , Brooklyn, NY

2. What are the key issues to understand in HIV/AIDS with adolescents and youth? • Scope of the epidemic • Developmental context • Age appropriate services • Subgroups of youth at risk • HIV counseling and testing • Rights to consent and confidentiality • Engaging in care • Transitioning • HAART and treatment adherence

3. Youth At Risk for HIV • Young males who have sex with other males regardless of their sexual identity • Heterosexually active females • Transgendered youth • “Ballroom” community • Sexual abuse • Survival sex • Teen pregnancy • Youth in foster care system • Homeless youth • Substance using youth • Youth in justice system • Long term survivors of perinatal HIV infection

4. 1. NYCDOHMH Surveillance Report, 2008

5. 1. NYCDOHMH Surveillance Report, 2008

6. Health Department Releases Estimate of Yearly HIV InfectionsCDC method suggests the virus is spreading in New York City at three times the national rate “Half of NYC’s 2006 infections occurred among men who have sex with men (MSM), a group that has always been heavily affected by HIV/AIDS and remains at high risk. MSM of all races were affected, and new infections were evenly distributed among black, white and Hispanic MSM. But the new findings point to a generational divide. Blacks and Hispanics accounted for 77% of the new infections among MSM under 30, versus 59% of those 30 to 50. Two thirds of MSM infections occurred in the older group in 2006, but past analyses show that diagnoses in older MSM are declining while diagnoses in younger MSM are increasing.” Press Release # 057-08Wednesday, August 27, 2008 http://home2.nyc.gov/html/doh/html/pr2008/pr057-08.shtml

7. *New York City HIV/AIDS Annual Surveillance Statistics, 2007

8. Unique Issues Surrounding Young Women and HIV • Black and Hispanic women account for 79 percent of all reported HIV infections among women ages 13 to 19 and 75 percent of HIV infections among women ages 20 to 24 in the U.S., although • together they represent only about 26 percent of U.S. women in this age group. This disproportionate burden is also reflected in NYC. • Of the 30,000 women and girls living with HIV/AIDS NYC, a disproportionate number (90 percent) are black or Hispanic; more than a third were infected through heterosexual activity (41 percent). • Females comprise a greater proportion of new HIV diagnoses among blacks, compared to other racial/ethnic groups. • Adolescent and young adult women face the additional societal HIV risks of power imbalance and dependency in relationships with older men, teen pregnancy, homelessness, unaddressed mental health needs.

9. Hallmarks of Adolescent Development • Sense of immortality • Risk taking is the norm • Emerging sense of identity • Emerging sense of autonomy and independence • Challenging authority figures • Experimentation with sex and gradual development of sexual identity • Experimentation with substance use • Peer pressure

10. Targeted Outreach and Engagement Techniques • Who: • Young MSM/Gay & Bisexual Adolescent and Young Adult Men from communities of color • Heterosexual Adolescent and Young Adult Women • Transgender Youth • Perinatally Infected Youth How: • Youth friendly HIV outreach messages, brochures, posters and events • Youth friendly and focused HIV counseling and testing- how to best make “routine”, developmentally appropriate questions, non-judgemental approach, right to consent and confidentiality, youth specific issues (school, family, sex, relationships, etc.), support, consent process crucial!! • Youth friendly HIV care services!!!!!!!!!!!!!

11. Youth Rights to Consent and Confidentiality in New York State • STD screening and treatment • Family planning/birth control • Prenatal care • Termination of pregnancy • HIV counseling and testing • HIV care • Substance abuse treatment • Mental health services • Transgender care

12. Differences in HIV Care Models:Pediatric vs. Adolescent vs. Adult Pediatric: • family-centered and multidisciplinary care with pediatric expertise • medical provider has more long standing relationship with care giver at home • primary care approach integrated into HIV care • issues of HIV disclosure to patient and youth’s confidentiality/right to consent • care usually offered in discreet, child-friendly and intimate setting • teen services supplemental to existing services

13. “Supplemental” Clinical Services for Perinatally Infected Youth • Sexuality • Pelvic examinations/Pap smears • STD screening • Pregnancy • Substance use • Issues of treatment options • Treatment adherence

14. Differences in HIV Care Models:Pediatric vs. Adolescent vs. Adults Adolescent: • Teen-centered and multidisciplinary care; provider may have minimal to no relationship with parent/care giver • Primary care approach integrated into HIV care with adolescent specialist providers as part of care team • Youth often does not disclose HIV status to family • Issues of confidentiality and consent; care usually offered in discreet, teen-friendly and intimate setting • Teen services core to clinic-sexuality, pelvic examinations/Pap smears, STD screening and tx, reproductive health,substance use, rights to confidentiality and consent, treatment education and adherence approaches • “Ownership” over HIV treatment decisions

15. Core Elements of A Successful Adolescent Care Program • Competent providers who enjoy working with youth • Staff that can relate to the “world” youth live in • Youth friendly space in a discrete location • Comprehensive and multidisciplinary services • “One Stop Shopping” principle vs. care by referral • Grant funding • Institutional support • Removal of barriers youth face when seeking to independently access health care services • Essential community linkages • Central role of adolescent specialist case managers

16. Differences in HIV Care Models:Pediatric vs. Adolescent vs. Adult Adult: • adult-oriented care based on strict medical model • Adult medical providers more often ID specialists than are pediatric or adolescent providers • Young person’s transitional issues usually not given any systematic specialized focus • Clinics tend to be very large and easy for transitioning patients to “slip through the cracks” unless very motivated