HIV in youth prevention in the emergency department initiative: A survey of pediatric emergency medicine providers.

BACKGROUND: The incidence of HIV among adolescents remains high, and adolescents are known to participate in sexual behaviors that increase their risk for HIV, such as unprotected sex and sex with multiple partners. HIV pre-exposure prophylaxis (PrEP) has been shown to be effective at preventing HIV when taken daily and is approved by the FDA for use in adolescents. Efforts to screen patients in adult emergency departments and connect them with PrEP services have been validated. We surveyed pediatric emergency medicine (PEM) providers to determine their knowledge of PrEP, prescribing practices, willingness to prescribe, and barriers to a screening protocol in the pediatric emergency department (PED). METHODS: We administered a survey to a multidisciplinary group of PEM providers to measure knowledge, use, willingness, and implementation barriers to PrEP as well as elements needed for a successful referral system. RESULTS: A total of 87 responses were included for analysis. While 79.1% of all providers had heard of PrEP, only 14.8% of prescribing providers had ever discussed PrEP with a patient, and none had ever prescribed PrEP. Overall, 76.3% of all providers were knowledgeable about PrEP based on answers to true/false questions, with prescribing providers significantly more likely to be knowledgeable compared to nurses (p = 0.005). Knowledgeable providers had higher willingness scores to refer for PrEP compared to providers who were not knowledgeable. Ninety-two percent of providers felt a PrEP referral process from the PED would be feasible. Creation of an eligibility algorithm and educational materials were the most common efforts providers preferred to make them more likely to refer for PrEP. The most notable barriers perceived by providers included patient noncompliance with therapy (20.9%), acceptance of PrEP discussion among patients and parents (19.8%), and cost of therapy (15.1%). CONCLUSION: PEM providers are knowledgeable about PrEP but have little experience with discussing or prescribing PrEP. Their willingness to refer for PrEP and anticipated feasibility of a PrEP referral system is encouraging. These results support the need for future educational efforts among PEM providers and creation of referral systems for PrEP services from the PED.

Comparison of Targeted and Routine Adolescent HIV Screening in a Pediatric Emergency Department.

OBJECTIVES: The aims of the study were (1) to compare targeted and routine HIV screening in a pediatric emergency department (PED) and (2) to compare provider documented HIV risk assessment with adolescent perception of HIV risk assessment conducted during the PED visit. METHODS: This prospective study ran concurrent to a PED routine HIV screening pilot. Adolescents could be tested for HIV by the PED provider per usual care (targeted testing); if not tested, they were approached for the routine screening pilot. A subset of adolescents completed a questionnaire on HIV risk. χ 2 analysis compared adolescents with targeted testing and routine screening. HIV-tested patients were asked if HIV risk was assessed; κ analysis compared this with documentation in the provider note. RESULTS: Over 4 months, 107 adolescents received targeted testing and 344 received routine screening. One 14-year-old patient tested positive by routine screening; this adolescent had 2 PED visits without targeted testing within 60 days. Compared with routine screening, adolescents with targeted testing were more likely female (82% vs 57%, P < 0.001), 16 years or older (71% vs 44%, P < 0.001), or had genitourinary/gynecologic concerns (48% vs 6%, P < 0.001). Adolescents with HIV risk factors were missed by targeted testing but received routine screening. Adolescents with documented HIV risk assessment were more likely to receive targeted testing. There was moderate agreement (κ = 0.61) between provider documentation and adolescent perception of HIV risk assessment. CONCLUSIONS: There are gaps in PED HIV risk assessment and testing, which may miss opportunities to diagnose adolescent HIV. Routine HIV screening addresses these gaps and expands adolescent HIV testing in the PED.

Substance Use Disorder Visits Among Adolescents at Children's Hospitals During COVID-19.

PURPOSE: To assess changes in adolescent visits with substance use disorders (SUDs) at children's hospitals during COVID-19. METHODS: We conducted a retrospective cohort study of adolescents (11-18 years) with SUD diagnoses during a hospital visit in the Pediatric Health Information System. Study periods were defined as spring (03/15-05/31), summer (06/01-08/31), and fall (09/01-12/31), pre-COVID-19 (2017-2019), or during COVID-19 (2020). We summarized the change in weekly median visits and interquartile range (IQR) by characteristics and compared between the two periods (e.g., spring pre-COVID-19 [3/15-05/31/2017-2019] versus spring COVID-19 [3/15-05/31/2020]) using median regression. RESULTS: There were 42,979 SUD visits (10,697 COVID-19; 32,282 pre-COVID-19) and 256 annual weekly median adolescent SUD visits [IQR 235, 280] pre-COVID-19 and 268 [IQR 245, 278] during COVID-19. The median number of weekly SUD visits increased by 14.3% during summer COVID-19 (median visits, [IQR]: 272 [268, 278]) compared to pre-COVID-19 (median visits: 237, IQR [216, 249]; p < .001) but did not significantly differ in spring (p = .091) or fall (p = .65) COVID-19. DISCUSSION: Our findings suggest increased problematic adolescent substance use during summer COVID-19. Efforts to increase the identification and treatment of adolescent SUDs remain critical.

Missed Opportunities for Sexual History Documentation and Sexually Transmitted Infection Testing in the Pediatric Emergency Department.

PURPOSE: Sexually transmitted infections (STIs) are disproportionally prevalent in adolescents, and adolescents often present to the pediatric emergency department (PED) for STI care. Prior studies have found low rates of sexual history documentation and STI testing in the PED. However, these studies have had limited sample sizes because of the burden of manual chart review. We aimed to estimate the rate of sexual history documentation and identify factors associated with STI testing in a large cohort of adolescents using natural language processing (NLP). METHODS: We applied a validated NLP algorithm to all adolescent visits over a three-year period to the PED at a single large children's health care organization with a chief complaint potentially related to an STI. We utilized NLP to determine the prevalence of sexual history documentation in these patients. We applied logistic regression models to determine associations between sexual history documentation, patient demographic factors, and STI testing. RESULTS: Of the 1,987 patient encounters included, only 56% had a sexual history documented, and only 40% of all patients were tested for STIs. Patients were more likely to have a sexual history documented and to be tested for STIs if they were of non-Hispanic black race/ethnicity, were >15 years of age, and had nonprivate insurance. Patients with a sexual history documented were seven times more likely to have STI testing ordered. Of patients tested (n = 728), 25% were positive for an STI. CONCLUSIONS: Despite presenting to the PED with symptoms potentially related to an STI, many adolescents are not receiving recommended sexual health care. Rates of sexual history documentation and STI testing varied by demographic factors including race, age, and insurance status. Utilizing NLP technology allowed us to examine a larger sample size than previously documented in the adolescent sexual history and PED literature. This study highlights critical opportunities to improve sexual health provision and equity of care provided in the PED.

Asymptomatic Adolescent HIV: Identifying a Role for Universal HIV Screening in the Pediatric Emergency Department.

Adolescents account for most undiagnosed HIV infections in the United States. Although the Centers for Disease Control and Prevention (CDC) recommends universal HIV screening for all patients ≥13 years, <10% of adolescents have been tested for HIV. To identify earlier opportunities for adolescent HIV prevention and diagnosis in a region of high HIV prevalence, we sought to describe pediatric emergency department (PED) visits made by a retrospective cohort of adolescents who were later diagnosed with HIV as young adults (<25 years) through an adult emergency department (ED) universal HIV screening program. CD4+ count was used to estimate the time of HIV infection before diagnosis and all PED visits in the 10 years before diagnosis were analyzed. Universal HIV screening in the adult ED diagnosed 193 young adults (median 22 years; 90% men; 29% stage 3); 70% had CD4+ at diagnosis that was used to estimate time of infection (mean 3.8 years). Thirty-eight HIV-infected young adults had a total of 109 PED visits in the 10 years before HIV diagnosis. Sexual history was documented in 12% of PED visits and a sexually transmitted infection test was sent in 6%. Ten HIV-infected young adults had 26 PED visits during the time in which they were likely already infected with HIV, each a potential missed opportunity for earlier diagnosis. HIV-infected and at-risk adolescents are underrecognized in PED visits. Implementation of CDC-recommended universal screening may lead to earlier diagnoses and improve outcomes; the PED may also be critical in identifying adolescents eligible for preexposure prophylaxis.

Unique Needs for the Implementation of Emergency Department Human Immunodeficiency Virus Screening in Adolescents.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommend universal human immunodeficiency virus (HIV) screening starting at 13 years, which has been implemented in many general U.S. emergency departments (EDs) but infrequently in pediatric EDs. We aimed to 1) implement a pilot of routine adolescent HIV screening in a pediatric ED and 2) determine the unique barriers to CDC-recommended screening in this region of high HIV prevalence. METHODS: This was a prospective 4-month implementation of a routine HIV screening pilot in a convenience sample of adolescents 13 to 18 years at a single pediatric ED, based on study personnel availability. Serum-based fourth-generation HIV testing was run through a central laboratory. Parents were allowed to remain in the room for HIV counseling and testing. Data were collected regarding patient characteristics and HIV testing quality metrics. Comparisons were made using chi-square and Fisher's exact tests. Regression analysis was performed to assess for an association between parent presence at the time of enrollment and adolescent decision to participate in HIV screening. RESULTS: Over 4 months, 344 of 806 adolescents approached consented to HIV screening (57% female, mean ± SD = 15.1 ± 1.6 years). Adolescents with HIV screening were more likely to be older than those who declined (p = 0.025). Other blood tests were collected with the HIV sample for 21% of adolescents; mean time to result was 105 minutes (interquartile range = 69 to 123) and 79% were discharged before the result was available. Having a parent present for enrollment was not associated with adolescent participation (adjusted odds ratio = 1.07, 95% CI = 0.67 to 1.70). Barriers to testing included: fear of needlestick, time to results, cost, and staff availability. One of 344 tests was positive in a young adolescent with Stage 1 HIV. CONCLUSIONS: Routine HIV screening in adolescents was able to be implemented in this pediatric ED and led to the identification of early infection in a young adolescent who would have otherwise been undetected at this stage of disease. Addressing the unique barriers to adolescent HIV screening is critical in high-prevalence regions and may lead to earlier diagnosis and treatment in this vulnerable population.

Updates on HIV nonoccupational postexposure prophylaxis.

PURPOSE OF REVIEW: Adolescents and young adults continue to contribute to new HIV infections despite improved antiretroviral regimens and HIV preexposure and postexposure prophylaxis (PrEP and PEP). Knowledge about nonoccupational HIV PEP (nPEP) is relevant and important for all pediatricians as adolescents present under a variety of circumstances disclosing past sexual activity. RECENT FINDINGS: nPEP is effective in preventing HIV infection, and newer regimens have been shown to increase compliance amongst users, have less side effects, and lead to less HIV resistance. Yet, research on physician prescription practices shows a lack of knowledge regarding appropriate HIV nPEP medication regimens, dosing, and follow-up recommendations. Updated national guidelines are available to providers who may be unfamiliar with indications and drug regimens for nPEP. Studies also provide different strategies to increase nPEP use and compliance among patients as well as ways to increase provider awareness of appropriate nPEP prescription. SUMMARY: Research of HIV nPEP shows that it is effective when used correctly, but there needs to be increased education and awareness to increase provider prescription and patient use as well as institutional changes to help patients complete the full course of medication.