Rates of Sexually Transmitted Infection Diagnoses Among US Youth With Perinatally and Nonperinatally Acquired HIV.

BACKGROUND: Of new sexually transmitted infections (STIs) in the United States, 50% occur among youth aged 15 to 24 years. Previous studies among youth with HIV (YHIV) do not distinguish STI trends among individuals with perinatally (YPHIV) and nonperinatally (YNPHIV) acquired HIV. METHODS: Among 3 Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) studies conducted between 2009 and 2015, we estimated incident diagnoses of trichomonal, bacterial, viral, and overall STIs stratified by sex assigned at birth, mode of HIV acquisition (perinatal [YPHIV] and nonperinatal [YNPHIV]), age (13-17 and 18-24 years), CD4 count (<200, 200-499, and ≥500/µL), and HIV viral load (VL) (<400 and ≥400 copies/mL). RESULTS: Among 3131 YHIV, across the 3 studies, mean (SD) age was 20.6 (2.6) years, 888 (28%) were female, 2498 (80%) had nonperinatal HIV acquisition recorded, and 2298 (73%) were African American/Black. Mean follow-up was 0.9 (0.3) years. Compared with YPHIV, YNPHIV spent less person-time with VL <400 copies/mL (47% vs. 53%) and more time off antiretroviral therapy (49% vs. 15%), and had higher overall STI rates (males, 65.9 vs. 8.5/100 person-years [PY]; females, 54.7 vs. 17.2/100 PY). Among YPHIV, bacterial STIs were higher during person-time spent with VL ≥400 vs. <400 copies/mL (male YPHIV, 10.9 vs. 0.6/100 PY; female YPHIV, 11.2 vs. 2.9/100 PY); no difference was observed among YNPHIV, which may be due to concurrent acquisition of HIV and other STIs and limited follow-up. CONCLUSIONS: Compared with YPHIV, YNPHIV spent less time on antiretroviral therapy and virologically suppressed; YNPHIV also had higher STI diagnosis rates. Very high STI diagnosis rates among YHIV, including among those without virologic suppression, highlight the importance of youth-focused efforts to support durable virologic suppression and identify and treat STIs.

High Prevalence of Anal High-Grade Squamous Intraepithelial Lesions, and Prevention Through Human Papillomavirus Vaccination, in Young Men Who Have Sex With Men Living With Human Immunodeficiency Virus.

BACKGROUND: Men who have sex with men (MSM) are at high risk for human papillomavirus (HPV)-related anal cancer. Little is known about the prevalence of low-grade squamous intraepithelial lesions (LSILs) and the anal cancer precursor, high-grade squamous intraepithelial lesions (HSILs), among young MSM with HIV (MSMLWH). HPV vaccination is recommended in this group, but its safety, immunogenicity, and protection against vaccine-type HPV infection and associated LSILs/HSILs have not been studied. METHODS: Two hundred and sixty MSMLWH aged 18-26 years were screened at 17 US sites for a clinical trial of the quadrivalent (HPV6,11,16,18) HPV (qHPV) vaccine. Those without HSILs were vaccinated at 0, 2, and 6 months. Cytology, high-resolution anoscopy with biopsies of lesions, serology, and HPV testing of the mouth/penis/scrotum/anus/perianus were performed at screening/month 0 and months 7, 12, and 24. RESULTS: Among 260 MSMLWH screened, the most common reason for exclusion was detection of HSILs in 88/260 (34%). 144 MSMLWH were enrolled. 47% of enrollees were previously exposed to HPV16. No incident qHPV type-associated anal LSILs/HSILs were detected among men naive to that type, compared with 11.1, 2.2, 4.5, and 2.8 cases/100 person-years for HPV6,11,16,18-associated LSILs/HSILs, respectively, among those previously exposed to that type. qHPV was immunogenic and safe with no vaccine-associated serious adverse events. CONCLUSIONS: 18-26-year-old MSMLWH naive to qHPV vaccine types were protected against incident qHPV type-associated LSILs/HSILs. Given their high prevalence of HSILs, there is an urgent need to vaccinate young MSMLWH before exposure to vaccine HPV types, before initiating sexual activity, and to perform catch-up vaccination.

Using Syndemics Theory to Investigate Risk and Protective Factors Associated with Condomless Sex Among Youth Living with HIV in 17 U.S. Cities.

Identifying risk and protective factors associated with condomless sex among youth living with HIV is imperative for developing effective HIV prevention strategies. A cross-sectional sample of 1728 participants, 12-26 years of age, recruited from adolescent medicine clinics in 17 U.S. cities completed an audio-computer assisted self-interview with questions about their substance use, psychosocial factors, and attitudinal and behavioral factors. Guided by syndemics theory, a path analysis was used to assess the interrelations of these factors. Analyses of model fit statistics indicated statistically significant direct pathways between substance use, psychosocial factors, self-efficacy for risk-reduction, alternative risk-reduction attitudes and behaviors and condomless sex. The total indirect effect of self-efficacy for risk-reduction on condomless sex through alternative risk-reduction attitudes and behaviors was also significant. Multi-faceted, tailored interventions that address individual risk and protective factors and their combined synergistic effects are urgently needed to prevent condomless sex among this population.

Prevalence and risk factors for oral DNA tumor viruses in HIV-infected youth.

Human papillomavirus (HPV), Epstein-Barr virus (EBV), and Kaposi sarcoma-associated herpes virus (KSHV) may promote oral cancers, especially among immunosuppressed individuals. The aims of this study were to examine whether demographic characteristics, medical history, sexual behaviors, substance use, CD4+ T-cell count, HIV viral load, and HPV vaccination were associated with HPV, EBV, and KSHV infection and viral load. Multivariable modeling using logistic or linear regression examined associations between independent variables and infection or viral load, respectively. Among 272 HIV-infected 12-24-year-old youth, 19.5% were positive for oral HPV, 88.2% for EBV, and 11.8% for KSHV. In multivariable models, recent marijuana use (OR 1.97, 95%CI 1.02-3.82) and lower CD4+ T-cell count (<350 vs. ≥350 cells/mm(3) : OR 1.92, 95%CI 1.003-3.69) were associated with HPV infection; lifetime tobacco use (estimated coefficient [EC] 1.55, standard error [SE] 0.53, P = 0.0052) with HPV viral load; recent tobacco use (OR 2.90, 95%CI 1.06-7.97), and higher HIV viral load (>400 vs. <400 copies/ml: OR 3.98, 95%CI 1.84-8.74) with EBV infection; Black versus White race (EC 1.18, SE 0.37, P = 0.0023), and lower CD4+ T-cell count (EC 0.70, SE 0.28, P = 0.017) with EBV viral load, male versus female gender (OR 10, 95%CI 1.32-100) with KSHV infection, and younger age at HIV diagnosis (1-14 vs. 18-20 years: EC 0.33, SE 0.16, P = 0.049; 15-17 vs. 18-20 years: EC 0.35, SE 0.13, P = 0.0099) with KSHV viral load. In conclusion, substance use and immunosuppression are associated with oral DNA tumor viruses in HIV-infected youth. J. Med. Virol. 88:1944-1952, 2016. © 2016 Wiley Periodicals, Inc.

Antiretroviral treatment initiation does not differentially alter neurocognitive functioning over time in youth with behaviorally acquired HIV.

Although youth living with behaviorally acquired HIV (YLWH) are at risk for cognitive impairments, the relationship of impairments to HIV and potential to improve with antiretroviral therapy (ART) are unclear. This prospective observational study was designed to examine the impact of initiation and timing of ART on neurocognitive functioning in YLWH in the Adolescent Medicine Trials Network for HIV/AIDS Interventions. Treatment naïve YLWH age 18-24 completed baseline and four additional assessments of attention/working memory, complex executive, and motor functioning over 3 years. Group 1 co-enrolled in an early ART initiation study and initiated ART at enrollment CD4 >350 (n = 56); group 2 had CD4 >350 and were not initiating ART (n = 66); group 3 initiated ART with CD4 <350 (n = 59) per standard of care treatment guidelines at the time. Treatment was de-intensified to boosted protease inhibitor monotherapy at 48 weeks for those in group 1 with suppressed viral load. Covariates included demographic, behavioral, and medical history variables. Analyses used hierarchical linear modeling. All groups showed improved performance with peak at 96 weeks in all three functional domains. Trajectories of change were not significantly associated with treatment, timing of treatment initiation, or ART de-intensification. Demographic variables and comorbidities were associated with baseline functioning but did not directly interact with change over time. In conclusion, YLWH showed improvement in neurocognitive functioning over time that may be related to practice effects and nonspecific impact of study participation. Neither improvement nor decline in functioning was associated with timing of ART initiation or therapy de-intensification.

Behavioral, immunologic, and virologic correlates of oral human papillomavirus infection in HIV-infected youth.

BACKGROUND: Little is known about the epidemiology or risk factors for oral human papillomavirus (HPV) in HIV-infected youth. The objectives of this study were to determine the prevalence and correlates of oral HPV infection and to explore the association between HPV vaccination and oral infection in HIV-infected youth. METHODS: Youth 12 to 24 years of age with behaviorally acquired HIV were recruited for this cross-sectional study. Procedures involved medical chart review, survey, and collection of an oral rinse sample. Univariable and multivariable logistic regression models were used to determine whether demographic, behavioral, immunologic, and virologic factors and history of vaccination were significantly associated with oral HPV infection. RESULTS: Mean age of the 272 participants was 21.5 years; 64% were non-Hispanic black and 20.2% were Hispanic; and 10.8% of men compared with 20.3% of women were fully vaccinated. Human papillomavirus prevalence was 19.7% in men and 18.6% in women (P = 1.0). Only men were positive for vaccine-type HPV: 5.6% were positive for HPV-6, HPV-11, HPV-16, and/or HPV-18, and 4.2% were positive for HPV-16 and/or HPV-18. Among men who were fully vaccinated, none were positive for HPV-6, HPV-11, HPV-16, and/or HPV-18, compared with 12 (6.3%) of men who were not fully vaccinated (P = 0.37). Two variables were marginally associated with oral HPV (P < 0.10): marijuana use in the previous 3 months and lower CD4+ T-cell count. CONCLUSIONS: Prevalence rates of oral HPV were relatively high in this population of HIV-infected youth and were similar in male and female youth. No fully vaccinated men were infected with vaccine-type HPV.

Incident anal human papillomavirus and human papillomavirus-related sequelae in HIV-infected versus HIV-uninfected adolescents in the United States.

BACKGROUND: Little is known about the incidence of anal human papillomavirus (HPV) infection and related sequelae, as well as factors associated with these outcomes, among adolescents who are HIV infected versus HIV uninfected but at risk. METHODS: We analyzed the data from a multisite US study, the Reaching for Excellence in Adolescent Care and Health Project. Adolescents aged 12 to 18 years who were behaviorally HIV infected (n = 319) or HIV uninfected but at risk (n = 177) were recruited. Incidence rates for anal HPV, high-risk anal HPV, anogenital warts, and anal dysplasia were calculated using Poisson modeling. Factors associated with these outcomes were examined using Cox proportional hazards modeling. RESULTS: Mean age at entry was 16.8 years; mean (SD) follow-up time for detection of anal HPV was 22.4 (10.8) months. Most participants (76%) were female; 70% were black non-Hispanic. HIV-infected (vs. HIV-uninfected) women had a significantly higher incidence of anal HPV (30 vs. 14 per 100 person-years; P = 0.002), high-risk anal HPV (12 vs. 5.3 per 100 person-years; P = 0.04), and anogenital warts (6.7 vs. 1.6 per 100 person-years; P = 0.002) but not anal dysplasia. Although incidence rates were higher for these outcomes among HIV-infected versus HIV-uninfected men, the differences were not statistically significant. Among women, factors associated with anal HPV and related sequelae differed by HIV status and included biological, behavioral, and HIV-related factors. No factors were associated with outcomes in men. CONCLUSIONS: HIV-infected versus HIV-uninfected adolescent women had higher rates of anal HPV and anogenital warts. Because HIV-infected youth are at increased risk of these outcomes, enhanced HPV prevention efforts such as vaccination are warranted for this group.

Comprehension of a simplified assent form in a vaccine trial for adolescents.

INTRODUCTION: Future HIV vaccine efficacy trials with adolescents will need to ensure that participants comprehend study concepts in order to confer true informed assent. A Hepatitis B vaccine trial with adolescents offers valuable opportunity to test youth understanding of vaccine trial requirements in general. METHODS: Youth reviewed a simplified assent form with study investigators and then completed a comprehension questionnaire. Once enrolled, all youth were tested for HIV and confirmed to be HIV-negative. RESULTS: 123 youth completed the questionnaire (mean age=15 years; 63% male; 70% Hispanic). Overall, only 69 (56%) youth answered all six questions correctly. CONCLUSIONS: Youth enrolled in a Hepatitis B vaccine trial demonstrated variable comprehension of the study design and various methodological concepts, such as treatment group masking.

Transition to adult services among behaviorally infected adolescents with HIV--a qualitative study.

OBJECTIVES: The present study aimed to describe the experiences of youth with behaviorally acquired HIV who transitioned to adult care, to identify difficulties encountered, and to explore areas for improvement. METHODS: Semi-structured interviews were conducted with 10 young adults ranging from 24 to 29 years old. Themes were derived from coding participant interviews. RESULTS: Participants experienced adolescent care providers as an important source of support, felt anxiety about transition, provided recommendations for improving the process, and described significant changes associated with adult HIV care. CONCLUSIONS: Findings support the development of a clear and structured transition process to address patients' fears and worries through early communication, planning, and coordination for adult healthcare, highlighting the need for future research in this area.

Partner Notification for Youth Living With HIV in 14 Cities in the United States.

BACKGROUND: Identifying factors associated with partner notification among youth living with HIV is critical for effective HIV prevention and treatment strategies. METHODS: A total of 924 male and female behaviorally infected youth aged 13-24 across 14 U.S. cities completed an audio computer-assisted self-interview including questions about demographics and experiences with patient- and provider-referral partner notification. RESULTS: The majority of participants self-identified as male (82.5%), Black/non-Hispanic (70.1%), and Hispanic/Latino (18.2%). Most males (93.4%) reported engaging in male-to-male sexual contact. Over three-quarters (77.6%) reported that all or some of their partners were contacted, while 22.4% indicated that none were contacted regarding potential HIV exposure. Most (52.4%) reported that only one person talked to them about notifying partners including the HIV tester (36.5%) followed by their health care provider/doctor (27.6%). Less than a fifth (18.3%) were themselves notified of their own exposure to HIV. Using multivariable logistic regression, 3 factors were associated with successful partner notification: (1) when more than one person talked to participants about partner notification (AOR = 1.87, 1.33-2.62); (2) if they themselves had been notified of their own HIV exposure (AOR = 1.83, 1.13-2.95); and (3) if their education included some college or technical school versus less than high school (AOR = 1.72, 1.04-2.85). CONCLUSIONS: Partner notification among youth living with HIV is unsuccessful at least 22.4% of the time, although minimal criteria for partner services are being met almost universally. Partner notification might benefit from enhanced guidelines that call for both HIV testers and HIV care providers to discuss this important strategy with HIV-positive youth.

Soluble CD14, CD163, and CD27 biomarkers distinguish ART-suppressed youth living with HIV from healthy controls.

OBJECTIVE: To define inflammatory pathways in youth living with HIV infection (YLWH), assessments of biomarkers associated with lymphocyte and macrophage activation, vascular injury, or bone metabolism were performed in YLWH in comparison with healthy controls (HC). DESIGN: Longitudinal multicenter study comparing biomarkers in YLWH suppressed on antiretroviral therapy (ART), those with ongoing viral replication, and HC were compared using single blood samples obtained at end of study. METHODS: Twenty-three plasma proteins were measured by ELISA or multiplex assays. Principal component analysis (PCA) was used to define contributions of individual biomarkers to define outcome groups. RESULTS: The study cohort included 129 predominantly African American, male participants, 21-25 years old at entry. Nine biomarkers of lymphocyte and macrophage activation and cardiovascular injury differed between HC and YLWH. Significant positive correlations were identified between lymphocyte and macrophage activation biomarkers among HC and YLWH. Correlations distinct to YLWH were predominantly between biomarkers of macrophage and vascular inflammation. PCA of outcome groups showed HC and suppressed YLWH clustering together for lymphocyte activation biomarkers, whereas macrophage activation markers showed all YLWH clustering distinct from HC. Cardiovascular biomarkers were indistinguishable across groups. Averaged variable importance projection to assess single biomarkers that maximally contribute to discriminate among outcome groups identified soluble CD27, CD14, and CD163 as the 3 most important with TNFα and LPS also highly relevant in providing separation. CONCLUSIONS: Soluble inflammatory and lymphocyte biomarkers sufficiently distinguish YLWH from HC. Persistent macrophage activation biomarkers may provide a means to monitor consequences of HIV infection in fully suppressed YLWH.

HIV Continuum of Care for Youth in the United States.

BACKGROUND: Beneficial HIV treatment outcomes require success at multiple steps along the HIV Continuum of Care. Youth living with HIV are a key population, and sites in the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) are known for modeling optimum HIV adolescent care. METHODS: A longitudinal cohort study conducted at 14 network sites across the United States assessed how the later steps of the Continuum of Care were achieved among the youth: engagement, treatment, and viral load (VL) suppression. Youth aged 13-24 who were behaviorally infected with HIV and linked to care at an ATN-affiliated site were eligible to participate. RESULTS: A total of 467 youth were enrolled and had 1 year of available data. Most were aged 22-24 (57%), male (79%), and black/non-Hispanic (71%). Most used alcohol (81%) and marijuana (61%) in the 3 months before enrollment, and 40% had a history of incarceration. Among this cohort of youth, 86% met criteria for care engagement; among these, 98% were prescribed antiretroviral therapy and 89% achieved VL suppression. Sustained VL suppression at all measured time points was found among 59% with initial suppression. Site characteristics were notable for the prevalence of adherence counseling (100%), case management (100%), clinic-based mental health (93%), and substance use (64%) treatment. CONCLUSIONS: Youth living with HIV in the United States can be successfully treated at health care sites with experience, excellence, and important resources and services. Sustained VL suppression may be an important step to add to the Continuum of Care for youth.

Long-term observation of adolescents initiating HAART therapy: three-year follow-up.

The PACTG 381 cohort included 120 adolescents infected via high-risk behaviors and treated with at least two NRTIs plus either a protease inhibitor or an efavirenz-containing HAART regimen. After 24 weeks of therapy, only 69 of 118 (59%) evaluable subjects had undetectable viral loads. We now present findings of the study after 3 years of follow-up. Virologic, immunologic, and treatment information were collected from subjects every 12 weeks beyond the first 24 weeks of therapy through 156 weeks. Of the 120 subjects starting HAART, 44 (37%) stayed on study treatment for the 3 years of observation. Twenty-nine (24%) subjects reached and maintained undetectable viral loads. Poorer adherence (p = 0.016), higher baseline viral load (p = 0.010), and CD8 naive counts (p = 0.034) predicted virologic failure. Immunologic measurements improved from entry to the end of follow-up in the subjects with undetectable viral loads. CD4 counts at the end of study were not significantly different from HIV-uninfected youth, but CD4%, CD8 counts and percent, and CD8 activation markers remained significantly different. Adolescents infected with HIV via high-risk behaviors have less than optimal responses to HAART therapy with only 24% achieving and maintaining undetectable viral loads over 3 years. Immunologic improvement was demonstrated and CD4 counts in subjects with virologic control reached levels in HIV-uninfected adolescents. Interventions, especially those focused on adherence, are necessary to improve HAART outcomes in adolescents.

Posttraumatic stress and trauma history in adolescents and young adults with HIV.

This study examined trauma history and posttraumatic stress in a sample of 30 adolescents and young adults with HIV/AIDS, recruited from December 14, 2004 through May 3, 2005. Overall, participants reported a mean of 5.63 traumatic events, with 93% of the sample reporting that receiving a diagnosis of HIV was experienced as traumatic. Of these, 13.3% met criteria for posttraumatic stress disorder in response to HIV diagnosis, while an additional 20% showed significant post-traumatic stress symptoms. Even greater rates of posttraumatic stress were reported in response to other trauma, with 47% of youth surveyed reporting symptoms of posttraumatic stress in response to such traumatic events as being a victim of a personal attack, sexual abuse, or being abandoned by a caregiver. These findings may inform professionals about the potential impact of the HIV diagnosis on adolescents and young adults, particularly as this may impact participation in medical care and need for mental health support.

Immune reconstitution and predictors of virologic failure in adolescents infected through risk behaviors and initiating HAART: week 60 results from the PACTG 381 cohort.

The responses to HAART in HIV-infected adolescents infected through risk behaviors are not well defined. PACTG 381 collected intensive immunologic and virologic data on youth naive to or with minimal exposure to antiretroviral therapy who began HAART. Subjects were evaluated according to their weeks 16-24 virologic response. Comparisons with a cohort of HIV-uninfected adolescents from the REACH cohort were performed. Cox proportional hazards models were used to identify baseline and week 24 predictors of virologic failure. Only 69 of 120 subjects (58%) achieved virologic suppression by weeks 16-24, whereas 55 of 69 (80%) demonstrated control to week 60. Higher CD4+ naive T cells (CD4+/62L+/RA+: hazard ratio [HR], 2.13; p = 0.018), higher CD8+ activated T cells (CD8+/CD38+/DR+: HR, 1.40, p = 0.028 per 100 cells/mm3) and higher CD8+ naive T cells (CD8+/62L+/RA+: HR, 1.72; p = 0.005) at weeks 16-24 in subjects with early viral success were predictive of subsequent failure. By week 60, total CD4+ T cells remained significantly lower than in uninfected controls. Adolescents beginning HAART achieve moderate rates of viral suppression by weeks 16-24. In those who do achieve early virologic control, suppression to week 60 is high although total CD4+ T cells remain significantly lower than in uninfected controls. Several T cell markers were predictive of subsequent virologic failure in subjects achieving short-term success. Further study is warranted to determine whether these predictors provide any benefit to clinical management.

Immune Reconstitution but Persistent Activation After 48 Weeks of Antiretroviral Therapy in Youth With Pre-Therapy CD4 >350 in ATN 061.

BACKGROUND: Measures of immune outcomes in youth who initiate combination antiretroviral therapy (cART) early in HIV infection are limited. DESIGN: Adolescent Trials Network 061 examined changes over 48 weeks of cART in T-cell subsets and markers of T-cell and macrophage activation in subjects with pre-therapy CD4 > 350 cells/mm. All subjects had optimal viral suppression from weeks 24 through 48. METHODS: Subjects (n = 48) initiated cART with tenofovir/emtricitabine plus ritonavir-boosted atazanavir. Data were collected at baseline and weeks 12, 24, and 48. Trends were compared to uninfected controls. RESULTS: Significant increases over 48 weeks were noted in all CD4 populations, including total, naive, central memory (CM), and effector memory RO (EM RO) and effector memory RA (EM RA), whereas numbers of CM and EM RO CD8 cells declined significantly. By week 48, CD4 naive cells were similar to controls, whereas CM CD4 cells remained significantly lower and EM RO and EM RA subsets were significantly higher. CD38 and HLA DR expression, both individually and when co-expressed, decreased over 48 weeks of cART on CD8 cells but remained significantly higher than controls at week 48. In contrast, markers of macrophage activation measured by sCD14 and sCD163 in plasma did not change with cART and were significantly higher than controls. CONCLUSIONS: In youth initiating early cART, CD4 cell reconstitution is robust with decreases in CD8 cells. However, CD8 T-cell and macrophage activation persists at higher levels than uninfected controls.

How to reach sexual minority youth in the health care setting: the teens offer guidance.

PURPOSE: To explore factors sexual minority youth believe make them feel safe in a health care setting. METHODS: Participants in three urban programs serving lesbian/gay/bisexual/transgendered and questioning (LGBTQ) youth engaged in a four-stage process to generate, prioritize, and explain their own ideas. In Stage III, 94 youth, aged 14 to 23 years, completed a survey comprised of the 34 highest rated items generated in earlier stages. Using a Likert scale, they answered, "How important are each of the following ideas in making you feel safe as an LGBTQ youth when you go for health care?" In Stage IV, youth discussed the results in focus groups. The Marginal Homogeneity Test divided the items into priority ranks and the Kruskal-Wallis test explored subgroup differences in item ratings. RESULTS: The 34 items were divided into six ranks. Five items shared the top rank: the clinician maintaining privacy, demonstrating cleanliness, offering respect, being well-educated, and being honest. The second rank was shared by the following: the clinician not talking down to patients, being a good listener, not downplaying patients' fears, being professional, holding a nonjudgmental stance of the LGBTQ lifestyle, and not assuming every LGBTQ youth has HIV. Interspersed among other ranks were items specific to the needs of sexual minority youth: the clinician not assuming LGBTQ sexual behavior was painful or dangerous; the clinician being educated about the gay lifestyle; clinician sensitivity to the needs of same-sex partners; staff sensitivity to the needs of closeted youth; having a choice of an LGBTQ provider; and the clinician not assuming heterosexuality. Youth who had not publicly disclosed their sexuality rated health information being offered in a private place higher (p =.01). CONCLUSIONS: LGBTQ youth value the same clinician characteristics desired by all adolescents: privacy, cleanliness, honesty, respect, competency, and a nonjudgmental stance. They clearly describe what attracts them (e.g., clinicians educated about their lifestyle) and what offends them (e.g., equating their sexuality with HIV). Clinicians need to achieve and convey a higher comfort level in addressing the special needs of sexual minority youth.

Lesbian, gay, bisexual, transgendered, and questioning youth: the importance of a sensitive and confidential sexual history in identifying the risk and implementing treatment for sexually transmitted infections.

STIs are one consequence of specific risk-taking behaviors, not sexual orientation. Providers who care for adolescents should be aware of the STIs for which LGBTQ youth are at risk and the necessary screening (see Table 1). Although it is vital to recognize that LGBTQ youth are at risk for STIs, it is important not to view the youth within this narrow perspective. LGBTQ youth, like all adolescents, should be appreciated for their individuality, idealism, and resiliency. Most LGBTQ youth emerge from adolescence as productive and healthy adults. Treating adolescents with understanding and respect and honoring confidentiality are integral to the physical and emotional health of young people dealing with sexual-identity issues. Understanding the process of sexual-identity formation is the first step in gaining knowledge and perspective about young people with sexual-identity issues and helping them reduce their risk for contracting STIs. Physicians caring for adolescents should consult recent comprehensive reviews to improve their understanding of the issues LGBTQ youth may encounter.

Exploration of the Effect of Tobacco Smoking on Metabolic Measures in Young People Living with HIV.

We conducted cross-sectional, multicenter studies in HIV-positive young women and men to assess metabolic and morphologic complications from tobacco smoking in 372 behaviorally infected HIV-positive youth, aged 14-25 years. Measurements included self-reported tobacco use, fasting lipids, glucose, fat distribution, and bone mineral density (BMD; dual-energy X-ray absorptiometry scans). Overall, 144 (38.7%) self-reported smoking tobacco and 69 (47.9%) of these reported smoking greater than five cigarettes per day. Smokers versus nonsmokers had lower mean total cholesterol (146.0 versus 156.1 mg/dL; P < 0.01) and lower mean total body fat percent (24.1% versus 27.2%, P = 0.03). There was no difference between smokers and nonsmokers in fasting glucose or BMD. There appear to be only minimal effects from tobacco smoking on markers of cardiac risk and bone health in this population of HIV-positive youth. While these smokers may not have had sufficient exposure to tobacco to detect changes in the outcome measures, given the long-term risks associated with smoking and HIV, it is critical that we encourage HIV-positive youth smokers to quit before the deleterious effects become apparent.

Linkage to care for HIV-positive adolescents: a multisite study of the adolescent medicine trials units of the adolescent trials network.

PURPOSE: To understand linkage to care practices at sites providing clinical services to newly diagnosed HIV-positive adolescents. METHODS: Qualitative analysis of detailed interviews conducted with 28 personnel involved in linkage to care at 15 sites providing specialty care to HIV-positive adolescents. RESULTS: We showed that multiple models exist for linkage to care, and that both formal and informal community relationships are important for successful linkage to care. Stigma was seen as a universal issue, enhancing the importance of the balance of confidentiality and social support. Barriers to care, such as mental health issues, substance use, and transportation, are common. CONCLUSIONS: We conclude that the complexity of linkage to care requires thought and planning as HIV testing is expanded to lower-risk populations.