Disclosure of serostatus by HIV infected youth: the experience of the REACH study. Reaching for Excellence in Adolescent Care and Health.

PURPOSE: To describe disclosure of HIV serostatus by infected youth to parents and sexual partners and to examine the association of disclosure with subject characteristics. METHODS: Baseline data on 317 HIV infected adolescents in national 15 site study were examined. Data sources included direct and computer-assisted interview, laboratory studies, and chart reviews. Examination of parental disclosure was restricted to subjects without parental permission requirements. Concordance in parental disclosure/support used McNemar's test. Associations between disclosure to parent(s) and subject characteristics were examined using logistic regression analysis. Repeated measure analysis was used for sexual partner disclosure. RESULTS: Subjects of both genders more often disclosed their HIV infection status to mothers than to their fathers (77% vs. 47%, p < .001). With disclosure, perceived support from either parent was high. In multivariate analyses, factors associated with maternal disclosure were length of time since diagnosis (OR = 1.43; 95% CI: 1.06-1.92), and Hispanic ethnicity (OR = .37; 95% CI: .15-.95). No factors were significantly associated with paternal disclosure in multivariate analysis, although length of time since diagnosis showed a trend (OR = 1.31; 95% CI: 1.00-1.74). Factors associated with disclosure to sexual partners were partner's HIV+ status (OR = 2.09; 95% CI: 1.11-3.93) and "main partner" status (OR = 3.17; 95% CI: 1.84-5.46). CONCLUSIONS: Although subjects were more likely to reveal their status to their mothers, parental support was perceived as high after disclosure to either parent. Since "time since diagnosis" was associated with parental disclosure, support systems are necessary for youth until such a disclosure can occur.

HIV-1 RNA levels and development of clinical disease in two different adolescent populations.

HIV infection rates in American youth continue to increase unabated. As adolescent-specific therapeutic interventions are planned, information on HIV infection's course and its predictors becomes critically important for valid and precise study design. We report on age-specific disease rates stratified by estimated time since infected and predictors of HIV disease progression through four clinical categories in two distinct adolescent populations. Adolescents with hemophilia infected through contaminated blood products showed disease progression rates of 18 to 23 events per 100 person-years (PYs) by age and years infected. Predictors of first progression included HIV-1 RNA >30,000 copies/ml (rate ratio [RR], 2.4; 95% confidence interval [CI], 1.5-3.9), antiretroviral monotherapy (RR, 2.4; 95% CI, 1.7-3.3); Latino/a ethnicity (RR, 2.2; 95% CI, 1.2-4.2) and initial intermediate clinical status (RR, 1.9; 95% CI, 1.3-2.9). Sexually-infected adolescents >18 years who had been infected >3 to 6 years had a disease progression rate of 16 events per 100 PY. For these youths, the sole predictor of first progression was viral load (VL) (RR for VL >30,000 copies per ml, 8.4; 95% CI, 2.8-25.1). This article examines the predictive capacity of viral load and evaluates other cofactors for disease progression in different adolescent populations. These data will be of value in clinical trial design.

Serologic examination of hepatitis B infection and immunization in HIV-positive youth and associated risks. The Pediatric AIDS Clinical Trials Group Protocol 220 Team.

This seroprevalence report examines serologic evidence of hepatitis B immunization or infection and associated demographic/behavioral factors in adolescent (aged 12-20) subjects enrolled in a nontherapeutic clinical trial at 43 Pediatric AIDS Clinical Trials Group (PACTG) clinical centers. Subjects (n = 94) infected with the human immunodeficiency virus (HIV) through sexual activity were categorized as hepatitis B virus (HBV)-immunized, HBV-infected, or nonimmune by hepatitis B serology performed on specimens collected within the subject's first 48 weeks on study (1993-1995). Sixteen percent of the 94 serologically classified subjects were immunized; 19% HBV-infected; 65% nonimmune. Of the three risk factor scores examined (sociodemographic, sexual, and substance abuse), substance use alone demonstrated a significant difference among groups (despite virtually no reported injecting drug behavior), with the sexual risk score exhibiting marginally significant differences. Logistic regression analysis (restricted to nonimmunized subjects) showed that male-male sexual activity raised the odds of HBV infection by a factor of 5.14 (95% confidence interval [CI]: 1.45-18. 23) relative to heterosexual activity; and that for every one point increase on the substance abuse risk scale the odds of infection increased 5% (95% CI: 0.99-1.10). The HBV infection rate in PACTG 220 HIV-positive females is twice United States population-based rates; the rate in PACTG 220 HIV-positive males is nearly seven times higher. Past immunization efforts in this population appear to have been based on sexual activity volume without regard to injecting-drug use in sex partners.

Psychiatric diagnoses in adolescents seropositive for the human immunodeficiency virus.

OBJECTIVE: To provide a descriptive analysis of the prevalence of past and current psychiatric disorders in adolescents positive for the human immunodeficiency virus (HIV). DESIGN: Structured interview in a convenience sample in a primary care urban adolescent clinic in Washington, DC. PARTICIPANTS: Thirty-four HIV-seropositive adolescents ranging in age from 16 to 21 years. MAIN OUTCOME MEASURES: The Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-P) was administered by a child psychiatrist or a clinical child psychologist. Extensive review of medical records was also conducted. RESULTS: A majority of the HIV-infected adolescents in our sample had received psychiatric diagnoses prior to their treatment at the clinic (53%), had a documented history of sexual abuse (50%), and had a history of substance use (82%). Psychiatric diagnoses determined by the SCID-P indicated that 85% of the sample had a current Axis I disorder, with 44% reporting ongoing depressive disorders. CONCLUSIONS: The majority of subjects in this sample had had a previous psychiatric diagnosis, and almost half had a current affective disorder. Psychiatric disorders, especially affective disorders, may be a risk factor for high-risk sexual behaviors and substance use that increases the risk for HIV infection in adolescent populations.

Inaccurate documentation of HIV-positive status in adolescents visiting an urban emergency department.

PURPOSE: To identify the frequency of documentation of human immunodeficiency virus (HIV)-positive adolescents' serostatus during urban pediatric emergency room visits, and to examine possible differences between those whose HIV positive serostatus was and was not documented. METHODS: Between 1986 and 1996, 115 HIV-positive adolescents (41 male, 74 female) were followed for primary medical care at the Children's National Medical Center's adolescent HIV clinic (Burgess Clinic) in Washington, DC. A retrospective chart analysis of visits to the emergency room by these adolescent patients known to be HIV positive was conducted. RESULTS: Forty-nine of the HIV patients (ages 10-23 years) visited the hospital's emergency room a total of 124 times in the time following notification (range, 2 days to 15 years; mean, 2.6 years) of their seropositivity and joining the program. Twenty-nine of the patients had no HIV seropositivity recorded during one or more of their visits; this prevalence represents 38% of the 124 emergency room visits. Twenty of the HIV-positive emergency room patients had no seropositivity documented during any emergency department visit. Of all 124 visits, 45 involved potential health care worker exposure to the HIV virus. Diagnosis of acquired immunodeficiency syndrome, CD4 count, age, gender, and year of visit did not differ among those with and without HIV documentation. CONCLUSION: Human immunodeficiency virus-positive adolescents are seen in this emergency room and their records do not reflect their infection status. These data reinforce the need for universal precautions for every patient.

A STD/HIV prevention trial among adolescents in managed care.

OBJECTIVE: To determine if sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, risk assessment, and education tools provided as part of office-based primary care reduce adolescent risky sexual behaviors. DESIGN: A randomized intervention trial with 3- and 9-month follow-up. SETTING: Five staff-model managed care sites in Washington, DC (n = 19 pediatricians). PATIENTS: Consecutive 12- to 15-year-olds receiving a general health examination; 81% minority. Participation rate = 215/432 (50%). Nine-month follow-up rate = 197/215 (92%). INTERVENTION: Audiotaped STD risk assessment and education about staying safe (safer = condoms, safest = abstinence). MAIN OUTCOME MEASURES: Adolescent-reported sexual intercourse and condom use. RESULTS: More intervention adolescents reported pediatrician discussion on 11/13 sexual topics. Although more vaginal intercourse (odds ratio [OR] = 2.46, 95% confidence interval [CI] = 1.04-5.84) was reported in the intervention group at 3 months, this was not true of overall sexual intercourse (OR = 1.55, 95% CI =.73-3.32). More sexually active adolescents reported condom use in the intervention group at 3 months (OR = 18.05, 95% CI = 1.27-256.03). At 9 months, there were no group differences in sexual behaviors; however, more signs of STD were reported by the control (7/103) than the intervention group (0/94). CONCLUSIONS: STD risk assessment and education tools administered in a single office visit facilitated STD/HIV prevention education. Any impact on sexual activity and condom use was short-lived. Further research is needed to develop brief, office-based sexual risk reduction for young adolescents.

Fathering pregnancies: marking health-risk behaviors in urban adolescents.

PURPOSE: To establish self-reported rates and associated correlates of fathering pregnancies in urban teen males, and to explore the possibility of using their pregnancy history as a marker for other health-risk behaviors. METHODS: A blinded, self-administered questionnaire was given to the predominantly African-American patients of an inner-city adolescent outpatient clinic. Urine was also collected in a blinded, anonymous fashion, matched to the questionnaires, and tested for five drugs of abuse. Males were classified as having or not having a pregnancy history (PH) according to a questionnaire response item. PH and non-PH participants were compared for eight risk factors using univariate and multivariate methods. RESULTS: A total of 24.2% reported a PH. These males were about 14 times more likely to report three or more sex partners in the last year, more than five times as likely to report a sexually transmitted disease history, more than three times as likely to test positive for drugs, and more than 2.5 times as likely to be inconsistent or nonusers of condoms as compared to males without a pregnancy history. An association between violent behavior and PH is unsupported. CONCLUSIONS: Pregnancy history can be a valuable marker for other risk factors among inner-city African-American males. With some patients, it may be easier for clinicians to discuss pregnancy history or fatherhood as opposed to drug abuse and other more sensitive risk factors. The topic can then be used as a gateway for discussion of other risk factors.

PIP: Findings are presented from a study conducted to establish self-reported rates and associated correlates of fathering pregnancies among urban male teenagers, and to explore the possibility of using their pregnancy history (PH) as a marker for other health risk behaviors. A blinded, self-administered questionnaire was given to a convenience sample of 399 young, nonvirgin men aged 12-19 years old, of mean age 16.3, recruited from April 1994 through March 1996 at an inner-city adolescent outpatient clinic. 93.8% of the subjects were African-American and 24.2% reported causing a PH. A urine sample was collected from 73.5% of the study participants and tested for 5 drugs of abuse. 27.7% of these men had traces of drugs in their urine, of whom more than 97% were positive for cannabinoids. Compared to the young men with no pregnancy history, those with a PH were 13.8 times more likely to report 3 or more lifetime sex partners, 5.4 times more likely to report a history of STDs, 3.1 times more likely to test positive for consuming drugs, and more 2.7 times more likely to be inconsistent or nonusers of condoms. No support was found for an association between violent behavior and PH.

The changing pattern of substance abuse in urban adolescents.

OBJECTIVES: To determine the prevalence of specific drug use in adolescents attending an adolescent health clinic and to compare current rates with a similar previous study. DESIGN: Blinded and anonymous urine samples obtained from patients presenting for routine health care were tested for the presence of cannabinoids, phencyclidine (PCP), amphetamines, opiates, and cocaine. SETTING: Adolescent medicine outpatient clinic. PATIENTS: Patients were between 12 and 21 years of age. Specimens from 1313 patients in 1995 to 1996 and 1312 patients in 1989 to 1990 were tested. MAIN OUTCOME MEASURES: Current drug use rates were compared with a similar screening of patients conducted in 1989 to 1990. Comparisons between studies were made on the basis of specific drug, age, and sex. RESULTS: For the most recent patient group, 14% were positive for 1 or more drugs and 13% were positive for cannabinoids. Males were significantly more likely to test positive for drug use than females. The oldest adolescents were more likely to test positive for drug use than younger adolescents. Comparing the 2 study year cohorts, patients tested recently were significantly more likely to have urine tests positive for at least 1 drug and cannabinoids in particular and less likely to have urine tests positive for cocaine. CONCLUSIONS: There has been an increase in positive urine tests in patients seen in our ambulatory clinic, with a strong shift toward cannabinoids and a shift away from cocaine. Practitioners need to be aware that drug use patterns in adolescents can shift relatively abruptly and counseling should be targeted to current drug use patterns.

Effect of HIV counseling and testing on sexually transmitted diseases and condom use in an urban adolescent population.

OBJECTIVE: To determine whether human immunodeficiency virus (HIV) counseling and testing has an effect on reducing subsequent risk behaviors in those tested, to evaluate stability in condom use over time, and to determine whether self-reported frequency of condom use relates to the incidence of sexually transmitted diseases (STDs). DESIGN: Cohort study with 2-year follow-up. SETTING: An urban adolescent-medicine clinic. PARTICIPANTS: A random sample of 149 patients (118 female and 31 male adolescents) with a mean (+/- SD) age of 16.4 +/- 1.51 years were selected from a cohort of 500 patients at high risk for HIV infection. The patients had received a risk behavior questionnaire during pretest counseling for HIV testing. They were divided into 3 groups, identified by the letter F, S, or R, based on their self-report of frequency of condom use at enrollment: 24% used condoms frequently/always (F); 40%, sometimes (S); and 36%, rarely/never (R). One hundred twenty-six patients (85%) made return visits. INTERVENTION: HIV counseling and testing. MAIN OUTCOME MEASURES: Medical record documentation of STDs before and after HIV testing, and self-reported condom use frequency. RESULTS: Before HIV testing, all 3 condom use groups had a similar frequency of STD visits per month. The number of STD visits per month did not decrease significantly in the posttest period for either the total group or each of the 3 subgroups. Also, most patients (F, 67%; S, 44%; R, 53%) in each of the 3 subgroups had shifted unfavorably to rarely/never (R) condom use within the month before their follow-up visit. Only 24% (8 patients) of those in the initial frequently/always (F) group reported continued frequent condom use. CONCLUSIONS: As has been found in adult studies, single-dose interventions such as HIV counseling and testing did not seem to reduce HIV risk behaviors in our sample of high-risk adolescent patients. None of the 3 groups showed a significant decrease in STDs after HIV testing and counseling. Also, our adolescent patients reported widely varying condom use frequency over time, yet the incidence of STDs did not correlate with self-reported condom use.

Direct evaluation of adolescent HIV counseling and testing services.

The incidence of HIV disease in adolescents is increasing. Studies indicate this population is not receiving adequate information or support to bring about healthy behavior choices that prevent infection, reinfection, or infection of a partner. Physicians themselves, according to a study, are providing services well below the current established guidelines. The current study provides direct evaluation of services provided to youths by adolescents trained to address critical issues using fictional (undercover) stories at actual sites advertising HIV/AIDS counseling and testing to teenagers. Thirty-three health-care sites were identified within the Washington, DC, area; eight were eliminated during the process, leaving 25 sites for appraisal. Less than 40% of the participating clinics that advertised HIV testing qualified for recommendation. In addition, many female youth evaluators reported they received unsolicited advice regarding abstinence or reduction of sexual activity; male evaluators did not report similar findings. Results of the study were translated into recommendations in the form of reports to those sites that chose to receive them. The authors recommend implementing a similar study on an annual basis of similar sites with publication of results in order to improve staff training and maintain standards that will encourage adolescent and young adult clients to be tested and follow through for test results and appropriate education and counseling.

Attempting to enhance the enrollment of adolescents into AIDS clinical trials: the design of ACTG Protocol 220.

The epidemic of HIV infection continues to grow in adolescents and young adults. Unfortunately, because treatment regimens have been developed based on data derived from clinical trials, little data are available on adolescents because they are infrequently included in these trials. In an effort to facilitate the enrollment of more adolescents into AIDS Clinical Trials Group (ACTG) clinical trials, we designed a nontreatment protocol to familiarize adolescents with clinical trials requirements. Two hundred fifty-six adolescents (150 females, 106 males) between the ages of 13 and 21 years were enrolled at 43 different clinical trials sites throughout the United States. The majority of patients (50%) were enrolled at sites that had specific programs for adolescents. Most of the young women (85%) had acquired their infection via heterosexual transmission, whereas the largest transmission categories in men were blood or factor transfusions (43%) or same-sex contact (34%). Admission CD4 counts were lower in males (mean = 396 cells/mm3) than in females (mean = 513 cells/mm3) (p = 0.01). Psychosocial profiles revealed a variety of ongoing risk behaviors in HIV-infected adolescents. Two years into the study, 223 patients are still being observed. We conclude that adolescents can be enrolled in an observational protocol. The success of this trial will be determined by how many ACTG Protocol 220 participants are ultimately enrolled in therapeutic trials.

Are adolescents accurate in self-report of frequencies of sexually transmitted diseases and pregnancies?

PURPOSE: Many surveys of adolescent behavior are dependent on self-reported data. We sought to assess the accuracy of adolescent self-report of sexually transmitted diseases (STDs) and pregnancies. METHODS: We randomly selected 149 (118 females, 31 males) adolescents to participate in this accuracy study. Follow-up questionnaires were administered to the 126 patients (99 females, 27 males) who returned after enrollment. Patients were asked about STDs and pregnancies during the follow-up period which ranged from 6 months to 1 year. All patient charts were reviewed to validate post-testing history. RESULTS: Return visits were made by 126 patients (84%). Fifty-one (40%) denied having had an STD at all during the follow-up period but were found to have had at least one STD. Another 11 (9%) admitted having had an STD but had multiple STDs in excess of what they reported. Only 46% of the patients provided accurate information on the follow-up questionnaire. Of the 99 girls who returned for follow-up, the inaccurate patients (10%) consisted of 9 who reported no visits for a pregnancy but had a pregnancy documented in their charts and 1 who underreported her number of pregnancies. Reliability analysis of the accuracy of STD and pregnancy self-report for our patients showed kappas ranging from 0.185 to 0.413 (slight and fair to moderate, respectively). Pearson correlation coefficients were 0.3107 and 0.4364 for STD and pregnancy, respectively. CONCLUSIONS: Our patients' histories of visits for STDs and pregnancies are often not substantiated by review of their medical records. The reason for the inaccuracies in self-report of sexual behaviors is unclear. Further research in this area should be done. Physicians must confirm patient history concerning sexual practices through appropriate record review and medical evaluation.

PIP: Many studies of adolescent sexual behavior are based on self-reported data. The present study sought to assess the accuracy of adolescents' self-reports of pregnancies and sexually transmitted diseases (STDs). Enrolled were 149 predominantly African-American adolescents (118 females and 31 males) who visited the Children's National Medical Center (Washington, DC) for outpatient care; 126 respondents (99 females and 27 males) completed a follow-up questionnaire 6-12 months later. The medical charts of these 126 adolescents were reviewed to validate post-testing history. Only 46% of adolescents provided accurate information on STDs in the follow-up questionnaire. 51 adolescents denied they had an STD during the follow-up period but, in fact, had at least 1 STD recorded. Another 11 acknowledged having had 1 STD but, in fact, had multiple STDs. In terms of pregnancies, 76% of female participants were accurate responders. 9 females who had a pregnancy recorded in their charts denied a pregnancy in the follow-up questionnaire and 1 underreported the number of pregnancies. Reliability analysis of the accuracy of STD and pregnancy self-reports showed kappas of 0.185 and 0.413, respectively, while the Pearson correlation coefficients were 0.317 and 0.4364, respectively. These findings indicate that adolescents frequently provide inaccurate information regarding their sexual histories. The contribution of factors such as discomfort with the interviewer, a lack of privacy in the interview, and a misunderstanding of information conveyed by health staff about STDs to this phenomenon is unknown, however.

Access to ambulatory care for adolescents: the role of a usual source of care.

Using data from the 1987 National Medical Expenditure Survey, characteristics of ambulatory service utilization for adolescents aged 11 through 17 were examined. Access to health care was further explored by identifying adolescents at risk of not receiving an ambulatory service in the event of symptomatology. Approximately two-thirds of an estimated 25 million adolescents experienced an outpatient visit. African American race, Hispanic ethnicity, middle income, and lack of insurance and a usual source of care placed adolescents at risk for not receiving an ambulatory service. Sixteen million adolescents experienced symptomatology, but only one-third saw a physician. Those lacking a usual source of care were at greater odds of not receiving care. For symptom-based care, inequities were related more to lack of usual source of care rather than socioeconomic characteristics. Health care reform efforts may benefit from ensuring that adolescents have an identified usual source of care to ensure equity of access to care.

The coincident diagnosis of pelvic inflammatory disease and pregnancy: are they compatible?

OBJECTIVES: To determine the frequency of coincident diagnoses of pregnancy and pelvic inflammatory disease (PID) in adolescents seeking care at a large urban children's hospital. DESIGN: All inpatient medical records for the period from January 1, 1984 through December 31, 1993 were searched for dual diagnoses of pregnancy and PID (presumed secondary to endometritis, salpingitis, or both). During this period, there were 1205 patients admitted for PID, 67 of whom were also pregnant. Ten of these 67 admissions were eliminated from this study because of incomplete or missing records, errors in diagnosis, or lack of proper examinations. The charts of the remaining 57 subjects were reviewed for demographics, physical findings, and laboratory studies. OUTCOME MEASURES: For the purposes of this study, a diagnosis of suspected PID was defined as lower abdominal tenderness, cervical motion tenderness, and adnexal tenderness ("major criteria"), as well as either a positive cervical specimen for Neisseria gonorrhoeae or Chlamydia trachomatis or adnexal fullness ("minor criteria"). RESULTS: The mean age of the 57 subjects was 16.8 years, and the mean gestational age was 6.7 weeks. Twenty-four (42.1%) of the subjects met the criteria for a concurrent diagnosis of PID and pregnancy; 13 had physical findings and a positive cervical specimen for either N. gonorrhoeae or C. trachomatis, and 11 subjects had the minor criteria of adnexal fullness. Twenty-six (45.6%) of the 57 subjects were primigravida, 35 (61.4%) had a history of a sexually transmitted disease, and 18 (31.6%) had been previously admitted to a hospital for PID. CONCLUSION: This study found that PID and pregnancy can coexist in adolescents. Therefore, physicians who treat adolescents must consider the possibility of PID in pregnant adolescents presenting with abdominal pain.

Is sexual abuse in childhood or adolescence a predisposing factor for HIV infection during adolescence?

This exploratory study was conducted to determine whether sexual abuse might be a risk factor or marker for other risk factors for Human Immunodeficiency Virus (HIV) infection. Twenty-five HIV-positive adolescents were assessed for a variety of possible risk factors for HIV infection, including prior history of sexual abuse. Fifteen (60%) had a history of sexual abuse. A history of sexual abuse may be a risk factor for HIV infection directly, or it may be associated with or predispose one to other risk factors. The latter mechanism may be related to the long-term negative outcomes of some individuals with a history of sexual abuse. These may include same-sex sexual experiences as an adolescent, re-victimization with additional episodes of abuse, multiple consensual sexual partners, and drug and/or alcohol abuse. Preventive interventions aimed at reducing the risk of HIV infection must take a history of sexual abuse into account. Patients with such a history deserve intensive psychological counseling to help prevent adverse behavioral outcomes that can result in HIV infection.

Adolescents and HIV infection: a clinician's perspective.

Increasing concern in the United States has centered on HIV infection in adolescents. While less than 0.4% of all reported cases of AIDS are reported in adolescents 13-19 years of age, it is speculated that upwards of 20% of all AIDS cases have acquired their infection as teenagers. Most cases are now reported to occur among minority youth and most are now related to sexual or drug use behavior. The natural history of HIV infection in adolescents has yet to be defined. Many adolescents have progressed to clinically significant low CD4+ cells by the time their infection is discovered. While traditional risk factors are also risk factors for adolescents, number of sexual partners and noninjection drug use appear to be related to an increased risk of HIV infection in this age group. Prevention efforts must target both techniques as well as one-on-one counselling. Health care providers have a unique role to play in both patient and community education.