Lawrence J. D'angelo, MD, MPH.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.