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Screening for HIV should be routine for all sexually active adolescents.
In September 2006, the Centers for Disease Control and Prevention issued new recommendations calling for annual routine HIV screening in health care settings for all patients aged 13–64 years, regardless of perceived risk status. The guidelines are notable in that they call for a policy of “opt-out” screening rather than requiring written informed consent, and they allow for screening to occur without pre-test counseling in situations where such a requirement would present a barrier (MMWR 2006;55:RR-14).
The CDC believes—and I agree—that these changes are necessary. Our current practice of screening only those individuals perceived to be at high risk isn't working. There are about 1 million HIV-infected people in the United States, as many as 25% of whom are undiagnosed. Not only are they missing out on the potential benefits of antiretroviral therapy, but their sexual activity represents a threat for transmission to others. Current HIV testing programs identify approximately 40,000 new cases every year, a number that has not changed in nearly a decade.
Teenagers are among those at risk. The CDC guidelines note that in the 2005 national Youth Risk Behavior Survey, 47% of high school students reported having had sexual intercourse at least once, and 37% of those who were sexually active had not used a condom during their most recent act of sexual intercourse. In 2005, according to the CDC, heterosexual intercourse overall accounted for 15% of HIV transmission in males and 80% in females. (Male-to-male sexual contact made up 67% of transmission among males.)
I strongly support routine screening for our adolescent patients but with certain modifications to the CDC's stated policy. While the idea of eliminating all risk profiling makes sense for the adult community, in adolescents I think it boils down to one question: Are you sexually active? If the answer is yes, no matter what the circumstances, screening is indicated. Clearly, this is an issue for every physician who treats adolescents.
I also think that, contrary to the guideline for adults, adolescents do need counseling about HIV before and after testing. Simply telling a teenager that you plan to test them for HIV unless they opt out is not adequate. At a minimum, we need to tell teens that sexual activity is a risk factor for the transmission of HIV, and for that reason we believe they should be tested. Just because a teen is monogamous doesn't mean her or his partner is. We must impress upon them that even if they're sure their partner is “safe,” they can't be confident that the same applied to their partner's previous partners.
We also should explain that the testing is a two-step process. The initial step (ELISA) identifies HIV-specific antibodies but sometimes is falsely positive. If the ELISA is positive, a Western blot test is done for confirmation. No matter what the result, a second visit is highly recommended. If the adolescent is HIV positive, this visit should be used to assess how the teen is handling the diagnosis emotionally, to determine the best course of action for treatment and to refer the teen for other support services.
If the test comes back negative, the primary care physician should still use the opportunity to remind teens that if they're sexually active and not using condoms, they're always at risk. The test was only a snapshot in time.
It's also important to explain beforehand what a positive test means: It indicates that there is an HIV infection, but it gives no information about what stage of the disease they're in. They could be very early in the course of disease, or very late in the course of disease and already have AIDS.
Just as the CDC recommends for adults, I believe that physicians should use every medical encounter with an adolescent, be it a sports physical or an acute illness visit, to do HIV counseling and screening.
The issue of parental consent is still problematic and a potential barrier. Ideally, of course, the teenager is willing to have his or her parent or guardian consent to testing. But if not, the laws concerning consent and confidentiality vary by state. In general, public health statute and legal precedent allow for evaluation and treatment of minors for sexually transmitted diseases without parental knowledge or consent. The Guttmacher Institute's Web site is an excellent resource for specific state-by-state information on laws governing minors' consent to medical care, access to STD services, and sex and STD/HIV education (www.guttmacher.org
Most state laws, however, don't yet address the issue of consent for screening for HIV in asymptomatic adolescents. The American Academy of Pediatrics advises that physicians obtain advice regarding the disposition of laws in their state addressing consent or other legal obligations from their attorney or another trusted local source, such as their hospital's office of legal compliance. The AAP Committee on Pediatric AIDS is expected to issue a statement in response to the CDC guidelines sometime in 2007.
Screening for HIV should be routine for all sexually active adolescents.
In September 2006, the Centers for Disease Control and Prevention issued new recommendations calling for annual routine HIV screening in health care settings for all patients aged 13–64 years, regardless of perceived risk status. The guidelines are notable in that they call for a policy of “opt-out” screening rather than requiring written informed consent, and they allow for screening to occur without pre-test counseling in situations where such a requirement would present a barrier (MMWR 2006;55:RR-14).
The CDC believes—and I agree—that these changes are necessary. Our current practice of screening only those individuals perceived to be at high risk isn't working. There are about 1 million HIV-infected people in the United States, as many as 25% of whom are undiagnosed. Not only are they missing out on the potential benefits of antiretroviral therapy, but their sexual activity represents a threat for transmission to others. Current HIV testing programs identify approximately 40,000 new cases every year, a number that has not changed in nearly a decade.
Teenagers are among those at risk. The CDC guidelines note that in the 2005 national Youth Risk Behavior Survey, 47% of high school students reported having had sexual intercourse at least once, and 37% of those who were sexually active had not used a condom during their most recent act of sexual intercourse. In 2005, according to the CDC, heterosexual intercourse overall accounted for 15% of HIV transmission in males and 80% in females. (Male-to-male sexual contact made up 67% of transmission among males.)
I strongly support routine screening for our adolescent patients but with certain modifications to the CDC's stated policy. While the idea of eliminating all risk profiling makes sense for the adult community, in adolescents I think it boils down to one question: Are you sexually active? If the answer is yes, no matter what the circumstances, screening is indicated. Clearly, this is an issue for every physician who treats adolescents.
I also think that, contrary to the guideline for adults, adolescents do need counseling about HIV before and after testing. Simply telling a teenager that you plan to test them for HIV unless they opt out is not adequate. At a minimum, we need to tell teens that sexual activity is a risk factor for the transmission of HIV, and for that reason we believe they should be tested. Just because a teen is monogamous doesn't mean her or his partner is. We must impress upon them that even if they're sure their partner is “safe,” they can't be confident that the same applied to their partner's previous partners.
We also should explain that the testing is a two-step process. The initial step (ELISA) identifies HIV-specific antibodies but sometimes is falsely positive. If the ELISA is positive, a Western blot test is done for confirmation. No matter what the result, a second visit is highly recommended. If the adolescent is HIV positive, this visit should be used to assess how the teen is handling the diagnosis emotionally, to determine the best course of action for treatment and to refer the teen for other support services.
If the test comes back negative, the primary care physician should still use the opportunity to remind teens that if they're sexually active and not using condoms, they're always at risk. The test was only a snapshot in time.
It's also important to explain beforehand what a positive test means: It indicates that there is an HIV infection, but it gives no information about what stage of the disease they're in. They could be very early in the course of disease, or very late in the course of disease and already have AIDS.
Just as the CDC recommends for adults, I believe that physicians should use every medical encounter with an adolescent, be it a sports physical or an acute illness visit, to do HIV counseling and screening.
The issue of parental consent is still problematic and a potential barrier. Ideally, of course, the teenager is willing to have his or her parent or guardian consent to testing. But if not, the laws concerning consent and confidentiality vary by state. In general, public health statute and legal precedent allow for evaluation and treatment of minors for sexually transmitted diseases without parental knowledge or consent. The Guttmacher Institute's Web site is an excellent resource for specific state-by-state information on laws governing minors' consent to medical care, access to STD services, and sex and STD/HIV education (www.guttmacher.org
Most state laws, however, don't yet address the issue of consent for screening for HIV in asymptomatic adolescents. The American Academy of Pediatrics advises that physicians obtain advice regarding the disposition of laws in their state addressing consent or other legal obligations from their attorney or another trusted local source, such as their hospital's office of legal compliance. The AAP Committee on Pediatric AIDS is expected to issue a statement in response to the CDC guidelines sometime in 2007.
Screening for HIV should be routine for all sexually active adolescents.
In September 2006, the Centers for Disease Control and Prevention issued new recommendations calling for annual routine HIV screening in health care settings for all patients aged 13–64 years, regardless of perceived risk status. The guidelines are notable in that they call for a policy of “opt-out” screening rather than requiring written informed consent, and they allow for screening to occur without pre-test counseling in situations where such a requirement would present a barrier (MMWR 2006;55:RR-14).
The CDC believes—and I agree—that these changes are necessary. Our current practice of screening only those individuals perceived to be at high risk isn't working. There are about 1 million HIV-infected people in the United States, as many as 25% of whom are undiagnosed. Not only are they missing out on the potential benefits of antiretroviral therapy, but their sexual activity represents a threat for transmission to others. Current HIV testing programs identify approximately 40,000 new cases every year, a number that has not changed in nearly a decade.
Teenagers are among those at risk. The CDC guidelines note that in the 2005 national Youth Risk Behavior Survey, 47% of high school students reported having had sexual intercourse at least once, and 37% of those who were sexually active had not used a condom during their most recent act of sexual intercourse. In 2005, according to the CDC, heterosexual intercourse overall accounted for 15% of HIV transmission in males and 80% in females. (Male-to-male sexual contact made up 67% of transmission among males.)
I strongly support routine screening for our adolescent patients but with certain modifications to the CDC's stated policy. While the idea of eliminating all risk profiling makes sense for the adult community, in adolescents I think it boils down to one question: Are you sexually active? If the answer is yes, no matter what the circumstances, screening is indicated. Clearly, this is an issue for every physician who treats adolescents.
I also think that, contrary to the guideline for adults, adolescents do need counseling about HIV before and after testing. Simply telling a teenager that you plan to test them for HIV unless they opt out is not adequate. At a minimum, we need to tell teens that sexual activity is a risk factor for the transmission of HIV, and for that reason we believe they should be tested. Just because a teen is monogamous doesn't mean her or his partner is. We must impress upon them that even if they're sure their partner is “safe,” they can't be confident that the same applied to their partner's previous partners.
We also should explain that the testing is a two-step process. The initial step (ELISA) identifies HIV-specific antibodies but sometimes is falsely positive. If the ELISA is positive, a Western blot test is done for confirmation. No matter what the result, a second visit is highly recommended. If the adolescent is HIV positive, this visit should be used to assess how the teen is handling the diagnosis emotionally, to determine the best course of action for treatment and to refer the teen for other support services.
If the test comes back negative, the primary care physician should still use the opportunity to remind teens that if they're sexually active and not using condoms, they're always at risk. The test was only a snapshot in time.
It's also important to explain beforehand what a positive test means: It indicates that there is an HIV infection, but it gives no information about what stage of the disease they're in. They could be very early in the course of disease, or very late in the course of disease and already have AIDS.
Just as the CDC recommends for adults, I believe that physicians should use every medical encounter with an adolescent, be it a sports physical or an acute illness visit, to do HIV counseling and screening.
The issue of parental consent is still problematic and a potential barrier. Ideally, of course, the teenager is willing to have his or her parent or guardian consent to testing. But if not, the laws concerning consent and confidentiality vary by state. In general, public health statute and legal precedent allow for evaluation and treatment of minors for sexually transmitted diseases without parental knowledge or consent. The Guttmacher Institute's Web site is an excellent resource for specific state-by-state information on laws governing minors' consent to medical care, access to STD services, and sex and STD/HIV education (www.guttmacher.org
Most state laws, however, don't yet address the issue of consent for screening for HIV in asymptomatic adolescents. The American Academy of Pediatrics advises that physicians obtain advice regarding the disposition of laws in their state addressing consent or other legal obligations from their attorney or another trusted local source, such as their hospital's office of legal compliance. The AAP Committee on Pediatric AIDS is expected to issue a statement in response to the CDC guidelines sometime in 2007.