Overview
Definition:
Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention strategy involving the daily use of antiretroviral medications by individuals who are HIV-negative but at high risk of acquiring HIV
For adolescents, this involves specific considerations regarding consent, adherence, and risk assessment tailored to their developmental stage and social context.
Epidemiology:
While HIV incidence has declined globally, adolescents, particularly those in vulnerable populations such as young men who have sex with men (MSM) and young women, continue to be at risk
Factors contributing to risk include unprotected sexual activity, substance use, and inconsistent condom use
Understanding regional epidemiology and specific risk factors within India is crucial.
Clinical Significance:
Implementing PrEP in at-risk adolescents is a critical public health intervention to reduce new HIV infections
It empowers young people to take control of their sexual health and can significantly impact the trajectory of the HIV epidemic among youth
For pediatricians and residents, understanding PrEP guidelines, eligibility, and management is essential for comprehensive adolescent care and successful DNB/NEET SS examination preparation.
Risk Assessment And Eligibility
History Taking:
A thorough, non-judgmental history is vital
Key areas include: History of unprotected sexual activity (vaginal, anal, oral)
Number of sexual partners
Sexually transmitted infections (STIs) in the past 6-12 months
Substance use (including injection drug use)
History of condom use consistency
Sex with partners with known HIV status or unknown status
Involvement in transactional sex
History of sexual abuse or coercion
Mental health status and readiness for adherence.
Sexual Behavior Patterns:
Focus on understanding current and past sexual behaviors that confer risk
Differentiate between occasional high-risk encounters and ongoing patterns of unprotected sex
Discuss partner type (casual vs
seroconcordant/discordant) and sexual orientation
Adolescents may have evolving identities, so an open and affirming approach is necessary.
Eligibility Criteria:
Adolescents aged 16 years and older are generally eligible for PrEP if they are HIV-negative and engage in behaviors that place them at substantial risk of HIV acquisition
This includes MSM with condomless anal sex, individuals with multiple partners, or those in serodiscordant relationships
Younger adolescents may be considered on a case-by-case basis with parental/guardian consent where legally mandated and clinically indicated.
Informed Consent And Assent:
For adolescents under 18, parental/guardian consent is typically required
However, adolescent assent is also crucial, ensuring the adolescent understands the treatment, its benefits, risks, and agrees to its use
In situations where involving guardians is not feasible or beneficial (e.g., due to abuse or coercion), confidentiality laws and clinical judgment regarding independent decision-making should be considered
Consult local laws and institutional policies.
Hiv Testing Before And During Prep:
HIV testing must be performed at baseline to confirm HIV-negative status before initiating PrEP
Follow-up HIV testing every 3 months is essential
Rapid HIV tests are useful, but confirmatory testing is required
A positive HIV test while on PrEP requires immediate cessation of PrEP and initiation of HIV treatment.
Management Of Prep
Pharmacological Options:
The primary recommended agent for PrEP in adolescents is tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) as a single daily tablet
Other regimens may be considered based on specific circumstances and evolving guidelines
Consider tenofovir alafenamide/emtricitabine (TAF/FTC) if renal concerns exist, though TDF/FTC is generally preferred for PrEP due to robust efficacy data.
Dosing And Adherence:
The recommended dose is one TDF/FTC (300mg/200mg) tablet taken daily
Adherence is paramount for efficacy
Discuss strategies to facilitate daily adherence, such as pillboxes, reminders, and integration into daily routines
Daily dosing is the most effective regimen
For specific high-risk exposures, event-driven PrEP (e.g., 2-1-1 dosing) may be considered for adult MSM, but daily dosing is the standard for adolescents.
Monitoring During Prep:
Regular follow-up every 3 months is mandatory
This includes: HIV testing
Renal function tests (serum creatinine, eGFR) – especially important with TDF
Liver function tests
Screening for STIs (gonorrhea, chlamydia, syphilis, HPV)
Pregnancy testing for females
Bone density scans may be considered if risk factors for osteoporosis are present, especially with prolonged TDF use.
Renal And Bone Health:
Tenofovir disoproxil fumarate (TDF) can be associated with renal tubulopathy and decreased bone mineral density
Regular monitoring of renal function is crucial
Adolescents with pre-existing renal disease or those taking concomitant nephrotoxic medications require careful monitoring and potential alternative agent consideration
Bone density screening may be considered in those with additional risk factors for osteoporosis.
Adolescent Specific Considerations
Psycho Social Factors:
Adolescents may face unique challenges including peer pressure, fear of disclosure, stigma, and difficulties with self-management
Supportive counseling, peer support groups, and involving trusted adults (school counselors, youth workers) can enhance engagement and adherence.
Stigma And Confidentiality:
Adolescents may fear stigma associated with HIV or PrEP
Maintaining strict confidentiality is essential
Education about the protective benefits of PrEP and destigmatizing HIV prevention is important
Discuss disclosure of PrEP use with the adolescent and develop a plan for when and how to disclose if necessary.
Sexual Health Education:
PrEP is one component of a comprehensive sexual health strategy
It does not protect against other STIs
Adolescents should receive ongoing education about safe sex practices, consistent condom use for STI prevention, and regular STI screening
Discuss contraception needs as well.
Transition To Adult Care:
As adolescents approach young adulthood, a structured transition plan to adult HIV prevention services is necessary
This involves ensuring continuity of care, understanding adult healthcare systems, and empowering them to manage their own health independently
Early planning for this transition is key.
Adverse Events And Management
Common Adverse Events:
The most common side effects are gastrointestinal (nausea, diarrhea, abdominal pain) and headache
These are usually mild and transient
Skin rashes can occur
Less commonly, renal dysfunction and bone density loss are observed with TDF.
Management Of Side Effects:
For mild GI upset, recommend taking PrEP with food or at bedtime
If symptoms persist or are severe, temporary interruption or switching to an alternative regimen may be considered
Thoroughly assess for other causes of symptoms
Educate adolescents on reporting any new or concerning symptoms.
Drug Interactions:
While TDF/FTC has fewer drug interactions than some other antiretrovirals, potential interactions should be considered, especially with other medications the adolescent may be taking (e.g., certain antiepileptics, rifampin, St
John's wort)
Always review concomitant medications.
Discontinuation Of Prep:
PrEP should be discontinued if the individual becomes HIV-positive, develops significant renal impairment, experiences severe adverse effects not manageable, or if the risk of HIV acquisition significantly decreases
Re-evaluation of risk is important before discontinuation.
Key Points
Exam Focus:
Understand the definition, indications, and contraindications for PrEP in adolescents
Know the preferred regimen (TDF/FTC daily) and the importance of adherence
Be familiar with the monitoring schedule (HIV, renal, STI tests every 3 months)
Remember the legal and ethical considerations regarding consent and assent for minors.
Clinical Pearls:
Establish a trusting relationship with the adolescent
Use non-judgmental language
Empower adolescents to take an active role in their sexual health
Integrate PrEP discussions into routine adolescent healthcare visits
Always counsel on consistent condom use for STI prevention.
Common Mistakes:
Failing to assess risk accurately
Neglecting adolescent assent or legal consent requirements
Inconsistent follow-up and monitoring
Not addressing adherence challenges proactively
Underestimating the impact of stigma and confidentiality concerns
Prescribing PrEP without confirming HIV-negative status.