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.