Adolescents living with HIV เรืองท้าทายในวัยร่นกับุ HIV By Kulkanya Chokephaibulkit, MD Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand กรมอนามัย มีค 16 Epidemiology: 2.1 million adolescents aged 10 - 19 years living with HIV globally • There are two HIV-infected adolescent populations – Grow up with HIV: mostly are perinatally acquired: • Currently, 30-70% of perinatal pediatric cohort are adolescents • Globally (2014), 3.2 M children (<15 yo) are living with HIV: they will be adolescents in 5-10 years – Recently infected: mostly behaviorally acquired: • Of the 2 M newly infected cases in 2013, 60% were adolescents 15-24 year-old • Young women, young gay men and MSM the highest risk group Children with HIV are Living Longer: 30-70% of them became adolescents Estimated Number and Age of Perinatally- The TREAT Asia Pediatric HIV Infected Youth Living with HIV in the US Observational Database (TApHOD), CDC HIV Surveillance Report 2011 (50 6 countries in Asia, Mar 2011 states) (Pediatric HIV clinics only) Sohn AH et al. JIAS 2013 <13 yrs <12 yrs >=13 yrs >= 12 yrs 10,798 persons with perinatal HIV living in 4,045 children: 53% female the US The Thai national pediatric HIVQUAL database, 2013 <=10 yrs (Pediatric HIV clinics only) 11-15 yrs 3,654 children: 54% female; 161 hospitals >15 yrs Approximately 1/3 (23-86%)of high risk populations to HIV are under 25 year-old Adolescents Grown-up With HIV VS Those Who Acquired HIV Recently Adolescents grown-up with HIV Adolescents recently infected • High proportion of orphanage, raised-up by • Healthier baseline non-parent caretakers • Mostly sexually acquired or IVDU • Better cope with HIV and treatment • Poor/chaotic family background • Good HIV knowledge • Higher risk behaviors, STI • Long experience of ART • Not accept/not believe about HIV • • More complications from chronic HIV and Poor HIV knowledge, misconceptions long-term ART • Poor compliance – Neurodevelopmental deficit – Poor growth, delayed puberty – Metabolic/ lipodystrophy • Tired /bored of ART Adolescents Grown-up With HIV VS Those Who Acquired HIV Recently Adolescents grown-up with HIV Adolescents recently infected • High proportion of orphanage, raised-up by • Healthier baseline non-parent caretakers • Mostly sexually acquired or IVDU • Better cope with HIV and treatment • Poor/chaotic family background • Good HIV knowledge • Higher risk behaviors, STI • Long experience of ART • Not accept/not believe about HIV • • More complications from chronic HIV and Poor HIV knowledge, misconceptions long-term ART • Poor compliance – Neurodevelopmental deficit – Poor growth, delayed puberty Many similarly teens’ problems….. – Metabolic/ lipodystrophy Moods, emotion….. Peer pressure, self esteem… • Tired /bored of ART Sex..etc UNAIDS 90-90-90 ambitious treatment target to help end the AIDS epidemic To achieve this goal in adolescents, the care and supports provided must answer to their needs By 2020 Worldwide, 36.9 million people are estimated to be living with HIV of whom 53% are diagnosed, 13.4 million people short of the 90% target. 41% are on treatment, 14.9 million people short of the target, and 32% are virally suppressed, 15.3 million people short of the target. Approximately 2 million people each year are becoming infected at current rates of transmission. Levi J et al. Can the UNAIDS 90-90-90 target be achieved? Analysis of 12 national level HIV treatment cascades.Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Vancouver, abstract MOAD0102, 2015. Can we achieve 90-90-90? Perinatally infected adolescents in Asia in 2011 Data from 18 pediatric sites in TApHOD (N=1254): high retention (>90%) but low viral suppression (68%) At Last visit Active F/U N=1061 Median age 14.7 (13.3-16.4) Single/double orphan 72.6% In school 93.2% HIV disclosed 62.2% VL<400 67.7% On Regimen NNRTI 70.6% Chokephaibulkit K. PIDJ 2014;33:291-4. Can we achieve 90-90-90? The estimated adolescent (13-29 year-old) HIV cascade of care in the US: Understanding the situation 40% 62% 44% 54% The cascade could be worse in less resource-settings Zanoni BC. AIDS Patient Care STDS. 2014 Mar;28(3):128-35. Let’s get to know adolescents We all were adolescents once. Developments of Adolescents General Rule of Teens The unique stage of life with significant physical, emotional, and mental change 12-14 (early) 14-17 (mid) 17-21 (late) - Stick with parents - Disagreement - Accept parents - Same sex peer - Peer is everything - Stable partner - Ambitious - Too confident, no fear - Moral, wiser - Poor temp control - Ready to take risk - Set goal, self control - Impatience - Sexual orientation - Rigid concept Peer pressure “What is right is what I want” Low tolerance of opposite The 5 important challenges to achieve 90-90-90 goal Behavioral Perinatal Acquired Acquired Early diagnosis Treatment and retention Complications Sexual health and STI Prevention (of transmission) Challenge 1. Early Diagnosis: The first step of success Most behaviorally acquired HIV-infected adolescents were not diagnosed until they were symptomatic or become pregnant A survey data collected in sub-Saharan Africa indicated that only 10% of young men and 15% of young women (15–24 years) were aware of their HIV status WHO, HIV and Adolescents: Guidance for HIV Testing and Counselling and Care for Adolescents Living with HIV, 2013. The reported patients with AIDS (symptomatic) in Thailand: majority were contracted during adolescence (for >10 yrs) but never been diagnosed How many cases were infected from these young people for 10 years without treatment? They were contracted at 15-24 yo. Number Male Female BATS, Thai MOPH How can we draw adolescents to get HIV testing? The currently available services are not youth friendly No Confidentiality stigma Fragmented Unfriendly Reimbursement environment Ad/ Demand promotion Derived from series of FGDs in various locations and youth backgrounds. We need Youth Friendly Clinics to draw the teens Important characteristics • No stigma (not sign of STD/HIV/RH) • Easily accessible • Convenient location • One-stop services of HTC, HIV-STI treatment, contraception, immunization, PEP, PrEP • Integrated services of medical health, mental health, reproductive health • Minimal charge (or free) • Youth friendly staff: respect their sexual orientation • Match with teen lifestyle: off-hour service time, Online, Line, Facebook, Instagram YFS Model Social Enterprise Clinic • Comprehensive sexual health service – Counselling on HIV/STI testing, prevention/treatment – Contraception – Mental health – Immunization – Lifestyle counseling: nutritional, hormone/Trans care, anal care, etc. • Gender responsive: MSM/TG/women/men • Integrated with online clinic and social medias • Great location: Red light district of BKK • Confidential and stigma-free: with beauty/acne treatment, acupuncture, etc. Need to be available at the clinic at low (no) cost iUSE –lovecare Station • Online youth clinic utilizing various social medias and application • Collaborative effort: • Path2Health Foundation • Siriraj Hospital • Queen Sirikit Hospital • Thai US Collaboration -Of >190,000 users, • Sponsor: UNICEF 79% were <24 Y (peak 12-17Y) -FAQ are: unplanned pregnancy, sexual health, emergency pill, menstruation Unlocking Parental Consent For The Under 18: To help Adolescents The 16 yo boy • Parental consent is a barrier to engaged known HIV testing in adolescents risk. He went for • The Thai Medical council issued blood donation in the new guidelines 2015 order to get the test – No need for written consent done free. – If the client is ready and able to understand, the test can be done regardless of age – The report of the test results to anyone are based on the best interest of the client. UNAIDS: Countries must consider lowering the age of independent consent so that more adolescents can access testing Opt-out Testing Normalize/destigmatize HIV testing • CDC recommendation since September 2006: – Routine HIV testing for everyone between the ages of 13-64 and all pregnant women, and at least yearly for high risk individuals – Use opt-out screening for HIV—meaning that HIV tests will be done routinely unless a patient explicitly refuses to take an HIV test – Eliminate the requirements for informed consent • The benefit of opt-out testing: – Earlier access to care and prevention of transmission with less stigmatization Challenge 2: Treatment and retention Treatment As Prevention (HPTN052) Early treatment can stop the epidemic! Linked Overall Number Follow-up Study Arm Number Infections (PY) Infections * Immediate 4 1 1,585 Delayed 35 27 1,567 p value <0.0001 <0.001 Immediate treatment was 96% effective in preventing transmission compared to CD4 guided treatment initiation Cohen MS. NEJM 2011;1-13. Challenges in adhering to ART • Denial and fear of their HIV infection; • Misinformation, Distrust • Low self-esteem; • Unstructured and chaotic lifestyles; • Fear and lack of belief in the effectiveness of medications; • Mood disorders and other mental illness; • Lack of familial and social support; • Absence of or inconsistent access to care or health insurance • Risk of inadvertent parental disclosure of the youth’s HIV status Treatment outcomes in adolescents is poorer than in adults % 90 78 80 70 59 60 56 50 43 Adult N=46 40 Adolescent N=46 30 Virologic 20 13 11 Outcomes 10 and Clinical 0 Retention VL <400 at 6 m. VL Rebound LTFU Ryscavage PA. JAIDS 2011 High attrition among youth (15-24 years of age) enrolled in HIV care: In 160 HIV clinics in Kenya, Mozambique, Tanzania, and Rwanda 1 Y after starting ART • Attrition was highest among youth • Male youth had higher attrition than female • Those attending clinic providing SH service and support group had lower attrition rate Lamb MR. AIDS. 2013 Sep 26. Always need to work on psychosocial/environmental factors to solve adherence problems The solutions could be: • Simplify the regimen, once daily, STR • Set-up DOT (with Facetime) • Arrange home/environment/agreement • Some tools (weekly (lovely) drug box, watches, incentives, etc.). Make it easy to carry out.