An Interview With John Steever, M.D.
John Steever, M.D.
Adolescents face a host of unique -- and often underappreciated -- challenges to effective health care and successful HIV treatment. John Steever, M.D., a physician in the Adolescent Health Center at Mount Sinai Medical Center in New York City, is deeply familiar with these challenges: He oversees care for roughly 100 HIV-positive youth.
Dr. Steever spoke by phone with our Community Editor Mathew Rodriguez about his work, how adolescent HIV care differs from adult HIV care, and the most important priorities that health care providers should keep in mind when treating HIV-positive adolescents.
Can you talk a little bit about the Mount Sinai Adolescent Health Center and what your role is there?
The Adolescent Health Center is actually one of the largest free-standing adolescent health centers in the United States. We see about 12,000 unique individuals every year there. We do it for free to the youth; we don't charge them anything. We are run off of various grants, so we can provide health care without any barriers to adolescents.
I am one of the general attendings there, so I see youth of all types, between the ages of 12 and 24 or 25, depending. We all do a lot of reproductive health care; GYN [gynecology] work; STD [sexually transmitted disease] screening; pregnancy screening; birth control dispensing. And all of this is done free to the kids. So all the lab work we do is free. All the birth control that we give out is free. We give out samples. And then when we treat STDs, we give out samples, as well. So the youth don't really have many barriers to getting [care].
We are really super-comprehensive. We have medical care. We have gynecological care. We have mental health, including psychologists, social workers, child psychiatrists. We also have health educators. We have a nutritionist on staff. We have a lawyer on staff for youth who might be needing help with legal issues. We have a dental clinic, and we have a new eye clinic that is available to the youth. And all these services are free. We do a combination of appointments and walk-ins.
What I do within that group: I specialize and supervise the medical care of the HIV-positive adolescents. We have about 100 kids in care who have HIV; some were born with it (perinatal acquisition), but the majority of them got it through sex. And the majority of those are young men of color who have sex with other men -- so, sort of reflecting the current epidemic in New York City right now.
What would you say to clinicians who may have less experience caring for HIV-positive youth? What do you think needs to be looked at differently when you're talking about positive adolescents, as opposed to older people?
Fundamentally, the guidelines basically say that you should start to treat people as soon as you make a diagnosis of HIV. This is the concept of test-and-treat -- and so you start people on HIV medicines right away, regardless of their CD4 count. So it could be really high, or really low, but you're going to start them on medications.
The idea is that then what happens is their viral load goes down, goes to undetectable; and they are less likely to transmit the infection to other people. And the idea is that if you could get everybody treated as soon as you've tested them, eventually you'd wipe out the infections because there would be no new infections.
The problem with this is that that takes a fair amount of sophistication. And I don't know that all teenagers are able to deal with that. When you give a diagnosis of HIV positive to a youth, not only are you giving them difficult news, which they may or may not be developmentally equipped to deal with, but they frequently have other variables in their life that make it more difficult.
For example, a young man who is a minority, of color, who is gay, is having sex with men: he may not be out to his family about that. And they may not be very supportive of that. So what you don't want to have happen is for them to discover that he's taking medicines -- because you've given a bottle of pills, and so the family members discover that not only is he HIV positive, but he's also gay. This could potentially lead to being kicked out of the home, or a hostile home environment, when we really want a supportive home environment. So there are scenarios that it may not be a good time for a youth to start HIV medicines until they are really ready, and have thought through all the repercussions of what would happen if they start medications: Do you have a place to stay? Do you have a place to hide your medications? Or do you feel comfortable including your family?