An Interview With John Steever, M.D.
"If a kid is going to get kicked out of their home, that's not the best time to start them on their medications."
I think family support, especially when you're a teenager, is incredibly important. But if a kid is going to get kicked out of their home, that's not the best time to start them on their medications.
Things like serious substance use should give a clinician pause before starting HIV medicines. Or an unstable home life -- so maybe they don't live at home, but they're couch surfing with friends -- or they're in a shelter. It's just much more difficult to manage your HIV care and worry about housing, food, clothing.
If you start somebody on medicines, you want them to be successful. If they're not successful and they cannot suppress their viral load, then they're likely to breed resistance to that medication. And since these are such young people, they're going to be in medicine for a long time. You have to make each regimen count; you don't want somebody to be hit-or-miss with their medicines in the beginning, get resistant and then have to switch relatively quickly.
"Since these are such young people, they're going to be in medicine for a long time. You have to make each regimen count."
I feel like you need to be ready, the patient needs to be ready, and you need to get your mental health people -- like your social worker or a case manager -- involved, to help explore how is this young person going to be successful in taking meds.
How do you recommend discussing HIV treatment with a newly diagnosed adolescent?
Well, I think the goal is really noble, and I definitely think that for adolescents the topic should be brought up. But I think you need to really slow the kid down and say, "OK, here are the advantages, and the disadvantages. Here's why we should start meds; and here's why this might be a bad idea. We're not going to do anything today. I want you to think about it. I want you to work with your social worker, your case manager, your mental health person," and really work through some of these things. Maybe teens should be encouraged to practice with a multivitamin. I think the guidelines are great, but there has to be some acknowledgment that you can't rigidly start something.
Or, if you are sort of backed into a corner about starting something, maybe for teenagers one of the first lines should be something that involves a protease inhibitor, because the genetic barrier to resistance is so much higher. You lose the convenience of a one-pill, once-a-day regimen. But you gain the advantage of having a medicine that is not likely to cause mutations quickly.
"For teenagers, I often reach for the protease inhibitors, just because it's a good class for them."
For teenagers, I often reach for the protease inhibitors, just because it's a good class for them.
Where can clinicians get help to broach those areas that may be outside their expertise, but are important to treating an adolescent with HIV?
If you're lucky, you've got a social worker in your office. I'm extremely lucky to have that myself. If you're not so lucky -- if you're in a solo practice, if there's not a lot of staff around you -- your nurse might be interested, and do some of this sort of work. But there are also organizations out there that will provide some of the case management structure for you. I'm sure that they are probably not in every city and every small town across the country. But, certainly, in some of the larger cities, there are organizations that help to provide structure. To have them at your fingertips, on your Rolodex, is probably a good thing.
Are there any hot-button issues in HIV care right now that you are especially excited about from the standpoint of an adolescent care provider?
I'm really eager to see what kind of long-acting injectable, or maybe even implantable, medicines scientists are going to be coming up with. I would like to see more resources put into something like that.
Somebody has to remember to take a pill every day right now, but as much as you can take the user out of the equation -- if you could do an injectable cocktail once a month, or once every three months -- I think that would really improve adherence to HIV medicine. That would really improve getting community viral loads down and, therefore, decrease the risk of transmission to other people.
Also, for people who are in a serodiscordant couple, having injectable pre-exposure prophylaxis might really go a long way to make a dent in the epidemic.
The other thing is (and I don't know how to do this), we've got to figure out how to reach out to more people. I think any barrier that can be removed to HIV testing should be done. For example, no one ever says at an annual physical, "Oh, we're going to draw a blood count, a CBC."
It should just be, "We're going to do the routine blood work that's done at a physical." And that should be part of it so that you catch people -- you just do a lot more of those and we can hopefully find more people who have the infection.
Test widely, and test often, as they say.
Thank you so much for talking with me.
This transcript has been edited for clarity.
Mathew Rodriguez is the community editor for TheBody.com and TheBodyPRO.com.
Follow Mathew on Twitter: @mathewrodriguez.
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