Key Issues Affecting the Care of HIV-Positive Adolescents
An Interview With 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?
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.
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.
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.