1. Dr Melinda Tenant-Flowers
3rd Annual Conference of the Children’s HIV Association
‘Young People and HIV: Back to the Future’
Dr Melinda Tenant-Flowers
King’s College Hospital NHS Trust, London
Friday 15 May, The Bridgewater Hall, Manchester

2. Contributors
Chair: Melinda Tenant-Flowers. King’s College Hospital London. Consultant GUM/HIV
Colin Ball. King’s College Hospital London. Consultant Paediatrics / HIV
Fiona Boag – Chelsea and Westminster Hospital NHS Foundation Trust, Imperial, London. Consultant  GUM/HIV
Caroline Foster – St Mary’s Hospital NHS Foundation Trust, Imperial, London. Consultant Paediatrics / HIV
Eva Jungmann – Archway Sexual Health Centre, Camden and Islington Primary Care Trust, London, Consultant GUM/HIV
Elaine Pearson Scott – Positive Parenting Children (PPC) (Lambeth)
Maria Phelan – Children and Young people HIV Network Coordinator, National Children, s Bureau
Katia Prime – St George’s Hospital Trust, London, Consultant GUM/HIV
Ella Sherlock – Clinical Psychologist HIV Child and Family Psychology Service CASCAID (Lewisham and Southwark)
Rebecca Wilkins – Community Matron, Diabetes Centre Newbury Park Redbridge PCT
Conflict of Interest / Competing Interest
None declared 2

3. Contents Definition of Adolescence Definition of Sexual Health
Aim and scope of Guidance
Existing Guidelines
Contents of Guidance
How to Talk
What to say
Epidemiology
HIV transmission risk
Criminalisation
Information on Genital infections and STIs
Common presentations of STIs
Preventing unwanted pregnancy
Next steps
Stakeholders - Potential 3

4. Definition of Adolescence
Various definitions in literature
Relate to age, growth or the onset of puberty.
Ages 10 to 20 years-old
Different epidemiological datasets
Health Protection data on Young People and Sexually Transmitted infections collects data on year-olds
UK Collaborative HIV in Paediatrics (CHIPS) data defines adolescence as commencing at age 12 years-old
Puberty and sexual activity commence at any time from 10 years old in UK born children
Below the age at which adolescents are deemed capable of legally consenting to sex
The term adolescent used in this guidance to denote young people aged years old. 4

5. Definition of Sexual and Reproductive Health
WHO defines sexual and reproductive health as ‘A state of physical, emotional, mental and social well being related to sexuality, NOT merely the absence of disease, dysfunction or infirmity’
Sexual and Reproductive Health services aim to prevent sexually transmitted infections (STIs) and unwanted pregnancies as well as screen for, diagnose and manage STIs and their sequelae to minimise morbidity and mortality 5

6. Existing Guidelines
Excellent evidence-based guidelines on adolescent sexual and reproductive health (SRH) already exist:
BASHH Standards for comprehensive sexual health services for young people under 25 years (2002)
FSRH Guidance Contraceptive choices for young people (2004)
BASHH United Kingdom National Guideline on the Sexual Health of People with HIV: Sexually Transmitted Infections (2006)
BASHH UK Guideline for the use of post-exposure prophylaxis (PEP) for HIV following sexual exposure (2006)
BASHH national Guidelines on Consultations requiring Sexual History Taking (2006)
FSRH BASHH Guidance The management of women of reproductive age attending non-genitourinary medicine settings complaining of vaginal discharge (2006)
CHIVA Growing Up, Gaining Independence Principles for Transition of HIV Care (2007)
CHIVA Practice Guidance on Talking to Children about their HIV Diagnosis (2007)
BHIVA BASHH FRSH UK guidelines for the management of sexual and reproductive health (SRH) of people living with HIV infection (2008)
BHIVA CHIVA Guidelines for the management of HIV infection in pregnant women (2008)
RCPCH Guidelines on Child Sexual Abuse (2008)
BASHH UK National Guidelines on the management of Sexually Transmitted Infections and related conditions in Children and Young People (Final draft out for consultation )
CHIVA Guidelines on HPV vaccination in HIV Infected Adolescents (2009 for consultation) 6

7. Aim of Guidance
Provide guidance and knowledge for Paediatric Healthcare Professionals (PHCP) managing adolescents with HIV
Enable them to answer questions put to them by adolescents about Sexual and Reproductive health
Enable them to start discussions about sexual and reproductive health (SRH)
Be able to inform adolescents what to expect from SRH Services
Provide information for PHCP on where to access existing guidelines 7

8. Aim of Guidance
Some PHCP may find themselves caring for adolescents with sexually transmitted HIV
For this group, the correct messages regarding SRH are still vital
HIV may have been sexually acquired through heterosexual or same gender sex with other males (MSM)
This guidance will also be of interest to PHCP caring for adolescents without HIV, who are about to become, or already are, sexually active 8

9. Aim of Guidance NOT intended to retrain PHCP as SRH experts
To inform their discussions with adolescents to enable them to answer basic questions about sexually transmitted infections (STIs), Sexual Health and conception / contraception-related issues or
initiate a discussion about their SRH needs
Recognise that PHCP will refer adolescents to their colleagues in Genitourinary Medicine (GUM) / SRH whenever possible
However, PHCP will, in many cases, have been caring for these adolescents for many years throughout their childhood
Therefore, in some cases, adolescents may ask their PHCP first about SRH matters because of the long term and trusting relationship that has developed 9

10. Aim of Guidance
Guide PHCP through a timeline for discussing SRH issues
For adolescents with vertically transmitted HIV, this process would normally start as they approach the time when their HIV diagnosis is disclosed to them as part of the preparation for transition to adult services
Appropriate language
Main topics to be covered
Relevant ethical, legal and confidentiality concerns and challenges experienced by HIV-infected adolescents in relation to SRH 10

11. Guidance Contents The Guidance is split into two main sections:
How to talk to adolescents about SRH
Most challenging?
2. Facts about SRH
Appendices
References
Sources of Information 11

12. Contents How to talk to Adolescents about SRH
Sexual Health Education needs of Adolescents
Sexual Development and Relationships
Sex and Relationships
Negotiating Sexual relationships
HIV transmission risks
Disclosure of HIV status - Who to tell, when and why
HIV disclosure and Criminalisation
Consent and Confidentiality
The Sexual Offences Act 2003
Assessing Fraser (Gillick) Competence
Talking about Sex
Talking about Sexual and Reproductive Health
STI and Conception risks
Sexual History taking
Psychosocial issues and services available
Sexual Assault. 12

13. Contents Facts about SRH
Epidemiology of Sexual Health in Adolescents in the UK 2009
Service provision for STI screening and contraception / conception advice
Common non-sexually acquired infections
STIs and their screening, diagnosis, morbidity, management and prevention
Partner notification
Common presentations of genital infections - non sexually acquired and sexually transmitted
Interaction between HIV transmission and STIs
Cervical screening
Contraception including emergency contraception and long acting reversible contraception (LARC)
Conception, fertility, pregnancy and STIs
Drug interactions between STI treatment and contraception and combination antiretroviral HIV therapy (CART) 13

14. How to talk
When young people were asked what they wanted from an adult when talking about sex, their top three requirements were someone who was:
Non-judgemental
Had correct information
Maintained confidentiality 14

15. What to say
Young people need age/developmentally appropriate and up to date information on topics including:
Puberty
Relationships
Sex
Contraception
STIs
HIV transmission -“protecting themselves and others”
Condom use - negotiation and condom failure
Partner disclosure
PEPSE
Emergency contraception
Fertility
Pregnancy
Mother-to-child transmission
Legal issues. 15

16. Epidemiology
CHIPS Data end September % children diagnosed in UK
N =1495
97% infected perinatally
75% Black African
Post CART median age over 11 years.
1147 current paediatric follow up
646 (56%) aged 10 years +
345 (30%) aged 13 years +
170 (11%) transferred adult services median age17years
HPA data
Route of infection horizontal transmission
48% heterosexual (Black Africans infected abroad)
48% MSM (white infected in UK) 16

17. Epidemiology
25%of UK adolescents have had sex before their 16th birthday
Boys report earlier sexual debut than girls and younger adolescents are less likely to use a condom at first sex than older adolescents
Despite a downward trend since 1998, the UK has the highest rate of teenage pregnancy in Western Europe
Conception rate in England of 41 per girls aged during 2007, half of which ended in legal termination
2007 HPA data - 50% all STI diagnoses diagnosed in year olds
65% all chlamydia
50% all gonorrhoea
50% all genital warts
New diagnoses chlamydia in year olds doubled in last 10 years 17

18. HIV Transmission Risk
KNOWN HIV positive and risk of transmission Varghese 2002
Type of sex act
Risk of HIV transmission per exposure
Receptive Vaginal
0.1% or 1 in 1,000
Insertive Vaginal
0.05% or 1 in 2,000
Receptive Anal
0.5% or 1 in 200
Insertive Anal
0.065% or 1 in 1,538
Receptive oral with ejaculation
% or up to 1 in 2,500 18

19. HIV Transmission Risk What increases the risk of transmission?
High plasma HIV viral load
HIV seroconversion
Advanced HIV disease
Concomitant sexually transmitted infections
Menstruation
What decreases the risk of transmission?
Condoms
Circumcision
CART (lowers viral load)
Post exposure prophylaxis (PEPSE)
Safer sex 19

20. Criminalisation
HIV positive adolescents do not need to disclose their status to sexual partners as long as they are having protected sex
If HIV positive young person is having unprotected sex or there has been a risk of exposure (e.g condom splits) they need to disclose their HIV status to that partner
Currently there is no specific legal guidance around HIV transmission for those under 16 years of age (Consultation with the CPS is in process)
Prosecution requires the following:
Transmission of HIV must have occurred - having unprotected sex is itself not a crime
The young person needs to be aware of their status
The young person needs to have engaged in a risky behaviour
The young person needs to understand the risks of transmission
If young people are not given this knowledge and then are involved in activities that may be thought of as illegal it could be that those who have neglected to inform them are vulnerable to prosecution 20

21. HIV infection can be transmitted to sexual partners
What to say
HIV infection can be transmitted to sexual partners 21

22. Common presentations of STIs
ASYMPTOMATIC
Discharge
Abdominal pain
Abnormal vaginal bleeding
Genital lumps 22

23. Genital Infection and STI Information
Genital Infections
NOT sexually transmitted - COMMON
Candida
Bacterial vaginosis
Sexually Transmitted Infections
Chlamydia
Gonorrhoea
Syphilis
Herpes simplex virus
Human papilloma virus
Hepatitis A/B 23

24. Contraception and Conception
Preventing Unwanted Pregnancy
Emergency contraception
Long Acting Reversible Contraception (LARC)
Other
Safe Conception and Pregnancy 24

25. Next Steps Other Proposed Stakeholders Consultation BHIVA, BASHH, FSRH
CHIVA website 25

26. What we need now These guidelines need feedback and consultation
Feedback from all paediatric HCP’s
Feedback from young people
Consultation will be facilitated through the CHIVA website

27. Acknowledgements
Thank you to everyone in the HYPNET working party!