ADOLESCENTS Strengthening Systems for Diagnosis of HIV & Linkage to Care Institute of Medicine April 15-16, 2010 Donna Futterman, MD | AdolescentAIDS.org Professor of Clinical Pediatrics, AECOM Director, Adolescent AIDS Program, Montefiore

AIDS is NOT Over for Youth 35% New HIV infections among youth ,000 Youth infected annually - 1 every hour 54% YMSM; 35% young women; 11% other young men >85% HIV+ youth sexually infected >80% HIV+ youth are racial/ethnic minorities >50% HIV+ youth untested (80% HIV+ gay youth unaware) Growing numbers Perinatally-infected reaching adolescence (2,700) AdolescentAIDS.org

HIV/AIDS Among Youth Youth Population 42,500,000 (15-24) HIV/AIDS Cases 56,500 (13-24) AdolescentAIDS.org

HIV Testing & Youth Who gets tested? (CDC 2009) 16% US 18-24yr olds 13% HS youth (19% 12 th grade) -15% Females, 11% Males -22% Blacks, 13% Hispanics, 11% Whites -22% of youth who ever had sex No youth-specific data on testing venues AdolescentAIDS.org

HIV+ Youth Engaged in Care in 2009 (12 ATN Sites)  Bronx  NYC San Francisco   Baltimore  Puerto Rico Chicago - Children’s  Philadelphia   Miami  Memphis St Petersburg & Tampa  AdolescentAIDS.org  Washington, DC Chicago - Stroger 

ATN Survey of 2009 HIV+ Youth N=400 AdolescentAIDS.org

ATN Survey of 2009 HIV+ Youth N=400 AdolescentAIDS.org

HIV Testing Among Youth: Barriers & Facilitators  Medical  Institutional and Legal  Youth and Cultural AdolescentAIDS.org

Medical Barriers  Most providers don’t see testing as part of routine care  Prevention counseling still assumed integral to HIV testing so think they don’t have the time or training needed to test  Provider’s fear delivering a positive diagnosis  Youth diagnosed late (CD4 = 378/mm c )  Providers unaware of risk, even for STI patients  Not all insurance companies reimburse for testing  Confidentiality and consent a problem for youth  Lack of streamlined administrative systems  Youth friendly health care not widely available AdolescentAIDS.org

Medical Facilitators  CDC and medical societies support routine testing  Most youth accept test when offered  Most states now have laws that streamline C&T and eliminate written consent  Tools exist for implementing routine testing and streamlining counseling (ACTS)  Increasingly, public health focused on improved case finding (Municipal scale-ups)  The Medical System holds the key:  Linkage to care is optimized in these settings  Consumers expect to receive confidential, quality care  Yet, potential not reached AdolescentAIDS.org

Municipal Scale-Ups

It’s Time for a Paradigm Shift! HIV/AIDS is a medical condition. Providers and institutions must stop sailing around HIV testing obstacles. It’s Time for a Paradigm Shift! HIV/AIDS is a medical condition. Providers and institutions must stop sailing around HIV testing obstacles.

The real mountain of work begins when patients learn they are HIV+ We must put our resources where they are needed by shifting tasks… The real mountain of work begins when patients learn they are HIV+ We must put our resources where they are needed by shifting tasks… FromTo Belaboring the decision to testDiagnosing HIV & providing care Patient requested onlyRoutinely offered by providers Testing by counselors onlyTesting by all providers

Institutional and Legal  Youth among the least insured (25% lack insurance)  Vulnerable communities not well served  Economic, racial, gender, and sexual orientation disparities  Homophobia and lack of data and effective outreach to LGBTQ communities  Sex education is inadequate  Lack of coordination within and between federal and local agencies serving youth  Confidentiality & Consent: Young people have legal rights and protections but many providers and youth unaware of laws  FACILITATOR: Youth can consent to HIV test and in 26 states can consent to treatment without parent AdolescentAIDS.org

Youth and Cultural  New generation every 5 years so need ongoing and updated programming and social marketing  Youth feel invincible, not afraid of HIV  AIDS is invisible in many communities  Fear of disclosure to parents; HIV, sex and sexual orientation  FACILITATOR: Free, rapid and painless testing AdolescentAIDS.org

Recommendations  National strategy to promote the routine offer of HIV testing in all youth serving organizations/institutions (i.e. medical, education, social services, corrections)  Make HIV testing a quality indicator for facility accreditation/evaluation  Mobilize and train providers to offer culturally competent testing routinely  Enhance promotion of testing among highest risk youth: msm, youth of color, youth with mental illness or substance use  Help newly diagnosed youth accept their status and access care AdolescentAIDS.org

Recommendations  Address laws/policies that impede youth from testing (i.e. age of consent, parental notification)  Address insurance coverage, stigma, housing instability, lack of HIV information  Monitor youth testing and service gaps  Enhance testing among youth-serving institutions  Ensure that youth care continues to be funded in era of health reform and budget cutbacks AdolescentAIDS.org

Contact Us Donna Futterman, MD Learn more about routine HIV testing: ACTSHIVTest.org