1. Ending the Epidemic Among Youth IAS 2016 | Durban | July 20, 2016
Donna Futterman, MD
Director, Adolescent AIDS Program
Professor of Clinical Pediatrics, Einstein College of Medicine
Bronx, New York

2. Key Questions What is the global picture of HIV among youth?
What are the challenges to decrease the burden of HIV among youth?
How do we turn Activism into Action to end the epidemic?

3. Globally, AIDS Deaths: Only Rising Among Adolescents
I’d like to start by talking about this picture that we’ve seen and heard about several times this week. [PAUSE] The only group in whom AIDS deaths are increasing is adolescents as shown by the red line above. Every day, 300 adolescents are dying due to AIDS.
At UNICEF, we’ve analysed the best data available and what we’ve found is that ten years ago, in 2005, 69,000 adolescents died of AIDS. By the end of 2012, that number had increased by 50% [REPEAT] 50% --- yet AIDS deaths had fallen by 30% across all age groups. [PAUSE]
This is a humbling reminder that we have not done our best for adolescents and we must turn our attention to addressing this gap. We have got to end the AIDS epidemic among adolescents and to address this inequity, we must act with urgency.
Source: UNAIDS 2012 HIV and AIDS estimates
AdolescentAIDS.org

4. Global:5M Youth Living with HIV Majority perinatally infected | 250,000 new infections annually | 2/3 female
Generalized Epidemics
Sexual transmission (Africa)
Perinatal (Africa)
Non-Generalized:
High-Risk Populations
IDUs (Asia & E. Europe)
YMSM (developed & developing countries)
Commercial & Transactional Sex
Youth in juvenile detention
More children will survive into adolescence
Majority of HIV+ mothers are also youth
AdolescentAIDS.org

5. Global HIV Care Cascade: How do we improve to 90-90-90 for youth?
Diagnosed
HIV+
Prescribed
ART
Suppressed
Virally
In 23 PEPFAR countries, the number of y.o. on ART will need to quadruple between 2014 and 2020 to meet goals.
ISSUES:
Most youth have not been tested.
Most youth have inadequate access to ART & youth-friendly adherence support.
Poor data & wide variance (27% -89%)
in reported global viral suppression in youth.
AdolescentAIDS.org

6. Optimizing the Care Cascade: HIV Testing
Most HIV+ youth don’t know
Majority not symptomatic
Need routine, targeted and ongoing testing
Routine testing needed in clinical sites
Outreach-based (schools, communities, venues)
Address consent and confidentiality with minors
Test all youth: undisclosed sexual activity/abuse and perinatally infected

7. Optimizing the Care Cascade: Youth-friendly Care
More intensive engagement & retention required
Providers: knowledgeable & nonjudgmental
Peer support: engage peers and cohort youth to single day
Address Coping, Stigma, Disclosure
Adherence to ARVs & Prevention
Respect minors’ confidentiality and consent
Transitioning to adult care

8. Optimizing the Care Cascade: Viral Suppression
Immediate treatment is game changer
Check pubertal development for dosing
Developmental issues key
Concrete and present-oriented thinking
Adverse events may seem intolerable
Meds rebellion as a form of independence
Mistrust providers YET trust misinformation from peers – learn barriers and motivators
Perinatally infected have unique needs
Monitor program & follow-up defaulters
PrEP
VAGINAL MICROBICIDES
30% reduction in male to female HIV transmission
Female-controlled prevention method
Acceptability and empowerment?
Sex less consistent, hard to include in research
Rectal microbicides key for MSM and some women
Biological issues in young women
Lack of progesterone in anovulatory menstrual cycle
Enhanced susceptibility to STIs with cervical ectopy
VMMC
Timing: babies, children, adolescents, adults
Surgical vs. ritual circumcision (rite of passage)
Disinhibition
Will lower condom use increase risk for women?
Increased risk post-op needs behavior intervention
Wide variation based on culture, religion, SES
60% reduction in female to male HIV transmission

9. Preventing New Youth Infections Must understand barriers and motivators
PMTCT
PrEP
Male Circumcision
Vaginal Microbicides
Vaccines
Prevention with Positives
Youth Engagement/Mobilization
PrEP
VAGINAL MICROBICIDES
30% reduction in male to female HIV transmission
Female-controlled prevention method
Acceptability and empowerment?
Sex less consistent, hard to include in research
Rectal microbicides key for MSM and some women
Biological issues in young women
Lack of progesterone in anovulatory menstrual cycle
Enhanced susceptibility to STIs with cervical ectopy
VMMC
Timing: babies, children, adolescents, adults
Surgical vs. ritual circumcision (rite of passage)
Disinhibition
Will lower condom use increase risk for women?
Increased risk post-op needs behavior intervention
Wide variation based on culture, religion, SES
60% reduction in female to male HIV transmission
PWP
Key element of HIV care and public health
Protect yourself/others from STIs and new HIV
Prevention messages
PrEP for HIV- partners
Condomize every time you have sex
Engage partners: testing/disclosure if safe
Fewer partners = less risk
Drugs and alcohol = greater risk (SEP)
Consider not having sex (other ways to express love)
Discuss safe pregnancy options (PMTCT)

11. Key lessons to end the epidemic!
New generation every 5 years
Multiple realities: some youth feel invincible, others fear HIV is inevitable
Sex is complicated
Vulnerable youth not well served
Gender, economic, racial, & sexual orientation disparities
Youth-friendly services must be scaled up
Ongoing commitment of leadership & funding
Mobilize youth leadership through activism

12. Acknowledgements Stephen Stafford Terri Jackson, MA, MPhil
Providers & Youth
Donna Futterman, MD

13. Ending the Epidemic Among Youth IAS 2016 | Durban | July 20, 2016
Donna Futterman, MD
Director, Adolescent AIDS Program
Professor of Clinical Pediatrics, Einstein College of Medicine
Bronx, New York

14. Ending the Epidemic Among Youth IAS 2016 | Durban | July 20, 2016
Donna Futterman, MD
Director, Adolescent AIDS Program
Professor of Clinical Pediatrics, Einstein College of Medicine
Bronx, New York