HIV infection in adolescents

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

An increasing number of HIV-infected children who acquired HIV infection through perinatal transmission are now surviving into adolescence. They generally have had a long clinical course and extensive ARV treatment history. Adolescents with behaviorally acquired infection (i.e., infection acquired via sexual activity or intravenous substance use) generally follow a clinical course similar to that in adults. Because behaviorally infected adolescents are at an early stage of HIV infection, they are potential candidates for early intervention and treatment.

Treatment

Dosing

• Many ARV medications (e.g., abacavir, emtricitabine, lamivudine, tenofovir, and some protease inhibitors [PIs]) are administered to children at higher weight- or surface area-based doses than would be predicted by direct scaling of adult doses, based upon reported PK data indicating more rapid drug clearance in children.
• Continued use of these pediatric weight- or surface area-based doses as a child grows during adolescence can result in medication doses that are higher than the usual adult doses.
• Many factors may affect the transition from pediatric to adult doses. In addition to toxicity, pill burden, adherence, and virologic and immunologic parameters, factors may include social determinants, such as housing, family support, employment, and recent discharge from the foster care system.

Specific issues in antiretroviral therapy for HIV-infected adolescents

Adolescent Contraception

• Adolescents with HIV infection, regardless of mode of acquisition, may be sexually active. Contraception methods and safer sex techniques for prevention of HIV transmission should be discussed with them regularly.
• Several PI and non-nucleoside reverse transcriptase inhibitor (NNRTI) drugs interact with oral contraceptives, resulting in possible decreases in ethinyl estradiol or increases in estradiol or norethindrone levels. These changes may decrease the effectiveness of the oral contraceptives or potentially increase the risk of estrogen- or progestin-related side effects.
• Providers should be aware of these drug interactions and consider alternative or additional contraceptive methods for patients receiving ARV drugs with such interactions.
• Whether interactions with ARV drugs would compromise the contraceptive effectiveness of progestogen-only injectable contraceptives (such as depot methoxyprogesterone acetate - DMPA) is unknown because these methods produce higher blood hormone levels than other progestogen-only oral contraceptives and combined oral contraceptives.
  • In one study, the efficacy of DMPA was not altered among women receiving concomitant nelfinavir-, efavirenz-, or nevirapine-based treatment, with no evidence of ovulation during concomitant administration for 3 months, no additional side effects, and no clinically significant changes in ARV drug levels.

Adolescent Pregnancy

• The possibility of planned or unplanned pregnancy should be considered when selecting an ARV regimen for the adolescent female.
• The most vulnerable period in fetal organogenesis is early in gestation, often before pregnancy is recognized. Therefore sexual activity, reproductive plans including preconception care, and use of effective contraception should be discussed with the patient.