Turning Challenges into Opportunities: Preventing and Treating HIV Infection among

Adolescents

Natella Rakhmanina, MD, PhDProfessor of Pediatrics

The George Washington UniversityChildren’s National Health System

Senior Technical Advisor Elizabeth Glaser Pediatric AIDS Foundation

Washington, DC

Asia Pacific HIV Clinical ForumHong Kong, 26-27 June 2019

Disclosure

• No conflicts to disclose

Outline

• HIV epidemic among adolescents

• Challenges and opportunities in prevention,

testing, ART and retention in care among

adolescents

• Important considerations for research and

services for adolescents

HIV Prevalence among Youth Globally

Source: UNAIDS 2018 estimates, July 2018

1.8 million adolescents living

with HIV

5% of all people living with HIV

New HIV Infections among Youth

Source: UNAIDS 2018 estimates, July 2018

590,000 youth 15-24 yrs were newly infected with HIV in 2017

250,000 (42%) among 15-19 yrs = 16 % of new adult HIV infections

Motherhood and HIV among Adolescent Girls

• Of every five new HIV infections among young people aged 15-24 years – three are among young women

• In Sub-Saharan Africa, 42%-50% of women 15-24 years of age had a pregnancy before the age of 18 years.

Sources: Population-based surveys, 2011–2016.The statistics are based on available data from27 countries in which 80% of all women aged 15–24 years in sub-Saharan Africa live;UNIADS 2018 estimate

Challenges with Prevention • 78 countries require parental consent for adolescents to

access sexual and reproductive health (SRH) services• 26/100 countries with a national preventive strategy

with condoms, have included condom promotion in secondary schools

• 67 countries criminalize same-sex sexual relations • 1/3 of adolescents globally have comprehensive

knowledge about HIV and prevention • PrEP programs are integrated within SRH and

frequently require risk-factor screening and pre-approval

• Adherence with PrEP is challenging in adolescents Source: UNAIDS, Women and HIV, 2019; Mensch et al. AIDS Behav, 2019, ASPIRE trial

Opportunities for Prevention • Focusing on long-term health of youth globally with

special focus on girls and women • Lowering the age of consent to access SRH services • Wider access to HIV prevention within SRH and

general health services – integrated health programs • Making SRH youth-friendly and accessible• Increasing knowledge about HIV, SRH and safe

behaviors among youth (digital tools, gaming, social media, educational sector and community outreach)

• Increasing adherence to PrEP – long-term injectable/implantable ARVs as prevention & combined with contraception for girls and women

Source: Azzopardi et al, Lancet 2019; DREAMS, PEPFAR; Sabben G et al, JMIR, Res Protoc 2019

Current Progress in Prevention among Youth

Source: UNAIDS 2018 estimates, July 2018

Challenges with Identification

• 45 countries have laws that impose the need for parental consent for adolescents <18 years to access HIV testing

• Plus 50 countries have such laws for adolescents <14 years and <16 years

• 23% of girls and 17 % of boys aged 15-19 in Eastern

and Southern Africa have been tested for HIV in the

past 12 months and received the result of the last test

• The testing rates in West and Central Africa and South

Asia are even lower

Source: UNAIDS 2018 estimates, July 2018

Percentage of adolescents 15–19 years and youth 20–24 years who have ever been tested for HIV and received results, in selected sub-Saharan

African Countries, 2007-2012

Opportunities for Identification • Decreasing age for the independent

consent to SRH and HIV testing • Integrating HIV testing into health

services for adolescents • Efficient testing strategies (index

case, partner testing, repeat testing within PMTCT cascade)

• Innovative approaches for HIV testing - self-testing (STAR project –highest proportion of first-time testers in 16-24 years old group)

Source: Hatzold K et al. Journal of the International AIDS Society 2019; Jubilee M et al, PLoSOne, 2019;

HIV positivity rate by age and HTS modality 2015-2017

Source: Jubilee M et al, PLoS One, 2019

Challenges with ART

• Adherence is a major barrier (87-92% by self-report vs 34-64% through EM)

• Adherence <90% on DTG-based ART associated with virologic failure in 12-17 years old (IMPAACT P1093)

• Toxicity issues (including fetal/child toxicity in females, e.g. DTG and contraception access, poorly developed PV systems)

• Drug-drug interactions with TB medications, contraceptives

Source: Craker et al, AIDS Behav, 2019; Viani Rm, et al, JPIDS 2019;

Opportunities for ART

• Fixed dose combination (FDC) once daily• Simplification strategies (short cycle, dual ART) • Long-term ARVs (IMPAACT 2017)• Combination with long-term

injectable/implantable contraceptives• Innovative ways to support adherence (mobile

apps, school ART access, digital tools such as gaming, pill boxes)

• Approach to ART as prevention for partners • Addressing long-term ART toxicity and non-

communicable diseasesSource: Turkova A, et al. PLoS One, 2018; Castel A et al, JMIR Serious Games, 2018; IMPAACT

Short Cycle vs Continuous Therapy in Youth, BREATHER Study

Source: Turkova A, et al. PLoS One, 2018

Challenges with Retention in Care and on ART

• Non-disclosure of HIV status• Loss to follow up • Transition in care (vertical and horizontal)• Suboptimal adherence evaluation and support• Mental health issues (e.g. depression, anxiety) • Substance abuse (e.g. alcohol, drugs)• Lack of social protection (poverty, abuse,

violence, drop out of education)• Health system factors (lack of training in

adolescent care among healthcare workers, long turn around time for viral load testing)

Youth HIV Cascade in the USA

Opportunities for Retention in Care and on ART

• Increasing resilience and self-motivation & self-

care skills (peer support, gaming, mobile

technology, mHealth, cash transfers)

• Peer support (Zwandiri CATS model, camps,

groups, media)

• Support of disclosure and transition in care

• Comprehensive interventions for treatment

failure

• Increasing social protection Sources: Ross J, et al. Journal of the International AIDS Society 2019;

https://www.pepfarsolutions.org/adolescents/2018

Supporting Retention in Care and on ART

Zwandiri CATS Model Zimbabwe, Africaid

New Horizons Collaborative Disclosure & Treatment Failure Management Tools

Challenges and Opportunities for Research

• Limited adolescent data• Challenges of consent and

assent• Challenges with

enrollment and retention • Limited involvement of

adolescents in the study design and ethic considerations

• IAS/CIPHER Collaborative Global Cohort (IeDEA)

• Successful past and ongoing studies (e.g. ATN, IeDEA, PHACS)

•Adolescents are able to obtain the services that are providedAccessible-

•Health services are provided in ways adolescents want to obtain themAcceptable-

•All adolescents, not just certain groups, are able to obtain the health services they need

Equitable-

•The health services that adolescents need are providedAppropriate-

•The right health services are provided in the right way and make a positive contribution to the health of adolescents

Effective-

Tailoring to the Needs of Youth

Ayesha (name fictitious), 18 year old PHIV“Growing up with HIV was honestly not that bad! Having a weak immune system at first seemed to be overwhelming, but as I got older and really understood my medical situation I began to just take it as, this is just a part of who I am! So what if you’re a little different from your friends and people around you. My advice to you is never let anything stop you… If you have a dream or a goal you want to reach, then go for it, don’t let your medical mishaps stop you from being you and going after your dreams.”

Meaningful Involvement

ASSET (Advanced Support Services, Education, and Treatment) US-Russia EGPAF Project, 2016

Meaningful participation requires engaging adolescents as equal

partners in the design, implementation, monitoring and evaluation of programmes and

policies.

Acknowledgements/Recognition

• Adolescents and young people

• Lynne Mofenson, EGPAF

• Elaine, Abrams, ICAP

• Chewe Luo, UNICEF

• EGPAF colleagues

• Annette Sohn, Thailand - Director of TREAT Asia, Vice

President of amfAR

E-mail: nrakhmanina@pedaids.org