The adolescent with HIV infection

INTRODUCTION — Exposure to human immunodeficiency virus (HIV) can be a consequence of many of the risk-taking behaviors that occur among adolescents. There are unique challenges to the prevention, diagnosis, and treatment of HIV infection among adolescents. A comprehensive program for adolescents at risk for HIV infection must include efforts at preventing infection (such as outreach programs and access to pre- and postexposure prophylaxis), easily accessible testing, risk reduction counseling, and behavioral health services. Education and prevention efforts must take into account the developmental level of the patient, as well as social and psychological variables. Programs that have been successful are youth-friendly, peer-oriented, inclusive of all sexual and gender groups, and targeted toward specific high-risk behaviors, offering a range of services through multidisciplinary teams [1,2].

Issues surrounding HIV infections vary widely between adolescents in resource-rich and resource-limited settings. This topic will review, principally within developed settings, the epidemiology of and risk factors for HIV infection among adolescents, strategies to provide services to adolescents, and age-specific recommendations for initiating treatment. Other aspects of pediatric and adolescent HIV infection are discussed separately:

●(See "Epidemiology of pediatric HIV infection".)

●(See "Pediatric HIV infection: Classification, clinical manifestations, and outcome".)

●(See "The natural history and clinical features of HIV infection in adults and adolescents".)

EPIDEMIOLOGY — In 2019, there were an estimated 1.7 million adolescents aged 10 to 19 living with HIV worldwide. The great majority of affected adolescents (88 percent) are in sub-Saharan Africa [3,4]. In 2015, HIV-associated mortality was the eighth leading cause of adolescent death globally [3].

In developed settings such as the United States, HIV infection rates vary by age, race, ethnicity, and geography (figure 1 and figure 2). In the United States, youth aged 13 to 24 years accounted for an estimated 21 percent of all new HIV infections in 2018. The majority of adolescents and young adults with HIV acquired HIV through sexual activity. Young men who have sex with men accounted for 82 percent of new HIV infections in males in this age group. Black youth accounted for an estimated 52 percent of all new infections, followed by Hispanic/Latino (25 percent) and White (18 percent) youth [5]. Geographically, southern states are disproportionately affected by HIV. Southern states accounted for more than one-half of new HIV diagnoses in 2018, while making up only 38 percent of the national population. It is estimated that over 40 percent of youth with HIV in the United States do not yet know that they are infected [6].

Although the vast majority of youth acquire their infections through sexual activity, there remains a small proportion who were infected perinatally. The survival of these children to adolescence and adulthood represents the success of antiretroviral therapy (ART), aggressive prophylaxis, and treatment of opportunistic infections [5]. In the United States, by the end of 2015, approximately 1.1 million people of all ages were living with HIV, with an estimated 10,000 individuals being classified as having become infected perinatally. These patients are rarely diagnosed in adolescence, but they make up a sizable proportion of youth living with HIV in the United States. (See 'Vertically infected adolescents' below.)

RISK FACTORS — Biologic, behavioral, and socioeconomic factors that contribute to the risk of becoming infected with HIV among adolescents are the same as in adults and are generally similar to those of other sexually transmitted diseases. These issues are discussed in greater detail separately. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'Risk factors' and "HIV infection: Risk factors and prevention strategies", section on 'Risk factors for infection'.)

Factors that place adolescents at high risk of acquiring HIV infection (thus warranting annual HIV testing) are summarized in the table (table 1) [7,8]. Among youth living with HIV, the predominant mode of acquisition is high-risk sexual behaviors (ie, male-to-male sexual contact and heterosexual contact with a person known to have or to be at high risk for HIV infection) (table 2).

Other important risk factors for unrecognized HIV infection in youth include:

●Inadequate sex education

●Socioeconomic challenges, including poverty

●Housing and food insecurity

●Incarceration

●Lack of medical insurance or limited access to confidential sexual health services

●Stigma and misperceptions about HIV and feelings of isolation, especially among gay, bisexual, or transgender adolescents

●History of sexual trauma

●Cognitive or behavioral health issues, including substance use

COUNSELING AND TESTING — A comprehensive program for youth and adolescents at risk for HIV infection should include:

●Efforts at preventing infection (such as outreach programs, including proactive education and counseling about condoms, pre-exposure prophylaxis [PrEP], and postexposure prophylaxis). This is especially important in populations at high risk for acquiring HIV (men who have sex with men, transgender persons, and people who sell sex).

●Easily accessible, confidential sexually transmitted infection (STI) and HIV testing and STI treatment.

●Counseling to support risk reduction.

At-risk adolescents may be among the least likely to seek testing or be engaged in routine preventive health care [1,9]. A report from the Youth Risk Behavior Surveillance System estimated that <10 percent of high school students in the United States were tested for HIV [6]. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'Specific concerns in adolescents'.)

Routine screening — We agree with the recommendations of the United States Centers for Disease Control and Prevention and the United States Preventive Services Task Force that all individuals aged 13 to 64 years be routinely screened for HIV infection [7,8,10]. Screening is usually implemented through an "opt-out" strategy, in which the patient is informed, verbally or in writing, that HIV testing will be performed unless he or she declines. The Society for Adolescent Health and Medicine also supports offering HIV testing as part of routine care for sexually active adolescents [11]. The American Academy of Pediatrics recommends that routine HIV screening be offered at least once to all adolescents (whether or not they report sexual activity) by 16 to 18 years [12,13]. Adolescents at high risk (table 1) should be tested earlier and should have screening repeated annually.

HIV testing should be incorporated into routine adolescent health care maintenance performed by the primary care provider. In most countries, a separate written consent for HIV testing is not required and parental consent or disclosure is not necessary for testing adolescents who do not wish to involve their parents. Though pretest counseling is an important aspect of care, particularly in adolescents at high risk, it is not a requirement and should not preclude performing routine screening [7]. (See "Screening and diagnostic testing for HIV infection", section on 'Consent'.)

Routine testing allows the identification of acute HIV infections and early initiation of antiretroviral therapy (ART). Acute infection is associated with higher viral loads and higher infectivity compared with chronic infection [14]. Initiating ART in the acute or early stage of infection will decrease onward infection. Early initiation of treatment is associated with improved clinical outcomes. In addition, it is important to subsequently notify partners and provide them with screening. This helps identify individuals who are at risk for acquiring HIV and provides them with ART PrEP. (See "HIV pre-exposure prophylaxis".)

Pretest considerations — The encounter for HIV testing serves as an opportunity to educate the teen and lay the groundwork for therapy, if indicated. The following issues should be considered:

●Reason for testing – Many adolescents seek testing within 24 hours of risky behavior. In this setting, it is particularly important for the adolescent to understand the need to retest if this initial test is negative. Another common reason adolescents seek testing is that they have already been given a positive test result but are seeking confirmation. Detailed discussions surrounding the timing of HIV testing and confirmation testing are presented separately. (See "Screening and diagnostic testing for HIV infection", section on 'Tests' and "Acute and early HIV infection: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

●Comorbidities and resources – Many adolescents with HIV have psychological comorbidities that have contributed to high-risk behaviors and will affect their ability to comply with complex treatment regimens [15]. Information regarding social and economic support systems will be essential to developing successful treatment and prevention plans. (See 'Psychosocial evaluation' below.)

●Privacy – Under the laws in the United States, adolescents generally can seek testing and treatment of any sexually transmitted illness (including HIV) without the permission of their parents. However, since a positive HIV test will permanently alter a patient's life, we encourage patients to consider who they would rely on for support in the event that the test is positive. (See "Confidentiality in adolescent health care", section on 'Sexually transmitted infections' and "Consent in adolescent health care", section on 'Sexually transmitted infections'.)

●Prevention – In advance of testing, all adolescents are encouraged to develop a personal protection plan that outlines the steps the patient will take to reduce risky behavior in the future. (See "Guidelines for adolescent preventive services", section on 'Step 4: Solutions' and "Prevention of sexually transmitted infections", section on 'Prevention counseling'.)

The Centers for Disease Control and Prevention provides guidelines for HIV counseling, testing, and referral [7].

Post-test counseling — Results should be revealed in a secure, private setting. The adolescent should be given time to react to the news, whether good or bad. The meaning of the result should be explained again, emphasizing the need for and timing of retesting if there has been any recent high-risk behavior.

Adolescents whose tests are negative should be encouraged to follow their personal protection plan. Referral for additional services may be useful. Adolescents with a positive test should be reassured about their future, informed about the availability of treatment, and linked to age-appropriate HIV medical care for confirmatory testing and further evaluation. Active interventions that directly link patients to HIV care (eg, a referral supported with a case manager or patient navigator) are more effective than merely providing contact information for HIV treatment centers. Consultation with a local youth HIV program and behavioral health services prior to the medical visit may help ensure appropriate interventions and answers to patient questions at the time of the medical visit.

In addition, the patient often will need assistance with the complex issue of disclosure of HIV status to family or trusted adults and/or to partners. Disclosure to others is complicated by fear of rejection and isolation and also requires support from health care providers. In many states, anonymous partner notification is available through the public health system.

DIAGNOSIS — Once linked to HIV care, the medical evaluation and diagnosis of HIV in adolescents are the same as in adults. This is discussed in greater detail separately. (See "Acute and early HIV infection: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

EVALUATION OF THE HIV-POSITIVE ADOLESCENT — Ideally, youth with HIV will have access to medical treatment in a youth-friendly center that emphasizes patient-centered multidisciplinary care to address both the medical and psychosocial needs of this vulnerable population. A multidisciplinary treatment team may include HIV-experienced clinicians, pharmacists, medical case managers, social workers, and mental health providers.

The initial evaluation begins with a thorough medical and psychosocial history, physical examination, laboratory testing, and immunizations.

Psychosocial evaluation — The diagnosis of HIV infection may be traumatic to the newly diagnosed adolescent and their family. Often, the first task for the HIV clinical team is helping the patient (and family members, if aware and involved) cope with the psychosocial impact of the diagnosis. Completing the initial medical and psychosocial evaluations over several visits can help establish rapport with the patient, allow the patient and/or the family time to adjust to the diagnosis, and assist the treatment team's ability to gather more information about the patient's circumstances and support system.

Once the patient and family have accepted the diagnosis, patient education is more likely to be successful. Topics to discuss include:

●Basic information about HIV infection, transmission, treatment, and prognosis – Patients may have urgent questions about mortality, childbearing, and future outlook. These should be addressed in a reassuring and hopeful manner, expressing the new diagnosis as an opportunity to be and stay healthy. In addition, family members often have questions about the risk of transmission within the household.

●Goals of therapy – Achieving and maintaining viral suppression, which will decrease HIV-associated complications and prevent transmission to others. It is helpful to provide a simple explanation of important measures of immune function and viral load.

●The proposed antiretroviral therapy (ART) regimen or regimen choices, including dosing schedule and potential side effects.

●The importance of adherence to ART and the potential for the development of drug resistance as a consequence of suboptimal adherence.

●Risk reduction and disclosure to sexual partners, especially with untreated patients who are still at high risk of HIV transmission.

Readiness to initiate antiretroviral therapy — A key factor to explore when considering initiating treatment is whether the patient is ready and able to adhere to HIV treatment. Readiness is the opinion held by both the patient and the medical team that the patient desires and is motivated to adhere to ART. It is also helpful to assess the patient's commitment to other aspects of HIV medical treatment, including office visits and laboratory tests.

There is no single objective measure for assessing readiness, nor does a patient's readiness always correlate with subsequent medication adherence [16]. We find it helpful to start the conversation by simply asking patients if they want to start treatment for HIV infection. Having a good support system is an important part of readiness. This can include both family members and friends, even if the patient is not yet ready to disclose their infection status to these individuals. In addition, success in academic and/or vocational endeavors may signify self-efficacy skills that would facilitate disease management. Other important factors to consider include assessment of high-risk behaviors, substance abuse, mental illness, comorbidities, socioeconomic factors (eg, unstable housing, food insecurity, lack of privacy to store medication), medical insurance status and adequacy of coverage, transportation barriers, ability to regularly fill and pick up prescriptions, and other factors that might impair adherence to ART and increase the risk of HIV transmission. If concerns or barriers are identified, appropriate support should be offered.

For patients who feel ready to start treatment and are perceived to be ready by the care team, ART initiation may occur rapidly, even on the first visit. Others may be reluctant to engage in care, and this conversation may continue over several visits before initiating ART. During this time, the treatment team should try to identify and address important barriers.

Once the patient and health care team have agreed to initiate ART, the treatment plan should be developed in partnership with the patient. It is important to consider the patient's daily schedule (sleep, work/school, meals, and privacy); tolerance of pill number, size, and frequency; any issues affecting absorption (eg, use of acid-reducing therapy and food requirements); and potential interactions with other medications. With the patient's input, a medication choice and administration schedule should be tailored to his or her needs.

It is important to review the logistics of obtaining medications and refills in detail with the patient. Transportation to pharmacy and to clinic visits should be assessed with linkage to appropriate services as needed. Plans to ensure uninterrupted access to ART via insurance, copay assistance, pharmaceutical company assistance programs, or AIDS Drug Assistance Programs, for example, should be made and reviewed with the patient. Much of this effort to inform, motivate, and reduce barriers can be achieved by various members of the multidisciplinary team and can be accomplished concomitant with, or even after, starting therapy [17].

Physical examination and laboratory testing — Physical examination and laboratory testing of adolescents with HIV are largely the same as for the adult and are discussed in greater detail separately. (See "Initial evaluation of adults with HIV".)

Recommendations for baseline and monitoring laboratory evaluations are available through the HIV.gov website. Screening for human papillomavirus-associated cervical and anal cancers and syphilis should be initiated at the time of diagnosis in adolescents with HIV. Patients should be assessed for signs and symptoms of acute retroviral syndrome. (See "Acute and early HIV infection: Clinical manifestations and diagnosis", section on 'Signs and symptoms'.)

Additional recommendations for baseline screening and monitoring for sexually transmitted and opportunistic infections are summarized in the table and reviewed in detail separately (table 3) [18]. (See "Screening for sexually transmitted infections" and "Overview of prevention of opportunistic infections in patients with HIV".)

TREATMENT

Antiretroviral therapy — We agree with guideline panels that recommend starting antiretroviral therapy (ART) in all patients regardless of clinical stage [19,20]. The goals of ART are to reduce HIV-related morbidity and mortality (from both infectious and noninfectious causes) and to prevent transmission of HIV to others. To achieve and sustain these goals, ART should result in maximal suppression of HIV RNA. Achieving viral suppression usually requires combination ART regimens, typically including three active drugs from two or more drug classes. There are a growing number of available potent antiretroviral medications (table 4). Many of these have fewer associated side effects than earlier antiretrovirals and simpler dosing regimens, including daily, single-tablet regimens available for adolescents and adults. Certain antiretroviral medications should be avoided in pregnant persons early in pregnancy and in those of childbearing potential who are at risk of becoming pregnant. Guidelines for appropriate use of ART agents in HIV-1-infected adults and adolescents are available through the HIV.gov website and are discussed in a separate topic review. (See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

Adherence to antiretroviral medications — Adherence to ART should be assessed and addressed at every visit. Patient self-report is the most frequently used method for evaluating medication adherence. It is important for the clinician to elicit this information in a nonjudgmental, routine manner that normalizes less-than-perfect adherence and allows patients to disclose lapses in adherence. Supporting adherence is an ongoing process best provided by a multidisciplinary treatment team that includes the provider, case managers, pharmacists, social workers, and mental health providers. Strategies for improving adherence include:

●Repetition of key messages regarding the value of medication adherence.

●Positive reinforcement (eg, providing praise for good adherence). In particular, informing patients of their low or suppressed viral load and increases in CD4 T-lymphocyte cell counts helps foster adherence.

●Identifying and remediating barriers associated with the prescribed regimen. Although once-daily regimens (including those with low pill burden [even if not just one pill once daily], without a food requirement, and with few side effects or toxicities) are associated with higher levels of adherence, many adolescents (particularly highly treatment-experienced perinatally infected youth) may prefer taking multiple smaller tablets instead of a single large tablet.

●Use of technology (eg, text message medication reminders) may help support patient engagement and improve adherence [21].

Support and general counseling — Not all adolescents are ready to initiate therapy at the initial HIV care visits. Some newly diagnosed patients come to the clinic for educational sessions and additional visits for general medical care prior to the initiation of ART. In this way, they become comfortable with their transportation options, the clinic registration system, and the procedures necessary to contact clinic staff for any problems. These skills are important when starting a new medical regimen. Some patients may need additional visits to ensure that mental health and counseling needs are being addressed.

Actively involving family members or other support persons in HIV education and counseling has been associated with enhanced self-report of adherence and improvement in immunologic status [22].

Psychosocial concerns should be assessed on a regular basis to identify stressors that may impact patient adherence to medical visits and medications. Support groups can be helpful in allowing youth to deal with the complex feelings of having a chronic illness. Confidentiality may be an initial concern. One possible solution is to begin the support group as a conference call. In general, the groups quickly feel comfortable moving toward face-to-face meetings.

Secondary prevention — Encouraging adherence to ART is an important secondary prevention intervention since suppression of plasma viremia decreases the risk of HIV transmission to others. Other strategies to reduce risk of transmission include reducing high-risk sexual behavior and encouraging consistent use of condoms. Whether currently in a relationship or not, the availability of partner testing, postexposure prophylaxis, and pre-exposure prophylaxis (PrEP) should be discussed and the importance of frequent sexually transmitted infection (STI) screening should be reinforced, especially if a partner is on PrEP or condom use is inconsistent. (See 'Condom use' below and 'Prevention' below.)

Immunizations — Immunizations for persons with HIV are discussed separately. (See "Immunizations in persons with HIV".)

Prophylaxis — Prophylaxis against opportunistic infections has been an important aspect of the successful treatment of patients with HIV who are immunocompromised. The organisms that cause these infections, antibiotics used for prophylactic treatment, and indications for initiating treatment are discussed elsewhere. (See "Overview of prevention of opportunistic infections in patients with HIV" and "Treatment and prevention of Pneumocystis infection in patients with HIV", section on 'Preventing initial infection'.)

Condom use — Condoms should be used every time with every sexual contact, even if the sexual partner is also HIV positive. Patients need to be educated regarding the risks of "HIV superinfection" (ie, introduction of infection with another strain of HIV following containment of the first). Infection with multiple STIs increases the risk of spreading HIV.

Nonoxynol-9 should not be used as a lubricant, and condoms lubricated with nonoxynol-9 should not be used for anal intercourse. Nonoxynol-9 can damage the cells lining the rectum, providing a potential portal of entry for HIV [23].

Condom use in prevention of HIV infection is discussed in greater detail separately. (See "HIV infection: Risk factors and prevention strategies", section on 'Condom use'.)

Contraception — Contraception should be discussed with all adolescents with HIV at every visit [24]. (See "Contraception: Issues specific to adolescents".)

For those using hormonal birth control, careful attention must be paid to the patient's ART therapy as there are several potential drug interactions. These issues are discussed separately. (See "HIV and women", section on 'Hormonal contraceptives'.)

Regardless of hormonal contraceptive use, females with HIV should be advised to consistently use condoms (male or female) during sex and adhere to an HIV regimen that effectively maintains viral suppression. (See 'Condom use' above and "HIV infection: Risk factors and prevention strategies", section on 'Condom use'.)

Persons of child-bearing potential should have a pregnancy test at baseline, and all patients should be queried regarding future plans for pregnancy/parenthood. Those seeking pregnancy should receive counselling regarding potential transmission to the fetus as well as to her partner. Certain antiretroviral medications should be avoided in persons who may become pregnant. Issues related to these concerns should be discussed with local experts in HIV, who can help with referral to a knowledgeable obstetrician for preconceptual counseling or specialized care. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'Rationale for maternal ART'.)

Providing gynecologic care for female adolescents with HIV is especially important, including diagnosis and treatment of vaginal infections and screening for cervical cancer. (See "Screening for cervical cancer in patients with HIV infection and other immunocompromised states".)

VERTICALLY INFECTED ADOLESCENTS — In the United States, perinatal HIV is increasingly rare. Adolescents who became infected with HIV by vertical or perinatal transmission have medical and psychosocial needs that differ from those who acquired HIV infection in their teens.

With the availability and early use of antiretroviral therapy (ART), perinatally infected youth are living longer and experiencing fewer infectious complications than in previous decades. Nonetheless, they have unique challenges related to being highly ART-experienced; bearing the psychosocial stressors of disclosure, stigma, and adherence; their own sexual and reproductive health; the risk of onward transmission; and the need to transition from long-term pediatric medical care into adult models of care.

Treatment teams must balance the desire to continue providing supportive comprehensive care to aging perinatally infected adolescents with the need to help prepare them for maintaining their health as they age and transition to other care providers.

Some challenges include:

●Optimizing ART regimens in highly treatment-experienced patients who may have a multidrug-resistant virus. Fortunately, the introduction of newer drugs with more single-tablet, fixed-dose combinations and fewer side effects has simplified this process.

●The prevalence of psychiatric and behavioral problems in perinatally infected children is higher than in the general population [25]. These comorbidities further complicate treatment adherence and retention in care.

●As perinatally infected youth age, there is a higher risk for medication nonadherence, which increases the risk of onward HIV transmission. This risk is exacerbated by anxiety surrounding the issue of disclosure to partners. In cross-sectional and longitudinal surveys of a cohort of perinatally infected children and adolescents (age 10 to 18 years), 62 percent of those who were sexually active (n = 92) reported unprotected sexual intercourse [26]. Only 33 percent disclosed their HIV status to their first sexual partner. Particularly worrisome, 42 percent of sexually active youth had HIV RNA ≥5000 copies/mL after sexual initiation and viral drug resistance was common.

●The developmental issues that affect adolescents with chronic disease create challenges for transitioning patients to adult models of care.

Long-term morbidities in youth treated for HIV in childhood are discussed in greater detail separately. (See "Pediatric HIV infection: Classification, clinical manifestations, and outcome", section on 'Long-term morbidities'.)

MONITORING FOR COMPLICATIONS

Noninfectious complications — Patients with HIV appear to have a higher risk of certain medical conditions, including metabolic complications, cardiovascular disease, and malignancies, compared with the general population. Some of these may be associated with HIV infection itself, risk factors prevalent in populations who have HIV, or use of antiretroviral therapy (ART). Optimal care of the patient with HIV requires knowledge about and evaluation for such potential complications (table 5). Wellness counseling, including discussions of nutrition, exercise, and avoidance or cessation of smoking, are especially important for youth with HIV and may have a significant impact on longevity and comorbidities. Noninfectious complications of HIV infection are discussed in detail separately. (See "Primary care of adults with HIV", section on 'Monitoring for complications and preventive care'.)

Infectious complications — Infectious complications of HIV infection most commonly occur in patients with CD4 count <200 cells/microL; however, certain infections, particularly thrush, may occur in patients with higher CD4 counts. Patients born outside of the United States or to immigrant parents may be at higher risk of infections such as tuberculosis. Infectious complications of HIV are discussed in detail separately. (See "The natural history and clinical features of HIV infection in adults and adolescents", section on 'Chronic HIV infection without AIDS' and "The natural history and clinical features of HIV infection in adults and adolescents", section on 'AIDS and advanced HIV infection' and "Overview of prevention of opportunistic infections in patients with HIV".)

PREVENTION — Primary prevention strategies are directed toward individuals who do not have HIV, with the goal of keeping them from acquiring HIV infection. These should include anticipatory guidance in the context of adolescent primary care and strategies that target high-risk populations. (See "HIV infection: Risk factors and prevention strategies".)

Effective interventions include consistent use of condoms, testing for and treating sexually transmitted infections (STIs), pre-exposure prophylaxis (PrEP) for those with ongoing risk for HIV infection (particularly young men who have sex with men, transgender youth, youth with significant STIs, and discordant partners of youth with HIV), and postexposure prophylaxis for those who have significant isolated exposure to HIV. PrEP and postexposure prophylaxis are discussed in detail separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults" and "HIV pre-exposure prophylaxis".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: HIV infection in adolescents".)

SUMMARY AND RECOMMENDATIONS

●Epidemiology – Most new human immunodeficiency virus (HIV) infections in adolescents are acquired through high-risk sexual behaviors (table 2). HIV infection rates vary by age, race, ethnicity, and geography (figure 1 and figure 2). (See 'Epidemiology' above.)

●Screening for HIV – We suggest routine HIV screening at least once for all adolescents (whether or not they report sexual activity) by 16 to 18 years of age (Grade 2C). For adolescents at high risk (table 1), HIV testing should be performed annually. Routine HIV screening is important because many infected adolescents are not aware that they are infected. Early diagnosis with linkage to care and initiation of antiretroviral therapy (ART) improve clinical outcomes and reduce the risk of onward infection. (See 'Routine screening' above and "Screening and diagnostic testing for HIV infection".)

●Initial evaluation of adolescents with HIV

•Psychosocial assessment – The care of adolescents with HIV infection requires ongoing psychosocial support to encourage engagement in care. This includes careful assessment of the individual's readiness to start ART and adhere to treatment. Important factors to consider include assessment of social support, high-risk behaviors, substance abuse, mental illness, comorbidities, socioeconomic factors (eg, unstable housing, food insecurity), medical insurance status, and transportation barriers. If concerns or barriers are identified, appropriate supports should be offered. (See 'Psychosocial evaluation' above and 'Readiness to initiate antiretroviral therapy' above and 'Support and general counseling' above.)

•Physical examination and laboratory testing – Physical examination and laboratory testing of adolescents with HIV are largely the same as for adults. Recommendations for baseline and monitoring laboratory evaluations are available through the HIV.gov website. Screening for human papillomavirus-associated cervical and anal cancers, syphilis, and other sexually transmitted infections (STIs) should be initiated at the time of diagnosis. (See "Initial evaluation of adults with HIV" and "Screening for sexually transmitted infections" and "Overview of prevention of opportunistic infections in patients with HIV".)

●Management

•Initiating antiretroviral therapy – The principles of ART in adolescents are largely the same as in adults. ART should be initiated in all patients with HIV, regardless of clinical stage. The goals of ART are to reduce HIV-related morbidity and mortality (from both infectious and noninfectious causes) and to prevent transmission of HIV to others. To achieve and sustain these goals, ART should result in maximal suppression of HIV RNA. Details regarding selecting an ART regimen are provided separately. (See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

•Other management considerations – Important components of the management of adolescents with HIV include:

-Immunizations (see "Immunizations in persons with HIV")

-Consistent use of condoms and frequent STI screening (table 3) (see 'Condom use' above and "Screening for sexually transmitted infections")

-Prevention of pregnancy; preconceptual counseling and access to expert obstetric care to avoid vertical or partner transmission and ensure healthy outcomes (see "Contraception: Issues specific to adolescents" and "Prenatal evaluation of women with HIV in resource-rich settings")

-Monitoring response to therapy, immune status and comorbidities, and appropriate use of prophylactic measures for prevention of opportunistic infections (table 5 and table 3) (see "Overview of prevention of opportunistic infections in patients with HIV")

-Monitoring for noninfectious complications and promotion of healthy lifestyle (see 'Noninfectious complications' above and "Primary care of adults with HIV", section on 'Monitoring for complications and preventive care')

-Transition planning and support and anticipatory guidance around life transitions that may impact engagement in care (see "Children and youth with special health care needs", section on 'Transition planning')

●Adolescents infected vertically – Adolescents who became infected with HIV by vertical or perinatal transmission have unique challenges, including being ART-experienced; the psychosocial stressors of disclosure, stigma, and adherence; their own sexual and reproductive health; the risk of onward transmission; and the need to transition from long-term pediatric medical care into adult models of care. (See 'Vertically infected adolescents' above.)

●Strategies to prevent HIV infection

•Reducing the risk of acquiring HIV – Primary prevention strategies are directed toward keeping individuals who do not have HIV from becoming infected. This includes anticipatory guidance in the context of adolescent primary care and strategies that target high-risk populations. Effective interventions include consistent use of condoms, testing for and treating STIs, PrEP for those with ongoing risk for HIV infection, and postexposure prophylaxis for those who have significant isolated exposure to HIV. (See 'Prevention' above and "Management of nonoccupational exposures to HIV and hepatitis B and C in adults" and "HIV pre-exposure prophylaxis".)

•Reducing the risk of HIV transmission to others – Adolescents with HIV should receive counseling aimed at reducing the risk of transmission to others and increasing self-care behavior. Strategies to reduce risk of transmission include reducing high-risk sexual behavior; using condoms; maintaining an undetectable viral load through adherence to ART; and referring partners and peers for screening, risk reduction, and pre-exposure prophylaxis (PrEP). (See 'Secondary prevention' above and 'Condom use' above.)