PrEP for Adolescents at Risk of HIV: CDC's 2020 Clinical Considerations

Preexposure prophylaxis (PrEP) — taking antiretroviral medicine to prevent HIV — is proven to lower the risk of getting HIV. This 2020 CDC report reviews what clinicians need to know when offering PrEP to adolescents, drawing on expert opinion, published research and a review of state laws. It is meant for providers who treat adolescents and for others who refer them or support their care, alongside the U.S. Public Health Service PrEP guideline and its clinical providers' supplement (2017 update).

What is approved

Why adolescents need it

In 2018, 1,688 people aged 15–19 were diagnosed with HIV, a rate of 8.0 per 100,000. Nationally, adolescents have lower diagnosis rates than people in their 20s, but in some groups their risk may match adults': a Chicago study of young gay, bisexual and other men who have sex with men (MSM) found HIV incidence at 16–17 no different from that at 18–20. A modeling study estimated that PrEP could meaningfully reduce new infections among Black and white adolescent sexual minority males.

Preventing HIV early matters. Compared with adults, adolescents with HIV may be more likely to struggle with taking medicine, fail to suppress the virus, rebound or drop out of care — which raises the risk of drug resistance, immune damage and passing the virus on — and infection early in life means more years of lifelong treatment. Yet many adolescents have not heard of PrEP or do not know how to get it, and some providers who feel unsure about it may not offer it to young people.

Safety

Overall, the data support PrEP's safety in adolescents.

• In adults, TDF/FTC has long been safe and well tolerated. The most common side effects in PrEP trials were headache, abdominal pain and weight loss. About 10% of adults have a short-lived start-up syndrome of mild to moderate stomach symptoms, headache and tiredness. Kidney problems were not significantly more common than on placebo, and creatinine changes and losses in bone density reversed when the drug was stopped.
• In adolescent trials — ATN 113 in the United States (ages 15–17) and CHAMPS PlusPills in South Africa (ages 15–19) — TDF/FTC was safe and well tolerated. In ATN 113 no confirmed lab abnormality was linked to the drug, there were no kidney problems or fractures, and one participant stopped for weight loss possibly related to it. Bone density rose as expected in growing teens, though the whole-body Z-score decreased; low adherence, especially after week 12, complicates these results.
• After stopping, in young people aged 15–19 who had shown bone or kidney signs, spine and whole-body Z-scores were still below baseline 48 weeks later, while hip scores recovered. A substudy found bone risk rose with low vitamin D and high drug exposure, and was higher in Black participants regardless of either. What these findings mean clinically is unknown. A meta-analysis of 13 PrEP trials found no increase in fractures, though follow-up may have been too short.
• Treatment experience in adolescents with HIV, at the same once-daily dose, found TDF and FTC well tolerated, with few people stopping for side effects and height unaffected.
• TAF/FTC has not been tested in adolescent PrEP trials; its approval drew on the DISCOVER trial in adult MSM and transgender women and on treatment trials in adolescents with HIV.

Ongoing monitoring — HIV tests, creatinine and STI screening — is recommended for everyone on PrEP. Routine bone scans are not, but people with a history of pathologic fracture or other bone risks should be referred. The evidence does not support specific vitamin D recommendations for all adolescents starting PrEP, and more research on bone effects is needed.

Consent and confidentiality

State laws vary widely. A 2017 review of all 50 states and the District of Columbia found:

• No state explicitly bans minors from consenting to PrEP on their own, and every state lets some minors consent to STI diagnosis and treatment.
• Seven states explicitly include HIV and prevention in the laws that let minors consent to such care.
• Nine states broadly let minors consent to any health care, arguably including PrEP; some set minimum ages.
• Elsewhere, case law or broad definitions may still allow it.

Consent is not confidentiality. In 23 states providers may tell parents or guardians that a minor sought HIV or STI services, and insurance statements sent to parents can reveal care. Title X–funded family planning clinics cannot require parental consent and must keep services confidential, which could make them a place for confidential PrEP, though HHS policy on PrEP under Title X needs clarifying and funding may limit access. Mandatory reporting laws can also require providers to report abuse, neglect, sexual abuse or trafficking. Providers need to know their own state's rules; health departments can help.

Working with teens and parents

Adolescence is a shift toward independence, and parents' role shifts with it. Parental monitoring that respects a teen's autonomy is linked with less risky and more protective behavior and with better adherence to medicine for chronic conditions, and parent–teen talks about HIV are linked with teens knowing about PrEP.

Involving parents can clash with a teen's confidentiality, and teens who worry about privacy are less likely to seek care. Time alone with the provider is linked to adolescents receiving more sexual health services; the American Academy of Pediatrics recommends starting it around age 11. It can matter especially for adolescent MSM and for teens who inject drugs. Providers should make PrEP decisions with the adolescent, respecting their autonomy as far as the law allows, and bring parents in when it is safe and appropriate.

The visit

• Introduce yourself to the adolescent before the parent, and offer time alone.
• Talk while the patient is dressed and seated away from the exam table, and explain confidentiality and its limits.
• Start with less sensitive topics — for example the HEEADSSS approach: home, education or employment, eating, activities, drugs, sexuality, suicide or depression, and safety — and take a sexual history with the "five Ps": partners, practices, protection from STIs, past STIs and prevention of pregnancy. Ask about trading sex for money, shelter, food, drugs, hormones or other needs.
• Use open-ended questions, active listening and respectful, nonjudgmental language; don't assume sexual orientation, gender identity or partners' sex; use the patient's chosen name and gender terms.

PrEP is one part of care for adolescents who inject drugs or have sex that puts them at risk. All adolescents need age-appropriate sexual health education, including abstinence, consistent and correct condom use and fewer partners, and the U.S. Preventive Services Task Force recommends intensive behavioral counseling for all sexually active adolescents. Teens facing mental illness, substance use, the justice system, unstable housing, food insecurity or transactional sex may need referrals beyond PrEP.

Starting and staying on PrEP

PrEP should start within 7 days of a negative HIV test. Cost and insurance barriers can delay it; HHS's Ready, Set, PrEP program and other resources can help.

Adherence decides whether PrEP works. In four adult trials, protection among people whose drug levels showed daily use ranged from 92% to 100%. Two other trials, VOICE and FEM-PrEP, found no difference between PrEP and placebo — and in them the drug was found in only a minority of participants' blood samples.

Adolescents found adherence hard. In the ATN studies, adherence fell when visits moved from monthly to quarterly, even with a structured counseling approach, suggesting young people may benefit from more frequent, supportive contact. Other ideas include after-hours clinics, peer navigators or adherence buddies, text-message reminders, and feedback from drug-level tests on dried blood spots or urine, which are being studied.

Persistence matters too. In one study of young MSM aged 16–29, 33% of 197 who had used PrEP in the past six months had stopped, most often because of trouble getting to appointments, a lapse in insurance, or feeling no longer at risk. Checking regularly whether a teen needs and wants to continue, and helping with barriers such as transport and insurance changes, can keep them protected.

If you or someone you know is thinking about suicide, call or text 988 to reach the 988 Suicide & Crisis Lifeline in the United States.

Sources

• Tanner MR, Miele P, Carter W, et al. "Preexposure Prophylaxis for Prevention of HIV Acquisition Among Adolescents: Clinical Considerations, 2020." MMWR Recommendations and Reports 69(3). CDC. The report spells "District of Colombia" once; it is corrected here.