STD Quarterly-Teen-agers and HIV testing: Removing barriers to care
Provider recommendation and free, confidential testing strong motivators
Are you talking with sexually active teens about HIV testing? You should be. A recommendation from a health care provider has been identified as a strong motivator among teens at high risk for infection to seek testing.1
While much has been accomplished in the field of HIV/AIDS prevention, more must be done among young people and people of color, in whom infection is taking an especially firm hold, says Victor Barnes, acting deputy director for the Division of HIV/AIDS Prevention at the Atlanta-based Centers for Disease Control and Prevention's (CDC) National Center for HIV, STD, and TB Prevention.
Young people are disproportionately affected by the epidemic, notes Barnes. In the United States, the CDC estimates that half of all new HIV infections are among people under 25, and the majority of young people are infected through sexual transmission.2
About half of all new AIDS cases among 13- to 19-year-olds are among women.3 In a study of 25 states, African-Americans account for 23% of HIV infections among those ages 13 to 24.4 Yet only 25% of sexually experienced teens ages 15 to 17 report ever having been tested for HIV.5
State laws allow tests
While entry age may vary from state to state, minors in every state are allowed to consent for diagnosis and treatment for sexually transmitted diseases. Since the mid-1980s, many states have enacted HIV-specific laws, including statutes that govern consent for HIV testing and treatment, to augment such legislation.6 At least 13 states — Arizona, California, Colorado, Connecticut, Delaware, Iowa, Maine, Michigan, Montana, New Mexico, New York, Ohio, and Wisconsin — have statutes that explicitly allow minors to consent to HIV testing or to receive a test without the consent of their parents.
In addition, counseling and informed consent have been incorporated as integral parts of the HIV testing process. Most states have enacted laws requiring informed consent for HIV testing, and federal legislation (the Ryan White CARE Act) requires counseling and informed consent for HIV testing performed in any facility receiving Ryan White funds, whether or not the testing is paid for with federal monies.6
If HIV testing is available to teens, why don't they seek knowledge of their HIV status? A survey of at-risk youth in Miami, Houston, New York City, and Newark, NJ, found that many teens do not see themselves at risk for the disease.1 Even though many knew someone in their neighborhood who was HIV-positive or who had died from AIDS, those surveyed did not link community infection rates with their own risk.
A fear of being labeled and stigmatized by families, friends, and communities also was named as a deterrent to testing. Perceptions of the consequences of living with HIV and the psychological hurdle of admitting mistakes and "incorrect" behavior also kept many from learning their HIV status.
Since many teens do not receive routine health exams, they only go for care when it is symptom-driven. This is especially true among adolescent males; unless they need physicals to play sports at school or are sick, young men reported that they rarely see a doctor. Lack of knowledge about the location of "teen-friendly" testing facilities also kept many teens from going for testing, according to survey results.
Lack of access for teens
There are very few specific places for teens to get HIV testing, and those places are not usually known, asserts Robert Johnson, MD, director of the Division of Adolescent and Young Adult Medicine (DAYAM) at the New Jersey Medical School in Newark. For those teens who may opt to visit their regular health care provider, access may not be what it should, he notes.
"I'm very sad to say that most health care providers who take care of teens don't think about this as a test that should be done, even when it is appropriate to do it," notes Johnson. "For example, kids can get a [sexually transmitted disease], and the health care provider may not even mention the fact that an HIV test should be done, or the health care provider may not be equipped to do the test."
According to the teens participating in the 1999 Kaiser Family Foundation survey, the key factors that motivate teens to seek HIV testing are:
• fear of exposure to HIV;
• presence of STD symptoms;
• recommendations of health professionals, parents, partners, and select peers;
• access to confidential, convenient, and caring youth health care centers;
• "teen-friendly" test sites.
"The key motivators for teens to seek HIV testing are knowing someone who has been tested and can walk them through the process; the testing facility/staff is non-threatening, nonjudgmental, approachable, and, most important, confidential; and the overwhelming need to know if they have been exposed," says Edwidge Jourdain Thomas, RN, MS, ANP, adult primary care provider and director of clinical cervices at Columbia University School of Nursing in New York City.
Most teens participating in the Kaiser survey say they go to public clinics for their medical care. Their impressions of the clinic staff were an important factor in whether they followed professional advice and returned for follow-up care, survey results showed.
The more teen-focused the facility, the more likely teens were to trust the individuals working there, the survey revealed. While some teens said providers' recommendations to be HIV tested made them "very nervous," they were responsive to such advice.
The underlying concerns for all age groups when it comes to health care are competence, consumer friendliness, and confidentiality, says Thomas, who is affiliated with Columbia Advanced Practice Nurse Associates (CAPNA) in New York City. CAPNA offers primary care to all age groups through advanced practice providers.
"We, including front office and practitioners, facilitate and coordinate — in partnership with our patients — their health care, and encourage them to call us with questions and concerns that we address promptly," notes Thomas. "We allow for one hour on our initial visits to establish a rapport with our patients and help them understand that our philosophy is that we are available to assist them through their illness/ill health or help them maintain their present level of wellness and/or to obtain a higher level."
Teens who visit a DAYAM clinic, whether it's for a cold, eating disorder, or orders from juvenile court, undergo a complete evaluation that includes a determination of their sexual health, says Johnson.
"If they are sexually active, then we ask the about the pattern of sexual activity, then we always do STD testing and offer HIV testing," reports Johnson. "One hundred percent of the time, the kids ask for and want an HIV test." (See story below for counseling tips and outreach ideas to encourage HIV testing for your adolescent patients.)
1. Michaels Opinion Research for the Henry J. Kaiser Family Foundation. Hearing their Voices: A Qualitative Research Study on HIV Testing and Higher-Risk Teens. Menlo Park, CA; June 1999.
2. Centers for Disease Control and Prevention. Young People at Risk — Epidemic Shifts Further toward Young Women and Minorities. Atlanta; September 1998.
3. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 1998 Year-end Edition, US HIV and AIDS Cases Reported Through December 1998. 1998; 10(2).
4. Diagnosis and reporting of HIV and AIDS in states with integrated HIV and AIDS surveillance — United States, January 1994-June 1997. MMWR 1998; 47:309-314.
5. Kaiser Family Foundation/MTV/Teen People. What Teens Know and Don't (But Should) About Sexually Transmitted Diseases: A National Survey of 15- to 17-Year-Olds. Menlo Park, CA; March 1999.
6. English A. Consent and confidentiality: Important elements in adolescents' access to HIV care. Youth Law News 1995; May-June.