Lesson 2. HIV in Adolescents and Young Adults

Adolescence and young adulthood is a period of intense physical and developmental transition that is characterized by experimentation and self-discovery.[1] This time period may pose unique challenges for the prevention and treatment of HIV.[2] Adolescents and young adults with HIV in the United States primarily represent two distinct groups based on when and how they acquired HIV: (1) those who acquired HIV through perinatal transmission and now have reached the age of adolescence or young adulthood, and (2) those who acquired HIV during adolescence or young adulthood through sexual contact or drug use.[3,4] In the United States, since the contemporary perinatal HIV transmission rate has been reduced to less than 1% of pregnancies in women with HIV, most adolescents and young adults living with HIV have acquired HIV through sexual contact or drug use.[2] This Topic Review will address routine care for adolescents and young adults with HIV, adolescent sexuality and reproductive health, transitioning from adolescent to adult care, and HIV preexposure prophylaxis (PrEP).

Definition of Adolescents and Young Adults

In the Centers for Disease Control and Prevention (CDC) surveillance reports, adolescents are defined as persons 13 to 19 years of age and young adults are defined as persons 20 to 24 years of age, unless otherwise specified.[5] In addition, the Adult and Adolescent ARV Guidelines also define adolescents as persons 13 to 19 years of age and young adults as persons 20 to 24 years of age.[2] In general, postpubertal adolescents and young adults should receive the same antiretroviral therapy as recommendations for adults, but adolescents in early puberty should receive antiretroviral therapy based on the sexual maturity rating (SMR) for females (Table 1) and males (Table 2).[2,6,7]

HIV Prevalence in Adolescents and Young Adults

For the year 2022, the Centers for Disease Control and Prevention (CDC) estimated 1,238,000 people were living with HIV in the United States.[8] For that same year, the CDC estimated the HIV prevalence for different age groups, including an estimated 42,200 persons 13 to 24 years of age who were living with HIV (Figure 1).[8] Based on these estimates, adolescents and adults comprise approximately 3.4% of the total number of people living with HIV in the United States.[8]

New HIV Infections in Adolescents and Young Adults

The CDC also estimates the number of new HIV infections that occur each year in the United States and there was an estimated 31,800 new infections for the year 2022.[5] Adolescents and young adults (persons 13–24 years of age) accounted for 6,400 (20.1%) of the new infections for the year 2022 (Figure 2).[8] The incidence of HIV among persons 13–24 years of age declined approximately 30% from 2018-2022 (9,200 to 6,400).[8]

Knowledge of HIV Status

Based on estimates from CDC surveillance data and estimates in 2022, adolescents and young adults with HIV have the lowest percentage of awareness of HIV status, with only 56.3% aware of their HIV diagnosis (Figure 3).[8] Although awareness of HIV status is low among adolescents and young adults, it has improved significantly from 2028 to 2022 (42.1% to 56.3%).[8]

CDC HIV Testing Recommendations

Since 2006, the CDC has recommended opt-out HIV testing for all persons 13 to 64 years of age, unless the local prevalence of undiagnosed HIV infection has been documented to be less than 0.1%.[9] Accordingly, routine HIV screening should include adolescents and young adults.[9] Testing should be performed annually (or more frequently) for individuals at higher risk of acquiring HIV—defined by the CDC as persons who use injection drugs (and their sex partners), persons who exchange sex for money or drugs, sex partners of persons with HIV, and men who have sex with men, or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.[9] Suboptimal HIV testing rates in vulnerable youth at risk of HIV acquisition translate into missed opportunities for HIV prevention and HIV treatment in these youth.

Youth Sexual Activity and HIV Testing Rates

In the United States, multiple sources and studies have shown that many adolescents and young adults regularly engage in sexual activity that could place them at risk of acquiring HIV. Data summary from the Youth Risk Behavior Surveillance System (YRBS) for the year 2023 reported that among high school students, 32% reported having sexual intercourse at least once in their lifetime, 21% reported being sexually active, 48% reported condomless sex at last intercourse, and 6% reported having had 4 or more lifetime sex partners (Figure 4).[10] For the year 2023, only 7% of the high school students reported they had ever been tested for HIV; female students were more likely than male students to get HIV tested (8% of females and 6%).[10] During the 10-year period from 2013 to 2023, there was a major decrease in the percentage who had ever had HIV testing in both males (11% to 6%) and females (15% to 8%).[10]

Barriers to HIV Testing in Adolescents and Young Adults

The reasons for the discordance between youth HIV risk activity and HIV testing rates are varied and include lack of knowledge about HIV risk, lack of perceived risk, sense of invulnerability to disease, lack of awareness of free and confidential HIV testing sites, and misconception that parental consent is required for HIV testing.[11,12,13,14] Additional HIV testing barriers that have been identified are lack of medical provider awareness that CDC HIV testing recommendations include testing of adolescents and young adults, lack of medical insurance, and overall limited engagement with health systems.[15] Educating pediatricians and primary care medical providers about HIV testing recommendations for adolescents and young adults has the potential to increase HIV testing, especially given that a private physician’s office or other clinic site is still the most likely setting for adolescents and young adults to get HIV testing.[12,15] In Connect to Testing and Prevention Services, a demonstration study conducted by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), investigators concluded that targeted, community-based HIV testing strategies can play an important role in identifying youths who have enhanced risk for acquiring HIV who are unaware of their HIV status.[16]

Factors Impacting Linkage and Engagement in Care

For persons diagnosed with HIV, linkage to care within 30 days of diagnosis and retention in HIV clinical care are associated with improved clinical outcomes, decreased mortality, and decreased HIV transmission to sex and injecting drug partners.[17,18] Although significant research has been conducted on interventions to improve linkage to care for persons newly diagnosed with HIV, few studies have included adolescents and young adults. Therefore, the individual and structural barriers for linkage to care and engagement in HIV care that are unique to adolescents and young adults remain poorly defined. Adolescents and young adults with HIV may struggle to navigate complex medical systems, especially as they transition from pediatric to adult health centers; during this transition, many adolescents and young adults lack full autonomy as they remain dependent on their families for health insurance, transportation, housing, and other needs.[17] For those young adults who are diagnosed with HIV while on a parental insurance plan, inadvertent disclosure of their HIV status may occur. In addition, receiving an HIV diagnosis during the vulnerable period spanning adolescence and early adulthood can lead to higher rates of depression and anxiety that may serve as barriers to engagement in care.[17]

Strategies for Improving Linkage to Care and Retention in Care

Interventions to improve engagement along every step of the HIV care continuum include the following: adolescent-targeted (or adolescent-friendly) services include providing dedicated adolescent-only office hours; screening for sexually transmitted infections (of genital and extragenital sites); providing condoms and hormonal contraceptives; offering preexposure prophylaxis and nonoccupational postexposure prophylaxis; connecting to peer educators and adolescent support groups; and linkage to care specialists and intensive case management.[19,20,21]

HIV Care Cascade/HIV Care Continuum

Limited data exist regarding the HIV care cascade (or HIV care continuum) outcomes in adolescents and young adults in the United States.[22,23,24] In 2022 end-of-year estimates based on CDC surveillance data, among persons with HIV 13 to 24 years of age, the overall rates of virologic suppression were only 37%, and the overall cascade of care numbers for all ages was lowest in the 13 to 24 year age group (Figure 5).[25] Unfortunately, there is a relative lack of data on the needs of adolescents and young adults with HIV, and more research is needed to develop optimal strategies for engaging, diagnosing, and managing this population.[19,26]

Baseline Evaluation for Newly Diagnosed Adolescents or Young Adults

For an adolescent or young adult newly diagnosed with HIV, the goals of the initial evaluation are the same as for adults and are outlined by the Adult and Adolescent ARV Guidelines: confirm the diagnosis of HIV, obtain a complete medical history, perform a physical examination, obtain relevant laboratory data, screen for sexually transmitted infections (at genital and extragenital sites of exposure), screen for mental health and substance use disorders, provide education about HIV, address reproductive health concerns, and link to appropriate primary care resources if necessary.[27,28] For younger adolescents, additional psychosocial intervention and additional education may be necessary, and this should ideally involve the parents or guardians, though this depends on multiple factors, including state law, institutional policy, maturity of the adolescent, and social situation. The initial evaluation of persons newly diagnosed with HIV is discussed in detail in the Initial Evaluation Lesson in the Basic Primary Care module.

Routine Monitoring

Routine laboratory and clinical monitoring of adolescents and young adults with HIV is the same as for adults with HIV and is outlined in the antiretroviral therapy guidelines.[29]

Initiating Antiretroviral Therapy for Adolescents and Young Adults

All adolescents and young adults with HIV should receive antiretroviral therapy, regardless of their CD4 cell count or HIV RNA level.[2] Adolescents or young adults who acquired HIV via perinatal transmission have typically been on antiretroviral therapy for many years prior to reaching adolescence and often have more complex antiretroviral regimens as a result of antiretroviral resistance mutations that accumulated over the many preceding years of receiving antiretroviral therapy.[30,31,32] All youth who acquire HIV as an adolescent or young adult should start on antiretroviral therapy (if they are not already receiving it).[2] Concurrent with initiating antiretroviral therapy, the clinician should assess for adherence issues and screen for mental health and substance use disorders.[2] In addition, reproductive health issues should be addressed in the process of starting antiretroviral therapy, including contraception, drug interactions between antiretrovirals and oral contraceptives, pregnancy intention or planning, preexposure prophylaxis for seronegative partners, and safer sex techniques to prevent transmission of HIV or other sexually transmitted infections.[27] Standard baseline laboratory testing, including an HIV drug resistance genotype, should be ordered prior to starting antiretroviral therapy.

Choosing Antiretroviral Therapy Regimens

The selection and dosing of antiretroviral medications for adolescents is based on sexual maturity rating rather than on age. The recommended antiretroviral regimens for initial therapy for post-pubescent adolescents whose sexual maturity rating is IV or V, and for all young adults, are the same as the Adult and Adolescent ARV Guidelines (Table 3).[27,33] For pre-pubescent adolescents with sexual maturity ratings between I and III, see separate Pediatric ART Guidelines in the Lesson HIV in Infants and Children.[6] For adolescent girls who may become pregnant, their antiretroviral regimen should be designated as a preferred regimen for use during pregnancy.[34,35,36]

Laboratory Monitoring after Starting Antiretroviral Therapy

Routine laboratory and clinical monitoring of adolescents and young adults after starting antiretroviral therapy is the same as for adults with HIV and is outlined below.[29,37] The following summarizes recommendations in the Adult and Adolescent ARV Guidelines for monitoring HIV RNA levels and CD4 cell counts after starting antiretroviral therapy:[29,37]

HIV RNA Monitoring

During the first 8 to 12 weeks after starting antiretroviral therapy, most individuals will achieve a reduction in HIV RNA levels to less than 50 copies/mL. For some individuals, particularly those with extremely high baseline HIV RNA levels, the time for virologic suppression may extend past 12 weeks. The important parameter is whether the HIV RNA levels continue to decline.

• Baseline: All individuals initiating antiretroviral therapy should have a baseline HIV RNA level.
• After Initiating Therapy: After starting antiretroviral therapy, an HIV RNA level should be obtained, preferably within 4 to 8 weeks. Subsequently, HIV RNA levels should be repeated every 4 to 8 weeks until the HIV RNA is suppressed to less than 50 copies/mL.
• After Virologic Suppression: Once HIV RNA levels are suppressed, the frequency of HIV RNA monitoring should extend to every 3 to 4 months.
• With Long-Term Virologic Suppression: For individuals who consistently take antiretroviral therapy as prescribed and have suppressed HIV RNA levels for at least 1 year (and stable clinical and immunologic status), HIV RNA monitoring can be extended to 6-month intervals.
• After Antiretroviral Regimen Change: Following any change in the antiretroviral regimen, the HIV RNA level should be checked within 4 to 8 weeks, whether the medication change was for drug toxicity, regimen simplification, or another reason. This recommendation holds even when the person has virologic suppression at the time of change in the antiretroviral regimen.

CD4 Cell Count
Individuals who have suppressed HIV RNA levels on antiretroviral therapy typically have an increase in CD4 count of approximately 50 to 150 cells/mm³ after the first year, with subsequent average yearly increases of approximately 50 to 100 cells/mm³ until a steady state is attained.

• Baseline: All persons starting antiretroviral therapy should have a baseline CD4 cell count checked.
• After Initiating Therapy: A repeat CD4 cell count should be obtained 3 months after starting therapy.
• During First 1–2 Years After Initiating Therapy: During the first 1 to 2 years while taking suppressive antiretroviral therapy, CD4 count monitoring should occur every 3 to 4 months if the CD4 cell count is less than 300 cells/mm³ and every 6 months if the CD4 count is greater than 300 cells/mm³.
• With Long-Term Stable Virologic Suppression: After 1 to 2 years taking antiretroviral therapy, the frequency of CD4 cell count monitoring for individuals with consistently suppressed HIV RNA levels should be determined by immune status:
  • If the CD4 count is less than 300 cells/mm³, CD4 monitoring can be extended to 6-month intervals.
  • If the CD4 count is consistently greater than 300 cells/mm³, monitoring should be considered optional, unless a recheck is indicated based on clinical changes.
• Change in Clinical Status: If an individual has a change in clinical status or has to initiate therapy with chronic corticosteroids or chemotherapy, the CD4 cell count should be checked more frequently, as clinically indicated.

Challenges with Adherence with Antiretroviral Therapy

As a group, adolescents and young adults with HIV struggle with adherence more than their adult counterparts and have lower rates of viral suppression and higher rates of viral rebound.[38] Multiple studies have identified several important barriers to antiretroviral medication adherence for adolescent populations, including depression, disruption of daily routine, poor understanding of the importance of adherence, denial and fear, forgetfulness, comorbid mental health diagnoses, substance use, lack of family and social support, and structural barriers such as homelessness.[2,39,40,41] In a study of adherence in youth (aged 12 to 24 years) with either perinatal HIV acquisition (“perinatal group”) or HIV acquisition through sexual activity or drug use, the two groups in the study had many overlapping adherence challenges but also had distinct reasons for having problems with adherence.[40] “Forgetting” to take the medication was by far the most common adherence barrier in both groups.[40]

Adherence Monitoring in Adolescents and Young Adults

The Pediatric ART Guidelines recommend assessing adherence at every visit and addressing strategies that optimize adherence at every visit. This approach should utilize evidence-based approaches for adherence monitoring, including monitoring of HIV RNA levels and one additional method.[42](Table 4)

Strategies for Improving Antiretroviral Adherence in Adolescents

Whenever possible, adolescents should be placed on a once-daily antiretroviral regimen with a low pill burden that has a low likelihood of causing side effects.[2,6] In some studies, reminder systems, such as cell phone calls, alerts, and text messaging, have been found to be particularly effective for adolescents and young adults.[2,40] Studies that have evaluated the usage of mobile phone and text messaging interventions to assist with medication adherence have found mixed results, depending on the measured outcome and the specific technology that was used.[43,44,45,46] In general, technologies involving two-way communication seemed to yield better antiretroviral adherence outcomes compared to stand-alone short message service (SMS) text message reminders.[45,46] A multipronged approach may prove more fruitful if it combines medication-specific adherence tactics, such as decreasing pill burden, with health care provider-oriented strategies that include supportive, emotional, or behavioral strategies for youth living with HIV. The Pediatric ART Guidelines provide strategies for improving adherence that are focused on initial intervention strategies, medication strategies, and follow-up intervention strategies (Table 5).[42]

The use of HIV preexposure prophylaxis (PrEP) is an important prevention strategy for persons who are at high risk of acquiring HIV, with several landmark clinical trials demonstrating safety and efficacy in preventing HIV acquisition in men who have sex with men (MSM), men and women in heterosexual HIV-serodifferent couples, and in people who inject drugs.[47,48,49,50,51,52] Most of these trials included a significant proportion of young adults aged 18 to 24 years in the patient population enrolled, but very few included adolescents (18 years of age or younger). The U.S. Public Health Service issued updated clinical practice guidelines for the use of HIV PrEP in 2021, with a 2025 update adding guidance on the use of lenacapavir for HIV PrEP.[53] The CDC recommendations for the use of HIV PrEP in adolescents and young adults are based on a weight greater than 35 kg (77 pounds), not on a specific age.[53] Planning for the potential use of HIV PrEP in adolescents requires an infrastructure for the coordinated delivery of HIV prevention services for adolescents, including HIV testing programs that link youth at-risk of acquiring HIV to HIV PrEP services if they test negative for HIV.[16,54]

Recommendations for Preexposure Prophylaxis in Youth

For young adults aged 18 to 24 years who are at risk of acquiring HIV, the guidelines for HIV PrEP are the same as for adults at risk of acquiring HIV.[53] Although there are no guidelines specific to adolescents, HIV PrEP is recommended for adolescents weighing at least 35 kg (77 lbs) who report sexual or drug use behaviors placing them at risk for HIV acquisition. Of the four medications used for HIV PrEP—oral tenofovir DF-emtricitabine, oral tenofovir alafenamide-emtricitabine, long-acting injectable cabotegravir, and subcutaneous lenacapavir—all have been studied and are FDA approved for use in persons who weigh at least 35 kg (77 pounds).[47,50,51,52,55,56] Note that tenofovir alafenamide-emtricitabine has not been FDA-approved for persons at risk of acquiring HIV through receptive vaginal sex.[53] In addition, although oral tenofovir DF-emtricitabine and subcutaneous lenacapavir are recommended for HIV prevention among people who inject drugs (PWID), no medications are specifically FDA approved specifically for preventing HIV acquisition through injection drug use. For further information on HIV PrEP, see the lesson HIV Preexposure Prophylaxis (PrEP), which is in Module 5 of this curriculum. For a more detailed discussion of HIV PrEP in Youth, see HIV PrEP for Adolescents and Young Adults in the National HIV PrEP Curriculum.

Major PrEP Studies in Adolescents and Young Adults

Two major trials have been conducted examining the safety and efficacy of tenofovir DF-emtricitabine for HIV PrEP specifically for adolescents and young adults in the United States.

• ATN 110: The Adolescent Trials Network 110 (ATN 110) study enrolled 400 adolescent males (aged 18 to 22 years who have sex with other males) between March and September 2013.[57] Using tenofovir diphosphate levels in dried blood spots as a marker for adherence with PrEP, the investigators concluded there was a major decline in adherence at week 24.[57] The rates of STIs were high at baseline (22% of participants) and remained high throughout the study.[57]
• ATN 113: The Adolescent Trials Network 113 (ATN 113) study enrolled 260 adolescent males living in the United States, aged 15 to 17 years, who have sex with other males.[58] In this study, open-label use of tenofovir DF-emtricitabine for HIV PrEP was found to be safe and well-tolerated, but adherence to PrEP, based on tenofovir diphosphate levels in dried blood spots, decreased markedly over time during the study (Figure 6).[58] The HIV seroconversion rate was 6.4 per 100 person-years.[58]

Legal Issues Related to HIV PrEP and Minors

All states and the District of Columbia permit minors to consent for testing and treatment of sexually transmitted infections without parental consent, and many explicitly designate HIV as a sexually transmitted infection in the law with respect to parental consent.[59] In addition, several states have laws that provide minors with broad authority to consent to any health care service or procedure, but these state laws have different age cutoffs and criteria (e.g., homelessness, living separate or apart from parents, and/or managing their own financial affairs) for minors to be granted this authority.[59] No states have a law that prohibits a minor from granting autonomous consent for preexposure prophylaxis. From a practical standpoint, it may be very difficult for a minor to maintain the confidentiality of their receipt of HIV PrEP from their parents (if they are on the parent’s health insurance plan), since many states allow medical providers to disclose the minor’s treatment information to the parents, and billing services often include information in the explanation of benefits and specific charges that would reveal receipt of HIV PrEP clinical services and medications for HIV PrEP.[59]

General Principles for Vaccine Administration in Youth with HIV

There are multiple sources of guidelines for immunizations involving adolescents and young adults with HIV. These include recommendations from The Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the Adult and Adolescent OI Guidelines.[60,61] It is beyond the scope of this topic review to cover all vaccines that should be considered for adolescents and young adults. Therefore, the following will focus on key recommendations for several commonly administered vaccines in adolescents and young adults, with a focus on recommendations from the Adult and Adolescent OI Guidelines since these are specific to people with HIV.[61] All inactivated vaccines are considered safe to administer to adolescents and young adults with HIV, irrespective of immune status. In addition, all adolescents with HIV through 18 years of age should receive most vaccines per standard recommended (or catch-up) schedules, with the following major exceptions:

• The measles-mumps-rubella (MMR) and vaccines is contraindicated if the CD4 count is less than 200 cells/mm³
• The varicella vaccines ia contraindicated if the CD4 count is less than 200 cells/mm³
• Live attenuated trivalent influenza vaccine is contraindicated, regardless of CD4 cell count

Human Papillomavirus (HPV) Vaccine

The 3-dose series of the 9-valent HPV vaccine (9vHPV) is recommended for all males and females with HIV who are aged 11 to 26 years; the series may be started as early as 9 years of age (and should be started at age 9 in children with a history of sexual abuse or assault).[61] All adolescents and young adults with HIV should receive the 3-dose 9vHPV vaccine series, regardless of the age when the HPV vaccine series is started.[61] For pregnant adolescent girls who have not received a complete HPV immunization series, the vaccine series initiation (or series completion) should be deferred until after pregnancy.[62]

Influenza

Annual inactivated influenza vaccine is recommended for all adolescents and young adults, including those with HIV and regardless of CD4 cell count.[62,63,64,65] The recombinant influenza vaccine should not be administered to persons younger than 18 years of age. The live-attenuated influenza vaccines should not be administered to any person with HIV, regardless of age.[61]

Meningococcal ACWY Vaccine

Immunization with the quadrivalent meningococcal conjugate vaccine (MenACWY) is recommended for all persons with HIV.[61] The primary vaccination series for individuals with HIV requires a 2-dose initial series, with the doses given at least 8 weeks apart. The following summarizes meningococcal ACWY vaccine booster dose recommendations for adolescents and young adults with HIV.[61]

• If the initial meningococcal series was administered prior to age 7 years, then the first booster dose should be given 3 years after completing the primary series, and then subsequent booster doses are given every 5 years.
• If the individual was 7 years of age or older when the primary series was given, then the first booster dose should be given 5 years after the primary series was completed, and then subsequent booster doses should be given every 5 years.

The pentavalent meningococcal vaccine (ABCWY) can be considered when there is an indication for immunization for both MenACWY and MenB.

Meningococcal B Vaccine

The serogroup B conjugate meningococcal vaccine is considered an optional vaccine for adolescents and young adults with HIV who are 16–23 years of age, with shared decision-making.[61] Two meningococcal B vaccines are available: MenB-FHbp and MenB-4C. For persons with HIV, the recommended dosing schedule is a 3-dose series administered at 0, 1-2, and 6 months.[61] If the second dose was administered at least 6 months after the first dose, a third dose is not needed. If the third dose is administered less than 4 months after the second dose, the dose should be repeated at least 4 months after the last dose. Adolescents and young adults previously immunized with MenB vaccine should receive a booster dose of the MenB vaccine if there is ongoing high risk for serogroup B meningococcal diseases and more than 1 year has elapsed since finishing the vaccine series. As long as this high risk persists, booster doses should be repeated every 2–3 years thereafter.[61] The MenB vaccine should be avoided during pregnancy unless the benefit of immunization outweighs the risk. The pentavalent meningococcal vaccine (ABCWY) can be considered when there is an indication for immunization for both MenACWY and MenB.

Pneumococcal Vaccine

The following summarizes pneumococcal vaccine recommendations for adolescents and young adults.[61] Pneumococcal vaccines include pneumococcal conjuagate vaccines (PCV) and pneumococcal polysaccharide vaccine (PPSV).[61]

• Initial Immunization Options: 1 dose of PCV20, 1 dose of PCV21, or 1 dose of PCV15 followed by one dose of PPSV23 at least 8 weeks later. Note that PCV21 is not recommended in regions of the United States where the prevalence of pneumococcal serotype 4 is greater than 30% among pneumococcal isolates.
• Prior Pneumococcal Immunization: In general, persons who receive prior immunization with older pneumococcal vaccines (PCV13 alone, PPSV23 alone, or doses of both PCV13 and PPSV23) can receive one dose of PCV20 or PCV21. Following PCV13, there should be at least a 1-year gap before administering PCV20 or PCV21. Following PPSV23, there should be a 5-year gap before giving PCV20 or PCV21.

Varicella Vaccine

Because the varicella vaccine is a live attenuated vaccine, adolescents and young adults with HIV should not receive this vaccine if their CD4 count is less than 200 cells/mm³.[61] The following summarizes recommendations for administering varicella vaccine to nonimmune adolescents and young adults.

• Adolescents and young adults without evidence of varicella immunity and who have a CD4 count of 200 cells/mm³ or greater should receive two doses of the single-antigen varicella vaccine administered subcutaneously, 4 to 8 weeks apart.
• All adolescents and young adults who receive the varicella vaccine should be instructed to return promptly for evaluation if they develop a varicella-like rash following receipt of the vaccine. If vaccination causes clinical varicella, antiviral treatment is indicated.

Screening for Sexually Transmitted Infections

All adolescents and young adults with HIV should undergo screening for sexually transmitted infections, according to the 2021 STI Treatment Guidelines.[66] These guidelines recommend screening for sexually transmitted infections in all sexually active persons with HIV at the initial HIV care visit and at least annually thereafter, with more increased screening based on the presence of ongoing risk factors and the prevalence of sexually transmitted diseases in the community.[66] Specific screening should be performed at genital and extragenital sites for curable sexually transmitted diseases (e.g., syphilis, gonorrhea, and chlamydia).[66] For those with ongoing sexually transmitted infection risk, screening (at genital and/or extragenital sites of exposure) is recommended once every 3 to 6 months.[66]

Contraceptive Management

Sexually active adolescent and young adult women with HIV should have access to the same array of contraceptive options as older women with HIV, including hormonal contraception (e.g., pill, ring, injection, or implant) and intrauterine devices (IUDs). Significant drug interactions can occur between hormonal contraceptives and certain antiretroviral medications; these interactions are detailed in the Adult and Adolescent ARV Guidelines in the table on Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives.[36] The CDC has published the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides specific guidance regarding hormonal contraceptive use for women at high risk of acquiring HIV.[67] These guidelines take into consideration the available data related to HIV acquisition or transmission associated with hormonal contraception use and the benefits of preventing unintended pregnancy.[68] A full discussion of contraceptive management for HIV in persons with HIV is available in a separate Topic Review HIV in Women in the Key Populations module.

Informing Children and Adolescents of Their HIV Status

For children who have acquired HIV perinatally, the timing of informing them of their HIV status is a highly sensitive and complicated issue. Studies of youth who acquire HIV perinatally found 10 years of age was the typical time for informing a youth of their HIV status, which is older than for many other chronic conditions.[69] The LEGACY study that included 571 youth with perinatally-acquired HIV found that 32% of those aged 13 years and older were unaware of their HIV status, and 25% of those unaware of HIV status were sexually active.[69] Lack of knowledge of HIV status as a young person who is entering adolescence is problematic and has obvious implications for HIV transmission.[69,70] The American Academy of Pediatrics strongly encourages the disclosure of HIV to school-aged children and states that adolescents should know their HIV status and be informed about the potential outcomes of their health behaviors (including sexual activity).[71]

Mental Health

Adolescents and young adults who acquired HIV perinatally have higher rates of mental health disorders compared with peers without HIV, as shown in one study that found a 12-month psychiatric disorder prevalence of nearly 70% among adolescents and young adults with HIV (or with a history of exposure to HIV).[] An extensive literature review further confirmed the high prevalence rates of psychiatric disorders in youth with HIV.[] According to a review of 8 small studies involving youth with HIV (who acquired HIV perinatally), the most common mental disorders were attention deficit hyperactivity disorder (28.6%), anxiety (24.3%), and depression (25%).[74] Youth with perinatally-acquired HIV may also have high rates of behavioral, developmental, and neurocognitive disorders.[75,76] Anxiety, depression, substance use, and post-traumatic stress disorder are common among youth with HIV who acquired HIV as an adolescent or young adult.[77]

Transitioning from Adolescent to Adult Care

Adolescents and young adults with chronic diseases, including HIV, may face a difficult time transitioning from adolescent to adult health care settings. The transition may be complicated by several different factors, including the presence of coexisting developmental or psychosocial delays, attachment to pediatric/adolescent providers, difficulty trusting a new provider, adjustment to an adult care setting that typically has less psychosocial support and allows less time per encounter, insurance and financial issues, and a lack of communication between pediatric and adult providers.[2,13,26,78,79,80] Medical providers and institutions transition youth to adult clinics at different ages (some at age 18, some at age 21, and some at age 24 or 25), so the maturity of the transitioning adolescent/young adult often varies in different health care settings. Adolescents with perinatal HIV may struggle with additional burdens, such as the loss of a parent to HIV.[78,79] Because of these many factors, there is often a high rate of attrition—and potentially an increase in mortality among adolescents with HIV—as they transition from the pediatric/adolescent multidisciplinary care setting to the adult medical care setting.[79,81]

Models of Transition to Adult Care

The concept of health care transition, which has been defined as the purposeful, planned movement of children with special health needs from child-centered to adult-centered care, is a relatively new frontier for HIV medicine, since children with HIV did not typically survive to adulthood prior to the availability of effective antiretroviral therapy.[78,80,82] Researchers have found that an organized, deliberate, developmentally appropriate, and compassionate process of medical care transition can improve outcomes as adolescents and young adults enter adult care settings.[26,83] Adolescents and young adults should be included in the conversations around transition, as there are clear discrepancies between what adolescents and young adults need and expect from their medical environment and what they experience (Table 6).[84,85] Various facilitators to a successful transition have been identified, such as developing a relationship with the new adult provider prior to the actual transition, educating adult HIV care teams about transition, developing an individualized transition plan, and providing a formal written transition document. [2,26,78,79,83] There are, however, no evidenced-based guidelines or models to inform the type of transitional care that should be provided to adolescents and young adults with HIV.

• In the United States, for the year 2022, adolescents and young adults comprised only about 3% of all persons living with HIV, but they accounted for approximately 20% of all new HIV infections.
• HIV testing rates are low among adolescents and young adults, and only 56% of adolescents and young adults with HIV are aware of their HIV status.
• All adolescents and young adults with HIV should receive antiretroviral therapy, both for their own health benefit and to reduce the risk of HIV transmission to others.
• Antiretroviral therapy selection and dosing for adolescents and young adults is based on their sexual maturity rating rather than on age. For adolescents and young adults who have a sexual maturity rating of IV or V, the antiretroviral regimen recommendations are the same as for adults.
• Concerns about barriers to adherence with adolescents should not exclude youth from receiving antiretroviral therapy, but should prompt extra effort to prepare youth for starting antiretroviral therapy and to support adherence while on treatment.
• All inactivated vaccines are considered safe to administer to adolescents and young adults with HIV, irrespective of immune status, but live vaccines, including the varicella vaccine and the MMR vaccine, should not be given to persons with a CD4 count less than 200 cells/mm³.
• Researchers have found that an organized, deliberate, culturally competent, developmentally appropriate, and compassionate process of transition can improve health outcomes as adolescents and young adults enter adult care settings, which is essential for their continued engagement in HIV.