Clinical Pearls & Morning Reports
The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend that health care providers weigh the potential risks and benefits of administering preexposure prophylaxis (PrEP) to adolescents on an individual basis and in the context of local laws. Read the NEJM Case Records of the Massachusetts General Hospital here.
Q: What age group is associated with the highest rate of HIV transmission?
A: The highest rate of HIV transmission according to age group is among persons 13 to 24 years of age.
Q: Is long-term adherence to tenofovir disoproxil fumarate and emtricitabine (F/TDF) for PrEP a major concern in adolescents?
A: Long-term adherence to PrEP is a major concern in adolescents and young adults. In the two U.S. studies of PrEP use in persons 15 to 22 years of age, there were steep declines in medication adherence, even though the participants consistently attended clinic visits. The declines were most marked after 3 months of PrEP, when the interval between clinic visits (determined by the study protocols) changed from 1 month to 3 months; Black males in particular were noted to be at risk for nonadherence. These and other data from the chronic disease literature suggest that adolescents require increased adherence support.
A: In adults, F/TDF for PrEP is associated with a modest decrease in bone mineral density that appears to be most pronounced in the first 6 months of therapy and may be reversible. Data have emerged that show that 48 weeks after discontinuation of PrEP in young men who have sex with men, bone loss was partially or fully reversed in those 18 to 22 years of age, but a bone mineral density lower than the baseline level often persisted in those 15 to 19 years of age. Bone changes appeared to increase with greater adherence (i.e., greater drug exposure). Adolescence is a critical time for attaining peak bone mass, and the long-term implications of decreased bone mineral density due to F/TDF for PrEP are unclear.
A: Patients need both the mental and the legal capacity to give informed consent for health services. Legal capacity means that a person has authority under the law to engage in certain activities. A person who has attained the age of majority is assumed to have the legal capacity to consent to health services. The age of majority, which varies according to state, is 18, 19, or 21 years. Parental consent for health services is needed for persons who have not yet attained the age of majority (minors), unless state laws allow minors to access some health services without parental consent. The age of consent can be waived on the basis of the disease for which the minor seeks health services. For services related to sexually transmitted diseases and HIV, some states have no minimum age of consent, whereas other states have an age of consent that is lower than the age of majority. Only a few state laws specifically permit minors to consent to services related to the prevention of sexually transmitted diseases or HIV, such as PrEP. However, the fact that minors can consent to PrEP does not mean that the service will not be disclosed to their parents. Laws vary from state to state regarding information that can be shared with parents.