The main issues that affect the care of HIV-positive adolescents
An interview with John Steever, Medico
Por Mathew Rodriguez
Do site TheBodyPRO.com
28 August 2014
John Steever, Medico
Teenagers face a series of challenges unparalleled - and generally less valued - with regard to effective medical care and successful treatment of the HIV virus. John Steever, Medico Health Center Adolescent Mount Sinai Medical Center in New York is deeply familiar with these challenges: he oversees the care of approximately 100 young HIV - positive.
Dr. Steever spoke by telephone with Mathew Rodriguez, Editor of our local community, about his work and how to care for HIV in adolescents differ from adults in HIV care, and bigger priorities that medical providers should keep in mind when treating HIV-positive adolescents.
You can tell a little about the Adolescent Health Center of Mount Sinai and what role it
The Center for Adolescent Health is actually one of the greatest centers self-sustainable adolescent health in the United States. There we see every year around 12, 000 unique individuals. We do this for free for youth; we do not charge them anything. We are free from various grants, so we can offer medical assistance without any barrier for teens.
I am one of the doctors there, so I see all kinds of young people, aged between 12 the 24 or 25 years. We all do many reproductive medical assistance; work GYN (Gynecology), of DST`s (Sexually Transmitted Diseases) tests, pregnancy tests, giving methods of birth control. And all this is done for free for the kids. So, all laboratory tests that we do are free. All methods of birth control that we donate are free. We donated samples. And then when we treat STDs, we also donated samples. So the youth did not find many obstacles to get medical care. We are really super understanding. We have a ward medical care. We have a wing of gynecological care. We have a mental health ward, including psychologists, social workers and child psychiatry. We also have health educators. We have a nutritionist on staff. We have an attorney on staff to young people who may need legal assistance. We have a dental clinic, and a new eye clinic that is available to young people. And all these services are free. We do a combination of appointments and fittings.
What I do in that group: I specialize and supervise the medical care of adolescent HIV - positive. We have around 100 young people in care who has HIV; some are born with the virus (perinatal acquisition), but most of them contracted through sexual intercourse. And the biggest of them are young men of color who have sex with other men - then this panorama reflects somewhat the epidemic in New York City.
What would you say to physicians with less experience involved in the care of young people with HIV? What do you think needs to be viewed differently when it comes to young people with HIV in care in relation to older people?
Fundamentally, the general basic guidelines say you should start treating people as soon as you diagnosed with HIV. This and the test-and-treat concept - so you get to treat people with HIV drugs immediately, regardless of CD4 them count. Thus, the count may be high or really low, but you will begin to treat them with drugs.
The idea is that then the viral load of them starts to fall drastically, it starts to undetectable, so there is less chance of them transmitting the infection to others. And the idea is that if you could treat all people diagnosed in as soon as you eventually you eradicate infections because there would be no new infections.
The problem with this idea is that it requires a relatively high degree of sophistication. And I do not know that all teenagers are prepared to deal with it. When you give the diagnosis of HIV-positive to a young, not only are you giving him hard news, they may or may not be developed enough to handle them, but they often also have other variables in their lives that can make the news even harder to bear.
For example, a young man who belongs to a minority, which is color, which is gay, this having sex with other men: he may not be willing to tell his family about it. And the family can not support this very fact. So, what you do not want to happen is that the family discover that he is taking drugs - because you gave him a bottle of pills, then the family not only discovers that he is one of the most HIV-positive adolescents, it is also gay. This can lead to expulsion from young house or a hostile family environment, when what we want is a supportive family environment. So there are scenarios where it is not the right time for this young start drug treatment for HIV time until he is really ready, and you've thought about all the consequences that would happen if I started taking the drugs: You have a place to stay? Do you have a place to hide your drugs? Or do you feel comfortable including your family?
The main issues that affect the care of adolescent HIV - positive
I think that family support, especially when you're a teenager, is extremely important. But if a young person will be kicked out, this is not the best time to start with your medicines.
Things like serious substance use should give doctors pause before starting medications for HIV. Or an unstable domestic life - then maybe they do not live at home but are spending time with friends - or living in shelters. And just a lot harder to take care of their HIV and worry about food, clothing, shelter.
If you begin treating someone, you want that person to get successful treatment. If they prove unsuccessful and not suppress their viral load, then it may be that they create resistance that medicine. And since they are young, they will make use of medications for long. You have to do each regime be worthwhile; you do not want your patient to playing "catch-up" with their medications at the beginning, become resistant to them and then stay relatively fast switching of medications.
"Since they are young, they will make use of HIV drugs for a long time. You have to do each regime be worth it. "
I feel that you need to be ready, the patient needs to be ready, and you need to engage your personal mental health ward - as a social worker or case manager - to help explore how this young man will succeed in taking drugs.
As you discuss the recommended treatment for HIV recently diagnosed with a teenager?
Well, I think the goal is really noble, and I think definitely the matter, with regard to teenagers should be brought up. But I think you should calm the young man and say, OK, here are the advantages, here are the drawbacks. Here is why we should start with the medications; and here's why it could turn out to be a bad idea. We will not do anything today. I want you to think about it. I want you to work with your social worker, with his case manager, with his personal mental health, and that you actually work with some of these things. Maybe the teens were to be encouraged to train with multivitamins. I think that the guidelines are great, but there has to be some recognition that you can not get something rigidly.
Or, if you are cornered about getting something, maybe for teens one of the first lines should be something involving a protease inhibitor, because the genetic barrier to resistance is much higher. You lose the convenience of a pill regimen, once a day. But you get the advantage of having a drug that does not cause mutations in the virus so quickly.
'"For teenagers I usually use the protease inhibitor, and just because a good lesson for them."
Where doctors can get help to address these areas that are outside your area of expertise, but are important to treat a teenager with HIV?
If you are lucky, you will have a social worker at his office. I myself am extremely lucky to have one. If you're not so lucky, if you are in solo practice, if there is not a great team around you - your nurse may be interested and do a bit of this kind of work. But there are some organizations out there that provide some case management structures for you. I'm sure they are not in every city and municipality through or across the country. But certainly in larger cities, there are organizations that help provide structure. Have them in the palm of hand and certainly a good thing.
There is some new issue that you, as a provider of care for adolescents with HIV, is cheerfully waiting?
I'm eagerly waiting to see what types of injectable drugs long term, or even implantable, scientists will launch. I would like to see more courses placed in this area.
Someone has to remember to take a pill every day now, but the more you can remove the user from the equation - if you could do an injectable cocktail once a month or once every three months - I think it really improve adherence to HIV medicine. This would really improve the reduction of communities of viral loads and thus reduce the risk of further transmission to others.
Also, for people who form a discordant serum couple, make pre-exposure prophylaxis also help to go the long way to cause a breach in the epidemic.
And the other thing (and I do not know how to do this), we need to figure out how to reach more people. I think that any barrier can be removed to enlarge the number of conducting HIV tests should be done. For example, no one ever says in an annual physical, "Oh, we'll do a complete blood count."
Should just be, and should be part of it, so you get people "We will do blood tests to routine physical examination is done." - You simply makes a lot more testing and hopefully we can find more people who have the infection .
Test widely, test often, as they say.
Thank you very much for talking to me.
This transcript has been edited for purity of sound.
Mathew Rodriguez and the local community editor for TheBody.com and The BodyPro.com
Siga Mathew no Twitter:@mathewrodriguez
Seropositive the Web Site Editor Note: I met a teenager who had just found out that was seropositive. She told her family and was labeled a drug addict, Chop the streets, fell in prostitution.
Prostiuindo up, "took revenge in the world" and contaminated two hundred people. When dropped itself had a terrible regret and threw himself from the top of the bridge Major Quedinho, there in Bela Vista, bohemian area of Sampa and over.
Died at 19 years early in life. Dealing with HIV adolescents - positive is extremely complex, for all that has been said here and the high pressure of these hormones heads still in training
Tradução: Rodrigo Pellegrini Sgobbi
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