Clinical Considerations When Prescribing PrEP for Adolescents
On April 24, the CDC published some considerations for clinical providers who are evaluating adolescents for treatment with PrEP.
Preexposure prophylaxis (PrEP) with antiretroviral medication has been proven to reduce the risk of acquiring HIV. Although PrEP is safe for use by adolescents, there are specific clinical considerations among that population that are unique. On April 24, the CDC published some of these considerations for clinical providers who are evaluating adolescents for treatment with PrEP.
In 2012, the combination treatment of the antiretroviral medication tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) was approved by the FDA for PrEP in adults. In 2018, labeling for TDF/FTC was approved by the FDA to be expanded to include use by adolescents who weigh at least 77 pounds. Following this in 2019, tenofovir alafenamide (TAF)/FTC was also approved by the FDA for PrEP for adolescents and adults weighing at least 77 punds, but this drug excluded cisgender women due to a lack of clinical data regarding its efficacy in that population.
When providers are evaluating adolescents for PrEP use, important considerations include PrEP safety data, legal issues about consent for clinical care and confidentiality, the therapeutic partnership with adolescents and their parents or guardians, the approach to the adolescent patient’s clinical visit, and medication initiation, adherence, and persistence.
Furthermore, within different states, there are specific statutes and regulations regarding the provision of health care to minors, which requires physicians to be familiar with their state’s laws.
PrEP use is also recommended for those who inject drugs or engage in sexual behavior that could put them at risk for HIV exposure. Consideration of these elements are important for clinicians to keep in mind, as PrEP use for individuals who use drugs would expand the patient picture to include individuals who are not only men who have sex with men (MSM), but other individuals who are at risk as well. Such instances may also require PrEP to be a single component of medical treatment for such individuals.
Ultimately, a comprehensive approach to adolescent health is recommended, which requires providers to partner with adolescent patients in acknowledgement of their legal autonomy, to the extent it allows, when making any decisions regarding PrEP use. The inclusion of parents in the conversation may also be advisable when it is safe and reasonable to do so, according to the guidance.
In studies evaluating PrEP’s use among adolescents, researchers found that adherence declined over time. However, this is not unique to adolescents, as adult patients have shown a similar trend in studies. For this reason, whenever prescribing PrEP to patients, clinicians should implement strategies to address medication adherence, with frequent clinical follow-ups being a possible approach, according to the CDC. This has the potential to improve adherence because data have shown that adolescents’ medication adherence may benefit from more frequent contact with clinical staff.
Although PrEP is a safe and effective intervention that reduces the risk of HIV acquisition, clinicians should keep in mind that all adolescents should be screened for behaviors that might put them at risk for acquiring HIV, as not only MSM are at risk.
There are resources available for clinicians to use when considering prescribing PrEP to patients. The Clinician Consultation Center offers a PrEP clinical consultation line for health care providers (855-448-7737), and the US Public Health Service has made available a guidance as well as references to other resources for clinicians to review.
Tanner MR, Miele P, Carter W, et al. Preexposure Prophylaxis for Prevention of HIV Acquisition Among Adolescents: Clinical Considerations, 2020. Centers for Disease Control; 2020. cdc.gov/mmwr/volumes/69/rr/rr6903a1.htm?s_cid=rr6903a1_e&deliveryName=USCDC_921-DM26466#conclusion. Accessed May 8, 2020.