Minority Youth, HIV and access to Pre-exposure Prophylaxis in NYC

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Problem

The number of cases of HIV throughout the United States has decreased or stabilized among intravenous drug users and heterosexuals, but increased among men who have sex with men (MSM) especially minority youth and young adults. In 2014, 22% of newly diagnosed HIV cases were in youth between the ages of 13 and 24 years of age and more than 80% of those individuals were MSM/bisexual. There has also been significant increases in minority cases of HIV (87% increase in black MSM who are newly diagnosed HIV cases).  Reasons for increased HIV rates in this population include poor education (in the form of age appropriate sexual education), risk taking behaviors (low use of barrier protection, multiple sexual partners), increases in sexually transmitted disease rates, substance abuse, psychosocial issues (loneliness, fear of rejection, bullying) and poor screening habits.

In New York City, sections of the Bronx, Brooklyn and Northern Manhattan have some of the highest rates of new HIV cases and these areas are also the location of the poorest neighborhoods in the city. As with the national trends, the majority of these new cases involve minority youth and increases in new cases in these communities suggest that there are multifactorial issues that need to be addressed.

pic.jpghttp://www.avert.org/professionals/hiv-programming/prevention/pre-exposure-prophylaxis

Prevention

One preventative that has been successful in reducing exposure to HIV is pre-exposure prophylaxis (PrEP). There is controversy regarding its use in adolescents because of concerns about bone growth and other potential side effects. When taken properly, it can reduce the risk of contracting the infection in high risk individuals by 92% making it an option that cannot be ignored.

Intervention

In NYS, minors do not have the same protections (NYS Public Health Law, Minors’ Consent Law) as those seeking reproductive health care or treatment for sexually transmitted disease. Individuals desiring this medication must have parental consent for treatment and many providers are unwilling to prescribe without some clear guidelines and protections from the state and the CDC. This requirement likely prevents minors from seeking care, making a powerful preventative unattainable to high risk youth. Amendments to the Minor Consent and Public Health Laws would set the groundwork for the introduction of PrEP to these populations in the city allowing clinicians to address this issue and hopefully see a reduction in new cases.

 

 

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8 Responses to “Minority Youth, HIV and access to Pre-exposure Prophylaxis in NYC”

  1. aadesoyeblogger Says:

    Really good point here. With increased rates among the youths, especially with high risk group (MSM), implemented preventive strategies such as the PrEP should be made more accessible to this particular group. I wonder if lack of clear guidelines on using PrEP in the youth has to do with the lack of robust data existing for this age group as it does with adults. Medication used for PrEP does have dosing guidelines for adolescents but only for HIV infection. In the face of the unknown and unclear risks vs. benefits when considering use for prophylaxis, I suspect final decisions may continue to remain clinician’s judgment until evidence allows for more clear guidelines from the CDC/FDA/WHO.

  2. lwang108 Says:

    Thanks for sharing this topic for HIV PrEP in minority youth. I totally agree with you that we should concern on this specific population to prevent HIV infection from youth. I just wonder if it will be more effective intervention to prevent minority youth, especial MSM from HIV infection through the education and tools protection. Since there are so many barriers for them to access PrEP, if we can investigate the number of this population through survey, or we can build up the hotline or website to guide them from very upstream, or we implement some education program in community, I believe the prevention from HIV infection for this specific population will success and the incidence will decrease.

  3. pamelamcdonaldblog Says:

    Great blog! I had no idea that minors needed consent for prophylaxis treatment in certain areas. I think it’s a tragedy and this barrier probably is contributing to continued transmission among our youth- and I completely agree that a 92% reduction isn’t something that should be carelessly dismissed. I also think that HIV needs to be catapulted into the media. We just don’t hear a lot about it anymore, I think it’s fallen off the public radar and there are a lot of misconceptions and misinformation guiding populations at risk-as well as the general public.

  4. shabanawalia Says:

    I agree with the above statement by Pamela. I was completely ignorant to the fact that minors needed consent for ppx in the new york state areas with the highest contraction rates. What about post exposure ppx? Are minors able to get this? I would hope so. I know it is reserved plenty of times for sexual assault cases, but I wonder if someone simply did not know how to contact their previous partner and wanted ppx if they would be able to get it? What else is NYS doing to stop the rates of new HIV infection from increasing among youth in these cities? I’m sure that there are plenty of clinics that youth and minors can go to however what other options do they have besides testing frequently and condom use; it does not seem like many. You raise many necessary points in a concise way.

  5. bbland1 Says:

    Thank you for a very interesting blog post and topic. I think that this post and topics really hits on the challenges of public health policy. I was also not aware about the requirement for parental consent for ppx and thank you for the great link with all the states minor consent laws. It would be interesting to compare states with similar restrictive policies and their HIV rates.

    I would be curious as to how that law came into being, or if it has something that has existed for awhile. In terms of trying to determine how best to update policy to improve health care I think it is important first to determine how the policy was enacted to begin with, i.e. was it recent and has a lot of public support or is there no political will to change it. To me, this seems like a public health problem in which a lot of the factors have been identified as well as a potential solution, but that the policy has not adopted to the change yet.

  6. ksingh18 Says:

    Very interesting post and comments. I certainly agree that unfortunately the challenges facing adolescents in terms of HIV prevention (particularly those in certain subpopulations such as MSM) can be daunting, and unfortunately policies such as this don’t make things any easier. However, I also have some minor qualms with necessarily saying PrEP should be available for any adolescent who requests it—putting aside the fact that drug has not been “adequately” studied in this population (although this is changing as we speak—see my point below) sometimes there are safer and even more effective and appropriate options, even for adult patients—it really just depends on the particular patient and tailoring to their needs. I’m not sure if any studies have been done on adherence rates to medications in adolescents vs adults, but as some of you are aware that is a big concern when if PrEP is taken incorrectly or inconsistently–not only could it not be effective, but resistance to this medication (Truvada) can also develop which would be unfortunate as it currently is one of the main “go to” meds for HIV treatment. That said, if policies such as this truly are limiting effective prevention options then this really needs to be re-evaluated—in my home state we are allowed to treat and give meds to teens without parental consent, which perhaps I have taken for granted!

    A few other related points:

    1. There actually are several current trials studying PrEP in adolescent populations in Africa, such as the CHAMPS trial being conducted in South Africa—I have not seen any preliminary data yet, but hopefully this will show a similar efficacy and low toxicity profile in this population which may encourage a change in clinical practice in the US.

    2. The potential drug toxicities related to PrEP (bone, kidney, etc.) mainly come about due to the drug Tenofovir (TDF) and how it is metabolized, and is some clinical cases can truly complicate treatment options. The good news, however, is that there is a newer formulation of this drug (TAF) that should significantly decrease the risk of these significant side effects, and I believe has recently been approved by the FD for treatment of HIV, but not has not yet been approved for PrEP—however, I think it’s only a matter of time before that happens.

  7. donnaatlanta Says:

    Thank you for this very interesting and important post! I chose to comment on this blog because I also recently became aware of the alarming rate of new HIV infections in certain groups in the United States.

    I moved to Atlanta about 2 years ago and I recently learned of the same issue occurring here in the MSM community. It was quite shocking to read about and I was really upset by it. I briefly lived in Botswana for an internship about 10 years ago and the HIV rate in parts of Atlanta are that of developing countries that are known for having the highest rates of HIV infection in the world.

    When I looked up the county’s public health website, I was disappointed by the lack of sophistication in their attempt to address this issue. The primary goal is to increase the amount of people who know theirs status. Prevention was not even on the list of priorities. I also discovered that there are significant barriers to accessing medication even if you know you have HIV. There are discounts given for people who can’t afford the medication, but the screening process for determining who is eligible includes an income check. Since the most affected are those with the least resources, just like in NY, it seems odd that the website shares this as a requirement for being screened to get medication. So I can only imagine the difficulty of accessing a preventative vaccine one might have as a minor with limited resources. What I find most troubling is that we have medications and tools that work, but the systems are structural barriers in place make it very hard for people to get the care they need.

    I agree that PrEP is a controversial choice, but do think any effort to thwart new infections should be explored after a thorough evaluation of the risks and benefits. However, it seems that the greater challenge is all the political and organizational barriers that exist for people to access any medication that prevents or treats HIV infection. If we want to see a real change, we have to address the systemic issues that prevent people with limited resources getting the appropriate care.

    Additionally, I recall the approval of Gardisil several years ago for the prevention of HPV in girls. This was a highly controversial approval and there were many ethical debates about whether we should allow minor to receive a preventative vaccine for a virus that is sexually transmitted. I wonder if the same ethical debates are being had with the use of PrEP.

    As for consenting minors without the approval of parents, I have never known of this to exist in the states I’ve lived. As far as I’m aware, it is the norm that a child needs to have parental consent to obtain these types of services. Maybe that is starting to change, but I am not shocked to read it.

    Thank you again for this really interesting post and to all the others who posted a comment. I really enjoyed reading, although this is a very sad topic to learn about.

  8. anatheaee Says:

    I find it fascinating and incredibly disheartening that people, especially young people, are still contracting HIV in such high rates.
    To me, it really shows the limits of the biomedical model in health care. Three percent of the domestic HIV/AIDS budget is spent on prevention activities, while 66% is for care and treatment or research. http://www.avert.org/professionals/hiv-around-world/western-central-europe-north-america/usa. Similar to any other health condition, we’re getting to a place where our biomedical advances have far outpaced our socioeconomic and prevention-specific advances. Lower socioeconomic status and greater income and wealth inequality leads to decreased health status, including an increased risk of contracting HIV as you mentioned, but reducing income inequality never seems to be a viable strategy.

    PrEP is a great medical advance, but the people who are contracting HIV today aren’t the people/kids who are going to take PrEP as prescribed. The people contracting HIV/AIDS have a set of social, economic, and political barriers to HIV prevention that the US hasn’t even begun to try to understand or combat.

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