3rd Annual Conference of the Children’s HIV Association
‘Young People and HIV: Back to the Future’
Dr Melinda Tenant-Flowers
King’s College Hospital NHS Trust, London
Friday 15 May, The Bridgewater Hall, Manchester
Contributors
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Chair: Melinda Tenant-Flowers. King’s College Hospital London. Consultant GUM/HIV
Colin Ball. King’s College Hospital London. Consultant Paediatrics / HIV
Fiona Boag – Chelsea and Westminster Hospital NHS Foundation Trust, Imperial,
London. Consultant GUM/HIV
Caroline Foster – St Mary’s Hospital NHS Foundation Trust, Imperial, London.
Consultant Paediatrics / HIV
Eva Jungmann – Archway Sexual Health Centre, Camden and Islington Primary Care
Trust, London, Consultant GUM/HIV
Elaine Pearson Scott – Positive Parenting Children (PPC) (Lambeth)
Maria Phelan – Children and Young people HIV Network Coordinator, National
Children, s Bureau
Katia Prime – St George’s Hospital Trust, London, Consultant GUM/HIV
Ella Sherlock – Clinical Psychologist HIV Child and Family Psychology Service
CASCAID (Lewisham and Southwark)
Rebecca Wilkins – Community Matron, Diabetes Centre Newbury Park Redbridge PCT
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Conflict of Interest / Competing Interest
None declared
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Contents
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Definition of Adolescence
Definition of Sexual Health
Aim and scope of Guidance
Existing Guidelines
Contents of Guidance
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How to Talk
What to say
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Epidemiology
HIV transmission risk
Criminalisation
Information on Genital infections and STIs
Common presentations of STIs
Preventing unwanted pregnancy
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Next steps
Stakeholders - Potential
Definition of Adolescence
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Various definitions in literature
Relate to age, growth or the onset of puberty.
Ages 10 to 20 years-old
Different epidemiological datasets
Health Protection data on Young People and Sexually Transmitted
infections collects data on 16-24 year-olds
UK Collaborative HIV in Paediatrics (CHIPS) data defines adolescence
as commencing at age 12 years-old
Puberty and sexual activity commence at any time from 10 years old in
UK born children
Below the age at which adolescents are deemed capable of legally
consenting to sex
The term adolescent used in this guidance to denote young people
aged 10-20 years old.
Definition of Sexual and Reproductive
Health
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WHO defines sexual and reproductive health as ‘A
state of physical, emotional, mental and social well
being related to sexuality, NOT merely the absence
of disease, dysfunction or infirmity’
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Sexual and Reproductive Health services aim to
prevent sexually transmitted infections (STIs) and
unwanted pregnancies as well as screen for,
diagnose and manage STIs and their sequelae to
minimise morbidity and mortality
Existing Guidelines
Excellent evidence-based guidelines on adolescent sexual and reproductive health (SRH) already exist:
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BASHH Standards for comprehensive sexual health services for young people under 25 years (2002)
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FSRH Guidance Contraceptive choices for young people (2004)
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BASHH United Kingdom National Guideline on the Sexual Health of People with HIV: Sexually Transmitted
Infections (2006)
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BASHH UK Guideline for the use of post-exposure prophylaxis (PEP) for HIV following sexual exposure
(2006)
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BASHH national Guidelines on Consultations requiring Sexual History Taking (2006)
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FSRH BASHH Guidance The management of women of reproductive age attending non-genitourinary
medicine settings complaining of vaginal discharge (2006)
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CHIVA Growing Up, Gaining Independence Principles for Transition of HIV Care (2007)
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CHIVA Practice Guidance on Talking to Children about their HIV Diagnosis (2007)
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BHIVA BASHH FRSH UK guidelines for the management of sexual and reproductive health (SRH) of
people living with HIV infection (2008)
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BHIVA CHIVA Guidelines for the management of HIV infection in pregnant women (2008)
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RCPCH Guidelines on Child Sexual Abuse (2008)
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BASHH UK National Guidelines on the management of Sexually Transmitted Infections and related
conditions in Children and Young People (Final draft out for consultation 2008-2009)
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CHIVA Guidelines on HPV vaccination in HIV Infected Adolescents (2009 for consultation)
Aim of Guidance
• Provide guidance and knowledge for Paediatric Healthcare
Professionals (PHCP) managing adolescents with HIV
• Enable them to answer questions put to them by adolescents
about Sexual and Reproductive health
• Enable them to start discussions about sexual and
reproductive health (SRH)
• Be able to inform adolescents what to expect from SRH
Services
• Provide information for PHCP on where to access existing
guidelines
Aim of Guidance
• Some PHCP may find themselves caring for adolescents with
sexually transmitted HIV
• For this group, the correct messages regarding SRH are still
vital
• HIV may have been sexually acquired through heterosexual or
same gender sex with other males (MSM)
• This guidance will also be of interest to PHCP caring for
adolescents without HIV, who are about to become, or already
are, sexually active
Aim of Guidance
• NOT intended to retrain PHCP as SRH experts
• To inform their discussions with adolescents to enable them to
answer basic questions about sexually transmitted infections
(STIs), Sexual Health and conception / contraception-related
issues or
initiate a discussion about their SRH needs
• Recognise that PHCP will refer adolescents to their colleagues
in Genitourinary Medicine (GUM) / SRH whenever possible
• However, PHCP will, in many cases, have been caring for these
adolescents for many years throughout their childhood
• Therefore, in some cases, adolescents may ask their PHCP first
about SRH matters because of the long term and trusting
relationship that has developed
Aim of Guidance
• Guide PHCP through a timeline for discussing SRH issues
• For adolescents with vertically transmitted HIV, this process
would normally start as they approach the time when their HIV
diagnosis is disclosed to them as part of the preparation for
transition to adult services
• Appropriate language
• Main topics to be covered
• Relevant ethical, legal and confidentiality concerns and
challenges experienced by HIV-infected adolescents in relation
to SRH
Guidance Contents
The Guidance is split into two main sections:
1. How to talk to adolescents about SRH
Most challenging?
2. Facts about SRH
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Appendices
References
Sources of Information
Contents
How to talk to Adolescents about SRH
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Sexual Health Education needs of Adolescents
Sexual Development and Relationships
Sex and Relationships
Negotiating Sexual relationships
HIV transmission risks
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Disclosure of HIV status - Who to tell, when and why
HIV disclosure and Criminalisation
Consent and Confidentiality
The Sexual Offences Act 2003
Assessing Fraser (Gillick) Competence
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Talking about Sex
Talking about Sexual and Reproductive Health
STI and Conception risks
Sexual History taking
Psychosocial issues and services available
Sexual Assault.
Contents
Facts about SRH
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Epidemiology of Sexual Health in Adolescents in the UK 2009
Service provision for STI screening and contraception / conception advice
Common non-sexually acquired infections
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STIs and their screening, diagnosis, morbidity, management and prevention
Partner notification
Common presentations of genital infections - non sexually acquired and
sexually transmitted
Interaction between HIV transmission and STIs
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Cervical screening
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Contraception including emergency contraception and long acting reversible
contraception (LARC)
Conception, fertility, pregnancy and STIs
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Drug interactions between STI treatment and contraception and combination
antiretroviral HIV therapy (CART)
How to talk
• When young people were asked what they wanted
from an adult when talking about sex, their top three
requirements were someone who was:
• Non-judgemental
• Had correct information
• Maintained confidentiality
What to say
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Young people need age/developmentally appropriate and up to date
information on topics including:
Puberty
Relationships
Sex
Contraception
STIs
HIV transmission -“protecting themselves and others”
Condom use - negotiation and condom failure
Partner disclosure
PEPSE
Emergency contraception
Fertility
Pregnancy
Mother-to-child transmission
Legal issues.
Epidemiology
CHIPS Data end September 2008 - 90% children diagnosed in UK
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N =1495
97% infected perinatally
75% Black African
Post CART median age over 11 years.
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1147 current paediatric follow up
646 (56%) aged 10 years +
345 (30%) aged 13 years +
170 (11%) transferred adult services median age17years
HPA data
• Route of infection 16-24 horizontal transmission
• 48% heterosexual (Black Africans infected abroad)
• 48% MSM (white infected in UK)
Epidemiology
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25%of UK adolescents have had sex before their 16th birthday
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Boys report earlier sexual debut than girls and younger adolescents are less
likely to use a condom at first sex than older adolescents
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Despite a downward trend since 1998, the UK has the highest rate of teenage
pregnancy in Western Europe
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Conception rate in England of 41 per 1000 girls aged 15-17 during 2007, half of
which ended in legal termination
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2007 HPA data - 50% all STI diagnoses diagnosed in 16-24 year olds
– 65% all chlamydia
– 50% all gonorrhoea
– 50% all genital warts
– New diagnoses chlamydia in 16-19 year olds doubled in last 10 years
HIV Transmission Risk
KNOWN HIV positive and risk of transmission Varghese 2002
Type of sex act
Risk of HIV transmission per
exposure
Receptive Vaginal
0.1% or 1 in 1,000
Insertive Vaginal
0.05% or 1 in 2,000
Receptive Anal
0.5% or 1 in 200
Insertive Anal
0.065% or 1 in 1,538
Receptive oral with ejaculation
0 - 0.04% or up to 1 in 2,500
HIV Transmission Risk
What increases the risk of transmission?
• High plasma HIV viral load
– HIV seroconversion
– Advanced HIV disease
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Concomitant sexually transmitted infections
Menstruation
What decreases the risk of transmission?
• Condoms
• Circumcision
• CART (lowers viral load)
• Post exposure prophylaxis (PEPSE)
• Safer sex
Criminalisation
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HIV positive adolescents do not need to disclose their status to sexual partners as long
as they are having protected sex
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If HIV positive young person is having unprotected sex or there has been a risk of
exposure (e.g condom splits) they need to disclose their HIV status to that partner
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Currently there is no specific legal guidance around HIV transmission for those under
16 years of age (Consultation with the CPS is in process)
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Prosecution requires the following:
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Transmission of HIV must have occurred - having unprotected sex is itself not a
crime
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The young person needs to be aware of their status
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The young person needs to have engaged in a risky behaviour
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The young person needs to understand the risks of transmission
If young people are not given this knowledge and then are involved in activities that
may be thought of as illegal it could be that those who have neglected to inform them
are vulnerable to prosecution
What to say
• HIV infection can be transmitted to
sexual partners
Common presentations of STIs
• ASYMPTOMATIC
• Discharge
• Abdominal pain
• Abnormal vaginal bleeding
• Genital lumps
Genital Infection and STI Information
Genital Infections
NOT sexually transmitted - COMMON
• Candida
• Bacterial vaginosis
Sexually Transmitted Infections
• Chlamydia
• Gonorrhoea
• Syphilis
• Herpes simplex virus
• Human papilloma virus
• Hepatitis A/B
Contraception and Conception
Preventing Unwanted Pregnancy
• Emergency contraception
• Long Acting Reversible Contraception (LARC)
• Other
Safe Conception and Pregnancy
Next Steps
• Other Proposed Stakeholders
– BHIVA, BASHH, FSRH
• Consultation
– CHIVA website
What we need now
• These guidelines need feedback and
consultation
• Feedback from all paediatric HCP’s
• Feedback from young people
• Consultation will be facilitated through
the CHIVA website
Acknowledgements
• Thank you to everyone in the HYPNET
working party!