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The aims of this study were to: 1) determine prevalence of anogenital and oral HPV, 2) determine concordance between HPV at anal, perianal, scrotal/penile, and oral sites; and 3) describe factors associated with anogenital HPV types targeted by the 9-valent vaccine. Data were collected from 2012 to 2015 among men who have sex with men 18–26 years of age enrolled in a vaccine trial (N = 145). Penile/scrotal, perianal, anal, and oral samples were tested for 61 HPV types. Logistic regression was used to identify factors associated with types in the 9-valent vaccine. Participants’ mean age was 23.0 years, 55.2% were African-American, and 26.2% were Hispanic; 93% had anal, 40% penile, and 6% oral HPV. Among those with anogenital infection, 18% had HPV16. Concordance was low between anogenital and oral sites. Factors independently associated with a 9-valent vaccine-type HPV were: race (African-American vs. White, OR=2.67, 95% CI=1.11–6.42), current smoking (yes vs. no, OR=2.37, 95% CI=1.03–5.48), and number of recent receptive anal sex partners (2+ vs. 0, OR=3.47, 95% CI=1.16–10.4). Most MSM were not infected with HPV16 or HPV18, suggesting that they may still benefit from HPV vaccination, but anogenital HPV was very common, highlighting the importance of vaccinating men before sexual initiation. Clinical trial number: NCT01209325 Keywords: Adolescents, Clinical trials, Men who have sex with men, Vaccine, Human papillomavirus, HIV

Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4,752 patients not previously diagnosed with HIV, 1,403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.

Objective This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls. Design Qualitative study. Methods Ninety-six 15 to 17-year-old girls from six urban U.S. sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth-interviews. Interviews were transcribed verbatim, and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified. Results Factors related to relationships rarely appeared to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, appeared to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR upon first impression. While most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation. Conclusion Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.

Background Young men who have sex with men (YMSM) are disproportionately impacted by HIV and other sexually transmitted infections (STIs) in the United States (US) and have low rates of HIV/STI testing. Provision of HIV self-testing and STI self-collection can increase testing rates, and access to these kits through mobile applications (apps) could help facilitate YMSM using HIV self-testing and STI self-collection. Methods Data for this study comes from two pilot randomized controlled trials (RCTs) of mobile apps within the Adolescent Trials Network-LYNX and MyChoices-aimed to increase HIV/STI testing among YMSM (age 15-24) who had not recently tested for HIV and were at high risk for HIV acquisition across five US cities. Both apps include the ability to order a HIV self-test with rapid results and a kit for STI self-collection and mailing of samples for syphilis, gonorrhea and chlamydia to a lab for testing. Using assessments of app users (n=80) at pre-randomization and at 3- and 6-months post-randomization and online interview data from a purposive sample of app users (n=37), we report on experiences and lessons learned with HIV self-testing and STI self-collection kits ordered via the apps. Results Participants were on average 20.7 years of age (SD =2.4), and 49% were non-White or multiple race/ethnicity. Sixty-three percent had a prior HIV test. Over half (58%) had a prior STI test, but only 3% had tested within the past 3 months. Nearly two-thirds ordered an HIV self-testing kit; of whom, 75% reported using at least one self-test kit over the study period. STI self-collection kit ordering rates were also high (54%); however, STI self-collection kit return rates were lower (13%), but with a high positivity rate (5.3%). Both HIV self-testing and STI self-collection kits were highly acceptable, and 87% reported that it was extremely/very helpful to be able to order these kits through the apps. The most common reason for not ordering the HIV/STI kits was preferring to test at a clinic. In interviews, participants expressed feeling empowered by being able to test at home; however, they also raised concerns around STI sample collection. Conclusions HIV self-testing and STI self-collection kit ordering via mobile apps is feasible, acceptable and may show promise in increasing testing rates among YMSM. The LYNX and MyChoices apps are currently being tested in a full-scale efficacy trial, and if successful, these innovative mobile apps could be scaled up to efficiently increase HIV/STI testing among youth across the US.

BACKGROUND HIV disproportionately affects young men who have sex with men (YMSM) in the United States. Uptake of evidence-based prevention strategies, including routine HIV testing and use of pre-exposure prophylaxis (PrEP), is suboptimal in this population. Novel methods for reaching YMSM are required. OBJECTIVE The aim of this study is to describe the development and evaluate the feasibility and acceptability of the MyChoices app, a mobile app designed to increase HIV testing and PrEP use among YMSM in the United States. METHODS Informed by the social cognitive theory, the MyChoices app was developed using an iterative process to increase HIV testing and PrEP uptake among YMSM. In 2017, beta theater testing was conducted in two US cities to garner feedback (n=4 groups; n=28 YMSM). These findings were used to refine MyChoices, which was then tested for initial acceptability and usability in a technical pilot (N=11 YMSM). Baseline and 2-month postbaseline assessments and exit interviews were completed. Transcripts were coded using a deductive approach, and thematic analysis was used to synthesize data; app acceptability and use data were also reported. RESULTS The MyChoices app includes personalized recommendations for HIV testing frequency and PrEP use; information on types of HIV tests and PrEP; ability to search for nearby HIV testing and PrEP care sites; and ability to order free home HIV and sexually transmitted infection test kits, condoms, and lube. In theater testing, YMSM described that MyChoices appears useful and that they would recommend it to peers. Participants liked the look and feel of the app and believed that the ability to search for and be pinged when near an HIV testing site would be beneficial. Some suggested that portions of the app felt repetitive and preferred using casual language rather than formal or medicalized terms. Following theater testing, the MyChoices app was refined, and participants in the technical pilot used the app, on average, 8 (SD 5.0; range 2-18) times over 2 months, with an average duration of 28 (SD 38.9) minutes per session. At the 2-month follow-up, the mean System Usability Scale (0-100) score was 71 (ie, above average; SD 11.8). Over 80% (9/11) of the participants reported that MyChoices was useful and 91% (10/11) said that they would recommend it to a friend. In exit interviews, there was a high level of acceptability for the content, interface, and features. CONCLUSIONS These data show the initial acceptability and user engagement of the MyChoices app. If future studies demonstrate efficacy in increasing HIV testing and PrEP uptake, the app is scalable to reach YMSM across the United States. CLINICALTRIAL Clinicaltrials.gov NCT03179319; https://clinicaltrials.gov/ct2/show/NCT03179319 INTERNATIONAL REGISTERED REPORT RR2-10.2196/10694

Background Men who have sex with men (MSM) are at high risk for human papillomavirus (HPV)–related anal cancer. Little is known about the prevalence of low-grade squamous intraepithelial lesions (LSILs) and the anal cancer precursor, high-grade squamous intraepithelial lesions (HSILs), among young MSM with HIV (MSMLWH). HPV vaccination is recommended in this group, but its safety, immunogenicity, and protection against vaccine-type HPV infection and associated LSILs/HSILs have not been studied. Methods Two hundred and sixty MSMLWH aged 18–26 years were screened at 17 US sites for a clinical trial of the quadrivalent (HPV6,11,16,18) HPV (qHPV) vaccine. Those without HSILs were vaccinated at 0, 2, and 6 months. Cytology, high-resolution anoscopy with biopsies of lesions, serology, and HPV testing of the mouth/penis/scrotum/anus/perianus were performed at screening/month 0 and months 7, 12, and 24. Results Among 260 MSMLWH screened, the most common reason for exclusion was detection of HSILs in 88/260 (34%). 144 MSMLWH were enrolled. 47% of enrollees were previously exposed to HPV16. No incident qHPV type–associated anal LSILs/HSILs were detected among men naive to that type, compared with 11.1, 2.2, 4.5, and 2.8 cases/100 person-years for HPV6,11,16,18–associated LSILs/HSILs, respectively, among those previously exposed to that type. qHPV was immunogenic and safe with no vaccine-associated serious adverse events. Conclusions 18–26-year-old MSMLWH naive to qHPV vaccine types were protected against incident qHPV type–associated LSILs/HSILs. Given their high prevalence of HSILs, there is an urgent need to vaccinate young MSMLWH before exposure to vaccine HPV types, before initiating sexual activity, and to perform catch-up vaccination., A high proportion of 18-26 year-old men-who-have-sex-with-men-living-with-HIV screened for a quadrivalent HPV (qHPV) vaccine trial had anal low-grade/high-grade squamous intraepithelial lesions (LSIL/HSIL). Vaccinees naive to qHPV types were protected against incident qHPV type-associated-LSIL/HSIL. Vaccination before sexual initiation is critically important.

BACKGROUND AND OBJECTIVES: Youth carry a disproportionate burden of new HIV infections. With our study, we aimed to characterize HIV testing experiences among adolescents and young adults admitted to a children’s hospital that is located in a high HIV-prevalent community and implemented routine HIV testing for all patients ≥13 years of age. METHODS: A total of 120 patients aged 13 to 24 years old who were admitted to our hospital and had a documented offer of routine HIV testing on admission were invited to complete a self-administered survey that asked about sex, race and/or ethnicity, HIV risk behaviors, and attitudes toward routine HIV testing in the hospital. Date of birth, admission diagnosis, and verification of HIV testing and results were collected by chart review. RESULTS: Study participants (N = 99) were 17.4 ± 2.3 years old, 52% female, 47% Hispanic, and 29% African American. Additional characteristics include the following: 65% had previous sexual activity, 11% had a history of sexually transmitted infections, and 12% were worried about their risk for HIV. Forty-seven percent of participants accepted HIV testing, with older patients (P < .01) and those reporting previous sexual activity (P < .01) and a previous HIV test (P < .01) being more likely to accept testing. A total of 96% of participants agreed that the hospital is a good place to offer HIV testing. CONCLUSIONS: Our findings support offering routine HIV testing to youth admitted to children’s hospital. Given the high incidence of new and undiagnosed HIV infections among youth, additional venues for HIV testing are essential.

Background Tenofovir disoproxil fumarate (TDF) decreases bone mineral density (BMD). We hypothesized that vitamin D3 (VITD3) would increase BMD in youth receiving TDF. Methods This was a randomized, double-blind, placebo-controlled trial of directly observed VITD3 vs placebo every 4 weeks for 48 weeks in youth aged 16-24 years with HIV, RNA load

BACKGROUND: Young women aged 15–24 years are disproportionately affected by the HIV epidemic. Two phase III trials of a vaginal ring containing 25-mg dapivirine demonstrated HIV-1 risk reduction in adult women older than 21 years but not in those aged 18–21 years. Lack of protection was correlated with low adherence. METHODS: In this phase-IIa, randomized, double-blind, placebo-controlled, US, multicenter trial of the dapivirine ring in sexually active females, aged 15–17 years, participants were randomized 3:1 to a dapivirine or placebo ring to be inserted monthly for 6 months (NCT02028338). Primary safety end points included grade 2 product related adverse events and any grade 3 and higher adverse events. Adherence to ring use was assessed by plasma dapivirine concentrations, residual levels in used rings, and self-report. A plasma dapivirine concentration of >95 pg/mL was used to define short-term adherence; a residual ring level of

Despite significant progress in the fight against HIV/AIDS in the United States, HIV prevention and treatment disparities among key populations remain a national public health concern. While new HIV diagnoses are increasing among people under age 30—in particular among racial, ethnic, and sexual minority adolescents and young adults (AYA)—dominant prevention and treatment paradigms too often inadequately consider the unique HIV service needs of AYA. To address this gap, we characterize persistent and largely overlooked AYA disparities across the HIV prevention and treatment continuum, identify AYA-specific limitations in extant resources for improving HIV service delivery in the United States, and propose a novel AYA-centered differentiated care framework adapted to the unique ecological and developmental factors shaping engagement, adherence, and retention in HIV services among AYA. Shifting the paradigm for AYA to differentiated HIV care is a promising approach that warrants implementation and evaluation as part of reinforced national efforts to end the HIV epidemic in the United States by 2030.

Few studies have examined sexual partnerships and HIV risk in diverse samples of African American/Black and Hispanic/Latino adolescent and young adult men who have sex with men (YMSM), a group that have a high burden of HIV in the United States. A community–venue recruitment approach was used, which identified significant differences in HIV risk by sexual partner type among 1,215 YMSM. Those with casual partners had a higher number of sexual partners, had more sexually transmitted infections (STIs), were more likely to engage in transactional sex, and to use alcohol, marijuana, or other substances compared with those with main partners only. Among those with female sexual partners, many used condoms “every time” when engaging in vaginal sex with casual partners, but a sizable proportion “never/rarely” used condoms with their main partners. Our findings demonstrate a need for tailored HIV prevention education and counseling with necessary skills regarding consistent and correct condom use with all sexual partnerships.

Background HIV disproportionately affects young men who have sex with men (YMSM) in the United States. Uptake of evidence-based prevention strategies, including routine HIV testing and use of pre-exposure prophylaxis (PrEP), is suboptimal in this population. Novel methods for reaching YMSM are required. Objective The aim of this study is to describe the development and evaluate the feasibility and acceptability of the MyChoices app, a mobile app designed to increase HIV testing and PrEP use among YMSM in the United States. Methods Informed by the social cognitive theory, the MyChoices app was developed using an iterative process to increase HIV testing and PrEP uptake among YMSM. In 2017, beta theater testing was conducted in two US cities to garner feedback (n=4 groups; n=28 YMSM). These findings were used to refine MyChoices, which was then tested for initial acceptability and usability in a technical pilot (N=11 YMSM). Baseline and 2-month postbaseline assessments and exit interviews were completed. Transcripts were coded using a deductive approach, and thematic analysis was used to synthesize data; app acceptability and use data were also reported. Results The MyChoices app includes personalized recommendations for HIV testing frequency and PrEP use; information on types of HIV tests and PrEP; ability to search for nearby HIV testing and PrEP care sites; and ability to order free home HIV and sexually transmitted infection test kits, condoms, and lube. In theater testing, YMSM described that MyChoices appears useful and that they would recommend it to peers. Participants liked the look and feel of the app and believed that the ability to search for and be pinged when near an HIV testing site would be beneficial. Some suggested that portions of the app felt repetitive and preferred using casual language rather than formal or medicalized terms. Following theater testing, the MyChoices app was refined, and participants in the technical pilot used the app, on average, 8 (SD 5.0; range 2-18) times over 2 months, with an average duration of 28 (SD 38.9) minutes per session. At the 2-month follow-up, the mean System Usability Scale (0-100) score was 71 (ie, above average; SD 11.8). Over 80% (9/11) of the participants reported that MyChoices was useful and 91% (10/11) said that they would recommend it to a friend. In exit interviews, there was a high level of acceptability for the content, interface, and features. Conclusions These data show the initial acceptability and user engagement of the MyChoices app. If future studies demonstrate efficacy in increasing HIV testing and PrEP uptake, the app is scalable to reach YMSM across the United States. Trial Registration Clinicaltrials.gov NCT03179319; https://clinicaltrials.gov/ct2/show/NCT03179319 International Registered Report Identifier (IRRID) RR2-10.2196/10694

Objective. In response to the current CDC recommendations for routine HIV testing in clinical settings, the Adolescent AIDS Program at Montefiore Medical Center in the Bronx, New York, developed the Advise, Consent, Test, Support routine HIV testing model (ACTS) in 2003. ACTS was piloted in 10 community health centers operated by Montefiore because they serve populations most at risk for HIV/AIDS. Methods. ACTS streamlined and codified the counseling and testing process, provided a routine HIV testing practice change plan, and provided training and communication materials that promoted routine HIV testing. To determine program success, we measured the number of patients seen at the clinics, the number of HIV test-eligible patients (those aged 13–64 years and not pregnant), the number and percent of patients receiving HIV testing, HIV test results, and the number of patients linked to care. Results. HIV testing in the 10 sites increased nearly threefold during the pilot period (2003–2007), from 3,944 of 49,125 eligible patients (8%) tested in 2003 to 11,212 of 55,629 eligible patients (20%) tested in 2007. With little ongoing support, the sites continued or maintained improvements: 13,226 of 56,686 eligible patients (23%) were tested in 2008, 15,965 of 57,025 eligible patients (28%) were tested in 2011, 17,483 of 60,514 eligible patients (29%) were tested in 2012, and 17,971 of 63,172 eligible patients (28%) were tested in 2013. Sites identified 433 HIV-positive patients from 2006 to 2013 (0.2%–0.6% annual seropositivity), and 96% of them were linked to care within 90 days of HIV diagnoses (range: 92% to 98% annually). Conclusion. ACTS demonstrated that substantial and sustained increases in routine HIV testing can be achieved in health-care settings, not by adding personnel or financial resources, but by using the model's practice change plan and streamlined HIV testing approach.

Adolescent women who have sex with women (WSW) and men (WSWM) are a unique group of girls with diverse sexual experiences. Despite having female sexual partners, these girls may be at increased risk for unplanned pregnancies and STIs as many WSW also have sex with men. Sexual histories for these girls should include gender neutral terms, open-ended questions, details of sexual behaviors, and gender of sexual partners. These histories should be conducted in a manner that facilitates honesty and trust while ensuring confidentiality. Heterosexuality should never be assumed. Problematic vaginal discharge from bacterial vaginosis and candida vulvovaginitis may be common complaints among these girls. Adolescent WSW should be offered routine chlamydia screening, HIV testing, and contraception counseling (including LARCs), encouraged to use barrier contraceptive methods, and screened for depression and intimate partner violence. Additionally, referrals to LGBTQ peer support groups may also be helpful in ensuring the wellbeing of these girls.

HIV positive adolescents require unique physical and emotional care as they navigate not only developmental challenges but also HIV-related issues including stigma, prevention, and maintaining long-term HIV health. The Hlanganani Program was created to address these issues and engage adolescents in care using a dynamic, 3-session cognitive behavioral support group facilitated by laypersons. Youth 16 to 24 years old, diagnosed within the previous 12 months, were invited to attend three sessions in clinics or other community spaces. Topics included: 1.) Coping and support; 2.) HIV health (including CD4 counts and ARVs); and 3.) HIV prevention. The program was developed and evaluated for feasibility, acceptability and improvements in participants' knowledge, attitudes and behavior. Impact on linkage to care was measured using participant clinic folders from two local youth clinics and was defined as attending at least one ART clinic visit if eligible (CD4

BACKGROUND Routine HIV testing of hospitalized patients is recommended, but few strategies to expand testing in the hospital setting have been described. We assessed the impact of an electronic medical record (EMR) prompt on HIV testing for hospitalized patients. METHODS We performed a pre-post study at 3 hospitals in the Bronx, NY. We compared the proportion of admissions of patients 21-64 years old with an HIV test performed, characteristics of patients tested, and rate of new HIV diagnoses made by screening while an EMR prompt recommending HIV testing was inactive vs. active. The prompt appeared for patients with no previous HIV test or a high-risk diagnosis after their last HIV test. RESULTS Among 36,610 admissions while the prompt was inactive, 9.5% had an HIV test performed. Among 18,943 admissions while the prompt was active, 21.8% had an HIV test performed. Admission while the prompt was active was associated with increased HIV testing among total admissions [adjusted odds ratio (aOR) 2.78, 95% confidence interval (CI): 2.62 to 2.96], those without a previous HIV test (aOR 4.03, 95% CI: 3.70 to 4.40), and those with a previous negative test (aOR 1.52, 95% CI: 1.37 to 1.68) (P < 0.0001 for all). Although the prompt was active, testing increased across all patient characteristics. New HIV diagnoses made by screening increased from 8.2/100,000 admissions to 37.0/100,000 admissions while the prompt was inactive and active, respectively (OR 4.51 95% CI: 1.17 to 17.45, P = 0.03). CONCLUSIONS An EMR prompt for hospitalized patients was associated with a large increase in HIV testing, a diversification of patients tested, and an increase in diagnoses made by screening.

Multiple population-based HIV prevention strategies from national, state, local, and institutional levels have been implemented in the Bronx, which has one of the highest HIV prevalences in the U.S. We examined changes in antiretroviral therapy (ART) use and associated outcomes between 2007 and 2014 among patients seen at one of >20 outpatient clinics affiliated with the largest Bronx HIV care provider. Among eligible HIV-infected patients age ≥13 years, we examined annual trends in ART use, mean HIV RNA level, and virologic suppression (

BACKGROUND Despite established recommendations from the Centers for Disease Control (CDC) to scale up testing efforts in the USA, this study shows full scale implementation of these recommendations may still be lacking. We hypothesize that patients experience ongoing missed opportunities for earlier diagnosis of HIV, despite frequent encounters to Montefiore Medical Center (MMC), an integrated hospital system in the Bronx, NY. METHODS Retrospective chart review via electronic medical records of patients newly diagnosed with HIV in 2012 and 2013 at varied MMC clinical sites. Missed opportunities were defined as > 1 prior health care encounter at MMC within three calendar years of diagnosis, in which HIV testing was not offered for those who had a prior negative test or no prior test. RESULTS There were 218 patients newly diagnosed with HIV at MMC during the study period; 31% presented with a CD4

BACKGROUND Adolescents and young adults comprise disproportionately high percentages of individuals living with human immunodeficiency virus (HIV) and those with undiagnosed HIV. Our objective was to determine factors associated with history of HIV testing and receipt of results among a sample of urban, high-risk, sexually active adolescents in 15 US cities. METHODS A total of 20 to 30 sexually active youths, aged 12 to 24 years, were recruited to participate in an anonymous survey and HIV antibody testing at 2 to 3 venues per city identified by young men who have sex with men, young women of color, or intravenous drug users. RESULTS Of the 1457 participants, 72% reported having been previously tested for HIV (89% of whom were aware of their test results). Our sample was diverse in terms of gender, race/ethnicity, and sexual orientation. Factors found to be predictive of testing typically reflect high risk for HIV, except for some high-risk partner characteristics, including having had a partner that made the youth have sex without a condom or had a partner with unknown HIV status. Factors associated with knowledge of serostatus are reported. HIV testing seems to be more associated with sexually transmitted infection testing services than with primary care. CONCLUSIONS More strategies are needed that increase testing, including targeting partners of high-risk individuals, insuring receipt of test results, and increasing testing in primary care settings.

Nearly 30% of pregnant women in South Africa are estimated to be HIV seropositive, yet adherence to guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) is often low. A pilot study was developed to see whether PMTCT services provided by the South African government could be enhanced by the Mamekhaya program, a combination of the mothers2mothers (M2M) peer-mentoring program and a culturally adapted cognitive-behavioral intervention (CBI) from the United States. Pregnant women attending two maternity clinics offering PMTCT in Gugulethu and Vanguard Townships, Cape Town, South Africa, were invited to participate in the study. Women at the intervention site (Gugulethu) received the support of a mentor mother and also attended an eight-session Mamekhaya CBI. At the control site (Vanguard), women received standard services provided by midwives and counselors. Baseline assessments were completed by all participants at enrollment (n = 160), and follow-ups were completed six months later by 44% of participants. Self-reports of adherence to PMTCT practices were high across both sites (90% or more engaging in the core practices). Women at the Mamekhaya site showed significantly greater improvement in establishing social support and reducing depression scores than women at the control site. Mamekhaya participants also showed trends for better attendance at follow-up medical visits, and greater improvements in positive coping. The greatest effect of the Mamekhaya program was to increase HIV knowledge scores, particularly with regard to understanding the meaning and importance of viral load and CD4 test results. Results from this pilot study show promise that augmenting basic PMTCT services with mentor mothers and a culturally adapted CBI can be effective in conveying information and in improving the emotional outlook and hopefulness of HIV-positive pregnant women in South Africa.

OBJECTIVE: In the United States, 15- to 24-year-olds represent ∼14% of HIV cases diagnosed in 2006 and almost 50% of the 19 million sexually transmitted infections (STIs) reported annually. This survey assessed pediatricians' practices regarding preventive health care screening, provision of reproductive health services including HIV and STI screening and counseling, and barriers to providing these services. METHODS: A random-sample mailed survey of 1626 US members of the American Academy of Pediatrics in 2005.A total of 752 completed questionnaires were returned (46% response rate). Analysis was limited to the 468 pediatricians who provided health supervision visits to patients who were older than 11 years. RESULTS: Most pediatricians discussed sexual activity at preventive care visits; similar numbers discuss abstinence (62%), condoms (61%), and STIs (61%) with slightly fewer discussing HIV (54%). Pediatricians occasionally or rarely/never discussed homosexuality/sexual identity (82%). Most (71%) identified adolescents with high-risk behaviors by clinical interviews. Approximately 30% prescribed condoms, 22% distributed condoms, and 19% provided condom demonstrations. Whereas 46% of pediatricians recommended STI tests for all sexually active teens, only 28% recommended HIV testing for this population. Hospital/clinic-based and inner-city practitioners were more likely to prescribe, provide, and demonstrate condoms and recommend HIV/STI tests for sexually active teens. The most frequently identified barrier to HIV and STI prevention counseling was lack of time. CONCLUSIONS: Pediatricians believed it is important to deliver reproductive health services, and most addressed adolescent sexual activity at preventive care visits but did not routinely address homosexuality/sexual identity. Counseling and testing practices varied by physician characteristics.

The incidence of HIV infection has increased to alarming proportions among minority youth, in particular among young men who have sex with men and among teenage girls. The unique socioeconomic, behavioral, and emotional vulnerability of adolescents for sexually transmitted diseases, including HIV, requires early identification of HIV infection for linkage to care. Differences in the clinical and psychosocial presentations of youth with perinatally versus behavioral acquired HIV infection are important and influence the acceptance of illness, self-efficacy, and antiretroviral treatment adherence. The ideal multidisciplinary team approach of culturally sensitive services for youth integrates clinical care, psychosocial and peer support interventions, transition planning, primary and secondary prevention, as well as comprehensive reproductive adolescent health services.

Substance abuse, specifically the use of illicit drugs that are administered intravenously, continues to play a role in the transmission of human immunodeficiency virus type 1 (HIV-1) among adolescents and young adults (youth). Risks of HIV-1 infection may result from direct exposure to contaminated blood through sharing of injection drug equipment and from unsafe sexual practices (while under the influence of drugs and/or in exchange for drugs). Reducing the risk of HIV-1 infection that is associated with illicit drug use requires prevention education and prompt engagement in treatment. Providing patients with education, instruction on decontamination of used injection drug equipment, improved access to sterile syringes and needles, and postexposure prophylaxis may decrease their risk of acquiring HIV-1 infection. Pediatricians should assess risk behaviors as part of every health care encounter, including queries about tobacco, alcohol, and marijuana use. The risks and benefits of postexposure prophylaxis with antiretroviral drugs should be considered for youth with a single recent (within 72 hours) high-risk exposure to HIV-1 through sharing needles/syringes with an HIV-1–infected individual or having unprotected intercourse with an individual who engages in injection drug use. Such prophylaxis must be accompanied by risk-reduction counseling, appropriate referrals for treatment, and evaluation for pregnancy and associated sexually transmitted infections. There is an urgent need for more substance-abuse prevention and treatment programs, legislation that facilitates unencumbered access to sterile syringes, and expedient availability of reproductive health care services for sexually active youth, including voluntary HIV-1 counseling and testing.

Adolescence is a time of dramatic physical, emotional, cognitive, and social change that brings new vulnerabilities. Youth represent half of all new HIV infections in the United States and the rest of the world. The number of newly infected adolescents who acquire the disease behaviorally and the number of perinatally infected children surviving into adolescence have both contributed to this growth. This article reviews the most recent epidemiology of HIV/AIDS in adolescents, gives guidance on clinical practice, including medical and psychosocial care, and examines prevention issues, including counseling and testing, which are needed to make programs effective for youth.

HIV infection in adolescents continues to challenge health providers, policymakers, and advocates for youth. There will be no relief from its complexities soon. Primary care providers are in a unique position to use effective HIV prevention and care interventions. Successful programs move beyond moralism to realism. They show a willingness to engage young people and their families in a sensitive dialogue about the needs of youthful sexual development. Youth at high risk for HIV should be identified and referred to comprehensive care and counseling as soon as possible. HIV-positive youth need intensive individual and group interventions to remain healthy and reduce transmission to others. To protect their patient population, health care providers will need to commit time and effort to making adolescents services visible, flexible, affordable, confidential, culturally appropriate, and universally available.

Purpose: To evaluate hepatitis B (HBV) vaccine response rates in HIV infected and high-risk HIV uninfected youth and examine associations with responsiveness in the HIV infected group. Methods: Cohorts within the Reaching for Excellence in Adolescent Care and Health (REACH) study population were defined based on receipt of HBV vaccine both retrospectively and prospectively. Sero-responsiveness was determined by HBsAb measurements. Testing was done for HBsAg, HBsAb, and HBcAb. For HBsAb, a value of > 10 International Units per liter was considered a positive response, and the data were collected as either positive or negative from each of the reporting laboratories. Covariates of responsiveness were explored in univariate and multivariate models for each cohort. Results: Sixty-one subjects had received a three-dose vaccination course at the time of entry into REACH. HIV uninfected subjects had significantly higher rates of response by serology compared with HIV infected subjects (70% vs. 41.1%; χ 2 = .05; RR=.586, 95% CI: .36–.96). By the time of an annual visit 43 subjects had received three vaccinations with at least one occurring in the study period. The rates of response were similar for the HIV infected and uninfected groups (37.1% vs. 37.5%) in this cohort. Univariate and multivariate analysis in the prospective HIV infected group ( N = 35) found an association between elevated CD8 + /CD38 + /HLA-DR + T cells and lack of HBV vaccine responsiveness (6.7% vs. 60%; χ 2 = .03; RR=.12, 95% CI: .02–.55). Conclusions: The poor HBV vaccine response rate in the HIV uninfected high-risk adolescents was unexpected and suggests that HBV vaccination doses have not been optimized for older adolescents. This is the first report of decreased responsiveness in HIV infected subjects being associated with elevated CD8 + /CD38 + /HLA − DR + T cells and suggests that ongoing viral replication and concomitant immune system activation decreases the ability of the immune system in HIV infected subjects to respond to vaccination.

In the US youths represent about 50% of all HIV infections worldwide and 18% of reported HIV cases. In this regard an intervention for HIV-infected youths consisting of two modules delivered in sequence were designed and evaluated for its efficacy. The first module "Stay Healthy" aims to increase the positive health behaviors of youths with HIV while the "Act Safe" module aims to enhance altruistic motivations to reduce transmission acts. HIV transmission behaviors and health practices of 310 HIV-infected youths were examined over a period of 15 months after they received a preventive intervention. The 13-24 year old respondents were assigned by small cohort to the two-module intervention totaling 23 sessions or a control condition. It is noted that subsequent to the "Stay Healthy" module number of positive lifestyle changes and active coping styles increased more often among female attendees than among female controls. Social support coping also increased significantly among males and females attendees compared with the controls. Following the "Act Safe" module attendees of the intervention condition reported 82% fewer unprotected sexual acts 45% fewer sexual partners 50% fewer HIV-negative sexual partners and 31% less substance use on a weighted index than those in the control condition. Overall prevention programs can effectively reduce risk acts among HIV-infected youths. However alternative formats need to be identified for delivering interventions.

This seroprevalence report examines serologic evidence of hepatitis B immunization or infection and associated demographic/behavioral factors in adolescent (aged 12-20) subjects enrolled in a nonth...

The REACH Project (Reaching for Excellence in Adolescent Care and Health) of the Adolescent Medicine HIV/AIDS Research Network was designed as a study of an adolescent cohort composed of HIV-1-infected and-uninfected subjects. The goal of the analysis presented was to examine the relationship of CD4+ T cell counts and HIV-1 plasma viral loads in adolescents. The CD4+ T cell counts of 84 HIV+ subjects who were 13 to 19 years of age were measured at the clinical sites, using ACTG standardized techniques. HIV-1 viral loads in frozen plasma were determined by the NASBA/NucliSens assay at a central laboratory. Past and current treatment with antiretroviral drugs was determined by medical record abstraction and interview data. The slope of the line generated by regressing log10 HIV-1 RNA (copies/ml) versus CD4+ T cell counts of REACH subjects who are antiretroviral drug naive was negative and significantly different than zero. A negative association has also been reported for antiretroviral drug-naive, adult ma...

HIV infection in adolescents continues to challenge health care providers, policy makers, and advocates for youth. Primary care providers working with parents of adolescents and at-risk youth are in a unique position to identify or help develop HIV prevention and care programs that address many needs. Effective interventions are those that move beyond moralism to realism and a willingness to engage youth and their families. Youth at high risk for HIV should be identified and engaged in primary care as soon as possible. HIV-infected youth need intensive individual and group interventions to keep themselves healthy and reduce transmission to others. Incumbent on all providers is to make adolescents' services visible, flexible, affordable, confidential, culturally appropriate, and available for all youth.

The level and consistency of HIV-related sexual and substance-use risk acts, health status, and medical adherence were examined among 102 HIV+ youths aged 14 to 23 years (27% African American, 33% Latino). Over their lifetime, youths engaged in unprotected sexual acts with multiple partners (M = 284; Median = 44; consistent condom protection, 5%) and substance use (21% injecting drug use; 68% hard drugs). When current risk behaviors were assessed twice over two consecutive 3-month periods, almost one third had been sexually abstinent. Among youths who were currently sexually active, most had multiple sexual partners (M = 5.7, Time 1; 4.9, Time 2) and used condoms (72-77% sexual acts protected); most of the youths (63-64%) always used condoms. Use of alcohol (63%), marijuana (41%), hard drugs (36%), and injecting drugs (12%) was substantial. Youths were relatively healthy (M T cells = 521.4; 14% T cells < 200; 1.9 diseases and 3.7 physical symptoms in the previous 3 months); they attended about one third of their medical appointments. While all youths were linked to adolescent HIV programs, unhealthy behavior and risk acts remained common. More effective and intensive intervention appears required.

Objective: To determine the demographic/clinical profile of human immunodeficiency virus (HIV)-infected adolescents in care at selected sites. Methods: We mailed surveys requesting prevalence data from physicians in government-funded HIV research and care programs on HIV-infected youth (10–21 years) receiving care. Results: A total of 49% responses yielded information on 978 subjects. Vertical, blood, and sexual were predominant transmission modes. Three-quarters were of an ethnic/racial minority; 50% were female. The earliest median CD 4 count was 0.467 × 10 9 /liter (467/μl). Percent asymptomatic varied by transmission: vertical (16%), blood products (40%), male—male sexual (67%) and female—male sexual (M: 73%) (F: 74%). Clinically indicated Pneumocystis carinii pneumonia prophylaxis was differentially prescribed: vertical (96%), blood (89%), and sexual (male—male-47%) (female—male: M: 36% and F: 56%). Of these youth 78% are not represented in national AIDS case data. Conclusions: Examination of numerator data from selected sites indicates three transmission-driven adolescent HIV epidemics with different characteristics. Minority youth are disproportionately represented; many vertically infected infants are surviving to adolescence; sexual activity is a significant transmission avenue. HIVinfected youth appear to enter care with considerable immunosuppression. Clinical profiles and treatment patterns appear to differ by transmission mode. Further study is needed on adolescent HIV disease progression and determinants of access to care and treatment.

According to the World Health Organization, half of the 14 million people with human immunodeficiency virus (HIV) worldwide were infected between the ages of 15 and 24 years. However, details about HIV-positive (HIV+) youths' risk-related behavior and social context have not been previously reported. Objectives. To outline detailed sexual and drug use practices, social and psychological status of HIV + youth compared with a cohort of HIV-negative (HIV-) youth; and to examine the ability of the health belief and risk-taking models to predict sexual and drug use acts of HIV + youth. Methods. HIV testing was conducted on and a 207-item structured interview covering HIV risk-related acts, protective factors and background information was administered to 72 HIV + and 1142 HIV - adolescents aged 13 through 21 years receiving care in an adolescent clinical care unit of a large medical center in New York City. Data were analyzed for adolescents reporting sexual intercourse (71 HIV + and 722 HIV-) by logistic regression analysis of five domains to identify variables significantly associated with HIV seropositivity. Results. Logistic regressions indicated significant differences in sexual risk acts based on serostatus and gender. Anonymous, blinded seroprevalence testing identified 11% more HIV + adolescents than would have been identified by current counseling and testing practices. HIV + adolescents were significantly more likely to be sexually abused (33 vs 21%, P < .05), engage in anal sex and survival sex (32 vs 4%, P < .01), unprotected sex with casual partners (42 vs 23%, P < .05), have had sex under the influence of drugs (52 vs 27%, P < .01), have a sexually transmitted disease (59 vs 28%, P < .01), use multiple drugs (43 vs 9%, P < .01) and engage in multiple problem behaviors (72 vs 30%, P < .01) than HIV - young people. HIV + females reported more oral (69 vs 45%, P < .01) and/or anal (42 vs 12%, P < .01) intercourse compared to HIV - females. HIV + males reported significantly higher rates of both insertive (82 vs 46%, P < .05) and receptive (51 vs 4%, P < .01) oral and anal (53 vs 13%, P < .01) intercourse than HIV - males. Protective factors were not significantly different for HIV + and HIV - young people. Conclusions. Routine, confidential HIV counseling and testing should be considered for adolescents having unprotected sexual intercourse when age-specific services are available for HIV + youth. Prevention programs should consider adolescents' history of abuse, homelessness and other social as well as psychological dimensions in designing comprehensive care strategies to address HIV+ adolescents' multiple problem behaviors and living situations. Current theoretical models of health behaviors should be reconsidered, given the lack of their association to HIV risk acts of HIV + youth. Age-specific services and interventions for HIV + youth are urgently needed as HIV is spreading among youth worldwide.

Adolescents who contracted HIV perinatally should be told of their disease status. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Like many others, I was swept up in the excitement about the progress we have made in the fight against HIV/AIDS on display at the recent International AIDS Conference in Washington, DC. However, our progress hasn't been universal. In fact, there are a number of areas in which we may be regressing. One is the course of the epidemic among America's youth. Young people between the ages of 13 and 29 have the steepest rise in new HIV infections, compared to stable incidence in other age groups, and account for 39% of all new infections while comprising only 21% of the U.S. population. ([ 1 ][1], [ 2 ][2]). The CDC estimates that overall, 20% of HIV-positive Americans don't know they are infected, but when youth are isolated from the equation, a staggering 60% have no idea they carry the HIV virus ([ 3 ][3]). Who are these youth? As with much of the domestic epidemic in the last decade, new infections occur disproportionately among youth of color, who represent 80% ([ 2 ][2]) of new infections. The disease has also hit hardest among young gay and bisexual men ([ 2 ][2]), which paradoxically results in putting many young women at risk for infection. In my clinic in the Bronx, New York, 50% of the clients who identify as young men who have sex with men report also having sex with women ([ 4 ][4]). By some definitions, there is a new generation every 5 years. Considering that the youth sitting in high school today will be out in the world in as little as 3 years, it's clear that those of us who are called to educate and care for youth must remain vigilant. We must invest in a continually updated and vigorous prevention, testing, and treatment program that evolves to engage each generation of youth. We must be guided by science and not politics. If we maintain the status quo, we risk losing the next generation of youth to apathy and losing our gains through a false hope in the scope of our progress. 1. [↵][5] CDC, “Diagnoses of HIV infection and AIDS in the U.S., 2009” (HIV Surveillance report, 2011), vol. 21. 2. [↵][6] CDC, “HIV among youth fact sheet” (December 2011). 3. [↵][7] CDC, MMWR HIV Surveillance 1981–2008 60, 689 (2011). [OpenUrl][8] 4. [↵][9] 1. A. Fernandez 2. et al ., “YMSM of Color: Perspectives from NYC,” International AIDS Conference, July 2012, Washington, DC. [1]: #ref-1 [2]: #ref-2 [3]: #ref-3 [4]: #ref-4 [5]: #xref-ref-1-1 "View reference 1 in text" [6]: #xref-ref-2-1 "View reference 2 in text" [7]: #xref-ref-3-1 "View reference 3 in text" [8]: {openurl}?query=rft.jtitle%253DMMWR%2BHIV%2BSurveillance%2B1981%253F2008%26rft.volume%253D60%26rft.spage%253D689%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [9]: #xref-ref-4-1 "View reference 4 in text"

There are no data to suggest that children who have gay or lesbian parents are different in any aspects of psychological, social, and sexual development from children in heterosexual families. There has been fear that children raised in gay or lesbian households will grow up to be homosexual, develop improper sex-role behavior or sexual conflicts, and may be sexually abused. There has been concern that children raised by gay or lesbian parents will be stigmatized and have conflicts with their peer group, thus threatening their psychological health, self-esteem, and social relationships. These fears and concerns have not been substantiated by research. Pediatricians can facilitate the health care and development of these children by being aware of these and their own attitudes, by educating themselves about special concerns of gay or lesbian parents, and by being a resource and an advocate for children who have homosexual parents.

Early linkage and retention in HIV clinical care is essential for optimal disease management, promotion of health, and receipt of secondary prevention messages to decrease onward transmission of HIV. Youth, specifically racial/ethnic minority young men who have sex with men (YMSM), continue to acquire new HIV infections and have been shown to be less likely to engage in regular HIV care and adhere to scheduled medical visits. The goal of the current study was to evaluate the characteristics of participants and program delivery that were associated with early linkage and retention in HIV care among HIV-infected YMSM of color enrolled in an outreach, linkage, and retention study. Of the 334 patients included in the linkage analysis, 72% were linked to care within 30 days of diagnosis, 81% within 60 days, and 87% within 90 days. While no patient-level characteristics were associated with early linkage, having the person who provided the positive HIV test result refer the patient to HIV care (p=0.048), specifically calling to make the appointment (p=0.009), was associated with earlier linkage. Retention of Latino participants (96.2%) was significantly higher than for the African-American (79.9%) youth (p=0.006). Overall, 221 participants had at least 1 year of possible follow-up and 82.8% of these participants were retained at 1 year. While unique challenges exist in the care of adolescents infected with HIV from identification to engagement and retention in clinical care, programs that are responsive and dedicated to the needs of these youth can be successful in retaining them in care.

We assessed changes in sexual behaviors from baseline to 12-month follow-up among a multisite cohort of HIV-positive racial/ethnic minority young men who have sex with men enrolled in an outreach, linkage, and retention study. In the 3 months prior to their baseline interview, more than three-quarters of participants (78.5%) reported sex with at least one man (mean: 2.3 partners). Among sexually active participants, 44.2% had one partner; 50.5% had 2-9 partners; and 5.3% had 10 or more partners. Over three-quarters (77.5%) reported engaging in sex with at least one steady partner, 43.5% with at least one casual partner, and 29.5% with both casual and steady partners. Exchanging sex for money, drugs, or other needs was reported by 13.2%. Use of condoms during oral and anal sex increased significantly from baseline to 12-month follow-up (oral sex: 29.1-42.5%, p=0.02; anal sex: 67.8-76.2%, p=0.05). While unprotected anal sex significantly decreased among individuals who were new to care (34.8-18.3%, p0.0001), it significantly increased among individuals who were previously in care (26.7-37.5%, p=0.03). Overall, exchange sex decreased from 13.3% at baseline to 5.0% at 12 months (p=0.001). Despite reductions in unprotected sexual encounters and exchange sex through one year of follow-up, many participants continued to engage in high-risk sexual behaviors. Retention within this study appeared to be associated with decreases in high-risk sexual behaviors, especially among participants who were new to care, although more research is needed. Future studies should investigate sexual network characteristics and the prevalence of behaviors such as serosorting.

Half of all new human immunodeficiency virus (HIV) infections in the United States occur among young people between the ages of 13 and 24. Sexual transmission accounts for most cases of HIV during adolescence. Pediatricians can play an important role in educating adolescents about HIV prevention, transmission, and testing, with an emphasis on risk reduction, and in advocating for the special needs of adolescents for access to information about HIV.

Objective To test whether “venue-based testing” could identify human immunodeficiency virus (HIV) infection in US youth, 12 to 24 years of age, who were otherwise not aware of their infection. Racial and ethnic minority women and men who have sex with men (WSM and MSM) compose the majority of new HIV cases among adolescents and young adults. Design Cross-sectional study. Setting Selected venues in communities surrounding the 15 Adolescent Trials Network for HIV/AIDS Interventions (ATN) clinical sites over a 3-month period. Participants At each venue, ATN sites recruited 20 to 30 English- or Spanish-speaking at-risk youth (12 to 24 years of age), resulting in a total of 1217 study participants, including 611 MSM and 606 WSM. Intervention Venue-based HIV testing with 2 components: an anonymous audio computer-assisted self-administered interview and an anonymous HIV antibody assay. Main Outcome Measure The prevalence of HIV infection in MSM and WSM. Results The prevalence of HIV infection in MSM and WSM was 15.3% and 0.3%, respectively. Sixty percent of the MSM and 100% of the WSM claimed to not know of their infection. Conclusion Venue-based testing may be an important strategy to identify HIV-infected younger MSM; however, other strategies are needed for WSM.

Despite the considerable resources that have been dedicated to HIV prevention interventions and services over the past decade, HIV incidence among young people in the United States remains alarmingly high. One reason is that the majority of prevention efforts continue to focus solely on modifying individual behavior, even though public health research strongly suggests that changes to a community's structural elements, such as their programs, practices, and laws or policies, may result in more effective and sustainable outcomes. Connect to Protect is a multi-city community mobilization intervention that focuses on altering or creating community structural elements in ways that will ultimately reduce youth HIV incidence and prevalence. The project, which spans 6 years, is sponsored by the Adolescent Medicine Trials Network for HIV/AIDS Interventions at multiple urban clinical research sites. This paper provides an overview of the study's three phases and describes key factors in setting a firm foundation for the initiation and execution of this type of undertaking. Connect to Protect's community mobilization approach to achieving structural change represents a relatively new and broad direction in HIV prevention research. To optimize opportunities for its success, time and resources must be initially placed into laying the groundwork. This includes activities such as building a strong overarching study infrastructure to ensure protocol tasks can be met across sites; tapping into local site and community expertise and knowledge; forming collaborative relationships between sites and community organizations and members; and fostering community input on and support for changes at a structural level. Failing to take steps such as these may lead to insurmountable implementation problems for an intervention of this kind.

To describe human immunodeficiency virus (HIV) testing patterns among high-risk, uninfected adolescents and HIV-infected adolescents, and factors associated with testing.HIV-infected adolescents (N = 246) and high-risk, uninfected adolescents (N = 141) at 15 sites nationwide were asked about the number of times they were tested for HIV, the type of agency at which testing occurred, and reasons for testing.The majority of participants reported being influenced to obtain testing by health care providers (53.1% of the HIV-infected group and 66.1% of the HIV-uninfected group, respectively). Female participants were somewhat more likely to have used a confidential or anonymous site for the most recent test, compared with male participants (73.5% and 67.5%, respectively). Among the HIV-infected group, feeling sick was the only factor associated with number of tests. Among the HIV-uninfected group, having more male partners, marijuana use in the past 3 months, white race, and having had same-gender partners in their lifetime (males only) were associated with number of tests. Multivariate analyses identified 2 significant models. Modeling the probability of having been tested 3 or more times, black participants were less likely to be tested than white participants (odds ratio [OR] = 0.4), and participants who felt sick were more likely to be tested than those who did not (OR = 1.7). Modeling the probability that the last test would be positive, black participants were more likely than white participants to test positive (OR = 2.3); those who were tested because they thought they might have gotten HIV from sex (OR = 3.0) or they felt sick (OR = 3.9) were more likely to test positive; participants who were tested because a health care professional recommended it were actually less likely (OR = 0.5) to test positive.Overall, these findings highlight the importance of making HIV testing more routinely available to sexually active adolescents. More work needs to be done to normalize HIV testing among adolescents, and more innovative approaches need to be implemented on a wide scale.

The Reaching for Excellence in Adolescent Care and Health (REACH) Project was designed as an observational study aimed to achieve a better understanding of HIV disease progression and co-morbidity in adolescents in the US. Direct interviews among 242 HIV-infected females and 83 males and 131 high-risk HIV-uninfected females and 40 males aged 12-18 years were conducted to examine the pathogenesis of HIV infection and its spectrum of disease in adolescents. The study also aimed to examine potential immunologic markers in peripheral blood for disease progression specific to adolescents infected with HIV. Results showed that HIV infection predominates among females and youths with poor knowledge on sexual risk behaviors. It was also shown that the seroconversion rate in the homosexual/bisexual male cohort was 7.7/100 person-years while there were no seroconversions among the HIV-uninfected females. Distribution of CD4+ T-cell numbers suggested a progression of the disease among the infected cohorts. Based on the findings the risk behaviors among HIV-infected cohorts demonstrate the need for theory-based development of secondary prevention programs for HIV-positive youth.