The Role of Health-Care Providers

“Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk reduction and offering HIV testing and prophylaxis to their youth patients,” according to AAP’s 2022 clinical report about HIV and PrEP. The report continues:

All youth at risk for HIV acquisition should be offered HIV PrEP as part of a comprehensive prevention strategy that includes other prevention measures, including adherence to daily administration, and safer sex practices, including barrier protection, to reduce the risk of STIs.”

Health-care providers can help prevent HIV in adolescents by taking the following key steps:

• Educate patients and families
• Offer PrEP brochures and websites, discuss HIV prevention strategies and explain confidentiality rules.
• Promote safe sex practices that prevent pregnancy and reduce the risk of HIV or other STI/STD infection.
• Offer non-stigmatizing risk counseling.
• Identify and engage youth at risk for HIV exposure or disease
  • Recognize clinical signs and risk factors for HIV and conduct screening as indicated on the Texas Health Steps Periodicity Schedule.
  • Establish trust by having private discussions with adolescents; maintain confidentiality.
  • Provide handouts and resources from DSHS’s HIV program, the CDC and the National Coalition for Sexual Health. (Links to resources are provided in the Appendix.)
• Conduct necessary exams and lab tests
• Before taking PrEP, individuals require:
• HIV testing to ensure an individual is HIV negative
• Hepatitis B testing
• Baseline evaluation and monitoring of renal function 
• Complete screenings for other STIs such as chlamydia, gonorrhea and syphilis. Also screen for hepatitis C, which can be transmitted through sexual activity, although that is uncommon. “Having a sexually transmitted infection, having sex with multiple partners, and engaging in anal sex appear to increase a person’s risk for hepatitis C” (CDC, 2020). STIs point to sexual activity that may result in HIV exposure.
• Discuss exam and lab findings
  • Develop a protocol for delivering exam and lab results to youth, including confidential notification when appropriate.
  • Connect with resources, such as DSHS’s HIV program, that can assist health-care providers in delivering and discussing test results.
  • Connect with local health departments, pediatric infectious disease clinics, HIV clinics and other community partners that can assist with appropriate care and counseling after diagnosis.
• Adherence counseling
• Studies show youth adherence to PrEP can slip because they are busy, forget to take it or worry others may think they have HIV.
• Develop support strategies to help ensure adherence, such as text reminders, peer navigation and other youth-focused interventions.
• Motivational interviewing during routine follow-up visits can empower an individual to make or sustain positive behavioral changes.
• Prescribe PrEP when warranted
• Youth taking PrEP require:
  • Routine follow-up visits every 3 months
  • HIV testing every 3 months
  • PrEP prescription refills
• If not comfortable prescribing PrEP, refer youth to an experienced PrEP provider while maintaining regular follow-up services. DSHS provides a list of physicians and clinics in Texas that provide PrEP. The CDC’s National Prevention Information Network and PleasePrEPme.org also offer searchable online databases of PrEP providers. Links to those resources are provided in the Appendix.
• Pediatricians and other primary care providers must be prepared to provide counseling, treatment, clinical and laboratory monitoring, and repeat HIV testing to youth who initiate PrEP elsewhere.
• Referral guidelines
• Individuals who test positive for HIV should be referred to an infectious disease physician for treatment.

Texas Health Steps Requirements

The Texas Health Steps Periodicity Schedule outlines the following requirements for lab tests, mental health screening and anticipatory guidance:

• At preventive medical checkups, conduct required and risk-based lab tests.
  • HIV screening is required once for all youth ages 16 through 18 years.
  • HIV risk-based screening is available for all youth ages 11 through 20 years.
  • Risk-based STD/STI screening for gonorrhea, chlamydia and syphilis is available for youth ages 11 through 20 years.
• Mental health screening is required at every preventive medical checkup for youth ages 11 through 20 years. Providers may receive reimbursement in addition to reimbursement for the checkup when mental health screening is completed using one or more of the validated screening tools listed on the Texas Health Steps Periodicity Schedule.
• Anticipatory guidance and health education are required at every preventive medical checkup.
  • Beginning at age 13 years, obtain an adolescent’s history of sexual activity and update it at each subsequent preventive medical checkup.
  • Provide information about sexuality, risks involved in sexual activity and the importance of preventing HIV and other STIs.
  • Offer a supportive atmosphere and factual, nonjudgmental counseling because youths may not realize all the activities that put them at risk for HIV and other STIs, such as oral sex.