HIV prevention: Considerations for adolescents and young adults

During the adolescent (ages 13-19) and young adult (ages 20-24) years, people are faced with significant physical and developmental changes that can pose challenges for preventing and treating HIV. Globally, there are an estimated 5 million adolescents and young adults (AYAs) living with HIV, according to UNICEF.¹ Of note, when looking more specifically at the adolescent population worldwide (15-19 years of age), there has been a decrease in the number of new HIV infections annually, with approximately a 50% decline in adolescent cisgender females since 2010. Despite the decline over the last 15 years, data estimate that 2023 saw just under 100,000 new HIV infections in adolescent cisgender females alone. Based on the current trends, there will be approximately 183,000 new HIV infections annually in the total adolescent population in 2030 worldwide.¹

In the United States, 1 of 5 new HIV infections are in AYAs.^2,3 HIV infections in AYAs can be categorized as early acquired (HIV acquired within first 10 years likely via peritoneal transmission) compared with those in the second decade through sexual contact or drug use. With the perinatal HIV transmission at less than 1% in the United States, most HIV infections in the AYA population are due to either sexual contact or drug use.³

Pre-exposure prophylaxis (PrEP) has demonstrated efficacy in preventing HIV infection. Although the landmark clinical trials did not include those younger than 18 years, the FDA granted an indication for oral PrEP in anyone who weighs 35 kg or more based on clinical trials demonstrating efficacy in adults. PrEP is a critical intervention/component to decreasing the incidence and rate of new HIV infections and is a critical part of the “Ending the HIV Epidemic” initiative.

HIV Prevention in AYAs

Opportunities for HIV prevention in AYAs started in 2018 when the FDA expanded the approved indications for tenofovir disoproxil fumarate-emtricitabine (TDF/FTC) for PrEP to include adolescents who weigh at least 35 kg. This was followed by approval of tenofovir alafenamide-emtricitabine (TAF/FTC) in adolescents and adults who weigh at least 35 kg and are at risk for acquiring HIV, excluding those at risk through receptive vaginal sex due to the lack of data in cisgender women in 2019.³

Although the major clinical trials evaluating TDF/FTC and TAF/FTC for PrEP did not include adolescents, 2 major trials evaluated use of TDF/FTC in the AYA population. The first trial, Adolescent Trials Network (ATN 110), evaluated TDF/FTC in males from 18 to 22 years of age who have sex with men. The authors evaluated the uptake and adherence to PrEP by measuring tenofovir diphosphate (TFV-DP) levels monthly for 12 weeks and then quarterly thereafter up to 48 weeks after study enrollment. Oral PrEP therapy was combined with behavioral interventions including sexual health and adherence counseling. More than 2,000 people were screened with 200 enrolled. A total of 13 people were found to be HIV-positive at baseline evaluation, 2 of whom were found to have acute HIV. At the 1-month check-in, the TFV-DP concentrations indicated that 45% of participants were taking at least 4 doses per week; however, that percentage dropped to 34% at 48 weeks, with a significant decline in adherence being observed at week 24. The decline in adherence correlated with the reduced clinic visits (monthly to quarterly). HIV seroconversion occurred in 4 individuals throughout the study period and occurred in those with TFV-DP levels below the level of quantifications.⁴

The primary investigator also conducted a similar trial, the ATN 113 study, which evaluated TDF/FTC in men who have sex with men who were 15 to 17 years of age. Individuals enrolled had a confirmed negative HIV test at baseline, were at high risk for HIV infection, and were willing to take TDF/FTC. Of the 2,864 people screened, 280 were found to be eligible with a total of 78 enrolled. Similar to the results of ATN 110, adherence rates were 54% at week 4 with a gradual decline over the first 3 months and a significant drop observed at week 24 to 28%. Three individuals acquired HIV during the study period, of which all had TFV-DP levels consistent with medication nonadherence and taking less than 2 doses per week at the presumed time of HIV acquisition.⁵

Kimball and colleagues describe the estimated number of adolescents prescribed PrEP from 2018 to 2021 using a national pharmacy database in AYA 13 to 19 years of age. PrEP prescriptions for adolescents increased by 76.2% from 2018 to 2021, with increases observed in all age groups and all sexes. The highest rate of PrEP prescriptions was seen in male sex and adolescents 18 to 19 years of age. A total of 29.6% of the total PrEP providers were pediatricians with specialty providers being widely distributed.⁶

Despite the promising trend with increased PrEP prescribing in the AYA population, the Department of Health and Human Services estimates that only 23.5% of AYAs with indications for PrEP in the United States are prescribed PrEP.³ Evidence demonstrates lack of awareness of PrEP, and processes to access PrEP, may be part of the reason for this low utilization rate. In addition, clinicians may not be comfortable prescribing PrEP to AYAs and when indicated. This represents a significant opportunity for discussion and expansion of PrEP prescribing in AYA age groups.

Current recommendations per the CDC recommend that all individuals, including AYAs, who are sexually active or request PrEP should be offered it. The American Academy of Pediatrics endorses this recommendation as well in offering and prescribing PrEP to these adolescents who are at risk for HIV acquisition.³

Prescribing Considerations

Legal Considerations

When prescribing PrEP to young people, several factors need to be considered including legal, confidentiality, and adherence issues. Minors are permitted to consent for testing for sexually transmitted infections (STIs) without parenteral consent across the United States. Many states include HIV as an STI specifically. There are no states that prohibit minors from consenting autonomously for PrEP. That being said, many states allow care providers to disclose medical information to parents or guardians, so it may be difficult to maintain confidentiality for the minor.

Legal issues regarding prescribing of PrEP can vary significantly from state to state based on the adolescent’s status as a legal minor, etc. Providers who are caring for AYAs and prescribing PrEP should be familiar with the state’s statutes and regulations.

Adherence Considerations

Adherence to PrEP is linked to efficacy, as demonstrated by randomized trials in adults as well as from ATN 110 and ATN 113. Data from reviews in adults revealed that people with concentrations demonstrating daily adherence resulted in protection against HIV in 92% to 100% of those individuals.³ Many young people are at risk for lower adherence, requiring different strategies or support methods to optimize adherence to PrEP therapy. The results from both ATN 110 and ATN 113 indicate that adherence rates to PrEP dropped off significantly at week 24 after therapy initiation.^4,5

Responses from those individuals who were nonadherent in ATN 113 commonly endorsed the following statement: “I worry others will see me taking pills and think I am HIV-positive.”5 Additional reasons they reported nonadherence included: being away from home (32%), being too busy (28%), forgetting (26%), and changes in routine (18%). These patients may require more age-focused adherence interventions including frequent clinic visits, with potentially more flexible clinic schedules, text message reminders, and peer navigators.³

In addition, similar socioeconomic barriers that can affect adherence in adults can affect adherence in AYAs. When prescribing PrEP, patients should be screened for potential barriers including unstable housing, insurance barriers, and ability to present to provider visits. A comprehensive team approach should be utilized to address any barriers identified to support the individual in adhering to PrEP therapy.

Discussion

PrEP is extremely effective and safe for administration in AYAs and should be offered to those at risk for acquiring HIV. When PrEP is indicated, it should be offered as part of a comprehensive care plan with providers ensuring education and care are tailored to the patient’s age and needs. Data have demonstrated that AYAs may have difficulty adhering to a daily regimen due to potential barriers including HIV stigma, housing stability, and changes in the individual’s routine. Prescribing of PrEP should be combined with close follow-up/support to address any barriers to adherence/continued therapy. Continued collaboration among care providers can help support AYAs at risk for HIV infection in use of PrEP and prevention of future HIV acquisition.

By Amanda Binkley, PharmD, BCIDP, AAHIVP

References

1. Adolescent HIV prevention. UNICEF data. Updated July 2024. Accessed March 11, 2025. bit.ly/3FmuQAe-IDSE
2. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV, 2024. Accessed March 6, 2025. bit.ly/4hepxQv
3. Peck ME. MMWR Morb Mortal Wkly Rep. 2024;73(47):1082-1086.
4. Hosek SG, Rudy B, Landovitz R, et al. J Acquir Immune Defic Syndr. 2017;74(1):21-29.
5. Hosek SG, Landovitz RJ, Kapogiannis B, et al. JAMA Pediatr. 2017;171(11):1063-1071.
6. Kimball AA, Zhu W, Leonard J, et al. Pediatrics. 2023;152(5):e2023062599.