Scott K. Jelinek, MD, MPH, MAEd, and Renata Arrington Sanders, MD, MPH, ScM
Case
A 17-year-old male presents to a busy emergency room, with a 2-week history of a sore throat. The sore throat is accompanied by a recent onset of chills, tactile fevers, fatigue, mild cough, and congestion. Despite trying over-the-counter remedies, he has persistent pain with difficulty opening his mouth. He has limited his daily activities to staying home, and his mother describes that his voice sounds softer than usual. He exhibits no drooling, has maintained normal oral intake, and reports no weight loss.
In private, he shares that he is sexually active with male and female partners.
Upon examination, he is febrile with a temperature of 39°C. He has 2+ enlarged tonsils with no sign of abscess, mild trismus, and bilateral anterior cervical lymphadenopathy. His neck is otherwise supple with a full range of motion. Initial assessments include imaging and infectious labs, all guiding the next steps in management.
Discussion
As healthcare providers, we often encounter cases that challenge us both medically and emotionally. This young patient, who disclosed being sexually active with both male and female partners, was found to have oral gonorrhea. More concerning, his initial HIV screening test came back positive, raising concerns about adolescent confidentiality and the potential disclosure of this information to family members.
I began by speaking with him privately, explaining the implications of the positive HIV test, including the meaning of the test, the importance of disclosure, and how to approach confidentiality with his parent/guardian. The fear and uncertainty in his eyes underscored the gravity of the situation. At that moment, it wasn’t just about delivering a test result; it was about providing reassurance, understanding, and guidance during a profoundly vulnerable time.
Despite his shock, the patient asked thoughtful questions, demonstrating strength in the face of such news. Given the sensitivity of his results, we had to navigate the conversation about whether he wanted to share this information with his parent/guardian. The principles of adolescent confidentiality were crucial here, as was creating a safe space where the patient felt empowered to make decisions about his care. In a moment of profound maturity, the patient requested I share the test results with his mother, expressing a desire for her support. His mother supported her son, and the conversation highlighted the role of family in adolescent health, particularly with sensitive diagnoses.
The confirmatory HIV test came back negative, indicating that the patient did not have HIV. I immediately contacted him and his mother to share the good news. They were elated. This provided an opportunity to discuss HIV prevention, the importance of family support, and how the mother could help her son achieve his future goals.
Take-Home Points for Primary Care Providers
Adolescents account for approximately 20% of new HIV infections and 50% of all sexually transmitted infections (STIs) in the United States.
The Centers for Disease Control and Prevention (CDC) recommends HIV screening for all adolescents aged 15 years and older, with annual screening for sexually active young men who have sex with men (MSM), those reporting multiple sex partners, and transgender and gender diverse (TGD) patients. Young MSM should be screened annually for syphilis, gonorrhea, and chlamydia at all sites of contact, regardless of condom use (see Figure 1).
More frequent screening (every 3 to 6 months) for STIs and HIV is recommended for those at increased risk, including those on pre-exposure prophylaxis (PrEP) or with multiple sex partners. Screening should be adapted based on anatomy and sexual behaviors. PrEP is a medication that can protect against acquiring HIV infection. Recent clinical guidelines encourage pediatricians to inform all sexually active patients about PrEP and to prescribe it to anyone who asks for it, regardless of specific HIV risk factors.
Pediatricians should routinely assess sexual risk during clinical visits using the CDC’s 5 Ps: Partners, Practices, Protection from STIs, Prior history of STIs, and Pregnancy intention. This structured approach facilitates discussions on safer sex practices and early intervention, which can significantly improve health outcomes.
Providing time for confidential care is essential, as adolescents are less likely to share private information without having alone time with their providers. Lack of confidential care can delay access to testing and treatment. While parental/guardian involvement is desirable, it may be contraindicated due to safety concerns. Checking in with the adolescent before involving a parent is crucial to developing a safety plan that ensures the adolescent feels supported and safe. Be aware of local laws that allow minors to consent to HIV/STI testing, treatment, and PrEP without parental consent.
Summary
This case exemplifies the multifaceted role providers play in adolescent health. Beyond diagnosing and treating illnesses, we are entrusted with guiding our patients through some of the most challenging aspects of their lives, fostering open communication, respecting their autonomy, and ensuring they feel supported.
At Children’s Hospital of Philadelphia (CHOP), we pride ourselves on providing state-of-the-art medical care while creating an environment where adolescents feel safe, heard, and respected. Our commitment to confidentiality and compassionate care builds trust and supports our patients in making informed decisions about their health.
In an era where STI and HIV prevention are crucial, this case underscores the importance of early access to interventions like PrEP and the provider’s role in advocating for adolescent health and well-being. The Adolescent Initiative (AI) at CHOP is an integrated clinic that provides HIV testing, prevention, and treatment services for adolescents and young adults (ages 12 to 24). For more information, contact the AI team at 800-879-2467 or visit www.chop.edu/adolescent-initiative.
Renata Arrington Sanders, MD, MPH, ScM, was appointed Chief of the Craig Dalsimer Division of Adolescent Medicine in 2023.
References and Suggested Readings
Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021:70(4);1-187.
U.S. Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States-2021 Update: a clinical practice guideline. Centers for Disease Control and Prevention Website. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf. Accessed September 4, 2024
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Scott K. Jelinek, MD, MPH, MAEd, and Renata Arrington Sanders, MD, MPH, ScM
Case
A 17-year-old male presents to a busy emergency room, with a 2-week history of a sore throat. The sore throat is accompanied by a recent onset of chills, tactile fevers, fatigue, mild cough, and congestion. Despite trying over-the-counter remedies, he has persistent pain with difficulty opening his mouth. He has limited his daily activities to staying home, and his mother describes that his voice sounds softer than usual. He exhibits no drooling, has maintained normal oral intake, and reports no weight loss.
In private, he shares that he is sexually active with male and female partners.
Upon examination, he is febrile with a temperature of 39°C. He has 2+ enlarged tonsils with no sign of abscess, mild trismus, and bilateral anterior cervical lymphadenopathy. His neck is otherwise supple with a full range of motion. Initial assessments include imaging and infectious labs, all guiding the next steps in management.
Discussion
As healthcare providers, we often encounter cases that challenge us both medically and emotionally. This young patient, who disclosed being sexually active with both male and female partners, was found to have oral gonorrhea. More concerning, his initial HIV screening test came back positive, raising concerns about adolescent confidentiality and the potential disclosure of this information to family members.
I began by speaking with him privately, explaining the implications of the positive HIV test, including the meaning of the test, the importance of disclosure, and how to approach confidentiality with his parent/guardian. The fear and uncertainty in his eyes underscored the gravity of the situation. At that moment, it wasn’t just about delivering a test result; it was about providing reassurance, understanding, and guidance during a profoundly vulnerable time.
Despite his shock, the patient asked thoughtful questions, demonstrating strength in the face of such news. Given the sensitivity of his results, we had to navigate the conversation about whether he wanted to share this information with his parent/guardian. The principles of adolescent confidentiality were crucial here, as was creating a safe space where the patient felt empowered to make decisions about his care. In a moment of profound maturity, the patient requested I share the test results with his mother, expressing a desire for her support. His mother supported her son, and the conversation highlighted the role of family in adolescent health, particularly with sensitive diagnoses.
The confirmatory HIV test came back negative, indicating that the patient did not have HIV. I immediately contacted him and his mother to share the good news. They were elated. This provided an opportunity to discuss HIV prevention, the importance of family support, and how the mother could help her son achieve his future goals.
Take-Home Points for Primary Care Providers
Adolescents account for approximately 20% of new HIV infections and 50% of all sexually transmitted infections (STIs) in the United States.
The Centers for Disease Control and Prevention (CDC) recommends HIV screening for all adolescents aged 15 years and older, with annual screening for sexually active young men who have sex with men (MSM), those reporting multiple sex partners, and transgender and gender diverse (TGD) patients. Young MSM should be screened annually for syphilis, gonorrhea, and chlamydia at all sites of contact, regardless of condom use (see Figure 1).
More frequent screening (every 3 to 6 months) for STIs and HIV is recommended for those at increased risk, including those on pre-exposure prophylaxis (PrEP) or with multiple sex partners. Screening should be adapted based on anatomy and sexual behaviors. PrEP is a medication that can protect against acquiring HIV infection. Recent clinical guidelines encourage pediatricians to inform all sexually active patients about PrEP and to prescribe it to anyone who asks for it, regardless of specific HIV risk factors.
Pediatricians should routinely assess sexual risk during clinical visits using the CDC’s 5 Ps: Partners, Practices, Protection from STIs, Prior history of STIs, and Pregnancy intention. This structured approach facilitates discussions on safer sex practices and early intervention, which can significantly improve health outcomes.
Providing time for confidential care is essential, as adolescents are less likely to share private information without having alone time with their providers. Lack of confidential care can delay access to testing and treatment. While parental/guardian involvement is desirable, it may be contraindicated due to safety concerns. Checking in with the adolescent before involving a parent is crucial to developing a safety plan that ensures the adolescent feels supported and safe. Be aware of local laws that allow minors to consent to HIV/STI testing, treatment, and PrEP without parental consent.
Summary
This case exemplifies the multifaceted role providers play in adolescent health. Beyond diagnosing and treating illnesses, we are entrusted with guiding our patients through some of the most challenging aspects of their lives, fostering open communication, respecting their autonomy, and ensuring they feel supported.
At Children’s Hospital of Philadelphia (CHOP), we pride ourselves on providing state-of-the-art medical care while creating an environment where adolescents feel safe, heard, and respected. Our commitment to confidentiality and compassionate care builds trust and supports our patients in making informed decisions about their health.
In an era where STI and HIV prevention are crucial, this case underscores the importance of early access to interventions like PrEP and the provider’s role in advocating for adolescent health and well-being. The Adolescent Initiative (AI) at CHOP is an integrated clinic that provides HIV testing, prevention, and treatment services for adolescents and young adults (ages 12 to 24). For more information, contact the AI team at 800-879-2467 or visit www.chop.edu/adolescent-initiative.
Renata Arrington Sanders, MD, MPH, ScM, was appointed Chief of the Craig Dalsimer Division of Adolescent Medicine in 2023.
References and Suggested Readings
Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021:70(4);1-187.
U.S. Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States-2021 Update: a clinical practice guideline. Centers for Disease Control and Prevention Website. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf. Accessed September 4, 2024