Youth at risk, including those at risk for substance use and those at risk for HIV infection, are the focus of two new policy statements from the American Academy of Pediatrics that aim to improve prevention and outcomes in adolescents.
One of the statements, "Substance Use Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Pediatricians," provides an algorithm-based approach to bolster pediatricians’ confidence and ability to address the matter of substance use with patients in the primary care setting (Pediatrics 2011;128:e1330-40).
Substance use is both common and risky in adolescence, and pediatricians are "ideally suited for preventing problem behaviors and consistently screening for them, including the development of mental health disorder and psychosocial problems, among which are substance use and addiction," according to lead authors Dr. Sharon J.L. Levy and Dr. Patricia K. Kokotailo of the AAP Committee on Substance Abuse.
"The SBIRT policy statement reinforces the recommendation that pediatricians screen all adolescent patients for alcohol and drug use as part of routine medical health care," Dr. Levy, director of the adolescent substance abuse program at Children’s Hospital Boston, said in an interview.
"What is unique about this statement is that we reviewed the literature and presented advice on how to use screening results to determine risk level, and we suggested brief, office-based interventions for every level – even positive reinforcement for those who have not initiated substance use," she added.
"HIV testing should be considered a routine part of health care and a step to increased HIV prevention."
The goal of universal SBIRT for adolescents, according to the statement, is to identify an individual’s experience along the spectrum from primary abstinence to addiction for each adolescent at each visit. The policy builds on the AAP’s existing statements on tobacco, alcohol, and other drug use by providing additional guidance and tools for preventing, detecting, and influencing the course of adolescent substance use.
In addition to providing tips and tools for screening, intervening, and referring, the statement also addresses the matter of dual diagnosis, as well as billing and payment issues.
"We hope that this statement will make it easier for pediatricians to not only screen, but use the results for a meaningful clinical interaction targeted at preventing or reducing substance use by teens," said Dr. Levy, also of Harvard Medical School, Boston.
Improving HIV Prevention in Adolescents
Similarly, the authors of "Adolescents and HIV Infection: The Pediatrician’s Role in Promoting Routine Testing" hope their new policy statement will pave the way for improved screening and prevention efforts in adolescents (Pediatrics 2011;128:1023-29).
Lead authors Dr. Patricia J. Emmanuel and Dr. Jaime Martinez of the AAP Committee on Pediatric AIDS noted that despite great progress in treatment and continued efforts to screen targeted populations, more than 1 million Americans were living with HIV in 2006, including 55,320 adolescents and young adults.
Approximately 20% of Americans with HIV are unaware of their infection, and 48% of youth aged 13-24 years with HIV are unaware of their infection, they said, noting that such individuals contribute to more than half of all new HIV infections.
Given these startling statistics, the new policy statement emphasizes the fact that most sexually active youth do not consider themselves to be at risk for contracting HIV, and promotes nonjudgmental risk counseling as a key part of health care visits with adolescents.
In one survey, 65% of high school students reported being sexually active by the 12th grade, and more than 85% had received education about HIV/AIDS, but only 13% had been tested.
Risk assessment and counseling, therefore, are imperative, according to the statement, which emphasizes that to reach youth, a supportive atmosphere and factual, nonjudgmental counseling are essential.
"Pediatricians should provide an environment of tolerance and facilitate open discussions regarding sexual risk and sexual orientation. In addition, physicians should know and recognize the symptoms of HIV, understand state laws regarding testing of youth, and routinely assess patient sexual and substance use behaviors," Dr. Emmanuel, professor of pediatrics and director of the clinical and translational science institute at the University of South Florida, Tampa, said in an interview.
The statement recommends that "routine HIV screening should be offered to all adolescents at least once by 16-18 years of age in health care settings when the prevalence of HIV in the patient population is more than 0.1%."
In areas where the prevalence is 0.1% or lower, routine HIV testing is nonetheless encouraged for all sexually active adolescents, as well as for those with other risk factors, such as substance use. Those at high risk should be tested annually.