San Francisco Youth Clinics Help Adolescents Access PrEP
In 2015, youth aged 13 to 24 accounted for 22 percent of all new HIV diagnoses in the United States, according to facts presented by the Centers for Disease Control and Prevention (CDC). Studies have shown that young people are a priority target for HIV prevention messages because it's more effective to change people’s behavior before they develop their sexual habits.
In San Francisco, especially, the incidence of HIV among young adults and adolescents has been on the rise in recent years. The estimated HIV incidence among people aged 13 to 29 has increased from about 100 (per 100,000) in 2009 to 150 (per 100,000) in 2013.
One way to target young people directly and get them practicing HIV prevention methods is through youth clinics. Three youth clinics of San Francisco Department of Public Health (SFDPH)—Cole Street Youth Clinic, Dimensions Queer Youth Clinic, and the Michael Baxter Larkin Street Youth Clinic—have begun to provide comprehensive PrEP services for young people ages 12 to 24.
HIV and adolescent healthcare providers from SFDPH initiated the PrEP program after identifying a gap in PrEP uptake among adolescents and young adults. As of now, about 90 young people have been able to access PrEP services, and interest has continued to increase over the past year.
“Working in an HIV specialty clinic for youth, I kept having this repeated experience of talking to young people newly diagnosed with HIV—some under the age of 18, and still in high school in San Francisco—who didn’t know about PrEP or didn’t have access to it,” said Adam Leonard from Cole Street Youth Clinic and Larkin Street Youth Services.
“PrEP knowledge, awareness and uptake is low among adolescents and young adults compared to other age groups,” said Hyman Scott, MD, medical director of Bridge HIV at San Francisco Department of Public Health. “We wanted to address that disparity with a concerted, coordinated effort across the youth-serving clinics in the SFDPH and also provide support to other youth providers outside the health department.”
Truvada can cost upwards of $2,000 per month without insurance and people under the age of 18 are not eligible for the Gilead co-pay assistance program. Medication affordability is a tough challenge for youth who may not have insurance, or have concerns about confidentiality if they are on their parents’ insurance, according to Scott.
To help younger clients afford Truvada, the only HIV medication approved for use as PrEP, the program offers financial assistance through an Emergency Youth Truvada Fund established by the Getting to Zero Consortium.
Confidentiality is also a concern for young people who wish to take PrEP without informing their parents or guardians of their decision.
“Particularly for LGBT youth—who may not be out to their parents—there could be safety concerns,” said Scott. “It can go beyond not wanting their parents to know they’re on PrEP, particularly if they’re still living at home. They may be outed from their parents opening a letter listing Truvada or PrEP. For some youth the risk of becoming homeless as a result is real.”
In order to avoid these outcomes, young people in California are protected by a law that stipulates people 12 years of age and older can consent to sexually transmitted infection prevention, treatment and care, including PrEP, without a parent needing to be notified.
“It’s not foolproof, and certainly we’re working with some challenging structural issues,” said Nordell. “But we are able to help young people use an online tool which guides them through how to request their insurance company limit the information shared with the primary account holder. Insurance companies are required by law to take this into account.”
More than just getting medication, the youth who enter the clinic get counselors and educators. The counselors help teenagers find the right HIV strategy for their needs. For those who do decide to start PrEP, they provide tailored adherence planning, help navigating issues related to confidentiality and assistance with insurance.
Most importantly, they help youth not only begin a PrEP regimen, but adhere to one. “Most of my PrEP clients check in with me by phone, at least once a week. Some check in with me every day, and that’s what has helped them most with daily adherence,” said Miranda Nordell, the PrEP coordinator at one of the clinics.
“For a lot of them, this is the first time they’re taking a daily medicine—it’s the first time they’re taking any medicine. It may even be the first time they are going to a pharmacy. There’s a lot more walking through potential barriers, and touching base in and outside the clinic that needs to happen in order for them to be successful.”