Monthly Archives: December 2017

HIV Screening Recommendations in Adolescents

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Lauren Middlebrooks, MD
lauren.sullivan. middlebrooks@emory.edu

 

 

 

 

 

 

 

HIV/AIDS
What an illness
My life is meaningless
You make my life lifeless
You make me hopeless
What an illness

You don’t care who you kill
It old and young
Big and small
Bad or good
What an illness

The sky was blue
Now its black
People hate each other
Because of you HIV/AIDS
What an illness

By SN, Primary school KaNyamazane, South Africa

As depicted in the poem above, written by a young child living with HIV in South Africa, HIV and AIDS has carried a reputation deeply rooted in fear, shame, and distrust.  Stigmas have impacted patient disclosure, provider discussion, and have limited early screening and diagnosis of at risk populations1. Once thought of as a disease only extending across international borders, Georgia is now ranked #5 in the United States (U.S.) for some of the highest rates of HIV in our nation.  The rising rates in downtown Atlanta specifically, have been compared to rates of HIV in third world countries, such as “Zimbabwe, Harare or Durban2.”  As if these statistics aren’t alarming enough, adolescents and young adults, ages 13-24, accounted for 22% of all new HIV infections in the U.S. in 2015—that’s roughly 1 in every 5 young people affected by this virus3.  In a 2005 Youth Risk Behavior Surveillance System assessment (YRBS), almost half of high school students surveyed nationwide reported having had sexual intercourse, yet only 11% had ever been tested for HIV4.  Adolescents and young adults quickly became an at-risk cohort, and in response to this new epidemic, the Centers for Disease Control and Prevention (CDC) made national recommends in 2006 for routine, opt-out HIV testing beginning at 13 years of age.  Interestingly, prior studies concluded not only that many clinicians had poor knowledge of these recommendations made over 10 years ago, but that the prevalence of HIV testing did not significantly change amongst high school students between the 2005 and 2015 YRBS’s.

Adolescents and young adults have the most challenges in links to primary care, mainly due to limitations in transportation, health insurance, and concerns for breeched confidentiality.  As a result, approximately 60% of HIV-positive adolescents remain unaware of their status.   Of adolescents who did see a primary provider, only half of primary care physicians even touched on sexual content, and the average amount of time discussing a sexual history was 36 seconds5.  It is our duty as providers to have open conversations with each one of our adolescent patients regarding their sexual history, preferences and practices.  It is also important that they understand the results will remain confidential and that every effort will be made to contact the patient directly with any new positive results. Per official recommendations, all patients 13-64 years of age are recommended to have at least one HIV test in their lifetime.  Persons who frequent high prevalent settings, including homeless shelter, prisons, and adolescent clinics, along with persons engaging in risky sexual behavior (multiple sexual partners, MSM, sex in exchange for money, substance abusers), may be tested at least once per year, or as frequent as every 3-6 months.

The most sensitive and specific tests for HIV are 4th generation antigen-antibody tests.  This is highly encouraged over others as it will more accurately capture true positives as soon as 4 weeks after exposure.  Positive tests should be relayed in person, not over the phone, and those patients can be referred to the Grady Ponce Center for further management and treatment.

Together we can normalize HIV screening in the adolescent and young adult population, reduce stigma associated with HIV/AIDS, and assist in managing this public health crisis.

For more information on the Grady Ponce Center, please visit: https://www.gradyhealth.org/specialty/ponce-de-leon-center/

or Contact Ponce Clinic Nurse-Deborah Ferris-404-516-4340 for any additional questions

References:

  1. 2017 August 29. HIV Stigma and Discrimination.  Retrieved from: https://www.avert.org/professionals/hiv-social-issues/stigma-discrimination
  2. Huddleson D. Atlanta HIV Epidemic Compared to Third World Countries. WSB-TV 2 Atlanta 2016. Retrieved from: http://www.wsbtv.com/news/2-investigates/atlantas-hiv-epidemic-compared-to-third-world-african-countries/263337845
  3. Health TGDoP. HIV Surveillance Fact Sheet, 2014. 2016
  4. Laura Kann P, Tim McManus, MS, William A. Harris, MM, Shari L. Shanklin, MPH, Katherine H. Flint, MA, Joseph Hawkins, MA, Barbara Queen, MS, Richard Lowry, MD, Emily O’Malley Olsen, MSPH, David Chyen, MS, Lisa Whittle, MPH, Jemekia Thornton, MPA, Connie Lim, MPA, Yoshimi Yamakawa, MPH, Nancy Brener, PhD, Stephanie Zaza, MD. Youth Risk Behavior Surveillance-United States 2005. Center for Disease Control and Prevention Morbidity and Mortality Weekly Report 2006;55(SS-5):19-22
  5. Alexander, S. C., Fortenberry, J. D., Pollak, K. I., Bravender, T., Davis, J. K., Ostbye, T., Shields, C. G. (2014). Sexuality Talk During Adolescent Health Maintenance Visits. JAMA Pediatrics, 168(2), 163.doi:10.1001/jamapdiatrics.2013.4338

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The new way to test poop! The GI PCR or FilmArray Gastrointestinal Panel

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Deborah Bloch, MD
deborah.bloch@emory.edu

Mark Gonzalez, MD
mark.gonzalez@choa.org

Craig Shapiro, MD
cshapi2@emory.ed

FilmArrayTM Gastrointestinal Panel?

The FilmArrayTM Gastrointestinal Panel is a rapid test (~2 hr turnaround time) offered by the CHOA microbiology lab for detection of common gastrointestinal pathogens (see Figure 1), which includes bacteria, viruses and parasites. Because of the comprehensiveness of the panel, in most cases stool culture, ova and parasite (O&P) examination, and antigen testing for Adenovirus 40/41, Rotavirus, Cryptosporidium spp. and Giardia lamblia no longer need to be ordered (see Figure 1 for additional information)

 

When should I order the FilmArrayTM Gastrointestinal Panel?

The panel should be ordered for a patient of any age with diarrhea (> 3 unformed stools in a 24 hour period who is not on a laxative) for whom you are worried about infection with a GI pathogen that may impact patient management or isolation practices. Testing should not be performed on formed stool. Please contact the microbiology lab (404-785-6426) or the ID consult service (404-785-DOCS) with any additional questions.

WHEN TO CONSIDER SENDING GI PCR PANEL FOR A PATIENT WITH DIARRHEA:

  • Fever and frankly bloody/mucusy diarrhea (if concern for C diff, also send stool for C diff toxin – not included in GI PCR panel)
  • Prolonged diarrhea>7 days (or before referral to GI for evaluation)
  • Travel-related diarrhea (if persistent or red flags; if concern for worms, also send stool for ova/parasites)
  • Immunocompromised patient – if concern for non-viral etiology
  • IBD patients- newly suspected or unusual change in stools in established IBD pt

What do the results mean?

For non-severe or prolonged (<7 days) illnesses caused by many of the pathogens detected (e.g. EAEC, EPEC, STEC, non-typhoidal Salmonella, all viral pathogens, Giardia lamblia and Cryptosporidium species), treatment is supportive; however, for patients in certain age groups, and patients with certain comorbidities or immunocompromising conditions, antimicrobial treatment may be indicated.

Because the FilmArrayTM Gastrointestinal Panel detects nucleic acids, it cannot differentiate active infection from treated infection or colonization; this must be done by correlating clinical symptoms. Results can remain positive for weeks or months after an infection especially in young children and immunocompromised patients.

Figure 1. Reported pathogens on the FilmArrayTM Gastrointestinal Panel at CHOA and which reflex to culture.

Should I also order a stool culture to get antimicrobial susceptibility results?

When testing is performed in the CHOA microbiology laboratory, a stool culture order is not necessary as positive panels will automatically reflex to culture, and if the isolate is recovered antimicrobial susceptibility testing will be performed when appropriate (Figure 1).

Should I order an O&P examination? What about for patients who drink and use well water?

O&P examinations should be ordered if you suspect a parasite other than those listed on the panel (e.g., for patients who returned from travel abroad). It should be noted that the top parasitic causes of well water contamination are Giardia and Cryptosporidium, which are tested for on the panel. Maximal sensitivity for parasite detection by O&P examination requires up to three stool specimens collected over a 7-10 day period.\

Should I order C. difficile toxin testing separately?

Yes, but it is not typically recommended for children under 2 year of age due to high rates of colonization. 

Should I reorder the FilmArrayTM Gastrointestinal Panel to test for cure?

No. Nucleic acids detected on the panel may remain positive for an indeterminate amount of time, and the FilmArrayTM Gastrointestinal Panel should only be ordered on unformed stool.