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Abstract
Objectives To assess sexual health and behaviour outcomes of young adults with perinatally acquired HIV-1 (PaHIV), and audit sexual health interventions against published standards of care.
Methods Retrospective case note audit of 16–25-year-olds with PaHIV attending a dedicated transition clinic from January 2005 to 2011.
Results Fifty-two young adults, 31 women, median age 20 years. 41 were sexually active; median age of coitarche 16 years. Median number of lifetime partners was 3.5, and five reported non-consensual sex. All had a sexually transmitted infection (STI) screen; 6 were diagnosed with an STI, genital warts (human papilloma virus) most frequently. The median interval from coitarche to first STI screen was 2 years. The pregnancy incidence was 103 per 1000 person years. 18/25 (72%) sexually active women had a cervical smear, four had colposcopy. All patients had hepatitis B virus (HBV) serology. 47 had not been vaccinated against HBV prior to transition. 23 completed HBV vaccination of which 11 had surface antibody >100 IU/ml at 1 year.
Conclusions The majority of our cohort was sexually active while still under the care of paediatric health services. Cervical screening and hepatitis B vaccination rates fell short of audit standards. Vaccination for hepatitis B should be considered prior to transfer of care to adult HIV services.
- ADOLESCENT
- PERINATAL INFECTION
- HIV
- HEPATITIS B
- SEXUAL HEALTH
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Background
Increasing numbers of children with perinatally acquired HIV-1 (PaHIV) infection are surviving to adulthood with only limited UK data on sexual and reproductive health.1 ,2 This study describes the sexual health-related outcomes at a dedicated transition clinic for young adults with PaHIV aged 16–25 years. These young adults were previously under paediatric care, with transfer to adult HIV services by 25 years of age for stable patients. All attendees were offered standard safe sex counselling and STI screening annually. Specialised sexual health written material developed by the HIV in Young People Network was available for all attendees. Outcomes were audited based on published standards of care, and compared with published data.
Methods
Retrospective case note review of all attendees with PaHIV aged 16–25 years at a London transition clinic from January 2005 to January 2011 inclusive. Data were collected using all consultations over the audit period for the following outcomes: reported sexual behaviour (age of coitarche, number of lifetime partners, non-consensual sex (NCS)); sexually transmitted infection (STI) screening; documented STIs; pregnancy; cervical smear testing; hepatitis B virus (HBV) vaccination and serological response. Contraception and condom use data were collected for the most recent consultation only. Data collection proforma available as a Supplementary Appendix. ‘Sexually active’ was defined as having had consensual penetrative vaginal or anal sex. An ‘STI screen’ included testing for Chlamydia trachomatis (CT), Neisseria gonorrhoea (GC), or syphilis, or genital examination on the same date. Imperial College Healthcare NHS Trust approved the study as a clinical audit. Audited outcomes: 90% of sexually active offered an STI screen, consisting of testing for CT, GC, syphilis; 90% of those offered an STI screen, accept3; annual cervical cytology for 100% of sexually active women4; 100% of sexually active women have baseline colposcopy4; 95% of patients have baseline HBV serology within 3 months and accept HBV vaccination within 6 months of transfer of care; 95% complete the vaccination course; 90% have serology within 6–8 weeks of the last vaccine dose.3 ,5
Statistical analysis
Sexual behaviours were compared between men and women using univariate tests. Where the outcome was a proportion, Fisher's exact test or χ2 tests were used for comparison. Where the outcome of interest was a continuous variable (eg, age) a Wilcoxon Rank Sum test was performed. Crude incidence rates were calculated for uptake of STI screens, positive STI screens and pregnancy. A significance level of 5% (p<0.05) was used. Analysis was carried out in SAS V.9.2.
Results
Fifty-two patients with PaHIV were included, 31 (57%) women, and 40 (77%) black African. Demographic data are summarised in table 1. The number of patients transferring increased year on year, while the age of transfer remained constant (median 17 years).
Summary of demographic, reported sexual behaviour and sexually transmitted infection testing and diagnosis outcomes (n=52 subjects)
Information on sexual behaviour and STI diagnoses was available for 50/52 patients, summarised in table 1. All sexually active patients were heterosexual except one bisexual man.
Information on condom use was available for 35/41 sexually active patients; 12/25 women used condoms as the main form of contraception; 9/25 (36%) were using a long-acting contraceptive. None were taking an oral contraceptive, and two women reported no contraception use.
Eight pregnancies occurred in six patients, resulting in three live HIV-uninfected babies, three elective terminations, one ectopic pregnancy and one spontaneous miscarriage. For all live births, maternal HIV viral load was <50 copies/ml at the time of delivery. Pregnancy incidence was 103 per 1000 person years. Median age at first pregnancy was 17.5 years (IQR 17–20); one man aged 20 years fathered a child.
Eighteen (72%) sexually active women underwent 37 cervical smears: 0.5 smears per person year. The median age at first smear was 19 years (IQR 18–20); median coitarche-first smear interval was 2 years (IQR 1–3); 3/18 (17%) had an abnormal first smear, 5/18 ever had an abnormal smear. 4/18 attended colposcopy: one had a normal examination; one had cervical intraepithelial neoplasia grade 1; two had human papilloma virus changes.
All patients had baseline HBV serology, 38/52 (73%) within 3 months of transfer of care: two had HBV/HIV coinfection, one had previously cleared infection, and two were vaccinated and immune. Forty-two patients were eligible for HBV vaccination (CD4 count >100 cells/microlitre) with Engerix B 20 mcg (at 0, 1 and 3 months). Thirty-four (81%) started the HBV vaccine course, 23 (54%) completed three doses, and 4 (9.5%) had serology 6–8 weeks after completion of the vaccine schedule. Eighteen (43%) were vaccinated within 6 months of transfer of care. Of those completing the vaccination course, 11/23 (48%) had hepatitis B surface antibody titres >100 IU/ml at 1 year.
Discussion
There are relatively few reported data on sexual behaviour and STIs in young adults with PaHIV, particularly from the UK, and 79% of our cohort was sexually active. All eligible had an STI screen, of which 6 (12%) had an STI diagnosed. This is a higher proportion of sexually active individuals, and more STIs compared with data from another London centre (44% sexually active, no STIs diagnosed), although that cohort was younger (all under 21 years, median age 19).2 US cohorts found lower rates of sexual activity and higher rates of STI.6–8 Data from our cohort for sexual activity, age at coitarche and median number of lifetime partners are in agreement with UK national survey data of the general population.9 Genital warts was the commonest STI in our cohort, as with US studies,6 ,7 while in the UK general population for this age group it was CT.9 Statistical analysis of our data on sexual behaviour revealed only two significant differences between the sexes: the number of lifetime partners, and coitarche-first STI screen interval.
Many of our patients reported being first sexually active while still in paediatric care, with a median period of 2 years without accessing STI screening. Reviewing clinical care in paediatric settings, to ensure young people can make informed choices about their sexual health and behaviour, should be considered. Data on condom use was missing for 6/41 patients: reported condom use in the preceding 4 weeks would be suitable for reaudit of this important aspect of sexual behaviour counselling.9 STI screening was the only outcome that approached audit targets.
NCS was reported by 5 (9.6%) patients in our cohort, and by 6/50 (12%) in a UK study of HIV-infected youth.10 Koenig described 10% adolescents with PaHIV reporting sexual abuse, and an association between NCS and on-going unprotected sex.8 In a UK national survey of the general population, NCS aged <16 years was reported by 2.8% of men and 10.6% of women 16–24-year-olds,11 figures lower than our cohort.
Cervical screening uptake and colposcopy referral fell short of audit targets. While 17% had an abnormal first smear, this was lower than reported in a US PaHIV cohort (47.5%).6 We found that most sexually active young adults with PaHIV are unprotected against HBV. HBV immunity in our cohort could be improved through vaccination uptake and completion, currently short of the audit standard. HBV vaccination was not routinely given in our paediatric clinic, however, subsequent to this audit it is being routinely recommended.
The main limitation of the study was the incomplete nature of data for some outcomes. Clinic attendees can use other sexual health services, so some events may not have entered our records. Age-specific outcome incidence was not studied; this may be worth future study as the cohort expands. The data presented serves as a baseline for future service audits.
Conclusion
The age of coitarche, the relatively high rates of NCS, and the risk of STI acquisition and pregnancy in this vulnerable group of young people must be taken into account when planning future adolescent services. Cervical screening, baseline colposcopy and hepatitis B vaccination were interventions that require the most improvement to reach outcome targets as based on current UK guidelines.
Key messages
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The majority of our the cohort were sexually active whilst still in paediatric care.
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Cervical screening and Heptitis B vaccination uptake fell short of audit standards.
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Vaccination for hepatitis B should be considered before transfer to adult HIV services.
Acknowledgments
Sarah Turner, Richard Hackett.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix
Footnotes
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Contributors All cited authors contributed to the writing of this paper. Sarah Fidler and Caroline Foster originated and oversaw the study from beginning to completion of writing; APC and SMcD did the data collection; statistical analysis was done by SJ, and APC wrote the manuscript, with all authors cited contributing to the writing process throughout.
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Competing interests None.
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Ethics approval This is an audit study of service provision outcomes. Permission to perform the audit was granted by Imperial College Healthcare NHS Trust.
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Provenance and peer review Not commissioned; externally peer reviewed.