HIV Specialist masthead
HIV Specialist Magazine
Fall 2025
Adolescents and Young Adults and HIV

Raising the Bar: HIV Risk and Prevention for Adolescents and Young Adults

Practical actions clinicians can take today to reduce HIV risk in AYAs

By Diana Howard, MD
Share this article:

I provide HIV care in Fresno, Calif., the third-highest incidence city for HIV in the state. In my clinic, I recently saw an 18-year-old who was newly diagnosed with HIV. When I asked if he had ever taken PrEP (pre-exposure prophylaxis), he looked surprised and said, “What is PrEP?”

That moment underscored what many of us already know: HIV prevention for adolescents and young adults (AYAs) remains inadequate. Too often, clinicians discuss unprotected intercourse and contraception but do not mention PrEP. HIV is not a condition of behavior but a disease of resources, and it is our responsibility to expand those resources. The conversation must begin in our exam rooms. Include PrEP in every discussion about contraception, STI screening, and sexual health. Patients rarely ask about PrEP—because they often do not know it exists. It is up to us to educate them.

AYA Risk is Unique

Adolescents and young adults face unique biological, behavioral, social, and structural factors that elevate their risk of HIV acquisition. Clinicians can translate evidence into actionable practice by integrating prevention, PrEP as well as PEP (post-exposure prophylaxis), testing, and youth-friendly care delivery. Confidentiality, nonjudgmental communication, and integrated services are critical to improving testing and prevention uptake.¹

Why AYAs are at Differential Risk

Biological susceptibility. Hormonal changes, mucosal immaturity, and higher prevalence of sexually transmitted infections (STIs) increase acquisition risk.² STI co-infections magnify local inflammation and target cell recruitment.

Behavioral patterns. Lower condom use, higher likelihood of multiple partners, and peer or venue-based exposure elevate risk. Delayed HIV testing leads to late diagnoses and missed opportunities for prevention.³

Substance use and mental health. Alcohol, stimulants, and cannabis impair judgment. Depression, trauma, and anxiety reduce adherence to PrEP and treatment.⁴

Structural and social determinants. Stigma, poverty, unstable housing, and lack of youth-friendly services remain major barriers.⁵ Housing instability, poverty, and school/work pressures disrupt continuity of care.

Cultural humility and subpopulations. Young men who have sex with men (MSM), Black, Indigenous, and Hispanic youth, and transgender/nonbinary youth carry disproportionate burdens.⁶

Mitigating Risk Factors

Below are some best practices for adolescent HIV prevention.

  1. Establish trust and confidentiality. Explain confidentiality at every visit. Interview adolescents directly and privately, including their concerns (e.g., mandatory reporting of abuse).⁷
  2. Use structured frameworks. Apply the HEEADSSS assessment and the 8 Ps sexual history.⁸ Ask open-ended questions and avoid assumptions about sexual orientation, gender identity, or partner gender.
  3. Normalize HIV testing. Screen all patients 15 and older as a standard practice. Retest at least annually, more often for high-risk patients.⁹
  4. Affirm identity and reduce stigma. Use chosen names and pronouns. Acknowledge unique risks for LGBTQ+ youth.¹⁰
  5. Prioritize prevention.
    • PrEP: Assess eligibility, formulations (daily vs event-driven 2-1-1), adherence, and monitoring. Provide same-day initiation when possible.¹¹
    • Event-driven PrEP (2-1-1). Consider for sexually active individuals with infrequent sex, where guideline-supported; ensure understanding and access.
    • PEP: Ensure rapid access within 72 hours of exposure.
    • Condoms/vaccines: Offer condoms, lubricants, and catch-up vaccines (HBV, HPV).
  6. Linkage to care. 
      • Initiate antiretroviral therapy promptly with adolescent- and youth-friendly approaches.
      • Support adherence with tailored strategies: Text reminders, peer navigation, digital tools, and mental health supports.¹²
      • Address transition planning to adult care early and coordinate with schools or guardians as appropriate for the patient’s context and confidentiality.
  7. Cultural humility and population considerations
      • For young MSM, transgender, and nonbinary youth, use inclusive language, affirm gender identity, and ensure access to gender-affirming care and specific risk-reduction resources.
      • In racial and ethnic minority AYAs, address structural barriers, provide culturally competent care, and connect with community-based organizations.
      • In congregate or high-risk settings (e.g., detention, shelters), ensure discreet, easily accessible testing and prevention services; partner with facility health teams.
  8. Address broader social determinants. Screen for housing instability, food insecurity, mental health, and substance use. Connect patients to resources whenever available.¹³
  9. Ensure continuity of care. HIV prevention is not a one-time conversation; schedule follow-ups for ongoing risk assessment.¹⁴

Clinician Toolkit for AYA

Clinical Scenario

A 16-year-old nonbinary patient presents with their same-gender partner. They report multiple partners and inconsistent condom use. They have not been tested for HIV in a year and are curious about PrEP.

Action steps:

  • Provide rapid HIV and STI testing.
  • Discuss PrEP formulations; initiate same-day counseling and referral.
  • Screen for mental health/substance use.
  • Verify vaccination status.
  • Schedule follow-up for adherence and ongoing risk assessment.

Diana Howard

DIANA J. HOWARD, MD, AAHIVS, is an assistant clinical professor of Family and Community Medicine at UCSF. She is a proud Latina physician with a diverse and accomplished background in family medicine and specialized care. She earned her MD from Ricardo Palma University in Lima, Peru, and trained through the UCLA IMG Family Medicine Pre-Residency Program. She completed her residency at Valley Health Team in Fresno, Calif. She is currently completing an Addiction Medicine Fellowship and working towards her World Professional Association for Transgender Health (WPATH) certification. Her clinical focus includes primary care, gender-affirming care, PrEP, and HIV management.

  1. Centers for Disease Control and Prevention. HIV and youth. CDC. Published 2023.
  2. McKinnon LR, Karim QA. Factors driving the HIV epidemic in southern Africa. Curr HIV/AIDS Rep. 2016;13(3):158–169.
  3. Zanoni BC, Mayer KH. The adolescent and young adult HIV cascade of care in the United States: exaggerated health disparities. AIDS Patient Care STDs. 2014;28(3):128–135.
  4. Reisner SL, Jadwin-Cakmak L, White Hughto JM, et al. Characterizing the HIV prevention and care continua in a sample of transgender youth. AIDS Behav. 2017;21(12):3312–3327.
  5. UNAIDS. Global AIDS Update 2023. Geneva: UNAIDS; 2023.
  6. Wilson EC, Chen YH, Pomart WA, Arayasirikul S. Connecting the dots: stigma, minority stress, and health disparities among minority youth. J Adolesc Health. 2016;59(2):S20–S26.
  7. American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: AAP; 2017.
  8. Goldenring JM, Rosen DS. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004;21(1):64–92.
  9. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR. 2006;55(RR-14):1–17.
  10. Johns MM, Lowry R, Andrzejewski J, et al. Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students. MMWR. 2019;68(3):67–71.
  11. Hosek SG, Landovitz RJ, Kapogiannis B, et al. Safety and feasibility of antiretroviral preexposure prophylaxis for adolescent men who have sex with men. JAMA Pediatr. 2017;171(11):1063–1071.
  12. Zanoni BC, Archary M, Buchan S, Katz IT, Haberer JE. Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa. Clin Infect Dis. 2016;62(3):374–383.
  13. Kasedde S, Luo C, McClure C, Chandan U. Reducing HIV and AIDS in adolescents: opportunities and challenges. Curr HIV/AIDS Rep. 2013;10(2):159–168.
  14. Taggart T, Grewe ME, Conserve DF, et al. Social media and HIV: a systematic review of uses of social media in HIV communication. J Med Internet Res. 2015;17(11):e248.
  15. American Academy of Family Physicians. HIV prevention and care for adolescents and young adults. Policy statement. Published 2022.
2025 v17 n3 Fall 1
More From This Issue
Feature
When ART Tips the Scale
Feature
Un-PrEPared
Feature
The Next Generation
Feature
The Power of a Single-Session: A Scalable Approach to Mental Health and HIV Care
Letter from the Director
Care That Centers the AYA Experience
In the News
One dose of antibiotic treats early syphilis as well as three doses 
In the News
AAHIVM Credentialing Program Changes
In the News
State Medicaid Officials Project Flat Enrollment Post Unwinding but Increased Spending and Budget Pressures, as States Prepare for Impact of Federal Medicaid Policy Changes
In the News
Treating opioid addiction in jails improves treatment engagement, reduces overdose deaths and reincarceration
At the Forefront
From Experience to Impact: The Leaders Behind the CAG
At the Forefront
The HIV Clinical Leadership Fellowship Program
Continuing Education
Addressing Vasomotor Symptoms (Hot Flashes) in Menopause and Perimenopause
Clinical Research Update
Clinical Research Update – Fall 2025
Scroll to Top

Search