It is exciting that we are on the brink of a new era – the advent of pre-exposure prophylaxis (PrEP) to reduce the risk of getting HIV. At the moment, PrEP is on the uptake in certain communities, and there are many efforts to make it widely available. But I have a concern.
Youth under the age of 18 need parental consent/consent of legal guardian to access PrEP in New York State. This is problematic and presents a barrier. Youth under the age of 18 may be the ones MOST at risk and that could benefit most from PrEP in their toolbox for making informed sexual and reproductive health (SRH) choices for themselves, as they may have limited to no access to relationships with adult guardians for a variety of complicated and often traumatic reasons.
An ideal, effective toolbox must also contain condoms, contraceptives, including emergency contraception and particularly long-acting reversible contraceptives (LARCS) such as IUDs/IUCs, along with the knowledge necessary for using them effectively and negotiating with partners; access to mental health services, and harm reduction services if appropriate; enriching educational, employment, and leisure/recreational opportunities; stable housing; balanced nutrition; and opportunities to engage and connect with caring community members, including peers, providers, and adults.
Teens are capable, competent and responsible. They also have the right to have a healthy, sex-positive sexual life if they so choose. They CAN make healthy decisions for themselves – particularly when they are: (1) equipped with comprehensive and medically accurate SRH education and knowledge; (2) empowered to advocate for themselves and their communities; and (3)accepted for who they are and where they are at.
Misperceptions about the ability of youth to make decisions for themselves regarding their SRH have been around for decades. The introduction of oral contraceptives in the 60s brought stigmatizing and erroneous messages to youth that could have benefitted from reliable access to contraception, resulting in unwanted and unintentional pregnancies. Recently, the issue of having emergency contraception (EC) available and accessible to youth brought concerns among parents, providers and legislators alike, fearing access to EC would elevate sexual risk behaviors among youth. Studies have shown that not to be the case. Even so, in New York State, EC is only available to youth 17 years and over without a prescription at pharmacies.
In New York State confidential family planning services can be accessed by youth under the age of 18 without the consent of a parent or legal guardian. An adolescent woman can opt for a pregnancy termination confidentially and without the consent of a legal guardian/parent. An adolescent can have an HIV test, but they are counseled that if their test result is reactive (HIV +), a parent/legal guardian must become involved in their care. This may be a barrier to testing for youth (although it is recommended best practice to work with youth to get a parent/legal guardian/caring adult to become involved in their care, if at all possible, regardless). Similarly, youth under the age of 18 in NYC/NYS cannot access PrEP without the consent of a parent/legal guardian. Again, a barrier.
What about homeless youth? What about youth in foster care with complicated relationships with biological family members, foster families, and case workers – often stuck in the system in limbo for years until they age out? Trauma early in life (known as adverse childhood experiences (ACES)) leave teens at-risk for engaging in risky sexual behaviors and poor SRH outcomes. Often, youth of color are over-represented among the homeless youth and foster care populations, as are youth engaging in sex trade activities in order to survive and make ends meet, leaving them at high-risk for not only HIV, but STIs and unwanted/unintentional pregnancies, sexual exploitation, and intimate partner violence (IPV).
What about youth that are fearful they will be hurt, abandoned, isolated, or kicked out of their homes if a parent/family member/legal guardian finds out that they are sexually-active, or about their sexual orientation and sexuality?
So this is my PrEP PLEA – as a researcher, former health educator and counselor to at-risk youth, and kid from the Bronx who saw many childhood friends become pregnant or contract an STI at a young age: Make PrEP easily accessible to adolescents – male and female, heterosexual and homosexual, YMSM, transgender, in a happy home, homeless, or in foster-care. Reduce barriers, including legal regulations and restrictions, to the use of PrEP for youth. Target research efforts to determine the effectiveness and acceptability of PrEP among adolescents under the age of 18, particularly those youth most at-risk for HIV, engaging in high-risk behaviors. Remove lingering barriers to HIV testing for youth under the age of 18. The sooner and younger we all learn how to protect ourselves, and have the ability to do so effectively within our power, the better the chances for halting the transmission of HIV in our most vulnerable communities.