Missed Opportunities: The Importance of HIV Screening in Adolescent Populations

Adolescents and young adults represent a substantial proportion of individuals newly diagnosed with HIV in the United States. Despite this, many youth living with HIV remain unaware of their status. HIV screening should be discussed and offered to adolescents; however, teens frequently report not being offered testing, and healthcare providers do not consistently adhere to screening practices. Detecting early HIV infection, including acute infection, is critical to initiating treatment, preventing transmission, and understanding patterns of disease. Acute HIV detection in adolescents and young adults is particularly challenging because early clinical manifestations are often nonspecific and may be misattributed to other common illnesses, such as influenza or mononucleosis. Maintaining a low threshold for testing, a high index of suspicion for HIV even in the presence of other diagnoses, and advocating for broad screening practices are essential to preventing missed diagnoses in this population. A 19-year-old male with a history of multiple sexually transmitted infections (STIs) was prescribed HIV pre-exposure prophylaxis (PrEP) but never initiated therapy. One year later, with a one-month prior negative fourth-generation HIV test, the patient developed a 103°F fever, back pain, myalgias, and a headache. Over the next several days, he presented to three emergency departments, but HIV testing was not performed. Subsequently, the patient presented to the clinic, and exam findings were consistent with streptococcal pharyngitis. Rapid strep testing was positive, and he was treated with intramuscular (IM) penicillin. However, serum testing from that visit showed HIV RNA PCR of 3,652,943 copies/mL (reference: undetectable, <20 copies/mL). The patient returned to the clinic two days later and was started on antiretroviral therapy. This case highlights the critical need for routine and timely HIV screening, specifically in the adolescent and young adult population, as acute HIV infection can present with non-specific symptoms as well as concurrent diagnoses such as strep throat. Clinicians must maintain a high index of suspicion and be knowledgeable about HIV testing modalities, particularly the fourth-generation antigen/antibody tests. Universal screening should not be based on self-reported risk behaviors, as they can be undisclosed. Barriers, including stigma, confidentiality concerns, and provider discomfort, hinder testing in primary care settings. Maintaining a high index of suspicion for HIV in adolescent and young adult patients is crucial, as missed or delayed diagnoses can accelerate disease progression and increase transmission. Integrating HIV testing into routine adolescent care helps normalize screening and reduce stigma.