Effective antiretroviral therapy (ART) has increased the proportion of HIV-infected children surviving into adolescence (Chandwani et al., 2012; Garvie, Wilkins, & Young, 2010; Rongkavilit et al., 2007; UNAIDS, 2012). Adolescents face many challenges, including changes in body image, mindset and frequent peer pressure to engage risky behaviors. Adolescents with perinatally acquired HIV-infection (pHIV) face additional challenges during adolescence such as delayed growth and pubertal development, HIV-related health problems, and stigmatization (D’Angelo, Trexler, Fletcher, & Platky, 2003; Schneir, Wolfe, & Mackenzie, 1992). Studies have reported early onset of sexual intercourse, high rates of unsafe sexual practices, and illegal drug use among HIV-infected adolescents (Bauermeister, Elkington, Brackis-Cott, Dolezal, & Mellins, 2009; Brogly et al., 2007; Elkington, Bauermeister, Brackis-Cott, Dolezal, & Mellins, 2009; Ezeanolue, Wodi, Patel, Dieudonne, & Oleske, 2006; Wiener, Battles, & Wood, 2007). pHIV and behaviorally acquired HIV-infected adolescents may have differed in their risk behaviors profiles, but challenges with ART adherence, safe sexual practices, and life skills were common to both (Bauermeister et al., 2009; Brogly et al., 2007; Elkington et al., 2009; Ezeanolue et al., 2006; Murphy et al., 2001; Rongkavilit et al., 2007; Wiener et al., 2007). The majority of HIV-infected adolescents in Bangkok were knowledgeable about HIV transmission and the importance of antiretroviral (ARV) adherence; however, more than half lacked family planning, reproductive health, and knowledge about sexually transmitted infections (STI) (Lolekha et al., 2015).

We developed the Happy-Teen Program, a clinic-based intervention program implemented in routine clinical care, aiming to help HIV-infected adolescents who were aware of their HIV status to gain the knowledge and skills necessary for appropriate self-care, to ensure reproductive health, good ART adherence, and STI- risk reduction (Chokephaibulkit, Boon-yasidhi, Leawsrisook, Lolekha, & Nuchanard, 2012). In this report, we explored the psychological needs identified among HIV-infected youth during individual counseling (IC) sessions and a Youth Counseling Needs Survey (YCS) form. Defining the specific psychosocial needs of this population may help us identify appropriate intervention models for HIV-infected youth.

This study was a part of the Happy Teen Program that has been described elsewhere (Chokephaibulkit et al., 2015). HIV-infected adolescents aged ≥12-years-old followed at Siriraj Hospital or Queen Sirikit National Institute of Child Health (QSNICH) and those who had been cared for at a Dhamaraksa orphanage in Lopburi Province were invited to participate in the program at either Siriraj Hospital or QSNICH. The Happy Teen Program activities included two group sessions and two IC sessions that focused on four health-related strategies (Figure 1).

All sessions were conducted during routine medical visits. Group sessions, mainly game-based activities covering the four strategies, were run by healthcare providers who were trained to facilitate, guide discussion, and help participants understand the key messages related to the strategies (Chokephaibulkit et al., 2015). After each group session, an IC session focusing on the same strategies was conducted by counselors at the next clinic visit. Before the IC session, participants were asked to complete a YCS, a short self-administered questionnaire developed by a study working group, aiming to identify issues that participants would like to discuss. Prior to the study, the YCS was pilot tested among 10 pHIV youths at QSNICH and Siriraj Hospital to validate that the questions were understood by the youth. All counselors were experienced and well-trained in patient counseling. During IC sessions, the counselors began with an introductory conversation, provided confidentiality information, and then moved on to discuss the youths’ concerns using the YCS to guide the discussion. Then, the counselors assessed participants’ psychosocial issues using HEEADSSS assessment (Goldenring & Rosen, 2004; Woods & Neinstein, 2008), identify youths’ strengths, and provided messages aiming to empower them. All problems detected were discussed and recorded in a semi-structured counseling form. Instructive guidance was provided according to the Happy Teen Program Manual (Chokephaibulkit et al., 2012). Referral to specialists was available if needed.

The study was approved by the Institutional Ethical Committees of the two participating hospitals: U.S. Centers for Disease Control and Prevention, and the Thailand Ministry of Public Health.

Characteristics of participants were presented as proportions. Psychosocial problems identified by the YCS and the counseling form during the IC sessions were organized by main psychosocial issues. Data were analyzed and presented as proportions (percentages). Difference in proportion of psychosocial problems identified by YCS and the counseling form were compared by McNemar’s chi-square test. Differences in proportion of psychosocial issues found during IC sessions by age group were compared by Pearson’s chi-square test or Fisher’s exact test where appropriate. All statistical testing was two tail with p < .05 considered statistically significant. All analyses were conducted using SPSS v. 16, Chicago, USA.

From October 2010 to July 2011, 220 youths were eligible to participate in the Happy-Teen Program. Of these, 197 (89.6%) participated in at least one activity of the program and 150 (68.2%) participated in YCS and IC sessions. Participant characteristics are shown in Table 1.

Of the 150 participants, the median age was 14 (range 11–18) years, and 92 (61.3%) were female. The median (interquartile range) time spent in IC session was 36.5 (range 15–85) minutes. Of the 150 participants, 138 had plasma viral load results. Proportion of participants who had VL <50 copies/mL increased from 103 (74.6%) at baseline to 114 (82.6%) one year after enrollment to the Happy Teen Program (p = .035) (Table 1).

A total of 130 (86.7%) youth reported having problems to discuss on the YCS or the IC session. This included 118 (78.7%) youths who reported having problems in the YCS and 122 (81.3%) in the IC session. Twelve (8.0%) youths reported no problems in the YCS, but were found to have problems during the IC session and 10 (6.7%) youths reported having problems in YCS had no issues detected by the counselors during the IC session (Table 2).

The most common problems found by counselors in IC sessions were related to issues of poor health attitudes and self-care (48.0%), lack of life skills (44.0%), poor communication skills (40.0%), problems with ART adherence (38.7%), and low self-value (34.7%). Youth reported fewer problems in the YCS than the IC sessions (Table 3).

The proportion of youth reporting problems did not differ by age. However, young adolescents tended to have more pubertal concerns than older youth, while those in middle and late adolescence tended to have more sexual risk behaviors (Table 4). All problems detected were discussed and guidance provided.

Contrary to our expectations that youth would report more concerns on the self-administered YCS, in fact, youth were more likely to discuss their concerns on self-care, ART adherence, sexual risks, and psychosocial issues with counselors. This finding may be due to a sense of trust established during the long-term relationships developed between participants and counselors in the study. In addition, confidentiality declaration was made at the beginning of each session (Woods & Neinstein, 2008). Consistent with other studies, we found some complicated psychosocial issues such as peer influences, family conflict, lacking of confidence to adopt safe sex practice (Henry-Reid, Wiener, & Garcia, 2007; Philbin et al., 2014; Wilson et al., 2001), sexual risk behaviors and other behavioral health risks in this population (Mellins et al., 2011). In the IC sessions, counselors were able to assess and prioritize problems and provide tailored-made management to each youth within half-an-hour. Serious and harmful issues were managed urgently (e.g., adolescents who planned to run away from home or commit suicide, etc.). For other risky behaviors such as smoking or drinking alcohol, counselors would provide harm-reduction information and follow-up at the next clinic visit (Rosen & Neinstein, 2008; Woods & Neinstein, 2008). For health promotion, all youth and their families should be provided anticipatory guidance such as knowledge on adolescent development, drugs and their negative consequences, and sex education (American Academy of Pediatrics, 2008).

Information from the YCS and the IC sessions allowed healthcare providers to design appropriate interventions for youth based on their needs (Chokephaibulkit et al., 2015). Similar to other successful models, our program also encourages youth to share their leadership skills and play an active role in the service system (Huba & Melchior, 1998).

The YCS, a self-administered questionnaire, used briefly before the IC session can help initiate conversations and sensitively probe for youth concerns. However, this study suggests IC sessions are important and may detect problems not elicited in the YCS and it can be implemented in routine service settings. The guidance and support from IC sessions may be able to improve ART adherence and prevent loss and psychosocial complications in youth (Agwu et al., 2015; Cervia, 2013).

This study had several limitations. The program was conducted in tertiary-care settings with experienced counselors who have long-established relationship with youth and their families. This might not be applicable to clinics with fewer resources. The majority of youth in the program were in young pHIV adolescents, and the concerns of older adolescents and behavior acquired HIV-infected adolescents may differ. Lastly, the small number of participants did not allow for comparisons psychosocial issues by age, risk factor or sex.

IC sessions should be implemented in the routine care of HIV-infected youth. The YCS is helpful to initiate conversations and to assess adolescent’s self-awareness, but IC sessions are important to elicit adolescent concerns and address other important issues, including risk assessment and health promotion.