HIV Is the Leading Cause of Death for Americans Ages 25 to 44
It is estimated that half of all new HIV infections in the U.S. are among people under 25, and the majority of them are infected sexually. HIV-related death has the greatest impact on young and middle-aged adults, particularly racial and ethnic minorities. HIV is the leading cause of death for Americans between the ages of 25 and 44. In 1994, 1 in every 3 deaths among African-American men in this age range was due to HIV. And 1 in every 5 deaths among African-American females the same age was HIV-related.
Among all men in the next younger cohort, 13- to 24-year-olds, 55% of reported AIDS cases in 1995 were among young MSM (men who have sex with men); 10% were among injection drug users (IDUs); and 6% were among young men infected heterosexually. Among young women the same age, 51% were infected heterosexually, and 17% were IDUs.
Surveys of HIV infection among young people are limited, but suggest that prevalence may be stabilizing overall. With sustained, targeted prevention for each group entering adolescence and young adulthood, it is possible to further reduce the toll AIDS takes on young Americans. To do that, more information is needed about the range of adolescent sexual behavior to help develop interventions that are targeted to young people, work within the context of adolescent sexual behavior, and focus on individual, social, and community-level change.
Assessing the Diverse Prevention Needs of Young People
To better understand adolescent behaviors and the impact of selected family, social, and cultural factors on those behaviors, CDC researchers conduct broad-based surveys of the extent of risk behaviors among young people, as well as focused studies of the factors contributing to risk and behavioral intent among specific groups of adolescents.
Surveys of risk behavior among young people suggest that prevention programs have helped increase condom use among adolescents who are sexually active, without increasing the level of sexual activity among young people. Five-year trends from the Youth Risk Behavior Survey (YRBS) show both a leveling of sexual risk behavior rates and increased condom use among sexually active young people. From 1990 through 1995 the percentages of high school students who reported ever having had sex, having four or more partners, or having intercourse in the 3 months prior to the survey all remained steady. In contrast, overall condom use at last intercourse was up significantly, from 46% in 1990 t o 53% in 1995. Female and African-American students posted the largest increases in condom use. While increased condom use is encouraging, YRBS findings indicate that more must be done to help young people delay initiation of sexual activity and reduce risky sexual behavior.
Other CDC research also suggests that new approaches to prevention may be needed to build upon success in increasing condom use, and to reduce the level of sexual activity among young people. In a recent survey of a group of 14-16 year old adolescents and their mothers, researchers found that the traditional definitions of "sexually active" and "not sexually active" may mask important behavioral intentions and sexual practices. Even adolescents who might traditionally be defined as not sexually active are actually engaging in or intend to engage in a range of sexual behaviors that could place them at risk for HIV infection. Of the adolescents in the survey, 99% could be classified into one of five categories: delayers (no intention to initiate intercourse); anticipators (intend to initiate in the next year); one-timers (has sex once, and not again); steadies (have intercourse with one partner); and multiples (have intercourse with multiple partners). Vital differences were found among the typology groups. For example, one-timers and steadies were significantly older than multiples when they first had intercourse. One-timers were significantly more likely to use condoms than were steadies or multiples. And only multiples reported having had a sexually transmitted disease.
The researchers also looked more closely at adolescent females in the study group and found that in addition to other risk factors, the age of a young woman's first sexual partner may be related to her level of risk. Young women whose first sexual partner is 3 or more years older may be at greater risk of HIV infection. Older men present a greater risk for HIV transmission because they are more likely to have had multiple partners and to have had more varied sexual and drug use experiences. The young women whose first partners were older were also less likely to use condoms. Power differences are greater between older and young partners, likely contributing to riskier behaviors young women report with older partners. All these differences must be taken into account as HIV prevention programs are developed and implemented.
Reaching Young People through Effective School-Based
and Community Programs
The foundation of all CDC's HIV prevention programs is that those closest to the problem are best able to solve it, equipped with needed tools. CDC's role is to provide those tools. In 1987, CDC launched a national program to help schools and other youth-serving agencies deliver effective HIV-prevention health education. CDC provides financial support and translates biomedical and behavioral research into practical interventions, so that schools and other agencies serving youth can implement effective HIV prevention education for youth.
CDC is also working with five communities to design targeted interventions to reach high risk youth in their local area. These programs are putting HIV prevention into action within the framework of social marketing, a discipline that combines communications and behavioral science with community mobilization. CDC is providing communities with financial resources and, more importantly, along with AED, is equipping them with intensive technical assistance that supports their efforts to apply research-driven, consumer-based research to design, develop, deliver, and evaluate HIV prevention marketing programs for youth. The Prevention Marketing Initiative provides communities with a practical structure for targeted programs and its application has resulted in several key learnings, applied at both the national and local levels.
For example, research in three cities found that among 18-25 year old heterosexuals, gender and ethnic differences seemed to be more directly related to sexual risk behaviors than differences in socioeconomic status or relationship status. Young adults in this study also expressed doubt and confusion about refusing to have sex without a condom when they were in a sexual relationship with either a casual or steady partner. This information has been applied in the design of community-level prevention programs in these 5 communities and in a national public service campaign entitled, "Respect Yourself, Protect Yourself." Radio and television spots feature diverse young people modeling safer sex behaviors, including abstinence, refusing to have sex without a condom, and talking with partners about safer sex.
Through these and other practical applications of communications and behavioral theory, CDC continues to put cutting-edge science into the hands of communities to effect HIV prevention for young adults. For more information on CDC's work in this area, see any of the following presentations in Vancouver.
Five-Year Trends in HIV Risk Behaviors Among Youth, Janet Collins.
The AIDS Community Demonstration Projects(ACDP): A Successful Multi-Site Community-Level Behavioral Intervention, Martin Fishbein.
Adolescent Sexual Experience: A New Typology, Kim S. Miller.
The Impact of Street Outreach for HIV Prevention in 5 High Risk Populations, John E. Anderson.
Evaluating School-Based HIV/AIDS Education Efforts: A Systematic Approach to Improving Program Quality, Stephen W. Banspach.
A Pilot Study of Risk Behaviors and Condom Use among Incarcerated Adolescents, USA, Juarlyn L. Gaiter.
Setting Priorities for HIV Prevention Programs in School, Pete Hunt.
Focus Group Themes That Will Shape Participatory Social Marketing Interventions in 5 Cities, May Kennedy.
HIV Prevalence, Risk Factors, and Predictors of Unprotected Sex Among Homeless and Runaway Youth in Four U.S. Communities, Duncan MacKellar.
Reaching And Involving Youth: A Prevention Marketing Approach, Chad Martin.
Case Study Methods for Process Evaluation of Participatory Social Marketing, Lauretta Pinckney, Martha Hare.
Initiation of Sexual Intercourse: Ages and Trends, Ellen Sogolow.
Research to Classroom: Selecting and Disseminating Educational Programs that Reduce HIV Risk Behaviors Among Adolescents, Susan Wooley.