Young People at Risk - Epidemic Shifts Further Toward Young Women and Minorities
In the United States, HIV-related death has the greatest impact on young and middle-aged adults, particularly racial and ethnic minorities. HIV is the second leading cause of death for Americans between the ages of 25 and 44. It is the leading cause of death for African-American men and women in this age group. Many of these young adults likely were infected as teenagers. It is estimated that half of all new HIV infections in the United States are among people under 25, and the majority of young people are infected sexually.
Among 13- to 24-year-olds, 52% of all AIDS cases reported among males in 1997 were among young men who have sex with men (MSM); 10% were among injection drug users (IDUs); and 7% were among young men infected heterosexually. In 1997, among young women the same age, 49% were infected heterosexually and 13% were IDUs.
Because of the long and variable time between HIV infection and AIDS, surveillance of HIV infection provides a much clearer picture of the impact of the epidemic in young people than surveillance of AIDS cases. CDC recently announced results from a study that analyzed data from 25 states* that had integrated HIV and AIDS reporting systems for the period between January 1994 and June 1997. In these states, young people (aged 13 to 24) accounted for a much greater proportion of HIV than AIDS cases (14% versus 3%). Nearly half (44%) of the HIV infections in that age group were reported among young females, and well over half (63%) were among African Americans. The study also showed that even though AIDS incidence (the number of new cases diagnosed during a given time period, usually a year) is declining, there has not been a comparable decline in the number of newly diagnosed HIV cases among young people.
*Alabama, Arizona, Arkansas, Colorado, Idaho, Indiana, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Virginia, West Virginia, Wisconsin, Wyoming
How Can We Improve Prevention Programs for Young People?
CDC's role is to provide communities with the best available science to guide comprehensive HIV prevention programs. As part of this process, CDC conducts an ongoing research synthesis process that seeks to identify the most recent and relevant scientific findings from around the world, both published and unpublished, and make them available to prevention program planners. CDC constantly combs the scientific literature, reviews domestic and international scientific databases, and speaks with colleagues around the world to identify effective interventions for all populations at risk, including youth.
Young people's prevention needs are as diverse as young people themselves. To reduce the toll AIDS takes on young Americans, a wide range of activities must be implemented.
Comprehensive, ongoing prevention efforts are needed for each group entering adolescence and young adulthood. All groups that exert influence over young people - families, schools, peer groups and social systems, youth-serving agencies, religious organizations - must be involved.
School-based programs. Because risk behaviors do not exist independently - for example, a young person's ability to resist peer pressure and social influences to smoke are integrally related to the ability to say no to risky sexual activity - topics such as HIV, STDs, unintended pregnancy, tobacco, nutrition, and physical activity should be integrated and ongoing for all students in kindergarten through high school. The specific scope and content of school health programs, especially those related to HIV and STD prevention, should be locally determined and consistent with parental and community values. For communities and schools that seek assistance, CDC and other organizations have identified elements of successful HIV education programs, and this information is widely available from CDC and other youth-serving agencies. Research has clearly shown that the most effective programs are comprehensive ones that include a focus on delaying sexual behavior and provide information on how sexually active young people can protect themselves.
Community-based programs. Addressing the needs of adolescents who are most vulnerable to HIV infection, such as homeless or runaway youth, juvenile offenders, or school drop-outs, is critically important. For example, a 1993 serosurveillance survey of females in four juvenile detention centers found that between 1% and 5% were HIV infected (median 2.8%). Increased HIV seroprevalence rates may be associated with higher rates of drug injection or high-risk sexual practices in these populations of adolescents. Community outreach programs play an important role in reaching these young people.
Sustaining prevention efforts for young gay and bisexual men. Targeted, sustained prevention efforts are urgently needed for young MSM as they come of age and initiate high-risk sexual behavior. Ongoing studies show that both HIV prevalence and risk behaviors remain high among young MSM. In a sample of young MSM ages 15-22 in 6 urban counties, researchers found that, overall, between 5% and 8% were infected with HIV. HIV prevalence was higher among young African Americans (13%) and Hispanics (5%) compared with young white MSM (4%).
Need to address sexual and drug-related risk. Many students report using alcohol or drugs when they have sex, and 1 in 50 high school students reports having injected an illegal drug. Surveillance data from the 25 states with integrated HIV and AIDS reporting systems between January 1994 and June 1997 showed that drug injection led to 6% of HIV diagnoses reported among those aged 13-24 during that time period, with an additional 57% attributed to sexual transmission (26% heterosexual, 31% from male-to-male sex).
Role of STD treatment in comprehensive HIV prevention programs for young people. An estimated 12 million cases of STDs other than HIV are diagnosed annually in the United States, and about two-thirds (roughly 8 million) of those are among people under the age of 25. A large body of research has shown that biological factors make people who are infected with an STD more likely to become infected with HIV if exposed sexually; and HIV-infected people with STDs also are more likely to transmit HIV to their sex partners. Expanding STD treatment services is critical to reducing the consequences of these diseases and also helping reduce risks of transmitting HIV among youth.
Ongoing evaluation of factors influencing risk behavior. To better understand adolescent behaviors and the impact of selected family, social, and cultural factors on risk behaviors, CDC conducts 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.
Eight-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. Still, more than one-quarter of adolescents report initiating intercourse by age 15. From 1990 through 1997 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 to 57% in 1997. 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, and done earlier, to help young people delay initiation of sexual activity and reduce risky sexual behaviors.
For young people, it is critical to prevent patterns of risky behaviors before they start. HIV prevention efforts must be sustained and designed to reach each new generation of Americans.
CDC Presentations Related to Youth
"Evaluation Results from the Safer Choices Project: A Multi-Faceted HIV Prevention Intervention Program for High School Students," Stephen Banspach
"Social-Normative Factors Partially Explain the Association Between Younger Age and HIV Risk in Gay and Bisexual Men in the U.S.," Gordon Mansergh
"Evaluation of a School Condom Availability Program: Impact on Sexual Behavior and Condom Use," Nancy Brener/John Moore
"Age of Initiation of Sexual Intercourse Among High School Students in the United States," Janet Collins
"Communities at Risk - Estimating the Impact of the HIV Epidemic Upon Adolescents and Young Adults at the Local Level," Paul Denning
"How Local Organizations Tailor Previously Evaluated Workshops for Teens," May Kennedy
"Room for Improvement: Informing and Evaluating Prevention Communications Programs for Adolescents Through Phone Surveys," May Kennedy
"Getting HIV Prevention Information into the Hands of Parents: Is the Print Media an Underutilized Resource?" Linda Koenig/Kim Miller
"Analysis of Family Communication about Sex: What are Parents Saying, and are Their Adolescents Listening?" Kim Miller
"Adolescent Sexual Behavior in Two Ethnic Minority Samples: The Role of Family Variables," Kim Miller
"Patterns of Condom Use Among Adolescents: The Impact of Maternal-Adolescent Communication," Kim Miller
"When Worlds Collide: Sex, Needles, and HIV Infection Among Young Injection Drug Using Men Who have Sex with Men," Greg Rebchook/Linda Valleroy
"A Randomized Clinical Trial of Three Intervention Models' Effectiveness in Lowering STD/HIV Risk of Substance-Dependent Adolescents," Janet St. Lawrence
"HIV and Predictors of Unprotected Receptive Anal Intercourse for 15- to 22-Year-Old African-American Men who have Sex with Men in Seven Cities, U.S.A.," Linda Valleroy
"HIV Prevalence and Predictors of Unprotected Receptive Anal Intercourse for 15- to 22-Year-Old Men who have Sex with Men in Seven Urban Areas, U.S.A.," Linda Valleroy
"Communication about Sexual Risk Between Teens and Their Partners: The Importance of Parent-Teen Communication Factors," Dan Whitaker/Kim Miller
"Parent-Adolescent Discussions about Sexual Initiation: Reducing the Impact of Peer Norms on Early Sexual Initiation," Dan Whitaker/Kim Miller