What Are Adolescents’ HIV Prevention Needs?
Can adolescents get HIV?
Unfortunately, yes. HIV infection is increasing most rapidly among young people. Half of all new infections in the US occur in people younger than 25. From 1994 to 1997, 44% of all HIV infections among young people aged 13-24 occurred among females, and 63% among African-Americans. While the number of new AIDS cases is declining among all age groups, there has not been a comparable decline in the number of new HIV infections among young people.1 Unprotected sexual intercourse puts young people at risk not only for HIV, but for other sexually transmitted diseases (STDs) and unintended pregnancy. Currently, adolescents are experiencing skyrocketing rates of STDs. Every year three million teens, or almost a quarter of all sexually experienced teens, will contract an STD. Chlamydia and gonorrhea are more common among teens than among older adults.2 Some sexually-active young African-American and Latina women are at especially high risk for HIV infection, especially those from poorer neighborhoods. A study of disadvantaged out-of-school youth in the US Job Corps found that young African-American women had the highest rate of HIV infection, and that women 16-18 years old had 50% higher rates of infection than young men.3 Another study of African-American and Latina adolescent females found that young women with older boyfriends (3 years older or more) are at higher risk for HIV.4
What puts adolescents at risk?
Adolescence is a developmental period marked by discovery and experimentation that comes with a myriad of physical and emotional changes. Sexual behavior and/or drug use are often a part of this exploration. During this time of growth and change, young people get mixed messages. Teens are urged to remain abstinent while surrounded by images on television, movies and magazines of glamorous people having sex, smoking and drinking. Double standards exist for girls-who are expected to remain virgins-and boys-who are pressured to prove their manhood through sexual activity and aggressiveness. And in the name of culture, religion or morality, young people are often denied access to information about their bodies and health risks that can help keep them safe.5 A recent national survey of teens in school showed that from 1991 to 1997, the prevalence of sexually activity decreased 15% for male students, 13% for White students and 11% for African-American students. However, sexual experience among female students and Latino students did not decrease. Condom use increased 23% among sexually active students. However, only about half of sexually active students (57%) used condoms during their last sexual intercourse.6 Not all adolescents are equally at risk for HIV infection. Teens are not a homogenous group, and various subgroups of teens participate in higher rates of unprotected sexual activity and substance use, making them especially vulnerable to HIV and other STDs. These include teens who are gay/exploring same-sex relationships, drug users, juvenile offenders, school dropouts, runaways, homeless or migrant youth. These youth are often hard to reach for prevention and education efforts since they may not attend school on a regular basis, and have limited access to health care and service-delivery systems.7
Can education help?
Yes. Schools are an important venue for educating teenagers on many kinds of health risks, including HIV, STD and unintended pregnancy. Across the US and around the world, studies have shown that sexuality education for children and young people does not encourage increased sexual activity and does help young people remain abstinent longer. Effective educational programs have focused curricula, have clear messages about risks of unprotected sex and how to avoid risks, teach and practice communication skills, address social and media influences, and encourage openness in discussing sexuality.8 In addition, HIV prevention programs that are carefully targeted to adolescents can be highly cost effective.9
Are schools the only answer?
No. Young people need to get prevention messages in lots of different ways and in lots of different settings. Schools alone can’t do the job. In the US, many schools are being hampered by laws and funding that prohibit comprehensive sexuality education. The federal government earmarked $50 million per year for school-based abstinence-only programs which emphasize values, character building and refusal skills, but do not discuss contraception or safer sex.10 Although abstinence programs are effective at delaying the onset of sexual activity, they typically do not decrease rates of sexual risk activity among adolescents the way that safer sex interventions do.11 Youth who are not in school have higher frequencies of behaviors that put them at risk for HIV/STDs, and are less accessible by prevention efforts. A national survey of youth aged 12-19 found that 9% were out-of-school. Out-of-school youth were significantly more likely than in-school youth to have had sexual intercourse, had four or more sex partners, and had used alcohol, marijuana and cocaine.12 More intensive STD/HIV and substance abuse prevention programs should be aimed at out-of-school youth or youth at risk for dropping out of school. Programs targeting hard-to-reach adolescents at high risk for HIV are necessary in many different venues outside of schools. Programs based in venues such as residential child care facilities, alternative schools and youth detention centers are needed. Peer educators can use an empowerment-oriented approach targeted to youth aged 12-17 to teach about preventing HIV and STDs, and to mobilize and link resources for young people through social and community networks.13 Families play an important role in helping teenagers avoid risk behaviors. Frank discussions between parents and adolescent children about condoms can lead teens to adopt behaviors that will prevent them from getting HIV and other STDs. Research has shown that when mothers talked about and answered questions about condom use with their adolescents prior to sexual debut, the adolescents reported greater condom use at first intercourse and most recent intercourse, as well as greater lifetime condom use.14 The WEHO Lounge in Los Angeles, CA, is a coffee house and HIV testing and information center located between two of the busiest gay discos in town. It offers free confidential oral HIV testing, weekly community forums, peer counseling, drug adherence support groups, free condom distribution and a comprehensive youth and HIV resource library. The Lounge also sells coffee drinks. By placing this resource in the community and adapting it to the needs and habits of young gay men, the program has been highly successful with clients.15 Project VIDA in Chicago, IL, a community-based service organization, provides HIV prevention for high-risk urban Latina females, ages 12-24. Project VIDA incorporates empowerment and self-care themes into peer-facilitated street/community outreach and group interventions. They act on the belief that it is impossible to separate HIV risks from other cultural, environmental, interpersonal, and intrapsychic stressors that Latina youths face; and that coping skills can help manage the perplexities of these challenges.16
What needs to be done?
HIV prevention programs for adolescents must consider the developmental needs and abilities of this age group. Programs should focus on contextual factors that lead young people to engage in higher rates of sexual activity and lower rates of condom use, such as low self-esteem, depression, substance use, gang activity, stress of living in turbulent urban environments, or boredom/restlessness related to unemployment. Any program for adolescents should be interesting, fun and interactive, and involve youth in the planning and implementation. This is especially true for out-of-the-mainstream youth and youth from diverse cultures. Programs for hard-to-reach youth who are most at risk for HIV infection should be implemented in venues outside of schools, such as runaway/homeless youth shelters, shopping malls, detention facilities and recreation/community centers. Adolescents not only need correct information and practice in self-protective skills, but also easy access to condoms in order to keep themselves risk-free.
1. Centers for Disease Control and Prevention. Young people at risk-epidemic shifts further toward young women and minorities. Fact sheet prepared by the CDC. July 1998. 2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1996. 3. Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996 . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:67-73. 4. Miller KS, Clark LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents . Family Planning Perspectives. 1997;29:212-214. 5. UNAIDS. Force for Change: World AIDS Campaign with Young People . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1998. 6. Centers for Disease Control and Prevention. Trends in sexual risk behaviors among high school students-United States, 1991-1997 . Morbidity and Mortality Weekly Report. 1998;47:749-752. 7. Rotheram-Borus MJ, Mahler KA, Rosario M. AIDS prevention with adolescents . AIDS Education and Prevention. 1995;7:320-336. 8. UNAIDS. Impact of HIV and sexual health education on the sexual behavior of young people: a review update . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1997. 9. Pinkerton SD, Cecil H, Holtgrave D.R. HIV/STD prevention interventions for adolescents: cost-effectiveness considerations . Journal of HIV/AIDS Prevention and Education for Adolescents and Children. 1998;2:5-31. 10. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997:A19. 11. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African-American adolescents: a randomized controlled trial . Journal of the American Medical Association. 1998;279:1529-1536. 12. Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and do not attend school-United States, 1992 . Morbidity and Mortality Weekly Report. 1994;43:129-132. 13. Zibalese-Crawford M. A creative approach to HIV/AIDS programs for adolescents . Social Work in Health Care. 1997;25:73-88. 14. Miller KS, Levin ML, Whitaker DJ, et al. Patterns of condom use among adolescents: the impact of mother-adolescent communication . American Journal of Public Health. 1998;88:1542-1544. 15. Weinstein M, Farthing C, Portillo T, et al. Taking it to the streets: HIV testing, treatment information and outreach in a Los Angeles neighborhood coffee house. Presented at the 12th World AIDS Conference, Geneva, Switzerland; 1998. Abstract #43125. 16. Harper GW, Contreras R, Vess L, et al. Improving community-based HIV prevention for young Latina women. Presented at the Biennial Meeting of the Society for Community Research and Action, New Haven, CT; June,1999.
Prepared by Gary W. Harper, PhD MPH* and Pamela DeCarlo** *Department of Psychology, DePaul University, **CAPS
April 1999. Fact Sheet #9ER
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 1999, University of California