A Changing Epidemic Calls For A Realistic Approach To Prevention

Also available in [PDF] format. Order publication online.

Young people in the United States continue to be at risk for HIV and AIDS. At the end of 2008, in 37 states and five U.S. dependent areas with confidential name-based HIV infection surveillance, 25,036 young people ages 13-24 were living with HIV, comprising sixteen percent of persons aged 13-24 at diagnosis. [1] But experts believe young people may suffer from up to 30 percent of all cases of HIV in the United States. [2] Youth of color and young men who have sex with men continue to be most at risk. It is important to promote programs that help young people lessen risky sexual behaviors by encouraging condom use, delay in sexual initiation, partner reduction, and early HIV testing and treatment. But research has shown that even when risk factors are equal, minority youth are more at risk for HIV. As such it is essential that research and resources be directed toward addressing the underlying social forces that contribute to these disparities and that policies and programs promote structural and social changes to ameliorate these factors.

HIV among Young PeoPle 13-24 In tHe unIted StateS: RacIal and Sexual mInoRItY YoutH aRe at gReatlY dISPRoPoRtIonate RISk

• From 2004-2007, 72 percent of HIV/AIDS diagnoses in young people aged 13-24 were in males, and 28 percent were in females. The majority of HIV/AIDS cases diagnosed among young men were attributed to male-to-male sexual contact. High-risk heterosexual contact attributed to the majority of HIV/AIDS cases diagnosed among young women. [3]
  
  
• In 2007, African Americans/blacks and Latinos/ Hispanics accounted for 87 percent of all new HIV infections among 13- to 19-year-olds and 79 percent of HIV infections among 20- to 24-year- olds in the United States even though, together, they represent only about 32 percent of people these ages. Asian and Pacific Islanders (APIs) and American Indians and Alaska Natives account for about one percent of new HIV infections among young people ages 13-24.
  
  
• Young women of color suffer disproportionate rates - in 2007, African American/black and Latinas/Hispanics women accounted for 82 percent of new infections in 13- to 24-year-old women in the United States, even though, together, they represent only about 26 percent of U.S. women these ages. In addition, African American/black women account for 62 percent and Latinas for 19 percent of cumulative AIDS cases among women ages 13-24.[4]
  
  
• Most young men who have HIV acquired it through male-to-male sexual contact, and the risk is increasing for young men who have sex with men (MSM). Between 2004 and 2007, HIV/ AIDS cases among young men ages 13-24 who have sex with men increased across all ethnic groups, with young African American/black men most greatly affected.[5]
  
  • From 2004-2007, 87 percent of HIV/AIDS cases among young men ages 13-19 and 83 percent of HIV/AIDS cases among young men ages 20-24 were attributed to male-to-male sexual contact. [3]
    
    
  • Sixty-two percent of HIV/AIDS infections among young men who have sex with men were in African Americans/blacks; 17 percent in Latinos/Hispanics; and 19 percent in whites.[5]
    
    
  • From 2001-2005, cases of HIV/AIDS among young African American/black men ages 13- 24 who have sex with men increased by 70 percent.[5]

Sexual RISk BeHaVIoRS Put manY Young PeoPle In dangeR

• From 1991–2009, the percentage of high school students reporting that they had ever had sexual intercourse decreased from 54.1 percent to 46 percent. In 2009, 24.0 percent of Asian, 42.0 percent of white, 47.9 percent of Native Hawaiian or other Pacific Islander, 49.1 percent of Latino/ Hispanic, 59.4 percent of American Indian/Alaskan Native, and 65.2 percent of black students reported that they had ever had sexual intercourse. [6]
  
  
• In 2009, the percentage of high school students reporting that they had sexual intercourse with four or more people during their life was highest among black students (28.6 percent) and American Indian/Alaskan Native students (23.4 percent). Eighteen percent (18.4 percent) of Native Hawaiian or other Pacific Islander, 14.2 percent of Latino/Hispanic students, 10.5 percent of white students, and 5.2 percent of Asian students reported having four or more partners. [6]
  
  
• Among sexually active high school students in 2009, 61.1 percent reported using a condom at most recent sex. Male students were significantly more likely to report condom use than female students (68.6 percent versus 53.9 percent, respectively).The prevalence of having used a condom was during most recent sex was higher among white students (63.3 percent) and black students (62.4 percent) than Latino/Hispanic students (54.9 percent). [6]
  
  
• Research has shown that many young people are not concerned about becoming infected with HIV. [7] [8] In addition, young people experience many barriers to HIV testing and are more likely than other population groups to not get tested for HIV. [9] [10]
  
  
• In addition, many young people are unaware of their HIV status. Nationwide, only 13 percent of high school students have been tested for HIV. The prevalence of HIV testing was higher among black high school students (22 percent) than Latino/Hispanic (13 percent) and white (11 percent) students. [11] In 2006, 16 percent of young adults 18-24 reported that they had been tested for HIV in the past 12 months. [12] A study in six major cities found that among 15- to 22-year-old MSM in the United States, about three quarters of those testing positive for HIV were unaware they had the virus, and black MSM had nearly seven times greater odds of having unrecognized HIV infection as white men.[13]
  
  
• Concurrent partnerships (multiple simultaneous sexual relationships or sexual relationships that overlap in time) put many young people at greater risk for HIV infection.[14]

FactoRS WHIcH contRIBute to unequal RISk FoR HIV/aIdS

• Increasingly, scientists recognize sexual networks, or connections between people living in the same community, as a driving force behind the HIV epidemic, especially for African Americans. Young people living in communities with high HIV prevalence are more at risk for HIV even if risk behaviors are the same as young people living in a community with lower HIV prevalence. [15, 16, 17, 18]
  
  
• Dating violence and sexual assault play a role in HIV transmission. Twenty percent of youth report experiencing dating violence. Women who experience dating violence are less likely to use condoms and feel more uncomfortable negotiating condom use. In one study, half of girls who reported HIV or sexually transmitted infections (STIs) had been physically or sexually abused.[19, 20, 21, 22]
  
  
• A study among black women in the South, a region with unusually high rates of HIV, concluded that socioeconomic factors, including financial dependence on male partners, feeling invincible, and low self-esteem, place young black women at risk for HIV/AIDS.[23]
  
  
• Having an STI (sexually transmitted infection) puts youth more at risk for HIV.[24] Almost half of the U.S.’s over 19 million STI infections each year occur in youth ages 15-24.[25] A recent study found that one in four young women ages 15-19 has an STI.[26] Young people of color experience STIs in greater numbers that White youth - African American and Hispanic Latino youth constituted 68 percent of Chlamydia cases among young people ages 15-24 and 82 percent of gonorrhea cases among young people ages 15-24 even though they make up only 30 percent of the population.[27]

eFFectIVe StRategIeS FoR HIV PReVentIon among Young PeoPle

No single strategy will work to reduce HIV/AIDS infection among young people. However, research has shown that culturally competent, honest programs, that include information about abstinence, contraception, and condoms, can be effective in helping youth reduce risk behaviors.[28,29] In addition, open and honest parent-child communication about HIV and its prevention can aid youth in making good decisions.[30,31] Finally, resources must be directed at understanding the epidemic’s impact on youth; at remedying the socioeconomic disparities which contribute to the epidemic; and at developing and testing a vaccine.

Written by Jennifer Augustine, MPH, Division Director, Health and Social Equity

ReFeRenceS

1. HIV/AIDS Surveillance in Adolescents and Young Adults (Slide set).  Centers for Disease Control and Prevention, 2010. Accessed from http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.html on 12/2/2010.

2. Morris, M., Handcock, M.S., Miller W.C., Ford, C.A. Schmitz, J.L.,Hobbs, M.M., Cohen, M.S., Harris K.M., Udry J.R. Prevalence of HIV Infection Among Young Adults in the United States: Results from the Add Health Study. American Journal of Public Health. 2006 June: 96(6): 1091-1097.

3. HIV/AIDS Surveillance in Adolescents and Young Adults (Through 2007). Centers for Disease Control and Prevention, 2009. Accessed from http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/slides/Adolescents.pdf on 3/22/10.

4. Cases of HIV Infection and AIDS in the United States and Dependent Areas, by Race/Ethnicity, 2003-2007. HIV/AIDS Surveillance Supplemental Report, 2009: 14(No.2). Accessed from http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2009supp_vol14no2/pdf/HIVAIDS_SSR_Vol14_ No2.pdf

5. HIV/AIDS Surveillance in Men who have Sex with Men. Centers for Disease Control and Prevention, 2009. Accessed from http://www.cdc.gov/hiv/topics/surveillance/resources/slides/msm/slides/msm.pdf on 3/22/2010.

6. Centers for Disease Control and Prevention. Youth risk behavior surveillance system, United States 2009. Morbidity and Mortality Weekly Report 2010: 57(SS-5): 1-148.

7. Kaiser Family Foundation. National Survey of Teens on HIV/AIDS, 2000.

8. O’Sullivan L.F., Udell, W., Patel V.L. Young urban adults’ heterosexual risk encounters and perceived risk and safety: a structured diary study. Journal of Sex Research 2006; 43(4):343-351.

9. Henry-Reid, L.M., Rodriquez F, Bell, M.A. et al. Youth counseled for HIV testing in school-and hospital-based clinics. JAMA 1998; 90:287-92

10. Peralta, L., Deeds, B.G., Hipszer, S., Ghalib, K. Barriers and facilitators to adolescent HIV testing. AIDS Patient Care STDS. 2007; 21(6) 400-408.

11. Centers for Disease Control and Prevention. HIV testing among high school students—United States, 2007. Morbid- ity and Mortality Weekly Report June 2009: 58(24) 665-668.

12. Centers for Disease Control and Prevention. Persons Tested for HIV --- United States, 2006. Morbidity and Mortality Weekly Report August 8, 2008: 57(31); 845-849

13. MacKellar, D. et al, Unrecognized HIV infection, risk behaviors, and perception of risk among young men who have sex with me: opportunities for advancing HIV prevention in the third decade of HIV/AIDS. Journal of AIDS, Vol.38, No.5, 2005.

14. Gorback, P.M., Drumright L.N., Holmes K.K., Discord, dis- cordance, and concurrency: comparing individual and partnership-level analyses of new partnerships of young adults at risk of sexually transmitted infections. Sexual Transmit- ted Diseases. 2005 January; 32(1):7-12.

15. Millett et al. Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors. AIDS 21 (15) 2083-2091.

16. Adimora et al. HIV and African Americans in the Southern United States: Sexual Networks and Social Context. Sexually Transmitted Diseases 2006: 33 (7 suppl): S39-45.

17. Hallfors DD et al. “Sexual and drug behavior patterns and HIV and STD racial disparities: the need for new directions.” American Journal of Public Health 2007; 97(1): 125-132.

18. Adimora AA et al. Ending the epidemic of heterosexual HIV transmission among African Americans. American Journal of Preventative Medicine 2009: 37(5):468-471.

19. Roberts TA, Klein J. Intimate Partner Abuse and High-Risk Behavior in Adolescents. Archives of Pediatrics & Adolescent Medicine 2003; 157:375-380.

20. Silverman JG, Raj A, Clements K. Dating Violence and Associated Sexual Risk and Pregnancy Among Adolescent Girls in the United States. Pediatrics 2004;114(2):e220-e225.

21. Decker et al. Dating Violence and Sexually Transmitted Disease/HIV Testing and Diagnosis Among Adolescent Females. Pediatrics 2005; 116 (2): e272-276

22. Raiford, J.L. et al. Effects of fear of abuse and possible STI acquisition on the sexual behavior of young African American women. American Journal of Public Health 2009; 99(6): 1067-1071.

23. CDC. HIV Transmission among Black Women – North Carolina, 2004. MMWR 2005; 54(4); 89-92.

24. The Role of STD Detection and Treatment in HIV Prevention – CDC Fact Sheet, Centers for Disease Control and Prevention. Accessed from http://www.cdc.gov/std/HIV/STDFact-STD&HIV.htm on 4/1/08.

25. Weinstock, H., et al. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004;36(1):6- 10.

26. Centers for Disease Control and Prevention. Oral Abstract D4a – Prevalence of Sexually Transmitted Infections and Bacterial Vaginosis among Female Adolescents in the United States: Data from the National Health and Nutrition- al Examination Survey (NHANES) 2003-2004. 2008 National STD Prevention Conference. Accessed from http://www.cdc. gov/stdconference/

27. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009.

28. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Infections. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2007.

29. Alford S. Science and Success, Second Edition: Sex Education and Other Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections. Washington, DC: Advocates for Youth, 2008.

30. Resnick MD et al. Protecting adolescents from harm: findings from the national longitudinal study on adolescent health. JAMA 1997; 278:823-32.

31. Miller KS et al. Patterns of condom use among adolescents: the impact of mother-adolescent communication. Am J Public Health 1998; 88:1542-44.