Are younger generations getting the message about HIV/AIDS prevention?

Although safer sex messages have been a part of the curriculum at high schools and middle schools throughout the United States since the early part of the HIV/AIDS epidemic and news about HIV/AIDS has made headlines since the early 1980s, an increasing number of experts are concerned that younger generations of Americans are not getting the message about HIV/AIDS prevention.

These concerns are based on more than merely anecdotal evidence. Research conducted last year by the CDC using data from 34 states (those with long-term confidential name-based HIV infection reporting) indicated that between 2004 and 2007, there were 5,575 new diagnoses of HIV among patients aged 13 to 19 years and 16,680 new diagnoses of HIV among patients aged 20 to 24 years.

Experts say the real number of HIV/AIDS cases in the United States is certainly higher than these figures indicate because the CDC only had data for 34 states, and the number of undiagnosed cases – particularly in younger patients who often have not yet experienced symptoms of HIV – is, most likely, significant.

"America’s youth continue to be significantly and disproportionately affected by HIV and other STDs," said Kevin Fenton, MD, director of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. "Nearly half – 48% – of infected youth have not been diagnosed and are unaware that they are infected. Many youth continue to become infected each year; in 2006, more than a third of new HIV infections occurred among those under the age of 30."

Perception of risk

Several experts who spoke with Infectious Diseases in Children for this article said there is a lack of awareness among many young people today about the risk for HIV/AIDS. Despite the statistics, many adolescents and young adults in the United States do not consider themselves to be at risk for HIV.

"Many of the adolescents I have worked with are aware of HIV/AIDS, but not aware that they may be putting themselves at risk for the disease in certain situations," Robert Johnson, MD, director of adolescent and young adult medicine and interim dean at New Jersey Medical School in Newark, N.J., told Infectious Diseases in Children. "Many of these young people simply do not think they could ever get HIV."

Heidi Schwarzwald, MD, MPH, associate professor of pediatrics at Baylor College of Medicine in Houston and vice president for clinical affairs at the Baylor International Pediatric AIDS Initiative, agreed that many adolescents do not believe that the risk for contracting HIV may apply to them.

"Most young people think they are not at risk," she said. "Data from the most recent Youth Risk Behavior Survey indicated that more than one-third of adolescents did not use a condom during their last sexual encounter. This was based on self-reported data, so the reality is that probably even fewer used a condom."

The attitude that many young people have toward HIV/AIDS may be due, in part, to the history of the epidemic in this country.

"In the early 1980s, when the epidemic began, HIV/AIDS was not recognized as a disease of young people," Rolando M. Viani, MD, associate professor of clinical pediatrics in the division of infectious diseases at the University of California, San Diego, said in an interview with Infectious Diseases in Children. "At that time, it was seen as a disease that primarily affected gay white men. Prevention and education efforts in the early days were often geared toward this population. There was virtually no outreach to young people."

However, as the HIV/AIDS epidemic evolved, other populations emerged as groups that should be considered at-risk, including urban populations, women and younger people.

Viani said he believes there is now "a silent epidemic" of HIV/AIDS among younger people in the United States. He said it is a silent epidemic because there is a lack of awareness of the risk for HIV among adolescents and, most likely, a high percentage of undiagnosed cases among this patient population.

"In the 1980s, many people who were at-risk for HIV/AIDS were aware of the disease and aware of its consequences," Viani said. "By the mid-1990s, with the development of highly active antiretroviral therapy, many Americans – and young people, in particular – began to see that HIV can be treated like any other illness. In some ways, this created a false sense of security. Young people today have not seen the epidemic killing their friends and partners like those at-risk did in the 1980s. Among many young people, this has led to the development of a somewhat nonchalant attitude about HIV risk. Many young people do not understand the difficulties they will face if they acquire HIV infection and the enormous challenge of HIV treatment."

Douglas Kirby, PhD, senior research scientist at Education, Training and Research Associates in Scotts Valley, Calif., said that young people’s perception of HIV/AIDS risk often varies by community and that young people who know someone who is HIV- positive are more likely to be aware of their risk for the disease. "If the young person is straight and white, there is often little concern about the risk for contracting HIV," Kirby told Infectious Diseases in Children.

But Kirby said he has found that adolescents and young adults who are in higher risk categories often have a higher perception of risk. "Among young men who have sex with men, the perception of risk is typically higher," Kirby said. "Also, I have found that the perception of HIV risk is often higher among black young people, particularly those who live in areas where HIV is more prevalent."

Targeting younger people

Viani said adolescents and young adults are notoriously a difficult population to reach for a variety of reasons. "One reason is that young people are typically usually healthy, so they don’t use the health care system," Viani said. "This makes them less likely to have regular contact with a health care provider who may talk to them about their risk. Also, younger patients who are HIV-positive may not have symptoms for which they seek medical help. Therefore, they remain undiagnosed for lengthy periods of time."

Schwarzwald said health care providers may need to develop unique methods of targeting adolescents. She mentioned a program in Houston that has been successful in recent years. "For the last three summers in Houston, there has been a ‘Hip Hop Concert for HIV,’" she said. "The price of admission is getting tested for HIV. This concert has successfully tested in one day almost as many people as are usually tested in the city of Houston during the course of a year."

Most experts agree that education about HIV/AIDS directed at young people can and should take place in several environments, including in the home, at school and in the office of a health care provider.

Johnson said he encourages parents to get more involved and to help educate their children about sexuality and the risk for HIV. "My belief is that sex education works best when done in the home," Johnson said. "Schools can play an important role as well, but the best teachers are parents and people in the family. I have found that adolescents who have discussions with their parents about sex are less likely to engage in unprotected sex and are more likely to make healthier sexual decisions."

Kirby, who has worked on various HIV/AIDS education and prevention programs designed for middle school and high school students, said studies have shown that age-appropriate programs can successfully help to influence young people to reduce their risk of contracting HIV.

"A recent review indicated that 68% of comprehensive HIV/AIDS education programs had a positive impact on one or more sexual behaviors among young people and that 38% had a positive impact on two or more sexual behaviors," Kirby said. "These results were seen not only in programs in the United States, but in other countries as well." The study was published in Sexuality Research and Social Policy; sexual behaviors documented in the studies included abstinence, fewer partners and condom use.

Kirby said programs that have been most successful in reaching adolescents have been those that actively involve the students more. "We have found that young people are more likely to tune out if the programs simply involve someone standing in front of them lecturing," he said. "Programs that are more engaging and help students personalize risk and learn refusal skills are likely to be more successful."

Controversy

Despite the successful effects that sex education programs in schools have had on HIV prevention, such programs often provoke controversy. In the United States, various religious and conservative groups have been critical of comprehensive sex education in public schools.

The issue became even more contentious during the eight years of the George W. Bush administration. Because of policies set forth by the Bush administration, there was a strong push for abstinence-only education in schools. Those programs stress that abstinence is the only foolproof method to prevent HIV and other STDs, as well as pregnancy. But these programs are often criticized for failing to educate students about safer sex practices, which leaves them uneducated and unprepared if or when they do begin to engage in sexual activity.

"Abstinence-only education programs do not work, and there are a number of problems with this type of approach," Viani said. "Data show that 50% of high school students are sexually active. By senior year, 70% of students have engaged in sexual activity. So if there is an abstinence-only message, these kids are tuning it out altogether."

Viani said he believes abstinence is an important message for adolescents, but it is only part of the message. "If the majority of adolescents are having sex, they need to know about harm reduction and safer sex practices," he said.

Johnson agreed with this assessment.

"Research by the CDC shows that there is good evidence for the effectiveness of comprehensive sexual education, but not for abstinence-only education," he said. "Abstinence-only education does not provide young people with the skills and knowledge they need. We should not be spending more money on these types of programs."

Education aimed at younger people may need to differ from that aimed at adults and may need to begin before sexual activity begins.

"The message about safer sex should be given earlier – even as early as elementary school," Viani said. "Messages can be tailored to be age-appropriate but should be given every year. The education can be a simple message about prevention and education but should be given through elementary, middle and high school."

Schwarzwald agreed that repetition of the message over many years is key. "It has to be consistent messages over a long period of time," she said. "You have to work with young people to build the skills they need to confidently negotiate sex, condom use and saying no. It takes a sense of self worth to consider your body worth protecting. Simply trying to ‘scare’ adolescents does not work."

Kirby said a clear and honest approach is optimal for sex education in adolescents. "When educating young people about sex and HIV/AIDS risk, the discussion should be practical and informative," he said.

Kirby also said that HIV/AIDS education programs should begin earlier. "It is best to begin programs before many young people have ever had sex," he said.

Adolescents in minority groups

A closer look at the statistics indicates that a high percentage of HIV cases are among men who have sex with men. The CDC data indicated that 87% of male patients aged 13 to 19 years who were newly diagnosed with HIV said male-to-male sexual contact was the source of transmission. Among newly diagnosed men aged 20 to 24 years, male-to-male sexual contact was cited as the source of transmission among 83% of patients.

These figures are frustrating for many HIV/AIDS experts because they indicate that younger generations of men who have sex with men have not internalized the message about safer sex and the risk of HIV/AIDS. In the early days of the HIV/AIDS epidemic, health groups such as Gay Men’s Health Crisis often led the way on HIV/AIDS education and prevention programs and significant education and prevention efforts were directed at MSM.

Some experts said there seems to be a generational attitude among younger MSM that HIV/AIDS is a disease of the past and that younger people today are not at risk.

Black adolescents have also been disproportionately affected by the HIV/AIDS epidemic. It has previously been well-established that in the United States, the HIV/AIDS epidemic has affected blacks in higher numbers than their white peers; this disparity extends to younger people as well. Seventeen percent of the total population of adolescents aged 13 to 19 years in the 34 states for which the CDC had data is black; yet the CDC data indicated that black adolescents represented 72% of the number of newly diagnosed HIV cases in these states in 2007.

CDC data also indicated that in the United States, the rate of new infections among black males aged 13 to 29 years is seven times higher than the rate for white males in the same age group and three times higher than the rate for Latino males in the same age group. The rate of new infections among black females aged 13 to 29 years is 11 times higher than the rate for white females in the same age group and four times higher than the rate for Latina females in the same age group.

Heterosexual contact

High-risk heterosexual contact is accounting for an increasing number of HIV/AIDS cases among adolescents; the rate of HIV acquisition among young women is increasing as well.

The CDC data showed that in younger age groups, women represent a high percentage of the total number of patients with HIV. In 2007, in the 34 states for which data were available, 31% of patients aged 13 to 19 years who were diagnosed with HIV infection were women. In comparison, 23% of patients diagnosed with HIV aged 20 to 24 years were women and 26% of patients diagnosed with HIV aged 25 years and older were women.

The data also indicated that from 2004 through 2007, most HIV/AIDS cases diagnosed among adolescent and young adult females were attributed to high-risk heterosexual contact. According to the CDC, between 2004 and 2007, there were 1,920 new cases of HIV among girls aged 13 to 19 years in the 34 states for which data were available. Of these cases, 1,694 were attributed to high-risk heterosexual contact. Among women aged 20 to 24 years, there were 4,417 new cases of HIV during this time. Of these, 3,846 were attributed to high-risk heterosexual contact. High-risk heterosexual contact was defined as having sex with someone known to have HIV or with someone at risk for HIV.

Efforts continue

Health officials are continuing to sound the alarm about HIV/AIDS risk among adolescents. New efforts are continuing to direct prevention and education efforts toward this population. Now that George W. Bush is no longer president, many expect the emphasis on abstinence-only sex education will end.

"Young Americans’ vulnerability to HIV and other STDs underscores the need for prevention efforts for this population," Fenton said. "It is important to understand the range of risk factors for youth, including lack of awareness and use of condoms, multiple partners, socioeconomic factors, stigma, and substance or alcohol abuse. Although abstinence and mutual monogamy with an uninfected partner are the best ways to prevent HIV or STD infections, it is also important for adolescents to understand and have access to the range of HIV prevention options. For those who are sexually active, it is critical that they know their HIV status."

Fenton said the CDC is increasing its efforts to expand HIV/AIDS prevention and education programs aimed at adolescents. "CDC is committed to working with its partners to reduce the burden of HIV and other STDs among young people," he said. "CDC is working with community partners, as well as state and local health departments, to implement programs to reach young people at risk. We are also working with partners and health care providers to continue to increase STD and HIV risk assessment, screening, treatment, and education for young people and others at risk." – by Jay Lewis

For more information:

• Hall H, et al. JAMA. 2008;300:520-529.
• Dilorio C, et al. Am J Public Health. 2007;97:1084-1089.
• Kirby D. Sexuality Research & Social Policy. 2008;3:18-27.