Fact Sheet: Number 1 (1994)

Preventing HIV/STD Among Adolescents

The sexually transmitted diseases, including human immunodeficiency virus infection and acquired immunodeficiency syndrome, are an increasing health problem in our country. They affect more than 40 million people with about 12 million new infections occurring each year.

Incidence Among United States Adolescents

• Among all sexually active people, teenagers have the highest rates of STD. At least 25% of sexually active teenagers have contracted an STD.
• AIDS cases and HIV infection are increasing among adolescents, with over 1400 AIDS cases occurring through September 1993.
• Among adolescent AIDS cases, older teens, males, and racial and ethnic minorities have been disproportionally affected. However, the number of female adolescent AIDS cases has recently outnumbered male adolescent AIDS cases.
• Every year 3 million adolescents one out of every eight are infected with an STD.
• A teenager in the U.S. gets an STD about every 13 seconds, with urban, low-income and female adolescents being particularly affected.
• The number of adolescent cases of many STDs, such as chlamydia, genital herpes, genital warts, and gonorrhea, have increased dramatically in recent years.

Determinants of HIV/STD Risk in Adolescents
Several determinants, including behavior, social, medical and institutional factors, contribute to HIV/STD in adolescents.

Coitus. Sexual intercourse places an adolescent at risk for HIV/STD. Most studies of adolescent coitus incidence have found basically similar results, with slight percentage declines in the past few years. A recent Centers for Disease Control and Prevention (CDC) study found that about 40% of ninth graders, about 48% of tenth graders, about 57% of eleventh graders, and about 72% of twelfth graders report ever having coitus.

Age of Initial Coitus. In recent CDC studies, adolescents who had coitus earlier in life reported a greater number of sexual partners. For example, 75% initiating coitus before age 18 reported having two or more partners, with only 20% of those starting after age 19 reporting more than one partner. The median age of first sexual intercourse was about 16 years old for males, and about 17 years old for females.

Number of Sexual Partners. Having multiple sexual partners over a short time period and during a lifetime increases HIV/STD risk. CDC reports that about 16% of 14-19 year olds reported four or more sexual partners.

Condom Use. The proper and consistent use of latex condoms during coitus can greatly reduce a person's risk of acquiring or transmitting HIV/STD. Condom use by sexually active adolescents appears to be increasing. However, a recent CDC study of adolescents aged 14-19 years found for those who had sex in the preceding three months, only 58% used a condom during the last coitus. Another CDC study reported that only 41% of 9-12th grade students with four or more partners used condoms.

Drug and Substance Use. Sharing injecting drug needles can expose one directly to HIV. Also, using alcohol and other drugs such as crack cocaine impairs judgment and increases high-risk behaviors. CDC found that about 1 in 70 high school students report having injected an illegal drug and about 18% of 12-19 year olds reported an episode of heavy drinking in the past 30 days.

Problem Behaviors. Studies have shown that adolescents are more likely to engage in high-risk sexual behavior when also participating in other problem behaviors such as anti-social behavior, cigarette smoking, alcohol use, and illegal drug use.

Attitudes. Feelings of invulnerability and hopelessness among adolescents encourage risk-taking. Low self-esteem and inadequate self-efficacy are associated with risk behavior. Negative attitudes about sexuality in young adults have been found to interfere with sexual communication and the performance of prevention acts.

Social/cultural Conditions. Poor role models, dysfunctional family life, and negative socioeconomic conditions may contribute to high HIV/STD prevalence in adolescents. Cultural ambivalence about sexuality and media glorification of sex without adequate prevention messages produce confusing images about sex.

Institutions. Easy access to HIV/STD health services is an important component of prevention. Unfortunately, accessibility is a problem for many adolescents, particularly those at greatest risk. Even though schools have many advantages in promoting HIV/STD prevention, many do not have adequate HIV/STD education programs.

Youth in High-risk Situations. Some adolescents are at a higher HIV/STD risk primarily because of societal conditions beyond their capacity to alter. Such youth include, for example, those who have run away or been rejected by their family, are homeless, are incarcerated, or have dropped out of school. Further, gay, lesbian, and bisexual youth, certain racial/ethnic groups (including African American and Hispanic/Latino youth in inner cities and Native American youth), young women, youth in rural and smaller communities, and youth with hemophilia and other coagulation disorders are at higher probability of being at risk for HIV/STD. Certainly, the practice of specific behaviors -- and not merely being a member of a certain group -- places one at risk for HIV/STD.

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Prevention Efforts
A comprehensive approach including accessible and improved health services, improved socioeconomic conditions and quality education has the most promise of controlling HIV/STD in adolescents. Better diagnostic, treatment, and counseling services can enhance prevention efforts. Attention to improving overall health behavior, school performance, home and family life, and peer choice, for example, would be valuable. Control programs should address the determinants of adolescent risk for HIV/STD. Also, research on effective behavior change strategies and programs should be conducted.

Educational programs designed to increase adolescent self-efficacy in practicing HIV/STD prevention and risk reduction are an important key to overall control efforts. Schools, youth-serving organizations, and minority organizations must conduct HIV/STD prevention programs. Special attempts should be made to reach out-of-school youth and youth in high-risk situations, such as runaway, migrant, incarcerated and homeless adolescents. HIV and STD prevention messages should be combined into one program.

Research on specific, school adolescent HIV/STD and sexuality education programs have shown positive results, such as delaying onset of coitus, increasing the use of protection against HIV/STD and pregnancy, and reducing the frequency and number of sex partners. Research studies of sexuality and HIV/STD education programs revealed that such programs do not hasten the start of coitus in adolescents. The successful programs (1) had a narrow focus on reducing specific sexual risk-taking behaviors, (2) emphasized the modeling and practice of prevention and risk reduction skills, (3) reinforced values and group norms against unprotected sex, and (4) discussed social pressures to have unprotected sexual activity.

The U.S. National Commission on AIDS recently made several recommendations concerning educational approaches for HIV prevention in adolescents, which are also applicable to a combined HIV/STD education program.

• HIV prevention programs should include information, examination of values and attitudes, skill building such as decision-making, negotiation, and refusal, and access to health care and social services.
• School-based HIV education should be presented as part of a comprehensive health science education curriculum that begins in elementary school, includes sexuality education and teaches general prevention skills.
• Schools and other youth-serving institutions should select curricula and teaching strategies that have been shown to be effective by evaluation.
• Parents and young people should be involved in the development of prevention programs.
• HIV prevention programs must be culturally and specific population sensitive, developmentally appropriate, nonjudgmental in approach, repeated, sustained over time, and complemented with efforts to change behavioral norms and to empower individuals.
• Utilizing peers as educators can be valuable if combined with other approaches in a comprehensive program.
• Prevention efforts limited to instilling fear or that omit important information will not facilitate wise health behavior or sustain risk reduction.
• Abstinence messages, such as postponing sexual activity, should be included, and adolescents that choose abstinence should be supported.
• Information and skill enhancement about methods of HIV/STD prevention other than abstinence, such as use of condoms, should be included. This information is needed immediately by the sexually active youth and by some who will be active in the future.
• Educational strategies dealing with prevention must be dealt with in a manner acceptable to the community. However, withholding complete prevention information can place adolescents at risk for HIV/STD.

Sources of Information
The information for this FACT SHEET was primarily derived from publications of the U.S. Centers for Disease Control and Prevention, the U.S. National Commission on AIDS, and the U.S. Department of Health and Human Services.

Biglan, A., Metzler, C. W., Wirt, R., Ary, D., Noell, J., Ochs, L., French, C., & Hood, D. (1990). Social and behavioral factors associated with high-risk sexual behavior among adolescents. Journal of Behavioral Medicine, 13, 245-261.

Fisher, W. A. (1990). All together now: An integrated approach to preventing adolescent pregnancy and STD/HIV infection. SIECUS Report, 18(4), 1-11.

Kirby, D., Short, L., Collins, J., Rugg, D., Kolbe, L., Howard, M., Miller, B., Sonenstein, F., & Zabin, L. S. (1994). School-based programs to reduce sexual risk behaviors: A review of effectiveness. Public Health Reports, 109, 339-360.

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