STATEMENT OF
C. EVERETT KOOP, M.D., ScD
SURGEON GENERAL

U.S. PUBLIC HEALTH SERVICE

AND

DEPUTY ASSISTANT SECRETARY OF HEALTH

DEPARTMENT OF HEALTH AND HUMAN SERVICES

BEFORE THE
SELECT COMMITTEE ON CHILDREN, YOUTH, AND FAMILIES

U.S. HOUSE OF REPRESENTATIVES

JUNE 38, 1987
Mr. Chairman and members of the Committee:

I welcome the opportunity to appear before you on an issue of the
utmost concern to me -- teenagers and AIDS. Asa practicing
pediatric surgeon for over forty years, the welfare of children

and young adults has always been foremost in my thoughts.

Adolescents and pre-adolescents are those with behavior we wish
to especially influence because of their vulnerability when they
are exploring their own sexuality and perhaps experimenting with
drugs. Teenagers often consider themselves immortal, and these

young people may be putting themselves at great risk.

Extent of Risk

Some data provide information about the risk Américan teenagers

have for becoming infected with the AIDS virus.
Oo About 2.5 million teenagers are affected by sexually
transmitted diseases each year. In the United States, the
most frequent mode of transmission for the AIDS virus is
through sexual contact. —
o American teenage females experience about one million
unplanned pregnancies each year. These data indicate not
only the extent to which teenagers are sexually active, but
also the extent to which they might transmit the virus

perinatally.
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o More than 80 percent of unmarried males and 70 percent of
unmarried females self-report that they have experienced
intercourse at least once by age 20.
o About one percent of American high school seniors self-
report having ever used heroin, 16.7 percent report having
ever used cocaine, and 23.4 percent report having ever used
stimulants; all of these drugs can be taken intravenously.
Although teenagers generally do not inject drugs, those who
do and share needles are at increased. risk for infection

with the AIDS virus.

Since the most frequent mode of transmission for the AIDS virus
is through sexual contact, it is clear that teenagers are very
much at risk. To date, only one percent of all AIDS cases has
occurred among persons under age 20 (most of whom were infected
by transfusion or perinatal transmission); about 21 percent of
all cases have been diagnosed in the 20-29 age group. Since the
time between infection with the AIDS virus and onset of symptoms
may be several years, some proportion of those aged 20-29 who
have been diagnosed with AIDS were most likely infected as

teenagers.

Although these data demonstrate that many teenagers are at risk
of becoming infected, most teenagers do not believe they are.
Indeed, a random sample of 860 Massachusetts youth aged 16-19

revealed that while 70 percent reported they were sexually active
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only 15 percent of them reported changing their sexual behavior
because of concern about contracting AIDS; and only 20 percent of

those who changed their behavior used effective methods.

I believe that education about AIDS should begin at home so that
children can grow up knowing the behavior to avoid to protect
themselves from exposure to the AIDS virus. This behavior should
be reinforced in the schools. I recommended that parents
establish the biological and moral bases for sexual activity
early so that when their children become teenagers they will make
decisions about their sexual behavior that can eliminate the risk

of getting AIDS.

Most teenagers want to know more about AIDS. Ina public poll
conducted in the fall of 1986, 86 percent of parents questioned
agreed that sex education courses should be taught in school;
and, of those, 95 percent agreed that such courses should teach
l2-year-olds about the danger of AIDS. The Nation's system of
public and private schools can play a vital role in

assuring that all young people rapidly understand the nature of
the epidemic they face, and specific actions they can take to
protect themselves from becoming infected, especially during
their teenage years, as well as when they become adults. We
believe that: (1) the scope and content of AIDS education should
be determined locally and should be consistent with parental

at

values; (2) that information developed by the Federal government
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to educate young people about AIDS should encourage responsible
sexual behavior -- based on fidelity, commitment, and maturity,
placing sexuality within the context of marriage; (3) any health
anformation provided by the Federal government that might be used
in schools should teach that children should not engage in sex

before they are ready to marry.

These principles, approved by the President and cited by
Secretary Bowen in the AIDS information-plan, will be followed to
the fullest extent in the development of any Federal educational

material that might be used in schools.

According to information gathered during the winter of 1986, 40
of the Nation's 73 largest school districts were providing
education about AIDS, 24 more were planning such education. Of
the districts that provided AIDS education, 90 percent provided
it during 10th grade 63 percent provided it during 7th grade and
60 percent provided it during 9th grade. I agree with Mayor Koch
of New York that, in addition to not using IV drugs, abstinence
from promiscuous sexual activity or monogamy is the only way for

adolescents to avoid getting AIDS.

School Health Education
Because AIDS is a fatal disease, and because educating young
people becoming infected through sexual contact can be

controversial, health education programs about AIDS should be
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developed as quickly as possible by all school systems with
parental participation. In each community, parents,
representatives of the school board, school administrators and
faculty, school health services, local medical societies, the
local health department, students ( at appropriate grades),
religious organizations, and other relevant community
Organizations should be involved in planning and periodically

assessing programs of school health education about AIDS.

It is most important that teenagers receive education that
specifically would enable them to understand and avoid behaviors
associated with transmission of the AIDS virus. A single
pamphlet, a single filmstrip, a single lecture about AIDS will
not be sufficient. Similarly, education about the biology of the
virus, the symptoms of the disease, or the social and economic
consequences of the epidemic will do little to influence its
Spread. Programs need to be designed specifically to help
teenagers adopt the kind of behavior which will keep them from
contracting this disease. It is especially important that school
sex education programs emphasize to teenagers the need to refrain
from sexual intercourse until they are ready to establish a
mutually faithful, monogamous relationship. I believe that it is
possible to focus on preadolescent youngsters and produce a

generation of teenagers who will remain abstinent until they

develop a mature,monogramous relationship.
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Outlined below are some of the efforts being undertaken by
agencies of the Public Health Service that focus on the problem
of AIDS among teenagers. All of these programs are meant to
assist local organizations in establishing their own prevention

programs.

CENTERS FOR DISEASE CONTROL (CDC)

In fiscal year 1987, CDC will work with national educational
organizations and State and local departments of education to
develop information that may help schools across the Nation

implement effective education to prevent the spread of AIDS.

National Organizations
CDC will award cooperative agreements to about seven national
organizations that represent parents, school boards, school
administrators, teachers, medical professionals, church groups,
and other important professional and voluntary health and
education organizations. In addition, four awards will be made
to national organizations that respectively can develop AIDS
education programs for minorities, mainly Black and Hispanic;
develop programs for college students and develop programs so
that colleges of education deliver inservice and preservice
training to teachers so that they may be able to provide
effective education about AIDS. Finally, one cooperative

agreement will be awarded to a national organization that can
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help all 56 State and Territorial departments of education to
assist schools in their respective jurisdictions provide

effective education about AIDS.
State and Local Departments of Education

In 1987, CDC plans to award cooperative agreements to ten State
departments of education and 12 local departments of education
that serve jurisdictions with the highest cumulative incidence of
AIDS. Nineteen States that had reported 200 or more diagnosed
AIDS cases, and 18 cities that reported 150 or more cases, by the
last day of 1986, will be eligible for these awards. The purpose
of these agreements is to provide fiscal support and technical
assistance to help State and local education departments
implement intensive education about AIDS principally for school-

age youth, in and out of school.
Training and Demonstration Projects

In the fall of 1987, CDC will provide additional support to each
of three local and one State departments of education to also
establish training and demonstration projects. Support
consequently will be provided to at least 300 local and State
department of education personnel from other jurisdictions to
attend these projects and_ to receive assistance for implementing

effective school health education about AIDS in their own areas.
Development and Dissemination of Educational Curricula and

Materials

Technical and limited fiscal assistance will be provided to help
relevant private sector organizations develop, evaluate, and
disseminate a variety of scientifically accurate and effective
educational materials for school-age populations. CDC has
established a subfile on School Health Education about AIDS
within its Combined Health Information Database system, an
annotated computerized bibliography that can be easily accessed.
The file describes age-appropriate AIDS education materials,
curricula, programs, research, and resources that have already
been developed and how to acquire them. A compendium of selected

resources will be published and disseminated periodically.
Research and Evaluation

CDC will compile synthesize, apply, and disseminate the results
of research that could improve the effectiveness of school health
education to prevent the spread of AIDS; and will assist
national, State, and local agencies to evaluate and consequently

improve their program efforts.
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ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION (ADAMHA )

An example of research on AIDS. conducted by the National
Institute on Drug Abuse that focuses on teenagers is an AIDS
demonstration/training project entitled AIDS Prevention Among
High Risk Adolescent Populations. This-one year project to be
awarded in fiscal year 1987 is designed to identify specific
subsets of adolescent populations at the highest risk for AIDS
and develop strategies for reaching, communicating AIDS
information to, and counseling them. After an initial data
collection effort, experts will be brought together to review
what has been learned regarding informing and counseling
adolescents. A guide will be developed based upon clinical
experience and research. A training program will be tested and

developed, also.

In addition, a group of young people who appear to be at high
risk for contracting AIDS are adolescents who are homeless and
living on the streets or in shelters. The National Institute of
Mental Health, in collaboration with other PHS components and the
Administration on Children, Youth and Families, has organized a
workshop on June 22-23 on AIDS and Adolescents in Crisis to
discuss prevention, intervention and treatment for this high risk

group.
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HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA)

Two of the four AIDS Service Demonstration Program grant projects
administered by HRSA have components on adolescent prevention/

eduction:

oO The New York State Department of Health has awarded a
three year subcontract to the Institute for the
Protection of Lesbian and Gay Youth. HRSA and Robert
Wood Johnson Foundation grant funds are assisting them
in developing AIDS/HIV infection materials and teaching
strategies for adolescents, and provide direct
counselling services at a “drop-in center" to high risk
adolescents, some of whom are homeless, and many of

whom are or have been involved with prostitution.

° The Los Angeles Department of Health, AIDS Program
Office, has three subcontracts supported with HRSA
service demonstration funds, that reach adolescents in
Black and Hispanic communities in Central, South
Central, and East Los Angeles. The Watts Health
Foundation and the Minority AIDS Project are involved
with risk reduction education programs, outreach and

referral services targeted to minority youth. El
ll
Centro Human Services organization is attempting to
reach adolescents at risk, particularly IV drug
abusers, in a predominantly Mexican American area of

Los Angeles.
NATIONAL INSTITUTES OF HEALTH (NIH)

The National Institute of Child Health and Human Development
(NICHD) plans to support several research initiatives that are
expected to provide valuable information related to AIDS and
teenagers. NICHD will request grant applications for projects
that would describe and explain the behavior patterns that put
teenagers at risk of exposure to HIV and for projects to study
the processes by which individuals incorporate concerns about
sexually transmitted diseases and AIDS into decisions to be
sexually active and to use or not use contraceptives. The
Institute also plans to support seminars concerning AIDS for
obstetricians, gynecologists, and pediatricians. These seminars,
planned for the fall of 1987, will provide information for
further dissemination to other medical providers, patients, and

educators.

CONCLUSION
Although 148 cases of AIDS have been reported to date_among young

people aged 13 to 19; there is hope that:
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° AIDS is not common yet among adolescents.

° We know a lot and can know more about how to
effectively work with this age group.

oO For many of our teenagers, this would be a preventive
intervention, especially in very young teens. And
after all, it is easier to prevent some behavior than
to change it.

° AIDS may give us the impetus to deal knowledgeably and
effectively with a whole range of health-related

behaviors in adolescents.

Let me conclude with a quote from the Surgeon General's Report on
AIDS, “Those of us who are parents, educators, and community
leaders, indeed all adults, cannot disregard this responsibility
to educate our young. The need is critical and the price of
neglect is high. The lives of our young people depend on our

fulfilling our responsibility."

Thank you for the opportunity to testify. I would be pleased to

answer any questions.