National Commission on AIDS

WASHINGTON, DC *« UNITED STATES OF AMERICA

 

“
 

JUNE 1993

Preventing HIV/AIDS
in Adolescents

National Commission on AIDS

WASHINGTON, DC * UNITED STATES OF AMERICA

 
The National Commission on Acquired Immune Deficiency Syndrome (AIDS) was
established by Public Law 100-607 “‘for the purpose of promoting the development of a
national consensus on policy concerning AIDS and of studying and. making
recommendations for a consistent national policy” concerning the HIV epidemic. The
Commission is a bipartisan body whose members were appointed by the President, the
United States Senate, and the United States House of Representatives.

Further information on the work of the Commission is provided at the end of this document

or can be obtained from Roy Widdus, Ph.D., Executive Director, National Commission
on AIDS, 1730 K Street, N.W., Suite 815, Washington, D.C. 20006. ‘

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NATIONAL COMMISSION ON AIDS

June E. Osborn; M.D., Chairman .
David E. Rogers, M.D., Vice Chairman
The Honorable Diane Ahrens
K. Scott Allen
Don C. Des Jarlais, Ph.D.
Eunice Diaz, M.S., M.P.H.
Mary D. Fisher
Donald S. Goldman, Esq.

Larry Kessler
Charles Konigsberg, Jr., M.D., M.P.H.
The Honorable J. Roy Rowland, M.D.

Ex Officio

Les Aspin, Ph.D., Secretary of Defense
Donna E. Shalala, Secretary of Health and Human Services
Jesse Brown, Secretary of Veterans Affairs

Department Representatives

Department of Defense
Col. Michael R. Peterson, D.V.M., Dr.P.H., Executive Secretary, Armed Forces
Epidemiological Board

Department of Health and Human Services
National AIDS Program Office
Valerie Setlow, Ph.D., Acting Director

Department of Veterans Affairs
Irwin Pernick, J.D., formerly Counselor to the Secretary,
presently, Associate Deputy Assistant Secretary for Policy
Marvelu R. Peterson, Ph.D., Associate Director, AIDS Services

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COMMISSION STAFF

Roy Widdus, Ph.D., Executive Director
Thomas D. Brandt, M.L.S.
Tracy L. Brandt
Megan L. Byrd
Adriana Carmack
Jason Heffner, M.Ed.
Sherell Jackson
Carlton H. Lee, Jr.
Juanita O. Pendleton
Tracy J. Shycoff
Patricia Sosa, Esq.
Vicky M. Tsaparas

Editor

Linda C. Humphrey

Consultant

Susan A. Messina

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TABLE OF CONTENTS

Preface

Acknowledgments

Introduction

HIV and Other Sexually Transmitted Diseases Among Adolescents

Adolescent Alcohol and Other Drug Use

Adolescent Developmental Issues

Cultural Diversity and Language Issues |

Health and Social Service Needs of Adolescents

Social and Economic Contexts: Youth in High-Risk Situations
Adolescents with Hemophilia and Other Coagulation Disorders
Runaway and Homeless Youth

Youth in Detention

Youth Who Use Alcohol and Other Drugs and Their Sexual Partners
Out-of-School Youth

Gay, Lesbian, and Bisexual Youth

Survivors of Childhood Sexual Abuse

Immigrant Youth

African American, Hispanic, and Other Youth of Color

Young Women

Youth in Smaller and Rural Communities

The Role of the Media
The Role of Schools in HIV Prevention
The Role of Other Youth-Serving Organizations In HIV Prevention

Parental and Youth Involvement

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ONDDAANNNN OO or

<o

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The Critical Links: Information, Attitudes, Skills Building, and Access
to Services

Information
Exploration of Attitudes and Values
Skills Building
Access to Services
School-Based HIV Education
Recommendations
References
APPENDIX A: Hearing Agendas

APPENDIX B: Resources on HIV/AIDS and Adolescents

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PREFACE

During the past four years, the National Commission on AIDS has conducted public
hearings and site visits to foster a greater understanding of the challenges facing our
nation as it confronts the HIV/AIDS epidemic. These activities have served as a crucial
part of the Commission’s effort to meet its statutory mandate under PL 100-607 of
“promoting the development of a national consensus on policy concerning AIDS.”

The Commission has heard compelling testimony on the importance of and need for a
comprehensive HIV/AIDS prevention strategy that reaches all Americans. We called for
such a national prevention initiative in our 1991 report, America Living With AIDS.

In various hearings, notably in Chicago on March 13, 1991, and recently in Austin,
Texas, on March 11, 1993, we heard specifically about the concerns of adolescents and the
need for expanded and improved youth-focused HIV/AIDS prevention strategies. Here
we outline conclusions the Commission has drawn in this area after listening to diverse
individuals and organizations that have been kind enough to share their experience and
wisdom with us. :

This report predominantly addresses what we must do to prevent further HIV infection
among adolescents. This should not divert attention away from the need to properly
address the needs of adolescents already living with HIV disease. Even though some risks
of HIV to adolescents are now under control—such as transmission through blood
transfusions, or through clotting factors to persons with hemophilia—no one should be
ignored.

The Commission believes that the challenges raised in this report warrant attention
and present opportunities for improving the nation’s response to the HIV/AIDS epidemic.
Rapid implementation of the recommendations made in this report—at federal, state, and
local levels—is essential. We owe this to future generations.

June E. Osborn, M.D. David E. Rogers, M.D.
Chairman Vice Chairman

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ACKNOWLEDGMENTS

The Commission is indebted to the many individuals whose dedication and expertise
guided its work and understanding of HIV/AIDS prevention and the adolescent population.
Aiding in the development of the Commission’s views were a variety of witnesses at
many hearings. The hearings in Chicago, Illinois in March 1991 and Austin, Texas in
March 1993 were specifically focused on youth issues and the testimony of the witnesses
at those hearings provided the foundation for this report. We also thank witnesses who
touched on these issues within hearings on broader topics.

Major assistance in preparing this document was provided by the Center for Population
Options (CPO). The Commission would like to thank the following individuals from
CPO for their efforts: Margaret Pruitt Clark, Jennifer Hincks Reynolds, J ay Coburn, and
Pamela Haugton-Denniston,

Amongst the other organizations that were helpful i in the report’ S preparation were
the American Red Cross Office of HIV/AIDS Education and the Centers for Disease
Control and Prevention.

We would like to thank all those individuals who commented on and assisted in the
development the report, particularly: Constance T. Cordovilla, Katherine Fraser, Brenda
Greene, Debra Haffner, and Dr. Heather Huszti.

Mr. Ted Karpf, and members of the staff of the CDC National AIDS Clearinghouse
are due the Commission’s gratitude for the work they did i in preparing a resource guide for
this report (Appendix B).

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Preventing HIV/AIDS in Adolescents

introduction

The HIV/AIDS epidemic threatens a new generation of Americans. Adolescents are
vulnerable to infection owing to a combination of behavioral, social, and in some cases

economic forces. Halting the spread of HIV among America’s adolescents requires, at the
minimum, a Clear understanding of:

¢ — the range of sexual and drug-taking activities in which young people engage;

* adolescent developmental issues and how to broaden adult/parental recognition
of these issues;

e the health and social service needs of adolescents;
¢ — the social and economic contexts in which many young people live;

¢ the range of values and attitudes that individuals associate with drug-using - -
and sexual behavior;

° the combination of knowledge, attitudes, skills, and services necessary to influence
behavior change; and

¢ the role of parents, schools, and other youth-serving organizations, as well as
young people themselves, in prevention.

Helping young people protect themselves from HIV also requires swift action to
break down barriers to offering young people the comprehensive HIV education and
services that they need. Greater action at all levels, particularly leadership from the federal
level, is necessary to address the prevention of HIV infection in adolescents.

HIV and Other Sexually Transmitted Diseases Among
Adolescents

HIV infection is spreading rapidly among teens. By the end of March 1993, 1,167
cases of AIDS among teenagers ages 13 to 19 were reported to the Centers for Disease
Control and Prevention (CDC, 1993b). Although the number of reported AIDS cases
among adolescents is relatively low (see table 1), the low number masks the true picture of

Preventing HIV/AIDS in Adolescents 1

 

 
 

Table 1: Cumulative AIDS Cases in Adolescents by Exposure Category and
Sex, Reported through March 1993, United States

 

 

Exposure Category 13-19 years
No. %
Males
Men who have sex with men 228 34%
Injection drug use 50 7%
Men who have sex with men and inject drugs . 37 6%
Hemophilia/coagulation disorder 278 41%
Heterosexual contact | 19 3%
Blood/blood product disorder 28 4%
Undetermined risk 31 5%
Total males 671
Females
Injection drug use 72 26%
Hemophilia/coagulation disorder 4 1%
Heterosexual contact 131 48%
Blood/blood product disorder 29 11%
Undetermined risk 39 14%
Total females 275

 

Source: CDC, 1993b.

adolescent HIV infection. Given the period of roughly ten years between infection with
HIV and onset of AIDS-related symptoms, it is more useful to look at the 20- to 29-year-
old age group to ascertain how infections in the teen years are likely to contribute to AIDS
cases of young people in their twenties. By March 1993, 10,949 AIDS cases were reported
among 20- to 24-year-olds and 44,171 among 25- to 29-year-olds (CDC, 1993b). These
young persons represent about 20 percent of people with AIDS—and were probably
infected with HIV as teenagers.

National studies indicate varying infection rates for teens. Among teenagers who
applied for military service between 1985 and 1989, 1 in 3,000 tested positive for HIV; for
African American teens, the infection rate was 1 in 1,000 (Burke et al., 1990). Among
U.S. Job Corps entrants between 1987 and 1990, more than 1 in 300 young people ages 16
to 21 tested positive for HIV. Among African American and Hispanic entrants aged 21,
the infection rate was nearly 1 in 80 (St. Louis et al., 1991). Both studies found higher
rates of infection among women than men in the 16 to 18 age group. Native American
youth also had higher rates of infection than whites. .

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2 Preventing HIV/AIDS in Adolescents
 

About half of the 20,000 people with hemophilia in the United States are HIV
positive; almost all were infected prior to 1985 when the U.S. blood supply was not tested
for HIV (Goldsmith, 1990; Kastor, 1993). Many of those individuals are teenagers. In
many cases, when children with hemophilia underwent HIV antibody testing prior to
adolescence, their parents were notified of their HIV-positive status, but the children were
not. This issue has been addressed by the network of hemophilia treatment centers.

U.S. teenagers engage in sexual behaviors that put them at risk for contracting HIV.
According to a 1990 study by the CDC, 39.6 percent of ninth graders, 47.6 percent of
tenth graders, 57.3 percent of eleventh graders, and 71.9 percent of twelfth graders report
ever having had intercourse (CDC 1992c). More than 19 percent of all high school
students have had four or more sexual partners. Male students were significantly more
likely than female students (26.7 percent versus 11.8 percent) to report having four or
more sexual partners (CDC, 1992).

While latex condom use among adolescents is rising, many young people still engage
in unprotected intercourse. Only 41 percent of students with multiple sexual partners in
1990 reported using condoms at last sexual intercourse; only 45 percent of all sexually
active students reported using condoms at last sexual intercourse (CDC, 1992a).

Rates of sexually transmitted diseases (STDs) in the adolescent population are
skyrocketing. Every year, three million teens—one out of every eight—are infected with
an STD (CDC, 1993c). Lesions from STDs such as occur with syphilis and genital herpes
are thought to facilitate the transmission of HIV (Quinn et al., 1988).

Adolescent Alcohol and Other Drug Use

The use of alcohol and other drugs by adolescents poses significant threats to their
health in many ways, including the likelihood of engaging in sexual behavior. Under the
influence of mind-altering substances, young people’s judgment is impaired and inhibitions
are lowered, which may lead them to engage in risky sexual behavior.

Eighty-nine percent of high school seniors report having tried alcohol (NIDA, 1991).
Four out of ten high school seniors report having tried marijuana (Bachman et al., 199 1).
Nine percent of high school seniors report ever having tried cocaine, and about 4 percent
report having tried crack (NIDA, 1991).

The most recent data released by the National Institute on Drug Abuse (NIDA)
suggest that while drug use among high school seniors has been gradually declining over
the past decade, more eighth graders are using illicit drugs (Portner, 1993).

Adolescent Developmental Issues

The formation of healthy sexual attitudes and behaviors is a necessary process for
every individual as he or she progresses from child to adult. Many adults, particularly
parents, are, however, ambivalent toward the emerging sexuality of teenagers. Unless
adult ambivalence and reluctance to discuss adolescent sexuality are dealt with, adolescents

will not be properly prepared for healthy futures. Adults are important role models in this
regard. .

Preventing HIV/AIDS in Adolescents 3

 

 
Adults do not always understand the crucial role that adolescent risk-taking plays in
the maturation process. One of the major developmental “tasks” necessary for teens to
accomplish on their way to adulthood is emancipation and independence from their
families. Pushing boundaries, testing limits, and questioning adult authority are ways for
young people to move to adulthood. While risk-taking behavior is a natural part of
adolescent experience, the presence of HIV makes sexual and drug-taking behaviors
particularly dangerous today.

Cognitive development also plays a role in teens’ ability to make wise decisions on
the road to independence. Teens in early adolescence (ages 12 to 14) are, in general,
concrete thinkers; they have difficulty projecting themselves into the future. “{T]hey are
less able to see the implications of their actions on their futures, and also are less able to
take responsibility for their actions and the consequences of their actions when they
occur” (Howard, 1993, p. 84).

There is debate about the role that “invulnerability” plays in adolescent risk taking.
Some argue that young people in middle to late adolescence have a strong sense of
personal invulnerability that allows them to deny the possibility of harm or danger stemming
from their actions. Others argue that for some young people, particularly the most
disenfranchised minority youth, it is not personal invulnerability that is operative, but
rather a loss of hope for the future (Fullilove, 1991). A recent study suggests that young
people judge risk in ways very similar to the way their own parents do. When 199
adolescents ages 12 to 18 and their parents were asked to evaluate the relative riskiness of
a variety of activities, the youths and their parents assessed the risks similarly. These
findings demonstrate that it is simplistic to argue that all adolescents fail to appropriately
assess personal risk (Goleman, 1993).

Sexuality, defined broadly as sexual feelings, attitudes, and behaviors, is a normal
part of human experience (Gagnon, 1992). In adolescence, particularly mid to late
adolescence, young people begin to attach more meaning to sexual feelings and behaviors.
Many young people begin to engage in increasing sexual intimacy, including sexual
intercourse, as they explore their feelings. Adolescents may use sexual behavior to meet
other needs, including touch, intimacy, and friendship needs, as well as a means of
achieving peer approval and demonstrating independence.

Cultural Diversity and Language Issues

The cultural and family norms to which adolescents are exposed will vary depending
upon their ethnic, racial, or religious group. There is also extensive diversity within the
major population groups into which the U.S. population is classified—African American,
Hispanic/Latino, Native American, Asian/Pacific Islander, and Caucasian (white). Further
differences relate to when and why individuals or their predecessors arrived in the United
States. Each group has unique norms and concerns, which should be taken into account in
the formulation of prevention efforts or services. The most logical, efficient, and appropriate
way to ensure that programs are designed in a culturally sensitive fashion is fully to
include persons from the group(s) intended to benefit from the interventions or services.
They should be included at all stages of policy formulation, program development, and
implementation. |

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4 Preventing HIV/AIDS in Adolescents
One in every 13 US. residents aged 5 or older speaks Spanish in their home.
Accounting for more than 17 million people, the diverse Hispanic community comprises
54 percent of the 31.8 million U.S. residents who do not mostly speak English at home. In
all there are 329 languages other than English used in the United States. Many of these
are used by relatively few individuals, but 11 languages are used by more than 400,000
speakers. Among languages with recent large relative increases in use are some of those
from Asia and the Pacific. The percentage of those speaking a foreign language at home
has risen to 14 percent in 1990—from 10.5 percent in 1980, an increase of 34 percent.
While most of those speaking another language at home also speak English, 5.8 percent,
or 1.8 million people, do not speak English at all (Bureau of the Census, quoted in USA
Today, Wednesday, April 28th, 1993).

The use of English-only HIV prevention materials will constitute a barrier in instances
where the first language of adolescents and/or their parents is a language other than
English. Simply translating English materials into other languages is not sufficient. Not
only should brochures, posters, and electronic media messages be culturally sensitive and
available in the appropriate language, but so should opportunities for discussion of the
relevant issues. The usefulness of materials for particular groups is best assured by
authorship or adaptation by persons fully familiar with the language and culture of the
intended audience. Sensitivity to language issues should obviously also extend to the

_ choice of media outlets to be employed in primary dissemination and reinforcement of

prevention messages.

Health and Social Service Needs of Adolescents

Adolescence is a time of life when most individuals are healthy, hence it is easy to
overlook the health-related concerns that many adolescents have. Access to and financial
coverage for such health services as may be available to adolescents may be linked to their
parents, which may limit the perceived suitability of certain services. The health care
reform process should address meeting the health services needs of all adolescents in
appropriate ways. Adolescents with recognized HIV infection, including those known to
have been infected through blood transfusion or clotting factors, require a range of health
and social services to allow them to live and fulfill personal aspirations as normally as
possible.

The majority of adolescents who obtain medical care receive it from providers who
have not received special training in adolescent health (Office of Technology Assessment,
1991c). Incentives to encourage providers to make a commitment to adolescent health
care should be considered. Health care providers should be trained to discuss sexuality
and other sensitive health issues with preadolescents and with older adolescents.

Social and Economic Contexts: Youth in High-Risk
Situations

Some young people are at higher behavioral risk for infection with HIV, owing
primarily to social and economic factors that are beyond their capacity to change. Young

Preventing HIV/AIDS in Adolescents | 5

 

 

 

 
people who are marginalized, who are poorly educated, who have little hope for meaningful
employment, who come from abusive families, and who grow up in violent neighborhoods
face a host of problems. For some, this complex of socioeconomic problems translates to
high risk of HIV infection from drug taking and unprotected sexual intercourse. Adolescent
HIV infection, however, is merely one symptom of a diseased social and economic system
that is failing, particularly in the inner cities. HIV education for such youth must incorporate
ways to deal with these large problems if it is to be effective at preventing new infection.
And society must at the same time address the broader social and economic problems that
result in these conditions.

The category “youth in high-risk situations” includes those who have hemophilia or
other coagulation disorders, have run away or been rejected by their family, are homeless,
are incarcerated, use alcohol and other drugs or are the sexual partners of those who do,
have dropped out of school or attend school only sporadically, are gay, lesbian, or
bisexual, are survivors of sexual abuse, or have recently immigrated to the United States.
The list must also include some larger categories, such as certain racial/ethnic groups
(including African American and Hispanic/Latino youth in most inner cities and Native
American youth), young women, and youth in smaller and rural communities. Nevertheless,
HIV infection is not about who you are, but rather about what you do. This list of
categories should in no way detract from that point; youth not in any of these categories
can and do have unprotected intercourse and use drugs. The categories are merely
surrogates for a higher probability of being at risk of HIV infection that may help target
interventions. The categories also are not mutually exclusive. Other categories could have
been identified, such as “youth in inner cities” who are often exposed to multiple social
problems.

Adolescents with Hemophilia and Other Coagulation Disorders

Currently, 31 percent (363) of all diagnosed AIDS cases in adolescents have occurred
in youth with hemophilia or other coagulation disorders (CDC, 1993b) who acquired HIV
infection through the use of blood clotting products (clotting factor concentrate) that were
contaminated. It has been estimated that, between 1980 and 1985, 50 percent of persons
with hemophilia were infected with HIV and 90 percent of those with severe Hemophilia
A were infected. With the advent of heat treatment techniques in 1985, HIV is no longer
being transmitted through factor concentrate.

Adolescents with hemophilia and HIV experience the same developmental pressures
as do other adolescents (as discussed earlier), and thus are at risk of spreading HIV to their
sexual partners. Since 1986 the CDC has provided funding for a comprehensive prevention
program for persons with hemophilia and their sexual partners, to be delivered through the
national network of hemophilia treatment centers (Mason, Olson and Parish, 1988). Over
the past seven years, the hemophilia community has developed comprehensive, skill-
based prevention programs for adolescents with HIV in conjunction with their medical
treatment.

Runaway and Homeless Youth

Youth advocates estimate that between 1 million and 1.3 million teens run away from
home every year due to conflict, violence, and abuse (General Accounting Office, 1990).
Many of these vulnerable young people—both male and female—exchange sexual activity
for money, food, shelter, or drugs (this has been referred to by some as “survival sex”).

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6 Preventing HIV/AIDS in Adolescents
 

HIV prevention is rarely a priority for young people burdened with a daily struggle for
survival. .

Youth in Detention

Research suggests that detained or incarcerated youth lack a future orientation, have
poor self-image, and perceive little or no value in modifying risk behaviors. African
American and Hispanic/Latino youth are disproportionately represented in detention centers,
accounting for approximately 60 percent of presently detained youth. African Americans,
Hispanics, and Native Americans and Asian/Pacific Islanders account for 42 percent, 15
percent, and 2 percent combined, respectively (Morris, Baker, and Huscroft, 1992).

Youth Who Use Alcohol and Other Drugs and Their Sexual Partners

Injection drug use is a major risk factor for HIV infection owing to the common
practice of sharing needles or “‘works” (syringes, cocaine cookers, and other paraphernalia).
Injection drug use is implicated in approximately one of eight diagnosed AIDS cases
among teens (CDC, 1993b). A fairly small percentage of young people are involved in this
type of risky behavior, however. Many more youth use alcohol and noninjectable drugs
that lead to impaired judgment and lowered inhibitions, leaving them vulnerable to engaging
in risky sexual behavior. The issue of sexually transmitted diseases among crack cocaine
users is well established; education and prevention activities should be focused on the
risks related to all kinds of drug use, particularly in the sexual context (Fullilove, 1991).
The sexual partners of injection drug users are at high risk for HIV infection, regardless of
whether or not they themselves inject drugs. Older, drug-using males often have younger
women as sex partners, and such women are vulnerable to HIV infection by this route of
transmission as well as by recruitment into drug injection.

Out-of-School Youth

Young people who have dropped out of school or only attend school sporadically—
often termed “out-of-school youth”—do not benefit from school-based HIV education and
are often socially isolated. The absence of adult support and guidance and extreme lack of
access to medical and social services present tremendous difficulties for these adolescents.
Out-of-school youth have been documented as suffering from depression, anxiety, and
low self-esteem (U.S. Department of Justice, 1990). As a result, out-of-school youth
frequently engage in risky sexual behavior and use of alcohol and other drugs.

Gay, Lesbian, and Bisexual Youth

While individuals will generally recognize their sexual orientation in adolescence,
some find it more difficult because of homophobia. The stigmatization and isolation of
gay, lesbian, and bisexual youth can sometimes lead them to engage in sexual and drug-
taking behaviors that put them at risk for HIV infection. Research suggests that these
youth are very vulnerable to depression, suicide, and substance abuse (Remafedi, Farrow,
and Deisher, 1991; Kruks, 1991; Gonsiorek, 1988). Young gay men constitute almost a
quarter of adolescent AIDS cases, “yet gay youth are consistently ignored in prevention
efforts throughout the country” (Futterman, 1991, p. 10). In a San Francisco study, almost
half of participants ages 17 to 19 had recently participated in unprotected anal intercourse,
compared to under a quarter of the 20- to 22-year-olds (AIDS Office et al., 1991). Recent
years have scen an increase in gay and lesbian-centered services, largely in urban centers,

Preventing HIV/AIDS in Adolescents | 7

 

 

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but most mainstream youth-serving agencies and schools are not yet comfortable with the
issues raised by adolescent homosexuality.

Survivors of Childhood Sexual Abuse

It is known that the long-term effects of childhood sexual abuse on emotional
development and self-esteem are usually quite debilitating and initial data suggest that
survivors of childhood sexual abuse are at particular risk of engaging in sexual and drug-
using behaviors that can lead to HIV infection. A small 1990 study of HIV positive
adolescents (ages 12 to 20) reported that 41 percent of the 34 subjects had histories of
childhood sexual abuse (Dekker et al., 1990). There are a great number of survivors of
childhood sexual abuse in the United States. Estimates vary, and are likely to be low due
to underreporting, but current statistics suggest that approximately 27 percent of women
and 16 percent of men were sexually abused by the age of 18 (Finkelhor et al., 1990).
Further study in this area is desirable.

Immigrant Youth

Immigrant youth face barriers similar to those faced by immigrant generations before
them. Incorrect and unfounded beliefs about the behavior of their U.S.-born peers make
them vulnerable to HIV infection. Research indicates that teens born in other countries are
more likely to believe that American youth their age engage in HIV-related risk behaviors.
The 3,049 immigrant students surveyed in Boston in 1990 were more likely than U.S.-
born students to believe that no one their age uses condoms (16 percent versus 6 percent)
and that everyone their age injects illegal drugs (29 percent versus 12 percent). The
overwhelming desire to “belong” to their peer group can influence immigrant teens to
engage in high-risk behavior (Hingson and Strunin, 1992).

African American, Hispanic, and Other Youth of Color

African American and Hispanic adolescents are overrepresented in the adolescent and
young adult AIDS population as discussed in the Commission report, The Challenge of
HIVIAIDS in Communities of Color, which addresses the origins and implications of the
disproportionate impact of HIV in these communities. In brief, conditions of poverty,
disenfranchisement, and loss of opportunity in inner cities, where large number of African
American and Hispanic/Latino youth live, have led to high rates of injection drug use with
resultant HIV transmission that in large measure explains the disproportionate distribution
of AIDS cases. For example, among teenage women with AIDS, 74 percent are African
American or Hispanic (CDC, 1993b), and among these women drug injection or sexual
contact with an injection drug user are the most common modes of exposure to HIV.

This disproportionality is likely to continue. A study of applicants to military service
between 1985 and 1989 revealed that African American applicants were five times as
likely to be infected with HIV as were white applicants (Burke et al., 1990). Concern is
mounting that Native American and Asian American adolescents will soon experience a
surge in HIV infection.

Young Women

Adolescent women are experiencing rates of HIV infection comparable to adolescent
men (Burke et al., 1990). A greater percentage of adolescents (ages 13 to 19) than adults
with AIDS are female (29 percent versus 12 percent) (CDC, 1993b). Some young women

8 Preventing i4IV/AIDS in Adolescents
often view their sexual role as a passive one; they see it as something that happens to
them, that they have little control over (Selverstone, 1992). If a young woman chooses to
be sexually active with a man, she needs the skills to successfully negotiate condom use
with him in order to protect herself from possible HIV infection. Condom use requires the
cooperation of the male, and many men are resistant to using them, leaving their female
sexual partners vulnerable. Hence, particular attention will be needed to building self-
esteem and good decision-making skills for those young women who might otherwise be
especially at risk from perceived lack of choice.

Youth in Smaller and Rural Communities .

The myth that HIV/AIDS is only a problem of the major cities is dangerous because it
allows the general public, policymakers, and service providers to ignore the invasion of
HIV into smaller and more rural communities. The rate of reported AIDS cases is
growing faster in small metropolitan, suburban, and rural areas than in large cities (CDC,
1993a). Data indicate that rural areas also experience the socioeconomic problems and
subsequent behaviors that can lead to HIV infection. For example, half the girls admitted
to drug abuse units in Lake County, Indiana, are survivors of sexual abuse, and most of the
young people have run away from home before being admitted for substance abuse
treatment. Over 80 percent of the young people over the age of 13 at the units have had
sexual intercourse (Dekker, 1991).

Many youth in the categories described in the preceding paragraphs are at higher risk
of contracting HIV, but all youth must be involved in prevention programs. Every youth
must recognize that engaging in unprotected sexual intercourse or in sharing of injection
equipment poses a risk of HIV infection.

The Role of the Media

The social context in which all American adolescents live is heavily influenced by the
media. News and entertainment media are pervasive, lacing daily living with contradictory
messages about sexuality, alcohol and other drug use, and violence. Disturbingly, all three
topics are often linked, particularly in the movies and music that most appeal to adolescents.
Story lines often portray the kinds of behaviors that are directly counter to those that HIV
educators attempt to reinforce (Wilhoit, 1993). While slightly more common in the nineties
than in previous decades, it is still rare for characters in television shows or movies to
model good communication about sexuality, sexual decision making, or condom/
contraceptive negotiation between sexual partners.

While television shows that glamorize sex and commercials that use sexuality to sell
products are commonplace, network television producers continue to ban condom
advertising (Selverstone, 1992). A potentially valuable path toward normalization and
acceptance of condoms, condom use, and responsible sexual behavior is thus blocked.
Some educational programs have been aired, but public service announcements are often
relegated to low audience time periods.

The news media could play a role in creating an environment in which messages
about healthy sexual behaviors, good HIV prevention, and school-based interventions are

Preventing HIV/AIDS in Adolescents 9

 

 

 
integrated. However, controversy sells newspapers and magazines. Thus, stories that are
sensational or depict conflict about HIV education programs are reported to the exclusion
of stories about successful projects (Fraser, 1993). The resulting stories, while not
necessarily irresponsible, create controversy and contribute to the general confusion about
effective methods and strategies to provide HIV preventive education (Jeter, 1993).

The Role of Schools in HIV Prevention

Schools—both public and private—are a highly efficient way to reach the majority of
young people in the United States with HIV prevention programs (Wilhoit and Fraser,
1993). The issue of whether or not schools should be engaged in the enterprise of
providing education beyond the “basics” (like mathematics and English)—providing health,
sexuality, and HIV prevention education as well as medical and social services—has been
much debated in the education and broader communities. The position of the National
Association of State Boards of Education (NASBE) is that schools cannot achieve their
primary mission of educating young people if they ignore the social and health problems
that interfere with students’ current and future education (Wilhoit, 1993). The National
School Boards Association has a similar position and supports a youth policy that advocates
dealing with the needs of the “whole child.” The American Federation of Teachers and
the Council of Chief State School Officers have both also articulated the need to address
the issues and populations mentioned in this report through their policy positions. The
Centers for Disease Control and Prevention’s Division of Adolescent and School Health
works broadly to identify risks to the health of youth and strengthen risk prevention
programs, including those in schools. Their program includes substantial attention to
sexual and drug use behaviors with the long-term objective of multidimensional school
health programs. Information resulting from risk behavior surveillance activities and
guidance on school health curricula (available in both English and Spanish) is particularly
useful.

Most other national organizations connected with school or college education, have
articulated policies favoring inclusion of instruction about health, sexuality, HIV, and
STDs in curricula for adolescents.

Even the best HIV prevention programs are likely to be undermined if they are
presented in large, impersonal, and chaotic schools that fail to provide a healthy learning
or teaching environment. Thus, NASBE promotes the broader concept of “healthy schools”
that are “explicitly concerned with ensuring that every adult and child is treated with
respect and given the opportunity to succeed,” and that, in particular, schools work in
partnership with the community to assure that students have access to health and other
needed social services (Wilhoit and Fraser, 1993).

Conceptually, HIV prevention education fits well into educational reform. What is
needed for America’s future is a revamping of education to give students the critical
thinking and analytic skills that allow them to apply knowledge, make decisions, and think
independently. Those are the skills needed in both today’s and tomorrow’s technology-
and information-based workplaces. The best HIV prevention education provides young
people with opportunities to learn and practice just those skills.

In the early years of HIV education too many programs were focused solely on the
provision of information. Some of their sponsors believed that if young people knew how

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10 Preventing HIV/AIDS in Adolescents
HIV is transmitted and that AIDS is fatal, they would use that knowledge to avoid
infection. Others omitted sensitive but critical elements in a desire to avoid controversy.
Providing information is easy but, unfortunately, behavior change is not that simple to
achieve. Information must be backed up with values exploration and skills building,
including responsible decision making, negotiation, refusal, and critical thinking skills.
Young people need the opportunity to practice the kinds of discussions they will need to
engage in and decisions they will need to make in order to effectively protect themselves
from HIV infection. They need encouragement and skills to talk to each other, their
parents, and other influential adults about their values and concerns. They also need
access to medical and social services. ’ .

The same knowledge, attitudes, and skills needed for effective HIV prevention also
prevent or reduce other risks, including other sexually transmitted diseases, unwanted
pregnancy, and alcohol or other drug use. “Numerous studies are documented that youth
who begin one negative health behavior are disproportionately more likely to experiment
with other negative health behaviors” (Howard, 1993, p. 86). Thus, HIV education should
be presented in an integrated, comprehensive health curriculum that includes discussion of
sexuality and that teaches general prevention skills, while still providing HIV-specific
information.

Skills-based health promotion and disease prevention education should begin in
elementary school to lay a foundation for healthy adolescent decision making. Joanne
Fraser, Director of the HIV/AIDS School Education Project of the South Carolina
Department of Education, notes:

Teaching [disease] prevention skills is like teaching reading. You can’t
do it one time; you have to start at the beginning and bring kids along
with a developmentally appropriate, sequenced, articulated curriculum.
As the skills get increasingly complex, you have to have more complex
kinds of situations in which to practice those skills. (Fraser, 1993, p. 17)

A majority of schools are not addressing the more sensitive skills when youth are
most likely to need them: only 48.2 percent of schools nationwide in 1990 included
condom use in skills building even at the high school level (Holtzman and Greene, 1992).
Local school boards play an important role and should work to improve programs for
adolescents along the lines suggested in this report.

The Role of Other Youth-Serving Organizations in HIV
Prevention

While schools are a logical and good place to reach the majority of American
adolescents, some of those most at risk for HIV infection may only sporadically attend
- school or may have dropped out entirely. The area of greatest need in HIV education—
that of youth in high risk situations—is the area in which public education is doing the
worst job (Wilhoit, 1993).

In order to reach these youth, other youth-serving organizations, especially those in
inner cities, must be engaged in the HIV prevention enterprise. Runaway and homeless

Preventing HIV/AIDS in Adolescents 17

 
shelters, gay and lesbian youth centers, community centers, athletic organizations, religious
institutions, and traditional youth-serving agencies such as the YMCA/YWCA, Salvation
Army, Camp Fire Boys and Girls, Big Brother/Big Sister programs, Red Cross chapters,
and the Boys and Girls Clubs of America can—and many do—provide solid HIV prevention
programs to the youth they serve. Teens who are not in school may still have connections
to many of these organizations and can benefit from caring adult attention and prevention
programs.

It is not just the out-of-school youth who are reached by such programs, however. In-
school youth who attend after-school or weekend programs sponsored by youth-serving
organizations will benefit from the reinforcement of HIV prevention messages received in
school. Out-of-school settings can offer young people more time to practice communication,
negotiation, and refusal skills than might be available in school. Lastly, leaders of these
programs can have a qualitatively different sort of relationship with youth that might
facilitate peer interaction and personal risk assessment.

Parental and Youth Involvement

Whether HIV prevention and health promotion programs are offered in schools or in
other youth-serving organizations, it is essential that parents and guardians, who are the
first educators of youth, and adolescents themselves be involved in designing them.
Successful programs need community support; consulting parents early on in program
design will help ensure that success. The Commission believes schools have an important
responsibility to provide comprehensive health, sexuality, and HIV/STD prevention
education. Parental acceptance of school programs to accomplish this requires that
parents understand the need for such instruction in the light of the HIV/AIDS epidemic,
other STDs, and teenage pregnancy. Part of the process of parental acceptance of the
school’s curricula, in an area that for many is value related, is reassurance that instruction
does not become promotion of particular behaviors or values that many parents would not
endorse. Thus families often need reassurance about program content and goals.

Actively involving parents and other family members in the program by providing
them with information and boosting their skills might help ensure that HIV and other
health messages will be reinforced in the home. Marion Howard, Clinical Director of the
Teen Services Program at Grady Memorial Hospital states: “when we... give youth new
messages about how to look at social pressure and peer pressure, we have to bring parents
along and help them learn how to support their young people in the messages we give
[them]” (Howard, 1993, p. 92).

The National Parent/Teacher Association (see Appendix B) is a useful source of
information on approaches to parental involvement in program development.

Youth involvement is critical because target group input is essential to designing
appropriate and effective interventions. Youth can give input into program planning,
design, and evaluation through a variety of formats, including youth representation on
committees, focus groups, and review panels. Young people’s opinions must not only be
solicited, but respected as well.

Youth can act directly as educators. Peer education is a promising way of providing
HIV education to young people. Peer educators David Kamens and Kate Barnhart provide

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12 Preventing HIV/AIDS in Adolescents

 

 
aa

eloquent testimony to the power and importance of peer education. The late David Kamens,

of Washington, D.C., noted:
[Mly message, I think, comes from that I’ve been there and I am 20 and :
when I was 18, 19, 20, I was going to other 17-, 18-, 19-, 20-year-olds
l and talking about the fact that they can make a difference for themselves
\ .... I’ve seen eyes light up. Kamens, 1991, p 69).

New York City public high school student Kate Barnhart states: |

The peer education approach has many benefits. Peer educators are \ |
constantly available. We can be approached informally in the halls,
gym, cafeteria, or anywhere . . . We can be telephoned at home if
questions arise. We are not confined to the role of educator or authority.
We make the transition to friend easily. (Barnhart, 1993, pp. 105-106)

Peer counselling promotes healthy choices for avoidance of pregnancy (Jay, DuRant,
Shoffit et al, 1986) and postponement of sexual intercourse (Howard and McCabe, 1990).
HIV-infected peer educators often have a special impact on youth.

Peer education is not a panacea; some research to date suggests that those young
people who benefit the most from peer education are the peer educators themselves
possibly because they receive more intensive exposure to the issues than others (Dryfoos,
1990). Therefore, peer education can be combined with other components of a prevention

program but should not stand alone. It also requires training and intensive support for the
youth educators.

The Critical Links: Information, Attitudes, Skills | )
Building, and Access to Services |

Information

If information about the consequences of unhealthy or risky behaviors were sufficient
to motivate people to adopt healthy behaviors, no one would smoke, everyone would wear
a seatbelt, all doctors’ recommendations about diet and exercise would be followed, and
there would be no drunk driving. Obviously, this is not the case, and most adults know
how difficult the struggle can be to change entrenched, often pleasurable, behaviors. It is
illogical, then, to expect young people to change their behavior based on information
alone, even if that information includes knowledge of their own HIV status. The
Congressional Office of Technology Assessment reports that HIV prevention programs
designed solely to provide information to young people will be ineffective (Office of

Technology Assessment, 1991a). Comprehensive HIV prevention should include
i information, exploration of values and attitudes, skills building, and access to services,
| including condom availability.

It is important that the information given must include complete, accurate, and age-
appropriate information as part of HIV prevention programs. A great deal of misinformation
still circulates among adolescents, which distracts attention from real ways in which HIV

Preventing HIV/AIDS in Adolescents 13

 

 
is spread. As Marion Howard of the Teen Services Program at Grady Memorial Hospital
declares: “[{A]nyone who’s involved in sex education, HIV education, knows that you
spend as much time correcting misinformation as you do giving information” (Howard,
1993, p. 85).

HIV education is severely undermined by declaring discussions of condoms,
nonpenetrative sexual activities (e.g., masturbation), homosexuality, and other controversial
topics off limits. “You don’t hand somebody a condom and kind of say, well, you know,
protect yourself, and then walk away. It’s not going to work,” explains Frances Kunreuther,
Executive Director of the Hetrick-Martin Institute for Lesbian and Gay Youth in New
York (Kunreuther, 1991, p. 14). .

Pedro Zamora, peer educator, notes:

We need to talk about all those sexual things that they could do without
putting them[selves] at risk, but nobody is talking about that. (Zamora,
1992, p. 282)

Kate Barnhart, student peer educator in Manhattan, states firmly:

Effective HIV education must encompass the full spectrum of teen
sexuality. This must include homosexuality, bisexuality, confusion
regarding sexual identity, and sexual experimentation. Other issues,
some of them among the most taboo topics in our society, must also be
addressed. These include rape, date rape, sexual abuse, incest, and
prostitution. (Barnhart, 1993, pp. 97-98)

The information provided to young people about sexuality and HIV should vary
according to the age of the young people. Simpler messages are appropriate for children.
As young people mature and move through high school age, they become ready for more
complex messages. In 1991 a national task force on sexuality education released an
important consensus proposal, Guidelines for Comprehensive Sexuality Education:
Kindergarten-12th Grade, that details the key concepts to be incorporated into health,
sexuality, and HIV education at different ages (SIECUS, 1991).

Information, no matter how complete, must be supported by an exploration of personal
values and attitudes, skills building, and access to services. The Office of Technology
Assessment reports that “preventive efforts that change environments, provide some form
of concrete aid or improve competencies are more effective primary prevention strategies
than strictly didactic education-based interventions” (Office of Technology Assessment,
1991b, p. I-25). _

Much controversy exists about whether or not providing sexuality information to
young people will cause them to engage in sexual activity. There is no evidence that
sexuality education promotes sexual activity (Wilhoit and Fraser, 1993), Such studies as
do exist suggest that it delays or has no effect on the initiation of sexual activity. Abstinence
messages—such as to postpone sexual activity—should be included because this can be
an effective way of reducing risk. Those who choose it require support. Information and
skills building about other means of reducing risk of HIV and other STDs, such as the use
of condoms, should be included. A successful research-based, abstinence-focused program
at Grady Memorial Hospital provides information on the use of birth control and condoms.

14 Preventing HIV/AIDS in Adolescents

\
Clinical Director Marion Howard says: “the two messages are not incompatible. One can
promote abstinence and still teach youth how to protect themselves against pregnancy and
diseases like AIDS” (Howard, 1993, p. 92).

Some opponents of comprehensive sexuality education charge that teaching about
both abstinence and safer sexual practices sends a “mixed” message that is confusing to
young people. It is not a contradictory message, rather a complex one, much like the
twofold message—don’t drink, but if you do drink, don’t drive. In both instances, the
adult community states what is the preferred behavioral option (abstinence from sexual
intercourse/abstinence from drinking alcohol), but then provides for options if the preferred
behavior is not chosen (use a condom/call a cab or parent for a ride home).

Exploration of Attitudes and Values

Adolescents benefit from the opportunity to examine their own values and attitudes.
Prevention programs that provide those opportunities are helping students to assess and
personalize their risk and their options. Marion Howard recommends giving young people
the opportunity to explore their attitudes and values, particularly as they relate to sexuality,
because “Values are beliefs on which we’re willing to act. We need to help [teens] look at
their attitudes. Young people need to get ownership of strong, positive sexual values [such
as] it is irresponsible to spread sexually transmitted disease” (Howard, 1993 p. 93).

Skills Building

Many teens lack important decision-making, negotiation, and refusal skills and rarely
have the opportunity to practice them. HIV prevention education that encompasses skills
building in these areas will strengthen adolescents’ abilities to make healthy decisions
about HIV prevention, as well as in many other parts of their lives. Young people need
more than pat phrases like “just say no.” They need to role-play difficult situations,
coming up with their own answers and contingency plans, so that, if and when they are
confronted with peer or partner pressure or their own sexual urges, they can draw upon the
skills they have practiced. Skills building for anticipating and avoiding potentially risky
situations, as well as handling them, should be included. The practicing of skills is of
critical importance in building the confidence to use them.

Adolescent women face a different set of negotiation challenges regarding abstinence
or safer sex behaviors than do young men. It is not that young women do not have sex
drives themselves, or that young men are unable to control their sexual urges. Rather, it is
the fact that in this culture some young women tend to view themselves, and are often
viewed by others, as the more passive partners in sexual relationships (Selverstone, 1992).
Condom use requires male cooperation. Condom purchases are embarrassing and confusing
for young women as well as young men. Research conducted in 1988 by the Center for
Population Options’ Teen Council reveals that adolescent women asking for assistance
with condom purchase encountered resistance or condemnation from store clerks 40
percent of the time (Center for Population Options, 1993a).

Given the pervasiveness of media messages extolling the virtues of sexual activity
and the use of sexuality to sell products, teens need media analysis skills that would
improve their ability to dissect and understand the media’s manipulation. Joanne Fraser
laments, “[W]e don’t teach kids media analysis skills. We teach them reading literature

analysis skills . . . [but] we have not translated those same kind of analytical skills into
looking at media” (Fraser, 1993, p. 56).

Preventing HIV/AIDS in Adolescents 15

 

 

 

WL RR RR

———
A number of curricula utilizing skills building have been evaluated and found to
reduce the risk of unprotected sexual intercourse. These include “Reducing the Risk”
developed by ETR Associates of Santa Cruz, California (Barth, 1993; Kirby et al., 1991)
and a program developed by Emory University School of Medicine and Grady Memorial
Hospital Teen Services Program (Howard and McCabe, 1990). For additional information
on well-evaluated skills-building curricula for primary prevention, consult Appendix B.

A further example of a skills-based prevention program is one developed by The
National Hemophilia Foundation (NHF) that also utilizes a peer education component.
The program used a prevention videotape, “Song of Superman,” specifically developed
for HIV-positive adolescents by the Canadian Hemophilia Society and NHF, and a
companion workbook of skills-building exercises. The program utilizes weekend retreats
for HIV-positive and HIV-negative adolescents where the video is shown, workbook
exercises are used, and a peer-led support group is held. Preliminary assessments indicate
positive behavioral and attitudinal changes after the weekend. Experience with this
program could be of great value because children with perinatally acquired HIV infection
may increasingly survive to adolescence. They will require programs to help them deal
with the issues they will face regarding sexual activity.

Access to Services

It is not sufficient to tell young people what HIV/AIDS is, allow them to practice
decision-making skills, and then leave them without the services necessary to allow them
to implement healthy behaviors. Hence, the last component of a comprehensive HIV
prevention program is access to services, including medical, social, and, in some cases,
legal. Young people need condoms and other latex barriers if they choose to engage in
sexual activities that might expose them to HIV. They need medical care, including
treatment for STDs. Some require alcohol and substance abuse treatment, virtually
nonexistent for adolescents. They might require a case manager’s assistance in accessing
nonmedical services. Adolescent-sensitive HIV counseling and testing should be available
to those who want it. | ) .

The HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric
Institute devised a model comprehensive HIV intervention program that has been
implemented and evaluated in several New York City agencies that serve either runaway
teens or young gay and bisexual men. Results reported in 1991 revealed that the young
people who received the comprehensive intervention reported both an increase in condom
use and a decrease in high-risk behavior (Rotheram-Borus et al., 1991).

Because the needs of adolescents at risk for HIV infection and those already infected
are both varied and monumental, it is essential that medical, social, and preventive
services be offered comprehensively to all adolescents who need them. The national
hemophilia program has provided comprehensive services to adolescents with hemophilia
and HIV since 1986 (Mason, Olson, and Parish, 1988). Providing essential medical and
social services increased the number of prevention sessions. It is essential that adolescents
with hemophilia and HIV infection be allowed to continue to use the system with which
they have developed a relationship and that similar services are offered to all adolescents
at risk for HIV infection.

Schools should act in partnership with other community groups to provide access to
services for all students. Some schools and communities will decide—as close to 500
already have—to provide some of these services on site, in school-based health centers, or

/

16 Preventing HIV/AIDS in Adolescents

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a

to link up with an off-site health center. Condom availability programs are gaining
momentum across the nation; some communities have decided and others will no doubt
decide in the future that making condoms available to sexually active students is a
responsible decision in the face of the HIV epidemic (Center for Population Options,
1993a). Providing condoms is insufficient if it is not included as part of a comprehensive
HIV prevention program embraced by the school and school district.

While certain health and counseling services may be available at some school sites,
expanding these and making services more widely available will require more resources.

School-Based HIV Education

States have by and large embraced HIV prevention education in schools. Over two-
thirds (38 states) require HIV/AIDS prevention education. Almost all states place HIV/
AIDS education within the framework of the health education curriculum, and all states
provide the rarely exercised option for parents to excuse their children from HIV/AIDS
instruction.

The Sex Information and Education Council of the U.S. (SIECUS) conducted an
analysis of state HIV/AIDS programs and curricula and reported some important weaknesses
in state materials, notably that only three states (Massachusetts, New Jersey, and South
Carolina) have curricula that adequately address the cognitive, affective, and skills domains.
In addition, SIECUS noted other weaknesses, including: a lack of instruction about sexual
responsibility and decision making; failure to discuss human sexuality in a positive
framework; inadequate instruction on condom use; overemphasis on abstinence that resulted
in no discussion of safer sex practices; and absence of discussion about sexual orientation.
In addition, not all localities are in compliance with state mandates (Britton, De Mauro,
and Gambrell, 1992).

Effective prevention efforts will not be possible without properly trained personnel to
conduct them. Inadequate teacher training hampers HIV prevention education in many
states, according to SIECUS. Gene Wilhoit, Executive Director of the National Association
of State Boards of Education, elaborates:

We don’t [always] get teachers that are trained to deliver [HIV education]
... They have not been taught about sexuality as [children]. Many are
uncomfortable about discussing this with their own children and families.
Many of them don’t have the attitudinal skills to deliver this kind of
curriculum. (Wilhoit, 1993, p. 35)

In addition to teachers, other school-based personnel such as counselors need trainin g.
Service providers in out-of-school settings need effective training also. For both teachers
and other youth-serving professionals, ongoing staff development should be a norm, not a
luxury (Coburn, 1993). Teachers who are adequately trained and who can feel comfortable
about providing HIV education will more effectively present HIV/AIDS programs. Those
who are untrained or reluctant to deliver HIV education should not be conscripted, since
they are unlikely to be effective.

Schools and other youth-serving institutions should select curricula and teaching
strategies that have been tested for efficacy through research and/or evaluation.
Modifications to carefully developed and tested programs, such as deleting “sensitive”
information, refusing to spend money on skills building, or refusing to make condoms

Preventing HIV/AIDS in Adolescents 17

 
available, create barriers to effective programs. Those who oppose or would choose to
alter effective methodologies should be asked to provide alternative approaches that have
similarly withstood the rigor of scientific research (Johnson, 1992),

Materials written for specific populations should be targeted in terms of content and
language. Judgments about the appropriateness of such materials should be based on
whether research and/or experience suggest they will be effective with the target audience,
rather than forcing them to conform to “general community standards” at the expense of
effectiveness.

Recommendations

A variety of cultural and political barriers to the provision of effective HIV prevention
education to America’s adolescents exist. Unlike babies and younger children, who make
up the pediatric AIDS population, adolescents do not always generate sympathy. Unlike
the adult AIDS population, they do not have much of an organized lobbying voice
(Coburn, 1993). Most adults are uncomfortable with adolescent sexual activity and many
continue to deny the amount and range of adolescent sexual experience, causing those
adults to withhold relevant sexuality information from young people. In addition, HIV/
AIDS has become one of the most politicized diseases in history. Questions about proper
HIV prevention messages, images, and programs have served as a flash point for much of
America’s anxiety about questions of sexuality.

1. Presidential and Congressional Leadership is Essential to Prevention Education

Neither previous administrations nor Congress has provided the vigorous and
unequivocal leadership needed to address the controversy and confusion about HIV
education. In fact, years of disagreement at the highest levels of the federal government
over the proper messages to give young people have helped to create and perpetuate a
national atmosphere of confusion and controversy. Controversy over and lack of
consensus about how much and what kinds of information should be provided in
schools continues to block effective action. A teacher living with AIDS, Marvin Jeter
of Ohio, notes: “School-based HIV prevention efforts continue to be stalled by
misunderstandings [and] politicizing about what prevention strategies are important
and effective” (Jeter, 1993, p. 39). Dispute about the proper role of schools in
addressing social problems, including HIV, and the capacity of schools to do so,
hampers efforts to move forward with a prevention agenda.

The Commission reiterates its previous recommendations that the President
should lead the American people to a new response to the HIV/AIDS epidemic,
should appoint a National AIDS coordinator, and should call for the development
of a national strategic plan to confront the epidemic. The national strategic plan
should contain plans for a national prevention initiative (National Commission
on AIDS, 1991 and 1993) that includes steps for educating the public more
thoroughly about AIDS and building community recognition of the need for
more effective prevention efforts, including those directed at youth. Congress
should place high priority on legislation directed towards comprehensive services
for youth.

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18 Preventing HIV/AIDS in Adolescents

 
 

One component to the national prevention initiative should address the
prevention of HIV infection in adolescents, particularly youth in high-risk
situations. Comprehensive HIV prevention should include information,
exploration of values and attitudes, skill building, and access to health care and
social services, including condom availability. School-based prevention should
be presented in an integrated, comprehensive health curriculum that includes
discussion of sexuality and that teaches general prevention skills, while still
providing HIV-specific information. Schools and other youth-serving institutions
should select curricula and teaching strategies that have been tested for efficacy
through research and/or evaluation. Programs should be: ‘developed with the
involvement of parents and young people. -

HIV prevention programs should be nonjudgmental in approach and
structured from a public health perspective to help young people learn how to
make healthy choices about sexuality. Such programs will be the most effective.
The information provided to young people about sexuality and HIV should vary
according to their age. Exhortations that adolescents perceive as unhelpful may
only serve to distance youth, who may already be alienated, even further from the
advice, care, and services they need and deserve. Prevention efforts limited to
instilling fear or that omit important information will not be effective in facilitating
healthy choices or sustained risk reduction.

Abstinence messages—such as the message to postpone sexual activity—should
be included because this can be an effective way of reducing the risk of HIV. Those
who choose abstinence require support. Information and skills building about other
means of reducing the risk of HIV and other STDs, such as use of condoms; should be
included. This potentially life-saving information is needed immediately by those
who are sexually active and by all who may become so at some point later in their
lives. Withholding such information leaves individuals vulnerable to HIV/STDs
through ignorance.

Promote Integrated Adolescent Programs

Categorical funding constraints make it difficult to best serve young people.
Schools and many other youth-serving institutions receive a mix of funds for a variety
of programs designed to improve healthy growth and development (Wilhoit and
Fraser, 1993). The difficulties presented by the inflexibility of categorical funding
streams make it difficult for programs to provide comprehensive prevention programs.
The inability to merge those funds to provide a comprehensive prevention program
limits their effectiveness. The sheer number of sources from which an individual
school or agency might receive funds can lead to overwhelming, time-consuming,
duplicative paperwork. For example, the Klein Bottle Youth Programs, a community-
based youth serving agency with an annual budget in excess of $2.5 million, draws on
over 65 federal, state, county, and city funding sources to provide comprehensive
services to youth in Santa Barbara, California (Coburn, 1993). Another example of
the problems created by categorical funding is the current regulatory restriction on
discussion of risky sexual behavior in Drug Free School programs, the largest federally
supported prevention initiative, even though this is a hazardous potential consequence
of drug use (Select Committee on Children, Youth and Families, 1992).

Preventing HIV/AIDS in Adolescents 19

 
 

20

 

Congress and Agencies should act to break down barriers to collaboration
and co-location of services established by categorical funding constraints. This
would allow schools and other youth-serving organizations to provide
comprehensive disease prevention and health promotion programs to young
people.

Strengthen Staff Training

There is a lack of training and capacity building for both teachers, other school
staff, and other youth-serving professionals, including health care providers who are
charged with providing HIV education treatment and services. While it is expensive
to provide adequate, ongoing staff development, it is essential for the provision of
adequate HIV prevention education. Pre- and inservice training and continuing
education are all necessary.

The issues raised by HIV—including sexuality, alcohol and other drug use,
sickness, and death—are emotionally charged topics that cannot be effectively
addressed by unprepared instructors. Congress should increase the level of federal
resources for teacher training and other educational staff development in the
sensitive areas raised in HIV education. Preparation must address not only
knowledge about HIV, but also help providers explore their own attitudes, which
affect what and how they teach. It should also offer opportunities to practice and
develop new teaching methods.

Enhance Health and Education Sector Collaboration

The education community does not have ready access to much of the cutting-
edge research on strategies for HIV prevention. The “transfer of technology” between
the research community and schools needs strengthening. Teachers, school
administrators, and school boards do not often read the technical journals in which
research results are published, and, even if they do, researchers’ language is often
difficult for nonexperts to understand (Wilhoit and Fraser, 1993).

Federal health and education agencies should increase cooperation in order
to facilitate “technology transfer” between the research and public health worlds
and the education sector and to involve the education community in health
promotion. Collaboration between state and local health agencies and education
agencies should also be encouraged.

Organizations that sponsor research and pilot projects should undertake and
publish meta-analyses that identify the program design and implementation
characteristics for prevention efforts that are predictors of effectiveness. Guidance
for local action should be developed through collaboration between federal health and
education agencies.

Address Youth Health Opportunities in Health Care Reform

As the nation moves forward with both health care and education reform, important
opportunities to address adolescent health needs emerge. Adequately providing for
the health needs of young people presents special challenges because of the
developmental, behavioral, and psychosocial aspects of adolescence. Providing
appropriate care for this population presents a unique opportunity for prevention of
disease and for the resulting future cost savings.

Preventing HIV/AIDS in Adolescents
“School health” should be made a priority in the education sector. Within
education reform, competency-based performance standards for health education,
sexuality education, and HIV education should be set that will ask students to
demonstrate mastery of a variety of health and prevention-related topics and
tasks.

Health care and education reform should merge to create “healthy schools”
that provide students with respect, adult mentoring, and critical thinking skills
and that also work in partnership with the community to ensure students’ access
to health and other social services.

Within health care reform, adolescent health issues must be addressed.
Incentives to encourage providers to make a commitment to adolescent health
care should be considered. The Commission reiterates the importance of its
previous recommendations in this regard, particularly those made in America
Living with AIDS and The Challenge of HIV/AIDS in Communities of Color.
Longer-term recommendations for universal health coverage and immediate
needs, during the transition to a new system, should both be addressed.

Expand Research on Adolescent Health

More research is needed to refine the knowledge base about adolescent sexual
and other risk-taking behavior and to point the way toward effective HIV prevention
strategies. Research, however, should not be funded at the expense of primary
prevention programs.

A coordinated research agenda should be instituted that includes:

a. A national survey on adolescent sexual behavior that will provide data
not only on prevalence and demographics of sexual activities, but also
on who and what has an impact on adolescent risk-taking behavior.

b. Research on effective behavior change strategies and programs, including
those that focus on youth in high-risk situations, and an assessment of
how well the comprehensive approach to risk reduction works. .

c. New research that builds upon previously implemented comprehensive
HIV programs for adolescents. Examples of such programs include the
HIV Center for Clinical and Behavioral Studies (Rotherman-Borus, 1991),
the Center for AIDS Prevention Studies at the University of San Francisco,
programs for gay and bisexual youth (Remafedi, Farrow, and Deisher, 1991),
and those programs implemented by the National Network of Hemophilia
Treatment Centers and The National Hemophilia Foundation.

Additionally, a greater commitment of resources is needed for research including
evaluation of interventions and for the dissemination of results from successful
programs.

Engage the Media in Health Promotion
Messages conveyed by the entertainment and advertising media that glamorize
sexuality or drug and alcohol use and ignore the consequences of unprotected

intercourse or substance abuse feed adolescent denial of the threat of HIV/AIDS and
other potential consequences,

Preventing HIV/AIDS in Adolescents 21
 

22

The federal government should work with the entertainment industry and
other media (for example, the advertising industry) to develop strategies for
conveying positive messages on HIV/STD and drug-use risk reduction to
adolescents.

Preventing HIV/AIDS in Adolescents
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Kamens, D. (1991). Testimony before the National Commission on AIDS: “‘Adolescents
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Kruks, G. (1991) Gay and lesbian homeless/street youth: Special issues and concerns.
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Rotheram-Borus, M.J., Koopman, C., Haignere, C., and Davies, M. (1991) Reducing HIV
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Preventing HIV/AIDS in Adolescents 25

 
 

 

St. Louis, M.E., Conway, G.A., Hayman, C.R., Miller, C., Petersen, L.R., et al. (1991)
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26 : | Preventing HIV/AIDS in Adolescents
APPENDIX A: Hearing Agendas
(Panel participants listed alphabetically)

Adolescents and HIV Disease

Chicago, IL
March 13, 1991
8:30 a.m. Opening Remarks: June E. Osborn, M.D.
8:35 Roundtable Discussion: Youth Issues
Susan Castillo, Youth Advocates Teen HIV Program,
San Francisco, CA
Anthony Dekker, D.O., Chicago College of Osteopathic
Medicine, Chicago, IL
DiAna DiAna, South Carolina AIDS Education Network,
Columbia, SC
Mindy T. Fullilove, M.D., New York State Psychiatric Institute
and Columbia University, New York, NY
Donna Futterman, M.D., Montefiore Medical Center,
New York, NY
David Kamens, Washington, DC
Frances Kunreuther, Hetrick-Martin Institute, New York, NY
Su Neuhauser, M.A., Office of AIDS Prevention, Chicago, IL
Jackie Sadler, M.P.H., DC Public Schools HIV/AIDS Education
Program, Washington, DC
S. Kenneth Schonberg, M.D., Montefiore Medical Center and
Albert Einstein College of Medicine, New York, NY
10:45 Break
11:00 Youth Panel
12:00 p.m. Lunch
1:30 Overview
Margaret C. Heagarty, M.D, Columbia University, Harlem
Hospital Center, New York, NY
1:50 _ Health Care Issues!Medical Dilemmas

Margaret C. Heagarty, M.D.
Sheila Swain, Jefferson, IA

Preventing AIDS in Adolescents Appendix A-1

 
 

 

ne at eee la ee

 

Hermann Mendez, M.D., SUNY Health Sciences at Brooklyn,
New York, NY

Janie Eddy, R.N., Children’s National Medical Center,
Washington, DC

Elizabeth C. Gath, M.D., Cook County Hospital, Chicago, IL

2:50 Break

3:00 Social/Family Issues

Ana Garcia, L.C.S.W., University of Miami School of Medicine,
Miami, FL

Joan McCarley, M.S.W., Terrific Inc., Grandma’s House,
Washington, DC

Toni P., Person Living with AIDS

Barbara J. Sabol, R.N., New York City Department of Human
Resources, New York, NY

Dottie Ward-Wimmer, R.N., Children’s National Medical Center,
Washington, DC

4:00 p.m. Public Comment
5:00 Adjourn
Sex, Society, and the HIV Epidemic

New Orleans, LA
May 18-19, 1992

May 18 ©

Site Visit

9:00 a.m. G.W. Carver School Based Health Clinic and Day Care Center,
New Orleans, LA

Hearing

1:00 p.m. Opening Remarks: June E. Osborn, M.D.

1:05 Toward A National Prevention Strategy

~ Thomas J. Coates, Ph.D., Director, The Center for AIDS Prevention

Studies, San Francisco, CA

1:45 Research on Sexual Behavior: Implications for the HIV Epidemic

John H. Gagnon, Ph.D., State University of New York at Stony
Brook, New York, NY

Appendix A-2 Preventing AIDS in Adolescents
2:15

2:45
3:00

4:45

May 19

9:00 a.m.

10:15

11:00

11:15 a.m.

12:00 p.m.

12:45

1:15

Culture, Ethnicity, and Gender in Sex Research
Vickie Mays, Ph.D., University of California, Los Angeles, CA

Break
Commission Business

Adjourn

Sex, Society and HIV

Priscilla Alexander, Global Programme on AIDS, World Health
Organization, Geneva, Switzerland

Jose Pares-Avila, M.A., Clinical Psychology Fellow, Harvard
Medical School, Boston, MA

Richard Green, M.D., J.D., UCLA School of Medicine,
Los Angeles, CA

John Money, Ph.D., Johns Hopkins University and Hospital,

- Baltimore, MD

Carole Vance, Ph.D., Columbia University School of Public Health,

New York, NY

Discussion
Break

Adolescents and Sexuality

Robert Selverstone, Ph.D., Board Member, Sex Information and
Education Council of the U.S. (SIECUS), New York, NY

Walter Shervington, M.D., Assistant Secretary for Mental Health,
State of Louisiana

Pedro P. Zamora, The Body Positive Resource Center, Inc.,
Miami, FL

Discussion
Public Comment

Adjourn

Preventing AIDS in Adolescents Appendix A-3
 

 

EE ne ee

 

Communication and the HIV Epidemic
Kansas City, MO & Kansas City, KS -
June 15-16, 1992

June 15

8:00 a.m. Breakfast with Representatives of AIDS Organizations
10:00 Opening Remarks: June Osborn, M.D., Chair

10:05 Welcoming Remarks |

10:15 ° What is Communication and Why is it Relevant to the Epidemic?
Mary D. Fisher, The Family AIDS Network, Boca Raton, FL
Robert Hornick, Ph.D., Annenberg School of Communication,
University of Pennsylvania, Philadelphia, PA

10:45 How are the Public Perceptions on HIV and AIDS Shaped?
: Mary Debus, Porter-Novelli, Washington, DC

Charles Eisendrath, M.A., University of Michigan, Ann Arbor, MI

Rita Lepicier, KCET Television, Los Angeles, CA

Theresa F. Rogers, Ph.D., Barnard College and Columbia University,
New York, NY

Stephen B. Thomas, Ph.D., University of Maryland,
College Park, MD

1:30 p.m. What is the Role of Communication in Primary Prevention?

Rashidah Hassan, R.N., BEBASHI, Philadelphia, PA

Emesto Hinojos, M.P.H., Gay Men’s Health Crisis, New York, NY

Jay Johnson, Topeka AIDS Project, Topeka, KS

Frederick C. Kroger, National AIDS Information and Education
Program, Centers for Disease Control and Prevention,
Atlanta,GA oe

Michael Ramah, AIDSCOM, Washington, DC

3:15 Break
3:30 . Discussion: How Can We Improve the Primary Prevention Effort?
4:00 Commission Business

5:30 Adjourn

Appendix A-4 Preventing AIDS in Adolescents
June 16

Battenfeld Auditorium, Student Center, University of Kansas Medical Center

8:30 a.m. Breakfast with Representatives of Programs for Adolescents
10:00 Opening Remarks: June Osborn, M.D., Chair
10:05 Welcoming Remarks: The Honorable Joan Finney, Governor of
Kansas
10:15 Care-Oriented Communication Issues
Panel] .
Lawrence S. Brown, M.D., M.P.H, Addiction Research and
Treatment Corp., Brooklyn, NY

John S. James, AIDS Treatment News, San Francisco, CA

Panel 2

Mike Barr, St. Vincent’s Hospital, New York, NY

Leonard A. Simpson, M.D., American Association of Physicians
for Human Rights, San Francisco, CA

Rochelle L. Rollins, M.P.H., Multi-Cultural AIDS Coalition,
Boston, MA

Prevention Strategies In the Workplace and Schools: Current Challenges
Austin, TX

March 10-11, 1993

March 10
10:00 a.m. Opening Remarks: June E. Osborn, M.D., Chair
10:10 Welcoming Remarks: David R. Smith, M.D., Texas Commissioner
of Health .
10:20 Behavioral Research and AIDS Prevention: Using the Workplace
and Schools
Anke Ehrhardt, Ph.D., American Psychological Association,
Washington, DC
Martin Fishbein, Ph.D., Professor of Psychology, University of |
Illinois, Urbana-Champaign, IL
10:45 Discussion

Preventing AIDS in Adolescents Appendix A-5
 

 

 

11:15

11:30

11:45 a.m.

12:30 p.m.
12:45

2:15

2:45

3:30

5:15

Appendix A-6

 

The CDC’s Role in Prevention Education in the Workplace and
Schools

James Curran, M.D., M.P.H., Centers for Disease Control and

Prevention, Atlanta, GA

Break
AIDS and the Workplace

Panel 1

Erline Belton, The Lyceum Group, Cleveland, OH

Jerald A. Breitman, Director, Professional Relations, Burroughs
Wellcome Co., Research Triangle Park, NC

Sharon F. Canner, Assistant Vice President, National Association
of Manufacturers, Washington, DC

Alan Emery, Ph.D., Consultant, San Francisco, CA

Benneville N. Strohecker, President, Harbor Sweets, Inc.,
Salem, MA

Questions -

Lunch .

Panel 2

Sandy Bartlett, Coordinator, Central Texas AIDS in the Workplace
Task Force, Austin, TX |

Carol Camlin, Manager, AIDS Education at Work, AIDS Action
Committee, Boston, MA

Ledia Martinez, M.D., M.P.H., Office of HIV/AIDS Education,
American Red Cross, Washington, DC

Brenda Moon, The George Meany Center for Labor Studies,
Washington, DC

Barney Singer, J.D., Assistant Chief Counsel for Labor Policy,
Small Business Administration, Washington, DC

Discussion
Discussant: B.J. Stiles, President, National Leadership Coalition
on AIDS, Washington, DC

Commission Business >

Adjourn

Preventing AIDS in Adolescents
March 11

9:30 a.m.

9:35

9:45

10:30 a.m.

11:00

11:15

12:00 p.m.

12:30

1:00

2:00

3:00

5:30

Preventing AIDS in Adolescents

School/Youth Prevention Strategies
Opening Remarks: June E. Osborn, M.D., Chair

Welcoming Remarks: Honorable Glen Maxey, Texas State
Representative

Panel 1

Joanne G. Fraser, Ed.D., Director, HIV/AIDS School Health
Education Project, South Carolina Department of Education,
Columbia, SC

Vicky Valdez Gomez, Director of Finance, Corporate Fund for
Children, Austin, TX

Marvin Jeter, Teacher Living with AIDS, Akron, OH

Gene Wilhoit, Exerutive Director, National Association of State
Boards of Education, Alexandria, VA

Discussion

Break

Panel 2

Kate Barnhart, student, New York City Public Schools,
Manhattan, NY .

Jay Coburn, B.S., Director, Training and Technical Assistance,
Center for Population Options, Washington, DC _
Marion Howard, Ph.D., Clinical Director, Teen Services Program,

Grady Memorial Hospital, Atlanta, GA
Discussion

Public Comment

Lunch

Presentation by ACTT (Active Community Teen Theater),
McAllen, TX

Commission Business

Adjourn

Appendix A-7
 

 

APPENDIX B: Resources on HIV/AIDS and Adolescents

A bibliography on HIV/AIDS and adolescents has been prepared for those desiring further
information on topics covered in this report by the staff of the CDC National AIDS
Clearinghouse. |

The bibliography contains material on:

HIV and other STDs,

Alcohol, tobacco and other drugs,
Adolescent developmental issues,

Health and social service needs,

Youth’s high risk situation,

Special populations,

Out-of-school youth,

Portrayal of youth in the media,

The role of schools,

Parent/peer/teacher training programs, and
Role of other youth-serving organizations...

Copies of the bibliography can be obtained from:

cDc National AIDS Clearinghouse
Post Office Box 6003
Rockville, Maryland 20849-6003

Phone: (1-800) 458-5231; (1-301) 217-0023 (international calls)
Fax: (1-301) 738-6616

TTY: (1-800) 243-7012

(available in English and Spanish)

The Clearinghouse will also prepare materials in response to requests on other informational
needs.

Preventing AIDS in Adolescents Appendix B-1