AIDS in Adolescents

AIDS Surveillance Report

CDC National AIDS Clearinghouse
PO Box 6033
Rockville, MD 20849-6003
1-800-458-5231
www.cdc.gov
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Introduction
Millions of people contracted human
immunodeficiency virus (HIV) annually
Globally about 30 million have already
developed the acquired immunodeficiency
syndrome (AIDS)
>90% of those diagnosed with AIDS are
dead

Introduction
End of 1996 - 581,429 cases reported in the
US
488,300 men
85,500 women
7,629 youth

Magnitude of the problem

Transmission: only three routes

Who is infected

sex, blood, and mother to child

Straight and gay, health care worker and drug

user, women and men, rich and poor, educated
and uneducated
Every race, every orientation, every nation

World - Wide Epidemic

Total

(Adults and children): 21,800,000

Developing World: 21,100,000

Sub-Saharan Africa & SE Asia: 18,000,000

(85 % of total)
South America and Caribbean: 3,100,000
(15%)

United

States: < 750,000

6

New HIV Infections 1995:

HIV

infected Babies born : 500,000

New Adult: 2,700,000
Rate = 7,000 per day or 1 every 12 seconds
Sub

Saharan Africa: 1,400,000

Rate = 4,000/day or 1 every 22 seconds

Southeast

Asia: 1,000,000

Rate = 3,000/day or 1 every 29 seconds

7

Total Cases of AIDS

Adults: 6,000,000
live in sub-Saharan Africa: 4,500,000 adults

Children: 1,600,000
live in sub-Saharan Africa: 1,360,000 children

Total AIDS 7,700,000

Developing World: 6,900,000
Developed World: 750,000
8

Died of AIDS:

Total
5,800,000
Children: 1,300,000
Adults: 4,500,000

History

First case of AIDS

Seaman who lived in Manchester, England in
1959

First AIDS in United States

16 year old boy in St. Louis in 1968

Clusters recognized in the US in 1981

Gays and IV drug users (IVD) in Los Angeles
and New York City

History
HIV was identified and named in 1983
AIDS diagnoses per year:

1992 =
1993 =
1994 =

47,572
106,618
80,691

Increase in 1993 included the expanded case

definition which makes it appear as though
AIDS actually declined in 1994

AIDS In Adolescents
Has increased dramatically since 1987
Latency = 5 to 10 years, generally regarded
as 10 years
Nearly 20% of all AIDS diagnosed each
year are in the age group of 20-29
About 4% annually are in the 20-24 years
age group

AIDS In Adolescents

There is a high
likelihood that
adolescents are
becoming infected
with the HIV and are
later diagnosed with
AIDS when they are
no longer adolescents

Transmission of the HIV

Unprotected sex with infected partner
Sharing contaminated needles with an
infected person
Transfusion or major contact with infected
blood
Transmission between mother and child
during fetal development, delivery, or
breastfeeding

Transmission of the HIV

Fluids

Sites

Blood
Seminal fluid
Vaginal fluid
Breast milk

Mouth
Vagina
Rectum
Skin opening

Patterns
Pattern I countries - Homosexual, mother to
child, and exposure to blood (US, Canada,
Western Europe)
Pattern II countries - Heterosexual (SubSaharan Africa, Latin America, & Caribbean)
Pattern III - Infected blood, travellers to high
rate areas, blood products (Eastern Europe,
Middle East, Australia)

Global Trend
Pattern I countries are becoming pattern II
countries
Men who developed AIDS through
heterosexual exposure increased from 1,613
to 3,328 between 92 & 93
Women who developed AIDS through
heterosexual exposure increased from 2,588
to 5,545 between 92 & 93

Adolescents at Risk
Shift in transmission via heterosexual activities
suggests that US adolescents are at particular risk
Adolescents are sexually active at rates 70% of
females and 80% of males by age 20
Male to female ratio in adults = 10:1
Male to female ratio in adolescents = 3:1 (more
consistent with Pattern II countries

Reference

Burke, D.S., Burndage, J.F., Goldenbaum,

M., Gardner, L.I., Peterson, M., Visintine,
R., & Redfield, R.R (1990). Human
immunodeficiency virus infections in
teenagers. Seroprevalence among
applicants for US military service. Journal
of the American Medical Association,
263(15), 2074-2077.

HIV in Adolescence:
A Rationale for Concern
Little data on HIV prevalence in the
adolescent population
Military service research (Burke, 1990)

48 of 150,043 women tested = HIV positive

345 of 991,445 men tested = HIV positive
Ratio = 1.09:1

How many were in the window?

HIV in Adolescence:
A Rationale for Concern

Job Corps seroprevalence rates (Hein, 1992,

1993):
3.9/1000

Runaway adolescents in New York (Hein,

1992)
18-20 years of age
15% seropositivity

References
Hein, K. (1992). Adolescents at risk for
HIV infection. In R.J. DiClemente (Ed.),
Adolescents and AIDS: A Generation in
Jeopardy (pp. 3-15). Newbury Park,
California: SAGE Publications, Inc.
Hein, K. (1993). "Getting real" about HIV
in adolescents. American Journal of Public
Health, 83(4), 492-494.

HIV in Adolescence:
A Rationale for Concern
Only a small percentage of at-risk
adolescents have been tested for
seroprevalence of HIV
The number of reported cases of AIDS
doubles every 14 months
Prevalence of HIV-infected youth is largely
unknown in the US

Development

Adolescence

Time of physiologic & psychological change

Family separation begins
Independent thought & action develop
Identity as a sexual self emerges
Time for exploring & experimenting with
various behaviors

Development

Those who engage in

sexual
experimentation may
not have reached a
level of cognitive
development that
allows them to be
future oriented or
nonegocentric

Development

Adolescents may be aware of various

dangers but often feel as though they are:
immune
immortal
will never die of anything

AIDS will never happen to me

Development

Risks may help

adolescents:
gain admission to peer
groups
enhance self-esteem
take control of their
lives
express opposition to
adult authority or
society

Development

Teens who experiment with drugs & sex are

vulnerable to
HIV infection
STDs
Unintended pregnancy

But, may be difficult to influence toward

HIV/AIDS prevention due to susceptibility
to negative peer pressures

Development

Adolescents may have

difficulty in grasping
the long-term
consequences of
potentially dangerous
behaviors

Sexual Behaviors
Who really knows how many adolescents
are sexually active?
Median age of first intercourse is often
reported as 14.5 years
Males usually one year younger than
females
Earlier onset usually means more sexual
partners

Sexual Behaviors

One in six high school

girls are sexually
experienced with at
least four different
partners (Freidman,
1992)

Reference
Friedman, L.S., & Goodman, E. (1992).
Adolescents at risk for HIV infection. Primary
Care, 19(1), 171-190.
Bandura, A. (1992). A social cognitive approach
to the exercise of control over AIDS infection. In
R.J. DiClemente (Ed.), Adolescents and AIDS: A
Generation in Jeopardy (pp. pp. 89-116). Sage
Publications, Newbury Park, California.

Sexual Behaviors

Females between 18 and 19 are the group

most likely to become sexually active
This may be due an inclination of females in
this age group to date men who re 2-3 years
older

San Francisco Research (Hein, 1992)

26% had experienced anal intercourse

Sexual Behaviors

Homeless adolescents often practice:

Anal, oral, and vaginal sex
Multiple partners
Rates of sexual abuse in homeless 20 times
greater than women in general

50% of rape victims are less than 18 years old

Many are violent attacks on the homeless

STDs in Adolescence
Sexually transmitted diseases often progress more
rapidly in the adolescent age group

Rates of gonorrhea,
chlamydia, and
syphilis are higher in
adolescents
Adolescents have the
highest rates of
hospitalization for PID

HPV progresses more

quickly in adolescents
as compared to adults
STDs may increase
the likelihood of HIV
transmission

Menarche
The age of menarche has decreased over the
past century
Women in the 1800s experienced menarche
at somewhere between 15 and 18 years
They married at 17 or 18 years
Had short sexually mature interval between
menarche and marriage
Less time to struggle with sexuality

Histochemical Vulnerability
of Adolescents

In adolescence, the columnar epithelium

extends from the endocervical canal into the
vagina (called ectopy as the columnar
epithelial cells normally remain within the
endocervical canal and squamous
epithelium - more protective - covers the
cervix with maturity)

Histochemical Vulnerability
of Adolescents
Columnar epithelium is more friable and
vascular
This site of columnar epithelial ectopy is the
primary site of invasion by chlamydial and
gonococcal agents causing STDs in
adolescents
May also be true for HIV

Histochemical Vulnerability
of Adolescents
Early adolescent females have a relative lack
of progesterone associated with the
anovulatory cycles that follow menarche
This hormonal deficiency may cause the
cervical plugs (usually protective) to be thinner
and may allow a virus to pass more easily into
the upper genital tract

AIDS Cases by Exposure

1994 - Men

HIV/AIDS Surveillance Report - 1994

53% - Men having sex with men

24% - IV drug use
1% - Transfusion
4% - Heterosexual contact

Exposure 1994 - Women

HIV/AIDS Surveillance Report - 1994

48% - IV drug use
0% - Transfusion (only 27 cases)
38% - Heterosexual contact (n=6,413)

For women, the greatest risk outside of injecting

drugs was having sex with an injecting drug user
(n=2,953)
Next was having sex with a bisexual male
(n=549)

Incidence/Rates of STDs in
Adolescents

Females are at the

highest risk and have
the highest rates of
STDs as compared to
males
Varying research
reporting clinical
detection of agents
causing STDs:

Chlamydia - 8-40% of
sexually active female
adolescents
Gonorrhea - 3-18%
Trichomonas - zero to 48%
H. simplex - 2%
Syphilis - 3%
HPV - 18 to 33% of females

References
Yankauer, A. (1994). Sexually transmitted
diseases: a neglected public health priority.
American Journal of Public Health, 84(12),
1894-1897.
Newcomer, S., & Baldwin, W. (1992).
Demographics of adolescent sexual
behavior, contraception, pregnancy and
STDs. Journal of School Health, 62(7),
265-270.

References
Yarber, W.L., & Parrillo, A.V. (1992).
Adolescents and sexually transmitted
diseases. Journal of School Health, 62(7),
331-338.
Adapted from MMWR Report (1993).
Selected behaviors that increase risk of HIV
infection, other sexually transmitted
diseases...... Journal of School Health,
63(2), 116-118.

HIV/STD Prevention

Most effective means of preventing HIV

Refrain from sexual intercourse
Maintaining monogamous sexual relationships
with uninfected partner
Avoiding IV drug use

Compliance with these measures is very

unlikely

Abstinence
Sexual abstinence is the most effective method
available to prevent the transmission of HIV as
well as other STDs
Few adolescents become abstinent after they once
become sexually active
Neither sex education nor AIDS prevention
education have been shown to be effective in
reducing rates of sexual intercourse in those who
are sexually active

Abstinence
(Education) will not make the
sexually active celibate (or)
impel the intravenous drug user
to renounce drugs..... (Albert
Bandura, 1992)

Abstinence Only Message

When this message is offered as the only
strategy to prevent HIV/AIDS and/or pregnancy
it ignores adolescents who are sexually active
It suggests that those who are sexually active are
bad
Those with history of involuntary sexual
intercourse may find this message confusing or
upsetting

The Theory of Utilitarianism

The usefulness of good and the determining
consideration of right conduct should be the
usefulness of its consequences
The aim of an action should have the
greatest amount of benefit for the greatest
number

References
DiClemente, R.J. (1992a). Epidemiology of
AIDS, HIV Prevalence, and HIV incidence among
adolescents. Journal of School Health, 62(7), 325330.
Hopp, J.W. (1994). AIDS/HIV resource unit.
Prepared for the North American Division of
Seventh-day Adventists, Principals/Bible
Conference, July 17-21, 1994, at La Sierra
University, Riverside, California.

References
Roper, W.L., Peterson, H.B., & Curran, J.W.
(1993). Commentary: Condoms and HIV/STD
prevention - clarifying the message. American
Journal of Public Health, 83(4), 501-503.
Weller, S.C. (1993). A meta-analysis of
condom effectiveness in reducing sexually
transmitted HIV. Social Science Medicine,
36(12), 1635-1644.

Reference

Perlman, J.A., Kelaghan, J., Wolf, P.H.,

Baldwin, W., Coulson, A., & Novello, A.
(1990). HIV risk difference between
condom users and nonusers among U.S.
heterosexual women. Journal of Acquired
Deficiency Syndrome, 3, 155-165.

Condoms
Frightening message to many
The abstinence message needs to be combined
with the alternative strategy of condom use
(DiClemente, 1992a)
Condoms are... the best public health HIVpreventive measure available to individuals who
lack the moral commitment to Biblical ideals
(Hopp, 1994)

Condom Effectiveness
Critics often cite a worst-case-scenario
when describing condom efficacy
These assertions may diminish the potential
efficacy of condoms
Those who need to use condoms may not do
so if they are taught that condoms are
ineffective

Condom Effectiveness

...promoting more widespread

understanding of condoms efficacy and
advocating their use by those who choose to
be sexually active is crucial to protecting
people from HIV infection and slow the
spread of HIV and sexually transmitted
diseases (Roper, 1993)

Condom Effectiveness
Consistent condom use provides a 70% -100%
reduction in the risk of transmitting the HIV
European study:

Among 24 couples (one partner HIV infected) who used

condoms correctly, none of the partners became
infected.
However, 44 couples (one partner HIV infected) who
reported inconsistent condom use saw 6 female partners
become infected

Condom Research

Meta-analysis of condom research to determine

true condom effectiveness (Weller, 1993)
HIV does leak through condoms
Probably no worse than 46% and no better than 82%
effective

45% of all new HIV cases may be prevented if

condoms are more widely used (Perlman et al.,
1990)

Condoms
Women who have sex with HIV positive partners
are at high risk and should be aware that the
apparent protection provided with condom use
against the HIV is no better than the 10% annual
failure rate for pregnancy (Perlman, 1990)
Nonoxynol-9 should be used in conjunction with a
condom

Reference

DiClemente, R.J., Durbin, M., Siegel, D.,

Krasnovsky, F., Lazarus, N., & Comacho,
T. (1992b). Determinants of condom use
among junior high school students in a
minority, inner-city school district.
Pediatrics, 89(2), 197-202.

Correlates of Condom Use

(DiClemente, 1992b):
Safe sex intentions
Adolescents who perceived their friends as using
condoms (OR = 2.21)
Adolescents who perceived condoms as effective
were two times more likely to use a condom
Adolescents who discussed AIDS with their partner
were 5.2 times more likely to report consistent
condom use

Correlates of Condom Use

(DiClemente, 1992b) continued:

Fewer lifetime sex partners
Male gender
High self-efficacy - 8.8 times more likely to use
condom
Those who did not experiencing sexual
disinhibition by using alcohol

References
Price, J.H., Desmond, S., & Kukulka, G. (1985).
High school students' perceptions and
misperceptions of AIDS. Journal of School
Health, 55(3), 107-109.
Strunin, L., & Hingson, R. (1987). Acquired
immunodeficiency syndrome and adolescents:
Knowledge, beliefs, attitudes and behaviors.
Pediatrics, 79(5), 825-828.

References
Hingson, R.W., Strunin, L., Berlin, B.M., &
Heeren, T. (1990a). Beliefs about AIDS... &
unprotected sex among Massachusetts
adolescents. American Journal of Public Health,
80(3), 295-299.
Hingson, R.W., Strunin, L., & Berlin, B.M.
(1990b). AIDS transmission: changes in
knowledge.... Pediatrics, 85(1), 24-29.

Early HIV/AIDS Research

First AIDS research in adolescents revealed

a low level of accurate knowledge about
HIV transmission (Price, Desmong, &
Kukulka, 1985)
60% didnt know HIV could be transmitted
through sexual intercourse
20% were unaware HIV could be transmitted
through needle sharing

Early HIV/AIDS Research

Massachusetts study - adolescents 16-19 years

(n=826) (Strunin & Hingson, 1987):
Only half had discussed AIDS in school
46% had discussed AIDS with a parent
80% had seen a physician in the previous year but
only 15% had been counseled about AIDS
Accurate HIV knowledge was low

Later HIV/AIDS Research

Massachusetts research repeated in 1988 &

1990 (Hingson & Strunin, 1990a & 1990b)
Misconceptions about HIV transmission had
diminished
Adolescents were much more knowledgeable
Condom use had risen from 2% to 14%
But, 14% more were sexually active

Later HIV/AIDS Research

All of the HIV research conducted around
1990 showed gains in knowledge
Gains were also seen on condom use but
these were offset by increases in sexual
activity
By 1990, adolescents were well informed
regarding HIV

Later HIV/AIDS Research

Adolescents

(1990) more correctly

understood accurate modes of HIV
infection, however, rates of sexual
intercourse continued to raise but the
rates of condom use were not
increasing proportionately

Recent Research
Accurate HIV/AIDS knowledge remains
high
However, there is little evidence that
accurate knowledge of the mechanisms of
HIV transmission have changed behavior
even though HIV is almost exclusively
transmitted by behavior that can be
modified

Reference
DiClemente, R.J. (1993a). Preventing
HIV\AIDS among adolescents... Journal of the
American Medical Association. 270(6), 760-762.
DiClemente, R.J., Brown, L.K., Beausoleil, M.S.
& Ludico, M.A. (1993b). Comparison of AIDS
knowledge and HIV-related sexual behaviors ...
Journal of Adolescent Health, 14, 231-236.

Knowledge and Behavior

There is only a weak

relationship between
accurate HIV
knowledge and the
adoption of HIV
preventive behaviors
during sexual
intercourse
(DiClemente, 1993a &
1993b)

Abstinence Only Programs

Evaluation of abstinence only programs is
discouraging
Only three methodologically sound research
projects have been reported in the literature.
None report significant success in reducing
sexual intercourse (Christopher & Roosa, 1990;
Roosa & Christopher, 1990; and Jorgensen et
al., 1993)

References
Christopher, F.S., & Roosa, M.W. (1990). An
evaluation of an adolescent pregnancy prevention
program: Is just saying no enough? Family
Relations, 39, 68-72.
Roosa, M.W., & Christopher, F.S. (1990).
Evaluation of an abstinence-only adolescent
pregnancy prevention program: A replication.
Family Relations, 39, 363-367.

References

Kirby, D., Short, L., Collins, J., Rugg, D.,

Kolbe, L., Howard, M., Miller, B.,
Sonenstein, F., & Zabin, L.S. (1994).
School-based programs to reduce sexual
risk behaviors: A review of effectivenes.
Public Health Reports, 109(3), 339-360.

References
Verby, C., & Herold, E.S. (1992). Parents
and AIDS education. AIDS Education and
Prevention, 4(3), 187-196.
DiClemente, R.J. (1991a). Predictors of
HIV-preventive sexual behavior in a highrisk adolescent .... Journal of Adolescent
Health, 12, 385-390.

References

Dusenbury, L., Diaz, T., Epstein, J.A.,

Botvin, G.J., & Caton, M. (1994). Attitudes
toward AIDS and AIDS education among
multi-ethnic parents of school-aged children
in New York City. AIDS Education and
Prevention, 6(3), 237-248.

Myth: AIDS Education

Encourages Sex

Kirby (1994) reviewed 23 school sex education

aimed at reducing sex behaviors
None significantly hastened the onset of intercourse

Kirby (1994)reviewed four AIDS programs

aimed at decreasing sexual activity
None showed increase decrease

Myth: AIDS Education

Encourages Sex

Verby & Herold

(1992) state that 95%
of parents in a
Canadian study
disagreed that
instruction on
contraception would
lead to sexual
experimentation

HIV/AIDS Education
Effective education leading to behavior change
is the only method of reducing HIV
transmission (Kirby, 1992; & DiClemente,
1991)
There is an urgent need for AIDS education and
programs which will influence adolescents to
use HIV/AIDS preventive measures
(Dusenbury et al., 1994)

HIV/AIDS Education

Virtually all youth are

in school before they
initiate HIV risktaking behaviors
Schools have the
broadest opportunity
for reducing HIV-risk
taking behaviors

HIV/AIDS Education
Parental support for AIDS education in high
HIV/AIDS education must be designed to meet
the needs of all students - even those who are
sexually active
Abstinence now is the primary message
Value of monogamous marriage must be stressed

HIV/AIDS Education

Condom
education is
necessary