Trends in HIV-Related Risk Behaviors Among High School Students -- United States, 1991-2011

Editorial Note

The findings in this report suggest that previously reported progress in reducing some HIV-related risk behaviors among students⁴ stalled overall and among certain populations of students. Most concerning are the decrease in condom use among black students since 1999 and the lack of any significant decrease since 1991 in the percentage of Hispanic students who have had sexual intercourse, four or more sex partners, and current sexual activity.

Another of the three primary goals of the National HIV/AIDS Strategy for the United States is to reduce HIV-related health disparities. In 1991, a gap of 32 percentage points was observed in sexual experience prevalence between black and white students (black: 81.5%; white: 50.0%). In 2011, this gap had been reduced to 16 percentage points (black: 60.0%; white: 44.3%). Large differences between black and white students in the prevalence of having four or more sex partners and current sexual activity also have been reduced over time. Nonetheless, black students still report significantly higher prevalence of sexual risk behaviors than white or Hispanic students and remain at increased risk for HIV infection and sexually transmitted diseases, a finding that underscores the importance of the decreasing trend in condom use among black students since 1999. YRBS data cannot isolate the effects of race/ethnicity from the effects of other factors on the prevalence of HIV-related behaviors. Additional research is needed to assess the effects of education, socioeconomic status, and cultural factors on the prevalence of these behaviors and to help intensify HIV prevention efforts in the communities where HIV infection is most heavily concentrated.¹

The findings in this report are subject to at least two limitations. First, these data apply only to youths who attend school and therefore are not representative of all persons in this age group. Nationwide, in 2009, of persons aged 16-17 years, approximately 4% were not enrolled in a high school program and had not completed high school.⁵ Second, the extent of underreporting or overreporting of self-reported behaviors cannot be determined, although the survey questions demonstrate good test-retest reliability.⁶

The National HIV/AIDS Strategy for the United States recommends educating young persons about HIV before they begin engaging in behaviors that place them at risk for HIV infection,⁷ and the Community Preventive Services Task Force recommends risk reduction interventions to prevent HIV infection among adolescents.⁷ Although in another study a median of 90% of all public secondary schools in 45 states taught HIV prevention in a required course during 2010, the percentage that taught 16 specific topics varied widely.⁸

To achieve the National HIV/AIDS Strategy for the United States goal of reducing the number of persons who become infected with HIV, further improvements in the prevalence of behaviors that contribute to HIV infection among young persons are needed. Renewed educational efforts that reach all students before risk behaviors are initiated and that seek to delay the onset of sexual activity, increase condom use among students who are sexually active, and decrease injection drug use are warranted.

References

1. Office of National AIDS Policy. National HIV/AIDS strategy for the United States. Washington, D.C.: The White House, Office of National AIDS Policy; 2010. Accessed July 20, 2012.
2. CDC. HIV among youth. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Accessed July 20, 2012.
3. CDC. Youth Risk Behavior Surveillance -- United States, 2011. MMWR 2012;61(No. SS-4).
4. Eaton DK, Lowry R, Brener ND, Kann L, Romero L, Wechsler H. Trends in human immunodeficiency virus- and sexually transmitted disease-related risk behaviors among U.S. high school students, 1991-2009. Am J Prev Med 2011;40:427-33.
5. National Center for Education Statistics. Common core of data: public elementary/secondary school universe survey. Washington, D.C.: US Department of Education, National Center for Education Statistics. Accessed July 20, 2012.
6. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolesc Health 2002;31:336-42.
7. CDC. Guide to community preventive services. Prevention of HIV/AIDS, other STIs and pregnancy: group-based comprehensive risk reduction interventions for adolescents. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Accessed July 20, 2012.
8. CDC. HIV, other STD, and pregnancy prevention education in public secondary schools -- 45 states, 2008-2010. MMWR 2012;61:222-8.

* Overall response rate = (number of participating schools/number of eligible sampled schools) x (number of usable questionnaires/number of eligible students sampled).

† The YRBS questions were as follows: "Have you ever had sexual intercourse?" "During your life, with how many people have you had sexual intercourse?" "During the past 3 months, with how many people did you have sexual intercourse?" "The last time you had sexual intercourse, did you or your partner use a condom?" and "During your life, how many times have you used a needle to inject any illegal drug into your body?" The wording of the question on injection drug use changed substantially after the 1993 survey, so 1991 and 1993 data on injection drug use are not included in this report.

§ A quadratic time effect indicates a significant but nonlinear trend in prevalence over time. Whereas a linear trend is depicted with a straight line, a quadratic trend is depicted with a curve with one bend. A temporal change that includes a significant linear and quadratic time effect demonstrates nonlinear variation (e.g., leveling off or change in direction of prevalence) in addition to an overall increase or decrease in prevalence over time.