November 30, 2012
Based on the most recent data available from 2009 and 2010, youths represent 6.7% of persons living with HIV in the United States and account for 25.7% of new HIV infections. Of new HIV infections among youths, 45.9% were among black/African American males, the majority of which were attributed to male-to-male sexual contact. Nationwide, the percentage of youths who had ever been tested for HIV was low compared with other age groups1: 12.9% among high school students (22.2% among those who ever had sexual intercourse) and 34.5% among persons aged 18-24 years.
The higher HIV prevalence among blacks/African Americans overall (nearly three times higher than among Hispanics/Latinos and nearly eight times higher than among whites ) and MSM overall (nearly 40 times higher than other men5) contributes to the disproportionate number of new HIV infections among black/African American youths and young MSM. Because of this disparity, black/African American youths are at higher risk for infection even with similar levels of risk behaviors.6 Other research has found that among young MSM, other factors such as stigma, discrimination,7 less condom use, more alcohol and drug use, and having sex with older partners8 contribute to even higher risk for HIV acquisition. This analysis also found that young MSM were significantly less likely to use condoms during last sexual intercourse, more likely to drink alcohol or use drugs before last sexual intercourse, and more likely to have four or more partners during their lifetime compared with young men who had sexual intercourse only with females. These behaviors are associated with substantial risk for infection. In one study among MSM, the attributable risk for new HIV infection was 29% for using alcohol or drugs before sex and 32% for having four to nine sex partners.9 Further, in a study of primarily young MSM, 75% of those with acute HIV infection reported sex under the influence of drugs or alcohol compared with 31% of HIV-uninfected MSM. Moreover, the risk for HIV infection doubled for MSM with a sex partner 5 years older and quadrupled with a sex partner 10 years older.8
More than half (59.5%) of youths with HIV are unaware of their infection.1 Although the number of new HIV infections is highest among males, fewer males have been tested for HIV than females. Routine HIV testing as part of regular medical care is recommended by CDC for all persons aged 13-64 years10 and by the American Academy of Pediatrics for all youths by age 16-18 years and all sexually active youths regardless of age.11 Better adherence to these guidelines, especially for males, is needed to increase early HIV diagnosis and facilitate treatment that improves health and reduces transmission.
Interventions for youths have been proven effective for delaying initiation of sexual activity, increasing condom use, and reducing other risk behaviors, such as drug and alcohol use.¶¶ The Community Preventive Services Task Force recommends risk reduction interventions in school and community settings to prevent HIV among adolescents.3 Individual- and group-level HIV prevention interventions provide knowledge, skill building, and increased motivation to adopt behaviors that protect against HIV infection, and some are designed specifically for youths at high risk for HIV.
For young MSM (those aged 18-29 years), "Mpowerment" is an effective community-level intervention that has been shown to reduce unprotected anal intercourse, the sexual behavior that carries the greatest risk for HIV transmission.12 However, additional individual- and group-level interventions specifically designed for young MSM, and young black/African American MSM in particular, are needed. Evidence-based behavioral HIV interventions for high risk youths can be adapted to address the unique needs of young MSM and to communicate the substantial risks associated with having sex with partners who are more likely to be infected, particularly those who are older.
Multicomponent school-based interventions, including classroom-based curricula and school-wide environmental changes, have been shown to decrease unprotected sex and increase condom use among youths.3 Policies can support these efforts by promoting in schools an inclusive environment for sexual minorities that reduces stigma and discrimination13 and requiring evidence-based HIV prevention education3 for all students. In addition, community organizations, schools, and health-care providers can establish procedures that reduce barriers and protect confidentiality (i.e., procedures that do not disclose information to unauthorized persons unless required under state law) for youths seeking sexual health services14 and facilitate access to education and other HIV prevention services.
Early diagnosis and treatment can reduce HIV progression and prevent transmission, but youths are less likely to be tested, access care, remain in care, and achieve viral suppression.15 Youth-friendly, culturally competent, confidential, and convenient health services facilitate access to and retention in care.*** Comprehensive health services, including HIV/sexually transmitted infection screening, treatment, and prevention services, and adjunct services, such as mental health, drug and alcohol treatment, and housing assistance, are necessary for youths at highest risk of acquiring or transmitting HIV. Because young MSM often acquire HIV from older, HIV-positive partners,8 regular testing, care, and treatment for adult MSM also are essential to prevent HIV infections among youths.
Limitations of the estimates of new HIV infections have been described previously.15 In addition, the findings in this report are subject to at least three more limitations. First, YRBS 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.4 Second, NHIS excludes active military personnel and those who live outside of households (e.g., persons who are incarcerated, in long-term-care institutions, or homeless), who might be at greater risk for HIV infection than persons in households. Finally, data from YRBS and NHIS are self-reported and subject to recall bias and potential underreporting of sensitive information, such as HIV risk factors and HIV testing.
To achieve the goals of the National HIV/AIDS Strategy for the United States (i.e., to reduce the number of persons who become infected with HIV and reduce disparities), public health agencies, in conjunction with families, educators, and health-care practitioners, must educate youths about HIV before they begin engaging in risk behaviors, especially young gay and bisexual males, particularly blacks/African Americans, who face a disproportionately higher risk.2 To delay the onset of sexual activity, increase condom use among those who are sexually active, and decrease injection drug use, multicomponent school- and community-based approaches that provide access to condoms, HIV testing and treatment, and behavioral interventions for those at highest risk are needed.
Reported by: Suzanne K. Whitmore, Dr.P.H., Laura Kann, Ph.D., Joseph Prejean, Ph.D., Linda J Koenig, Ph.D., Bernard M. Branson, M.D., H. Irene Hall, Ph.D., Amy M. Fasula, Ph.D., Angie Tracey, Jonathan Mermin, M.D., Linda A. Valleroy, Ph.D., Div of HIV/AIDS Prevention, Div of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Suzanne K. Whitmore, firstname.lastname@example.org, 404-639-1556.
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