Young people in the United States remain at risk for HIV infection. An estimated 56,300 Americans are infected with HIV each year.1 Of these, 34% -- or approximately 19,000 -- are adolescents or young adults aged 13-29 years.1 Young men who have sex with men (YMSM), especially black YMSM, are at highest risk. This fact sheet highlights the ongoing risk for HIV infection among YMSM and underscores the need to reach each new generation with effective HIV prevention messages and services. Schools and education agencies are important partners in this effort.
HIV infection affects certain groups of young people disproportionately, especially:
Young men who have sex with men:
- Among adolescents aged 13-19 years, nearly two-thirds of all diagnosed HIV infections are from male-to-male sexual contact.2
- From 2005 to 2008, YMSM aged 13-24 years had the greatest percentage increase in diagnosed HIV infections* of all age groups (Figure 1).3
- In 2008, 75% of all diagnosed HIV infections in youth aged 13-19 years were among black youth, even though blacks represented only 17% of the population in that age group.2
- Nearly two-thirds (63%) of all YMSM aged 13-24 years with HIV infection in 2008* were black YMSM, followed by white YMSM (18%) and Hispanic/Latino YMSM (17%).3
- Black YMSM also experienced the largest increase of all racial/ethnic groups in diagnosed HIV infections -- from 1,841 in 2005 to 3,188 in 2008 (Figure 2).3
The reasons for these disparities are varied and not well understood, but possible factors include the following:
- Lack of knowledge of infection status. A high percentage of HIV-infected men who have sex with men (MSM) do not know they are infected, especially MSM of color and YMSM.4 Those who do not know they are infected might be less likely to take measures to keep from spreading the virus to others.
- Failure to reach MSM with effective interventions or prevention education. A CDC study of gay and bisexual men in 15 cities found that 80% had not been reached in the past year by HIV interventions known to be most effective.5 In addition, sex education programs that do not include information about sexual orientation or that ignore issues in the lives of sexual minority youth might not be effective in preventing HIV transmission among those students.
- Use of alcohol and illegal drugs. Alcohol, methamphetamine, and other "party drug" use is common among some YMSM and can lead to risky sexual behavior.6
- Complacency about risk. Improved treatment for HIV infection has helped many people with HIV infection live longer and healthier lives. An unintended consequence of this success is that younger MSM, who did not witness the toll of AIDS in the early years of the epidemic, might view HIV as less dangerous and become complacent about risks.6
- Mental health consequences of stigma and discrimination. Bullying, harassment, family disapproval, social isolation, and sexual violence -- which are experienced frequently by gay, lesbian, and bisexual youth -- can cause feelings of shame and poor self-esteem. This can lead to higher rates of emotional distress, suicide attempts, substance use, and risky sexual behavior.7-9
Racial/ethnic disparities in HIV/AIDS among young MSM are also not well understood. The disparities do not appear to reflect individual racial or ethnic differences in risk behaviors such as unprotected anal sex, commercial sex work, sex with a known HIV-positive partner, or HIV testing history.10 Possible factors include the high prevalence of HIV in black male social networks, elevated rates of STDs among black men, and the reduced likelihood of black men receiving treatment (which can reduce the amount of HIV in the blood and potentially decrease transmission).10
Strategies for Addressing HIV Among YMSM in Schools
Collect and Analyze Data on Sexual Identity, Sex of Sexual Contacts, and Associated Health Risk Behaviors Among Youth
The Youth Risk Behavior Survey** is being used by some states and large urban school districts to monitor health risk behaviors and selected health outcomes among sexual minority students.† States and school districts participating in the YRBS can add optional questions to the standard YRBS questionnaire, including:
During your life, with whom have you had sexual contact?
☐ I have never had sexual contact
☐ Females and males
Which of the following best describes you?
☐ Heterosexual (straight)
☐ Gay or lesbian
☐ Not sure
In 2009, a total of 17 states and large urban school districts included one or both of these questions on their YRBS. Among these:
- 9 asked about both the sex of students' sexual contacts and about students' sexual identity.
- 4 asked about the sex of students' sexual contacts only.
- 4 asked about students' sexual identity only.
Analyses of YRBS data have contributed greatly to knowledge about health risks among gay, lesbian, and bisexual youth.11-13 A CDC analysis of data from 13 YRBS sites found that sexual minority students, especially those who identified as homosexual or bisexual, were disproportionately likely to engage in many health risk behaviors, including sexual risk behaviors (such as having sexual intercourse for the first time at younger ages, having multiple sex partners, and not using condoms); tobacco, alcohol, and other drug use; and behaviors related to attempted suicide.13
Adding these YRBS questions enables states and districts to identify risk behaviors among sexual minority students and then adjust intervention priorities accordingly. Furthermore, by documenting that many youth do engage in same-sex sexual activity and various health risk behaviors, these data can help establish the imperative for meeting the health needs of sexual minority youth in schools.
Establish Safe and Supportive School Environments
HIV prevention activities are more likely to have an impact if they take into account the context in which risk behaviors occur. For YMSM and other sexual minority students, this means addressing the challenges these young people face at school. A survey using a convenience sample of more than 7,000 middle and high school students across the United States found that, in the past year,
- Eight in 10 lesbian, gay, bisexual, or transgender students had been verbally harassed at school because of their sexual orientation.
- Six in 10 felt unsafe at school because of their sexual orientation.
- Almost a third skipped a day of school in the past month because they felt unsafe.14
For youth to thrive in their schools and communities, they need to feel socially, emotionally, and physically safe and supported. A positive school climate has been associated with decreased depression, suicidal feelings, substance use, and unexcused school absences among lesbian, gay, bisexual, and transgender students.15,16
Gay-straight alliances (GSAs) are one approach being used to create safe and welcoming school environments. Research has shown that in schools with support groups such as GSAs, lesbian, gay, and bisexual students were less likely to experience threats of violence, miss school because they felt unsafe, or attempt suicide than those in schools without such groups.1
Provide Professional Development for School Staff
School health professionals can benefit from training to help them understand the needs of lesbian, gay, and bisexual youth and shape behavioral health messages accordingly. During 2006-2011, CDC funded the American Psychological Association (APA) Healthy Lesbian, Gay, and Bisexual Students Project to help schools and youth-serving organizations improve health and mental health outcomes for sexual minority youth. APA created a training manual and offered science-based workshops for school counselors, nurses, psychologists, and social workers on how to effectively reach sexual minority students with HIV prevention messages and other health information. Many education agencies funded by CDC have formed their own training cadres to offer the workshop locally.
Implement School-Based HIV Prevention Policies, Practices, and Interventions
CDC funds state, territorial, tribal, and local education agencies to help schools implement policies and practices to reduce sexual risk behaviors. Recognizing that YMSM are a major risk group for HIV infection, a number of these agencies are taking action to address the needs of sexual minority youth. Examples of program activities include:
- Ensuring that health education curricula include prevention information relevant to sexual minority students.
- Providing training for district and school staff to help them understand the special concerns and needs of this population.
- Supporting schools in establishing GSAs or similar groups.
- Linking schools to community organizations that provide health and mental health services for lesbian, gay, and bisexual youth.
Specific program activities are described at www.cdc.gov/lgbthealth/youth.htm.
In 2011, CDC awarded funds to the Gay, Lesbian, and Straight Education Network (GLSEN) and the Gay-Straight Alliance Network (GSAN) to assist CDC-funded public health and education agencies and community-based organizations in establishing policy and environmental changes to help schools and communities meet the health and mental health needs of lesbian, gay, bisexual, and transgender youth.
CDC also funds health departments and community organizations to promote the use of evidence-based HIV prevention interventions, many of which are geared toward YMSM and young people of color. Information about these interventions is available at www.cdc.gov/hiv/topics/research/prs/evidence-based-interventions.htm.
* In the 37 states and five U.S. dependent areas with confidential name-based reporting since at least January 2005.
** The Youth Risk Behavior Surveillance System (YRBSS) monitors health risk behaviors and the prevalence of obesity and asthma among youth and young adults. YRBSS includes a national school-based survey conducted by CDC and surveys conducted by state, territorial, and local education and health agencies and tribal governments. Information is available at www.cdc.gov/yrbs.
† Sexual minority students are defined as students who identify themselves as gay or lesbian, bisexual, or unsure of their sexual identity or who have had sexual contact with persons of the same sex or with both males and females.
- Hall HI, Ruiguang S, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA 2008;300:520-529.
- CDC. HIV surveillance in adolescents and young adults; 2010.
- CDC. HIV surveillance in men who have sex with men; 2010.
- CDC. Prevalence and awareness of HIV Infection among men who have sex with men -- 21 cities, United States, 2008. MMWR 2010;59(37):1201-1207.
- CDC. MMWR analysis provides new details on HIV incidence in U.S. populations. Atlanta: U.S. Department of Health and Human Services; 2008.
- CDC. HIV and AIDS among gay and bisexual men; 2010.
- Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. JAMA 1997;278:823-32.
- Garafolo R, Wolf RC, Kessel S, Palfrey J, DuRant RH. The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101:895-902.
- Just the Facts Coalition. Just the facts about sexual orientation and youth: a primer for principals, educators, and school personnel. Washington, DC: American Psychological Association; 2008.
- Millett G, Flores F, Peterson JL, Bakeman R. Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors. AIDS 2007;21:2083-91.
- Goodenow C, Netherland J, Szalacha L. AIDS-related risk among adolescent males who have sex with males, females, or both: evidence from a statewide survey. American Journal of Public Health 2002;92:203-10.
- Robin L, Brener ND, Donahue SF, Hack T, Hale K, Goodenow C. Associations between health risk behaviors and opposite-, same-, and both-sex sexual partners in representative samples of Vermont and Massachusetts high school students. Archives of Pediatric and Adolescent Medicine 2002;156:349-55.
- CDC. Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9-12 -- Youth Risk Behavior Surveillance, selected sites, United States, 2001-2009. MMWR Early Release 2011;60[June 6]:1-133.
- GLSEN. The 2009 National School Climate Survey. New York: Gay, Lesbian, and Straight Education Network; 2010.
- Eisenberg ME, Resnick MD. Suicidality among gay, lesbian and bisexual youth: the role of protective factors. Journal of Adolescent Health 2006;39:662-668.
- Espelage DL, Aragon SR, Birkett M. Homophobic teasing, psychological outcomes, and sexual orientation among high school students: What influence do parents and schools have? School Psychology Review 2008;37:202-216.
- Goodenow C, Szalacha L, Westheimer K. School support groups, other school factors, and the safety of sexual minority adolescents. Psychology in the Schools 2006;43:573-89.