Epidemiology of AIDS, HIV Prevalence, and HIV Incidence Among Adolescents Ralph J. DiClemente
ABSTRACT: Health educators, policy analysts, and public health officials are becoming more aware of the serious threat HIV poses to the health of US.adolescents. While AIDS among adolescents remains relatively uncommon, considerable data indicates this age group has alarmingly high HIV infection rates and that minority adolescents are at disproportionately greater risk of HIV infection relative to their White peers. Recent sermonversion studies of active duty military personnel indicate that the number of new HIV infections (incident cases) are especially high among Black adolescents. Findings suggest the urgent need for more tailored HIV prevention programs, especially gender- and ethnicspecific programs. (J Sch Health. 1992;62(7):325-330)
G
rowing awareness exists of the threat that HIV infection and AIDS poses for adolescents.14 While the number of diagnosed cases of AIDS among adolescents remains relatively small compared with older age groups, ample cause for concern exists. Substantial epidemiologic data describes the prevalence of high-risk behaviors among adolescents that increase the probabilBehaviors such as inconsistent ity of HIV infe~tion.~.~ condom use among sexually active adolescents, multiple sex partners, injection drug use, and the use of alcohol and other drugs that result in greater sexual disinhibition are associated with greater likelihood of exposure to HIV.' While each behavior singularly increases the probability for HIV infection, they are more often reported in combination, further elevating an adolescent's risk for infection. Other articles in this journal issue address the prevalence and determinants of these risk behaviors. This paper provides an overview of the epidemiology of AIDS, HIV prevalence, and HIV incidence among U.S.adolescents. Relying on the number of AIDS cases to formulate public and school health policy severely underestimates the threat HIV infection poses for adolescents. While the information presented initially describes AIDS cases among adolescents, this is done primarily to summarize CDC data and establish a departure point for presenting HIV prevalence and incidence data. Given the relatively long latency period from infection to clinical diagnosis, both these epidemiologic measures are preferable to AIDS prevalence for assessing the threat of HIV for adolescents. Moreover, due to the lengthy latency period, it is unlikely AIDS rates among adolescents would demonstrate a sharp increase even with an increase in HIV infection rates. An increase in HIV infection among adolescents would result in a greater number of diagnosed AIDS cases among older age groups, for instance, adults ages 20-24, or 25-29. As a detailed examination of the AIDS surveillance data indicates, rates are not uniform among adolescents. Multicultural populations, especially Blacks and Latinos, are disproportionately represented among AIDS cases, even among adolescents ages 13-19. HIV prevalence and incidence data also suggest that Black Ralph J. DiClemente. PhD, Center f o r AIDS Prevention Studies, University of California, 74 New Montgomery St., Suite 600, San Francisco, CA 94105.
adolescents are at substantially higher risk than other ethnic groups. PREVALENCE OF AIDS AMONG ADOLESCENTS As of March 1, 1991, 167,803 cases of AIDS were reported to the U.S. Centers for Disease Control.* Of these, 150,128 were male and 17,675 were female. The number of cases among adolescent males and females ages 13-19 were 494 and 165, respectively. The proportion of adolescent cases between ages 13-19 represents less than 1% of all diagnosed AIDS cases for males and approximately 1070 of all diagnosed cases for females. The relatively small proportion of AIDS cases among adolescents should not be interpreted as an indicator of the low-risk status for this age group, given the long latency period.g-" It is important to consider not only the proportion of adolescent AIDS cases, but also those diagnosed with AIDS as young adults, in the age groups 20-24 and 25-29. Males diagnosed with AIDS in the age groups 20-24 and 25-29 account for 4% and 16% of total male AIDS cases. Similarly, females diagnosed with AIDS between the age groups 20-24 and 25-29 account for 6% and 18% of female AIDS cases. Combining the number of AIDS cases diagnosed within the age groups 13-19, 20-24, and 25-29 for males and females, respectively, the proportion of cases increases markedly to 20% and 25% of all male and female cases (Figure 1). Thus, while the proportion of adolescent cases is small, the proportion of young adults, an undetermined proportion who contracted HIV infection as adolescents, is substantially larger. ETHNIC DIFFERENCES IN AIDS PREVALENCE AIDS is not uniformly distributed as ethnic differences are substantial. Blacks and Latinos are over-represented among AIDS cases. By calculating annual rates per 100,OOO population using the 1990 U.S.Census projections, data indicate Blacks and Latinos have significantly higher rates relative to White males." Black and Latino males had annual rates of 92.4 and 71.9, relative to a rate of 27.4 for White males. For females, ethnic differences are more pronounced. Black and Latina
Journal of School Health
September 1992, Vol. 62, No. 7
325
females have AIDS annual rates of approximately 20.0 and 12.6, compared with a rate of 1.5 for White females. Unfortunately, these rates combine adolescent and adult cases, obscuring contrasts for ethnic differences among adolescents alone. Further, comparable data for adolescents are unavailable from the Centers for Disease Control, and projections of the number of ethnic group members between ages 13-19 are presently unavailable from the U.S.Census. This lack of data limits ethnic group comparisons. To develop a measure that could estimate ethnic differences among adolescents, 1980 census data" was used to identify the number of U.S. adolescents in specific gender-ethnic groups and applied to each year of the AIDS epidemic and projected over each year of the epidemic. The cumulative number of AIDS cases in each ethnic group reported to the CDC through February 1991 was used as the numerator,' yielding ethnicspecific prevalence over the duration of the AIDS epidemic. This index provides only an approximate measure of ethnic differences, given the changes in U.S. demography over the past decade. However, given the lack of available data, it provides a basis for examining variation in AIDS between gender-ethnic groups. The findings indicate all multicultural adolescent populations - Black, Latino, AsiadPacific Islander, and Native American - have a higher prevalence of AIDS per 100,OOO population relative to White adolescents (Figure 2). The most striking disparity is among Black and Latino adolescents, who are 5.1 and 4.7 times more likely to be diagnosed with AIDS than White adolescents (Table 1). Among males, Blacks and Latinos
have a prevalence 3.7 and 4.3 times greater than White males, while Black and Latina females have a prevalence rate 11.5 and 5.7 times higher respectively, than their White counterparts. HIV EXPOSURE CATEGORIES
Differences exist between adolescents and adults diagnosed with AIDS with respect to the proportion of cases identified in particular exposure categories. These are the CDC categories which define risk factors for transmission of HIV. Among adult AIDS cases, the preponderance of cases are reported in the exposure categories of male homosexual/bisexual contact and intravenous drug use. These categories account for 59% and 22070, respectively, of all cases reported through February 1991. For adolescents, only 26% and 11% of AIDS cases are reported in these exposure categories. For adults, heterosexual exposure accounts for 5% of AIDS cases while among adolescents, heterosexual contact accounts for 14% of AIDS cases. However, these data are slightly inaccurate. While the CDC describes exposure categories separately for adolescents ages 13-19, it does not provide a contrast with adult cases but rather combines adolescent/adult cases for particular exposure categories. Thus, though the number of adolescents with AIDS is small, the evidence suggests that heterosexual contact plays a somewhat more predominant role in HIV transmission among adolescents than among adults. ~~~~
Table 1 Prevalence of AIDS per 1,000,000 Population Among Adolescents Ages 13-19: By Ethnlclty Ethnlclty Black Lallno Asian Native American Whlle
Mabt Rev. REV. Ratlo' 7.4 3.7 8.7 4.3 3.9 1.9 4.2 2.1 2.0 1.0
Fernalas
OVNEll
PW.
pnv. 4.6 2.3 0.5 0.9 0.4
Ratlo' 11.5 5.7 1.2 2.2 1.0
Rev. 6.1 5.6 2.3 2.6 1.2
~
Prev. =Prevalence expressed as number of cases per 1,000,000populafion 'Prevalence Ratio calculated with White as the referent cafegory Number of AIDS cases reported to CDC through February 1991
326
Journal of School Health
September 1 9 9 2 , Vol. 6 2 , No. 7
Pnv. Ratlo' 5.1 4.7 1.9 2.2 1.0
H I V SEROPREVALENCE AMONG ADOLESCENTS Monitoring an evolving epidemic has proven challenging because of reliance on surveillance data that emphasizes a clinical endpoint - AIDS. The number of clinical AIDS cases among adolescents severely underestimates the threat posed by HIV infection and provides insufficient information for the allocation of health care and prevention resources. Another, more precise gauge of the threat of HIV for adolescents is based on the findings from HIV seroprevalencestudies. Currently, no representative population-based studies exist for estimating seroprevalence among adolescents. The absence of population-based data limits assessing the magnitude of risk for adolescents and reduces the capability to monitor changes in infection rates over time. Much of the HIV seroprevalence data is derived from studies of applicants for military service or active duty 'military personnel. Other studies have focused on disadvantaged youth receiving training in the Job Corps, homeless youth, adolescents seeking treatment in sexually transmitted disease clinics, and adolescents seeking medical care. Table 2 contains seroprevalence data obtained from various adolescents surveys. While these subpopulation studies provide an assessment of the impact of HIV on adolescents, the data cannot be generalized to the adolescent population-at-large. In an HIV seroprevalence study of adolescent applicants for military duty, Burke and colleaguesls focused the data analysis exclusively on HIV infection among youths younger than age 20. Reviewing 1,141,164 serologic evaluations from adolescent applicants for U.S. military service between October 1985 and April 1989, 393 teen-agers were identified as seropositive. The overall HIV prevalence was 0.34 per 1,OOO applicants. Seroprevalence varied markedly with ethnicity. Seroprevalence among Black applicants was 1.00 per 1,OOO compared with White (0.17) and Latino (0.29) applicants, respectively. Separate analyses by gender and race/ethnicity indicated that for males, prevalence for Blacks, Whites, and Latinos was 1.06, 0.18, and 0.31, respectively, while corresponding rates for Black, White, and Latina females were 0.77, 0.12, and 0.16. To control for potential confounding factors, a maximum likelihood analysis was conducted, which calculated adjusted odds ratios predicting the risk of being seropositive. This analysis indicates Blacks were 4.9 times more likely to be seropositive than Whites, and Latino applicants were 1.1 times as likely to be seropositive relative to White applicants. With respect to gender, males are 1.4 times more likely to be seropositive compared with female applicants. The unrepresentative nature of the sample studied, however, especially the potential for high-risk individuals to self-defer, suggests seroprevalence may be substantially higher. A recent study of U.S. Army active-duty personnel has identified substantial variation in HIV seropositivity by ethnicity and age group, similar to studies of applicants for military service.l 6 Higher seroprevalence was identified among Blacks and Latinos, with Blacks having slightly higher rates than Latinos. Black or Latino soldiers had an overall seropositivity of 5.1 /1 ,OOO and 4.0/ 1,ooO,respectively. HIV prevalence ratios compared
to White soldiers were 4.0 for Blacks (95% confidence interval (CI) 3.6 - 4.4) and 3.2 for Latinos (95% CI 2.5 -3.9). When only soldiers younger than age 20 are considered, the overall prevalence is 0.5/1,OOO with male and female seropositivity being 0.4 and 0.9, respectively, and the male:female ratio being 0.5. For soldiers between age 20-24, however, the overall seropositivity increases to 1.8/1,OOO, with a sharp increase for males to 1.9/1,OOO. For females, seroprevalence declines slightly to 0.7/1,000. The male:female ratio of 2.8 shows a marked change in this age group, with males significantly more likely to be HIV positive than females. To identify determinants of seropositivity, a multivariate logistic model was constructed which controlled for the simultaneous effects of demographic and other potential confounding factors. This analysis indicates that males, after statistic adjustment, are significantly more likely to be seropositive than females. Blacks and Latinas were 3.7 and 3.0 times more likely to be seropositive compared with White active duty personnel. Comparable to seroprevalence studies of military applicants, these findings demonstrate a significantly higher risk for HIV infection among Black and Latino adolescents. Since 1987, the Division of AIDWHIV at CDC has serologically evaluated disadvantaged adolescents between the ages of 16-21 for Job Corps training, with more than 60,OOO entrants having been screened each year at 106 sites throughout the U.S." A major distinction between this seroprevalence survey and military data is there are no exclusion criteria which would prevent application and entrance into the Job Corps for adolescents with a history of drug use or an alternative sexual orientation. However, current drug addiction is an excludable condition. The Job Corps data from 1987 to December 1989 indicate that disadvantaged adolescents, especially minority adolescents, are at increased risk of being seropositive. Seroprevalence for the entire sample was 0.36%; 0.37% for males and 0.32% for females. Ethnic differences, however, were substantial. Black males had the highest seroprevalence rate of all ethnic-gender groups. Black and Latino males had seroprevalence rates of 0.55% and 0.30% relative to a rate of 0.14% for White males. Similarly, Black females had the highest seroprevalence (0.48%) compared with Latino and White females (0.18% and O.OSVo), respectively. Table 2 Prevalence of HIV Infection per 1,000 Population for Selected Surveys: By Ethnlciv Ethnlclty
Sbdv Burke et al (1990) Keliey et al (1990)b St. Louis et al (1991) St. Louis et al (1990) Stricof et al (1991) D'Angeb et al (1991p
Sispk or S b Military applicanls Active-duty military Job Corps entrants General hospital Homeless shelter Ambulatory clinics
Bbck
Latho
1.0 5.1
0.29 4.0 2.6 4.9
5.3 8.3
46.0
68.0
3.7
-
Whb 0.17
1.25 1.2 2.7 60.0
-
aall findings have been converted and are presented as rate of seropositive adolescents per 1,000 to permit comparability with other surveys bsample of active duty militafy personnel is not exclusively comprised of adolescents cThis survey does not report ethnic comparisons. More than 88% of the sample was African-American, while 12% was defined as "Other" ethnic groups. Attributable to their small proportion in the sample. comparisons with "Other" ethnic groups would not be informative.
Journal of School Health
September 1992, Vol. 62, No. 7
327
Other adolescent samples in which prevalence rates have been identified include homeless youth. A seroprevalence study was conducted among adolescents receiving health care at Covenant House, a facility serving runaway and homeless youth in New York City.” The study was limited to adolescents between ages 15-20 undergoing initial medical examination between October 1, 1987 and December 31, 1989. In this study, 2,667 specimens were serologically evaluated for presence of HIV antibody. While this adolescent subgroup is not representative of the adolescent population, it reflects a segment at high risk and offers a relative contrast to other populations for which HIV seroprevalence is available. Overall, HIV seroprevalence was high; 5.3% of the adolescents were HIV positive. Latinos had the highest HIV seroprevalence(6.8Vo) followed by Whites (6.Ocrl0), and Blacks (4.6Vo). Males had higher rates than females; 6.0% vs. 4.2%. Controlling for other demographic characteristics, ethnicity is found not to be significantly associated with HIV seroprevalence; odds ratio and 95% confidence interval for Latinos 1.1 [0.7 -1.51 and Blacks 0.7 [0.4 - 1.21 compared with Whites. After adjusting for other demographic factors, age was the only demographic characteristic identified as differentially associated with HIV seroprevalence. Older adolescents (age 19 and age 20) were 2.7 and 3.7 times more likely to be seropositive than adolescents ages 15-16. This represents one of the few studies that has not identified a higher seroprevalence among Black and Latino adolescents relative to White adolescents. Between 1987 and 1989, adolescents age 13 or older attending three ambulatory clinics at Children’s Hospital Medical Center, Washington, D.C., who had blood drawn for a medical test, were screened to identify presence of HIV a n t i b ~ d y . ’During ~ the 15-month duration of the survey, 3,520 adolescents had blood drawn. Most adolescents were Black (88.2%) and the mean age was 16.3 years with a range of 13-20 years. Of all blood specimens tested, 13 were seropositive, yielding an overall prevalence of 3.7/1,000. The prevalence was higher in females than males (4.7 vs. 1.7) and among adolescents ages 15-18 compared with adolescents younger than 15 (4.9 vs. 1.7). Of particular importance is that of adolescents considered at high-risk based on screening criteria, 4.1070 (41/1,000) were seropositive; however, risk criteria could correctly identify only 38% of those adolescents who were seropositive. Another source of seroprevalence data is from a cross-sectional survey in an inner-city sexually transmitted disease clinic.20Results indicated seroprevalence of HIV infection among adolescents ages 15-19 is 2.2%; with gender-specific rates of 2.5% for females and 2% for males. In this population 28% of the seropositive women were age 20 or younger. Having an active sexually transmitted disease also was identified as an independent risk factor strongly associated with seropositive status. In a review of seroprevalence studies conducted at sexually transmitted disease clinics in the U.S.,” the median seroprevalence rate for persons younger than 20 was 1 . 1 Yo with a range from 0% - 2%. Persons between ages 20-29, however, show a substantially higher median seroprevalence of 4.5%, with a range from
328
Journal of School Health
September 1992, Vol. 62,
0.5%
- 7.5%.
Another survey, the CDC Sentinel Hospital Surveillance study,22while not specifically focusing on adolescents, provides seroprevalence data on patients seeking treatment at 26 hospitals across the U.S.To control for potential over-representation among HIV-infected patients seeking medical care for conditions related to infection, exclusion criteria were implemented that screened patients whose reason for seeking care involves a condition often associated with HIV infection or HIV risk factors. Blood specimens were serologically evaluated for presence of HIV antibody; evaluations were conducted anonymously to protect the patient’s identity. Unlike seroprevalence surveys conducted with applicants for military service, findings from the sentinel hospital survey are not subject to self-selection or self-deferral biases, which may underestimate HIV seroprevalence. From January 1988 to June 1989, 89,547 blood specimens were serologically evaluated for antibody to HIV. Overall HIV seroprevalence was 1.3%. HIV seroprevalence was most prominent in ages 2544, though a sharp increase in seroprevalence rates began in the mid-adolescent years. At two hospitals in communities with the highest AIDS prevalence, 1.1070 and 3.8% of adolescents ages 15-19 were identified as HIV seropositive. Additional ethnic-specific data is presented in Table 2. When considering only adolescents ages 13-19, seropositivity varies markedly by ethnicity. While White adolescents had a seroprevalence of 1.2 per thousand, Black and Latino applicants had a prevalence of 5.3 and 2.6 per thousand, respectively.
HIV lNClDENCE (SEROCONVERSION) AMONG ADOLESCENTS While seroprevalence data helps identify the existing number of HIV- infected individuals, it also is important to obtain incidence data - the number of seronegative persons who on subsequent HIV testing are identified as seropositive. Direct measurement of the incidence of new HIV infections greatly enhances the ability to track the evolving epidemic and substantially improves the accuracy of epidemic forecasts. Given the widespread dissemination of information about HIV and AIDS, incidence data also provides some insight into the effectiveness of prevention efforts. However, assessing HIV incidence is difficult to measure because it only can be observed in persons who undergo repeated serological evaluation (at least two separate time points) for antibody to HIV. Such information is available for adolescents and young adults on active duty in the U.S. military.*’ Since 1985, active duty soldiers in the U.S. Army have been tested routinely for the presence of HIV antibody and are required to undergo repeated serologic evaluation every two years. Repeated testing permits identification of incidence of new HIV infections in previously seronegative soldiers. U.S. Army data can be categorized by age group. For this paper, Army personnel younger than age 20 are of special interest. However, as two time points are
No. 7
required to evaluate incidence, and adolescents are eligible to enlist only at age 17, the data will reflect change in incidence for this limited age group. Another caveat is the actual number of incident cases was low; 22 Whites and 26 Blacks seroconverted during the study. Nonetheless, the data provide information on the frequency of HIV disease in healthy adolescent populations. The overall incidence was substantially different for White and Black personnel younger than age 20, .22 and .76 per 1,OOO person-years, respectively. More importantly, when data was divided into period-specific incidence rates to identify changes in the incidence of HIV infection over time, Blacks had higher periodspecific incidence rates for 1987, 1988, and 1989. Further, period-specific incidence rates declined significantly among White adolescents from 1987-1989; this decrease was not evident among Black adolescents. Blacks had sharply higher seroconversion rates in 1989 than in 1987, a period when HIV prevention education programs and media campaign information were being disseminated rapidly (Figure 3). For 1989, Black adolescents had an incidence rate ratio 14-fold greater than Whites. More alarming, for 1989, Black adolescents (younger than age 20), had the highest incidence rate of HIV infections of any ethnic-age group studied. This sharp rise in HIV incidence indicates a need for more intensive HIV education tailored directly for this ethnic subgroup. A similar study was conducted among personnel in the U.S. Navy and Marine Corps.'' In this study, all active duty personnel who had an enzyme-linked immunoabsorbent assay (ELISA) blood test for HIV with negative results were followed over time as in the Army study. For Navy personnel between ages 17-19, the incidence rate per 1,OOO person-years for Whites and Blacks was .19 and .22, respectively. However, for ages 20-24, the incidence rate among Blacks is markedly higher than among White adolescents (1.9 vs. .55/1,000 person-years at risk). Incidence rates for White Marine Corps personnel ages 17-19 and 20-24 were .O and .17. Similar data for Blacks were .52 and .73. These findings are comparable to Army data, though the incidence rate for Blacks ages 17-19 is not as high.
CONCLUSION Though clinically overt disease remains uncommon, relative to older age groups, results of the screening process of civilian applicants for military service, seroprevalence studies of select adolescent populations and seroconversion (incidence) studies conducted with U.S. active duty military personnel indicate subclinical HIV infections are not uncommon in this population. On a national level, applying the seroprevalence identified by the most recent survey of adolescent applicants for military service," 1 of every 3,000 teen-age applicants was seropositive. Moreover, AIDS, HIV infection, and HIV incidence are not uniformly distributed among ethnic groups. Data from prevalence and incidence studies suggest Blacks are more likely to have higher prevalence rates of AIDS and HIV infection and more likely to have markedly higher HIV incidence rates. The population presenting for military service and select subpopulations of adolescents using medical facilities and clinics for the homeless may not be representative of the U.S. population, nonetheless, the data are alarming and warrant considerable attention from health educators, policy analysts, and school officials to prevent increased disease morbidity and transmission among the adolescent population. References 1. US Dept of Health and Human Services. Surgeon General's Report on AIDS. Washington, DC: US Government Printing Office; 1986. 2. Institute of Medicine. Confronting AIDS. Washington, DC: National Academy Press; 1986. 3. Nicholas SW, Sondheimer DL, Willoughby AD, Yaffe SJ, Katz
SL. Human immunodeficiency virus infection in childhood. adolescence, and pregnancy. A status report and national research agenda. Pediatrics. 1989;83:293-308. 4. Hein K. Commentary on adolescent acquired immunodeficiency syndrome: The next wave of the human immunodeficiency virus epidemic. J Pediatr. 1989;114144-149. 5 . DiClemente RJ. The emergence of adolescents as a risk group for human immunodeficiency virus infection. J Adolesc Res. 1990;5: 7-17. 6. Hein K. AIDS in adolescents: A rationale for concern. NY State J Med. 1987;88:290-295. 7. Vermund SH, Hein K. Gayle HG. Cary JM, Thomas PA,
Drucker E. Acquired immunodeficiency syndrome among adolescents: Case surveillance profiles in New York City and rest of the United States. Am J Dis Child. 1989;343:3220-1225. 8 . HIV/AIDS Surveillance. Atlanta, Ga: Centers for Disease Control; March 1991. 9. Lui K. Darrow WW, Rutherford GW. A model-based estimate of a mean incubation period for AIDS in homosexual men. Science. 1988;240:1333-1335. 10. Bacchetti P, Moss AR. Incubation period of AIDS in San Francisco. Nature. 1989;338:251-253. 11. Hessol NA, Lifson AR, O'Malley PM, Doll LS, Jaffe HW,
Rutherford GW. Prevalence, incidence, and progression of human immunodeficiency virus infection in homosexual and bisexual men in hepatitis B vaccine trials, 78-88. Am J Epidemiol. 1989;130: 1167-1175. 12. Selik RM, Castro KG, Pappaioanou M. RaciaVethnic differences in the risk of AIDS in the United States. Am J Public Health. 1988;78: 1539-1545. 13. HIVIAIDS Surveillance: Year-end edition. Atlanta, Ga: Centers for Disease Control; January 1991. 14. Bureau of the Census. 80 Census of Population: Generalpopu-
lation characteristics. United States summary. Washington, DC: US Dept of Commerce; 1981. 15. Burke DS, Brundage JF, Goldenbaum M,Gardner LI, Peterson M, Visintine R, et al. Human immunodeficiency virus infections
Journal of School Health
September 1992, Vol. 62, No. 7
329
in teenagers. J A M A . 1990;263:2014-2077. 16. Kelley PW, Miller RN, Pomerantz R, Wann F, Brundage JF, Burke DS. Human immunodeficiency virus seropositivity among members of the active duty US Army, 85-89.A m J Public Health. 1990;80:405-410. 17. National H I V Seroprevalence Surveys: Summary of results. Atlanta, Ga: Centers for Disease Control; 1990. 18. Stricof RL, Kennedy JT, Nattell TC, Weisfuse IB, Novick LF. HIV seroprevalence in a facility for runaway and homeless adolescents. Am J Public Heolth. 199I;(Suppl):8l:50-53. 19. D'Angelo LJ, Getson PR, Luban NLC, Gayle HD. Human immunodeficiency virus (HIV) infection in urban adolescents: Can we predict who is at risk? Pediatrics. To be published. 20. Quinn TC, Glasser D, Cannon RO, Matuszak DL, Dunning RW, Kline RL, et al. Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases. N
Engl J Med. 1988;318:197-203.
21. Cannon RO, Schmid GP, Moore PS, Pappaioanou M. Human immunodeficiency virus (HIV) seroprevalence in persons attending STD clinics in the United States, 85-87. Sex Trans Dis. 1989;16: 184-189. 22. St Louis ME, Rauch KJ, Petersen LR, Anderson JE, Schable CA, Dondero TJ. Seroprevalence rates of human immunodeficiency virus infection at sentinel hospitals in the United States. N Engl J Med. 1990;323:213-218. 23. McNeil JG, Brundage JF, Gardner LI, Wann ZF, Renzullo PO, Redfield RR, et al. Trends of HIV seroconversion among young adults in the US Army, 85-89.J A M A . 1991;265:1709-1714. 24. Garland FC, Mayers DL, Hickey TM, Miller MR. Shaw EK, Gorham ED, et al. Incidence of human immunodeficiency virus seroconversion in US Navy and Marine Corps personnel, 1986 through 1988. J A M A . 1989;262:3 161-3165.
The &page Implementation Guide pairs each of the eight Standardsof SchoolNursing Practice with "how to" suggestions to assist school nurses develop, enhance, standadze and evaluate school health programs in their schools and communities. Contemporary Issues in School Nursing are also explored, including Liability Issues HlV in the School Setting 0 Future of School Nursing School-based C l i n i ~ ~ The 27-page appendix contains more than 10 forms that can be used immediately in your school health office. They include a sample "Accident Report"; "Daily Log of Treatment Administered"; "School Nursing Summary Sheet"; and a "Daily Medication Log". A two-page "School Nursing Activity Calendar"and a "Position Description of the School Nurse" are also included for reference. 1991. $10.95 for ASHA members and $12.50 for nonmembers, contact: PublicationsDept., ASHA, 7263 State Route 43, P.O.Box 708, Kent, OH 44240. Convenient telephone ordering with MasterCard or VISA at (216) 678-1601.
Add $3.00 shipping Q handling, make checkspayable to ASHA, and include your shipping address.
330
Journal of School Health
September 1992, Vol. 62, No. 7
ABSTRACT: Health educators, policy analysts, and public health officials are becoming more aware of the serious threat HIV poses to the health of US.adolescents. While AIDS among adolescents remains relatively uncommon, considerable data indicates this age group has alarmingly high HIV infection rates and that minority adolescents are at disproportionately greater risk of HIV infection relative to their White peers. Recent sermonversion studies of active duty military personnel indicate that the number of new HIV infections (incident cases) are especially high among Black adolescents. Findings suggest the urgent need for more tailored HIV prevention programs, especially gender- and ethnicspecific programs. (J Sch Health. 1992;62(7):325-330)
G
rowing awareness exists of the threat that HIV infection and AIDS poses for adolescents.14 While the number of diagnosed cases of AIDS among adolescents remains relatively small compared with older age groups, ample cause for concern exists. Substantial epidemiologic data describes the prevalence of high-risk behaviors among adolescents that increase the probabilBehaviors such as inconsistent ity of HIV infe~tion.~.~ condom use among sexually active adolescents, multiple sex partners, injection drug use, and the use of alcohol and other drugs that result in greater sexual disinhibition are associated with greater likelihood of exposure to HIV.' While each behavior singularly increases the probability for HIV infection, they are more often reported in combination, further elevating an adolescent's risk for infection. Other articles in this journal issue address the prevalence and determinants of these risk behaviors. This paper provides an overview of the epidemiology of AIDS, HIV prevalence, and HIV incidence among U.S.adolescents. Relying on the number of AIDS cases to formulate public and school health policy severely underestimates the threat HIV infection poses for adolescents. While the information presented initially describes AIDS cases among adolescents, this is done primarily to summarize CDC data and establish a departure point for presenting HIV prevalence and incidence data. Given the relatively long latency period from infection to clinical diagnosis, both these epidemiologic measures are preferable to AIDS prevalence for assessing the threat of HIV for adolescents. Moreover, due to the lengthy latency period, it is unlikely AIDS rates among adolescents would demonstrate a sharp increase even with an increase in HIV infection rates. An increase in HIV infection among adolescents would result in a greater number of diagnosed AIDS cases among older age groups, for instance, adults ages 20-24, or 25-29. As a detailed examination of the AIDS surveillance data indicates, rates are not uniform among adolescents. Multicultural populations, especially Blacks and Latinos, are disproportionately represented among AIDS cases, even among adolescents ages 13-19. HIV prevalence and incidence data also suggest that Black Ralph J. DiClemente. PhD, Center f o r AIDS Prevention Studies, University of California, 74 New Montgomery St., Suite 600, San Francisco, CA 94105.
adolescents are at substantially higher risk than other ethnic groups. PREVALENCE OF AIDS AMONG ADOLESCENTS As of March 1, 1991, 167,803 cases of AIDS were reported to the U.S. Centers for Disease Control.* Of these, 150,128 were male and 17,675 were female. The number of cases among adolescent males and females ages 13-19 were 494 and 165, respectively. The proportion of adolescent cases between ages 13-19 represents less than 1% of all diagnosed AIDS cases for males and approximately 1070 of all diagnosed cases for females. The relatively small proportion of AIDS cases among adolescents should not be interpreted as an indicator of the low-risk status for this age group, given the long latency period.g-" It is important to consider not only the proportion of adolescent AIDS cases, but also those diagnosed with AIDS as young adults, in the age groups 20-24 and 25-29. Males diagnosed with AIDS in the age groups 20-24 and 25-29 account for 4% and 16% of total male AIDS cases. Similarly, females diagnosed with AIDS between the age groups 20-24 and 25-29 account for 6% and 18% of female AIDS cases. Combining the number of AIDS cases diagnosed within the age groups 13-19, 20-24, and 25-29 for males and females, respectively, the proportion of cases increases markedly to 20% and 25% of all male and female cases (Figure 1). Thus, while the proportion of adolescent cases is small, the proportion of young adults, an undetermined proportion who contracted HIV infection as adolescents, is substantially larger. ETHNIC DIFFERENCES IN AIDS PREVALENCE AIDS is not uniformly distributed as ethnic differences are substantial. Blacks and Latinos are over-represented among AIDS cases. By calculating annual rates per 100,OOO population using the 1990 U.S.Census projections, data indicate Blacks and Latinos have significantly higher rates relative to White males." Black and Latino males had annual rates of 92.4 and 71.9, relative to a rate of 27.4 for White males. For females, ethnic differences are more pronounced. Black and Latina
Journal of School Health
September 1992, Vol. 62, No. 7
325
females have AIDS annual rates of approximately 20.0 and 12.6, compared with a rate of 1.5 for White females. Unfortunately, these rates combine adolescent and adult cases, obscuring contrasts for ethnic differences among adolescents alone. Further, comparable data for adolescents are unavailable from the Centers for Disease Control, and projections of the number of ethnic group members between ages 13-19 are presently unavailable from the U.S.Census. This lack of data limits ethnic group comparisons. To develop a measure that could estimate ethnic differences among adolescents, 1980 census data" was used to identify the number of U.S. adolescents in specific gender-ethnic groups and applied to each year of the AIDS epidemic and projected over each year of the epidemic. The cumulative number of AIDS cases in each ethnic group reported to the CDC through February 1991 was used as the numerator,' yielding ethnicspecific prevalence over the duration of the AIDS epidemic. This index provides only an approximate measure of ethnic differences, given the changes in U.S. demography over the past decade. However, given the lack of available data, it provides a basis for examining variation in AIDS between gender-ethnic groups. The findings indicate all multicultural adolescent populations - Black, Latino, AsiadPacific Islander, and Native American - have a higher prevalence of AIDS per 100,OOO population relative to White adolescents (Figure 2). The most striking disparity is among Black and Latino adolescents, who are 5.1 and 4.7 times more likely to be diagnosed with AIDS than White adolescents (Table 1). Among males, Blacks and Latinos
have a prevalence 3.7 and 4.3 times greater than White males, while Black and Latina females have a prevalence rate 11.5 and 5.7 times higher respectively, than their White counterparts. HIV EXPOSURE CATEGORIES
Differences exist between adolescents and adults diagnosed with AIDS with respect to the proportion of cases identified in particular exposure categories. These are the CDC categories which define risk factors for transmission of HIV. Among adult AIDS cases, the preponderance of cases are reported in the exposure categories of male homosexual/bisexual contact and intravenous drug use. These categories account for 59% and 22070, respectively, of all cases reported through February 1991. For adolescents, only 26% and 11% of AIDS cases are reported in these exposure categories. For adults, heterosexual exposure accounts for 5% of AIDS cases while among adolescents, heterosexual contact accounts for 14% of AIDS cases. However, these data are slightly inaccurate. While the CDC describes exposure categories separately for adolescents ages 13-19, it does not provide a contrast with adult cases but rather combines adolescent/adult cases for particular exposure categories. Thus, though the number of adolescents with AIDS is small, the evidence suggests that heterosexual contact plays a somewhat more predominant role in HIV transmission among adolescents than among adults. ~~~~
Table 1 Prevalence of AIDS per 1,000,000 Population Among Adolescents Ages 13-19: By Ethnlclty Ethnlclty Black Lallno Asian Native American Whlle
Mabt Rev. REV. Ratlo' 7.4 3.7 8.7 4.3 3.9 1.9 4.2 2.1 2.0 1.0
Fernalas
OVNEll
PW.
pnv. 4.6 2.3 0.5 0.9 0.4
Ratlo' 11.5 5.7 1.2 2.2 1.0
Rev. 6.1 5.6 2.3 2.6 1.2
~
Prev. =Prevalence expressed as number of cases per 1,000,000populafion 'Prevalence Ratio calculated with White as the referent cafegory Number of AIDS cases reported to CDC through February 1991
326
Journal of School Health
September 1 9 9 2 , Vol. 6 2 , No. 7
Pnv. Ratlo' 5.1 4.7 1.9 2.2 1.0
H I V SEROPREVALENCE AMONG ADOLESCENTS Monitoring an evolving epidemic has proven challenging because of reliance on surveillance data that emphasizes a clinical endpoint - AIDS. The number of clinical AIDS cases among adolescents severely underestimates the threat posed by HIV infection and provides insufficient information for the allocation of health care and prevention resources. Another, more precise gauge of the threat of HIV for adolescents is based on the findings from HIV seroprevalencestudies. Currently, no representative population-based studies exist for estimating seroprevalence among adolescents. The absence of population-based data limits assessing the magnitude of risk for adolescents and reduces the capability to monitor changes in infection rates over time. Much of the HIV seroprevalence data is derived from studies of applicants for military service or active duty 'military personnel. Other studies have focused on disadvantaged youth receiving training in the Job Corps, homeless youth, adolescents seeking treatment in sexually transmitted disease clinics, and adolescents seeking medical care. Table 2 contains seroprevalence data obtained from various adolescents surveys. While these subpopulation studies provide an assessment of the impact of HIV on adolescents, the data cannot be generalized to the adolescent population-at-large. In an HIV seroprevalence study of adolescent applicants for military duty, Burke and colleaguesls focused the data analysis exclusively on HIV infection among youths younger than age 20. Reviewing 1,141,164 serologic evaluations from adolescent applicants for U.S. military service between October 1985 and April 1989, 393 teen-agers were identified as seropositive. The overall HIV prevalence was 0.34 per 1,OOO applicants. Seroprevalence varied markedly with ethnicity. Seroprevalence among Black applicants was 1.00 per 1,OOO compared with White (0.17) and Latino (0.29) applicants, respectively. Separate analyses by gender and race/ethnicity indicated that for males, prevalence for Blacks, Whites, and Latinos was 1.06, 0.18, and 0.31, respectively, while corresponding rates for Black, White, and Latina females were 0.77, 0.12, and 0.16. To control for potential confounding factors, a maximum likelihood analysis was conducted, which calculated adjusted odds ratios predicting the risk of being seropositive. This analysis indicates Blacks were 4.9 times more likely to be seropositive than Whites, and Latino applicants were 1.1 times as likely to be seropositive relative to White applicants. With respect to gender, males are 1.4 times more likely to be seropositive compared with female applicants. The unrepresentative nature of the sample studied, however, especially the potential for high-risk individuals to self-defer, suggests seroprevalence may be substantially higher. A recent study of U.S. Army active-duty personnel has identified substantial variation in HIV seropositivity by ethnicity and age group, similar to studies of applicants for military service.l 6 Higher seroprevalence was identified among Blacks and Latinos, with Blacks having slightly higher rates than Latinos. Black or Latino soldiers had an overall seropositivity of 5.1 /1 ,OOO and 4.0/ 1,ooO,respectively. HIV prevalence ratios compared
to White soldiers were 4.0 for Blacks (95% confidence interval (CI) 3.6 - 4.4) and 3.2 for Latinos (95% CI 2.5 -3.9). When only soldiers younger than age 20 are considered, the overall prevalence is 0.5/1,OOO with male and female seropositivity being 0.4 and 0.9, respectively, and the male:female ratio being 0.5. For soldiers between age 20-24, however, the overall seropositivity increases to 1.8/1,OOO, with a sharp increase for males to 1.9/1,OOO. For females, seroprevalence declines slightly to 0.7/1,000. The male:female ratio of 2.8 shows a marked change in this age group, with males significantly more likely to be HIV positive than females. To identify determinants of seropositivity, a multivariate logistic model was constructed which controlled for the simultaneous effects of demographic and other potential confounding factors. This analysis indicates that males, after statistic adjustment, are significantly more likely to be seropositive than females. Blacks and Latinas were 3.7 and 3.0 times more likely to be seropositive compared with White active duty personnel. Comparable to seroprevalence studies of military applicants, these findings demonstrate a significantly higher risk for HIV infection among Black and Latino adolescents. Since 1987, the Division of AIDWHIV at CDC has serologically evaluated disadvantaged adolescents between the ages of 16-21 for Job Corps training, with more than 60,OOO entrants having been screened each year at 106 sites throughout the U.S." A major distinction between this seroprevalence survey and military data is there are no exclusion criteria which would prevent application and entrance into the Job Corps for adolescents with a history of drug use or an alternative sexual orientation. However, current drug addiction is an excludable condition. The Job Corps data from 1987 to December 1989 indicate that disadvantaged adolescents, especially minority adolescents, are at increased risk of being seropositive. Seroprevalence for the entire sample was 0.36%; 0.37% for males and 0.32% for females. Ethnic differences, however, were substantial. Black males had the highest seroprevalence rate of all ethnic-gender groups. Black and Latino males had seroprevalence rates of 0.55% and 0.30% relative to a rate of 0.14% for White males. Similarly, Black females had the highest seroprevalence (0.48%) compared with Latino and White females (0.18% and O.OSVo), respectively. Table 2 Prevalence of HIV Infection per 1,000 Population for Selected Surveys: By Ethnlciv Ethnlclty
Sbdv Burke et al (1990) Keliey et al (1990)b St. Louis et al (1991) St. Louis et al (1990) Stricof et al (1991) D'Angeb et al (1991p
Sispk or S b Military applicanls Active-duty military Job Corps entrants General hospital Homeless shelter Ambulatory clinics
Bbck
Latho
1.0 5.1
0.29 4.0 2.6 4.9
5.3 8.3
46.0
68.0
3.7
-
Whb 0.17
1.25 1.2 2.7 60.0
-
aall findings have been converted and are presented as rate of seropositive adolescents per 1,000 to permit comparability with other surveys bsample of active duty militafy personnel is not exclusively comprised of adolescents cThis survey does not report ethnic comparisons. More than 88% of the sample was African-American, while 12% was defined as "Other" ethnic groups. Attributable to their small proportion in the sample. comparisons with "Other" ethnic groups would not be informative.
Journal of School Health
September 1992, Vol. 62, No. 7
327
Other adolescent samples in which prevalence rates have been identified include homeless youth. A seroprevalence study was conducted among adolescents receiving health care at Covenant House, a facility serving runaway and homeless youth in New York City.” The study was limited to adolescents between ages 15-20 undergoing initial medical examination between October 1, 1987 and December 31, 1989. In this study, 2,667 specimens were serologically evaluated for presence of HIV antibody. While this adolescent subgroup is not representative of the adolescent population, it reflects a segment at high risk and offers a relative contrast to other populations for which HIV seroprevalence is available. Overall, HIV seroprevalence was high; 5.3% of the adolescents were HIV positive. Latinos had the highest HIV seroprevalence(6.8Vo) followed by Whites (6.Ocrl0), and Blacks (4.6Vo). Males had higher rates than females; 6.0% vs. 4.2%. Controlling for other demographic characteristics, ethnicity is found not to be significantly associated with HIV seroprevalence; odds ratio and 95% confidence interval for Latinos 1.1 [0.7 -1.51 and Blacks 0.7 [0.4 - 1.21 compared with Whites. After adjusting for other demographic factors, age was the only demographic characteristic identified as differentially associated with HIV seroprevalence. Older adolescents (age 19 and age 20) were 2.7 and 3.7 times more likely to be seropositive than adolescents ages 15-16. This represents one of the few studies that has not identified a higher seroprevalence among Black and Latino adolescents relative to White adolescents. Between 1987 and 1989, adolescents age 13 or older attending three ambulatory clinics at Children’s Hospital Medical Center, Washington, D.C., who had blood drawn for a medical test, were screened to identify presence of HIV a n t i b ~ d y . ’During ~ the 15-month duration of the survey, 3,520 adolescents had blood drawn. Most adolescents were Black (88.2%) and the mean age was 16.3 years with a range of 13-20 years. Of all blood specimens tested, 13 were seropositive, yielding an overall prevalence of 3.7/1,000. The prevalence was higher in females than males (4.7 vs. 1.7) and among adolescents ages 15-18 compared with adolescents younger than 15 (4.9 vs. 1.7). Of particular importance is that of adolescents considered at high-risk based on screening criteria, 4.1070 (41/1,000) were seropositive; however, risk criteria could correctly identify only 38% of those adolescents who were seropositive. Another source of seroprevalence data is from a cross-sectional survey in an inner-city sexually transmitted disease clinic.20Results indicated seroprevalence of HIV infection among adolescents ages 15-19 is 2.2%; with gender-specific rates of 2.5% for females and 2% for males. In this population 28% of the seropositive women were age 20 or younger. Having an active sexually transmitted disease also was identified as an independent risk factor strongly associated with seropositive status. In a review of seroprevalence studies conducted at sexually transmitted disease clinics in the U.S.,” the median seroprevalence rate for persons younger than 20 was 1 . 1 Yo with a range from 0% - 2%. Persons between ages 20-29, however, show a substantially higher median seroprevalence of 4.5%, with a range from
328
Journal of School Health
September 1992, Vol. 62,
0.5%
- 7.5%.
Another survey, the CDC Sentinel Hospital Surveillance study,22while not specifically focusing on adolescents, provides seroprevalence data on patients seeking treatment at 26 hospitals across the U.S.To control for potential over-representation among HIV-infected patients seeking medical care for conditions related to infection, exclusion criteria were implemented that screened patients whose reason for seeking care involves a condition often associated with HIV infection or HIV risk factors. Blood specimens were serologically evaluated for presence of HIV antibody; evaluations were conducted anonymously to protect the patient’s identity. Unlike seroprevalence surveys conducted with applicants for military service, findings from the sentinel hospital survey are not subject to self-selection or self-deferral biases, which may underestimate HIV seroprevalence. From January 1988 to June 1989, 89,547 blood specimens were serologically evaluated for antibody to HIV. Overall HIV seroprevalence was 1.3%. HIV seroprevalence was most prominent in ages 2544, though a sharp increase in seroprevalence rates began in the mid-adolescent years. At two hospitals in communities with the highest AIDS prevalence, 1.1070 and 3.8% of adolescents ages 15-19 were identified as HIV seropositive. Additional ethnic-specific data is presented in Table 2. When considering only adolescents ages 13-19, seropositivity varies markedly by ethnicity. While White adolescents had a seroprevalence of 1.2 per thousand, Black and Latino applicants had a prevalence of 5.3 and 2.6 per thousand, respectively.
HIV lNClDENCE (SEROCONVERSION) AMONG ADOLESCENTS While seroprevalence data helps identify the existing number of HIV- infected individuals, it also is important to obtain incidence data - the number of seronegative persons who on subsequent HIV testing are identified as seropositive. Direct measurement of the incidence of new HIV infections greatly enhances the ability to track the evolving epidemic and substantially improves the accuracy of epidemic forecasts. Given the widespread dissemination of information about HIV and AIDS, incidence data also provides some insight into the effectiveness of prevention efforts. However, assessing HIV incidence is difficult to measure because it only can be observed in persons who undergo repeated serological evaluation (at least two separate time points) for antibody to HIV. Such information is available for adolescents and young adults on active duty in the U.S. military.*’ Since 1985, active duty soldiers in the U.S. Army have been tested routinely for the presence of HIV antibody and are required to undergo repeated serologic evaluation every two years. Repeated testing permits identification of incidence of new HIV infections in previously seronegative soldiers. U.S. Army data can be categorized by age group. For this paper, Army personnel younger than age 20 are of special interest. However, as two time points are
No. 7
required to evaluate incidence, and adolescents are eligible to enlist only at age 17, the data will reflect change in incidence for this limited age group. Another caveat is the actual number of incident cases was low; 22 Whites and 26 Blacks seroconverted during the study. Nonetheless, the data provide information on the frequency of HIV disease in healthy adolescent populations. The overall incidence was substantially different for White and Black personnel younger than age 20, .22 and .76 per 1,OOO person-years, respectively. More importantly, when data was divided into period-specific incidence rates to identify changes in the incidence of HIV infection over time, Blacks had higher periodspecific incidence rates for 1987, 1988, and 1989. Further, period-specific incidence rates declined significantly among White adolescents from 1987-1989; this decrease was not evident among Black adolescents. Blacks had sharply higher seroconversion rates in 1989 than in 1987, a period when HIV prevention education programs and media campaign information were being disseminated rapidly (Figure 3). For 1989, Black adolescents had an incidence rate ratio 14-fold greater than Whites. More alarming, for 1989, Black adolescents (younger than age 20), had the highest incidence rate of HIV infections of any ethnic-age group studied. This sharp rise in HIV incidence indicates a need for more intensive HIV education tailored directly for this ethnic subgroup. A similar study was conducted among personnel in the U.S. Navy and Marine Corps.'' In this study, all active duty personnel who had an enzyme-linked immunoabsorbent assay (ELISA) blood test for HIV with negative results were followed over time as in the Army study. For Navy personnel between ages 17-19, the incidence rate per 1,OOO person-years for Whites and Blacks was .19 and .22, respectively. However, for ages 20-24, the incidence rate among Blacks is markedly higher than among White adolescents (1.9 vs. .55/1,000 person-years at risk). Incidence rates for White Marine Corps personnel ages 17-19 and 20-24 were .O and .17. Similar data for Blacks were .52 and .73. These findings are comparable to Army data, though the incidence rate for Blacks ages 17-19 is not as high.
CONCLUSION Though clinically overt disease remains uncommon, relative to older age groups, results of the screening process of civilian applicants for military service, seroprevalence studies of select adolescent populations and seroconversion (incidence) studies conducted with U.S. active duty military personnel indicate subclinical HIV infections are not uncommon in this population. On a national level, applying the seroprevalence identified by the most recent survey of adolescent applicants for military service," 1 of every 3,000 teen-age applicants was seropositive. Moreover, AIDS, HIV infection, and HIV incidence are not uniformly distributed among ethnic groups. Data from prevalence and incidence studies suggest Blacks are more likely to have higher prevalence rates of AIDS and HIV infection and more likely to have markedly higher HIV incidence rates. The population presenting for military service and select subpopulations of adolescents using medical facilities and clinics for the homeless may not be representative of the U.S. population, nonetheless, the data are alarming and warrant considerable attention from health educators, policy analysts, and school officials to prevent increased disease morbidity and transmission among the adolescent population. References 1. US Dept of Health and Human Services. Surgeon General's Report on AIDS. Washington, DC: US Government Printing Office; 1986. 2. Institute of Medicine. Confronting AIDS. Washington, DC: National Academy Press; 1986. 3. Nicholas SW, Sondheimer DL, Willoughby AD, Yaffe SJ, Katz
SL. Human immunodeficiency virus infection in childhood. adolescence, and pregnancy. A status report and national research agenda. Pediatrics. 1989;83:293-308. 4. Hein K. Commentary on adolescent acquired immunodeficiency syndrome: The next wave of the human immunodeficiency virus epidemic. J Pediatr. 1989;114144-149. 5 . DiClemente RJ. The emergence of adolescents as a risk group for human immunodeficiency virus infection. J Adolesc Res. 1990;5: 7-17. 6. Hein K. AIDS in adolescents: A rationale for concern. NY State J Med. 1987;88:290-295. 7. Vermund SH, Hein K. Gayle HG. Cary JM, Thomas PA,
Drucker E. Acquired immunodeficiency syndrome among adolescents: Case surveillance profiles in New York City and rest of the United States. Am J Dis Child. 1989;343:3220-1225. 8 . HIV/AIDS Surveillance. Atlanta, Ga: Centers for Disease Control; March 1991. 9. Lui K. Darrow WW, Rutherford GW. A model-based estimate of a mean incubation period for AIDS in homosexual men. Science. 1988;240:1333-1335. 10. Bacchetti P, Moss AR. Incubation period of AIDS in San Francisco. Nature. 1989;338:251-253. 11. Hessol NA, Lifson AR, O'Malley PM, Doll LS, Jaffe HW,
Rutherford GW. Prevalence, incidence, and progression of human immunodeficiency virus infection in homosexual and bisexual men in hepatitis B vaccine trials, 78-88. Am J Epidemiol. 1989;130: 1167-1175. 12. Selik RM, Castro KG, Pappaioanou M. RaciaVethnic differences in the risk of AIDS in the United States. Am J Public Health. 1988;78: 1539-1545. 13. HIVIAIDS Surveillance: Year-end edition. Atlanta, Ga: Centers for Disease Control; January 1991. 14. Bureau of the Census. 80 Census of Population: Generalpopu-
lation characteristics. United States summary. Washington, DC: US Dept of Commerce; 1981. 15. Burke DS, Brundage JF, Goldenbaum M,Gardner LI, Peterson M, Visintine R, et al. Human immunodeficiency virus infections
Journal of School Health
September 1992, Vol. 62, No. 7
329
in teenagers. J A M A . 1990;263:2014-2077. 16. Kelley PW, Miller RN, Pomerantz R, Wann F, Brundage JF, Burke DS. Human immunodeficiency virus seropositivity among members of the active duty US Army, 85-89.A m J Public Health. 1990;80:405-410. 17. National H I V Seroprevalence Surveys: Summary of results. Atlanta, Ga: Centers for Disease Control; 1990. 18. Stricof RL, Kennedy JT, Nattell TC, Weisfuse IB, Novick LF. HIV seroprevalence in a facility for runaway and homeless adolescents. Am J Public Heolth. 199I;(Suppl):8l:50-53. 19. D'Angelo LJ, Getson PR, Luban NLC, Gayle HD. Human immunodeficiency virus (HIV) infection in urban adolescents: Can we predict who is at risk? Pediatrics. To be published. 20. Quinn TC, Glasser D, Cannon RO, Matuszak DL, Dunning RW, Kline RL, et al. Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases. N
Engl J Med. 1988;318:197-203.
21. Cannon RO, Schmid GP, Moore PS, Pappaioanou M. Human immunodeficiency virus (HIV) seroprevalence in persons attending STD clinics in the United States, 85-87. Sex Trans Dis. 1989;16: 184-189. 22. St Louis ME, Rauch KJ, Petersen LR, Anderson JE, Schable CA, Dondero TJ. Seroprevalence rates of human immunodeficiency virus infection at sentinel hospitals in the United States. N Engl J Med. 1990;323:213-218. 23. McNeil JG, Brundage JF, Gardner LI, Wann ZF, Renzullo PO, Redfield RR, et al. Trends of HIV seroconversion among young adults in the US Army, 85-89.J A M A . 1991;265:1709-1714. 24. Garland FC, Mayers DL, Hickey TM, Miller MR. Shaw EK, Gorham ED, et al. Incidence of human immunodeficiency virus seroconversion in US Navy and Marine Corps personnel, 1986 through 1988. J A M A . 1989;262:3 161-3165.
The &page Implementation Guide pairs each of the eight Standardsof SchoolNursing Practice with "how to" suggestions to assist school nurses develop, enhance, standadze and evaluate school health programs in their schools and communities. Contemporary Issues in School Nursing are also explored, including Liability Issues HlV in the School Setting 0 Future of School Nursing School-based C l i n i ~ ~ The 27-page appendix contains more than 10 forms that can be used immediately in your school health office. They include a sample "Accident Report"; "Daily Log of Treatment Administered"; "School Nursing Summary Sheet"; and a "Daily Medication Log". A two-page "School Nursing Activity Calendar"and a "Position Description of the School Nurse" are also included for reference. 1991. $10.95 for ASHA members and $12.50 for nonmembers, contact: PublicationsDept., ASHA, 7263 State Route 43, P.O.Box 708, Kent, OH 44240. Convenient telephone ordering with MasterCard or VISA at (216) 678-1601.
Add $3.00 shipping Q handling, make checkspayable to ASHA, and include your shipping address.
330
Journal of School Health
September 1992, Vol. 62, No. 7
