Journal of Adolescence 1992, 15,345-371
HIV and AIDS among adolescents in the United States: increasing risk in the 1990s SUZANNE BOWLER,* AMY R. SHEON, LAWRENCE J. D’ANGELO,** STEN H. VERMUND Acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) are growing problems among U.S. adolescents. By examining recent data on AIDS surveillance and HIV seroprevalence, surveys on teenagers’ knowledge, beliefs, and behaviors related to HIV/ AIDS, key treatment issues, and barriers to prevention, this manuscript reviews the problem and proposes possible ways of combating it. African American youth have the highest rates of AIDS and white youth the lowest. However, the largest number of AIDS cases overall has been recorded in white males, reflecting relatively high case rates in boys with hemophilia and in young male homosexuals. Predominant HIV risk factors for adolescents are unprotected sex and/or sharing injection drug equipment with an infected partner. Relatively high rates of HIV infection in adolescent females may indicate their greater physiological vulnerability than adult females to sexually transmitted diseases (STDs). Data from HIV seroprevalence studies suggest a substantially increased heterosexual epidemic in the 199Os, especially in large east coast cities and southeastern rural areas where drug use and/or STDs are highly prevalent. More comprehensive prevention and treatment services are needed to prevent ongoing expansion of HIV infection and AIDS in the adolescent age group.
INTRODUCTION
HIV infection poses a serious health threat to many U.S. adolescents. Of a total of 199,406 AIDS cases reported to the U.S. Centers for Disease Control (CDC), 20% occurred among young adults ages 20-29 years as of the end of October 1991 (CDC, 1991~). It can be inferred that many were Reprints requests should be addressed to: Dr Sten H. Vermund, Division of AIDS, NIAID/NIH, 6003 Executive Boulevard, Room 2A42. Bethesda, MD 20892, U.S.A. Amy R. Sheon & Sten H. Vermund Epidemiology Branch, Clinical Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD. *The MayaTech Corporation, Silver Spring, MD. ** Department of Adolescent and Young Adult Medicine, Children’s National Medicine Center and Department of Paediatrics, George Washington University School of Medicine and Health Science. 0140-1971/92/040345
+ 27 $08.00/O
D 1992 The
Association
for Professmnals
in Services
for Adolescents
S. BOWLER ET AL.
346
infected with HIV during their adolescent years because of the long latency period of the disease (Gayle and D’Angelo, 1991). There has been a 53% increase in cumulative AIDS cases among both adolescents and young adults between the end of 1988 and the end of 1990 (CDC 1989~; 19916). Among teenagers aged 13-19 years, total cumulative reported AIDS cases rose from 325 to 629, from 3,576 to 6,720 among adults aged 20-24 years, and from 13,483 to 25,634 among adults aged 25-29 years. In addition, AIDS became the seventh leading cause of death among people aged IS-24 by 1988 (CDC, 1989b), and is now the fourth leading cause of death among young adults aged 20-24 (Gayle and D’Angelo, 1991). The seriousness of this problem is reflected not merely in the increases in the number of AIDS cases among adolescents and young adults but also in the rapidly rising rates of HIV infection in adolescents (CDC 1989a; 1991b; D’Angelo, 1991; D’Angelo, et al., 1991; St Louis, et al., 1991). While all sexually active and injection drug using adolescents are theoretically at risk for AIDS, this risk is greatest for teens who live in communities where HIV infection is common. Since teenagers are vulnerable to HIV infection when they begin to experiment with sex and drugs, preventive interventions are crucial (Gayle and D’Angelo, 1991; Hein, 1989; Vermund, et al., 1989). Yet adolescents from the United States and many Westernized countries are likely to be the most difficult age group to influence toward HIV/AIDS prevention, due largely to their (1) susceptibility to negative. peer pressure; (2) propensity to take risks, including sexual and drug experimentation; (3) sense of invulnerability and immortality; and (4) difficulty grasping the long-term adverse consequences of current behavior (Hein, 1989; Irwin and Millstein, 1986; Prothrow-Stith, 1989). This article reviews current knowledge about HIV and AIDS among U.S. adolescents including surveillance data, barriers to prevention, and selected treatment issues. Two definitions of adolescence are used in this article. CDC (1991b) defines adolescence as ages 13 to 19 years, and the American Academy of Pediatrics and Society for Adolescent Medicine as the ages of 13 to 21 years. Unless indicated otherwise, CDC AIDS surveillance data presented in the following sections, including Figures 1 and 2, are based on the number of reported cases from 1981 to the end of December 1990, as reported through January 1991. SURVEILLANCE
Major
characteristics
of adolescents
with AIDS
AIDS surveillance data (CDC, 1991b) indicate that older, male, black (African-American), and Hispanic (Latino) adolescents are over represented among those with AIDS. Seventy-five percent of teenage AIDS
HIV AND AIDS
AMONG
ADOLESCENTS
347
cases occur among adolescents between the ages of 17 and 19 (Gayle and D’Angelo, 1991) and 67% among males between the ages of 13 and 19 (CDC, 1991b). However, the adolescent male/female ratio is 3 : 1 as compared to 1O:l among adults (CDC, 1991b). Geographically, the distribution of AIDS among adolescents aged 13-19 years has been relatively stable since 1984, with a majority of adolescent cases reported from New York, Florida, California, Texas, Puerto Rico, and New Jersey. A disproportionate number of adolescents with AIDS are found in urban areas with total populations of over one million; 42% of the total 1980 U.S. population of all ages lived in these metropolitan areas where 72% of total AIDS cases have been reported. There is some geographic variation in the distribution of AIDS cases among Hispanics. For example, AIDS case reports and mortality data for the years 1981-1987 on persons of all age groups living in New York City reveal that Puerto Ricans have been the most severely affected of all new York racial/ethnic groups (Menendez, et al., 1990). In every region of the United States between June 1, 1981 and December 12, 1988, the cumulative incidence of AIDS in heterosexual injection drug users (IDUs) was several time greater among Puerto Rican-born persons than among other Latin American-born persons. Most AIDS cases among Puerto Ricanborn persons were among heterosexual IDUs, which was not the case among persons born in other parts of Latin America (Selik, et al., 1989). These statistics underscore the need to consider differences within ethnic or racial groups. Cumulative incidence rates stratified by racelethnicity among adolescents and young adults through December 1990 (Figure l), demonstrate that as among adults of all ages, blacks and Hispanics are disproportionately represented among adolescents with AIDS, and that AIDS rates among males are higher than among females, although for black adolescents, females have nearly the same rate as males.
Modes
of transmission
Among adolescents (13-19 years) and young adults with AIDS, the most common modes of HIV transmission vary by both age and gender as indicated in Figure 2. Heterosexual contact is a far more prevalent source of infection for young women than men in the United States, due in part to the more efficient transmission of HIV from men to women than vice versa (Friedland and Klein, 1987; Padian, Shikoski and Jewell, 1991; Vermund et al., 1991). In addition, among non-injection drug using women of all ages who contracted AIDS through heterosexual contact (33% out of total AIDS cases among women), 63% of this subgroup were
348
S. BOWLER
ET AL.
sexual partners of IDUs (CDC surveillance data for the end of December, 1990 [CDC, 1991bl). AIDS surveillance statistics suggest that behavioral factors replace transfusion as the dominant mode of HIV transmission among older adolescents with reported AIDS (Table 1). By 1985, all U.S. blood banks had instituted blood screening, blood donor self-deferral, and heat treatment of clotting factors (CDC, 1985). Almost all post-1985 cases of HIV infection in the United States will have resulted from sexual or drug-use exposures. Modes of HIV transmission also vary among adolescents of different racial/ethnic groups (Gayle and D’Angelo, 1991). CDC data through the end of December 1990 indicate that among white youths, blood transfusion is responsible for a majority (53%) of AIDS cases, as compared with blacks and Hispanics, among whom homosexual/bisexual contact and injection drug use account for the majority of cases (39% and 29%, respectively). HIV
seroprevalence
among adolescents
Since the median incubation period for developing AIDS symptoms is estimated to be over 10 years (Lui et al., 1986), it is not surprising that infection rates among adolescents greatly exceed case rates. Back-calculation
125
(508) 25
0
White
Black Males
Figure 1. 1981 through
Hispanic
White
Black
Hispanic
Females
Cumulative AIDS Incidence Rates per 100,000 (Number) 1990 for the United States, as reported through January CDC (1991b). a, 13-19; , 20-24.
Reported from 1991. (Source:
HIV AND AIDS
AMONG
ADOLESCENTS
349
(a method described for the non-technical reader in Vermund, 1991) from reported AIDS cases has been used to estimate that the number of adolescents (ages 13-19 years) infected with HIV from 1981 through 1987 was 17,000 (Gayle and D’Angelo, 1991). This estimate, albeit imprecise, helps provide a more useful indication of the magnitude of HIV/AIDS among adolescents than the reported number of AIDS cases alone. A number of seroprevalence surveys have now been completed among adolescents in different sites, using different data-collection methods, as indicated in Table 2. The highest documented adolescent HIV infection
Adolescents
(ages 13-19 years) 3%***
6 “A*
(9)
l
TZ
(35) Moles (total
472)
Females [total’ 157) Young adults Cages 20-24
Males (total’
0 0
Heterosexual Other
Femoles
5652)
q Homo/btsexuol contact q lnjectlon drug use q Homosexual and InjectIon drug n Hemophlllo and other tronsfuslon contact with IDU
years)
q q 0
q n q
{total
Heterosexual contact Heterosexual contact Heterosexual contact InjectIon drug use Hemophlha and other Other
1068)
wth lDU* wth mole with HIV/AIDS+c wth bisexual male*** transfusion
Figure 2. Cumulative AIDS Cases Among Adolescents and Young Adults by Exposure Category in the United States Reported through December 31, 1990, as Reported through August 14, 1991. (Source: CDC Division of HIV/AIDS, August 14, 1991).
350
S. BOWLER
Table 1.
Ages
Age-related
Transfusion-related
ET AL.
differences
in modes of transmission
(Males and Females) Behavior Related
13-14 15-16
9 1% 72%
9 % 24%
17-19 20-24
25% 2 %
69% 94%
Adapted from Gayle and D’Angelo,
Unknown/Other 0 % 4% 6% 4%
Total 100% 100% 100% 100%
1991.
rates are among runaway and homeless youth in New York City; lower rates were found in nationwide studies of more broadly representative samples of youth, such as Job Corps applicants and military recruits. An important contribution to understanding seroprevalence rates on a population basis comes from anonymous HIV testing within mandatory newborn genetic screening programs (Gwinn et al., 1991), which reveal a prevalence of infection among childbearing women. For a 27 month period ending in March 1990, infants born to women in New York State were tested for evidence of maternal HIV infection. Results indicate that 5*8/1000 teenagers under the age of 20 delivering in New York City were infected, compared to 1*3/1000 teenagers in the same age group delivering elsewhere in the state (Novick, et al., 1991). The much higher seroprevalence among newborns born to adolescent mothers in New York City as compared to the rest of the state underscores the importance of geographic differences in drug use. Despite the fact that more cases of AIDS have been reported in teenage males than females nationwide, there is some evidence that teenage women may be at comparable risk for HIV infection as their male counterparts in some cities. A blinded, unlinked, anonymous HIV seroprevalence survey which was conducted among adolescent patients visiting a Washington, D.C. hospital between October 1, 1987 and May 1991, indicates a higher rate among females than among males, as shown in Table 2 (D’Angelo, 1991).
MAJOR
HIV/AIDS
RISK
FACTORS
Adolescents at high risk for HIV/AIDS include those who engage in unprotected sex, have multiple sexual partners, share needles and other injection drug equipment, or have sex with a “high-risk” person (Kipke, Futterman and Hein, 1990). Youth at the highest risk because they engage
HIV AND AIDS AMONG ADOLESCENTS
351
in several or all of these activities are often those who are homeless and/or IDUs or users of crack runaway, school dropouts, youth offenders, cocaine (Hein, 1989; Vermund et al., 1989; Fullilove, 1990; Hein, 1991 a; Rotheram-Borus, Koopman and Ehrhardt, 1991). Unsafe sex Heterosexual activity among U.S. adolescents has increased dramatically since the early 1970s (CDC 1991d; O’Reilly and Aral, 1985; Sonenstein, Pleck and Ku, 1989). Data from a series of national surveys of young women conducted during the 1970s and from National Surveys of Family Growth conducted during the 1980s by CDC’s National Center for Health Statistics (NCHS, 1991), indicate that the proportion of adolescent women who reported that they had had premarital sexual intercourse increased from 28.6% in 1970 to 51.5% in 1988 (CDC, 1991d). It has been estimated that between 125,000 and 200,000 adolescents become involved in prostitution each year (Prothrow-Stith, 1989). The high rate of teenage pregnancy in the United States provides evidence of widespread unprotected sex in this population (Hayes, 1987; Kibrick, 1988; Zelnick and Kantner, 1980). Birthrates for all unmarried adolescents aged 15-19 years have jumped from 22.4/1000 to 40.6/1000 between 1970 and 1989 (NCHS, 1991). Young girls most likely to become pregnant have lower education levels and are from poorer backgrounds than those who do not get pregnant (Manoff et al., 1989). The current epidemic of sexually transmitted diseases (STDs) among U.S. adolescents further reflects the high prevalence of unprotected sex in this population. Age-stratified national data on STD rates using sexually active individuals as the denominator indicate that 15-19 year-old adolescents have the highest rates of gonorrhea, syphilis, chlamydial cervicitis, and hospitalizations for pelvic inflammatory disease (PID) (Kipke, Futterman and Hein, 1990; Aral et al., 1988; Bell and Hein, 1984). Adolescents who have such STDs as herpes, chancroid, and syphilis, may be more susceptible to HIV infection because open lesions in the genital area can increase the likelihood of HIV contact with a CD4+ or other infectable cell. It is not known whether inflammatory STDs such as gonorrhea, trichomonas, or even human papillomavirus (HPV) might also predispose individuals to increased HIV risk (Alexander-Rodriguez and Vermund, 1987; Bickell et al., 1991; Rosenfeld et al., 1989). STD and behavioral data suggest that only a small number of adolescents take adequate precautions to prevent HIV infection, and partners or sexually active female adolescents rarely use condoms (Jaffe et al., 1988; Kegeles, Adler and Irwin 1989; Keller et al., 1991; Weisman et al., 1989).
1988-89
Facility Type
1) STD
1988-89
1987-90
10/85-3/91
2/874/87
10/87-5/91
2) Women’s Health Centers
3) Department of Labor Screening Center
4) Military Testing Units
5) STD Clinic
6) Children’s National Medical Center Clinics
Clinics
Survey Period
Table 2.
I
11,481
943
666,972
137,209
108,000
Sample
Adolescent patients Males Females
Adolescent patients Young adult patients
Adolescents Male Female Young Adults Male Female
Job Corps. entrants** Male Female White Black Hispanic
Young Adults
13-19
15-19 20-24
20-24
17-19
0.627 0.62 0.63
2.2 3.6
0.03 0.03 0.03 0.16 0.17 0.08
0.36 0.37 0.32 0.12 0.53 0.26
(r3.1)
20-24 16-21
(&
‘7)
0..5+ (O-4.6) 1.8# (O-3-4)
% Seroprevalence (range)
15-19
20-24
Young adult patients Adolescents
IS-19
Adolescent patients
Population
Age Groups
HIV seraprevalence sumeys of adolescents and young adults
Washington,
Baltimore, ,Maryland
Nationwide
DC
(Highest prevalence in Northeast and rural South)
Nationwide
Nationwide
Region(s)
z h)
of surveys.
1) and 2) CDC (19896); (1991); 8) Schoenbaum,
Sources:
*Median
**The
and homeless
for
does not accept any known injection drug users.
Newborns to adolescent mothers: Total White Black Hispanic
Newborns to adolescent mothers: Total White Black Hispanic
Patients screened syphilis
Women getting first trimester abortions (none used IV drugs: 35.7% women or sex partners used non-IV cocaine and/or heroin)
Runaway youth
HIV and AIDS among adolescents in the United States: increasing risk in the 1990s SUZANNE BOWLER,* AMY R. SHEON, LAWRENCE J. D’ANGELO,** STEN H. VERMUND Acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) are growing problems among U.S. adolescents. By examining recent data on AIDS surveillance and HIV seroprevalence, surveys on teenagers’ knowledge, beliefs, and behaviors related to HIV/ AIDS, key treatment issues, and barriers to prevention, this manuscript reviews the problem and proposes possible ways of combating it. African American youth have the highest rates of AIDS and white youth the lowest. However, the largest number of AIDS cases overall has been recorded in white males, reflecting relatively high case rates in boys with hemophilia and in young male homosexuals. Predominant HIV risk factors for adolescents are unprotected sex and/or sharing injection drug equipment with an infected partner. Relatively high rates of HIV infection in adolescent females may indicate their greater physiological vulnerability than adult females to sexually transmitted diseases (STDs). Data from HIV seroprevalence studies suggest a substantially increased heterosexual epidemic in the 199Os, especially in large east coast cities and southeastern rural areas where drug use and/or STDs are highly prevalent. More comprehensive prevention and treatment services are needed to prevent ongoing expansion of HIV infection and AIDS in the adolescent age group.
INTRODUCTION
HIV infection poses a serious health threat to many U.S. adolescents. Of a total of 199,406 AIDS cases reported to the U.S. Centers for Disease Control (CDC), 20% occurred among young adults ages 20-29 years as of the end of October 1991 (CDC, 1991~). It can be inferred that many were Reprints requests should be addressed to: Dr Sten H. Vermund, Division of AIDS, NIAID/NIH, 6003 Executive Boulevard, Room 2A42. Bethesda, MD 20892, U.S.A. Amy R. Sheon & Sten H. Vermund Epidemiology Branch, Clinical Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD. *The MayaTech Corporation, Silver Spring, MD. ** Department of Adolescent and Young Adult Medicine, Children’s National Medicine Center and Department of Paediatrics, George Washington University School of Medicine and Health Science. 0140-1971/92/040345
+ 27 $08.00/O
D 1992 The
Association
for Professmnals
in Services
for Adolescents
S. BOWLER ET AL.
346
infected with HIV during their adolescent years because of the long latency period of the disease (Gayle and D’Angelo, 1991). There has been a 53% increase in cumulative AIDS cases among both adolescents and young adults between the end of 1988 and the end of 1990 (CDC 1989~; 19916). Among teenagers aged 13-19 years, total cumulative reported AIDS cases rose from 325 to 629, from 3,576 to 6,720 among adults aged 20-24 years, and from 13,483 to 25,634 among adults aged 25-29 years. In addition, AIDS became the seventh leading cause of death among people aged IS-24 by 1988 (CDC, 1989b), and is now the fourth leading cause of death among young adults aged 20-24 (Gayle and D’Angelo, 1991). The seriousness of this problem is reflected not merely in the increases in the number of AIDS cases among adolescents and young adults but also in the rapidly rising rates of HIV infection in adolescents (CDC 1989a; 1991b; D’Angelo, 1991; D’Angelo, et al., 1991; St Louis, et al., 1991). While all sexually active and injection drug using adolescents are theoretically at risk for AIDS, this risk is greatest for teens who live in communities where HIV infection is common. Since teenagers are vulnerable to HIV infection when they begin to experiment with sex and drugs, preventive interventions are crucial (Gayle and D’Angelo, 1991; Hein, 1989; Vermund, et al., 1989). Yet adolescents from the United States and many Westernized countries are likely to be the most difficult age group to influence toward HIV/AIDS prevention, due largely to their (1) susceptibility to negative. peer pressure; (2) propensity to take risks, including sexual and drug experimentation; (3) sense of invulnerability and immortality; and (4) difficulty grasping the long-term adverse consequences of current behavior (Hein, 1989; Irwin and Millstein, 1986; Prothrow-Stith, 1989). This article reviews current knowledge about HIV and AIDS among U.S. adolescents including surveillance data, barriers to prevention, and selected treatment issues. Two definitions of adolescence are used in this article. CDC (1991b) defines adolescence as ages 13 to 19 years, and the American Academy of Pediatrics and Society for Adolescent Medicine as the ages of 13 to 21 years. Unless indicated otherwise, CDC AIDS surveillance data presented in the following sections, including Figures 1 and 2, are based on the number of reported cases from 1981 to the end of December 1990, as reported through January 1991. SURVEILLANCE
Major
characteristics
of adolescents
with AIDS
AIDS surveillance data (CDC, 1991b) indicate that older, male, black (African-American), and Hispanic (Latino) adolescents are over represented among those with AIDS. Seventy-five percent of teenage AIDS
HIV AND AIDS
AMONG
ADOLESCENTS
347
cases occur among adolescents between the ages of 17 and 19 (Gayle and D’Angelo, 1991) and 67% among males between the ages of 13 and 19 (CDC, 1991b). However, the adolescent male/female ratio is 3 : 1 as compared to 1O:l among adults (CDC, 1991b). Geographically, the distribution of AIDS among adolescents aged 13-19 years has been relatively stable since 1984, with a majority of adolescent cases reported from New York, Florida, California, Texas, Puerto Rico, and New Jersey. A disproportionate number of adolescents with AIDS are found in urban areas with total populations of over one million; 42% of the total 1980 U.S. population of all ages lived in these metropolitan areas where 72% of total AIDS cases have been reported. There is some geographic variation in the distribution of AIDS cases among Hispanics. For example, AIDS case reports and mortality data for the years 1981-1987 on persons of all age groups living in New York City reveal that Puerto Ricans have been the most severely affected of all new York racial/ethnic groups (Menendez, et al., 1990). In every region of the United States between June 1, 1981 and December 12, 1988, the cumulative incidence of AIDS in heterosexual injection drug users (IDUs) was several time greater among Puerto Rican-born persons than among other Latin American-born persons. Most AIDS cases among Puerto Ricanborn persons were among heterosexual IDUs, which was not the case among persons born in other parts of Latin America (Selik, et al., 1989). These statistics underscore the need to consider differences within ethnic or racial groups. Cumulative incidence rates stratified by racelethnicity among adolescents and young adults through December 1990 (Figure l), demonstrate that as among adults of all ages, blacks and Hispanics are disproportionately represented among adolescents with AIDS, and that AIDS rates among males are higher than among females, although for black adolescents, females have nearly the same rate as males.
Modes
of transmission
Among adolescents (13-19 years) and young adults with AIDS, the most common modes of HIV transmission vary by both age and gender as indicated in Figure 2. Heterosexual contact is a far more prevalent source of infection for young women than men in the United States, due in part to the more efficient transmission of HIV from men to women than vice versa (Friedland and Klein, 1987; Padian, Shikoski and Jewell, 1991; Vermund et al., 1991). In addition, among non-injection drug using women of all ages who contracted AIDS through heterosexual contact (33% out of total AIDS cases among women), 63% of this subgroup were
348
S. BOWLER
ET AL.
sexual partners of IDUs (CDC surveillance data for the end of December, 1990 [CDC, 1991bl). AIDS surveillance statistics suggest that behavioral factors replace transfusion as the dominant mode of HIV transmission among older adolescents with reported AIDS (Table 1). By 1985, all U.S. blood banks had instituted blood screening, blood donor self-deferral, and heat treatment of clotting factors (CDC, 1985). Almost all post-1985 cases of HIV infection in the United States will have resulted from sexual or drug-use exposures. Modes of HIV transmission also vary among adolescents of different racial/ethnic groups (Gayle and D’Angelo, 1991). CDC data through the end of December 1990 indicate that among white youths, blood transfusion is responsible for a majority (53%) of AIDS cases, as compared with blacks and Hispanics, among whom homosexual/bisexual contact and injection drug use account for the majority of cases (39% and 29%, respectively). HIV
seroprevalence
among adolescents
Since the median incubation period for developing AIDS symptoms is estimated to be over 10 years (Lui et al., 1986), it is not surprising that infection rates among adolescents greatly exceed case rates. Back-calculation
125
(508) 25
0
White
Black Males
Figure 1. 1981 through
Hispanic
White
Black
Hispanic
Females
Cumulative AIDS Incidence Rates per 100,000 (Number) 1990 for the United States, as reported through January CDC (1991b). a, 13-19; , 20-24.
Reported from 1991. (Source:
HIV AND AIDS
AMONG
ADOLESCENTS
349
(a method described for the non-technical reader in Vermund, 1991) from reported AIDS cases has been used to estimate that the number of adolescents (ages 13-19 years) infected with HIV from 1981 through 1987 was 17,000 (Gayle and D’Angelo, 1991). This estimate, albeit imprecise, helps provide a more useful indication of the magnitude of HIV/AIDS among adolescents than the reported number of AIDS cases alone. A number of seroprevalence surveys have now been completed among adolescents in different sites, using different data-collection methods, as indicated in Table 2. The highest documented adolescent HIV infection
Adolescents
(ages 13-19 years) 3%***
6 “A*
(9)
l
TZ
(35) Moles (total
472)
Females [total’ 157) Young adults Cages 20-24
Males (total’
0 0
Heterosexual Other
Femoles
5652)
q Homo/btsexuol contact q lnjectlon drug use q Homosexual and InjectIon drug n Hemophlllo and other tronsfuslon contact with IDU
years)
q q 0
q n q
{total
Heterosexual contact Heterosexual contact Heterosexual contact InjectIon drug use Hemophlha and other Other
1068)
wth lDU* wth mole with HIV/AIDS+c wth bisexual male*** transfusion
Figure 2. Cumulative AIDS Cases Among Adolescents and Young Adults by Exposure Category in the United States Reported through December 31, 1990, as Reported through August 14, 1991. (Source: CDC Division of HIV/AIDS, August 14, 1991).
350
S. BOWLER
Table 1.
Ages
Age-related
Transfusion-related
ET AL.
differences
in modes of transmission
(Males and Females) Behavior Related
13-14 15-16
9 1% 72%
9 % 24%
17-19 20-24
25% 2 %
69% 94%
Adapted from Gayle and D’Angelo,
Unknown/Other 0 % 4% 6% 4%
Total 100% 100% 100% 100%
1991.
rates are among runaway and homeless youth in New York City; lower rates were found in nationwide studies of more broadly representative samples of youth, such as Job Corps applicants and military recruits. An important contribution to understanding seroprevalence rates on a population basis comes from anonymous HIV testing within mandatory newborn genetic screening programs (Gwinn et al., 1991), which reveal a prevalence of infection among childbearing women. For a 27 month period ending in March 1990, infants born to women in New York State were tested for evidence of maternal HIV infection. Results indicate that 5*8/1000 teenagers under the age of 20 delivering in New York City were infected, compared to 1*3/1000 teenagers in the same age group delivering elsewhere in the state (Novick, et al., 1991). The much higher seroprevalence among newborns born to adolescent mothers in New York City as compared to the rest of the state underscores the importance of geographic differences in drug use. Despite the fact that more cases of AIDS have been reported in teenage males than females nationwide, there is some evidence that teenage women may be at comparable risk for HIV infection as their male counterparts in some cities. A blinded, unlinked, anonymous HIV seroprevalence survey which was conducted among adolescent patients visiting a Washington, D.C. hospital between October 1, 1987 and May 1991, indicates a higher rate among females than among males, as shown in Table 2 (D’Angelo, 1991).
MAJOR
HIV/AIDS
RISK
FACTORS
Adolescents at high risk for HIV/AIDS include those who engage in unprotected sex, have multiple sexual partners, share needles and other injection drug equipment, or have sex with a “high-risk” person (Kipke, Futterman and Hein, 1990). Youth at the highest risk because they engage
HIV AND AIDS AMONG ADOLESCENTS
351
in several or all of these activities are often those who are homeless and/or IDUs or users of crack runaway, school dropouts, youth offenders, cocaine (Hein, 1989; Vermund et al., 1989; Fullilove, 1990; Hein, 1991 a; Rotheram-Borus, Koopman and Ehrhardt, 1991). Unsafe sex Heterosexual activity among U.S. adolescents has increased dramatically since the early 1970s (CDC 1991d; O’Reilly and Aral, 1985; Sonenstein, Pleck and Ku, 1989). Data from a series of national surveys of young women conducted during the 1970s and from National Surveys of Family Growth conducted during the 1980s by CDC’s National Center for Health Statistics (NCHS, 1991), indicate that the proportion of adolescent women who reported that they had had premarital sexual intercourse increased from 28.6% in 1970 to 51.5% in 1988 (CDC, 1991d). It has been estimated that between 125,000 and 200,000 adolescents become involved in prostitution each year (Prothrow-Stith, 1989). The high rate of teenage pregnancy in the United States provides evidence of widespread unprotected sex in this population (Hayes, 1987; Kibrick, 1988; Zelnick and Kantner, 1980). Birthrates for all unmarried adolescents aged 15-19 years have jumped from 22.4/1000 to 40.6/1000 between 1970 and 1989 (NCHS, 1991). Young girls most likely to become pregnant have lower education levels and are from poorer backgrounds than those who do not get pregnant (Manoff et al., 1989). The current epidemic of sexually transmitted diseases (STDs) among U.S. adolescents further reflects the high prevalence of unprotected sex in this population. Age-stratified national data on STD rates using sexually active individuals as the denominator indicate that 15-19 year-old adolescents have the highest rates of gonorrhea, syphilis, chlamydial cervicitis, and hospitalizations for pelvic inflammatory disease (PID) (Kipke, Futterman and Hein, 1990; Aral et al., 1988; Bell and Hein, 1984). Adolescents who have such STDs as herpes, chancroid, and syphilis, may be more susceptible to HIV infection because open lesions in the genital area can increase the likelihood of HIV contact with a CD4+ or other infectable cell. It is not known whether inflammatory STDs such as gonorrhea, trichomonas, or even human papillomavirus (HPV) might also predispose individuals to increased HIV risk (Alexander-Rodriguez and Vermund, 1987; Bickell et al., 1991; Rosenfeld et al., 1989). STD and behavioral data suggest that only a small number of adolescents take adequate precautions to prevent HIV infection, and partners or sexually active female adolescents rarely use condoms (Jaffe et al., 1988; Kegeles, Adler and Irwin 1989; Keller et al., 1991; Weisman et al., 1989).
1988-89
Facility Type
1) STD
1988-89
1987-90
10/85-3/91
2/874/87
10/87-5/91
2) Women’s Health Centers
3) Department of Labor Screening Center
4) Military Testing Units
5) STD Clinic
6) Children’s National Medical Center Clinics
Clinics
Survey Period
Table 2.
I
11,481
943
666,972
137,209
108,000
Sample
Adolescent patients Males Females
Adolescent patients Young adult patients
Adolescents Male Female Young Adults Male Female
Job Corps. entrants** Male Female White Black Hispanic
Young Adults
13-19
15-19 20-24
20-24
17-19
0.627 0.62 0.63
2.2 3.6
0.03 0.03 0.03 0.16 0.17 0.08
0.36 0.37 0.32 0.12 0.53 0.26
(r3.1)
20-24 16-21
(&
‘7)
0..5+ (O-4.6) 1.8# (O-3-4)
% Seroprevalence (range)
15-19
20-24
Young adult patients Adolescents
IS-19
Adolescent patients
Population
Age Groups
HIV seraprevalence sumeys of adolescents and young adults
Washington,
Baltimore, ,Maryland
Nationwide
DC
(Highest prevalence in Northeast and rural South)
Nationwide
Nationwide
Region(s)
z h)
of surveys.
1) and 2) CDC (19896); (1991); 8) Schoenbaum,
Sources:
*Median
**The
and homeless
for
does not accept any known injection drug users.
Newborns to adolescent mothers: Total White Black Hispanic
Newborns to adolescent mothers: Total White Black Hispanic
Patients screened syphilis
Women getting first trimester abortions (none used IV drugs: 35.7% women or sex partners used non-IV cocaine and/or heroin)
Runaway youth
