Young people in the U.S. continue to be at risk for HIV. In 2008, according to the CDC, 16% of people with HIV were between 13 and 24 years old. A 2006 study suggested that "15% to 30% of all cases of HIV occur among individuals younger than 25 years." Hardest hit have been young people of color, and young men who have sex with men. What can HIV prevention programs do to help young people protect their health and their futures?
According to the CDC, the majority (72%) of new HIV cases in young people are among men, and most of those (85%) are attributed to male-to-male sexual contact. Most new HIV cases among women are attributed to heterosexual contact. For both young men and women, the vast majority of new infections occur among minority youth. In the U.S., African-Americans and Latinos account for 87% of all new HIV infections among 13- to 19-year-olds and 79% among 20- to 24-year-olds. Yet together they make up only about 32% of people in this age group in the general population.
Men who have sex with men (MSM) are the only risk group in which the rate of new infections has increased steadily each year since the 1990s, even as it has decreased among other populations. Each day, nine young African-American men are diagnosed with HIV.
Young people aged 15 to 24 are the group most likely to experience sexually transmitted infections (STIs), a risk factor for HIV. The CDC has estimated that young people account for up to half of the nation's 19 million new STI infections each year. These rates are even higher among minority youths. In 2006, young African-American men between 15 and 19 years of age had 39 times the rate of gonorrhea compared with white men in the same age range. A recent study of STIs among young women aged 15 to 19 found that 48% African American women in this age range had an STI, compared with about 20% of white women.
Many young people engage in behaviors that put them in danger. For example, 39% of all high school students say they didn't use a condom the last time they had sex, while 46% of young MSM had unprotected anal intercourse in the last year. Sexual relationships with multiple partners that overlap in time increase many young people's risk for HIV. Studies have found that because of medications that allow HIV-positive people to live longer, some young people may be taking more sexual risks as they become less fearful of HIV. This includes unprotected sex with untested or known HIV-positive individuals.
Young people face barriers to HIV testing, including stigma, confidentiality concerns, or fear that their parents may be informed. In addition, many young people are unaware of their HIV status. Nationwide, only 13% of high school students have been tested for HIV. In one nationwide study, 10% of young MSM tested positive, and 69% of those who did had previously been unaware that they had HIV. Another study revealed that young black MSM had a nearly seven times greater chance of having unrecognized HIV infection as young white MSM.
Especially among racial and sexual minority youth, having older partners means young people are even more likely to be exposed to HIV and STIs. Compared with black and Latina peers whose first sex occurred with a male of their own age, young women whose partner was older were significantly less likely to use condoms during first sex, and to have used them consistently since becoming sexually active. One study of young MSM found that the odds of HIV infection increased significantly as the age of their sexual partners increased. People in the study whose partners were five or more years older had twice the odds of getting HIV as study participants as a whole.
Among young women, dating violence and sexual assault also play a role in HIV transmission, and 20% report experiencing dating violence. Women who experience violence are less likely to use condoms than those who do not, and they feel more uncomfortable negotiating condom use. In one study, half of girls who reported HIV or STIs had been physically or sexually abused.
A common misconception is that young African-Americans are simply not as careful as whites in protecting their sexual health. But research has shown that even when risk factors are equal, sexually active minority youth face a higher risk of HIV and STIs. The people in their "pool" of sexual partners are more likely to be HIV positive or have an STI, raising the odds of infection. But why?
Several linked issues contribute to higher infection rates among African-American young people. Racism is the most significant contributor, especially for those living in the South. Racism is intertwined with underemployment and unemployment, decreased access to medical care, and with incarceration.
Almost 25% of African-Americans live in poverty, compared with 11% of whites. Those who live in poverty are more likely to commit crime, especially drug-related crime. They are more likely to live in unstable neighborhoods with higher rates of crime and more liquor stores. Poverty also contributes to problem alcohol use, which leads to unemployment and unstable relationships. Unstable relationships can lead to unprotected sex if partners are afraid that insisting on condoms will endanger the relationship.
Meanwhile, strict sentencing laws around drug-related crime have resulted in the incarceration of millions of African Americans, especially men. More than one in four are incarcerated during their lifetime. Certainly, unprotected sex in prison is one way HIV can be transmitted. Men in prison have less sex overall, but more risky sex than men who are not incarcerated. Another effect of imprisonment is strained relationships with long-term partners or wives. This can lead to concurrent partnerships.
Those living in poverty also have less access to medical treatment and may go for long periods of time either unaware they have HIV or an STI or without treatment.
In addition to racism, the social stigma surrounding homosexuality also adds to health issues. Men who are secretive about same-sex behavior may have decreased access to medical treatment. They may be less likely to seek treatment and may be diagnosed later than those who are openly gay.
For young people of color who become sexually active, the deck is stacked against them in terms of maintaining their sexual health. HIV prevention efforts, which teach healthier behaviors like using condoms, are still vital, but are only a part of a successful prevention strategy. Addressing other factors which contribute to the spread of HIV is important.
Complex issues are fueling HIV transmission among young people, particularly young people of color. In order to address that, interventions must address individual behavior and the social and cultural issues that fuel HIV transmission. The following critical components for HIV/STI prevention are drawn from research.
No single strategy will work to reduce HIV among young people. But research has shown that culturally competent programs that include information about abstinence, contraception, and condoms can be effective in helping young people reduce risk behaviors. In addition, open and honest parent-child communication about HIV can help them make good decisions. Finally, resources must be directed at understanding the epidemic's impact on the young, addressing the issues that contribute to the epidemic, and developing and testing a vaccine.
Jennifer Augustine is the Division Director of Health and Social Equity at Advocates for Youth. Emily Bridges is Director of Public Information Services at Advocates for Youth.