In 2006, an estimated 56,300 people in the United States became infected with HIV. Of these, 34% -- or approximately 19,000 -- were adolescents or young adults aged 13-29 years.¹ These numbers highlight the ongoing risk of HIV infection among young people and underscore the need to reach each new generation with effective HIV prevention messages and services. Schools and education agencies are important partners in this effort.

Overview

HIV/AIDS affects certain groups of young people disproportionately.

The burden of HIV infection falls disproportionately on certain groups of young people, including young men who have sex with men (YMSM) and youth of color.

• More than half (54%) of all cases of HIV infection or AIDS among young people aged 13-24 during 2003-2006* were from male-to-male sexual contact. Thirty-four percent were from heterosexual contact.²
• Seventy percent of all HIV/AIDS diagnoses among youth aged 13-19 in 2006 were among black youth, even though blacks represented only 17% of the population in that age group.²
• Of all YMSM, young black men who have sex with men (MSM) bear the greatest burden. More than twice as many black MSM aged 13-24 were diagnosed with HIV infection or AIDS in 2006* as their white or Hispanic counterparts.³
• Black and Hispanic MSM are more likely to become infected at a younger age (13-29 years), whereas white MSM are more likely to become infected when they are older (30-39 years).⁴

HIV/AIDS has increased most among YMSM, especially young men of color.

• From 2001 through 2006, male-to-male sex was the largest HIV transmission category in the United States* and the only one associated with an increasing number of HIV/AIDS diagnoses.³
• Of all age groups of MSM, HIV/AIDS cases increased most among YMSM aged 13-24 (Figure 1).
• Among YMSM aged 13-24, young black MSM had the most dramatic increase in diagnoses -- from 938 cases in 2001 to 1,811 cases in 2006, an increase of 93% (Figure 2).

* In the 33 states that had long-term, confidential, name-based reporting. Click images to enlarge.

The reasons for these disparities are varied and not well understood.

The reasons for continued high HIV/AIDS rates among YMSM are multiple and complex. Possible factors include the following:

• The alarming percentage of young HIV-infected MSM who do not know they are infected. In one recent study, 77% of young, urban MSM aged 15-29 who tested HIV-positive as part of the study mistakenly believed they were not infected. The percentage was even higher for young black HIV-infected MSM, 90% of whom did not know their infection status.⁴ People who don't know they are infected might be less likely to take measures to keep from spreading the virus to others.
• Failure to reach MSM with effective HIV interventions or prevention education. A CDC study of MSM in 15 cities found that 80% had not been reached in the past year by HIV interventions known to be most effective.⁵ In addition, sex education programs that exclude information about sexual orientation or ignore issues in the lives of sexual minority youth might not be effective in preventing HIV transmission among those students.
• Unintended consequences of successful treatment. Improved treatment for HIV infection has helped many people with HIV infection live longer and healthier lives. An unintended consequence of this success is that younger MSM, who did not witness the toll of AIDS in the early years of the epidemic, might view HIV infection as less dangerous and more treatable, leading them to become complacent about risks.⁶
• Use of alcohol and illegal drugs. Alcohol, methamphetamine, and other "party drug" use is prevalent among some YMSM and can lead to risky sexual behavior.⁶
• Elevated rates of sexually transmitted diseases (STDs) among MSM. Having an STD can raise the risk of HIV infection by two- to fivefold. STDs also appear to increase the risk of transmitting HIV to sex partners.⁶
• Mental health consequences of stigma and discrimination. Bullying, harassment, family disapproval, social isolation, and sexual violence -- which are experienced frequently by sexual minority youth -- can lead to feelings of shame and poor self-concept. This can lead to higher rates of emotional distress, suicide attempts, substance use, and risky sexual behavior.^7-9

The racial/ethnic disparities in HIV/AIDS among young MSM are also not well understood. The disparities do not appear to reflect individual racial/ethnic differences in risk behavior. An analysis of 53 studies found no significant differences between black and white MSM in levels of unprotected anal intercourse, commercial sex work, sex with a known HIV-positive partner, or HIV testing history.¹⁰ Other possible factors include the high prevalence of HIV in black male social networks, elevated rates of STDs among black men, and the reduced likelihood of black men receiving antiretroviral treatment, which can reduce the amount of HIV in the blood and potentially decrease transmission.¹⁰

Strategies for Addressing HIV/AIDS Among YMSM and Other Sexual Minority Youth* in Schools

Collect and analyze data on same-sex sexual behavior.

To collect information about same-sex sexual behavior among high school students and its association with other health risks, some states and cities have added a question to their Youth Risk Behavior Survey (YRBS).† In 2007, seven states (Connecticut, Delaware, Maine, Massachusetts, Rhode Island, Vermont, and Wisconsin) and five cities (Boston, Chicago, District of Columbia, Milwaukee, and New York City) asked about same-sex sexual behavior in their YRBS. In those states and cities, the prevalence of same-sex sexual contact (i.e., sexual contact with "males" or "females and males") among male high school students ranged from 2.4% to 7.1%. Among female students, prevalence of same-sex sexual contact (i.e., sexual contact with "females" or "females and males") ranged from 3.5% to 10.5%.

Massachusetts has included YRBS questions on same-sex sexual behavior and sexual identity since 1993. Analyses of the Massachusetts data have contributed greatly to our knowledge about health risks among youth who have sex with partners of the same sex or both sexes. Key findings include the following:

• Adolescent males who had sex with both males and females, compared with males who reported same-sex or opposite-sex sexual contact only, had significantly higher rates of injection drug use, forced sex, history of an STD, and failure to use a condom at last sexual intercourse.¹¹
• Young males who had sex with males only or with both males and females were less likely to indicate that they had received AIDS education in school than young males who had sex with females only.¹¹
• Students who had sex partners of both sexes were at greater risk for harassment, violence, suicidal behavior, alcohol and other drug use, and unhealthy weight control practices than those with opposite-sex or same-sex partners only.¹²

The benefits of adding a question about the gender of adolescents' sex partners to the YRBS are many. Collecting such data enables states and cities to analyze same- or both-sex sexual activity in relation to unprotected sex, substance use, suicidal behavior, and other health risk behaviors and then adjust intervention priorities accordingly. Furthermore, by documenting that many youth do engage in same-sex sexual activity and sexual risk behaviors, these data can help establish the imperative for meeting the health needs of sexual minority youth in schools.

The following question is on the list of optional YRBS questions:

During your life, with whom have you had sexual contact?
º I have never had sexual contact º Males		º Females º Females and males

Establish safe and supportive environments.

HIV prevention activities are more likely to have an impact if they take into account the context in which risk behaviors occur. For YMSM and other sexual minority youth, this means addressing the challenges these young people face at school. A survey using a convenience sample of more than 6,000 middle and high school students across the United States found that

• Nearly 9 of 10 gay, lesbian, bisexual, or transgender students were harassed at school in the past year.
• Six of 10 felt unsafe at school because of their sexual orientation.
• Almost a third skipped a day of school in the past month because they felt unsafe.¹³

Such victimization, in turn, is associated with HIV risk behaviors. The Massachusetts YRBS found that YMSM who had been threatened or bullied at school were more likely to have ever been diagnosed with an STD, injected drugs, had more than four sex partners, and not used a condom the last time they had sexual intercourse than those who had not been threatened or bullied at school.¹⁴

One approach being used to create safe and welcoming school environments is the formation of Gay-Straight Alliances (GSAs) in schools across the country. CDC recently collaborated with Seattle Public Schools to evaluate the effectiveness of the school system's initiatives to establish safe and supportive school environments for sexual minority youth. The evaluation found that GSAs provided avenues for students to participate meaningfully and feel more connected at school, an important protective factor.

Provide professional development for school staff.

School health professionals might benefit from training to help them understand the needs of sexual minority youth and shape behavioral health messages accordingly. To this end, CDC funds the American Psychological Association (APA) Healthy Lesbian, Gay, and Bisexual Students Project to help schools and youth-serving organizations improve health and mental health outcomes for sexual minority youth.

APA provides science-based workshops for school counselors, nurses, psychologists, and social workers on how to effectively reach sexual minority youth with HIV prevention messages and other health information. A number of education agencies funded by CDC's Division of Adolescent and School Health (DASH) -- including those in Connecticut, Massachusetts, Delaware, and San Diego, California -- have formed their own training cadres to offer the workshop locally. For more information, visit www.apa.org/pi/lgbc/hlgbsp.

Implement effective policies, practices, and interventions.

DASH funds state, territorial, tribal, and local education agencies to help schools implement policies and practices to reduce sexual risk behaviors. Recognizing that YMSM are a major risk group for HIV infection, a number of these agencies are taking action to address the needs of sexual minority youth:

• The Rhode Island Department of Education established a statewide task force on lesbian, gay, bisexual, transgender, queer, and questioning youth. Working with Youth Pride, Inc., the state's only organization dedicated to sexual minority youth, the task force released a plan in 2006 entitled Band-Aids Don't Cut It: A Statewide Plan to Address the Needs of Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning Youth. The plan makes comprehensive recommendations in the areas of education, policy, health and human services, child welfare, mental health, and data collection. Among the many recommendations were that 1) questions about same-sex sexual activity and sexual orientation be added to the state YRBS, 2) training be provided for teachers, administrators, and school staff on issues pertaining to sexual minority youth, 3) GSAs be established when requested by students, and 4) lesbian, gay, bisexual, transgender, queer, and questioning identity be included in definitions of diversity.
• The HIV/AIDS Prevention Unit of the Los Angeles Unified School District (LAUSD) developed a chapter about sexual orientation for inclusion in the Sexuality and Society textbook (Holt, Rhinehart, and Winston, 2005) that is used in required health education courses in LAUSD high schools. The district employs two full-time staff members to address issues pertaining to sexual minority youth, and approximately 35,000 LAUSD employees and students -- including all teachers hired since 2003 -- have received the district's anti-bias training. In addition, the district has 50 active GSAs, cosponsors an annual Model of Pride conference, and accommodates safe zones for students who have concerns around perceived sexual orientation and mistreatment by peers.
• In response to requests from school districts throughout Michigan for guidance on creating safe school environments for sexual minority students, the Michigan Department of Education (MDE) collaborated with the Calhoun (Michigan) Intermediate School District (CISD) to update CISD's guide and training program on the topic and to offer trainings statewide. Now in its 4th edition, nearly 2,000 copies of A Silent Crisis: Creating Safe Schools for Sexual Minority Youth have been distributed throughout Michigan and 20 other states. MDE has conducted workshops using the guide for nearly 900 educators in 180 Michigan school districts. The guide is available at www.emc.cmich.edu/products/misc/SilentCrisis.htm.
• The School District of Philadelphia offers teachers and staff in all K-12 schools a training entitled "Fostering Knowledge About and Respect for LGBT Youth." The training helps teachers and school staff members understand terminology and issues regarding sexual orientation, reinforces district policy prohibiting harassment, and involves teachers in role plays where they learn how to respond to harassing language.

CDC's Division of HIV/AIDS Prevention also funds health departments and community organizations to promote the use of evidence-based HIV interventions, many of which are geared toward YMSM and young people of color. Information about these interventions is available at www.cdc.gov/hiv/topics/research/prs/evidence-based-interventions.htm.

* The term "sexual minority youth" is used here to refer to young people who identify as gay, lesbian, or bisexual; who are questioning their sexual orientation; who are same-sex attracted; who engage in sexual activity with persons of the same sex, regardless of how they identify; or who are transgender.

† The Youth Risk Behavior Surveillance System (YRBSS) monitors priority health risk behaviors and the prevalence of obesity and asthma among youth and young adults. YRBSS includes a national school-based survey conducted by CDC and local surveys conducted by state, territorial, and local education and health agencies and tribal governments. Information is available at www.cdc.gov/yrbs.

References

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