insurance and remain ineligible for Medicaid. Young adults ages 19-24 are even less likely to be privately insured or eligible for public assistance.

In 1989, the most recent year for which data are available, at least 1.6 million adolescents in the U.S. needed treatment for alcohol and other drug abuse, but only 123,500 actually received it. Select Committee interview respondents from around the country reported critical drug treatment shortages.

Although many experts agree the most promising strategy to reduce risky behavior and promote healthy decisions is a comprehensive K-12 school health program, only about 300 schools in the country have any kind of school-linked health facility. These facilities provide access to general primary care, counseling, and preventive services to many youth who may not have another health care provider. By November 1991, only one in eight school-linked health facilities distributed condoms or was planning to do so.

LEGAL AND ETHICAL CONSIDERATIONS FOR PROVIDING HIV-RELATED SERVICES TO ADOLESCENTS REMAIN

The HIV epidemic has raised complicated legal and ethical issues for adolescents living with the virus and society at large. These include HIV-antibody testing, access to medical treatment, protection against discrimination, privacy rights, duty to warn, types and content of educational interventions, and liability concerns.

Early treatment has delayed the progression of HIV disease, causing some to advocate increased HIV-antibody testing. However, few resources have been devoted to providing adequate counseling and treatment, and the privacy of youth who are tested is often unprotected. Without addressing these concerns, experts warn that HIV-antibody screening of adolescents does more harm than good.

Adolescents' authority to consent for HIV testing and treatment for HIV-related services varies by state. By

September 1991, 11 states (AZ, CA, CO, DE, IA, MI, MT, NM, NY, OH, and WI) had specific statutes authorizing minors to consent for HIV testing. Twelve states (AL, FL, IL, KY, MI, MT, NV, SC, TN, VT, WA, and WY) had specific statutes authorizing minors to consent to testing and treatment for HIV as an STD. Still other states have specific statutes authorizing adolescents to consent only to treatment for AIDS or HIV.

State laws, financial barriers and a dearth of adequately trained health care providers severely impede the provision of adequate HIV-related medical treatment to adolescents. Participation in experimental clinical trials makes high-quality medical services available to some adolescents. Adolescents' authority to consent to participation in research, however, is even more limited than the authority to consent to established treatment.

FEDERAL EFFORTS TO COMBAT HIV AND AIDS AMONG ADOLESCENTS UNDERFUNDED, UNCOORDINATED AND INSUFFICIENT

While many Federal agencies report HIV-related efforts that serve or target youth, it is virtually impossible to determine the depth or extent of these efforts. Among the primary Federal agencies that provide health care research, treatment, prevention, and services to youth, total HIV-related spending was approximately $107 million in FY 1991 -- estimated to be less than 5% of the total Federal AIDS budget. The Health Care Financing Agency, which administers Medicaid, is unable to determine the cost of HIV-related care provided to adolescents.

Federal HIV-related efforts targeting or serving adolescents are piecemeal and uncoordinated. Federal health policy regarding adolescents and HIV is essentially nonexistent. No agency surveyed by the Select Committee had evaluated its HIV-related efforts for adolescents on an agency-wide basis, and few resources are dedicated to disseminating promising model programs.

The Ryan White CARE Act, the Federal law most likely to improve adolescents' access to HIV-related treatment and services, has been severely underfunded. In the past two years, funding for Ryan White programs was less than onethird of the total authorized by Congress.

Federal programs such as community and migrant health centers (CHCs and MHCs) and Title X family planning clinics have the potential to reach medically underserved teens with key HIV-related information (e.g., instructions for proper condom usage) and services. Yet, between 1980 and 1991, funding for CHCs and MHCs declined by 2.4% and funding for Title X decreased by 61%, adjusted for inflation.

Categorical funding of prevention efforts prohibits efforts to address related risky behaviors, such as sexual activity and drug use. The Office of Drug Free Schools in the U.S. Department of Education has one of the largest Federal prevention budgets, and Drug Free Schools programs are mandated in every state. Despite apparent leeway in the statute and the recommendation of the Office of Substance Abuse Prevention, the U.S. Department of Education has refused requests to include information about other HIVrelated risk behaviors in this prevention program.

• The Centers for Disease Control (CDC) allocates funds to state and local educational agencies to provide HIV prevention education to in-school and out-of-school youth. In 1990, the General Accounting Office (GAO) found that only two-thirds of public school districts offered any formalized HIV education, that teacher training was insufficient, and that HIV prevention programs in schools were unevaluated. While CDC has begun to respond to many of the criticisms raised by GAO and others, (i.e., with new regional teacher training centers), current funding constraints mean that prevention programming is available only to a small minority of those at highest risk, and stateof-the-art school-based programing is sparse.

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FEDERAL RESTRICTIONS ON EXPLICITNESS PREVENTION MATERIALS AND LACK OF BEHAVIORAL RESEARCH LIMIT PROGRAM EFFECTIVENESS

• While communities have the final say regarding curriculum issues, CDC guidelines for the content of prevention programs fail to recommend that explicit means for reducing AIDS risk be described in middle schools. According to the Institute of Medicine at the National Academy of Sciences, the omission of information about the protective value of consistent condom usage is potentially dangerous since some students are sexually active during these years.

Few national data exist to assess the extent of many behaviors that put youth at risk of HIV, particularly among populations that are believed to be at increased risk of infection. Objections to research about the environmental influences on and prevalence of risky sexual behavior in adolescents have had chilling effects on efforts to gather information necessary for HIV prevention. Critical behavioral research has been cancelled, and the scientific community has been made aware that similar studies will not be funded in the future.

Experts have called CDC requirements for content of HIVrelated materials cumbersome and overly restrictive. These requirements have resulted in the elimination of discussions of homosexuality and specific behaviors that put an adolescent at risk of HIV from basic "AIDS 101" curricula. A newly revised version still requires duplication of review processes, and prohibits language that will be offensive to "...a majority of adults outside the intended audience."

The CDC and numerous researchers have found that correct and consistent use of latex condoms lubricated with the spermicide nonoxynol 9 prevents transmission of STDs, including HIV. However, a new CDC public information campaign fails to mention either condoms or sex in public

service announcements.

KEY FINDINGS FROM INTERVIEWS
CONDUCTED BY SELECT COMMITTEE ON

CHILDREN, YOUTH, AND FAMILIES

Community support for HIV prevention and services for teens is critical to program success. In order to determine how to increase community support for efforts to protect adolescents from HIV infection, and how to overcome community resistance to these programs, the Select Committee on Children, Youth, and Families conducted interviews with representatives of 29 programs in 20 states that attempt to prevent adolescent HIV infection. Major findings were:

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Apathy is a greater problem for prevention programs than community resistance. Resistance had a silver lining it often shattered apathy in the community at large and motivated active support for programs that help keep teens safe.

Parent involvement in planning is linked with involvement of other community segments.

Community support snowballs when key groups are recruited.

• Programs that work with national organizations to provide state-of-the-art services gain the most support from community leaders and organizations.

Programs that belong to coalitions operate with lower budgets.

Programs find the local data from the Youth Risk Behavior Survey valuable in fighting denial and apathy and in planning prevention efforts, but need more information about the sexual and drug-use behaviors of American teens.

Programs that evaluate their efforts enjoy the greatest support; evaluation by outside experts is linked with support from the local business community.