B. SEROPREVALENCE STUDIES INDICATE RAPID SPREAD OF HIV AMONG ADOLESCENTS The CDC estimates that approximately one million Americans are currently infected with HIV and that at least 40,000 new HIV infections occur each year among adults and adolescents.15 As noted previously, while AIDS case data provide a readily available source of data about the HIV epidemic, they severely underestimate its spread. Probability samples of the prevalence of HIV infection among individuals drawn from well defined populations would provide a more accurate assessment of the extent of the epidemic.16 With few exceptions, however, HIV seroprevalence studies are drawn from samples of convenience which do not include adolescents. 17 Seroprevalence studies based on nonprobability samples that have included adolescents and young adults have found a wide range of HIV infection. For example, among the nearly 950 youth ages 15-19 who used an STD clinic in Baltimore during a four-month period in 1987, 2.2% (or about one in 50) were infected with HIV. Among patients ages 15-24 who were served by a Bronx hospital during a nine-month period in 1988, 3.6% of males and 2.5% of females were infected with HIV.18 In New York City, one in 170 teenage women (under age 20) who delivered live births between November 30, 1987 and March 31, 1990 was infected.19 By contrast, among students served by 17 U.S. college health units between 1988 and 1989, 0.2% (or one in 500) was infected with HIV.20 To date there are no national epidemiologic studies of HIV infection among adolescents. The lack of population-based data makes it impossible to accurately estimate the prevalence of HIV infection among adolescents. The largest samples for national seroprevalence studies involving adolescents have come from applicants for U.S. military service and Job Corps) entrants.2 (See Table 6 for summary.) Job Corps is a Federally-funded educational and training program to help economically disadvantaged youth (ages 14-21) complete their education and learn skills that will help them obtain employment. Table 6: Comparison of HIV Infection Rates Among Young (k) Burke, D.S., et al. "Human Immunodeficiency Virus Infections in Teenagers: St. Louis, M.E., et al. "Human Immunodeficiency Virus Infection in Disadvantaged Adolescents: Findings From the U.S. Job Corps." JAMA. Vol. 266. No. 17. November 1991. p. 2387-2391. As indicated in Table 6, more than one in every 300 adolescents who entered the Job Corps during the study period was infected with HIV, compared with more than one in every 3,000 teenagers who applied for entry into military service. The tenfold difference in seroprevalence rates reflects differences in HIV prevalence in the populations sampled. The military sample was dominated by whites and high school graduates; the Job Corps sample consisted of predominantly disadvantaged minorities and high school dropouts. While drug addiction excludes applicants to both Job Corps and military service, the Job Corps does not exclude adolescents with a history of drug use, or who are homosexual and/or bisexual.22 Despite differences in populations, both studies found higher rates of HIV infection in African-American and Hispanic youth than in white youth. By age 21, nearly one in 80 minority entrants to the Job Corps was infected with HIV.23 The military and Job Corps studies also found that HIV infection rates were higher in females ages 16-18 than among males. In fact, the ratios of male-to-female infections were significantly lower than those found from AIDS case surveillance data, (1.1:1 and 1.2:1 in the military and the Job Corps studies respectively, compared with 2.7:1 in youth ages 13-19 diagnosed with AIDS). C. DATA REGARDING SEXUAL BEHAVIORS AND DRUG USE AMONG ADOLESCENTS ALSO INDICATE THEY ARE AT RISK OF HIV INFECTION Since the early 1970s, the incidence of sexually transmitted diseases (STDs), unintended pregnancy, and other problems associated with sexual activity have increased among adolescents in the United States.24 For example, approximately one million adolescent females become pregnant each year. By 1989, birth rates for teenagers had increased to levels not observed for 15 years.25 Additionally, 86% of all STDs occur among persons ages 15-29 years.26 While not all teens are sexually active or drug users, available data indicate that many adolescents currently engage in sexual and drug use behaviors that put them at risk for HIV infection. HIV infection. For adolescents who have not had sexual intercourse and who have not shared needles or syringes, the risk of HIV infection is low. At higher risk are adolescents who: ⚫ engage in sexual intercourse at early ages; ⚫ have several sexual partners; ⚫ have a sexually transmitted disease; ⚫ practice intercourse without consistent and proper use of latex condoms with spermicide; engage in male-to-male sexual relations; ⚫ engage in anal intercourse; ⚫ inject drugs (including cocaine, amphetamines, steroids, and heroin); or who have sex with injecting drug users. As noted by the National Research Council in 1990, no single statistic captures the complex dimensions of risk or the considerable variation in the prevalence of sexual and drug use behaviors across all ages, genders, and racial subgroups.28 However, research describing the prevalence of the abovementioned behaviors among adolescents provides an alternative method of estimating their risk of HIV infection. By age 20, 68% of adolescent females and 86% of adolescent males are sexually active. Two national surveys offer estimates of trends in adolescent sexual behavior: the 1988 National Survey of Family Growth (NSFG) and the 1988 National Survey of Adolescent Males (NSAM). During the past two decades, there has been a steady increase in both the proportion of young teens who are sexually active, and in the number of their premarital sexual partners. 29 Greater Proportion of Adolescent Females Sexually Active, Age of First Intercourse Dropping According to the NSFG study, the percent of females ages 15-19, who reported having engaged in sexual intercourse rose from 47% in 1982 to 53% in 1988.30 As shown in Figure 2, much of the increase can be attributed to increases occurring among white and non-poor teens, thus narrowing racial and Percent Figure 2: Percent of Adolescent Females Ages 15-19 Who Ever Had Sexual Intercourse, By Race/Ethnicity and Poverty Level, 1982 and 1988(1) Reprinted with the permission of The Alan Guttmacher Institute from Jacqueline |