Dr. McGuire reconvened the CHAC meeting at 8:32 a.m. on November 14, 2006 and yielded the floor to the first presenter.
Dr. Howell Wechsler, Director of the CDC Division of Adolescent and School Health (DASH), provided an update on CDC’s adolescent sexual and reproductive health activities. Of all high school students in the United States, 47% are sexually experienced. Persons 15-24 years of age account for nearly 50% or 9.1 million of all new STDs acquired each year. Based on data from 33 states with confidential name-based HIV infection reporting systems, an estimated 4,824 HIV cases occur annually among persons 15-24 years of age. Persons 15-19 years of age account for 831,000 of all pregnancies that occur each year.
Recent trends in STD, HIV and teen pregnancies are summarized as follows. Since the early 1990s, the percent of sexually active youth has decreased and the use of condoms and contraception has increased among sexually active youth. Improved screening has led to increased rates of some STDs. Pregnancy rates have decreased overall, but smaller reductions were seen in ethnic/minority youth. Most recent data suggest that rates are not continuing to decrease and have remained level in most states.
Racial/ethnic populations are disproportionately affected by these trends. The rate of sexual intercourse is 68% among AA high school students compared to 51% among Hispanics and 43% among whites. AA adolescents represent 70% of all HIV/AIDS cases among persons 13-19 years of age. Data from 2004 showed that Hispanics accounted for ~83% of teen births compared to 61% among AAs and ~27% among whites. The 47% decline in teen birth rates among AAs was the largest compared to whites and Hispanics.
CDC recently published a paper on the percentage of high school students who ever had sexual intercourse by race/ethnicity from 1991-2005. The data showed a dramatic reduction in AA students who had sexual intercourse through the 1990s, but the decrease has stopped since 2001. The slight reduction in sexual intercourse among Hispanic adolescents was not statistically significant.
DASH, DHAP, DSTDP and the CDC Division of Reproductive Health formed an internal Workgroup on Adolescent Sexual and Reproductive Health (WASRH) which developed a report on CDC activities in this area. The four divisions allocated a total of $77.3 million to conduct 192 different youth projects in three categories: (1) research on adolescent sexual and reproductive health; (2) direct services for HIV, STD and pregnancy prevention; and (3) training, technical assistance and capacity-building programs for adolescent sexual and reproductive health.
For the research category, the four divisions have conducted studies on sexual risk behaviors, pregnancy, STDs and HIV. The projects were designed as observational, surveillance, intervention or primary prevention studies in various units and settings, such as individual, group, family or community units and clinic, community, school or juvenile justice settings. A three-phased activity was conducted to identify, package and disseminate evidence-based interventions. Collaborations were established with national organizations and state teen pregnancy coalitions to assist local groups in selecting, adapting and implementing science-based programs.
For the direct services category, the four divisions provided STD screening and treatment, HIV C&T, training for peer-based education and support, social marketing campaigns, prevention education, behavioral interventions, infrastructure development, surveillance and program evaluation. Funding was awarded to ten CBOs to offer prevention programs to young MSM of color.
Of the populations served across sites, ~50%-80% were <21 years of age. At least 10% of youth were included in 35 state and local health departments that were funded to provide program services. Seven CDC programs targeted or provided services to HIV-infected youth or youth at high risk for HIV, such as MSM, female sex workers, homeless youth and youth in juvenile justice systems. CDC supported comprehensive STD prevention systems through its Infertility Prevention Program, 50 state health departments and seven local health departments.
For the capacity-building assistance category, the four divisions provided information, technical assistance, training and technology for persons and organizations to improve service delivery and effectiveness. These services were targeted to education agencies at state, territorial and local levels, national NGOs, state teen pregnancy coalitions, Title X regional training centers and CBOs. The capacity-building activities were designed for utilization of science-based approaches to promote adolescent reproductive health, consumer outreach, recruitment, training, leadership development and strategic planning.
Dr. Wechsler concluded his update by responding to CHAC’s request during the previous meeting for more information on CDC’s adolescent sexual and reproductive health activities. The Health Education Curriculum Analysis Tool (HECAT) was developed to provide evidence-based guidance to schools on selecting curricula that would most likely be effective in improving the health of young persons. HECAT has been undergoing the HHS clearance process for more than one year.
DASH provided input on a document that was developed by the Office of Population Affairs on a scientific process for abstinence-only grantees to plan abstinence programs with a more rigorous approach. This document has been undergoing the federal clearance process for 1.5 years. Two evidence-based interventions developed by DHAP are still undergoing the HHS clearance process.
Dr. Wechsler also pointed out that materials were distributed to CHAC. One handout described individual projects and funding amounts for 17 national non-governmental organizations that were awarded to support HIV prevention for youth over the next five years. Another handout described additional HIV projects conducted by other grantees. Overall, Dr. Wechsler was pleased that CDC’s current activities are eliminating silos and barriers to streamlining services for young persons.
Dr. Jose Morales, of HRSA, described HRSA’s services for adolescents living with HIV/ AIDS. HRSA is an access agency with programs that are designed to provide care to persons with HIV, ensure the quality of care, include secondary prevention and decrease transmission. Under Title IV of the CARE Act, HRSA implements 17 programs specifically for youth living with HIV/AIDS and provides services to this population on the basis of gender, race/ethnicity and exposure. HRSA’s total budget for the 17 youth programs is ~$4 million. Demographics of clients in Title IV programs are 2% transgender with an equal balance between males and males, 65% AA, 20% Hispanic, 34% with heterosexual contact, 26% MSM, and 24% perinatal.
HRSA’s Title IV programs on sexual and reproductive health for adolescents are guided by the following strategies. Additional morbidity should be limited with annual gynecological tests and PAP smears for young female adolescents. Appropriate routine testing of STDs should be administered to young female adolescents. Mother-to-child transmission should be prevented with ART. Early prenatal care should be available to improve health. ART should be provided to neonates. HRSA’s Title IV programs are required to link to Title X programs and include family planning services through either referrals or onsite pregnancy tests.
HRSA takes several actions to monitor the quality of care of Title IV programs for adolescents. Close communication and coordination are maintained with grantees through regular contact with project officers, compliance site visits and technical assistance. Under the National Quality Center, grantees can use the HIVQUAL method and other quality processes to focus on annual syphilis testing, Pap smears and other testing for other STDs. HRSA’s focus on quality in 2007 will assist providers in improving efforts to obtain Pap tests.
HRSA established several criteria to determine the success of its Title IV programs for youth. Activities should be client-centered to meet the needs of clients from both developmental and geographical perspectives. Interventions should be designed to be client-driven, non-judgmental and caring. Services and systems should be integrated to serve different types of youth, including gay, lesbian, bisexual, transgender, heterosexual and street youth. Referrals should be incorporated into programs to decrease the loss of clients. Collaborative efforts should be undertaken with testing sites to reduce the time between discovery of HIV infection and entry into care.
Peers should be used for case finding, C&T and speaking to youth. Youth should be trained and employed for outreach, education and C&T. Youth should be educated to deliver education in schools and other community settings. Case finding should be performed in high-risk situations and should be consistent in reaching these areas. Multiple strategies should be implemented to reiterate consistent messages. The role of peers should be obvious and identifiable. Appropriate services should be offered to establish trust with potential clients. HRSA is currently funding eight demonstration projects under the SPNS initiative targeting young MSM of color. The projects are focusing on outreach, care and prevention for young HIV-infected men 13-24 years of age. Three key objectives were established for the projects. Innovative outreach strategies would be supported to assist HIV-infected persons learn their status. HIV-infected persons would be linked with primary care services that are appropriate for youth. Transmission of HIV infection would be prevented among target clients. The grantees are now completing the third year of the five-year funding cycle of the young MSM of color initiative and have established a web site with strategies, project summaries and other information to monitor progress and resources.
AETCs are using a variety of tools to educate providers on offering education, training and other services for adolescents living with HIV/AIDS. For example, the Pennsylvania/Mid-Atlantic AETC developed a series of reference tools on case finding, primary and secondary prevention for adolescents, clinical risk assessment and screening. HRSA will continue its close collaborations with CDC to ensure that project officers in the two agencies coordinate prevention, care and treatment efforts with the same grantee. The partnership has served as a valuable mechanism for HRSA and CDC project officers to communicate on a regular basis, share information and maximize resources.
Dr. Morales confirmed that HRSA will continue to develop innovative strategies to address challenges in its Title IV programs for adolescents. The most effective C&T models will be identified to find and retain infected youth in care. Assistance will be provided to transition youth to adult care systems to ensure continuity of care and other services.
Mr. Shepherd Smith, of The Institute for Youth Development, described strategies to incorporate public health principles into HIV/AIDS prevention for youth. The primary predictor of an individual acquiring HIV or another STD is the number of lifetime sexual partners. The age of sexual debut plays a significant role in the number of lifetime sexual partners. Two studies showed tremendous differences between adolescents with sexual debut at <14 years of age versus those with sexual debut at >17 years of age. The risk of acquiring an STD was 30-fold higher and the risk of having >6 sexual partners by 20 years of age was 7.5-fold higher with early sexual debut compared to delayed sexual debut. The results were similar between sexually active males and females.
A study showed that the median age at sexual debut was 14.5 years among HIV-positive females compared to 15.5 years among HIV-negative females. The median number of lifetime partners, acquisition of any STD and rates of unprotected vaginal sex were higher in HIV-positive females, but regular condom usage was the same between the two groups.
A study showed that forced or unwanted sex among female teens was higher at earlier ages. A study was conducted with students in grades 9-12 who reported having >4 sexual partners during their lifetime. The findings showed that this population is at highest risk, but have the lowest usage of condoms on a regular basis. By race/ethnicity and gender, young AA males were found to be at highest risk compared to Hispanics, whites and females.
Findings from all of these studies emphasize the need to better articulate the benefits of delayed sexual debut and a reduction in sexual partners. Activities targeted to youth do not clearly communicate the following messages: “more risk with more sexual partners;” “less risk with fewer sexual partners,” and “virtually no risk with one lifetime uninfected partner.” Youth programs also do not specifically target messages to young males about forced or unwanted sex with females.
Several factors have a positive influence on youth. Data show that parents, particularly those with high monitoring of their children, are the primary influence on delayed sexual debut. Youth who eat dinner with their parents >5 times per week are less likely to use alcohol, tobacco or marijuana compared to youth who infrequently eat dinner with parents 0-2 times per week. Shared family meals facilitate accountability, bonding and communication. Youth who develop refusal skills regarding sexual activity are less likely to attempt suicide or engage in other risky behaviors.
A study showed that youth were extremely challenged by achieving perfect use of contraception because the subjects chose intimacy rather than correct usage. In a study with males who were taught about condom use during college, 60% did not discuss condom use with partners before sex; 43% put condoms on after starting sex; 42% wanted to use condoms, but had none available; 40% did not leave space at the tip of the penis; 32% lost erections in association with condom use; 30% placed the condom on upside down; and 15% removed the condom before ending sex.
Mr. Smith pointed out that several conclusions can be reached based on data from the youth studies. One lifetime partner should be a universal goal and mentioned often in HIV prevention messages. Emphasis should be placed on limiting the number of partners. All youth should be encouraged to delay sexual debut. More attention and resources should be directed toward gay, AA and Hispanic youth. Specific programs should be developed to reduce the number of partners in these populations.
More education should be provided to parents about their responsibility to the sexual health of their children. More support should be offered to after-school programs. NCHHSTP should closely collaborate with DASH to develop more youth programs. For example, DASH has developed strong relationships with numerous youth-serving organizations, while NCHHSTP has the science base and expertise in HIV/AIDS and STDs. DASH’s organizational network and NCHHSTP’s knowledge should be combined to jointly provide HIV and STD education to adolescents.
Dr. David Wiley, Professor of Health Education at Texas State University, described several efforts schools can undertake to end the conspiracy of silence regarding HIV and STD prevention and treatment for youth. Data were collected and evaluated on the characteristics of effective curriculum-based programs. The focus on behavior should be specific and narrow, such as delaying sex or using condoms. Theoretical approaches with demonstrated efficacy in influencing other risky health-related behaviors should be replicated.
Clear messages should be communicated about sex and protection against STDs or pregnancy. Basic rather than detailed information should be provided. Peer pressure should be addressed. Communication skills should be taught. Interactive activities should be incorporated. The age, sexual experience and culture of young persons in the program should be reflected. Programs should last at least >14 hours. Leaders should be carefully selected and trained.
In terms of laws for sexuality and STD/HIV education in U.S. schools, the District of Columbia and 19 states require sexuality education, while 32 states do not have this requirement. The District of Columbia and 36 states require STD and HIV/AIDS education, while 15 states do not have this requirement. The content of these requirements varies among states, such as a full-fledged curriculum approved by the state, local rather than state control of the law, guest presenters speaking to a class, or distribution of materials to students. Title V grantees must adhere to eight federal mandates of an abstinence educational or motivational program.
Federal funding for abstinence-only sexuality education progressively increased over the years with Texas serving as the largest recipient in 2005. Texas has no approved curriculum for sexuality education, but a textbook was developed for this purpose. However, the textbook does not mention contraception and uses “scare tactics” about the possibility of being prosecuted for rape or sex with a minor.
Texas spends >$9 billion each year to address teen pregnancies and the consequences of unintended births. In 2004 alone, these costs included $165 million for public health care, $83 million for child welfare, $161 for incarceration of youth of teen mothers, and $349 million for lost tax revenues. Taxpayers in Texas spent $15.1 billion to support >745,000 teen births between 1991-2004.
Dr. Wiley encouraged all states to consider available options to improve HIV and STD prevention and treatment programs for youth. For example, existing state mandates should be reviewed to determine if federal funding can be more flexible to discuss all sexual options with youth.
The Florida, Kansas and South Carolina Departments of Education convene “Finding Common Ground Summits” with supplemental abstinence funding from CDC. Staff from abstinence-only, planned parenthood, comprehensive and family programs attend the summits in an effort to identify areas where agreement can be reached at the local level, such as sharing resources at health fairs and presenting packets of materials to school districts from all programs.
Cadre members are trained and team-building activities are conducted to develop more effective youth programs. Action planning summits are held six months later and activities are followed at the state level. The summits have been extremely successful in convening staff from various programs with diverse perspectives to communicate, collaborate and cooperate in HIV and STD prevention and treatment programs for youth. Efforts are underway to replicate the summits in more states. HECAT provides evidence-based guidance to schools on designing, selecting and evaluating appropriate curricula for youth. However, HECAT is still undergoing the HHS clearance process and cannot be distributed to schools at this time. CHAC should make a strong recommendation to the HHS Secretary to expedite the clearance process for immediate dissemination of HECAT to schools.
A stronger focus should be placed on developing and distributing culturally-appropriate materials to underserved populations, particularly AA and Hispanic youth. School board members, administrators and teachers should be trained and informed about solid data that show linkages between student health outcomes and academic achievement. Assistance should be provided to schools on developing policies for HIV, human sexuality education and testing. Schools should be supported with advocacy and skills on managing controversies related to HIV and STD prevention and treatment programs for youth.
Several CHAC members made suggestions for CDC and HRSA to consider in refining national strategies to prevent and treat HIV and STD infection in youth.
- More emphasis should be placed on involuntary sexual debut through force, domestic violence or other types of abuse in the home. Appropriate messages on this issue should be developed and delivered beginning at the first-grade level.
- A clear distinction should be made between “functional” and “dysfunctional” families. For example, youth who eat dinner with their parents >5 times per week could be just as likely to engage in risky behaviors as those who share meals with their parents on a more infrequent basis.
- Stronger efforts should be made to engage the media in youth initiatives because the vast majority of advertisements and entertainment programs promote sex.
- Parents should be educated about the critical importance of serving as
true role models. For example, adolescents will be less likely to follow
parental advice if parents have multiple sex partners, give birth to
children out of wedlock, and engage in the same risky behaviors as youth.
- HRSA should include pregnancy prevention and hepatitis B and HPV
vaccination in its strategies to limit additional morbidity of STDs among
- HRSA should reconsider its focus on annual syphilis testing because this infection has a larger impact on older adults than youth. Emphasis should be placed on the ongoing chlamydia epidemic because this infection primarily affects persons <20 years of age.
- Copies of articles should be distributed and references should be provided for studies that are used to support youth programs. Inaccurate data will continue to serve as a barrier to effective implementation of HIV and STD prevention and treatment initiatives for youth. For example, a study cited in one of the panel presentations on infection rates with HIV prevention tools was flawed in several areas. The study showed that condoms resulted in an 80% infection rate of HIV after a decade of use. However, no data from any other source have shown that condoms led to even an 8% infection rate per year. Oral acyclovir and vaccines were described as HIV prevention tools in the study, but no data have been published in this area. The study referred to a decade of female condom use, but efficacy data have not been collected in this area for the past ten years. No solid data were provided to support the statement that 75% of persons were infected after a decade of life with no knowledge of the population or discordant couples.
- More emphasis should be placed on reaching high-risk youth in the non-general population. For example, curriculum- or school-based programs would not be effective for AA and Hispanic youth, high school dropouts, homeless youth with no family foundation or youth sex workers.
- Innovative strategies should be developed to reach youth who use the Internet for sex. For example, HIV prevention and other health education materials could be developed and posted on the “My Space” web site, chat rooms and other Internet tools used by youth.