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Selected Behaviors That Increase Risk for HIV Infection, Other Sexually Transmitted Diseases, and Unintended Pregnancy Among High School Students -- United States, 1991

Since the 1970s, sexual activity has increased among adolescents in the United States (1); at the same time, rates of sexually transmitted diseases (STDs) (1), unintended pregnancy (2), and -- beginning in the 1980s -- human immunodeficiency virus (HIV) infection (3,4) also have increased among adolescents. This report presents 1991 self-reported data from students in grades 9-12 about behaviors that can result in HIV infection, other STDs, or unintended pregnancy.

Data were collected from two school-based components of CDC's Youth Risk Behavior Surveillance System (5): 1) state and local Youth Risk Behavior Surveys (YRBSs) conducted by departments of education in 23 states * and 10 cities during April-May 1991 and 2) the national YRBS conducted during the same period. The 33 state and local sites drew probability samples from well-defined sampling frames of schools and students in grades 9-12. Seventeen sites had adequate school- and student-response rates to allow computation of weighted results of known precision; 16 sites had overall response rates below 60% or unavailable documentation, which precluded making estimates of known precision. The national survey used a three-stage sample design to obtain a sample of 12,272 students representative of students in grades 9-12 in the 50 states and the District of Columbia.

For the state and local surveys, school-response rates ranged from 48% to 100%; student-response rates ranged from 44% to 96% (6); and state and local sample sizes ranged from 369 to 5834 students. The grades and sex of students were distributed evenly for most samples, but the racial/ethnic characteristics of the samples varied. For the national survey, the school-response rate was 75% and the student-response rate was 90%. Risk behaviors addressed in the survey included having sexual intercourse, having sexual intercourse with multiple sex partners, injecting-drug use (IDU) **, not practicing contraception, and not using condoms.

Of students participating in the state and local surveys, 33%- 79% (median: 55%; national prevalence: 54%) reported ever having had sexual intercourse (Table 1); 54%-78% (median: 70%; national prevalence: 69%) reported being currently sexually active (i.e., having had sexual intercourse during the 3 months preceding the survey); and 8%-46% (median: 20%; national prevalence: 19%) reported having had sexual intercourse with four or more partners during their lifetime. In 27 of 28 sites, male students were more likely than female students to report ever having had sexual intercourse and having had four or more sex partners during their lifetime while, in 26 of 28 sites, female students were more likely than male students to report being currently sexually active.

Among the state and local surveys, the percentage of students who reported IDU ranged from 1% to 4% (median: 2%; national prevalence: 2%) (Table 1). In all sites, 5% or less of male and female students reported IDU.

Among students participating in the state and local surveys who reported current sexual activity, 58%-87% (median: 77%; national prevalence: 82%) reported they or their partner used contraception*** at last sexual intercourse and 28%-53% (median: 48%; national prevalence: 46%) reported they or their partner had used a condom at last sexual intercourse (Table 2). In all sites, male and female students reported similar rates of contraceptive use.

Reported by: J Moore, EdD, Alabama State Dept of Education. J Campana, MA, San Diego Unified School District; M Lam, MSW, San Francisco Unified School District. D Sandau-Christopher, State of Colorado Dept of Education. J Sadler, MPH, District of Columbia Public Schools. D Scalise, MS, School Board of Broward County; N Gay, MSW, School Board of Dade County, Florida. R Stalvey, MS, Georgia Dept of Education. J Schroeder, Hawaii Dept of Education. J Pelton, PhD, Idaho Dept of Education. B Johnson Biehr, MS, Chicago Public Schools. J Harris, MEd, Iowa Dept of Education. N Strunk, MS, Boston Public Schools. R Chiotti, Montana Office of Public Instruction. J Owens-Nausler, PhD, Nebraska Dept of Education. B Grenert, MEd, New Hampshire State Dept of Education. D Chioda, MS, Jersey City Board of Education; D Cole, MEd, New Jersey State Dept of Education. K Meurer, MS, New Mexico State Dept of Education. G Abelson, CSW, New York City Board of Education; A Sheffield, MPH, New York State Education Dept. P Ruzicka, PhD, Oregon Dept of Education. C Balsley, EdD, School District of Philadelphia; M Sutter, PhD, Pennsylvania Dept of Education. M del Pilar Cherneco, MPH, Puerto Rico Dept of Education. J Fraser, EdD, South Carolina State Dept of Education. M Carr, MS, South Dakota Dept of Education and Cultural Affairs. E Word, MA, Tennessee State Dept of Education. P Simpson, PhD, Dallas Independent School District. L Lacy, MS, Utah State Office of Education. S Tye, PhD, Government of the Virgin Islands Dept of Education. B Nehls-Lowe, MPH, Wisconsin Dept of Public Instruction. B Anderson, Wyoming Dept of Education. Div of Epidemiology and Prevention Research; National Institute on Drug Abuse; Substance Abuse and Mental Health Services Administration. Div of Adolescent and School Health, and Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report and in previous studies (7,8) indicate that a substantial proportion of students throughout the United States engage in behaviors that simultaneously place them at risk for HIV infection, other STDs, and unintended pregnancy. The only completely effective means of preventing unintended pregnancy and STDs is to refrain from sexual intercourse. For persons who are sexually active, the risk for unintended pregnancy can be decreased by the correct and consistent use of condoms or other contraceptives. The risk for STDs, including HIV, can be decreased by correctly and consistently using condoms, maintaining a monogamous sexual relationship with an uninfected partner, reducing the number of sex partners, and avoiding IDU.

The findings in this report can be used to plan and evaluate national, state, and local progress toward achieving national health objectives for the year 2000. Objectives 5.4, 18.3, and 19.9 are to reduce the proportion of adolescents who have engaged in sexual intercourse to 15% or less by age 15 years and to 40% or less by age 17 years (9). Only two sites have met the 40% objective for students in grades 9-12. Objective 5.5 is to increase the proportion of adolescents aged less than or equal to 17 years who have had sexual intercourse but have abstained from such activity for the previous 3 months to at least 40%; only two sites have met this objective. Objective 5.6 is to increase the proportion of sexually active, unmarried persons aged less than or equal to 19 years who use contraception to at least 90%; no site met this objective. Objectives 18.4 and 19.10 are to increase the use of condoms during last sexual intercourse among sexually active, unmarried females and males aged 15-19 years to 60% and 75%, respectively; no site met these objectives.

Nationwide, HIV education is required by 78% of districts for students in grades 6-8 and 47% of districts for students in grades 9-12 (10). Special efforts must be directed toward providing programs for students in grades 9-12 who are at greatest risk for HIV infection. CDC has been providing fiscal and technical assistance to all state education agencies, 16 local education agencies in cities with the highest number of AIDS cases, and 23 national organizations to make available effective HIV education programs for youth. These programs are intended to help adolescents develop skills they will need to remain sexually abstinent and to increase the use of contraceptives, including condoms, among youth who do not refrain from having sexual intercourse.


  1. CDC. Premarital sexual experience among adolescent women -- United States, 1970-1988. MMWR 1991;39:929-32.

  2. Hayes CD, ed. Risking the future: adolescent sexuality, pregnancy, and childbearing. Vol 1. Washington, DC: National Academy Press, 1987.

  3. CDC. AIDS and human immunodeficiency virus infection in the United States: 1988 update. MMWR 1989;38(no. S-4):1.

  4. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, October 1992.

  5. Kolbe LJ. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Education 1990;21:44-8.

  6. CDC. Participation in school physical education and selected dietary patterns among high school students -- United States, 1991. MMWR 1992;41:597-601,607.

  7. CDC. Sexual behavior among high school students -- United States, 1990. MMWR 1992;40:885-8.

  8. CDC. Selected behaviors that increase risk for HIV infection among high school students -- United States, 1990. MMWR 1992;41:231,237-40.

  9. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  10. Holtzman D, Greene BZ, Ingraham GC, Daily LA, Demchuk DG, Kolbe LJ. HIV education and health education in the United States: a national survey of local school district policies and practices. J Sch Health 1992;62:421-7.

    • The District of Columbia, Puerto Rico, and the Virgin Islands are categorized as states for funding purposes. ** Students were classified as injecting-drug users only if they 1) reported such behavior that was not prescribed by a physician and 2) answered affirmatively to any of these questions: "During your life, how many times have you used any form of cocaine including powder, crack, or freebase?"; "During your life, how many times have you used any other type of illegal drug such as LSD, PCP, ecstacy, mushrooms, speed, ice, heroin, or pills without a doctor's prescription?"; or "During your life, how many times have you taken steroid pills or shots without a doctor's prescription?" *** Contraceptive methods included birth control pills, condoms, withdrawal, or some other reported method.

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