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Journal Issue: Critical Health Issues for Children and Youth Volume 4 Number 3 Winter 1994

Public Policy Implications of HIV/AIDS in Adolescents
Jill F. Blair Karen K. Hein

Characteristics of the HIV Epidemic Among Adolescents

Adolescents Are Not Big Children

The route of HIV infection among children is almost always vertical from an infected mother. HIV-infected young children have a shorter survival time than adolescents on average.3 HIV prevention programs designed to address perinatal infection should be aimed at sexually experienced young men and women, the pool of potential parents. A small but growing proportion of long-term surviving infants infected with HIV are now reaching adolescence. Specific educational and health care services need to be developed to support these young people as they progress from childhood to adolescence.

Adolescents Are Not Small Adults

HIV-infected adolescents differ also from their adult counterparts. A greater proportion of infected teenagers acquire HIV through heterosexual transmission as compared with adults; a higher percentage of teenage patients are asymptomatic, becoming symptomatic with HIV-related illnesses during adulthood; and a higher percentage of infected youth are black or Hispanic as compared with adults. There are also unique legal issues that exist for adolescents regarding consent for HIV testing and treatment, and limited access to treatment, including clinical trials.4 Disclosure of HIV serostatus to partners and parents is particularly difficult for young people as well.5 Finally, there are cognitive differences which affect the acquisition and application of knowledge, information, and skills.6

Health care providers often assume that HIV testing and related services require parental consent, but laws vary from state to state. While every state has laws protecting the confidentiality of medical information, this protection is not necessarily extended to minors. Depending on such circumstances as whether the condition presents imminent danger to the young person or others and the nature of the treatment or services (for example, mental health, drug use, hospitalization), parental involvement may or may not be required. Some states explicitly require notification of parents when an HIV test result is positive for a minor, while others permit notification under other laws related to medical treatment for minors.7

Unique Needs of Adolescents

The World Health Organization estimates that half of the 14 million people in the world who are infected with HIV were infected between the ages of 15 and 24. In the United States, the three largest national studies of youth in the military, college health services, and the Job Corps report overall HIV infection rates of 1/1,000, 2/1,000, and 3/1,000, respectively. The rates vary enormously by region, gender, and ethnic/racial groups. The fastest growing rates of HIV are no longer reported from the large coastal cities known to be hard hit in the early 1980s. Now, mid-Atlantic states are reporting the greatest increase in HIV rates among young women, according to the latest study of female Job Corps students. Studies of youth living in high-risk situations, such as those in a shelter in New York City, report much higher rates, up to 160/1,000 for older adolescent males. In several recent studies, young women are now becoming infected at a faster rate than either young men or adult women. For example, in the most recent report from the Job Corps, female students had HIV rates twice as high as those of their male counterparts. In Asia, where HIV is spreading quickly, teenaged girls ages 15 to 19 are reported to have the highest rates among women. AIDS cases in adolescents are not a good indicator of the extent of HIV infection because most teenagers with HIV have not been tested and because it takes, on average, 10 years for people with HIV to be diagnosed with AIDS.

From a treatment perspective, assessment of individual social, psychological, and physical development is essential before specific treatment plans can be developed. This requires understanding of adolescent development and addressing barriers to care. In addition, the health assessment—including a social and medical history, physical examination, and laboratory evaluation—of teenagers differs from that of young children and adults. Special attention needs to be paid to this age group with respect to the presenting signs and symptoms of HIV-related disease, types of immunization given, the dosage of medications, and the range of normal values for laboratory testing of immune function, anemia, and liver function.8 In summary, there are unique epidemiologic features of the HIV epidemic among youth, in addition to special legal and programmatic requirements for age-appropriate care of adolescents.

Adolescent Risk Behavior

All adolescents in the United States of America are affected by the HIV epidemic, whether infected or not. Virtually all adolescents have heard about AIDS, most now have heard about someone with HIV or AIDS, and an increasing number know of someone with HIV, whether it be a family member, neighbor, friend, adult, or national celebrity.

According to the 1990 Youth Risk Behavior Survey administered by the Centers for Disease Control (CDC) and Prevention,9 the median age of reported first intercourse is 16.1 years for young men and 16.9 years for young women. One-third of the young men and 20% of the young women initiate intercourse before the age of 15. Among 9th- to 12th-graders, 19% report having had four or more sexual partners during their lifetime. Concomitant with these rates of sexual activity are the highest rates of sexually transmitted disease, such as gonorrhea, syphilis, chlamydia, and herpes, of any sexually active age group.10 Each year between 2.5 and 3 million young people become infected with a sexually transmitted disease. Therefore, most adolescents are at risk for acquiring HIV during their teenage years because HIV has now spread to all 50 states and much of the sexual intercourse in which adolescents are engaging is unprotected.

Age-appropriate health education programs for adolescents should be built on the premise that teenagers need to learn and know about their own bodies.11 At the same time, they should develop positive views of sexuality and intimacy in addition to knowing about the unwanted consequences of sexual intercourse, such as sexually transmitted disease or unplanned pregnancy. Practicing new skills and experimenting to learn personal limits are natural parts of this stage of development. The risks associated with normal adolescent development can be managed only through the acquisition of explicit knowledge and the modulation, if not the modification, of one's behavior. So, it is not only the consequences of HIV infection among adolescents that make this topic of particular importance to policymakers, but also the nature of the debate it inspires and the strategies it requires.12

Mixed messages about human sexuality generally, and its relationship to adolescent development specifically, make it difficult for public policymakers to navigate both the complexity and the controversy associated with HIV transmission and adolescent behavior. Whether this epidemic is seen from a health or education perspective, the threat of HIV to adolescents requires an acknowledgment of adolescent sexuality and risk behavior, and impugns the practice of making concessions and compromises to assuage controversy.