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Special Report: Youth & HIV Risk
Minority MSM population key part of growing epidemic in teens
New biomedical prevention is needed
HIV clinicians are seeing growing numbers of teenagers and adults under age 25 among new HIV infection cases. It's a phenomenon that has researchers and public health officials scrambling to develop biomedical HIV prevention interventions specifically for youth.
The latest data from the Centers for Disease Control and Prevention (CDC) suggest that more than a third of all new HIV infections in the United States are among youth, 13-29 years old, and it's concentrated among young men who have sex with men (MSM) and young minorities.1-3
"It's really the young MSM population that has 200% to 300% increases in HIV infection," says Craig M. Wilson, MD, professor and chair of the Adolescent Medicine Trials Network at the University of Alabama at Birmingham in Birmingham, AL.
International surveillance data suggest that more than 40% of all new HIV infections are among people under the age of 25.4
"The bigger issue is you're setting the risk factors at that stage for what would become infections in early adulthood," Wilson says. "So prevention strategies have to get to young people much earlier than they have."
Also, surveillance data show a shift in who is becoming infected. Around the turn of the 21st century, the epidemic had been shifting toward minority females in the Southern United States, he notes.
"Since that time, it's shifted away from that group," Wilson explains. "The numbers now are continuously growing in young MSM, particularly minorities, and that's what we see in all of our clinics."
HIV clinics now see that three out of four new HIV patients who are adolescents are MSM of color in the 17 to 20 year-old age group, Wilson says.
"Young women were coming in to be screened during pregnancy, but as the nation's teenage pregnancy rate is coming down, those numbers are going down," he adds. "And it's not just that those numbers have gone down, it's that MSM numbers have gone up."
Young MSM of color are at an incredibly high risk of contracting HIV, and HIV clinics are seeing more of this population, says Sybil Hosek, PhD, a clinical psychologist and HIV researcher for the John Stroger Hospital of Cook County in Chicago, IL.
The problem is that clinical trial data on treating adolescents are scarce.
"Essentially, we're excluding young people from important biomedical trials," says Ralph DiClemente, PhD, a professor of public health at the Rollins School of Public Health, Emory University in Atlanta, GA.
"Much of the data we have are only on adults," he adds. "Extrapolating those findings to young people will be pretty dangerous."
Data low, risk high
Without including youths in clinical trials and studies of prevention interventions, the HIV medical community places them at risk.
"Young people engage in sex, use drugs, drive while drinking, and do a lot of risky behaviors," DiClemente says. "So clearly the impetus here is we don't want to exclude the young people from participating in trials that could be a benefit to them personally or to all adolescents."
DiClemente's recent research showed that it's possible to enroll young people in clinical trials, although numerous barriers exist.5
A very significant barrier is adolescents' lack of understanding about clinical research and randomization. And, parents of minors might decline their participation in trials due to their own lack of understanding or because they distrust investigators and fear the risks are greater than stated.5
Also, HIV biomedical prevention trials might not be "adolescent friendly," particularly in the common belief that adolescents are less likely to be adherent to treatment or the intervention.5
One strategy for overcoming the barriers is for investigators to inform the community about the study well before the trial begins, DiClemente says.
"Get community input," he advises. "People will have questions, and it's only fair we address those questions forthright, being transparent as to what our purposes are and describing risks, as well as benefits."
Researchers could hold town hall meetings, engage focus groups, and then return to discuss additional information with their constituents, he says.
"For our focus groups we ran groups in hotels and restaurants and provided lunches and dinners," DiClemente says. "We wanted to make people understand how we valued their participation and their input, and we'd treat them as valued guests at our meetings."
"A lot of the front-end work doesn't sound glamorous, but it's really critical to doing clinical research in communities," he adds.
In Hosek's PrEP research, enrollment of young MSM of color, ages 18 to 22, has gone better than expected, she says.
"We have youths who are willing and ready to engage," Hosek says.
Investigators felt it was ethically necessary to provide more HIV education than they might for a typical HIV adult trial, so they implemented the CDC's evidence-based prevention intervention called Many Men Many Voices. It was designed for MSM of color, she explains.
"We wondered if they would want to do this program, and we found they are loving it," Hosek says. "We haven't lost anyone enrolled in the trial."
Perhaps another reason for the trial's enrollment and retention success is that researchers have invested more time in this study cohort than they might in a typical adult HIV trial.
Recruiters and case managers visited the target population in clubs, dances, and other social venues. They call them for regular phone contact, communicate via the Internet, and speak with recruits between study visits, Hosek explains.
The study visits occur each month instead of the typical three month or six month intervals, and the nurse practitioners who work with the youths are experienced in working with adolescents, she adds.
No magic bullet
The research work being done now could be crucial to turning the epidemic around, but it won't be simple.
"Everyone has to get used to the fact that there won't be a magic bullet here," Wilson says.
"We need a multi-prong, multifunctional, and different approach for different populations," he says. "We're waiting for the first biological, a microbicide or rectal microbicide for MSM."
Soon, there might be some positive news in this arena among the pre-exposure prophylaxis (PrEP) trials.
"There are a number of PrEP trials going on right now, including one we have," Wilson says. "Ours is an acceptability adaptation trial, a small study that targets a young population."
Hosek also is involved in an ongoing PrEP feasibility trial in which she and co-investigators are looking at whether this approach will work for young people, mostly young MSM of color.
Results from the first PrEP studies might be available by the end of 2010, Hosek says.
"It's very, very exciting," Hosek says. "Most of us are assuming there will be some level of efficacy."
The search for effective biological or behavioral HIV prevention strategies might be especially pertinent now. A recent study shows that the percentage of students who were taught about HIV/AIDS in school decreased from 1997 to 2009 from 91.5% to 87%.6
The 2009 youth risk behavior surveillance data, conducted by the National Center for Chronic Disease Prevention and Health Promotion, show that adolescents continue to engage in risk behaviors with 34.2% of high school students nationwide reporting that they are currently sexually active, and 38.9% of these students had not used a condom during their last sexual intercourse.6
The high school student survey also found that 12.7% of students had been tested for HIV, not including blood donation tests.6
Researchers need to study HIV in youths separately from adult studies because adolescence is a distinct developmental period, Hosek says.
"They're not just miniature adults," she explains. "The way HIV intervention messages are crafted and implemented need to be developmentally specific, so you can't just have an adult trial and let it roll out to youth."