Don’t count on HIV+ youths to stop their risky behavior

Youths take more chances than do adults

HIV-infected youths are twice as likely to engage in risky behaviors, including unsafe sex and sharing needles, as HIV-infected adults, a new study shows.1

The study offers sobering evidence that young people who know they have HIV often put their sexual partners at risk of infection because they fail to use condoms or avoid high-risk behaviors. Researchers did not address whether the higher risky behavior rate was due to a lack of education, apathy, or other factors.

"In the study, you could infer that some of the risky behavior might be related to drug use, for instance, or psychiatric disorders, or so forth," says Catherine Diamond, MD, MPH, assistant clinical professor at the University of California Irvine Medical Center in Orange. Diamond was a co-author of the study.

The study also challenges and deflates a mainstream assumption that people who have HIV are cautious about how and with whom they have sex.

Published in the American Journal of Public Health in January, the study defined youths as people who were 21 or younger when first diagnosed with HIV and 24 or younger when the project began. Adults were those who were infected at 22 years or older or who were 25 years or older at study entry. Researchers analyzed data collected between January 1990 and February 1998 by the Seattle-King County Adult/Adolescent Spectrum of HIV-Related Diseases Study.

Researchers defined risky behaviors as documented behaviors that occurred after the first HIV diagnosis, including unprotected anal, genital, or oral sex; exchange of sex for drugs or money; needle-sharing without bleach; new onset of sexually transmitted diseases (STDs); and new pregnancy in women, says Susan Buskin, PhD, MPH, an epidemiologist with Public Health - Seattle & King County in Seattle. Buskin also was a co-author of the study.

"We’ve been looking at this issue for quite a while," Buskin says. "We see STDs occurring among people with HIV, and we’re concerned that people at risk for acquiring HIV and those with HIV need to be addressed through prevention messages."

Buskin’s and Diamond’s study reinforces how important it is that prevention efforts focus on people who are HIV-positive, says Rosemary Ryan, PhD, principal investigator of Project SHAPE and a research associate professor at the University of Washington School of Social Work in Seattle.

"One of the major headlines in all this [research] is that for a number of years we have done prevention and care services separately, and there has been an assumption that if people are positive, they’re not sexually active anymore, and so they’re safe — and that’s not true," Ryan says.

HIV-positive men aren’t discussing sexuality

"Project SHAPE is specifically targeted to HIV-positive men, and one of the things we found in the pilot work is that HIV-positive men didn’t talk about their sexuality with anybody, including their health care providers," Ryan says. "The bottom line is, we’re not doing a good job with HIV-positive individuals."

Prevention programs typically are targeted toward HIV-negative people. Once a person becomes HIV-positive, the prevention efforts stop and HIV health care begins, she adds. (See story on Project SHAPE, p. 32.)

The fact that young people are becoming infected and then engaging in risky behaviors is not new, says Audie Lemke, MSW, director of the HIV/AIDS Project Development and Evalu a tion Unit of the School of Social Work at the University of Washington in Seattle. Lemke heads the Positive Power project, which targets HIV-infected gay and bisexual men in an effort to reduce the risk of further transmission.

"It’s always been the young people who’ve been infected and have higher rates of gonorrhea and STDs because they are more sexually active," Lemke says. "We do find that younger men are more likely not to use condoms for anal sex."

Lemke conducted a survey that asked HIV-positive gay and bisexual men whether they have had unprotected anal sex within the past two months and why they did it. The survey gave them 25 choices that included such answers as "I wanted to die," "I wanted to infect my partner," and "I was too drunk."

"I was too drunk’ was the most common answer given," Lemke says.

The study found that 28% of young men engaged in risky behavior, compared with 16% of adult men. About two-thirds of both the young and adult men had become infected through having sex with men. Among young women, 66% engaged in risky behavior, compared with 46% of adult women. Part of the difference in data between men and women was because pregnancy was a risk factor for women, Buskin says.

"That might have overestimated risky behaviors," she says.

Among young HIV-infected women, 36% had become pregnant; among adult HIV-positive women, 19% had become pregnant.

Another factor contributing to the higher risky behavior rate among women is that women often have regular pelvic exams and their STDs are diagnosed more readily than are men’s STDs, Diamond says. "This gives them an increased amount of evidence of risk."

Also, the study showed that unsafe homosexual sex among the young men and unsafe heterosexual sex among the young women were the biggest risk behaviors exhibited by the two groups.

Some of the study’s other findings were:

• Among youths, the median age for HIV diagnosis was 20 years.

• Among adults, the median age for HIV diagnosis was 32 years.

• CD4 cell counts at study entry were higher among youths than adults.

• Youths visited outpatient centers less frequently than adults did.

• About 48% of the youths had a psychiatric disorder of anxiety, depression, or psychosis; 56% of the adults had a psychiatric disorder.

• Youths were more likely to use illegal drugs.

Naturally, there should be more of an emphasis put on prevention programs that target youths, as well as those targeting all gay and bisexual men, Lemke says.

Full funding vs. spreading money around

Federal, state, and local governments should focus on fully funding a few proven prevention programs rather than spreading a little money around to a lot of different prevention approaches, Lemke suggests.

"When I submit a proposal for $380,000 and it has all these different components in it and then I end up with half of that amount, the [government] is not really getting the program that I wrote because I have to go back and cut and whack items," he explains. "So you end up with something that isn’t what they thought they were getting."

Prevention programs take a variety of different forms. For instance, the Positive Power project targets at-risk and HIV-infected men who have sex with men through a holistic approach.

"It’s focused on where are you today and where do you want to be tomorrow in relationships with others, in sexual relationships, with risk and non-risk behavior," Lemke says. "What kind of behavior are you engaging in, and do you want to change it, and if not, what will reduce the likelihood that you’ll infect someone else?"

Prevention program targets gay media

With a small marketing budget, the project puts advertisements in gay and non-mainstream publications and produces a Web site (www. positivepower.org). The project also sends posters to physicians and other health care providers in King County.

Other prevention efforts in the Seattle area include the following:

• The Young Men’s Survey, conducted by Public Health - Seattle and King County along with the Centers for Disease Control and Prevention in Atlanta, is a multisite HIV prevalence and risk behavior survey of young gay and bisexual men. The project conducts a comprehensive survey of young men’s sexual and drug behaviors and provides them with counseling and referrals to social and health services.

• YouthCare, an organization for youths who are infected with HIV or at risk for HIV, focuses on serving runaway, homeless, gay, and other youths. The organization provides HIV testing, prevention services, and peer involvement.

• Project Action has established vending machines with condoms at youth-oriented sites, including community centers. The machines are placed in restrooms, and the condoms cost 25 cents. Project Action also has sponsored a media campaign that promotes condom use.

Unfortunately, Diamond says, not enough prevention efforts are targeted to women who have HIV.

"Women need more individualized counseling," Diamond says. "And I think it’s important to address other issues like substance abuse or mental illness that might cause women to engage in risky behaviors."

Physicians could address these issues and educate the women, or they could refer women to a prevention counseling service that does so, she suggests. "We need to address this more as a public health issue and say we’re going to make this a part of routine care. Just like the HIV-infected person sees a nutritionist or sees a physician, they’ll also see someone who will counsel them on their risky behaviors."

Reference

1. Diamond C, Buskin S. Continued risky behavior in HIV-infected youth. Am J Publ Health 2000; 90:115-118.