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HIV Testing Among High School Students --- United States, 2007
In the United States, an estimated 1.1 million persons were living with human immunodeficiency virus (HIV) infection in 2006, of whom an estimated 232,700 were undiagnosed and unaware they were HIV infected (1). Adolescents and young adults aged 13--24 years represented 4.4% of the total but disproportionately comprised an estimated 9.9% of the undiagnosed cases (1). Early diagnosis of HIV infection facilitates medical interventions and enables infected persons to reduce high-risk behavior and the likelihood of further HIV transmission. To determine the extent to which adolescents are being tested for HIV, data from the 2007 Youth Risk Behavior Survey (YRBS) (the most recent data available) were analyzed. The results indicated that nationwide, 12.9% of all high school students had ever been tested for HIV. The prevalence of HIV testing increased with increasing grade and decreased with increasing age at first sexual intercourse. Prevalence of HIV testing was higher among female students (14.8%) than male students (11.1%), higher among non-Hispanic black students (22.4%) than Hispanic (12.7%) and non-Hispanic white students (10.7%), was higher among students who had ever had sexual intercourse (22.3%) than those who had never had sexual intercourse (4.0%), and among students who had ever had sexual intercourse. To decrease the number of undiagnosed HIV infections among adolescents and promote HIV prevention, CDC recommends that health-care providers offer HIV screening as part of routine medical care. High schools can support those screening efforts by including information on obtaining HIV testing in their HIV curricula.
YRBS, a component of CDC's Youth Risk Behavior Surveillance System,* estimates the prevalence of health risk behaviors among high school students through biennial national, state, and local surveys. The 2007 national survey obtained cross-sectional data representative of public- and private-school students in grades 9--12 in the 50 states and the District of Columbia. Students completed an anonymous, self-administered questionnaire that included a question about HIV testing.† Students from 157 schools completed 14,103 questionnaires. The school response rate was 81%, the student response rate was 84%, and the overall response rate was 68%.§ After quality control measures, data from 14,041 students were available for analysis; 12,120 (86.3%) students answered the HIV testing question. A more detailed description of YRBS methods has been published (2).
For this analysis, data were weighted to adjust for nonresponse and oversampling of black and Hispanic students. Analyses were conducted on weighted data using statistical software to account for the complex sample design (2). T-tests were used to determine statistically significant differences in HIV testing by sex, race/ethnicity, whether students had been taught in school about acquired immunodeficiency syndrome (AIDS) or HIV infection,¶ and whether students had ever had sexual intercourse.** The Cochran-Mantel-Haenszel trend test was used to determine statistically significant differences in HIV testing by grade and age when students had first sexual intercourse.†† Race/ethnicity data are presented only for non-Hispanic black, non-Hispanic white, and Hispanic students (who might be of any race).
The analysis showed that, nationwide, 12.9% of students had ever been tested for HIV (excluding tests for blood donation) (Table 1). Overall, the prevalence of HIV testing was higher among female students (14.8%) than male students (11.1%; p<0.001), higher among non-Hispanic black students (22.4%) than Hispanic students (12.7%; p<0.001) and non-Hispanic white students (10.7%; p<0.001), and increased by grade from 9.1% among 9th-grade students to 18.9% among 12th-grade students (p<0.001). HIV testing also was more common among students who had ever been taught in school about AIDS or HIV infection (13.2%) than among those who had not (9.7%; p<0.001), and higher among students who ever had sexual intercourse (22.3%) than among students who had not (4.0%; p<0.001). Among students who had ever had sexual intercourse, the prevalence of HIV testing decreased by age at first sexual intercourse, from 30.7% among students who first had sexual intercourse before age 13 years to 12.6% among students who first had sexual intercourse at age 17 years or older (p<0.001). The prevalence of HIV testing increased with increasing grade among non-Hispanic white female students (p<0.001), non-Hispanic black female students (p<0.001), Hispanic female students (p=0.02), and non-Hispanic black male students (p=0.002) (Table 2). Among students who ever had sexual intercourse, the prevalence of HIV testing increased with increasing grade among non-Hispanic white female students (p=0.02), non-Hispanic black female students (p=0.003), Hispanic female students (p=0.01), and non-Hispanic black male students (p=0.002). The prevalence of HIV testing was highest among 12th-grade non-Hispanic black students who had ever had sexual intercourse; 49.4% of female and 33.4% of male students in this group had been tested for HIV.
Reported by: A Voetsch, PhD, A Balaji, PhD, J Heffelfinger, MD, K Miller, PhD, B Branson, MD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; D Eaton, PhD, L Kann, PhD, Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note:
At the end of 2006, an estimated 48% of adolescents and young adults infected with HIV were unaware of their infection (1), representing missed opportunities for diagnosis, treatment, and reduction in the number of new HIV transmissions. The findings from this analysis indicate that in 2007, 12.9% of high school students overall and 22.3% of students who ever had sexual intercourse had been tested for HIV. These results are similar to those of the 2000 National Survey of Teens on HIV/AIDS that determined that 10% of adolescents overall and 27% of sexually active adolescents aged 15--17 years reported ever being tested for HIV (3).§§ The results for non-Hispanic black students are especially relevant, because, as of 2007, non-Hispanic blacks accounted for 72% of HIV diagnoses among adolescents aged 13--19 years (4). This analysis indicated that non-Hispanic black students had the highest overall race/ethnicity-specific percentage of students tested (22%), and among all students who had sexual intercourse, non-Hispanic black students in 12th grade had the highest testing prevalence. These findings suggest that, with respect to race/ethnicity, students with the highest group risk are getting tested at higher rates.
Visits to health-care providers are opportunities for HIV testing. Data collected during 1994--1996 for the National Longitudinal Study of Adolescent Health reveal that two thirds of adolescents aged 15--17 years had a physical examination in the preceding 12 months (5). In the 2000 National Survey of Teens, two thirds of the adolescents who reported being tested for HIV had asked to be tested, and most had been tested in health-care settings, including general health clinics (50%), private physician offices (31%), and HIV clinics (9%) (3).
In 2006, CDC recommended routine HIV screening for all patients aged 13--64 years (6). Certain persons at high risk for HIV should be tested at least annually: 1) injection-drug users and their sex partners, 2) persons who exchange sex for money or drugs, 3) sex partners of HIV-infected persons, and 4) men who have sex with men or heterosexual persons who have had more than one sex partner since their most recent HIV test or whose sex partners have had more than one sex partner since their most recent HIV test. In addition, all patients seeking treatment for STDs and those attending STD clinics should be screened routinely for HIV during each visit for a new health concern, regardless of known or suspected risk behaviors for HIV infection.
The Society for Adolescent Medicine recommends offering testing and effective risk-reduction counseling and assistance as part of routine care of sexually active adolescents, especially those who live in high HIV prevalence areas (7). The American College of Obstetricians and Gynecologists also recommends HIV screening for sexually active women aged <19 years (8). Although the results of this report show that the prevalence of HIV testing was higher among female than male students and increased with increasing grade, 73% of female students who had sexual intercourse had never been tested for HIV.
Routine HIV screening in health-care settings, as recommended, could increase the proportion of adolescents who are tested for HIV among those who receive medical care. Adolescents who have had sexual intercourse or are considering having sexual intercourse should know their HIV status and the HIV status of their sex partners (6). Previously published YRBS data for 2007 showed that 15% of high school students had had sexual intercourse with four or more persons during their lifetime (2). Such students and adolescents at high risk for HIV infection should be tested at least annually (6).
The findings in this report are subject to at least three limitations. First, these results apply only to adolescents who attend school and therefore are not representative of all adolescents. In 2005, of persons aged 16--17 years in the United States, approximately 4% were not enrolled in a high school program and had not completed high school (9). Second, the extent of YRBS underreporting or overreporting of behaviors such as HIV testing or age at first sexual intercourse has not been determined. Third, rates of HIV infection and sexual behaviors vary geographically, and this national analysis cannot be applied to regions, states or cities.
HIV testing among sexually active adolescents is an important strategy to reduce the incidence of HIV infection (6). The results of this analysis showed that students who had been taught about AIDS or HIV in school were more likely to have had an HIV test than were those who had not been taught about AIDS or HIV. Although approximately 90% of high school students have been taught about AIDS or HIV (2), only 12.9% have had an HIV test. High schools can enhance their HIV prevention curricula by including information on locations and procedures for obtaining free, confidential HIV testing.¶¶ In accordance with state and local policies, school health professionals could refer at-risk students for HIV prevention, counseling, and testing services. Many schools collaborate with local health centers and community-based organizations to help students receive screenings and some school-based health clinics offer HIV testing on-site.*** Health-care providers, educators, and parents or guardians play critical roles in providing support and guidance to adolescents in making decisions about the timing and frequency of HIV testing. Because adolescents might be sexually active but unwilling to discuss this information, health-care providers should provide HIV testing routinely to all patients aged ≥13 years in accordance with CDC recommendations.
References
- Campsmith M, Rhodes P, Hall I. Estimated prevalence of undiagnosed HIV infection in the United States at the end of 2006. [Abstract]. In: 16th Conference on Retroviruses and Opportunistic Infections; February 16--20, 2009; Montreal, QC, Canada. Available at http://www.retroconference.org/2009/Abstracts/33682.htm.
- CDC. Youth risk behavior surveillance---United States, 2007. MMWR 2008;57(No. SS-4).
- Kaiser Family Foundation. National survey of teens on HIV/AIDS 2000. Menlo Park, CA: Kaiser Family Foundation; 2000. Available at http://www.kff.org/youthhivstds/3092-index.cfm.
- CDC. HIV/AIDS surveillance in adolescents and young adults (through 2007). Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm.
- Yu SM, Bellamy HA, Schwalberg RH, Drum MA. Factors associated with use of preventive dental and health services among U.S. adolescents. J Adolesc Health 2001;29:395--405.
- CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14).
- D'Angelo LJ, Samples C, Rogers AS, Peralta L, Friedman L. HIV infection and AIDS in adolescents: an update of the position of the Society for Adolescent Medicine. J Adolesc Health 2006;38:88--91.
- ACOG Committee Opinion. Routine human immunodeficiency virus screening. Obstet Gynecol 2008;112(2 Pt 1):401--3.
- Laird J, Cataldi EF, KewalRamani A, Chapman C. Dropout and completion rates in the United States: 2006. Washington, DC: National Center for Education Statistics, Institute of Education Sciences, US Department of Education; 2008. Available at http://nces.ed.gov/pubs2008/2008053.pdf.
* Additional information available at http://www.cdc.gov/yrbss.
† Determined by response to the question, "Have you ever been tested for HIV, the virus that causes AIDS [acquired immunodeficiency syndrome]? (Do not count tests done if you donated blood.)."
§ Overall response rate = (number of participating schools / number of eligible sampled schools) × (number of useable questionnaires / number of eligible students sampled).
¶ Determined by response to the question, "Have you ever been taught about AIDS or HIV infection in school?"
** Determined by response to the question, "Have you ever had sexual intercourse?"
†† Determined by response to the question, "How old were you when you had sexual intercourse for the first time?"
§§ The Kaiser survey asked, "Have you ever been tested for HIV?" Of those tested overall, approximately 90% were tested at a clinic or doctor's office and 1% were tested as part of a blood drive or donation.
¶¶ National HIV and STD testing resources, including locations of testing sites, are available at http://www.hivtest.org, and information about youth-friendly HIV testing, counseling, and care is available at http://www.adolescentaids.org.
*** Some examples are available at http://www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hivtesting_adolescents.pdf.
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