Adolescents and HIV

Condom Negotiation Strategies

Study Question: How effective are nonverbal and indirect condom negotiation strategies among White and Asian-American young people?

Study Participants: Only questionnaires from single, heterosexual Asian and White American students who had used condoms during their most recent sexual encounter were analyzed. A total of 83 participants met all of the above criteria, of which 60 were White Americans and 23 were Asian American. Participants ranged from age 18-22 (Mean age = 20.31). 68% of the sample were women. 36% of the sample had not had sex in the last month, and 34% had sex over four times in the last month.

Study Methods: Participants responded to a supplemental survey to the National College Health Assessment Survey (NCHAS) distributed by mail to 2,000 randomly selected undergraduate students. 83 of the respondents fit the criteria for the study. Students were asked to answer questions that investigated how individuals persuade or influence their sexual partners to use condoms. Students that had used a condom during their most recent sexual encounter were asked to rate the degree to which they used the condom negotiation strategies on a 7-point scale. To determine which strategies were verbal-direct, verbal-indirect, nonverbal-direct, and nonverbal-indirect, five trained undergraduate female raters were asked to rate the degree to which strategies were verbal and direct. Interrater reliability was .95. Verbal-direct strategies include threatening, pleading and health reasons (e.g. a threat, "no condom, no sex" to persuade partner; pleading, begging or complaining to persuade partner; and health reasons, either pregnancy or STDs). Verbal indirect communication includes deceiving, flattery, and dropping hints. Nonverbal direct strategies include opening the condom in front of a partner. Lastly, nonverbal indirect strategies could include placing a condom near the pillow or dresser, or placing a pamphlet about safe sex in view of a partner.

Study Findings: 58% of survey respondents reported they always used condoms, 15% reported moderate use of condoms, and 27% reported that they did not use condoms in the past month. Reasons for using condoms included sexually transmitted disease (STD) prevention (4%), pregnancy prevention (50%) and both STD and pregnancy prevention (46%). Results indicated that all four strategies were used to negotiate condom use. The vast majority of individuals used verbal-directed strategies (86%) and nonverbal-direct strategies (75%). Asian Americans (59%) were significantly more likely to use verbal-indirect strategies than White Americans (35%). Women were more likely to use nonverbal-indirect strategies (51%) than men (21%).

Limitations: The study authors listed limitations such as the low response rate to the NCHAS questionnaire (28%), thereby limiting generalization the results. However, the authors also indicate that a self-administered questionnaire attaches importance to confidentiality and the sensitivity of the topic. This study also examined Asian-Americans as a whole group rather than examining intra-Asian group differences. Previous studies have documented intra-Asian cultural differences in openness to discuss sexuality, thereby influencing condom negotiation strategies. The recommendations for future research address these limitations.

Lessons Learned: HIV interventions focused on condom negotiations may benefit from alternatives to verbal-direct communication strategies, especially when working with Asian-American individuals or women. Incorporation of verbal-indirect strategies such as hinting to one's desire to use condoms, as well as nonverbal-indirect strategies such as placing a condom in plain view of one's partner could prove to be highly effective HIV/AIDS prevention strategies a among these populations.

Source: Lam, A.G., Mak, A., Lindsay, P.D., Russell, S.T. What really works? An Exploratory Study of Condom Negotiation Strategies. ADIS Education and Prevention, 2004; 16(2): 160-171.

Risk Behaviors for Latino Youth

Study Question: What are the perceptions of risk factors that lead to unsafe sex among Latino women?

Study Participants: A sample of 38 women of Mexican, Puerto Rican and Central American descent voluntarily participated in six separate focus groups in the Chicago area. Women ranged from ages 18 to 47 and attended the focus group site most convenient to them.

Study Methods: Women participants were gathered into focus groups with 3-9 participants per group. Four groups were in Spanish, and two were in English. One group included only HIV-positive women receiving services from a Latino community agency. Women were informed that the purpose of the focus group was to have a comprehensive discussion that covered risky sexual behaviors, HIV/AIDS, and pregnancy of both adults and youth. They were then asked what they believed were the most important concerns in their communities. The sessions were recorded and coded to identify the main themes that concerned these women.

Study Findings: The following six themes emerged from the focus group discussions surrounding teen issues and concerns: (1) the culture of risky behaviors, (2) romance: illusion and reality, (3) parental involvement - a protective factor, (4) HIV: knowledge versus ignorance, (5) HIV among youth: fear, stigma, and anger, (6) saving our youth. Participants cited exposure to peer pressure for teens, gangs, substance abuse, early and unprotected sexual relations, cultural issues, and minimal youth activities as prevalent challenges to youth in their communities. Participants agreed that Latina teens have unrealistic romantic ideas about sex, pregnancy, and parenthood. Participants also indicated that though parental involvement is protective for risky behaviors, they feel inadequately prepared to provide teens with the required information to get them through adolescence safely. Regarding HIV infection, comments provided examples of stigmatization, fear of rejection from the community, uncertainty about the extent to which parents should discuss sexuality with their children, and an overall lack of sexual knowledge and a family history of women not discussing sex, which has not prepared them to provide teens with the information requisite to move through adolescence.

Limitations: Though the authors do not explicitly state any limitations, the small sample size, should be considered, as well as the study design that relied on group self-report.

Lessons Learned: The authors outline implications for the education of children and youth that must include myths about HIV infection to preclude stigmatization of those who are HIV-positive. Increasing both youth and parental knowledge of HIV/AIDS is the first step in preventing stigmatization that can result in unsafe sexual practices and HIV infection. Study results of these focus groups indicate that teens do initiate sex at a young age, so parents and providers should be encouraged to discuss family behavioral expectations during the early preteen years. Recommendations for nurses included the need to encourage open communication between parents and children, to support parents as they practice protective parenting, and to help families communicate their understanding of what it means to be a teen in the twenty-first century in the United States.

Source: Talashek, M.L., Peragallo, N., Norr, K., Dancy, B.L. The Context of Risky Behaviors for Latino Youth. Journal of Transcultural Nursing, 2004 Apr; 15(2): 131-138.

Risk Behaviors Among Spanish-Dominant Latino Youth

Study Question: What factors influence sexual intercourse and condom use behaviors in Spanish-dominant Latino youth?

Study Participants: The population of "Spanish-dominant youth" refers to Latino adolescents who requested to answer a questionnaire in Spanish and participated in Spanish-language intervention groups. 141 participants met these criteria (77 girls and 64 boys), aged 12-18 years (mean 15) predominantly from Puerto Rico, with a smaller number (8.7%) from the Dominican Republic. Over half of the participants reported speaking only Spanish or Spanish more than English.

Study Methods: The theory of planned behavior framework was applied to the examination of Spanish-dominant Latino youth and HIV risk and prevention behaviors. A randomized control trial designed to reduce the risk of sexually transmitted HIV among Latino youth resulted in substantive data about behavioral beliefs, normative beliefs, and perceived behavioral control and self-efficiency. Students were invited to participate in the Latino Youth Health Promotion Program, an 8-hour program conducted over two consecutive Saturdays. Once there, their language of preference was verified (Spanish), and they were given a version of the questionnaire. The questionnaire assessed five behavioral beliefs regarding sexual intercourse (goals, self-pride, parental pride, popularity and prevention). Other items measured included attitudes toward having sexual intercourse in the next 3 months, behavioral beliefs regarding condoms, as well as subjective norms and normative beliefs regarding mother, father, peer, and sexual partner approval of condom use.

Study Findings: Approximately 35% of participants reported ever engaging in sexual intercourse. A small percentage reported condom use during the most recent sexual intercourse experience (16.7%). Compared with the general 1999 Youth Risk Behavior Study (CDC, 2002), Latino youth were less likely to report that they had ever engaged in sexual intercourse (35% vs. 49.9%), had engaged in sex during the preceding 3 months (15.2% vs. 36.3%), and had used a condom in their last sexual intercourse experience (16.7% vs. 58%). Analyses showed significant effects of attitudes and normative beliefs as predictors of intentions to engage in sexual intercourse in the next 3 months. Specifically, youth that maintained a positive attitude regarding sex and that perceived greater partner approval for having sex, reported stronger intentions to have sex.

Some predictors for those less likely to engage in sexual intercourse behavior included beliefs that they were likely to feel proud of themselves if they did not have sex, perceived their parents would be proud of them if they did not have intercourse, or believed that having sex would interfere with their career goals. The importance of partner approval for sexual intercourse, parental pride and career goals appeared as significant predictors of abstinence.

Limitations: Due to the primarily Puerto Rican subject population, it is difficult to generalize the results of this study to adolescents of other Latino subgroups. The authors also indicate the importance of determining whether the theoretical mediators identified as predictors of intentions and past behavior are similar to or different from those that predict actual behavior. Other limitations include the small sample size and reliance on self-report measures.

Lessons Learned: This study explored initial efforts to address the needs of Spanish-dominant Latino youth. The results affirm that culturally and linguistically effective interventions with this subgroup of Latino youth do correspond with the theory of planned behavior and the salient beliefs that may be predictive of sexual risk and protective behavior.

Source: Villarruel, A.M., Jemmott, J.B., Jemmott, L.S., Ronis, D.L. Predictors of Sexual Intercourse and Condom Use Intentions among Spanish-Dominant Latino Youth: A Test of the Planned Behavior Theory. Nursing Research, 2004 May/Jun; 53(3):172-181.

Psychiatric Hospitalizations among Youth with HIV

Study Question: Are pediatric patients with HIV/AIDS at increased risk for psychiatric hospitalization? What are some predictors of first psychiatric hospitalization?

Study Participants: Data from Pediatric Acquired Immunodeficiency Syndrome (AIDS) Clinical Trials Group (PACTG) 219C-enrolled subjects were studied between September 2000 and December 2002. This group includes all perinatally HIV exposed (infected, undetermined status, or uninfected) infants, children, and adolescents and children with postperinatally acquired HIV infection being monitored at a PACTG site. Baseline characteristics from the enrolled infants, children and adolescents in PACTG 219C included a total of 2298 HIV-infected and 1021 HIV -exposed, uninfected infants, children and adolescents.

Study Methods: The PACTG 219C database was reviewed for psychiatric hospitalizations among perinatally HIV-infected and perinatally HIV-exposed, uninfected participants (children and adolescents). The relative risks were calculated using maximum likelihood estimation of the incidence of psychiatric hospitalizations among HIV-infected PACTG 219C participants less than 15 years of age.

Study Findings: No psychiatric hospitalizations were observed among the 1021 HIV-negative members of the cohort. Results indicated that knowledge of HIV seropositivity status and significant life events were associated with increased risks of psychiatric hospitalization. A multivariate analysis determined that participants who were aware of their HIV seropositivity status were 6 times more likely to be hospitalized because of psychiatric illnesses, compared with participants who were unaware of their HIV status.

Limitations: Due to study restrictions, the uninfected children were younger than the infected children. This age discrepancy between the infected and uninfected PACTG 219C cohorts limited comparisons that may have clarified the specific effects of HIV infection and other chronic risk factors. Also, as with any observational study, the children with the most severe mental disorders may not be able to meet the demands of the study (i.e. neuropsychchologic testing and other lengthy clinical assessments), and thus may not be enrolled in PACTG 219C.

Lessons Learned: The statistics of suicide rates among persons 15-19 years of age, specifically among non-Hispanic, black, male subjects, suggests that clinicians should be alert for potential increased risks of suicide in this population. More generally, children with chronic HIV infection are living longer. The incidences of psychiatric hospitalizations and major psychiatric illness may increase. The authors strongly suggest that screening for warning signs of psychiatric illness should be conducted within the context of comprehensive primary care. Referrals to mental health services should be provided when psychiatric issues become apparent.

Source: Gaughan, D.M., Hughes, M.D., Oleske, J.M., Malee, K., Gore, C.A., Nachman, S. Psychiatric Hospitalizations among Children and Youths with Human Immunodeficiency Virus Infection. Pediatrics, 2004 Jun; 113(6): 544-551.

CDC - U.S. Youth Risk Behavior Surveillance

Study Question: What are the rates of risk behaviors among youth in the U.S.?

Study Participants: Study sampling was obtained from the 2003 national Youth Risk Behavior Survey (YRBS) from the Quality Education Data (QED), Inc. database. The sampling included all public and private schools, with students in at least one of grades 9-12 in the 50 states and the District of Columbia. 15,214 usable questionnaires were compiled, representing 158 schools.

Study Methods: Students completed the self-administered questionnaire during one class period and recorded their responses directly on a computer-scannable questionnaire booklet or answer sheet. The core questionnaire was composed of 87 multiple choice questions assessing risk behavior. Data analysis focused on behaviors that contribute to unintentional injuries and sexual behaviors that contribute to unintended pregnancy and STDs, including HIV infection.

Study Findings: Nationwide, 46.7% of students had engaged in sexual intercourse during their lifetime. Overall, 9th grade males (37.3%) reported a higher prevalence of having had sexual intercourse than 9th grade females (27.9%). Black males (73.8%) and Hispanic males (56.8%) reported the highest prevalence of having had sexual intercourse, than black females (60.9%) and Hispanic females (46.4%) respectively.

More male students reported having sexual intercourse before age 13 years than female (4.2%) students. Nationwide, 14.4% of students had four or more sex partners through the 12th grade. Approximately one third (34.3%) of students grades 9-12 report having had sexual intercourse during the 3 months preceding the survey (considered sexually active). Of those that reported they were currently sexually active, 17.0% reported either they or their partner had used birth control pills to prevent pregnancy before the last sexual intercourse. 4.2% of students had been pregnant or had gotten someone pregnant. Among the 34.3% of currently sexually active students nationwide, 63.0% reported that either they or their partner had used a condom during last sexual intercourse. The prevalence of condom use during last intercourse was higher among male (68.8%) than female (57.4%) students. 25.4% reported having had drunk alcohol or used drugs before last sexual intercourse. Overall the prevalence of alcohol or drug use before last sexual intercourse was higher among male (29.8%) than female (21.0%) students.

Nationwide, 87.9% of students had been taught in school about acquired immunodeficiency syndrome (AIDS). From 77.9%-93.6% of students reported having been taught in school about AIDS or HIV infection in state surveys, and from 78.8% to 92.7% across local surveys.

Limitations: Limitations include the design of self-report by teens.

Lessons Learned: U.S. adolescents self-report a strong tendency of engaging in risky behaviors. Overall, male students seem to be more susceptible to sexual behaviors that contribute to unintended pregnancy and STDs, including HIV infection than female students. Greater public awareness to increase teen knowledge about sexual behavior is needed. Healthcare providers should engage adolescents in discussions about their risky behaviors in an age-appropriate and age-sensitive manner. Clear racial/ethnic competence training and education is also needed to decrease the consistently higher prevalence of minority males and females engaging in risky behaviors.

Source: CDC MMWR, Youth Risk Behavior Surveillance - United States 2003. 2004, May; 53(SS-2): 1-20.