HIV infection and AIDS in adolescents

JOURNAL OF ADOLESCENT

i-&IETY

HEALTH

1994;15:427-434

FOR ADOLESCENT MEDICINE

A Position Paper of the Society for Adolescent Medicine Executive Summa y Although adolescents represent less than 0.4% of the reported cases of AIDS in this country, there is growing concern that HIV infection may be spreading in this age group despite current efforts at education, prevention, and care. The Society for Adolescent Medicine believes that preventing and treating HIV infection in adolescents and young adults should be a major concern for health care providers and public health authorities. In order to accomplish tnis, the following priorities must be addressed: 1. Documentation of the extent cf the problem of HIV infection in teenagers. This mnst be accomplished by continuing and expanding the surveillance of HIV infection in selected adolescent populations and by augmenting epidemiologic data with information concerning the natural history of HIV infection in adolescents and young adults. 2. Development of adolescent-specific systems of care (organized on a regional basis) for those infected or at high risk of infection. This care must include diagnostic and therapeutic services for conditions that are common to ad;Jlescents as well as those that are specifically associated with HIV infection. It should also include psychological and social support services and be coordinated through an appropriate primary care provider. Ideally, this care will be available and regionally organized through the cooperation of care providers as well as federal, state, and local health agencies. 3. Development of a rational approach to counseling and testing of adolescents. There should be no mandatory of testing of adolescents. Confidential testing should be readily available to adolescents and every effort should be made to ensure the rights of privacy of the patient. Anonymous testing should also be available for those who so choose. Programs and the clients they serve should be made aware of the positive and negative features of each approach to testing. Counseling should be developmentally and culturally sensitive and always identify risks as well as benefits of testing. Both counseling and testing should take place in settings in which adolescents feel comfortable and where care and support services can be made readily available. Appropriate parental

or other adult support should be incorporated into the process whenever possible. 4. The needs of “special populations” of adolescents, including gay and bisexual youth, homeless and runaway youth, incarcerated and detained youth, youth in foster care, youth using alcohol or other drugs, and youth with hemophilia should be addressed by care providers as well as federal, state, and local health and social service agencies. Particular emphasis should be placed on removing financial and institutional barriers to care for these adolescents. 5. Prevention should be reaffirmed as the best means of interrupting the pandemic of HIV infection and implemented in an adolescent-specific manner. Efforts should target youth at greatest risk of HIV infection and focus on repeated contact, aggressive follow-up, and the integration of prevention education with practical life skills. All prevention programs shouid have well identified and easily accessible links to counseling and testing as well as care and treatment services. Mass prevention efforts should begin by age nine years and provide specific and explicit messages. HIV infected youth should receive special interventions as a means of secondary prevention. Adolescents should be considered appropriate candidates for medical prevention efforts, including vaccines, should these become available. 6. Efforts to make changes in the aforementioned areas should be validated by appropriate research studies. Funding for such adolescent-specific research must continue to be provided by federal,,. state, and local agencies and private foundations. Particular attention should be directed toward d0cumentin.g the natural history of HIV infection in adolescents, determining what makes for a successful secondary prevention program, determining the effects of counseling and testing on adolescent behaviors, and finding appropriate ways to validate prevention intervention studies. The Society for Adolescent hIMedicinehas long been on the forefront of this ePidr?ric and efforts to stem its spread to teenagers. The Society, in conjunction and cooperation with its members, private foundations, and federal agencies, will work to see that its specific recommendations to advance these six identified areas of need are carried forward in as timely a fashion as possible.

QSociety for Adolescent Medicine, 1994 Mlished by Elsevier Science Inc., 85 Avenue of the Americas, New York, NY 1OfllG

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D ANGELO, ET AL.

All adolescents are touched by the worldwide pandemic of human immunodeficiency virus (HIV) infection. With more than 1500 cases of AIDS having now been reported ‘;n adolescents ages 13-19 in the United States and another 9000 cases reported in individuals between the ages of 20-24, it is apparent that this infection will continue to create health and social problems for adolescents and young adults in this country for many 7 years to come. The situation elsewhere in the world is no better, with adolescents playing a major role in the chain of transmission in Africa, Southeast Asia, India, and Europe. We believe that it is necessary for those who provide care to adolescents to be knowledgeable and involved in the following issues. Only in this way will we have educated providers and patients who will be ready, willing, and able to advocate for their health and/or the health of others.

Background Epidemiology of AIDS and HIV Infection in Adolescente In the United States, as of June 30, 1993,130l cases of AIDS had been reported in individuals between the ages of 13 and 20 years (1). Although this represented less than 0.4% of all cases of AIDS reported in this country, given the fact that the latency period from infection until the clinical manifestations of HIV infection become apparent is a median of 8-12 years, counting cases of AIDS in adolescents underestimates the ultimate magnitude of the threat that this infection poses for young people. Of those with diagnosed AIDS, more than 50% are minority youth (African-American and Hispanic). Although the largest single group of adolescents with reported cases are males exposed through the receipt of blood factor component transfusions (31%), the majority of cases (54%) occur in adolescents whose behavior has somehow put them at risk of infection. The male to female ratio of reported cases is lower in adolescents than in any age group except infants. Whereas the overall rate is 7.&l, the rate in adolescents is 2.7~1.This observation is not meant to minimize the risk for adolescent males who participate in high-risk behaviors such as anal intercourse, injection drug use, or sex with individuals who have high rates of infection. Rather, it emphasizes the reality that both male and female adolescents are at risk of HIV infection and that this risk appears to be higher in adolescent females than in older women. Given the likelihood that most HIV infected ado-

JOURNAL OF ADOLESCENT HEALTH Vol. 15 No. 5

lescents will remain asymptomatic during the adolescent years, far more relevant than the overall number of cases of AIDS in adolescents is the number of individuals infected who are either asymptomatic or not yet defined as a case of AIDS. Different seroprevalence surveys have shown that the rates of HIV infection vary greatly among specific groups of adolescents. The largest pool of data from adolescents comes from military recruit surveys (2,3). Overall, the rate of infection in those 15-19 years applying for military induction is 0.3/1000. However, that figure is twice as high for youth from Chicago, four times as high in those from Miami, fives times as high in teens from New York, and 15 times as high for a teenaged recruit from Washington, D.C. Similar data has been gathered from the Job Corps serosurveys (4:, where the overall positivity rate is 3.6/1000. This varies considerably by age (the rate in older is higher than that in younger adolescents), and ethnic group (African-American youth higher than Hispanics who are higher than Caucasian youth) but is remarkably similar across gender. Focused surveys from a variety of convenience samples of youth who are living in high-risk situations show rates that are in some cases 15 times that high (5-7). Although it is obvious that rates of infection change with locale and patient group, surveillance remains an important tool for planning both services and allocation of resources. For this reason, changes in the comprehensive network of nationwide seroprevalence studies should be undertaken with caution so as not to ignore the role of adolescents in sustaining the overall rate of infection in the community. Clinical Profile, Medical Care, and Access to Services of HIV Infected Adolescents in High-Risk Situations The true clinical profile of adolescents infected with the human immunodeficiency virus is unknown. Given the fact that many reported cases of AIDS in adolescents have occurred in individuals who have acquired their infection via blood or factor transfusion, it is ;ikely that the profile of those infected is not accurately reflected by the distribution of actually diagnosed. AIDS cases. Despite the seroprevalence studies cited previously, a more comprehensive picture of the risk behavior of HIV infected adolescents is not currently available. Also unknown is the na.tural historj’ of infection with HIV in adolescents. Although one study sug-

July 1994

HIV INFECTION AND AIDS

gests that adolescents with hemophilia are more resilient to the effects of HIV infection (8), anecdotal information from practitioners who care for a number of HIV infected adolescents suggests just the opposite: once teenagers are infected, their immune function deteriorates at the same rate or even more rapidly than the immune function of infected adults (91. This controversy is currently unresolved.. Because adolescents as a group are less likely to receive appropriate and continuous primary care than any other age group, it is not surprising that the most disenfranchised members of this age group, youth at risk of or infected by the human immunodeficiency virus, experience significant barriers accessing age specific subspecialty care centering on their HIV risk or their actual infection. Most adult and pediatric centers specializing in HIV/AIDS clinical services are unfamiliar with the unique care needs of adolescents. Primary care services specializing in the care of teenagers often do not have the special ability to care for HIV infection. This makes the plight of the at-risk or infected adolescent even more acute. Nine “Pediatric AIDS Health Care Demonstration Projects” focusing on the health needs of HIV infected adolescents have been partially supported by the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSAl. Located in cities where the risk of HIV infection for teenagers is substantial, these programs have provided models of the provision of a continuation of primary, secondary, and tertiary care. Unfortunately, the lack of mechanism for dissemination and a more centrally coordinated system of HIV specialty care for teenagers has deprived many other cities and their teens at risk from benefiting from the experience or expertise of these centers. HIV Counseling

and Testing in Adolescents

Age-specific guidelines and services for adolescents are also needed with respect to YIIV counseling and testing. Although some guidelires exist, they exist in a climate in which there is universal testing of two very large groups of adolescents-all individuals who apply for induction into the military or admjssion to the Job Corps. In addition, many young persons in juvenile detention and correctional facilities are being tested for HIV on a routine basis. Beyond that, there is little support for confidentgal and anonymous testing programs for adolescents although a few have been deveioped. The dilemmas of “when to test?” “how to test (confiden-

429

tial, anonymous, etc.,)?” and “what to do with the results of tests?” continue to remain unresolved. At minimum, it is critically important that voluntary testing is available to those adolescents who want and need it, that involunta,-y testing is avoided, that testing is not used as a basis for discrimination or exclusion from services, that informed consent is consistently obtained, that appropriate counseling is available and provided, and that confidentiality is strictly maintained. Finally, it is essential that HIV testing be the basis for individualized prevention counseling and for linking at risk youth to appropriate services including both primary care and early intervention for HIV disease (10). One of the most important benefits associated with HIV testing for adolescents is the possibility of early intervention, including the provision of specialized HIV-related therapy and prophylactic treatment as well as ongoing primary care. However, for many adolescents access to preventive, primary, and specialized health care is limited. Special Populations Although all adolescents who participate in risk behaviors are poter?aZy at risk of HIV infection, certain groups of teenagers whose life circumstances may influence their partic@tion in these brhaviors remain at disproportionately high risk of HIV infection and AIDS and are in need of additional services. These include youth engaging in same gender sexual behavior, homeless and runaway youth, incarcerated and detained youth, youth in foster care, youth using alcohol and other drugs, and youth with hemophilia. Although there is growing awareness of the special needs of these adolescents, approaches to prevention and treatment of HIV infection for these groups are often neither more organized nor more coordinated than the services for adolescents in general. Prevention Traditional approaches for the control of sexually transmitted diseases include education, health pro motion (including risk reduction and disease avoidance models), early detection, treatment, and partner notification. The availability of Hepatitis B vaccine has added immunization to these approaches. Unfortunately, the prospects for a vaccine to prevent HIV are hopeful, but as yet unrealized. The other preventive modalities have been used in the AIDS epidemic to varying degrees across the U.S.

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School and community-based m’ass education and their attempts to shape healthy social norms have been the mainstays of prevention for youth. Most states and protectorates have required or recommended AIDS education in public schools, with wide discretion in implementation. Schools and clinics have uSed harm-reduction and/or disease avoidance models with variable intensity. HIVrelated public service messages, media coverage, print materials, videotapes, movies, and music are ubiquitous, but vary widely in content with few containing age-specific or sufficiently explicit information about HIV transmission and prevention. In a few communities, condoms are readily available to teenagers, and a growing number of school districts are considering the implementation of condomavailability programs. As a consequence of mass education and health promotion efforts, basic knowledge of HIV among adolescents has increased (11,12). Cross-sectional surveys of schools, clinics, and households also have chronicled modest improvements in youths’ attitudes and behaviors (13,14). During the last decade, rates of condom use during intercolvrse increased, but reported rates of consistent use by sexually active teenagers remained low (14). There is little evidence that the incidence and mean age at onset of sexual intercourse among adolescents has changed significantly. Illicit substance abuse by secondary students declined during the 198Os, continuing a downward trend that antedated the AIlX epidemic. Some intensive HIV prevention programs have i?und short-terms gains in knowledge and attitudes (. 6-20) and condom acquisition (20,21). Several have demonstrated retention of new information (:2-24X lower rates of sexual intercourse (20,24), fewer sexual partners (22,23), and improved use of c;tjndoms (20,23) for up to six months after interventiens. In other settings, improvements in knowledge ha Je been found to be transient (19) or unaccompanis?d by behavioral change (4,21). i3y contrast, there is little experience with intenS&Z secondary prevention programs for youth who engage in high-risk behaviors, particularly young men who have sex with men, young women who are the sexual partners; of injection drug users, and young drug-users themselves. Need,le-exchange programs for injecting drug users have not been Tc:idely implemented, nor has the impact of HIV antibody counseling and testing on adolescents’ behavior been studied. There are few programs to preventsecondary transmission from infected adolescents to others.

JOURNAL OF ADOLESCENT HEALTH Vol. 15 No. 5

The best ways to encourage, measure, and sustain HIV risk-reduction among adolescents remain to be determined. Programs that involve peer counseling, development of prevention skills, and repeated contact with clinics appear promising. Information about youth who fail to respond to preventive interventions is lacking. High-risk youth outside of traditional school and clinical settings continue to pose special challenges to prevention initiatives.

Recclmmendafiorzs Epidemiology Continued monitoring of the rates of HIV infection and AIDS in adolescents will be important in deciding how and where medical, psychologic and social services are most needed, testing and counseling initiatives most appropriate, and prevention efforts best put in place. Therefore, we encourage the following: Recomlnen&tiotz #1 increase serosurveillance studies to determine the level of infection and the antecedent risk factors for HIV infection; Recommendntiopl ##2 augment basic epidemiologic data with information concerning the presentation and course of HIV infection in adolescents; Re~onzmend~tion #I3 develop a consensus on adequate definition of “adolescence” “youth”, or other appropriate descriptive construct and sfuizdclrdize this across all reporting lines; Recommendation

#4 develop a calculated national projection of HIV infection among adoIescents using data from selected cities, as well as suburban and rural areas throughout the United States.

Clinical Profile and Medical Care More complete information concerning the clinical profile of HIV infection in adolescents is necessary to develop appropriate care services. This includes information on the clinical course of HIV infection in adolescents, as well as psychological and social sequeIae of this illness. Moreover, there Esa need to incorporate information concerning the response of adolescents to medications, particularly with regard to drug distribution, metabolism, and excretion in accordance with Tanner staging and physiologic development. Therefore, we also call for the following: Recommendation

#5 guarantee access to diagnostic testing necessary to determine the presence and

July 1994

HIV INFECTIOP! AND AIDS

progress of conditions and infection:; common in all adolescents as well as those likely to occur in HlV infected youth including, but not limited to, a) an age-appropriate history and physical examination including a careful history of living situation, lifestyle, sexual orientation, actual sexual behaviors and practices, and substance use (this should occur in a nonjudgmental and supportive manner and be conducted by a knowledgeabjle, sensitive, health care provider trained in both adolescent health care and $IlV issues); b) serologic tests and cultures for sexually transmitted diseases, opportunist infections, and related mahgnancies; c) markers of immune system competence (CD4 lymphocyte subset evaluation) and indicators of treatment success or failure; d) proper staging of HIV disease based on Centers for Disease Control and Prevention criteria. Recommend&io~ #6 assure the availability of ready access to therapeutic modalities to treat conditions common in all adolescents as well as those particularly prevalent in HIV infected youth including:

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mental options, including counseling to pregnant adolescents and appropriate protocols to ensure the referral of infants born to infected mothers. Recomnzendatiofr #7 create regional care networks organized under the auspices of the Society for Adolescent Medicine in cooperation with existing centers (HRSA funded programs and others) that will ensure that all adolescents will have access to appropriate HIV specific services. HIV Counseling

and Testing

With regard to counseling and testing services for adolescents, we make the following recommendations: Reconzmendrrtion #8 develop counseling and testing services specifically oriented to the developmental and psychosocial needs of adolescents. These should be widely available, efficient, and inexpenliive and should adhere to the following guidelines and principles: HIV testing of a) there should be no mandatory individual adolescents or population groups as a prerequisite for admission to programs, services, or placements;

a) psychological support services including individual, family, and groaip counseling and therapy;

bl there should be no involuntary ing of adolescents;

b) social support services including assistance with obtaining entitlements, securing food, housing, continuing education and/or employment opportunities and problems related to potential or experiences of discrimination due to HIV status;

c) an adolescent should not be tested for HIV without consent; informed consent should be obtained from the adolescent if the adolescent is capable of consenting or, if the adolescent is not capable of giving consent, consent should be obtained from some other person with appropriate legal authority or from a court.

c) access to medical treatments including zidovudine (AZT), dd1, ddC, and other approved antiviral agents; prophylaxis for opportunistic infections (such as Pneumocystis carinii, Mycobacterium avium intracellulare, Toxoplasma gondii, etc.,.); conditions whose treatment and course are altered by the presence of concomitant HIV infection (i.e., TB, syphilis); and immunizations for common preventable infections including Hepatitis B; d) access to clinical trials, preferably in a setting should make geared to youth. This program available a wide array of protocols covering a range of HIV-related health problems including infection, and primary infection, opportunistic perinatal transmission; e) provision or referral. for related services drug treatment, penatal care, housing; f) provision

of appropriate

informed

such as

and nonjudg-

routine

HIV test-

Reconvnendhn

#9 foster the recognition of specific indications for testing an adolescent and use these indications as an active guide as to whom to offer testing. Testing should be offered to:

a) anyone

who voluntarily

requests testing;

b) anyone who has signs Or symptoms consistent with HIV infection without an alternative etiologic diagnosis; c) anyone who currently engages in or previously has engaged in high-risk behavior; d) anyone who has a history of sexually transmitted disease; e) anyone who is pregnant and either is known to be at increased risk for HIV infectior. based on reported personal behavior or is at unanown risk; f) anyone

who has history

of sexual abuse; or

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D’ANGELO, ET AL.

g) anyone who received multiple transfusions or clotting factor infusions between 1978 and 1985. Recomrnendution MO when indicated, conduct HIV testing based on clinical criteria or an appropriate request of an adolescent, in settings where pretest and post-test counseling that is sensitive, age-appropriate, and culturally appropriate is available. Confidential testing is preferred because it more readily allows the immediate provision of medical and support services to be offered to the adolescent. However, anonymous HIV testing services should also be available for the adolescent who prefers to be tested in this manner. This modality of testing is often preferred by older or emancipated adolescents. If anonymous testing is provided, efforts need to be made prior to offering these services to a particular adolescent to ascertain if he/she will be responsible in returning for results and if an appropriate support mechanism is in place to help them cope with a positive test result. Whether the testing is confidential or anonymous, special preparations should be made, including training of staff, to ensure that services are appropriate to the adolescent age group. In each case in which HIV testing is offered to an adolescent: a) the offer to test an adolescent should be made only after individualized counseling which develops a personalized client-risk assessment including evaluation of the adolescent’s sexual, behavioral, medical, and psychological history and weighing of the possible risks and benefits of testing; b) the counseling should result in a personalized plan for the adolescent client to reduce the risk of HIV infection/ transmission. c) the counseling should include an explanation to the adolescent of the circumsta>nces under which the test results will be disclosed and to whom; and d) the identification and participation of a supportive adult should be encouraged and if an adolescent is unable to identify such an adult, the program or health care professional providing the testing should assist the adolescent in identifying someone. Recommendation #ll strictly maintain the s:onfidentiality of an adolescent’s HIV test results and other HIV-related information. Recommendation #12 share HIV-related information about an adolescent among health care profes-

JOURNAL OF ADOLESCENT HEALTH Vol. 15 No. 5

sionals and other service providers only with appropriate authorization. The following guidelines should be adopted: a) tes:: results should only be released with the explicit agreement, preferably in writmg, of the adolescent if the adolescent has consented to the test; or b) in those extraordinary instances when an adolescent has not consented to the test, authorization to release the test results should be obtained from someone with proper legal authority to do so as directed by order of the court. Recommendation #13 those with access to HIV test results should treat these results and other HIVrelated information with sensitivity in order to minimize the risk of discrimination that often occurs against adolescents with HIV infection or those perceived to be at high risk for infection. Recommendation #24 provide extensive counseling and support t,o adolescents who have tested positive for HIV to enable them to inform their sexual or needle-shadng partners that they are HIV infected. Specifically: a) an offer should be made to assist them in the notification process; and b) ongoing counseling should be provided to adolescents who are initially reluctant or unwilling to inform their partners to help them to understand the importance of doing so. Recommendation HIS provide access to HIV testing and follow-up care to adolescents in juvenile deteltion or correctional facilities, foster care, or the mental health system. Specifically: al they should be able to receive careful assessments, pre-test and post-test counseling, and confidential HIV testing if appropriate; b) they should be tested only with their voluntary informed consent; and c) the privacy of these young people should be protected to the maximum extent possible, although legal requirements applicable to youth in these systems may sometimes place limitations on the confidentiality of information, or on who makes decisions concerning disclosure. Recommendation #26 ensure that facilities and health care professionals offering HIV testing to adolescents provide linkage to treatment, take steps to ensure that adolescents who are tested for HIV have access t2 necessary health care, and implement HIV testing of adolescents on a wide-

July 1994

spread basis only after the appropriate linkages are in place. Specifically, linkages must be cstablished enabling adolescents who are tested for HIV to obtain: a) primary health care; b) specialized diagnostic and treatment services related to HIV infection, including early intervention services; and c) ongoing mental health services tc, assist in dealing with the diagnosis.

Special Populations Adolescents who are somehow outside of many traditional sources of care have been deemed “special populations” of adolescents. Our specific recommendations aimed at these adolescents include the following: Recommendutiorr #i7 address the needs. of special populations of adolescents at federal,.,.state, and local government levels. Comprehensive health care services should be available to these youth and targeted prevention projects should be available to help reduce their risk of infection. Programs should be gender and culturally sensitive. Recommendation #28 remove potentiai financial barriers to health care for aJJ adolescents, particularly those from groups deemed “special populations” should be removed. Adolescents should be appropriately included in all entitlement programs. Health care reform must pay special attention to adolescents.

Prevention Currently, prevention is the only available means to control the spread of the HIV epidemic. Although prevention efforts should inchrde all adolescents, it should be acknowledged that the likelihood of contracting HIV infection is not uniform throughout the population. Efforts should then be concentrated on those individuals in most immediate danger of coming into contact with HIV. Prevention programs must be able to meet the specific needs of communities and reach individuals before exposure occurs. Specific recommendations include the following: Recommendation #29 prioritize adolescent prevention interventions so that intensive HIV prevention programs are aimed at youth at greatest risk of HIV infection: young men who have sex with men, injection drug users, young men or women

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whose sex partners include injection drug users, young men or women with other sexually transmitted diseases, homeless and/or runaway youth, youth in detention, youth in detoxification programs. Recommendation #I20 focus these programs on repeated contacts, aggressive follow-up, and teaching practical life skills. The use of peer educators and counselors is encouraged. RecommenhtIon #21 link prevention programs
Research Efforts to make changes in the preceding areas must be supported with appropriate research. Although accomplishments to date have been important, we recommend the following: Recommendation #2C make available appropriate funding to continue to ensure that scien:ific observations are the basis of service-oriented projects and interventions. Key areas of researc: have been identified by both the Society for Adolescent Medicine and the Adolescent Advisory Group of the Health Services Research Adnrinistration and include the following: a) documentation of the natural history of HIV infection in adolescents. b) determination of successful secondary prevention efforts with HIV infected youth.

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D’ANGELO, ET AL.

c) effects of HJV testing

attitudes and behaviors. Recommendatiort #27 conduct a national survey of sexual behavior, attitudes, and knowledge in teenagers. Recommendation #28 plan and implement a prospective study of intensive prevention intervention that employs both biologic as well as selfreport psychosocial endpoints. on

Conclusions The increase in the number of HIV infected adolescents in this country has captured the attention of many prominent observers. It has become increasingly obvious that there will be no simple answer to this epidemic for either adolescents, children, or adults. For this reason, a comprehensive approach to prevention, care, and research is necessary. This approach must be structured in such a way that it ensures the broadest participation possible by health care providers, advocates for adolescents, and teens themselves. Working together, we may have a chance to save their futures and ours. This is a special responsibility and one that the Society for Adolescent Medicine realizes it must accept immediatt!y.

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11. Hingson R, Strunin L, Berlin B. Acquired immunodeficiency transmission: changes in knowledge and behaviors among teenagers, Massachusetts statewide surveys, 1986 to 1988. Pediatrics 1990;85:24-29. 12. Steiner JD, Sorokin G, Schiedermayer DL et al. Are adolescents getting smarter about acquired immunodeficiency syndrome? Change ir knowledge and attitude over the past 5 years. Am J Dis Chiid 1990;144:302-306. 13. DiClemente RJ. Ado!.?scents and AIDS current research, prevention strategies and public policy. In: Temshok L, Baum A, eds. Psychosocial Pcrspectiues on AIDS: Etiology, Prevention, and Treatment. New Jersey; Erlbaum Associates, 199a51-64. 14. Hingson R, Strunin L. Monitoring adolescents’ response to the AIDS epidemic: changes in knowledge, attitudes, beliefs and behaviors. In: DiClemente R, ed. Adolescents and A.IDS: a generation in jeopardy. Newbury Park, CA; Sage PuNications, 1992;17-33. 15. Sonenstein F, Heck J, Ku L. Sexual activity, condom use and AIDS awareness among adolescent males. Fam Plan Perspect 1989;21:152-158. 16. DiClemente RJ, Pies C, Stoller E et al. Evaluation of schoolbased AIDS education curricula in San Francisco. J Sex Res 198u;26:188-198. 17. Rickert. VI, Jay SM. Gottlieb A. Effects of a peer-counseled AIDS education program in knowledge, attitudes, and satisfaction of Adolescents. J Ado1 Health 1991;12:3w. 18. Siegel DM, Neuderfer J, Zimmerli WH, Gildson D. Teaching about sexuality and AIDS a comparison of health professionals and peer educators. Am J Dis CHiId 1989;143:414(abstr). 19. Kowaleski L, Zeller R, Willis C. An evaluation of AIDS education: a quasi-experimental exploration. J Allied Health 19?1;191-202. 20. Jemmott JV, Jemmott LS, Fang GT. Reductions in HIV riskassociated sexual behaviors among black male adolescents: effects of AIDS nrevention intervention. Am J Public Health 1992;82:372-376.’ 21. Rickert VI. Jay SM, Gottiieb A. A comparison of three clinicbasea AIDS education programs on female adolescents’ knowledge, attitudes, and behaviors. J Ado1 Health Care 1998:11:298-303. 22. Miller L, Downer A. AIDS: what you and your friends need to know-a lesson plan for adolescents. J School Health 1988;58:137-141. 23. Rotherum-Borus MJ, Koopman C, Haignere C, Davies M. Reducing HIV sexual risk behaviors among runaway adolescents. JAMA 1991;266:1237-1241. 24. Slap GB, Plotkin SL, Khalid N et al. A human immunodeficiency virus peer education program for adolescent females. J Ado1 Health 1991;12:434-442. Prepared by: 1. Lawrence J. D’Angelo, M.D., M.P.H. Children’s National Medical Center George Washington University Richard Brown. M.D. Department of Pediatrics San Francisco General Hospital Abigail English, J D. National Center f br Youth Law Karen Hein M.D. Department of I’/diatrics Montefiore Medic\ a1 Center Albert Einstein College of Medicine Gary Remafedi, M.D. Department of Pediatrics University of Minnesota Medical Center