What Works in HIV Prevention for Youth

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Chapter 1: Introduction and Overview

2001

Above all, HIV prevention works: there is a wide range of proven strategies to reduce behaviors that increase the risk of transmitting or acquiring HIV.

-- Institute of Medicine, 2000

As each generation comes of age, there is a substantial increase in the rate of infection as individuals enter their late teens and early twenties, with infection rates peaking in the mid-to-late twenties. Sustained, targeted prevention for each group entering young adulthood is what will keep these waves from developing.

-- Centers for Disease Control and Prevention (CDC), 1997

Despite remarkable advances in research and clinical practice, AIDS is not over. Without a stronger commitment to HIV prevention for youth, it never will be. Even the very best treatments fall far short of a cure, and a vaccine is nowhere in sight. Young people need the tools to protect themselves from HIV infection, and we know a lot about what works. Making proven interventions available to young people is the only way to stop the spread of AIDS with this generation.

Every year, public health officials announce that at least half of new HIV infections in the U.S. are in young people under the age of 25, a statistic so often repeated that it is losing its ability to shock and alarm. As the frontline in the war on AIDS, community-based organizations (CBOs) have a special responsibility to keep Americans from growing accustomed to over 20,000 young people becoming HIV infected each year. CBOs are well-positioned to protect young people from the devastation of AIDS and the consequences of decisions made too young.

What Works in HIV Prevention for Youth offers insights from prevention science and community-based programs about strategies and approaches that can help prevent new HIV infections among America's adolescents and young people. It is a collaborative effort of AIDS Action and AIDS Alliance for Children, Youth & Families. We hope that this guide will be useful to community-based organizations wishing to begin, improve, or expand HIV prevention services targeted toward youth.

An Intractable Problem

Noting that at least one young American under age 20 was becoming infected with HIV every hour of every day, the Office of National AIDS Policy (ONAP) in 1996 called American youth a "generation at risk." Today, this characterization is as true as it was five years ago. Although protease inhibitors and other new treatments dramatically reduced the AIDS death rate for youth -- a 35 percent decline among those 15 to 24 years of age, from 1996 to 1997 alone -- there has been no decline in the number of new HIV infections among young people. AIDS remains a brutal disease and a significant threat to America's youth.

Any young person who engages in the normal experimentation and sexual curiosity that mark adolescence as a developmental period is at some risk for HIV infection, especially in geographic regions with a high HIV prevalence. But, as it does with adults, AIDS most threatens youth who already face poverty, racism, homophobia, gender inequality and other power differentials in relationships, poor access to health care, and homelessness. These same young people may also be struggling with sexual identity, self-esteem, and discrimination or exploitation. Homeless and runaway street youth, juvenile offenders, and young people who exchange sex for drugs, money, or affection are especially at risk.

Solutions

While HIV/AIDS among youth is a problem that defies easy solutions, HIV prevention science does provide some answers. We know much about what works to prevent HIV infection in youth, including programs that are frank and targeted -- employing both the languages and vocabularies of the young people and communities the programs are trying to reach, and offering risk- and harm-reduction strategies to youth who are doing things that put them at risk. Unfortunately, such programs are not available in most schools and communities (ONAP, 2000).

If preventing HIV infection among young people were simply a matter of applying research data, prevention programs across the country would feature "school-based HIV education for youth, condom availability, explicit public service messages targeted to people most at risk, and needle exchange and syringe purchase, as well as more traditional abstinence-based approaches" (FCAA, 1997, p.8). Clearly, there is an enormous gap between this ideal and what actually exists in local communities. In part, that's because HIV is contracted through sexual and drug-using behaviors that adults don't want to talk about with adolescents; they don't want to believe that teens even have sex or use drugs. In part, it reflects the triumph of politics over science. But it is never too late to do the right thing for America's youth.

Community-based organizations are uniquely able to fill the gap between what prevention science identifies as effective HIV prevention for youth and what is available locally. Indeed, a central tenet of the CDC's HIV prevention programs is that "those closest to the problem, equipped with needed information and tools, are best able to solve it" (CDC, 1998a, p.1). As families, schools, youth-serving organizations, and policy makers struggle to integrate their desire to protect adolescents from AIDS with their concerns for traditional values and community norms, CBOs are providing leadership locally. They are helping to develop a community consensus for HIV prevention and putting in place effective science-based HIV prevention interventions targeted for those most in need. This document seeks to support these efforts by offering those closest to the problem an update on what is working in HIV prevention for youth.

Overview of the Guide

Chapter Two "Youth and HIV/AIDS Today," is a snapshot of the current epidemic among young people in the United States, including the disproportionate impact of HIV and AIDS on young men who have sex with men and young African American and Latina women. The behaviors and life circumstances that put certain groups of young people at very high risk for HIV infection are reviewed, and the need for voluntary HIV counseling and testing for youth is outlined.

Chapter Three "What Prevention Science Research Says," summarizes findings from research on effective HIV prevention programs for youth, as well as on characteristics of effective prevention interventions across the board. The need for both individual-level and community-level interventions is stressed.

Chapter Four "What's Working in Local Communities," provides examples of HIV prevention strategies and models that community-based organizations are putting into practice to help reduce new HIV infections among adolescents and young people. Programs from across the country using peer education and social marketing are profiled. A contact person is listed for readers who want more information about individual programs.

Chapter Five "Summary and Resources," concludes the guide by inviting CBOs to accept the challenge of reducing the 20,000 new HIV infections each year among America's youth and advising careful adaptation of proven HIV prevention interventions to meet local needs and circumstances. It also refers CBOs who want to explore more fully the art and science of HIV prevention for youth to a variety of resources for more information, most of which is obtainable free of charge, either through the Web or through toll-free numbers.

References includes the references for the cites used throughout the document.

What Works in HIV Prevention for Youth

Chapter 2: Youth and HIV/AIDS Today

2001

Teenagers, especially young women and men in disadvantaged urban communities of color, are poised to become the tragic new face of AIDS in the United States.

-- The Kaiser Family Foundation, 1999

AIDS has already exacted a heavy toll on young Americans; over 126,000 of them have developed AIDS in their twenties (CDC, 2001). The typical delay between HIV infection and the onset of AIDS means that most of them were infected as teenagers. There continues to be 40,000 new HIV infections in the United States every year, and it has long been estimated that young people under age 25 account for at least 20,000 of these new infections, while youth between the ages of 13 and 20 make up half of that 20,000 (CDC, 2000c). But not all young people are equally at risk. This chapter profiles the epidemic among American youth, including the population groups most affected today and the behaviors that are putting young people at risk.

Unequal Jeopardy

Young people whose life circumstances contribute to high-risk behavior have been especially hard hit by HIV and AIDS. Just two groups -- young gay and bisexual men and young black and Latina women infected through heterosexual sex -- are thought to account for at least 75 percent of HIV-infected youth. Also at high risk for infection are youth of color, those exploring same-sex relationships who do not identify as gay or bisexual, drug and alcohol users, young people who have been sexually abused or exploited, out-of-school youth, those who are homeless, migrant youth, juvenile offenders, and other young people living on the margins of society. There is considerable overlap among these groups of young people, confounding risk factors and making it difficult for many who do become infected to identify just how and when.

Among adolescents, race is even more a factor in the epidemic than it is among adults (Collins, 1997). African American and Latino youth -- gay and straight, male and female -- are affected by HIV and AIDS far out of proportion to their numbers in the population (see Figure 1 & 2). Although African Americans make up only 15 percent of U.S. teenagers, they account for 60 percent of new AIDS cases reported in 1999 in that age group (13-19 years), up from 57 percent reported in 1998 (CDC, 2000b; Kaiser Family Foundation [KFF], 2000). Latinos, who constitute 13 percent of the adolescent population, represent 24 percent of new AIDS cases among teens in 1999 (CDC, 2000b). Together, black and Latino youth represent 84 percent of newly reported cases of HIV infection (Schemo, 2000).

For most of the epidemic, males have greatly outnumbered females among people living with HIV and AIDS. In 1999, for the first time, more females than males were diagnosed with HIV among 13 to 19 year olds -- over six out of every 10 new HIV infections reported in this age group (CDC, 2000b). In that same year, girls account for 58 percent of new AIDS cases reported among adolescents (KFF, 2000b).

Young Gay and Bisexual Men

Half of young men ages 13 to 24 reported to be living with HIV through June 2000 were exposed to the virus through sex with other men, and half of AIDS cases reported in 1999 in that age group were also among men who have sex with men (CDC, 2000a, 2000c). As with all other ages and exposure categories, young African Americans and Latinos are over-represented among men who become HIV infected through sex with men when compared to their numbers in the general population. In a recently released six-city CDC study, young urban gay and bisexual men had an alarming 12.3 percent rate of HIV infection, compared to a 7 percent overall rate in a similar study from 1994-1998 (Valleroy, et al., 2001). Most alarming, though, was the finding that 30 percent of young gay and bisexual black men, ages 23-29, are HIV infected.

Unsafe sex is clearly a problem among some groups of young gay and bisexual men. In the 1994-98 CDC study of 3,500 men ages 15 to 22 who have sex with men, 41 percent reported having engaged in unprotected anal sex, an extremely high-risk activity, in the previous six months. Bisexual men also are a bridge for HIV transmission to women. One in six of those young men had recently had sex with women, and nearly one-fourth had recently had unprotected sex with both men and women. Because sexual identity and sexual behavior do not always match, HIV prevention programs and strategies must be developed for young men who have sex with men but do not think of themselves as gay or bisexual. Such men are not likely to be reached by prevention messages aimed at men who identify as part of the gay community.

Young Women of Color

Young disadvantaged women, particularly African American women, are becoming HIV infected at higher rates -- and at younger ages -- than their male peers (CDC, 1998). This was demonstrated conclusively through HIV test results from over 350,000 16 to 21 year olds entering the Job Corps, a federally funded training program for disadvantaged out-of-school youth. Among the young women, rates of HIV infection were seven times higher for African Americans than for their white counterparts. For the population as a whole, black and Hispanic adolescents and women ages 13 to 24 account for more than three-fourths of all AIDS cases reported among females in that age group (CDC, 2000b).

Homeless and Runaway Youth

Homeless and runaway youth also are among those at highest risk for HIV and AIDS. No one knows how many young people are living in these circumstances. Estimates vary widely, ranging from 730,000 to 1.3 million (ONAP, 2000). In order to survive on the streets, many of these young people exchange sex for money, food, or shelter; many also use injection and other drugs. The rate of HIV infection in homeless and runaway youth is also unknown, with one four-city study finding a median HIV infection rate of 2.3 percent among homeless youth, and some shelters reporting rates as high as 10 percent (ONAP, 2000).

Geography

One of the greatest risk factors for young people is where they live, because they tend to socialize, explore, and develop relationships close to home. A high HIV prevalence in a community greatly increases their risk of becoming HIV infected compared to youth living in communities where few people are infected. The highest rates of adolescent HIV infection are in the South and along the East Coast, as well as in Texas, California, and some Midwestern states. However, new HIV infections are appearing all over the country, and young people in rural and other low-prevalence areas who live in high-risk circumstances also need HIV prevention education and access to targeted HIV prevention interventions.

Risk Behaviors

Membership in a particular population group does not confer automatic risk for HIV infection. Risk depends on behavior, and millions of American youth are engaging in sexual and drug-using behaviors that put them at risk for HIV. In fact, experimentation and risk-taking are considered fundamental to the period of adolescence, and as long as the epidemic exists each generation of American youth will need access to the information and skills necessary to make good decisions and to stay healthy.

More than in any other age group, HIV is spread sexually in young people (Collins, 1997). The good news is that there has been a drop in sexual risk behaviors and an increase in condom use among sexually experienced high school students (National Center for Health Statistics (NCHS), 2000). The bad news is that two-thirds of the 12 million Americans who have sexually transmitted diseases (STDs) are under age 25, and each year three million teenagers contract a STD (CDC, 1999) -- indicators of continuing high-risk sexual behavior among young Americans. Despite significant drops in the prevalence of sexual intercourse among high school students in the past decade, by their senior year 65 percent of American students have had intercourse.

Although condom use reported at last intercourse by high school students went up from 46 percent to 58 percent between 1991 and 1997 (KFF, 2000b), too many sexually active youth are not using condoms. And, there are signs that young people at highest risk in particular are not consistently protecting themselves with condoms, such as the 46 percent of young urban men who have sex with men in one study who reported recent unprotected anal sex (Valleroy, et al., 2001). Among some groups of young women, not using a condom may be a statement about their feelings for their partners. In interviews with over 500 African American adolescent females, Crosby and his colleagues (2000) found that more than 75 percent had sex with a steady partner, while less than 10 percent had casual sex; not using a condom with a steady partner was seen as a sign of intimacy in the relationship and trust in their partner.

This is consistent with findings from several recent studies that many sexually active teens, despite knowing the facts about HIV and STDs, do not consider themselves at risk for infection. A recent Kaiser Family Foundation/MTV survey found that 68 percent of sexually active 15 to 17 year olds do not think they personally are at risk (Kaiser, 2000b).

Drug and alcohol use among youth also contributes to sexual risk behaviors, putting many young people at risk for HIV infection by impairing their judgment. One in four sexually active high school students say they were under the influence of alcohol or drugs the last time they had sex. Substance abuse also is a direct risk for some young people through shared needles: one in 50 high school students say they have injected illegal drugs (CDC, 1997).

Clearly, American youth are at risk for HIV infection from the same behaviors that put adults at risk. Young people, however, may have less power and fewer skills when it comes to navigating through high-risk circumstances. Many studies have documented that youth whose first sexual intercourse occurred in their early teens report a very high incidence of involuntary or coerced sex, and in some groups of girls, early sex is relatively common. Almost one-third of babies born to 15-year-olds have fathers who are at least 21 (FCAA, 1997). Coercive early sex and early sex with partners several years older are both factors associated with high risk for HIV infection.

Counseling and Testing

Because most youth who are HIV infected don't know it, they are not receiving the care that can help prevent or delay HIV's early damage. Getting tested is a first step to getting the health care they need and learning how to protect themselves and their partners. Those who test negative can get counseling and support to help them stay that way.

Voluntary counseling and testing is an important component of youth HIV prevention, but adolescents and young people face significant barriers to getting tested. Many who are at risk have no health care provider they can turn to for advice and do not know how to arrange for an HIV test. A recent Kaiser Family Foundation national survey found that two-thirds of teens do not know for sure where to go to get tested, including a majority of those who are sexually active (KFF, 2000a). Some counseling and testing facilities are open primarily during school hours. Many sites are geared toward adults and are not youth-friendly in language, environment, or approach. In some states, parents will be notified of an adolescent's HIV-positive test result. In others, parental permission is a significant barrier for youth who are afraid to tell their parents why they need to be tested. Even when young people manage to overcome these barriers and get tested for HIV, many never return for their test results.

Community-based organizations can change this for the better. Where feasible, a CBO might choose to open a youth-friendly counseling and testing program. Those already operating testing programs can review them to see if they are, in fact, youth friendly and how they can be modified, if necessary, to better serve adolescents and young people. CBOs not in a position to offer such services directly can form strong links with youth-friendly testing sites and actively encourage young people in high-risk circumstances to get counseled and tested.

Chapter 3: What Prevention Science Research Says

2001

Prevention science has identified programs that can reduce risk behavior. . . . Some of the proven programs were designed for small group or classroom use. With an emphasis on communication, negotiation, and refusal skills, they state clearly that abstinence is important, and also provide information about condoms and other contraceptives. Other effective programs offer individualized counseling to high-risk youth, or use outreach workers to deliver prevention messages. A final group of programs mentor young people in activities that make the future seem brighter and staying safe seem worthwhile.

-- Office of National AIDS Policy, 2000

Prevention science combines behavioral and social science perspectives to evaluate the effectiveness of HIV prevention. Many questions are still unanswered -- especially with respect to youth of color, both young men who have sex with men and young black and Latina women -- but the evidence is clear and compelling: prevention works. A variety of HIV prevention interventions have been proven effective in reducing HIV risk behavior among youth (see Chapter Five references, Compendium of HIV Prevention Interventions with Evidence of Effectiveness and Replicating Effective Programs Plus). No one intervention is best for all young people, and both individual-level and community-level interventions are necessary to defeat the epidemic in America's youth (Kelly, 2000).

This chapter offers an overview of what prevention science has to say about what works for preventing HIV infection in young people.

Characteristics of Effective Prevention

Although HIV prevention interventions must be targeted to the specific needs of individuals and communities, prevention science has discovered principles and characteristics of effective prevention generally. Coates and his colleagues (1996) identify nine such principles, which can be a useful guide for CBOs considering initiating HIV prevention programs as part of their constellation of services:

Principles of Effective HIV Prevention

1. Sustained interventions are more likely to lead to sustained behavior change.
2. More intense interventions are more likely to result in greater risk reduction.
3. Accessibility to devices that are necessary for safer practices reduces risk of HIV infection.
4. Skill building and the modification of social norms appear to enhance behavior change.
5. Timing of interventions matters.
6. Individual-level interventions can change behavior, but are probably not equal to the task of risk reduction for populations with high prevalence of HIV infection.
7. HIV counseling and testing have a place in HIV risk reduction, but are not sufficient for HIV prevention.
8. Working at the level of community can sometimes lead to significant behavioral changes.
9. Media interventions can sometimes lead to significant general population behavior changes. (Coates et al., 1996, p.1146)

These principles are consistent with the findings of the CDC's HIV/AIDS Prevention Research Synthesis Project (1999) and the recent report to Congress from the Institute of Medicine (2000) on the state of HIV prevention in the United States.

Targeted Prevention

Prevention research and the experiences of CBOs both attest to the importance of targeted HIV prevention. Prevention can be targeted in a variety of ways to match multiple risk factors and circumstances. Interventions can be targeted by age, gender, sexual experience, ethnicity, behavioral risk, or neighborhood, among others. Many HIV prevention programs and interventions use a combination of factors in targeting their services.

The Asian & Pacific Islander Coalition on HIV/AIDS (APICHA) in New York City is one such program. This CBO seeks to meet the needs of New York's Asians and Pacific Islanders, richly diverse communities that vary greatly with respect to culture and ethnicity. Therefore, APICHA offers a broad range of HIV prevention programs to reach these communities, many of whose members do not use mainstream services because of language and cultural barriers. The Young People's Project's bilingual volunteers reach youth with HIV prevention interventions through school-based workshops and one-on-one street outreach at community centers, video arcades, pool halls, and other places where Asian young people gather.

Timing, Frequency, and Intensity

Early and often are good guideposts for HIV prevention interventions for youth. Early prevention education encourages young people to adopt healthy behaviors and to avoid beginning unhealthy ones. Prevention is most effective when it reaches adolescents before they initiate sexual and drug-using behaviors that put them at risk for HIV. In a study on the impact of mother-adolescent communication on HIV prevention among 372 sexually active teens, the CDC found that condom use increases only among teens whose mothers talk to them about condoms before they have intercourse for the first time (CDC, 1998c). These teens are three times more likely to use condoms than teens who either never discuss condoms with their mothers or who discuss them only after initiating sexual activity. Condom use at first intercourse dramatically predicts future use, with youth who use condoms at first intercourse 20 times more likely to use condoms subsequently.

Below a certain threshold of frequency, many youth HIV prevention interventions are not effective in changing risk behavior. The frequency differs with the intervention and the group targeted, but, in general, effective interventions for youth are sustained and intense. In a social marketing campaign aimed at getting prevention messages out to youth, more frequent exposure to the messages resulted in youth feeling more able to avoid sexual risk. Reporting on a scientific review of successful interventions, Collins (1997) called 10 to 14 sessions with homeless and runaway youth a "full dose," while 12-session interventions produced substantial change in risk behavior among gay men.

Information Combined with Skill Building

Behavioral prevention interventions attempt to prevent someone from acquiring or transmitting the virus by trying to change individual sexual and drug-using behavior. In the early days of the epidemic, most interventions were based on the assumption that knowing the facts about HIV transmission would prevent someone from becoming infected. Despite early successes, however, it soon became apparent that information is not enough; high rates of risky behavior continue in hundreds of thousands of individuals who know how HIV is transmitted. Dozens of prevention science studies have since demonstrated that behavioral interventions that combine information with skills building are more effective in producing sustained behavior change and risk reduction. For example, Lawrence and colleagues (1995) in a study with 246 African American adolescents compared a cognitive-behavioral intervention with information only and found that one year after intervention almost three times as many abstinent teens had initiated intercourse in the information-only group than had in the skills training and information group.

Involving Families

Prevention science has demonstrated that involving parents is an effective strategy for preventing HIV infection in youth. Frank discussions about sex between parents and young people can lead youth to adopt healthy behavior, such as condom use. One survey of 522 African American adolescent girls found that those who regularly discussed sex with their parents were significantly less likely to engage in risky sexual behavior and much more likely to bring up STD and HIV prevention with their sexual partners when compared to girls whose parents did not talk with them about sex (Crosby, et al., 2000).

The AIDS and Adolescents Network of New York (AANNY) demonstrates how involving parents can help overcome community resistance to HIV prevention education in the schools. AANNY recruits and trains lesbian and gay youth, their parents, and lesbian and gay parents to serve as advocates and educators for school-based AIDS education. Since 1987, this diverse group of youth service providers, health care providers, teachers, activists, researchers, parents, and youth have been promoting HIV/AIDS education and prevention programs for young people, as well as advocating for public policies to end the epidemic among youth. AANNY offers a series of small interactive workshops facilitated by parents and youth who have experience in peer education and advocacy around HIV. Among the workshop content are: HIV/AIDS 101, adolescent development, sexual identity issues, attitudes about sexuality, communication, and living with HIV/AIDS in the family.

Sexuality Education and HIV Prevention Education

Both the Institute of Medicine and the President's Council on HIV/AIDS recently identified a key problem in preventing HIV among America's teenagers -- the proliferation of abstinence-only sexuality education in our schools at the expense of comprehensive programs:

". . .  the nation is spending approximately $440 million in federal and state funds over five years on abstinence only sex education -- in the absence of any evidence that this approach is effective, much less cost-effective -- solely because of social forces that prevent effective comprehensive sex education courses from being offered." (IOM, 2000, p.9)

"Unlike many other nations, the U.S. government has been unwilling to implement systematic, population-wide education that teaches children and adults about sexual and drug-related risks for transmitting HIV. This barrier to explicit sexual and drug-related conversations with young people has had enormous consequences. . . . Fears that explicit sexual information would increase sexual initiation among U.S. youth have not been supported by studies that have evaluated such claims. Yet too many policy makers continue to push to censor the prevention that youth receive by mandating and funding 'abstinence only' approaches." (PACHA, 2000, p.20)

One of the most persistent challenges to HIV prevention for youth is the widely held belief that early sexuality and HIV prevention education lead to promiscuity, a myth that underpins the abstinence-only movement. In fact, the opposite is true. Several studies reviewing the scientific literature found that teens who receive HIV education are less likely to engage in sexual intercourse; those who do have sex less often and use contraceptives more when they have intercourse (IOM, 2000; Kirby, 1995). In contrast, no scientific evidence supports the effectiveness of abstinence-only programs.

Although most young people know the facts about HIV transmission (KFF, 2000b), they still want and need to know more, including how to protect themselves. Unfortunately, in schools all across the country, they are being taught less now than they were a dozen years ago. Abstinence-only programs are proliferating: in 1999, 23 percent of public school sexuality teachers reported teaching abstinence as the only way to prevent STDs, including HIV, compared with 2 percent in 1988 (Alan Guttmacher Institute, 2000).

Because policies on sexuality education and condom availability are to a large extent determined locally, community-based organizations are much better positioned than national ones to advocate for comprehensive sexuality and HIV prevention education in their local schools. Where such advocacy is not successful, CBOs can help to fill the gap by offering these kinds of programs for youth.

Even when schools do provide comprehensive programs, many youth at highest risk are out of school entirely, while others do not attend regularly. These young people will not be reached by school-based programs, and they are significantly more likely than in-school youth to be sexually active, to have had four or more sex partners, and to have used alcohol and other drugs (Harper and DeCarlo, 1999) -- all behaviors that put them at very high risk for HIV infection. Prevention programs for these young people are needed in venues accessible to them, and CBOs can play an important part in meeting this need.

Peer Education

Peer education is a highly effective prevention strategy with youth. In fact, it is more than just a strategy; it is also an "approach, a communication channel, a methodology, [and] a philosophy" (UNAIDS, 1999, p.2). Peer education uses young people as credible prevention messengers to effect change among other young people. It has been successful both at the individual level, in changing attitudes and skills, and also at the societal level in influencing group norms. Peer education is consistent with several behavior change theories, among them social learning theory, the theory of reasoned action, the diffusion of innovation theory, and the theory of participatory education.

Social Marketing

Community-level interventions have demonstrated considerable efficacy in preventing HIV infections. The social marketing of condoms in developing countries is one often-cited example of a remarkably effective community-level intervention (IOM, 2000). Social marketing uses advertising expertise -- media campaigns and other marketing strategies -- to reach large numbers of people and influence their attitudes and behavior, motivating them to healthy behavior change. Because advertising is so effective in helping to define youth culture, social marketing for HIV prevention has great potential for use with young people. Evaluations of social marketing stress that the messages must be delivered through diverse channels, be sustained over time, and respond to changes in the market (Collins, 1997).

The CDC studied the effectiveness of social marketing approaches with adolescents in a five-city project called the Prevention Marketing Initiative (PMI). Volunteer coalitions that included youth as members planned and launched youth-oriented media campaigns that reached thousands of young people with HIV prevention messages. In one city, in 15 zip codes with high STD rates, 60 percent of 15 to 18 year olds reported hearing of PMI, and the campaign was associated with significant increases in condom use (Kennedy and Mizuno, 1999).

One effective social marketing approach uses members of high-risk populations who are popular with other members to advocate behavior change at the community level. This "opinion leader" model, developed by Kelly and his colleagues at the Center for AIDS Intervention Research (CAIR), recruits popular people within a community and trains them to deliver and model prevention messages to their peers. This approach has been used successfully with gay men in bars, with inner-city women in housing developments, and with young people, among others.

Chapter 5: Summary and Resources

2001

We do not yet have a cure or a vaccine to prevent HIV and AIDS. AIDS is still winning the war, but we do have an arsenal of weapons at our command. We have the resources and the know-how. Now we must have the will, the energy, and the passion to continue the fight. Community-based organizations on the front lines can make all the difference between a resigned acceptance of 20,000 new infections each year among American youth and an ardent recommitment to HIV prevention.

Key to making a difference for youth at the local level is the adoption or careful adaptation of successful HIV prevention interventions, paired with ongoing evaluation of their effectiveness in reducing risky behavior or increasing safer behavior. This concluding chapter refers CBOs to readily available resources that can help them achieve this goal.

Adapting Prevention Programs

Adapting proven HIV prevention interventions to meet local needs and client circumstances is a cost-effective and often-successful strategy for CBOs. Before a CBO chooses to adapt, it is critically important to understand the characteristics of the original intervention and its audience, and how they are similar to or different from the CBO's intended use. The Center for AIDS Prevention Studies illustrates this crucial aspect of adapting programs:

"One successful prevention program for gay men in small cities recruited popular opinion leaders from bars, and trained them to deliver and model prevention messages to their peers. This program was then adapted to address minority women in inner city housing developments. However, the program didn't work there. The reason? Women didn't know their neighbors, and because of high crime rates in the housing developments, were reluctant to open their doors to someone they didn't know. This program was then reworked, starting by helping women in the housing developments establish a sense of community through potluck dinners and music festivals. As a result, not only did the women increase condom use and communication, but the community began to tackle other issues besides HIV such as drugs and violence in the housing development." (DeCarlo and Kelly, 1996, p.3)

Failing to account for such differences can torpedo an intervention that might otherwise be successful. Recognizing them and making adjustments allows CBOs to tailor interventions to local needs and populations while retaining the core of what makes an intervention work.

Resources

CBOs interested in beginning or expanding their HIV prevention services for youth can choose from a wide range of easily obtainable resources, the majority of them free of charge. The CDC is a rich source of information, a great deal of it available on the Web. Many prevention science centers, such as the Center for AIDS Prevention Studies at the University of California San Francisco also have useful Web sites. CBOs, too, are increasingly making available information about their prevention programs through their own Web sites or through collaborative efforts. Finally, a number of local and national organizations offer CBOs direct technical assistance.

Centers for Disease Control and Prevention

The CDC is responsible for administering federal HIV prevention programs and is an excellent resource for a wide range of information from epidemiological data to fact sheets and updates to consensus documents on HIV prevention. Almost all of this information is available for downloading from the Web. The CDC's home page is www.cdc.gov.

Look for Compendium of HIV Prevention Interventions with Evidence of Effectiveness at www.cdc.gov/hiv/pubs/hivcompendium/HIVcompendium.htm. The CDC developed the compendium to respond to requests from CBOs and others for science-based interventions that work. It is a collection of summaries of rigorously studied behavioral and social interventions that are state-of-the-science, have no negative findings, and have demonstrated evidence of effectiveness in reducing sex- and drug-related risk behaviors or improving health outcomes, with a statistically significant difference between the intervention and control groups. The summaries include content, method, intervention goal, setting, population, findings, and a contact person. Nine interventions included in the Compendium target youth.

Interventions included in the document were identified by CDC's HIV/AIDS Prevention Research Synthesis Project, an ongoing database of studies. For more information on the Compendium, contact Linda Kay at the CDC, 1600 Clifton Road, Mailstop E-37, Atlanta, GA 30333, (404) 639-1900.

Look also for Replicating Effective Programs Plus at www.cdc.gov/hiv/projects/rep/default.htm. Like the Compendium, the REP+ site offers descriptions of science-based programs with demonstrated effectiveness in reducing risky behaviors or encouraging safer ones. The CDC has translated program information into everyday language and packaged it to be user-friendly. REP interventions are available for a variety of populations; information is provided on the research behind the interventions and on how to get program materials.

Center for AIDS Prevention Studies (CAPS)

CAPS is a program of the AIDS Research Institute at the University of California San Francisco. CAPS conducts theory-based HIV prevention research and focuses heavily on disseminating research results in a variety of user-friendly formats. For this reason, CAPS is an excellent resource for CBOs. CAPS' Web site, HIV InSite (hivinsite.ucsf.edu), offers a comprehensive array of prevention tools, fact sheets, monographs, reports, articles from the media, and links, including links to download documents from other sources. A stated goal of the site's prevention section is to help service providers build strong programs based on prevention science.

A CAPS publication of special interest to CBOs wanting to know more about targeting HIV prevention for youth is Dangerous Inhibitions: How America is Letting AIDS Become an Epidemic of the Young. The sections on "Understanding Risk" and "Rethinking the Message" offer a succinct analysis of why prevention paradigms for youth need changing and why some research methods are missing the mark.

CBOs can contact CAPS at: AIDS Research Institute, University of California San Francisco, 74 New Montgomery, Suite 600, San Francisco, CA 94105, (415) 597-9100.

The Kaiser Family Foundation

The Henry J. Kaiser Family Foundation is an independent philanthropy dedicated to health care issues. The foundation runs its own research and communications programs, often partnering with universities, policy think tanks, and other organizations. The Kaiser Family Foundation is a leading source for policy and program information related to HIV/AIDS, and disseminates the "Daily HIV/AIDS Report." Most foundation products are available free from the publications request line (1-800-656-4533) or through download from www.kff.org. The Web site includes a section devoted to HIV/AIDS prevention, including links to facts sheets, briefs, and reports.

Of special interest to CBOs concerned about youth-friendly HIV testing services is Hearing Their Voices: A Qualitative Research Study on HIV Testing and Higher-Risk Teens, a report on research conducted for the Kaiser Family Foundation about the attitudes and concerns of at-risk youth toward HIV testing. The report, which is based on a series of in-depth interviews and focus groups with 73 high-risk teenagers in Miami, Houston, New York City, and Newark, examines the complex issues surrounding adolescents' views of and experiences with HIV testing, including why they do or do not get tested.

What Works in HIV Prevention for Youth

References

2001

1. AIDS Action Foundation. (1997). Recommendations for integrating behavioral and social science perspectives into primary HIV prevention. Washington, DC: Author.
2. Alan Guttmacher Institute. (2000, September). Trend toward abstinence-only sex ed means many U.S. teenagers are not getting vital messages about contraception (press release). Washington, DC: Author.
3. Centers for Disease Control and Prevention (CDC). (2001, January). Cases .
4. CDC. (2000, December). HIV/AIDS surveillance report, 12(1).
5. CDC. (2000). HIV/AIDS surveillance report, 11(2).
6. CDC. (2000). Young people at risk: HIV/AIDS among America's youth (webpage). www.cdc.gov/hiv/pubs/facts/youth.htm.
7. CDC. (1998, June). Linking science and prevention programs -- The need for comprehensive strategies (CDC Update). Atlanta: Author.
8. CDC. (1998, September). National data on HIV prevalence among disadvantaged youth in the 1990s (CDC Update). Atlanta: Author.
9. CDC. (1998, October). Patterns of condom use among adolescents: The impact of mother-adolescent communication (CDC Update). Atlanta: Author.
10. CDC. (1997, July). Comprehensive HIV prevention messages for young people
11. CDC. (1994, December). HIV/AIDS surveillance report, 5(4).
12. Collins, C. (1997, February). Dangerous inhibitions: How America is letting AIDS become an epidemic of the young. Monograph Series Occasional Paper #3. San Francisco: Center for AIDS Prevention Studies (CAPS), University of California San Francisco.
13. Crosby, R.A., DiClemente, R.J., Wingood, G.M., Sionean, C., Cobb, B., and Harrington, K. (2000). Correlates of unprotected vaginal sex among African American female adolescents: Importance of relationship dynamics. Archives of Pediatrics and Adolescent Medicine, 154(9), 893-899.
14. DeCarlo, P., and Kelly, J. (1996). Can HIV prevention programs be adapted? San Francisco: CAPS, University of California San Francisco.
15. Freudenberg, N., and Radosh, A. (1998). Protecting youth, preventing AIDS. New York: Academy for Educational Development.
16. Funders Concerned About AIDS. (1997, July). Taking action to prevent AIDS. New York: Author.
17. Harper, G.W., and DeCarlo, P. (1999, April). What are adolescents' HIV prevention needs (fact sheet). San Francisco: CAPS, University of California San Francisco.
18. HIV/AIDS Prevention Research Synthesis Project. (1999, November). Compendium of HIV prevention interventions with evidence of effectiveness. Atlanta: CDC.
19. Institute of Medicine. (2000, September). No time to lose: Getting more from HIV prevention. Washington, DC: National Academy Press.
20. Kaiser Family Foundation (KFF). (2001, May). Key Facts: Women and HIV/AIDS. Menlo Park, CA: Author.
21. Kaiser Family Foundation. (2000). A national survey of teens on HIV/AIDS. Menlo Park, CA: Author.
22. Kaiser Family Foundation. (2000, August). Teen sexual activity (fact sheet). Menlo Park, CA: Author.
23. Kelly, J. (2000, Summer). Mobilizing community strengths to prevent AIDS. CAIR Connection. Milwaukee: Center for AIDS Intervention Research.
24. Lawrence, J.S., Brasfield, T.L., Jefferson, K.W., Alleyne, E., O'Bannon, R.E., and Shirley, A. (1995). Cognitive-behavioral intervention to reduce African American adolescents' risk for HIV infection. Journal of Consulting Clinical Psychology, 63(2), 221-237.
25. National Center for Health Statistics (NCHS). (2000). Health, United States 2000. Hyattsville, MD: Author.
26. Office of National AIDS Policy. (2000). Youth and HIV/AIDS 2000: A New American agenda. Washington, DC: Author.
27. Presidential Advisory Council on HIV/AIDS (PACHA). (2000, September). AIDS. No Time to Spare: The Final Report to the President of the United States. Washington, DC: Author.
28. Schemo, D.J. (2000, December 28). Sex Education With Just One Lesson: No Sex. The New York Times.
29. UNAIDS. (1999, December). Peer Education and HIV/AIDS: Concepts, Uses and Challenges. Document #UNAIDS/99.46E. Geneva, Switzerland: Author.
30. Valleroy, L., et al. (2001, February). High HIV and Risk Behavior Prevalence Among 23-29-Year-Old Men Who Have Sex With Men in 7 US Cities. Abstract 211. 8th Conference on Retroviruses and Opportunistic Infections, Chicago, IL.