Strategy Summaries for PS13-1308

Schools are vital partners in helping young people learn how to take responsibility for their health and adopt lifetime health-enhancing attitudes and behaviors. Health education—integral to the primary mission of schools—provides young people with the knowledge and skills they need to become successful learners and healthy and productive adults. Increasing the number of schools that provide health education on key health problems, such as HIV, other STD, and pregnancy, is a critical objective for improving our nation’s health. Sexual health education programs should —

• Be medically accurate and consistent with scientific evidence.
• Be tailored to students’ needs and the contexts and educational practices of communities.
• Use effective classroom instructional methods.
• Allow students to develop and demonstrate developmentally appropriate sexual health-related knowledge, attitudes, skills, and practices.

Independent reviews of the scientific evidence show that well-designed and well-implemented HIV/STD prevention programs are effective in decreasing sexual risk behaviors among youth.

Specific outcomes include —

• Delaying first sexual intercourse.
• Reducing the number of sex partners.
• Decreasing the number of times students have unprotected sex.
• Increasing condom use.

Additionally, HIV/STD prevention programs —

• Were not shown to hasten initiation of sexual intercourse among adolescents.
• Can be cost-effective.

In 2010, young people aged 13–24 accounted for 26% of all new HIV infections in the United States, and nearly half of the 19 million new sexually transmitted diseases (STD) reported each year are among young people aged 15–24. Many adolescents engage in sexual risk behaviors that can result in such unintended health outcomes. For example, among U.S. high school students surveyed in 2013, almost half reported ever having had sex. Of those sexually active in the previous 3 months, about 40% did not use a condom. Clinical services can help prevent new cases of HIV and other STDs by increasing testing, treating infections, and reducing risk behaviors.

Several national guidelines for adolescent preventive care specifically include recommendations for the provision of sexual and reproductive health services for adolescents including:

• HIV testing beginning at age 13 in areas more affected by HIV.
• Gonorrhea and chlamydia screening of sexually active females ages 25 and under.
• Human Papillomavirus (HPV) vaccination beginning at ages 11–12.

Despite these official guidelines and recommendations, adolescents may not seek or have access to health services because of unique barriers that particularly hinder use of sexual health services.

Schools in the United States have a critical role to play in facilitating delivery of such needed preventive services for adolescents:

• Schools are an appropriate venue for HIV, STD, and teen pregnancy prevention programs.
• Schools have direct daily contact with almost 15 million students attending grades 9-12.
• Many schools have healthcare service infrastructure in place.

For these reasons, one of CDC-Division of Adolescent and School (DASH)’s key programmatic strategies is to improve schools’ capacity to increase adolescents’ access to key preventive sexual health services via either direct provision of on-site services or referrals to adolescent-friendly community-based health service providers.

Research shows that safe and supportive school environments are associated with improved education and health outcomes for all students. Promoting and providing a learning environment in which all students and staff can expect to feel safe and supported is an essential function of schools. The school environment is shaped by district and school policies and practices; school structure and decision-making processes; and classroom factors, such as teachers’ classroom management methods and peer-to-peer/teacher-to-student relationships.

When students find their school environment to be supportive and caring and their parents engaged in their school lives, they are less likely to become involved in substance abuse, violence, and other behaviors that are associated with HIV and STD risk. For those students at disproportionate risk of HIV/STD—such as young men who have sex with men (YMSM), who often experience increased victimization (e.g., bullying or harassment)—safe and supportive school environments are especially important.

Research on prevention of school-based bullying and harassment has identified promising practices including —

• Implementing and enforcing a school-wide anti-bullying and harassment policy.
• Improving the supervision of students.
• Using school rules and behavior management techniques in the classroom as ways to keep students safe.

In addition, school connectedness and parent engagement in schools have been identified as promising protective factors for adolescent sexual and reproductive health risk behaviors and outcomes.

Young people who share certain demographic characteristics are disproportionately affected by HIV infection and other STD. Specifically—

• Among adolescent males aged 13–19 years, approximately 91% of diagnosed HIV infections in 2010 were among young men who have sex with men (YMSM).
• Youth who identify as lesbian, gay, bisexual, or transgender (LGBT) are more likely than their heterosexual peers to experience early sexual debut, have more lifetime and recent sex partners, engage in unprotected sexual intercourse, and use alcohol or other drugs prior to last sexual intercourse.
• 1.5 to 2 million youth per year are homeless or have run away from home. Homeless youth are highly likely to experience early sexual debut, have multiple sex partners, engage in unprotected sexual intercourse, and use alcohol or other drugs prior to sex resulting in a high risk of acquiring HIV.
• Among students who are sexually active, alternative school students are less likely to have used a condom during sexual intercourse and are nearly twice as likely to use alcohol or drugs prior to sexual intercourse compared to mainstream high school students.

Developing or strengthening efforts for addressing the health needs of LGBT youth, homeless youth, or youth in alternative school settings is a priority in this cooperative agreement. Funded sites should choose specific evidence-informed practices on the basis of their particular needs, but might include strategies such as identifying LGBT-friendly health providers; developing guidance to link homeless students to necessary health and social services; and implementing evidence-based interventions that have been designed for use in alternative school settings, such as All4You!

Compared with HIV infections in the general population, HIV infections among young men who have sex with men (YMSM) continue to be disproportionately high, especially in communities of color. In 2010 —

• One-quarter (25.7%) of all new HIV infections were among youth aged 13–24, and YMSM accounted for almost three-quarters (72.1%) of all new HIV infections in that age group.
• More than half of all the HIV infections among YMSM aged 13–24 were among African Americans (54.4%) and approximately one-fifth were among Latinos (21.6%).

Increasing attention has been given to the HIV prevention needs of YMSM; however, these efforts have largely focused on young adults rather than on adolescents. Although teen YMSM (13–19 years old) have typically received HIV prevention services from community-based organizations (CBOs) that focus primarily on runaway or out-of-school youths, YMSM who are in school also are at risk for HIV infection.

CDC recommends that all adolescents and adults aged 13–64 get routine HIV testing and MSM get HIV testing at least annually. Although many adolescents engage in sexual behaviors that place them at risk for HIV infection, relatively few have been tested for HIV. According to 2013 Youth Risk Behavior Survey results, only 22% of sexually experienced high school students had ever been tested for HIV. These statistics highlight the need for programs targeted specifically for teen YMSM with a focus on increasing their access to sexual health services and decreasing sexual risk behaviors.

Schools can connect YMSM to HIV and STD testing and other sexual health services in their communities, and some schools can offer those services directly to youth. In addition, evidence-based interventions (EBIs) that were developed for other populations of youth, or for young adult YMSM, can be adapted to reduce HIV risk among teen YMSM. Because YMSM are more likely to miss school or drop out, a core component of an HIV prevention program for teen YMSM is creating safe and supportive environments for all students.