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With an estimated 11 million cases worldwide, adolescents are the fastest growing group of persons newly diagnosed with human immunodeficiency virus (HIV) and are at the center of the worldwide AIDS pandemic (United Nations Children's Fund, Joint United Nations Programme on HIV/AIDS & World Health Organization, 2002). The most recent epidemiological data from the U.S. Centers for Disease Control and Prevention (CDC) indicate that 89% of all recent adolescent heterosexually acquired HIV infections occurred in girls (2004c).
Similarly, 40% of the chlamydia cases reported in 2000 were among young women 15 to 19 years of age. The disproportionately high rates of sexually transmitted infections (STIs) among adolescent girls are particularly important because the presence of STIs is known to facilitate HIV transmission (CDC, 2000). Despite the extensive evidence indicating the effectiveness of condom use in preventing STI and HIV transmission (Holmes, Levine, & Weaver, 2004; Warner & Hatcher, 1998), adolescent girls continue to engage in behaviors that increase their risk for infection (Morrison-Beedy, Carey, & Aronowitz, 2003).
In the last half-decade of the U.S. HIV epidemic, scientists observed disproportionately high rates of infection among females of color (CDC, 2001a). In an urgent effort to address the disparity between Black and White HIV rates, individual and group level HIV prevention interventions, as well as community level prevention campaigns were designed to address ways to increase HIV knowledge and pro-risk reduction attitudes and behaviors in the Black U.S. population (CDC – AIDS Community Demonstration Projects Research Group, 1999; DiClemente & Wingood, 1995; Lauby, Smith, Stark, Person & Adams, 2000). Recently, and arguably because of these efforts, researchers are reporting a stabilization of the HIV rate among Blacks (CDC, 2003b) as well as decreases in HIV risk behaviors, increases in HIV related knowledge, and increases in HIV testing rates (CDC, 2004a). The progress noted among the U.S. Black population is in accord with the goals of the federal governments Healthy People 2010 plan (United States Department of Health and Human Services, 2000). However, similar progress has not been reported among Whites. The purpose of this article is to provide evidence of the racial differences in concurrent patterns of HIV testing and HIV risk-related behaviors in the same sample of adolescent girls who consented to participate in a pilot randomized controlled HIV prevention intervention.
Although recent epidemiological data still provide evidence that both the prevalence and incidence of HIV is disproportionately higher in Blacks than in Whites (CDC, 2001a; 2003b), the incidence rate for Blacks has remained relatively stable while that of Whites has increased during the past 7 years (CDC, 2001a). Other studies also provide evidence that there are racial differences in HIV-associated risk-taking behaviors. The most recent national Youth Risk Behavior Surveillance (YRBS) report, which provides information on 15,214 adolescents in grades 9- 12, offers numerous examples of higher risk behaviors among White adolescent girls as compared to Black adolescent girls (CDC, 2004b). For example, regarding substance use behaviors by racial category, YRBS reports that rates of current alcohol use, lifetime and current cocaine use, and lifetime heroin use were higher for White adolescent girls than for Black adolescent girls, including the use of these substances before sex (CDC, 2004b). These data are pertinent given that behavioral research has shown that drug use increases the likelihood that these girls wil, engage in risky sexual behaviors and decreases the likelihood that they will be able to effectively insist on safer-sexual practices win partners (Morrison et al., 2003).
Further indicators of increased sexual risk behavior by White adolescent girls are reflected in the prevalence of sexual activity and condom use. Again, according to the 2003 national YRBS, the prevalence of current sexual activity was higher for White adolescent girls than for Black adolescent girls (CDC, 2004b). The survey also shows that White adolescent girls were less likely to report using a condom during last sexual intercourse episode than the Black adolescent girls in the sample. Similarly, an earlier study by Hines and Graves (1998) also found lower rates of condom use among Whites than Blacks in their sample. The risk posed by low prevalence of condom use and high prevalence of sexual activity among White adolescent girls in this sample may be compounded by the high reports of drug use (cocaine, heroin, alcohol) in the same sample. These risk behavior data, though not necessarily inconsistent, are counterintuitive given CDC (2004b) reports that in 2002, the number of Whites diagnosed with HIV (8,347) was 57% that of the number of Blacks diagnosed with HIV (14,398), although Blacks only comprise approximately 12% of the U.S. population.
Several plausible explanations for the inconsistency between HIV prevalence data and the reported HIV sexual risk behavior data of White adolescent girls have been proposed. Among these, the CDC (2003b) itself cautions that “HIV surveillance reports may not be representative of all persons infected with HIV because not all persons infected with HIV have been tested” (p. 33). Ebrahim and colleagues. (2004) conducted a secondary analysis on a representative sample of 161,403 adult men and women to determine if HIV testing patterns in this sample differed by race. Their study found that Whites had statistically significantly lower HIV testing rates than did Blacks in the sample. In a recent survey given to a nationally representative random sample of 2,902 adult men and women, 46% of Whites reported that they had been tested for HIV compared to 68% of Black respondents (Kaiser Family Foundation, 2004). The survey also found that 15% of Whites reported having been tested in the last 12 months compared to 36% of Blacks (Kaiser Family Foundation, 2004). Still another study has shown that even after suspected exposure, adult White females waited longer than Black females to be tested for HIV (Seigel, Karus, & Raveis, 1997).
The reason for the racial disparities in testing and HIV risk-related behaviors are not accounted for easily. Most of the data relating to this issue is on adults, but the patterns inform our understanding of HIV testing rates in adolescents as well. Studies have consistently shown that overall, Whites of all ages tended to have higher HIV-related knowledge than Blacks (Ebrahim, Anderson, Weidle, & Purcell, 2004; Hines & Graves, 1998; Morrison-Beedy, Carey, & Aronowitz, 2003). This greatly decreases the likelihood that the HIV-related risk behaviors of White adolescent girls result from a lack of HIV-related knowledge. An increased fear of stigma and discrimination related to HIV testing among Whites could account for differences in testing patterns. However, in the Kaiser Family Foundation (2004) survey, Black and White adults did not differ in their perception of stigma related to HIV testing. Furthermore, of those respondents surveyed who reported that they have never been tested (mostly White respondents), an overwhelming 72% reported that they never got tested because they did not think they were at risk. Only 6% of those who were never tested reported they did not know where to obtain an HIV test. Another 6% reported not testing due to concerns about confidentiality, while only 2% did not test because they were afraid of getting a positive test result (Kaiser Family Foundation, 2004). Thus, most adults, especially Whites, did not get tested because they did not think they were at risk. Surprisingly, while racial differences in HIV risk-related behaviors are well documented in some studies, and HIV testing patterns are equally well documented in other separate unrelated studies, there has not been extensive documentation on the existence of these phenomena within a sample of adolescent girls.
The current study was undertaken to concurrently examine the rates of HIV-related risk behaviors and HIV testing rates between Black and White adolescent girls consenting to participate in an HIV prevention intervention. The findings reported here inform both nursing and public health practice regarding whether groups of adolescent girls are provided with HIV prevention and testing services at levels sufficiently proportionate to their level of HIV risks. Furthermore, the specific implications for health care practice and future clinical research are highlighted.
The sample in this study consisted of 116 unmarried sexually active girls ages 15 to 19 enrolled in a pilot randomized controlled trial of a gender-specific HIV prevention intervention who classified themselves as Black (N = 43) or White (N = 73). These girls were unmarried and sexually active with a male partner in the past three months. The mean age for the Black girls was 16.7 years (SD=1.4) and for the White girls was 17.5 years (SD=1.3). The average level of education completed was 10th grade for Blacks and 11th grade for Whites. Sixty percent of the Black girls were classified as economically disadvantaged (for example, received a free school lunch program), versus 15% of the White participants. Trained research assistants recruited girls from an urban health clinic in central New York State that provides gynecologic and reproductive health services to teenagers. The University's Institutional Review Board approved the study before any participants were recruited.
To assess for HIV risk and HIV testing history, participants were asked to report on their sexual and substance use history. HIV risk data collected included having: (a) ever been tested for HIV and (b) had a steady sexual partner in the past 3 months. In addition, count data were used to report the following behaviors: (a) total number of sex partners in the past year. (b) number of men had sex with over the past 3 months. (c) number of partners who use IV drugs over the past 3 months. (d) number of times had sex for money or drugs over the past 3 months. (e) number of times had vaginal sex with and without a condom over the past 3 months. (f) number of times had anal sex with and without a condom over the past 3 months. (g) number of episodes received and gave oral sex over the past 3 months. and (h) number of times used alcohol or drugs before sex over the past 3 months. These items have been used and validated in prior HIV prevention research with adult men and women (Carey et al., 1997; Carey et al., 2000). Because there were no reports of protected anal sex, this variable was deleted from the analysis.
The Statistical Package for the Social Sciences (SPSS) was used to conduct chi-squared analysis on HIV testing and steady partner status. In addition, independent t-tests were used to compare the mean variable scores between Black and White adolescent girls on HIV risk related and health promotion behavior items. Differences in HIV risk behavior and testing patterns based on other demographic variables, specifically age, socioeconomic status, and education also were assessed. The variable age was recoded into two categorical and mutually exclusive groups of participants to clearly identify if any risk behaviors and testing patterns differed by age group (Munro. 2001). Age was categorized and recoded to one “younger” group of girls ages 15 to 17 and one “older” group of girls ages 18 to 19. The significance level for the p value was set at the standard less than 0.05.
In this study, Black and White adolescent girls differed on frequency and incidence of several HIV-related risk behaviors (p<.05). Statistical data for these differences are listed in Table 1. White adolescent girls in the study had greater number of total sex partners in the last year and a greater number of partners who injected drugs than Black girls. White adolescent girls also reported, in the past 3 months, that they had more vaginal sex with a latex condom, more vaginal sex without a latex condom, and more episodes of oral sex (giving and receiving). There were no racial differences in the self-report of unprotected anal sex. White girls also reported more alcohol use before sex than Black adolescent girls, but there was no difference in the self-report of drug use before sex, or in engaging in sex for money or drugs. Black and White girls did not differ in the number of men with whom they had sex over the last 3 months or in their self-report of having a steady partner in the past 3 months. There were no risk behaviors in which Blacks had higher frequencies than the White adolescent girls in the sample.
There were no statistical differences in HIV-related risk behaviors based on the variables of socioeconomic status and education level; however, some behaviors did differ by age. Specifically, younger and older adolescent girls differed on frequency and incidence of some HIV risk related behaviors. These behaviors are presented in Table 2. Younger and older adolescent girls did not differ on the number of total sex partners they have had in the last year or the number of sexual partners who injected drugs. Although older girls reported having more male sexual partners than younger girls, they did not differ in their self-report of having had a steady partner in the past 3 months. Older girls were more than twice as likely to report having vaginal sex with a condom and three times as likely to report having vaginal sex without a condom than younger girls. Older girls also were five times more likely to engage in anal sex than younger girls. Although there was no age difference in the number of times adolescent girls performed oral sex on a male partner, older girls were more likely to receive oral sex. Older girls also were more likely to use alcohol before sex, but no more likely than younger girls to use drugs before sex or to report having had sex for money or drugs.
Despite their more frequent participation in HIV-related risk behaviors, White adolescent girls were significantly less likely to get tested for HIV than Black girls. Less than half (42%) of White girls had been tested for HIV as compared to almost two-thirds of Black girls (67%). Although the differences were not statistically significant, more older girls (60%) had been tested for HIV as compared to younger girls (48%).
While the findings from this study are consistent with national epidemiological data regarding the risk behavioral profiles of adolescent girls overall and by racial category (CDC, 2004b), they raise some important clinical issues. Some researchers have reported observing differences in HIV testing rates between Black and White adolescent girls, while other researchers have reported observed differences in HIV risk behavior by race. In this study, we examined both the risk-related behaviors and testing patterns of adolescent girls within the same sample in order to more clearly identify behavioral and testing patterns by race and age.
The White adolescent girls in this sample reported engaging in high-risk behaviors more frequently than the Black adolescent girls in the sample. White girls reported a higher total number of sexual partners, more partners who used IV drugs, greater number of episodes of vaginal sex without a condom, more frequent oral sex, and more frequent alcohol use before sex. Although the incidence of high-risk HIV-related behaviors was higher in White adolescent girls, they were significantly less likely to have been tested for HIV.
We also found that girls' self-reported behavioral data differed by age with older girls reporting a higher incidence of multiple risk behaviors over the past three months. Nonetheless, racial differences were still observed in HIV risk behavior and testing patterns, even when variables that differed by age were excluded. It remains that in this sample, White adolescent girls reported engaging in more risky sexual behaviors and being tested for HIV less than Black girls, and these behaviors could not be attributed to age alone.
These results have important implications for the primary care of adolescents. If White girls are more likely to engage in risky sexual behaviors yet are less like to be tested, HIV cases may go undetected, and clinicians may have inaccurate data to identify risk groups, such as White adolescent girls. Evidence from this study and other studies suggest that current figures on HIV incidence and prevalence may not be wholly reflective of the actual national incidence of HIV in adolescents.
The CDC (2003b) recognizes this possibility, stating that “many factors including the extent to which testing is routinely offered to specific groups may influence testing patterns” (p. 33). A major reason why White adolescent girls may not be “routinely offered” HIV testing in adequate numbers may be that health providers do not believe they are at risk. In a recent national survey, only 35% of Whites reported having ever talked to a health provider about HIV compared to 55% of Blacks (Kaiser Family Foundation, 2004).
Additionally, the findings in this study have important implications for health care providers who also provide health counseling to adolescent girls. The specific risk behaviors of adolescent girls, both Black and White, must be considered to identify and utilize pertinent counseling strategies. In each analysis, both White and older (though not necessarily White) adolescent girls were found to be more likely to use alcohol before sex. White girls and older girls also engaged in more vaginal sex without latex condoms. Similar findings related to alcohol use and high-risk sexual behavior (Levy, Claudia, Handler, Flay, & Weeks, 1993: Levy et al., 1995) underscore the need for providers to address the concurrent influences of alcohol and drug use on sexual behavior in adolescent girls. Unsafe sexual behaviors, some of which may be triggered by substance use and subsequent unsafe sexual decisions, must be directly addressed in counseling sessions. We also found that White adolescent girls also were more likely to engage in both giving and receiving oral sex. Although on a continuum of HIV risk behavior, oral sex presents a lower risk for HIV transmission than unprotected anal or vaginal sex: counseling sessions should also speak to the risk of contracting other STIs through oral sex.
Older adolescent girls (starting at age 17) reported more total male sexual partners within the past year and more episodes of unprotected anal sex than younger adolescent girls with no differences by race. This highlights the need for clinicians to begin offering prevention counseling and testing to girls as soon as they become sexually active, since the risky behaviors become more prevalent with age. It also is important to note that there is only a 1-year age difference between the younger and older girl groups in our study. This suggests that there is a rapid increase in risky behaviors after the onset of sexual activity. Thus, the window of opportunity for provider intervention may be very short – making the timing of prevention messages and HIV testing critical.
Recent innovations in HIV antibody testing technology will facilitate routine HIV testing in various settings. One of the strategies/priorities suggested in the CDC's Advancing HIV Prevention: New Strategies for a Changing Epidemic is for health providers to expand routine, voluntary HIV testing (CDC. 2004a). Most notably, the Oraquick (serum) and Oraquick (saliva) tests have been approved by the Food and Drug Administration (FDA) and are available for commercial use. These tests are rapid tests with high sensitivity and specificity comparable to the standard venipuncture ELISA test that is widely used today. Results from these rapid tests are available in 20 minutes and can be made available to adolescent patients before their clinical visit ends. The CDC has also encouraged community-based organizations around the country to implement rapid testing procedures as part of its Advancing HIV Prevention: New Strategies for a Changing Epidemic (2003a). Although state and federal agencies have recognized testing as a public health priority for adolescents, it is paramount that providers recognize this as a priority within their practice settings.
The results of this study must be viewed within the context of its limitations as well. This cross sectional design does not allow causal inferences to be made. For example, the authors are unable to determine if older and White girls engaged in oral sex more frequently than younger or Black girls simply as an additional sexual choice or as a way to decrease their risk for HIV (as compared to unprotected anal or vaginal sex). The authors also relied, as do most sexual behavior studies, on self-reported behavioral data. Although self-report can be vulnerable to a socially desirable response set, we attempted to reduce this by stressing the confidential nature of the assessment. The frequent risk behaviors reported by the participants suggested that the authors were at least partially successful in reducing biased reporting. Lastly, the sample was comprised only of girls who identified themselves racially as either Black or White, thus any generalization of findings to other racial groups cannot be inferred.
HIV incidence and prevention are priorities in the health care of adolescents, particularly adolescent girls. While published work documents higher rates of HIV in Black adolescent girls, the data evidenced in this article suggest that White adolescent girls may presently be engaging in more HIV related risk behaviors than Black girls, but are not being tested for HIV at the same rates. This discrepancy between risk behavior and HIV testing may result in significant under reporting of HIV incidence and prevalence in the U.S. population of White adolescent girls. Providers should make HIV testing a priority within their practice settings for all adolescent girls, regardless of the race or “risk group” membership.
Fiscal arguments may be made for emphasizing HIV testing in identified “risk groups.” However, it would be beneficial to act in a primary and proactive manner by increasing routine testing efforts in more groups that are not necessarily identified as the “risk groups” instead of allowing an undetected rise of HIV rates in these groups (Morrison-Beedy & Nelson, 2004). Indeed, the cost of administering a 20-minute rapid HIV test is much less than the costs for HIV medical care from adolescence into older adulthood.
Finally, if the nation is to achieve its Healthy People 2010 goal of “increasing the proportion of HIV-infected adolescents who receive testing and treatment” (United States Department of Health and Human Services, 2000, p. B13-13), much will depend on health providers to ensure that adolescents are made aware of their risks for HIV infection, informed of the benefits of testing, and encouraged to be tested for HIV. This study suggests that clinicians may need to broaden their scope of concern to adolescents girls of all races and ages.
Support for this article was provided by Grant R01 #NR008194 from the National Institutes of Health/National Institute of Nursing Research.
The Evidence-Based Practice section focuses on: the search for and critical appraisal of the “best evidence” to answer challenging clinical questions; single studies with strong clinical practice applications; or evidence-based strategies to improve practice so that the highest quality, up-to-date care can be provided to children and their families. To obtain author guidelines or submit manuscripts, please contact Bernadette Melnyk, PhD, RN, CPNP/NPP, FAAN, FNAP or Leigh Small, PhD, RN-CS, PNP; Section Editors;