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2.  HIV viral load levels and CD4+ cell counts of youth in 14 cities 
AIDS (London, England)  2014;28(8):1213-1219.
To describe the HIV viral load and CD4+ cell counts of youth (12–24 years) in 14 cities from March 2010 through November 2011.
Baseline HIV viral load and CD4+ cell count data were electronically abstracted in a central location and in an anonymous manner through a random computer-generated coding system without any ability to link codes to individual cases.
Among 1409 HIV reported cases, 852 participants had data on both viral load and CD4+ cell counts. Of these youth, 34% had CD4+ cell counts of 350 or less, 27% had cell counts from 351 to 500, and 39% had CD4+ cell counts greater than 500. Youth whose transmission risk was male-to-male sexual contact had higher viral loads compared with youth whose transmission risk was perinatal or heterosexual contact. Greater than 30% of those who reported male-to-male sexual contact had viral loads greater than 50 000 copies, whereas less than 20% of heterosexual contact youth had viral loads greater than 50 000 copies. There were no differences noted in viral load by type of testing site.
Most HIV-infected youth have CD4+ cell counts and viral load levels associated with high rates of sexual transmission. Untreated, these youth may directly contribute to high rates of ongoing transmission. It is essential that any public health test and treat strategy place a strong emphasis on youth, particularly young MSM.
PMCID: PMC4151121  PMID: 25028912
CD4+ cell count; HIV; linkage to care; viral load; youth
3.  Receipt of Sexual Health Information From Parents, Teachers, and Healthcare Providers by Sexually Experienced U.S. Adolescents 
To describe the extent to which sexually experienced adolescents in the United States receive sexual health information (SHI) from multiple of three sources: parents, teachers, and healthcare providers.
Descriptive analysis.
2006–2010 National Survey of Family Growth.
Heterosexually experienced, unmarried/non-cohabiting females (n = 875) and males (n = 1,026) ages 15–19 years.
Main Outcome Measures
Self-reported receipt of birth control, sexually transmitted infection/human immunodeficiency virus (STI/HIV), and condom information from parents, teachers, and healthcare providers.
Parent and teacher SHI sources were reported by 55% and 43% of sexually experienced female and male adolescents, respectively, for birth control information; and by 59% and 66%, respectively, for STI/HIV information. For sexually experienced adolescents reporting both parent and teacher sources, about one-third also reported healthcare provider as a source of birth control information, and one-quarter of females and one-third of males reported a healthcare provider as a source of STI/HIV information, respectively. For sexually experienced adolescents reporting no SHI from either parent or teacher sources, only one in ten reported healthcare providers as a source of birth control information, with a similar proportion reporting healthcare providers as a source of STI/HIV information. SHI receipt was found to vary by gender with more females than males reporting birth control information receipt from parents and teachers, and about one in six males reporting no birth control or condom information receipt from either source.
Study findings highlight gaps in sexual health information receipt from parents, teachers, and healthcare providers among sexually experienced adolescents, as well as gender differences across information sources.
PMCID: PMC4034256  PMID: 23743003
Sex education; Sex information; Sexual development
4.  Impact of Individual Values on Adherence to Emergency Contraception Practice Guidelines Among Pediatric Residents 
To evaluate the impact of individual, system, and interpersonal factors on emergency contraception practices. We hypothesized that abortion attitudes and attitudes toward teen sex would be significant individual factors influencing emergency contraception practices.
This was a cross-sectional, anonymous Internet survey.
Four pediatric residency programs in the Baltimore, Maryland–Washington, DC, metropolitan area during April to June 2007.
One hundred forty-one pediatric residents completed the survey.
Main Exposure
Abortion attitudes were assessed by participants’ level of agreement with abortion in 7 scenarios. Attitudes toward teen sex were assessed by participants’ level of agreement with 5 statements about the acceptability of teens having sex.
Main Outcome Measures
Emergency contraceptive counseling behavior was assessed by reported frequency of including emergency contraception in routine contraceptive counseling. Intention to prescribe emergency contraception was assessed by reported likelihood of prescribing in 5 scenarios.
When controlling for demographics and other predictors, residents with less favorable abortion attitudes were more likely to have the lowest intention to prescribe emergency contraception. Residents with more positive attitudes toward teen sex and who had a preceptor encourage emergency contraception prescription were more likely to include emergency contraception in routine contraceptive counseling most/all the time and to have the highest intention to prescribe.
Efforts to challenge and affect attitudes toward teen sex and to prompt residents to prescribe emergency contraception in clinical settings may be needed to encourage more proactive emergency contraceptive practice in accordance with national practice guidelines.
PMCID: PMC4332886  PMID: 19805714
5.  Relationships Between Perceived STD-Related Stigma, STD-Related Shame and STD Screening Among a Household Sample of Adolescents 
Important barriers to STD testing for an individual may include STD-related stigma, defined as personal fears about negative societal attitudes toward STD infection, and STD-related shame, defined as anticipated negative personal feelings resulting from a positive STD test. Obtaining a clear understanding of the relationship between STD-related stigma, STD-related shame, and STD testing may help inform programs and policies to reduce STD transmission.
Measures derived from previously published scales were used to assess an urban, household sample of 594 15–24 year olds’ perceptions of STD-related stigma (Cronbach’s alpha 0.92), STD-related shame (Crobach’s alpha = 0.89), and receipt of an STD test in the past year. Logistic regression was used to examine the associations between STD testing and perceptions of stigma, shame, and other participant characteristics.
Thirty-seven percent of males and 70% of females reporting receiving an STD test in the past year, the majority of which occurred in the context of a routine health care visit. For both males and females, perceiving higher levels of STD-related stigma was independently associated with decreased odds of having been STD tested (OR = 0.54 and 0.48, respectively). STD-related shame was not related to STD testing.
STD-related stigma may be an important barrier to STD screening for adolescents and young adults. Given the fact that most participants reported receiving an STD test during a routine health visit, it is unclear whether STD-related stigma may be associated with care seeking versus acceptance of STD screening at a routine health visit.
PMCID: PMC4334654  PMID: 20444177
6.  Adding to the HIV Prevention Portfolio – the Achievement of Structural Changes by 13 Connect to Protect® Coalitions 
Opportunities to control risk factors that contribute to HIV transmission and acquisition extend far beyond individuals and include addressing social and structural determinants of HIV risk, such as inadequate housing, poor access to healthcare and economic insecurity. The infrastructure within communities, including the policies and practices that guide institutions and organizations, should be considered crucial targets for change. This paper examines the extent to which 13 community coalitions across the U.S. and Puerto Rico were able to achieve “structural change” objectives (i.e., new or modified practices or policies) as an intermediate step toward the long-term goal of reducing HIV risk among adolescents and young adults (12-24 years old). The study resulted in the completion of 245 objectives with 70% categorized as structural in nature. Coalitions targeted social services, education and government as primary community sectors to adopt structural changes. A median of 12 key actors and six new key actors contributed to accomplishing structural changes. Structural change objectives required a median of seven months to complete. The structural changes achieved offer new ideas for community health educators and practitioners seeking to bolster their HIV prevention agenda.
PMCID: PMC4306189  PMID: 25632407
HIV prevention; adolescents; community mobilization; structural change; coalition
7.  Achieving a Healthy Zoning Policy in Baltimore: Results of a Health Impact Assessment of the TransForm Baltimore Zoning Code Rewrite 
Public Health Reports  2013;128(Suppl 3):87-103.
The social determinants of health (SDH) include factors apart from genes and biology that affect population health. Zoning is an urban planning tool that influences neighborhood built environments. We describe the methods and results of a health impact assessment (HIA) of a rezoning effort in Baltimore, Maryland, called TransForm Baltimore. We highlight findings specific to physical activity, violent crime, and obesity.
We conducted a multistage HIA of TransForm Baltimore using HIA practice guidelines. Key informant interviews identified focus areas for the quantitative assessment. A literature review and a zoning code analysis evaluated potential impacts on neighborhood factors including physical activity, violent crime, and obesity. We estimated potential impacts in high- and low-poverty neighborhoods. The findings resulted in recommendations to improve the health-promoting potential of TransForm Baltimore.
Mixed-use and transit-oriented development were key goals of TransForm Baltimore. Health impacts identified by stakeholders included walkability and healthy communities. For Baltimore residents, we estimated that (1) the percentage of people living in districts allowing mixed-use and off-premise alcohol outlets would nearly triple, (2) 18% would live in transit-oriented development zones, and (3) all residents would live in districts with new lighting and landscaping guidelines. Limiting the concentration of off-premise alcohol outlets represented an opportunity to address health promotion.
Changes to Baltimore's zoning code could improve population health including decreasing violent crime. HIAs are an important platform for applying SDH to public health practice. This HIA specifically linked municipal zoning policy with promoting healthier neighborhoods.
PMCID: PMC3945454  PMID: 24179284
8.  Methamphetamine Use and Risk for HIV Among Young Men Who Have Sex With Men in 8 US Cities 
To examine methamphetamine use and its association with sexual behavior among young men who have sex with men.
Cross-sectional observational analysis.
Eight US cities.
As part of the Adolescent Trials Network for HIV/AIDS Interventions, adolescent boys and young men who have sex with men, aged 12 to 24 years, were recruited from social venues (eg, clubs, parks, and street corners) between January 3, 2005, and August 21, 2006, to complete a study survey.
Main Outcome Measures
Reported methamphetamine use in the past 90 days and reported sexual risk behavior compared with individuals reporting no hard drug use and individuals reporting hard drug use in the past 90 days.
Among 595 adolescent boys and young men, 64 reported recent methamphetamine use, and 444 reported no recent hard drug use (87 reported use of hard drugs other than methamphetamine). Recent methamphetamine use was associated with a history of sexually transmitted diseases (51.6%), 2 or more sex partners in the past 90 days (85.7%), sex with an injection drug user (51.6%), and sex with someone who has human immunodeficiency virus (32.8%) compared with individuals reporting no recent hard drug use (21.1%, 63.1%, 10.7%, and 11.1%, respectively; P<.05 for all [n=441]). Recent users of methamphetamine were more likely to have a history of homelessness (71.9%) and were less likely to be currently attending school (35.9%) compared with individuals reporting no recent hard drug use (28.4% and 60.4%, respectively; P<.001 for both).
Adolescent boys and young men who have sex with men and use methamphetamine seem to be at high risk for human immunodeficiency virus. Prevention programs among this age group should address issues like housing, polydrug use, and educational needs.
PMCID: PMC3278965  PMID: 21810635
9.  HIV Prevalence Overall and among High-HIV-Risk Behaviorally Defined Subgroups among Heterosexuals at Community-Based Venues in a Mid-Atlantic, US City 
A clear understanding of local transmission dynamics is a prerequisite for the design and implementation of successful HIV prevention programs. There is a tremendous need for such programs geared towards young African-American women living in American cities with syndemic HIV and injection drug use. In some of these American cities, including Baltimore, the HIV prevalence rate among young African-American women is comparable to that in some African nations. High-risk heterosexual sex, i.e., sex with an injection drug user or sex with someone known to have HIV, is the leading risk factor for these young women. Characterizing transmission dynamics among heterosexuals has been hampered by difficulty in identifying HIV cases in these settings. The case identification method described in this paper was designed to address challenges encountered by previous researchers, was based on the Priorities for Local AIDS Cases methodology, and was intended to identify a high number of HIV cases rather than achieve a representative sample (Weir et al., Sex Transm Infect 80(Suppl 2):ii63-8, 2004. Through a three-phase process, 87 venues characterized as heterosexual sex partner meeting sites were selected for participant recruitment in Baltimore, MD. One thousand six hundred forty-one participants were then recruited at these 87 venues, administered a behavioral risk questionnaire, and tested for HIV. The HIV prevalence was 3 % overall, 3 % among males, and 4 % among females and ranged from 1.7 to 22.6 % among high-HIV-risk subgroups. These findings indicate that attributing HIV transmission to high-risk heterosexual sex vs. other high-HIV-risk behaviors would be difficult. Moving beyond individual risk profiles to characterize the risk profile of venues visited by heterosexuals at high risk of HIV acquisition may reveal targets for HIV transmission prevention and should be the focus of future investigations.
PMCID: PMC3732685  PMID: 23135804
HIV; Heterosexual; Prevalence; Disease transmission; Infectious; Drug user; Adult
10.  Core Sexual/Reproductive Health Care to Deliver to Male Adolescents: Perceptions of Clinicians Focused on Male Health 
Male adolescents experience adverse sexual/reproductive health (SRH) outcomes, yet few providers deliver male SRH care. Given the lack of evidence base for male SRH care, the purpose of this study was to examine perceived importance in delivering SRH care to male adolescents among clinicians focused on male health.
Seventeen primary care clinicians focused on male health, representing pediatricians, family physicians, internists, and nurse practitioners, were individually queried about male adolescents’ SRH needs and perceived importance to screen/assess for 13 male SRH services using a case-scenario approach varying by visit type and allotted time.
Participants were highly consistent in identifying a scope of 10 SRH services to deliver to male adolescents during a longer annual visit and a core set of 6 SRH services during a shorter annual visit including 1) counseling on sexually transmitted infection/human immunodeficiency (STI/HIV) risk reduction including testing/treatment; and assessing for 2) pubertal growth/development; 3) substance abuse/mental health; 4) non-STI/HIV genital abnormalities; 5) physical/sexual abuse; and 6) male pregnancy prevention methods. Participants did not agree whether SRH care should be delivered during non-annual acute visits.
Despite lack of data for male SRH care, clinicians focused on male health strongly agreed upon male SRH care to deliver during annual visits that varied by visit type and allotted time. Study findings provide a foundation for much needed clinical guidelines for male adolescents’ SRH care and have implications for education and training health professionals at all levels and the organization and delivery of male SRH services.
PMCID: PMC3383603  PMID: 22727075
Adolescent males; Clinical practice; Health care delivery/access; Reproductive health
The aim of this study is to examine how physicians use clinical practice guidelines that call for routine HIV screening in a general adolescent medicine clinic and to determine how adolescent patients respond to routine screening. Physicians offered screening to 116 of 217 patients (53%) aged 13-21 who completed a survey. Physicians’ offers conformed to the latest Centers for Disease Control and Prevention (CDC) guidelines with 73% of patients because some patients not offered a test had been screened within the last year. Physicians were three times more likely (OR = 3.0; 95% CI = 1.3-6.8) to offer HIV screening to sexually active adolescents than to adolescents who reported no sexual history. Adolescent medicine physicians and their patients endorse the idea of routine screening as embodied in the latest CDC recommendations, but adolescents with no sexual history are less likely than other adolescents to accept screening when it is offered and to support a clinic policy of routine screening. Both physicians and their adolescent patients continue to test based on risk assessments.
PMCID: PMC3105471  PMID: 21204629
12.  Adherence to Scheduled Appointments among HIV-Infected Female Youth in Five US Cities 
Identify factors associated with appointment-keeping among HIV-infected adolescents and young adults.
HIV-infected adolescent and young adult females in five US cities were followed for a period of 18 months to examine adherence to scheduled clinic visits with their HIV care provider. Psychosocial and behavioral factors that have been shown in other populations to influence appointment adherence were measured at baseline and follow-up visits using an ACASI questionnaire. These factors included mood disorder, depressive symptoms, social network support, health care satisfaction, disease acceptance, HIV stigma, alcohol use, and marijuana use. CD4 count and prescription of ART medication were also monitored to understand the influence of health status on appointment-keeping.
Participants included 178 youth with a mean age of 20.6 years. Forty-two percent had clinically significant depressive symptoms, 10% had a diagnosable mood disorder, 37% reported marijuana use in the last 90 days, and 47% reported alcohol use. Overall, participants attended 67.3% of their scheduled visits. Controlling for age and health status, marijuana use was the only variable that was associated with appointment-keeping behavior.
Considering the importance of appointment-keeping for maintaining personal health and preventing further transmission, screening HIV-infected adolescents for marijuana use could help alert providers of this specific barrier to visit compliance.
PMCID: PMC2824596  PMID: 20159506
13.  Neighborhood Drug Markets: A risk environment for bacterial sexually transmitted infections among urban youth 
Social science & medicine (1982)  2012;74(8):1240-1250.
We hypothesized that neighborhoods with drug markets, as compared to those without, have a greater concentration of infected sex partners, i.e. core transmitters, and that in these areas, there is an increased risk environment for STIs. This study determined if neighborhood drug markets were associated with a high-risk sex partnership and, separately, with a current bacterial STI (chlamydia and/or gonorrhea) after controlling for individual demographic and sexual risk factors among a household sample of young people in Baltimore City, MD. Analyses also tested whether links were independent of neighborhood socioeconomic status. Data for this study were collected from a household study, systematic social observations and police arrest, public health STI surveillance and U.S. census data. Nonlinear multilevel models showed that living in neighborhoods with household survey-reported drug markets increased the likelihood of having a high-risk sex partnership after controlling for individual level demographic factors and illicit drug use and neighborhood socioeconomic status. Further, living in neighborhoods with survey-reported drug markets increased the likelihood of having a current bacterial STI after controlling for individual level demographic and sexual risk factors and neighborhood socioeconomic status. The results suggest that local conditions in neighborhoods with drug markets may play an important role in setting-up risk environments for high-risk sex partnerships and bacterial STIs. Patterns observed appeared dependent on the type of drug market indicator used. Future studies should explore how conditions in areas with local drug markets may alter sexual networks structures and whether specific types of drug markets are particularly important in determining STI risk.
PMCID: PMC3383619  PMID: 22386616
USA; sexually transmitted infections; drug markets; social epidemiology; medical geography; core transmitters
14.  New sexually transmitted infections among adolescent girls infected with HIV 
Sexually Transmitted Infections  2007;83(6):468-469.
Although the prevalence of sexually transmitted infections (STIs) among girls infected with HIV has been reported, the incidence of STI diagnoses has not been well documented. The objectives of this study were to examine (1) incident STI diagnoses and (2) the association between viral load (VL) and incident STI diagnosis among HIV‐infected adolescent girls in care.
This was a prospective longitudinal 18‐month study of girls enrolled in the Adolescent HIV trials network. Cox proportional hazard modelling was performed to evaluate the incidence of STI by baseline viral load.
The mean (SD) age of participants was 20.6 (2.0) years, viral load of participants was 66 917 (165 942) copies/ml and median viral load was 7096 copies/ml. The incidence of STIs for the entire cohort was 1.4 per 100 person‐months. During the 18‐month follow‐up period, there were no significant differences in the STI incidence between the high and low viral load groups (hazard ratio (HR) = 0.86, 95% CI 0.37 to 1.95) There was also no significant association between STI incidence and log‐transformed viral load (HR  = 1.10, 95% CI 0.92 to 1.3).
Adolescent girls with HIV infection continue to acquire sexually transmitted infections after diagnosis. This analysis does not suggest that VL is a critical factor in STI acquisition over time. Additional work exploring the role of other contextual factors on STI acquisition among HIV‐infected adolescent girls is warranted.
PMCID: PMC2598696  PMID: 17699560
adolescence; HIV; sexually transmitted infection (STI)
15.  Desire for Pregnancy and Risk Behavior in Young HIV-Positive Women 
AIDS Patient Care and STDs  2012;26(3):173-180.
This cross-sectional study utilized data from 130 young women with behaviorally acquired HIV to examine the association between desire for pregnancy (DFP) and both sociodemographic variables and sexual risk behaviors. A single item was utilized to assess DFP. Bivariate and multivariate regression analyses were conducted. At the bivariate level, DFP was associated with increased rates of intercourse, decreased condom use, increased partner concurrency, increased rates of unprotected sex with a nonconcordant partner, and a higher number of previous sexually transmitted infections (STIs). Multivariate analyses suggested that DFP was associated with increased likelihood of recent intercourse, condom-unprotected sex, and oral sex. DFP was related to few sociodemographic variables but was associated with having fewer children currently, a history of victimization, and decreased rates of disclosure of HIV status. The few sociodemographic variables that were associated with DFP suggest that social relationships may play a role in DFP. DFP was associated with sexual behaviors that may place young women at risk for STI acquisition and secondary HIV transmission to partners. Health care providers should assess DFP in routine HIV care, providing education about fertility options, interventions for vertical transmission, family planning, and risk reduction counseling.
PMCID: PMC3286807  PMID: 22482121
Increasingly, HIV prevention efforts must focus on altering features of the social and physical environment to reduce risks associated with HIV acquisition and transmission. Community coalitions provide a vehicle for bringing about sustainable structural changes. This article shares lessons and key strategies regarding how three community coalitions located in Miami and Tampa, Florida, and San Juan, Puerto Rico engaged their respective communities in bringing about structural changes affecting policies, practices and programs related to HIV prevention for 12–24-year-olds. Outcomes of this work include increased access to HIV testing and counseling in the juvenile correctional system (Miami), increased monitoring of sexual abuse between young women and older men within public housing, and support services to deter age discordant relationships (Tampa) and increased access to community-based HIV testing (San Juan).
PMCID: PMC2850206  PMID: 20166784
17.  Age‐bridging among young, urban, heterosexual males with asymptomatic Chlamydia trachomatis 
Sexually Transmitted Infections  2006;83(2):136-141.
To determine the prevalence of age‐bridgers among urban males aged 14–24 years, asymptomatically infected with chlamydia and to determine factors that distinguish age‐bridgers from non age‐bridgers. An index was defined as an age‐bridger if within 2 months, he had had at least two sexual partners who differed from him in age by ⩾2 years.
Infected males provided data about themselves and up to four sexual partners in the past 2 months. Bivariate and multivariable logistic regression was used in the analysis.
The prevalence of age bridging was 21% in Baltimore and 26% in Denver. In both cities, in bivariate analysis, age‐bridgers and their partners engaged in significantly more risky sexual behaviours. In adjusted multivariable analysis after controlling for number of sexual partners, age bridging was associated with having a sexual partner in the past 2 months, who, at time of last sexual intercourse, was drinking.
Age‐bridgers represented major proportions of the study populations and, along with their sexual partners, were more likely to engage in risky sexual behaviours. Male age‐bridgers may be key players in the transmission of sexually transmitted infections among youth linking age‐disparate sexual networks.
PMCID: PMC2598631  PMID: 17151025
18.  Screening Juvenile Justice-Involved Females for Sexually Transmitted Infection: A Pilot Intervention for Urban Females in Community Supervision 
Little is known about Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) rates in community-supervised juvenile justice-involved (CSJJI) females, or how to best provide screening for sexually transmitted infections in this population. A pilot intervention allowed case managers to offer optional CT/GC screening to CSJJI females during mandated visits. Anonymous satisfaction surveys and discussion groups assessed intervention acceptability. Case managers met with 514 CSJJI females; 102 (20%) agreed to screening and 117 tests were completed. Among those screened, 21 (18%) had CT and 3 (3%) had GC. Intervention feedback from case managers and clients was positive, but there were barriers to recruitment. Lessons learned from this case manager-facilitated intervention may increase the acceptability and effectiveness of future screening methods in this setting.
PMCID: PMC4009726  PMID: 23983235
sexually transmitted infection screening; juvenile justice health care; community-based screening
19.  Sexually transmitted infection risk behaviors in rural Thai adolescents and young adults: Support for gender- and age-specific interventions 
Sexually transmitted diseases  2013;40(3):216-220.
STI prevalence and risks in a sample of rural Thai adolescents and young adults (14–29 years old) were examined. Unprotected sex with a casual partner conferred the greatest risk for prevalent STIs, particularly for younger adolescents and alcohol use increased the STI risk for women but not for men.
PMCID: PMC3572507  PMID: 23403603
Thailand; adolescents; sexually transmitted infections; gender; social norms
20.  Strategies and Outcomes of HIV Status Disclosure in HIV-Positive Young Women with Abuse Histories 
AIDS Patient Care and STDs  2013;27(3):191-200.
Young women with HIV and histories of physical and/or sexual abuse in childhood may be vulnerable to difficulties with disclosure to sexual partners. Abuse in childhood is highly prevalent in HIV-positive women, and has been associated with poorer communication, low assertiveness, low self worth, and increased risk for sexual and other risk behaviors that increase the risk of secondary transmission of HIV. HIV disclosure may be an important link between abuse and sexual risk behaviors. Qualitative interviews with 40 HIV-positive young women with childhood physical and/or sexual abuse were conducted; some women had also experienced adult victimization. Results suggest that HIV-positive women with abuse histories use a host of strategies to deal with disclosure of HIV status, including delaying disclosure, assessing hypothetical responses of partners, and determining appropriate stages in a relationship to disclose. Stigma was an important theme related to disclosure. We discuss how these disclosure processes impact sexual behavior and relationships and discuss intervention opportunities based on our findings.
PMCID: PMC3595953  PMID: 23596649
21.  Annual physical examination reports vary by gender once teenagers become sexually active 
Few sexually active male adolescents receive sexual/reproductive health (SRH) services. We examine whether the association between adolescents’ sexual behavior status and physical examination over time can help us understand why.
We conducted longitudinal cohort analysis of the National Longitudinal Study of Adolescent Health with 9239 adolescents who completed the baseline school (1994/95) and Wave 2 (1996) follow-up surveys approximately 1.5 years later (retention rate=71%). We fit logistic regression models with random effects to estimate individual odds of reporting a physical examination in the past 12 months at follow-up, as compared to baseline, stratified by sexual behavior status and gender, and adjusting for sociodemographic and healthcare access factors.
34.5% males and 38.2% females reported experiencing vaginal intercourse by follow-up, and 22.4% males and 24.7% females reported first experiencing intercourse during the study. Among sexually active adolescents, about half reported annual exams and one-fifth no exams. Among females, baseline to follow-up exam reports significantly increased in: sex initiators (adjusted Odds Ratio [95% confidence interval]=2.09 [1.66–2.64]); those reporting sex at both times (2.16 [1.51–3.09]); and those reporting no sex either time (2.47 [2.00–3.04]). Among males, baseline to follow-up exam reports significantly increased in those reporting no sex either time (1.57 [1.26–1.96]) and showed increasing trends in sex initiators (1.27 [0.92–1.76]).
A majority of sexually active adolescents report annual physical exams over time. Providers should not miss opportunities to deliver evidence-based SRH to sexually active adolescents. Future efforts are needed to increase all adolescents’ access to SRH services.
PMCID: PMC3124664  PMID: 21700156
Health Services Accessibility; Male; Female
22.  Television Viewing in Low-Income Latino Children: Variation by Ethnic Subgroup and English Proficiency 
Childhood Obesity  2013;9(1):22-28.
Television viewing is associated with an increased risk for obesity in children. Latino children are at high risk for obesity and yet little is known about differences in television viewing habits within this population. The purpose of this study is to determine if hours of television viewed by young children with low-income Latina mothers differs by maternal ethnic subgroup and English language proficiency.
This was a cross-sectional analysis of data from the Welfare, Children, & Families: A Three City Study. Participants were 422 low-income Latina mothers of Mexican and Puerto Rican descent with children ages 0–4 years old. The dependent variable was hours of daily television viewed by the child. The independent variable was maternal ethnic subgroup and English language proficiency. Analyses involved the use of multiple negative binomial regression models, which were adjusted for demographic variables.
Multivariable regression analyses showed that compared to children with mothers of Mexican descent, children of mothers of Puerto Rican descent watch more daily television (<2 years old, incidence rate ratio (IRR)=4.18, 95% confidence interval (CI) 1.68, 10.42; 2–4 years, IRR=1.54, 95% CI 1.06, 2.26). For children with mothers of Mexican descent, higher maternal English language proficiency was associated with higher amounts of child television viewing (IRR=1.29, 95% CI 1.04, 1.61). No relationship was found for children of Puerto Rican descent.
Child television viewing varies in low-income Latino children by maternal ethnic subgroup and English language proficiency. Interventionists must consider the varying sociocultural contexts of Latino children and their influence on television viewing.
PMCID: PMC3601541  PMID: 23301653
23.  Norms governing urban African American adolescents’ sexual and substance-using behavior 
Journal of adolescence  2012;36(1):31-43.
Using a probability-based neighborhood sample of urban African American youth and a sample of their close friends (N = 202), we conducted a one-year longitudinal study to examine key questions regarding sexual and drug using norms. The results provide validation of social norms governing sexual behavior, condom use, and substance use among friendship groups. These norms had strong to moderate homogeneity; and both normative strength and homogeneity were relatively stable over a one-year period independent of changes in group membership. The data further suggest that sex and substance using norms may operate as a normative set. Similar to studies of adults, we identified three distinct “norm-based” social strata in our sample. Together, our findings suggest that the norms investigated are valid targets for health promotion efforts, and such efforts may benefit from tailoring programs to the normative sets that make up the different social strata in a given adolescent community.
PMCID: PMC3604793  PMID: 23072891
Adolescents; Friendships; African American; HIV risk behavior; Norm validity; Norm stability
24.  Differential Challenges in Coalition Building among HIV Prevention Coalitions Targeting Specific Youth Populations 
Journal of prevention & intervention in the community  2012;40(2):10.1080/10852352.2012.660124.
Coalitions provide the potential for merging the power, influence, and resources of fragmented individuals and institutions into one collective group that can more effectively focus its efforts on a specific community health issue. Connect to Protect® coalitions devote resources to address the HIV epidemic at a structural level. This research examines differential challenges in coalition processes that may facilitate/hinder coalition building to achieve HIV prevention through structural change. Qualitative interviews conducted with community partners participating across 10 coalitions were analyzed to compare responses of those individuals working on HIV prevention coalitions targeting adolescent and young adult gay and bisexual men versus those targeting adolescent and young adult heterosexual women. Community partner responses revealed differences across several key areas including: a) acceptability and goals in discussing sexual issues with adolescents, b) goals of sexual health promotion activities, and c) competition among collaborating agencies. Themes highlighted in this research can complement existing community intervention literature by helping community mobilizers, interventionists, and researchers understand how cultural norms affect youth-specific coalition work.
PMCID: PMC3818727  PMID: 24188354
coalitions; African American and Latino adolescent and young adults; structural change; HIV prevention
25.  The Available Pool of Sex Partners and Risk for a Current Sexually Transmitted Infection 
Annals of epidemiology  2010;20(7):532-538.
STI transmission models propose that incident STIs are related to exposure to infected sex partners. The objective of this study was to determine whether the prevalence of STIs among the available pool of sex partners in a neighborhood, measured indirectly, is an independent determinant of a current incident STI.
The target population comprised 58,299 English-speaking, sexually active 15–24 year olds in 486 census block groups (CBGs) in Baltimore, MD. A sample of 65 CBGs was selected using a stratified, systematic, probability-proportional-to-size strategy and 13,873 households were randomly selected. From 2004–2007, research assistants administered an audio-CASI survey and collected biologic samples for gonorrhea and chlamydia testing.
The final sample size included 575 participants from 63 CBGs. Additional data provided gonorrhea prevalence from 2004–2005 per 15–49 year olds per 100,000 per CBG. After adjusting for individual-level STI risk factors in a multilevel probability model, adolescents and young adults living in high (vs. low) prevalence STI areas were 4.73 times (95% confidence interval (CI): 3.65–6.15) more likely to have a current incident STI.
To inform prevention programs, future research should focus on identifying mechanisms through which context causes changes in local sexual networks and their STI prevalence.
PMCID: PMC2884146  PMID: 20538196
Sexually transmitted diseases; gonorrhea; residence Characteristics; adolescent; urban population; urban health

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