The Invincible Ones

Because he was a virgin, those in the group he hoped to join said he was a “punk,” told him he had to have sex to prove to them he wasn’t one. So the fifteen-year-old prepared himself for his first sexual experience. Bolstering his confidence with alcohol and marijuana, he went to a party where he found a partner and had unprotected sex. Returning to the group, he was told that he was still a punk, that he needed to do it twice—so he did. For his efforts he contracted chlamydia and HIV.

“He had a baby face,” says Charles “Poncho” Brown, an AIDS educator with the Multicultural AIDS Coalition in Boston and the Upham’s Corner Health Center in Dorchester, Massachusetts. “He could have been my son.” It was Brown who had the unhappy task of informing the fifteen-year-old he had tested positive for HIV.

photo: Human Issues Collaborative

Young people throughout the world have the highest rate of new HIV infections. In fact, worldwide, AIDS is the sixth leading cause of death for individuals between the ages of fifteen and twenty-four. The average ten-year period between HIV infection and the onset of AIDS means that most young adults with AIDS were infected as teenagers. In the United States, one in four new infections—one new infection every hour—occurs in youths between the ages of thirteen and twenty-one. National estimates as of 1999 indicate that one-half or more of all new infections occur among people under age twenty-five.

Risk-Taking Behavior
A recent study by researchers from the University of Washington School of Public Health and the Seattle–King County Department of Public Health found that young people were more than twice as likely as adults to take risks that could result in HIV infection—like sharing needles and engaging in unprotected sex.

“Teenagers feel invincible,” says Maurice Melchiono, a family nurse practitioner at Children’s Hospital in Boston and the hospital’s nursing director for primary care. “It’s okay to feel that way. It’s part of the normal development process.” He points out that teens’ belief in their own invincibility needs to be balanced against the harsh facts of HIV infection. “They need help to stay healthy.”

Ethan Herschman, educational coordinator for the Boston Living Center, agrees. “Risk-taking is a part of adolescence. Risk is a part of growth. I don’t want to wholly take that away—but they need to understand risk,” he says. Herschman, who arranges for people with HIV to speak at schools in both high- and low-income areas, notes, “This notion that ‘I am invincible’ crosses all class lines.”

Adolescents are at risk in part because risk-taking behaviors are integral to the typical adolescent experience. Sexual intercourse and injection drug use are the most common modes of HIV infection among most recently infected adolescents. Most HIV-infected young people have become infected through sexual activity, which often begins in their teenage years. And experimentation with drugs and alcohol—both of which are associated with an increase in risk-taking behaviors—is common during the teenage years. Studies regularly conducted by the Centers for Disease Control and Prevention (CDC) in high schools indicate that about 60 percent of students in grades nine through twelve have had sexual intercourse. Of these, only half report using a condom on the last occasion. About one-fifth say that they have had more than four sexual partners during their lives.

Talking with Teens
To be effective, prevention efforts need to speak to each risk group—including teenagers from different cultures, backgrounds, and levels of sexual experience—in a way that is relevant to them. A press release issued in August 1999 by the National Center for HIV, STD and TB Prevention states that prevention programs can be effective for young people, but that they must be sustained and they must provide more than “just the facts.”

“The most effective prevention messages are those which help provide skills to be used interpersonally regarding refusal, delay, and negotiation: ability to say no when pressured to have sex, to put off sex if unwanted, and to negotiate to use condoms. Role plays, rehearsals, et cetera, are most critical,” says Rick Zimmerman, associate professor of communication, behavioral science, and sociology at the University of Kentucky in Lexington. Programs that combine social and peer support and access to condoms and other prevention means have successfully reduced adolescents’ risk-taking behaviors, without resulting in greater incidence of sexual activity. In fact, they may result in less sexual activity.

“Unfortunately, politics, religion, and supposed values often get in the way of delivering the messages that would be most likely to succeed: ‘remain abstinent if you can, but learn how to negotiate for condom use if you’re already active,’” Zimmerman says.
In addition to arranging for others to speak through the Boston Living Center, Herschman, who is living with HIV, sometimes speaks to young people himself. “Kids can tell you that HIV can be transmitted through fluids,” he says, “but it’s an abstract concept to them. It’s not a reality. You have to make them realize it’s their world.”

“Message tailoring” helps listeners identify with speakers. Herschman carefully chooses speakers who best match—in terms of race, religion, and economic background—the adolescents with whom they will be meeting. “Some kids will say ‘It’s a gay thing,’ or ‘It’s a drug thing,’” Herschman explains. “This approach helps them realize, ‘I’m at risk. Behavior puts you at risk.’” In Herschman’s experience, when a teen can talk with a person living with HIV who shares a similar background, HIV and everything associated with it becomes more tangible. “When someone like them admits to succumbing to peer pressure, that makes it a reality. Telling your story is what gets it out of the abstract.”

Prevention measures should come not just from school or community programs, however. Health care providers and parents can also help educate teens effectively about risk and ways to avoid it. Providers should address not just HIV but a broad spectrum of related issues. “Kids want to hear about it. Providers need to talk about alcohol, drugs, pressure, sexuality, about how we stay healthy,” says Melchiono.

Kim Miller, a CDC-affiliated research sociologist, recently studied the effects of mother-to-adolescent communication about behaviors that prevent HIV infection. She found that teens who talked with their mothers about condoms before experiencing their first sexual encounter were three times more likely to use condoms than teens who did not have that conversation. In addition, condom use at first intercourse was associated with a twentyfold increase in lifetime condom use. “We found that kids really wanted to hear from their parents more than any other source,” Miller says. “And the more the parents talk with their teens—the more skilled the parents are—the less likely the kids are to initiate intercourse or to fail to protect themselves.”

Now Miller is doing a new intervention study in which she will focus on teaching parents to talk “substantively, skillfully, early, and often” to their teens about safer sex. While adolescents are asserting their independence, trying to find their way in the world, she says, parents still can convey important messages. “Listening is important,” says Miller, adding that parents should also recognize the need to initiate the conversation and not wait to be asked. “Parents should take the plunge. It’s never too late.”

Denial, Disclosure, and Partner Notification
Young people who receive a seropositive test result may struggle with conflicting emotions. On the one hand, they wish to maintain a belief in their own invincibility; on the other, they are faced with their own mortality. Because of this, it may take an HIV-infected adolescent months to accept his or her serostatus and to seek treatment. A positive test result is an intensely confusing, frightening thing for a youth, one that layers itself on an already turbulent landscape that may include the struggle to develop a sexual identity or to cope with a substance abuse problem.

Adolescents who receive the news that they are infected with HIV may experience anxiety and depression. Health care professionals can help by taking care and time in explaining a test result and its significance, by explaining treatments and their outcomes, and by encouraging the teenager to ask questions.

Once an adolescent understands and accepts that he or she is infected with HIV, that adolescent must then decide who to tell and when. The pressures of being a teenager can make disclosure to peers extremely difficult. “One kid I work with—he just turned sixteen, and he’s having a lot of problems at school,” says Melchiono. “Kids are saying he’s gay, giving him a hard time.” The perception of “normalcy” is paramount among adolescents, Melchiono explains.

Herschman agrees. “Adults are in a different place emotionally,” he says. “When you’re younger, you really do care what people think. The stigma is less meaningful to adults.”

Herschman has a hard time getting younger people to speak publicly at schools. “There just aren’t many young people with HIV who are comfortable speaking about it,” he says. Herschman believes this reflects the lingering belief on the part of many that HIV-infected individuals are to blame for their own situation. He supports this point by noting that teens who were infected at birth or from blood transfusions are more comfortable than most HIV-infected teens about discussing their HIV status before an audience.

Because of this stigma, many teens will tell their friends that they have cancer, asthma, or a blood infection rather than admit they are HIV positive. Disclosure can be particularly troubling for young people who are gay or are substance abusers. In addition to disclosing their HIV status, they also may be forced to reveal their sexuality or drug use. In addition, young people must deal with the tension that arises when their need to separate and stand alone is at odds with their inclination to turn to an adult when they are faced with illness. Disclosure to parents and other family members may be impossible. “They don’t want to be rejected from their parents. In some cases the parents only find out after their child is dead,” says Melchiono.

Disclosure to sexual partners is also difficult and frightening. When it comes to disclosure to a new partner, “we encourage being as honest as you can,” Melchiono says. Health care providers or other supportive adults can help adolescents with disclosure and notification by talking about the process and role playing through possible scenarios. The level of precaution, however, should not change. “Adolescents should practice safer sex with every person,” Melchiono adds. “We always suggest that you presuppose that everyone is HIV infected.”

The Influence of Peers
Brown’s anecdote about the fifteen-year-old who needed to prove he wasn’t a punk illustrates the degree to which the effects of peer pressure put adolescents at risk. “Peer pressure is the number one destroyer of these teens,” says Brown.

Peer pressure can be put to good use, however, when educators use it to help craft prevention efforts. “Peer education works,” says Herschman. “And peer pressure works. It’s human nature for young people to listen to someone with something in common with them.”

—Rachel Solar-Tuttle is a freelance writer living in Brookline, Massachusetts.