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This study assessed HIV testing among 2,621 urban young men who have sex with men (YMSM). Of these, 77% were men of colour, 30% reported recent unprotected anal intercourse (UAI), 22% had never tested for HIV and 71% had not tested recently. Ever testing was associated with older age (OR=1.28), being employed (OR=1.34), exposure to more types of HIV preventions (linear trend p=0.02), sex with a main partner (OR=1.92), sex with a non-main partner (OR=1.36), UAI with a non-main partner (OR=0.53), UAI in the last three months (OR=1.32), knowing a comfortable place for testing (OR=5.44) and social support (OR=1.47). Rates of ever testing increased with behavioural risk with main partners; rates were lowest for men reporting high-risk with non-main partners. Recent testing was associated with greater numbers of HIV-prevention exposures (linear trend p = <0.001), sex with a main partner (OR=1.30), knowing a comfortable place for testing (OR=2.31) and social support (OR=1.23). Findings underscore the urgency of promoting testing among YMSM, point to components for the recruitment and retention of young MSM of colour in testing programmes and highlight the need for a theory-based approach to intervention development.

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The purpose of this study was to evaluate the use of a statewide human immunodeficiency virus (HIV) surveillance system to link infected adolescents with care. Eligible participants were HIV-seropositive youths who were reported to the Department of Health from 1985 to 1998 in a state with mandatory, name-linked reporting of HIV and acquired immunodeficiency syndrome (AIDS) cases. Standard public health disease surveillance and intervention strategies were used to link participants with HIV/AIDS case management services. Enrollment in case management services was assessed before and after the intervention was implemented in 1993. The proportion of participants receiving case management services increased from 33% to 51% (p = 0.058) after the intervention was implemented. Although enrollment in case management did not vary significantly with participants' demographic and transmission characteristics, people of color were less likely than Caucasians to be located and interviewed. In conclusion, the system of name linked reporting of HIV/AIDS cases was used successfully to increase case management by 55% above baseline levels.

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This paper uses confirmatory structural equation models to develop and test a theoretical model for understanding the service utilization history of 4679 youth who received services from 10 national HIV/AIDS demonstration models of youth-appropriate and youth-attractive services funded by the Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration. Although the projects differ from one another in the areas of emphasis in their service models, each is targeted to youth at high risk for HIV, or those youth who have already contracted HIV. Collectively, the projects represent a comprehensive adolescent HIV service model. This paper examines the characteristics of the services provided to young people ranging from outreach to intensive participation in medical treatment. Major typologies of service utilization are derived empirically through exploratory factor and cluster analysis methods. Confirmatory structural equation modeling methods are used to refine the exploratory results using a derivation and replication strategy and methods of statistical estimation appropriate for non-normally distributed service utilization indicators. The model hypothesizes that youth enter the service system through a general construct of connectedness to a comprehensive service model and through service-specific methods, primarily of outreach or emergency services. Estimates are made of the degree to which a comprehensive service model drives the services as opposed to specific service entry points.

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This article describes data from 4,111 males and 4,085 females participating in 10 HIV/AIDS service demonstration projects. The sample was diverse in age, gender, ethnicity, HIV status, and risk for HIV transmission. Logistic regression was used to determine the attributes that best predict substance abuse. Males who were younger; HIV positive; homeless; involved in the criminal justice system; had a sexually transmitted disease (STD); engaged in survival sex; and participated in risky sex with men, women, and drug injectors were most likely to have a substance abuse history. For females, the same predictors were significant, with the exception of having an STD. Odds ratios as high as 6 to 1 were associated with the predictors. Information about sexual and other risk factors also was highly predictive of substance abuse issues among youth.

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Over 8,000 adolescents and young adults (4,111 males; 4,085 females) reported on several HIV-related risk behaviors during enrollment into 10 service demonstration projects targeted to youth living with, or at risk for, HIV. Distinct risk patterns emerged by gender when predicting HIV serostatus (versus unknown serostatus/negative serostatus). Males who had injection drug risk histories, had sex with an HIV positive partner, had sexually transmitted diseases, had sex with males, and/or were homeless had an inflated risk of being HIV positive. Females who engaged in sex with an HIV partner, had sex with an injection drug user, and/or had sexually transmitted diseases, were at the highest HIV risk. For both samples, engaging in sex with women reduced the likelihood of HIV positive status. Very basic information about risk factors obtained at service intake offers important information about HIV status of "high risk" youth presenting for care in community programs, as well as suggests clear risk factors for targeted preventive efforts.

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OBJECTIVES: To analyze temporal trends in drug use and the relationship between drug use before or during sex and unprotected intercourse among a sample of young gay and bisexual men. METHODS: Data were obtained from cross-sectional surveys of 9 annual cohorts. Respondents were 877 13- to 21-year-old gay and bisexual male volunteers. Trends in the use of substances before or during sex were analyzed. Univariate and multivariate measures of the association between substance use before or during sex and unprotected anal intercourse were calculated. RESULTS: Between 1994 and 1997, the use of marijuana, cocaine, amphetamines, and mean scores on a measure of overall drug use severity increased significantly in a sample of young gay and bisexual men. Significant univariate associations were found between drug use before or during sex and unprotected anal intercourse for the following substances: alcohol, marijuana, cocaine, amphetamines, barbiturates, heroin, LSD, volatile nitrites, tranquilizers, and methaqualone. In multivariate analyses, however, only cocaine use predicted failure to use condoms during anal intercourse. CONCLUSION: Although amphetamine and other drug use increased among young gay and bisexual men, only cocaine use was a significant, independent predictor of the failure to use condoms during anal intercourse.

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Homosexuality has existed in all civilizations, but societal disapproval and cultural taboos have negatively influenced its recognition. A significant percentage of youths identify themselves as homosexual, and even more experience sex with the same sex or are confused about sexual feelings. A unifying etiological theory attributes the expression of sexual orientation to genes that shape the central nervous system's development, organization, and structure via prenatal sex steroids. Environmental factors may influence the expression of genetic potential. Several models of psychosocial development describe initial stages of awareness and confusion about same-sex attractions, followed by acknowledgement of homosexuality, disclosure to others, and eventual integration of sexual identity into a comprehensive sense of self. Stressors related to isolation, stigma, and violence may predispose homosexual adolescents to impaired social, emotional, and physical health, resulting in depression and suicide, school problems, substance abuse, running away eating disorders, risky sexual behavior, and illegal conduct. As with all adolescents, the overall goals in the care of homosexual youth are to promote normal adolescent development, social and emotional well-being, and physical health. A comprehensive, multidisciplinary approach is required to address medical, mental health, and psychosocial issues within the context of the adolescents' community and culture.

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The survival of human immunodeficiency virus (HIV)-positive adolescents may be abbreviated by delays in health care delivery. Methods of linking youth with services have not been well studied. With support from the Special Projects of National Significance Program, the Youth and Acquired Immunodeficiency Syndrome (AIDS) Projects' (YAP) Adolescent Early Intervention Program offers early intervention health care services to all affected youth in Minnesota, a state with mandatory reporting of HIV/AIDS cases. The conceptual framework is a novel application of traditional public health disease surveillance strategies to link HIV-positive adolescents with health care services. The target population is composed of all 13-22-year-old HIV-positive persons reported to the Minnesota Department of Health (MDH). MDH staff locate and contact HIV-positive youth, conduct structured interviews regarding health status and needs, and facilitate enrollment at YAP. Sixteen male and 20 female participants (mean age 21 years; 56% people of color; 32% gay or bisexual) reported serious health risks, including inconsistent condom use (83%), poverty (78%), high school dropout (56%), unemployment (50%), illegal conduct (50%), medical debt (42%), unstable living situations (33%), running away (33%), substance abuse (33%) and attempted suicide (28%). More than one third reported each of six HIV-related symptoms. Seventy-five percent of participants sought advocacy/case coordination; 56%, clinical trials of experimental therapies; and 50%, vocational training and access to entitlement/eligibility programs. Linking HIV-positive youth to care is a valuable extension of the work of disease intervention specialists in states with similar reporting systems.

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OBJECTIVES: This study examined the relationship between sexual orientation and suicide risk in a population-based sample of adolescents. METHODS: Participants were selected from a cross-sectional, statewide survey of junior and senior public high school students. All males (n = 212) and females (n = 182) who described themselves as bisexual/homosexual were compared with 336 gender-matched heterosexual respondents on three outcome measures: suicidal ideation, intent, and self-reported attempts. Logistic regression analyses were used to examine the association between sexual orientation and outcome measures with adjustment for demographic characteristics. RESULTS: Suicide attempts were reported by 28. 1 % of bisexual/homosexual males, 20.5% of bisexual/homosexual females, 14.5% of heterosexual females, and 4.2% of heterosexual males. For males, but not females, bisexual/homosexual orientation was associated with suicidal intent (odds ratio [OR] = 3.61 95% confidence interval [CI = 1.40, 9.36) and attempts (OR=7.10; 95% CI=3.05, 16.53). CONCLUSIONS: There is evidence of a strong association between suicide risk and bisexuality or homosexuality in males.

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The objective of this study was to evaluate the cost-effectiveness of an HIV prevention intervention for gay and bisexual male adolescents. The intervention included individualized risk assessment and counseling, peer education, optional HIV testing, and referrals to needed services. From 1989 to 1994, 501 male volunteers, 13 to 21 years of age, who self-identified as gay/bisexual or as having had sex with men, completed preintervention and postintervention surveys to assess changes in HIV risk behavior. An HIV transmission model was constructed to project the HIV seroprevalence in the target population over a 10-year period from the self-reported number of partners for unprotected anal intercourse. Cost-effectiveness was analyzed from a societal perspective. Total costs of the intervention, including medical treatment costs saved, were projected to be $1.1 million U.S. for the 10-year period. The number of HIV infections averted and the quality-adjusted life years (QALYs) saved were projected to be 13 and 180, respectively. An incremental cost-effectiveness ratio was projected to be $6180 U.S. per QALY saved. The intervention was found to be cost-effective from the societal perspective. In addition, HIV prevalence in the target population was projected to be 6.1% without and 5.6% with intervention by the end of the 10-year period. This study highlights that an HIV prevention program can be cost-effective even if the effects on behavior are partial and short term.

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BACKGROUND: Research and public health interventions designed to reduce the risk of sexually transmitted diseases (STDs) often are based on self-reported condom use. Yet, validation of self-reported condom use, in particular with adolescents, has rarely been described in the literature. METHODS: Baseline data were obtained from 540 adolescents, 13-21 years of age, enrolled in a 1-year longitudinal study of health beliefs, sexual behaviors, and STD acquisition. Of the 445 participants reporting to be sexually active, 404 (90.8%) agreed to a complete physical examination, including a genital examination, with STD screening after completing the self-administered written questionnaire. Participants' written self-report of condom use was compared to histories obtained by clinicians and laboratory diagnosis of acute STDs to assess validity of written self-report. RESULTS: Complete data were available for 321 females and 77 males of whom 52 females and 5 males had laboratory evidence of 63 infections. Although three individuals who had STDs reported to be consistent users of condoms, a significant association (P < 0.05) was found between those who reported more frequent condom use with the last two partners and the absence of STDs. CONCLUSION: In this group of adolescents, self-report of condom use with the last two partners was associated with the absence of an acute STD. This finding suggests that self-reported condom use is a valid indicator of risk for STDs, with implication for those working with adolescents clinically and in research contexts.

PIP: Although most research on sexually transmitted disease (STD) risk behavior surveillance and prevention is based on self-reports of condom use, there have been few attempts to assess the extent to which self-reports accurately reflect true behavior. To validate this methodology, baseline data were obtained from 540 US male and female adolescents 13-21 years of age enrolled in a 1-year longitudinal study of sexual behaviors and STDs. Of the 445 participants who reported they were sexually active, 398 underwent genital examination and STD screening. 52 females and 5 males had laboratory evidence of acute STDs. 15.2% of females and 32.3% of males reported consistent condom use with their most recent sexual partner. Although 3 young people with STDs had reported they were consistent condom users, a significant (p 0.05) inverse association was found between consistency of reported condom use with the last 2 sexual partners and the occurrence of an acute STD. This finding suggests that, even among adolescents, self-reported condom use is a valid indicator of STD risk.

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PURPOSE: To describe the self-reported sexual behaviors of human immunodeficiency virus (HIV)-seropositive youths with congenital coagulopathies in order to guide the development of interventions to prevent secondary transmission. SUBJECTS: A total of 297 HIV-seropositive males, 12-24 years of age, were sampled from 11 hemophilia treatment centers and 28 affiliated subsites. METHODS: Review of clinical records and self-administered survey of HIV-related knowledge, attitudes and behaviors. Subjects were classified and compared by self-reported sexual behavior over the lifetime and the prior 6 months into five mutually exclusive groups (G1-5). RESULTS: A total of 42% of subjects were virgins who never had oral, vaginal, or rectal sex (G1); 10% were nonvirgins who had abstained (G2); 13% were virgins and nonvirgins who had intimate touch only (G3); 21% had intercourse and always used condoms (G4); and 13% had had unsafe intercourse (G5). Among the groups, G5 was the oldest, least likely to forego sex, most angry and anxious when reminded of HIV, and most reluctant to disclose serostatus to friends. CONCLUSIONS: Most subjects (87%) had safer sex or abstained in the last 6 months. A relatively small group of HIV-seropositive youth with bleeding disorders were engaged in unprotected intercourse and in need of intensive help with HIV risk reduction.

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PURPOSE: To describe two cases of factitious HIV disease and their implications for clinical practice and research. METHODS: Review of medical records and literature search. RESULTS: A 19-year-old female and 17-year-old male were referred to an adolescent HIV clinic for evaluation and treatment of HIV disease. The former reported having been tested at a primary care clinic because of her history of transfusions, although the likely route of infection was intravenous drug use. The 17-year-old claimed to have contracted HIV through unprotected vaginal intercourse. Both patients reported HIV-related symptoms and prior seropositive HIV antibody test results which could not be corroborated. Other important features were histories of mental health problems, lack of apparent distress regarding HIV infection, and extensive knowledge of HIV disease. CONCLUSIONS: In both cases, the most likely diagnosis was Factitious Disorder with combined psychological and physical signs and symptoms, based on the feigning of seropositive HIV test results, report of physical symptoms undocumented by physical examination, the need to assume the sick role, and the absence of obvious secondary gain. This report serves to underscore the need to confirm the presence of HIV infection in young people who seek treatment for HIV disease, especially when clinical presentations resemble these cases.

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OBJECTIVE: To identify important cognitive and behavioral predictors of sexually transmitted disease (STD) risk behavior among a sexually active adolescent cohort. DESIGN: One-year longitudinal study of health beliefs, sexual behaviors, and STD acquisition among 549 adolescents, 14 to 21 years of age. SETTING: School- and community-based health clinics in a large metropolitan area. PARTICIPANTS: Data from 410 sexually active adolescents completing surveys at baseline and 1-year follow-up. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Sexually transmitted disease risk behavior--a composite measure of condom use consistency with most recent sexual partner(s), number of vaginal sex partners, and frequency of intercourse with most recent sexual partner(s). RESULTS: For girls (n = 335), a model including baseline STD risk behavior, condom use self-efficacy, oral contraceptive use, communication with sexual partners about STD prevention, and alcohol use in connection with sexual activity explained 21.1% of the variance in STD risk behavior at 1-year follow-up. For boys (n = 75), the strongest predictors of STD risk behavior at follow-up included baseline STD risk behavior, perceived susceptibility to STD, condom use self-efficacy, negative outcome expectations associated with condom use, and perceived barriers to STD prevention. CONCLUSIONS: Efforts targeting reduction in STD risk behavior must begin before the onset of somewhat stable patterns of sexual risk behavior. Among adolescents who are sexually active, interventions should include components that increase condom use self-efficacy, build skills to communicate with sexual partners about STD prevention, and address behaviors associated with STD risk behavior including oral contraceptive use.

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We hypothesized that persons with HIV who perceive themselves as having waning health status may participate in fewer sexual behaviours than HIV-infected persons without HIV-related health problems. The object-ives of this study were to compare health care provider responses with participant responses for health status and for sexual activity and to examine the relationship of HIV-related health status to the sexual behaviour of HIV-seropositive adolescents and young men with haemophilia. A detailed questionnaire designed by researchers from 11 participating US haemophilia treatment sites and CDC personnel was administered to 306 HIV-seropositive young men with haemophilia aged 12-25 years. A health care provider from the haemophilia treatment centre also completed a questionnaire on each respondent. Self-assessment of HIV-related health status was similar to provider assessment of health status. Providers accurat-ely assessed participant sexual activity (overall Kappa = 0.62). Participation in vaginal intercourse and condom use was independent of health status. Following extensive educational efforts, most HIV-seropositive adolescents and young men with haemophilia are aware of the relationship between their HIV seropositivity and health status. Waning health status does not reduce participation in penetrative sexual behaviours or increase use of condoms. HIV prevention efforts should continue for this population.

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OBJECTIVE: To describe the health outcomes and health care utilization of nonhemophiliac adolescents diagnosed with human immunodeficiency virus (HIV) infection. DESIGN: Cross-sectional survey. SUBJECTS: All state residents without hemophilia, 13-21 years of age at the time of HIV infection diagnosis, reported to the Department of Health through April 1992. SETTING: A state where HIV and acquired immune deficiency syndrome (AIDS) are reportable conditions. METHODS: Structured interviews. RESULTS: The survey response rate was 67%. Most subjects reported preexisting and current psychosocial problems. In 35% of cases, subjects did not recall giving consent for HIV antibody testing; and many reported that seropositive results were delivered inappropriately. Eighty-seven percent of subjects reported recent medical care, without statistically significant differences related to gender, race, or mode of transmission. Within 3.5 years (median) of the diagnosis of HIV infection, 55% of participants reported having physical limitations that were found only to be associated with duration of illness. CONCLUSIONS: The findings highlight the need for better understanding of the progression and comorbidities of HIV disease during adolescence, counseling and testing practices, and expanded access to supportive services.

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OBJECTIVE: The hypothesis that homosexual orientation would be associated with higher rates of body dissatisfaction, dieting, and eating disordered behaviors in males, but lower rates in females, relative to those of heterosexual orientation, was examined. METHODS: A population-based sample of 36,320 students in Grades 7 through 12 completed a health behavior survey that included questions on sexual orientation, body satisfaction, and weight control behaviors. A subset of heterosexual males (N = 212) and females (N = 182) were selected for comparison with the adolescents who self-identified as homosexual (N = 81 males and N = 38 females) or bisexual (N = 131 males and N = 144 females). RESULTS: Homosexual males were more likely to report a poor body image (27.8% vs. 12.0%), frequent dieting (8.9% vs. 5.5%), binge eating (25.0% vs. 10.6%), or purging behaviors (e.g., vomiting: 11.7% vs. 4.4%) compared with heterosexual males. Homosexual females were more likely than heterosexual females to report a positive body image (42.1% vs. 20.5%). However, they were not less likely to report frequent dieting (20.8% vs. 23.7%), binge eating (25.0% vs. 31.8%), or purging behaviors (e.g. vomiting: 19.4% vs. 12.1%). DISCUSSION: These results support the hypothesis that homosexual orientation is associated with greater body dissatisfaction and problem eating behaviors in males, but less body dissatisfaction in females. The possible role of sociocultural influences or gender identification on these relationships is discussed.

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OBJECTIVE: To identify temporal trends and predictors of human immunodeficiency virus (HIV) antibody testing in homosexual and bisexual youth, using the Health Belief Model as a conceptual framework. DESIGN: Cross-sectional survey. SUBJECTS: Five hundred one male volunteers, 13 to 21 years old, self-identified as homosexual, bisexual, or as having sex with men, were enrolled from June 1, 1989, to May 30, 1994. METHODS: Structured reviews and written instruments, including measures of perceived susceptibility to and severity of HIV disease, benefits and barriers to testing, and cues to action. Based on significant (P < .001) bivariate association, variables were selected for forward stepwise logistic regression analysis. OUTCOME MEASURES: Self-reported HIV antibody testing. RESULTS: Forty-five percent of the subjects had undergone HIV antibody testing, with no significant differences between annual cohorts. Predictors of testing were having discussed same-sex feelings or experiences with a physician or counselor, a history of unprotected receptive anal intercourse, substance abuse, younger age at self-identification as bisexual or homosexual, ever having had a steady male partner, having many friends who understand sexual orientation, living away from family, and older age. CONCLUSIONS: Testing practices did not change significantly across time. Human immunodeficiency virus testing was related to age, risky behaviors, living situation, bisexual or homosexual acculturation, and contacts with health professionals, corresponding to Health Belief/Model dimensions of perceived susceptibility, barriers, and cues to action.

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