Are adolescents more at risk for STIs/HIV than adults? If so, why?

Are female youth more at risk biologically than older women?

What other factors put youth at greater risk for HIV/STI infection?

What is the most important HIV prevention message for youth?

What is the current situation regarding adolescents and STIs/HIV/AIDS?

Why are adolescents particularly vulnerable to STIs and HIV?

What are the health and social consequences of high STI rates among young people?

Q: Are adolescents more at risk for STIs/HIV than adults? If so, why?

Yes. About seven of every ten STI infections occur among individuals ages 15-24. Sexually active, unmarried adolescents are at high risk for STIs not only for psychological and behavioral reasons but also for biological and social reasons.

Psychological factors that put many adolescents at increased risk for STIs include a general sense of invulnerability, the desire to try new experiences, and the willingness to take risks, including changing sexual partners often or having a partner who has multiple partners. In addition, many adolescents lack knowledge of STIs that contributes to risk-taking behaviors, find it difficult to use condoms consistently and correctly, or lack communication and negotiation skills, making condom use difficult.

Q: Are female youth more at risk biologically than older women?

Adolescents are probably more biologically susceptible to STIs than older women because of a condition called cervical ectopy. This is a normal condition that is present in most female adolescents and becomes less common with age. Cervical ectopy develops when the cells that line the inside of the cervical canal extend onto the outer surface of the cervix. These cells are more vulnerable to infections such as chlamydia and gonorrhea. In addition, the risk of acquiring trichomoniasis, chlamydia, herpes and HPV (human papilloma virus) is possibly greatest at first exposure to the STI. Because first exposure often occurs during adolescence, both male and female adolescents are particularly vulnerable. Getting one STI makes it more likely that an adolescent may acquire other STIs.

Q: What other factors put youth at greater risk for HIV/STI infection?

Social and programmatic factors can also increase risks associated with STIs. Programmatic factors include limited access to family planning or STI services; inconvenient clinic hours or locations; cost prohibiting purchases of condoms from pharmacies, other shops, or clinics; lack of confidentiality, trained clinic staff or staff members with negative attitudes about adolescent sexual activity and contraceptive use, and legal restrictions. Social factors include adolescents' relative lack of power in relationships with adults and others, who may be their partners. Some adolescents experience nonconsensual sexual relationships with older, more powerful partners with whom they may feel unable to negotiate safer sex practices.

Q: What is the most important HIV prevention message for youth?

Because youth are more biologically vulnerable to STIs than adults, abstinence from sexual intercourse or condom use when sexually active should be especially emphasized for young men and women. Abstinence is the most effective means of protection against pregnancy and STIs. For sexually active adolescents, condoms are the only method that provides protection against both viral and bacterial STIs.

Adolescents and young adults have a disproportionate number of STIs compared to adults. STIs can result in serious health consequences, both for young people and their children. Because women often show no symptoms for the most common STIs, chlamydia and gonorrhea, they are diagnosed and treated less frequently than men, who generally have symptoms. Adolescents face special obstacles in obtaining diagnosis and treatment even when they do show symptoms. They are reluctant to seek care, and/or providers are often hesitant to treat them. ¹² Because STIs increase an individual's susceptibility to human immunodeficiency virus (HIV) infection, it is extremely important for these diseases to be treated.^{7, 10} Also, STIs can cause tubal infection and thus infertility.

Q: What is the current situation regarding adolescents and STIs/HIV/AIDS?

Young people are vulnerable to sexually transmitted diseases for both biological and behavioral reasons. In fact, worldwide, the highest reported rates of STIs are found among young people aged 15-19 and 20-24. In the developed world, two-thirds of all reported STD infections occur among men and women under the age of 25. In developing countries the proportion is even higher.⁶ Here are some prevalence data for specific diseases:

• Adolescents represent a large proportion of overall chlamydia infections worldwide � at least one-third. In Haiti and Nigeria, this age-group is reported to have the highest level of culture-detectable chlamydia.^{3, 4, 6} Prevalence levels can be as high as one-half of all sexually active young women.⁶

• Rates of gonorrhea are often highest among adolescents.⁸ As is true of other curable STDs, South Asia and sub-Saharan Africa have a disproportionate number of these infections, and adolescents comprise about one-third of all cases.⁶

• Syphilis, in contrast to gonorrhea and chlamydia, is most common among adults but remains a major problem for teenagers in developing countries.⁶ In rural Nigeria, for example, nearly 3% of sexually active teenagers have active syphilis.⁴

• Trichomonal infections are the most common curable STD worldwide, representing more than half of all treatable STD cases. Adolescents make up a disproportionate share of these cases.⁶ In Nigeria, nearly one-fourth of adolescents have been identified with this infection.⁴

• Bacterial vaginosis is a common condition among sexually active women though its prevalence among adolescents is not specifically known.

• Although generally less prevalent among young adults, infection with the herpes simplex virus nevertheless affects adolescents, often leading to genital ulceration.⁶

• Adolescents have a higher prevalence of genital human papilloma virus (HPV) than other age groups. ¹⁴ One US study showed that up to one-half of sexually active young women have cytologic evidence of infection, even though there is less evidence of external genital warts.⁵

• Hepatitis B virus is widespread, especially in Asia, and has possibly severe health consequences for both adolescents and their offspring.⁶

• About one-half of all human immunodeficiency virus (HIV) infections occur among men and women 24 and younger. Up to 60 % of new infections in developing countries occur among 15-24-year-olds.¹⁹ Twice as many young women as men in this age-group are newly infected. ¹⁹ In rural Tanzania, females aged 15-24 show the highest HIV infection rate.¹⁰

Q: Why are adolescents particularly vulnerable to STIs and HIV?

For biological, behavioral, and cultural reasons, young people are at especially high risk of contracting STDs, including HIV:

• Sizable numbers of adolescents are sexually active. In some countries, sexual activity begins in early adolescence, either within or outside of marriage. Young age at first intercourse is a strong risk factor for STDs.^{11, 15}

• Their immature reproductive and immune systems make adolescents more vulnerable to infection by various STD agents.^{6, 12}

• Adolescents, especially young girls, are less able to refuse sex and/or less able to insist on adequate protection. Sometimes sexual activity involves abuse or coercion which, in turn, is linked to young age at first intercourse and to more than one sexual partner�both STI risk factors.¹¹

• Conditions such as poverty, homelessness, political strife, and dislocation, which are increasingly common among young people in developing countries, are associated with sexual abuse or with sexual intercourse exchanged for money or support for basic needs.^{1, 12}

• Young people are ill-informed about STIs, their symptoms, the need for treatment, and where to obtain treatment. Combined with many adolescents' fear of the medical system, these circumstances often result in avoidance and delays in seeking health care.²⁰ Untreated STIs result in increased susceptibility to HIV infection. ¹⁰

• Reproductive health service providers tend not to welcome adolescent clients. Studies in Antigua, Senegal, and Thailand, among other settings, have found health facilities where adolescent clients are denied privacy and confidentiality, and in which the staff are often rude or moralizing.¹⁸

Q: What are the health and social consequences of high STI rates among young people?

Early acquisition of an STI increases the probability of recurrent infections because of longer exposure time and the likelihood of a greater number of partners.^{6, 13} Recurrence can exacerbate the health consequences. For example, repeat chamydial infection is more likely than primary infection to be associated with fallopian tube damage.^{16, 17}

• Pelvic inflammatory disease (PID), typically resulting from lower genital tract infection as a result of chlamydia or gonorrhea, is more common among sexually active female adolescents than among women in the older age-groups. PID can result in tubal infertility or ectopic pregnancy.⁶

• Genital human papilloma virus (HPV), which is widespread among adolescents, causes genital warts. In addition, adolescents are at greater risk of developing HPV-associated cancers.¹⁴

• Frequent health consequences of the Hepatitis B virus, in addition to hepatitis, include cancer and cirrhosis. ⁶

• STDs increase the likelihood of negative pregnancy outcomes for both the adolescent mother and her infant. STDs such as syphilis, hepatitis B, and HIV can be transmitted to newborns.⁶ Bacterial vaginosis and trichomoniasis are related to preterm delivery and low birthweight.⁶ These problems are made worse by the fact that fewer adolescents than older women seek prenatal care or other reproductive health services for the treatment of these infections.^{5, 6}

• HIV infection is enhanced by the presence of other STDs. Thus adolescents are at increased risk of HIV infection because of their high STD rates.^{7, 10} While AIDS usually develops fully only after the young person is out of the teenage years, the consequences are nevertheless devastating.

• Many teenagers experience serious psychological consequences as a result of becoming infected with an STD. Typical reactions of guilt and shame often prevent young people from seeking treatment in a timely fashion. ⁹

• Infertility as a result of STDs can lead to men abandoning or divorcing their partners. In some societies, women without support turn to commercial sex for survival.⁷

 References

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Reprinted with permission from Pathfinder International's "FOCUS on Young Adults" Project, 2002.