Correlates of Sexual Activity and Sexually Transmitted Infections Among Human Immunodeficiency Virus-infected Youth in the LEGACY Cohort, United States, 2006

Adolescence is often considered a critical period in the reproductive life cycle of an individual, characterized by sexual and lifestyle behavioral experimentation and risk taking. Not surprisingly, the burden of sexually transmitted infections (STIs) falls disproportionately on young adults. In 2000, approximately half of the estimated 18.9 million STIs reported in the United States (US) occurred among adolescents and young adults (15–24 years)1; and from 2005 to 2008, the rate of human immunodeficiency virus (HIV) diagnosis increased among persons aged 15 to 24 years.2 Although adolescents in the general US population have experienced recent improvements in indicators related to sexual behavior, high rates of unintended pregnancies and STIs, particularly among African Americans and Latinos, remain a public health concern.3,4 With the advent of highly active antiretroviral therapy, many perinatally HIV-infected (PHIV) children are reaching adolescence and young adulthood5-9 and exploring their sexuality.10 Sexual risk behavior among youth living with HIV in the US, most of whom acquired HTV behaviorally (BHIV), is common.11-13 Data on the sexual behavior of PHIV adolescents are, however, limited. In 2000, a cross-sectional substudy of 131 adolescents who were infected with HIV as children and had a mean age 15.5 years, reported consensual sexual relations among 24 children (18%).9 This study was limited by the lack of data on sexual behavior for 53% of the study population. Another cross-sectional survey of PHIV adolescents and young adults at an urban tertiary care center in the US reported that 19 of 57 (33%) eligible youth aged between 13 and 24 years were sexually active. Twenty-six percent of those who were sexually active reported initiation of sexual activity before age 15 years, and half of sexually active female participants had ever been pregnant.14 However, this study used a small convenience sample from a single clinic site and did not include a comparison group to examine the role of perinatal HIV infection and other predictors of risk behavior. More recently, a longitudinal study (n = 40) conducted among 13- to 24-year-old adolescents with perinatally or transfusion-acquired HIV infection, reported increasing prevalence of sexual activity from 28% to 41% during a 21-month time span.15 On the contrary, other research suggests that some adolescents with PHIV avoid sexual relationships entirely, due to fear of disclosing their HIV status to a partner or as a harm reduction strategy.16 The American Academy of Pediatrics strongly encourages disclosure of HIV infection status to adolescent patients.17 However, disclosure of HIV infection status to children and age at disclosure remains one of the most sensitive issues in the management of children with perinatal HIV infection18; and limited data exist on the association between sexual activity and self-disclosure of HIV status in PHIV adolescents. Because most PHIV youth have received regular medical care since birth and reach sexual debut after diagnosis of HIV infection, they represent a unique population for studying the prevalence and correlates of sexual activity. It is important to understand the sexual behavior of PHIV children as they reach adolescence to determine the best strategies for reducing the likelihood of acquisition of additional STIs and to prevent secondary transmission of HIV from this population. The goals of the present study were to (1) describe the sexual behavior of BHIV and PHIV adolescents (13–24 years) in 2006; (2) determine correlates of sexual activity in 2006 among PHIV adolescents; and (3) compare the risk of an STI diagnosis in 2006 among sexually active PHIV and BHIV adolescents in the United States. Because most BHIV youth were infected with HIV sexually and most were sexually active in 2006, we did not include them in our second goal of the study of correlates of sexual activity.