• School-based programs are critical for reaching youth before behaviors are established. Because risk behaviors do not exist independently, topics such as HIV, STDs, unintended pregnancy, tobacco, nutrition, and physical activity should be integrated and ongoing for all students in kindergarten through high school. The specific scope and content of these school health programs should be locally determined and consistent with parental and community values. Research has clearly shown that the most effective programs are comprehensive ones that include a focus on delaying sexual behavior and provide information on how sexually active young people can protect themselves. Evidence of prevention success can be seen in trends from the Youth Risk Behavior Survey conducted over an 8-year period, which show both a decline in sexual risk behaviors and an increase in condom use among sexually active youth. The percentage of sexually experienced high school students decreased from 54.1% in 1991 to 49.9% in 1999, while condom use among sexually active students increased from 46.2% to 58.0%. These findings represent a reversal in the trend toward increased sexual risk among teens that began in the 1970s and point to the success of comprehensive prevention efforts to both delay first intercourse among teens and increase condom use among young people who are sexually active.
• Efforts to reach out-of-school-youth are made by community-based programs. Addressing the needs of adolescents who are most vulnerable to HIV infection, such as homeless or runaway youth, juvenile offenders, or school drop-outs, is critically important. For example, a 1993 serosurveillance survey of females in four juvenile detention centers found that between 1% and 5% were HIV infected (median 2.8%).
• Prevention efforts for young gay and bisexual men must be sustained. Targeted, sustained prevention efforts are urgently needed for young MSM as they come of age and initiate high-risk sexual behavior. Ongoing studies show that both HIV prevalence and risk behaviors remain high among young MSM. In a sample of young MSM ages 15-22 in seven urban areas, researchers found that, overall, 7% were infected with HIV, with higher prevalence among young African American (14%) and Hispanic (7%) men than among young white men (3%).
• We must address sexual and drug-related risk. Many students report using alcohol or drugs when they have sex, and 1 in 50 high school students reports having injected an illegal drug. Surveillance data from the 32 states with integrated HIV and AIDS reporting systems suggest that drug injection led to at least 5% of HIV diagnoses reported among those aged 13-24 in 1999, with an additional 49% attributed to sexual transmission (both heterosexual and MSM).
• STD treatment must play a role in prevention programs for young people. An estimated 12 million cases of STDs other than HIV are diagnosed annually in the United States, and about two-thirds of those are among people under the age of 25. Research has shown that biological factors make people who are infected with an STD more likely to become infected with HIV if exposed sexually; and HIV-infected people with STDs also are more likely to transmit HIV to their sex partners. Expanding STD treatment is critical to reducing the consequences of these diseases and helping to reduce risks of transmitting HIV among youth.
• Evaluation of factors influencing risk behavior must be ongoing. Both broad-based surveys of the extent of risk behaviors among young people and focused studies of the factors contributing to risk and behavioral intent among specific groups of adolescents must be conducted and analyzed.

For young people, it is critical to prevent patterns of risky behaviors before they start. HIV prevention efforts must be sustained and designed to reach each new generation of Americans.