HARWELL, TODD S. MPH*; TRINO, RUTH MD, MPH†; RUDY, BRET MD‡; YORKMAN, SHIRLEY*; GOLLUB, ERICA L. DrPH†
DETAINED AND/OR INCARCERATED male adolescents have been shown to be at high risk for both sexually transmitted disease (STD) and human immunodeficiency virus (HIV) infection.1-5 These youth are also less knowledgeable about prevention strategies as compared with non-detained in-school adolescents.1 Previous studies have found high prevalence rates of STD among this population.4 A national HIV seroprevalence study completed at 31 adolescent detention centers and correctional facilities in the United States found seroprevalence rates ranging from 0% to 6.3% among males (median rate of 0.3%).6 Further indicators of risk include a report by Rosenberg et al. that estimated that the age of onset of HIV infection overall has declined substantially over the past decade.7 Using a back-calculation model, the authors found that one of every four newly infected persons from 1987 to 1991 was younger than 22 years.
Despite the high prevalence of STD and HIV risk activities among this population, less than 60% of facilities that house detained youth in the United States provide any form of HIV prevention education.8 This represents a missed opportunity to provide information, skills-building, and motivation to reduce risk, particularly because intervention programs have been shown to be feasible and effective in this setting.9,10 Additionally, given the high rates of reconfinement, the opportunity to reach high-risk youth in these settings is potentially expanded several-fold.11
Previous studies have described the risks and knowledge of detained youth overall.1-6 However, little is known about the risk and knowledge within a population of those with multiple admissions. The objective of this study was to compare the levels of sexual and substance use-related risk and the knowledge regarding STD and HIV among male adolescents with multiple admissions versus those with first admissions to a detention facility. We hoped these data would help us define and differentiate the level of risk and knowledge among these subpopulations as a basis for the development of specific STD and HIV intervention strategies.
This study was conducted from September 1996 through April 1997 at the Youth Study Center in Philadelphia, Pennsylvania (Department of Human Services, Division of Juvenile Justice Services), and was approved by the Institutional Review Board of the City of Philadelphia's Department of Public Health. The Youth Study Center is the sole facility in the county of Philadelphia that processes and admits youth that have been detained and/or arrested. More than 4,647 youth were admitted to this facility from July 1995 through June 1996. The mean and median lengths of stay were 13.1 and 4.0 days, respectively. All youth entering this facility have a mandatory medical history and screening performed upon admission.
Sampling of youth admitted to the facility was done on both weekdays and weekends (usually only Saturday). Study staff recruited youth for interviews during the heaviest period of admissions to the institution: usually, noon to 9 p.m. on weekdays and Saturday mornings. A list of recent (past 24 hours) admittees was generated and a consecutive sample of youth not previously interviewed by the study staff was located with the assistance of the residential staff. Youth in classes or mandatory activities associated with the facility were sometimes not able to be interviewed; some were, however, eventually interviewed later in the day. A description of the project, the goals, and the types of questions to be asked were described to each youth, and informed consent was obtained. They were then asked to participate in a brief structured interview performed by two trained project staff (not employed at the facility). The principal interviewer (SY) had 5 years of counseling experience with high-risk youth and trained the second interviewer in the early phase of the study. Interviews were completed in a closed and separate room away from both the medical and security staff employed at the facility. Youth were instructed that all information collected during the interview was confidential and that none of the information would be shared with the facility staff unless the youth specifically requested it.
A standardized data collection form was developed for the study, and the interview questions were pilot tested before initiation. These questions included items regarding demographic characteristics, substance use histories, sexual histories, and HIV/STD knowledge. Substance use questions were adapted from the Addiction Severity Index.12 The admission history (total number of admissions to the facility) of each youth was abstracted from the medical record. All interview forms were coded only with a study identification number to ensure confidentiality of the information.
Demographic characteristics of interest included age, race, and whether they had been in school in the past year (see Table 1). Youth were asked if they had used any of the following substances in their lifetime and in the past 6 months: crack cocaine, cocaine hydrochloride, marijuana, phencyclidine (PCP), alcohol, opiates, or inhalants. They were asked if they had ever injected drugs, if anyone else had ever injected them with drugs, and if they had ever been in a drug and/or alcohol treatment program.
The sexual history questions included history of sexual intercourse (vaginal and/or anal sex), age at first intercourse, and number of lifetime sexual partners. Youth (all subjects were male) were asked if they had ever gotten a girl pregnant, had a sexually transmitted disease, had sex with a male, had sex with a person who was an injection drug user, exchanged sex for drugs or money, or exchanged drugs or money for sex. The HIV risk assessment questions were adapted from the Centers for Disease Control and Prevention's HIV counseling and testing data collection tool. Youth who reported being sexually active in the past 6 months were asked additional questions, including whether they had receptive and/or insertive oral, vaginal, and anal sex and whether they or their partner had used a condom the last time they had vaginal or anal sex.
The HIV/STD knowledge questions assessed issues related to transmission and prevention of HIV and STD, as well as injection drug use. Additionally, all youth were asked to identify their perceived level of risk of becoming HIV-infected on a three-point scale (low, medium, or high risk).
Discard blood from routinely collected syphilis serology was labeled with the study identification number and transported to a reference laboratory for HIV testing. Standardized HIV testing protocols were used to determine HIV antibody seropositivity.
Data were entered and analyzed using SPSS v6.1 (Chicago, IL). The statistical methods included the Pearson chi-square test, Fisher's exact test, and the independent t-test accounting for homogeneity of variance. Multivariate logistic regression analyses were used to adjust for age. Odds ratios (OR) and 95% confidence intervals were then calculated.
During the 9 months that this study was conducted, a total of 3,316 youth were admitted to the facility. Of these youth, 90% were male, and 44% were between the ages of 15 to 16 years. The majority of youth admitted were African American (71%), whereas fewer were Latino (14%), white (13%), Asian/Pacific Islander (2%), or of other races (1%). Of these youth, 864 were selected for recruitment. Discarded blood was available for 777. The HIV seroprevalence rate was 0.3% (2/777).
Of the 864 youth selected for recruitment, 543 (63%) were located within the facility and were asked to participate in the interview. Two of these youth (0.4%) refused to participate. Youth not located had either left the facility for placement, were released, or had other required engagements within the facility. The majority of youth interviewed (n = 541) were male (90%), between 15 to 16 years of age (47%), and African American (72%). The sample of interviewed youth were similar to the population admitted to the facility by gender (p = 0.99), age (p = 0.10), and race (p = 0.99).
Four hundred eighty-six males are included in this current analysis. Most of these male adolescents were African American (73%), whereas fewer were Latino (14%), white (11%), or Asian/Pacific Islander (2%). Their mean age was 16.0 years (SD = 1.4). Two hundred ninety-one previously had been admitted to this facility (60%), and the mean number of lifetime admissions was 3.5 (SD = 2.4).
Table 1 displays the demographic characteristics of the sample. Youth with multiple admissions (YMA) tended to be older than those with first admissions (YFA) and were less likely to have been in school in the past year (19% versus 30%). No differences were found by race.
Overall, the most frequently used substances were marijuana (66%), alcohol (50%), and PCP (17%), whereas fewer youth reported use of cocaine hydrochloride (6%), opiates (3%), crack cocaine (2%), or inhalants (1%). Table 2 displays the self-reported substance use (past 6 months) and history of drug/alcohol treatment among these adolescents by admission status. After adjusting for age, YMA were more likely to report recent use of PCP as compared with those with first admissions. No differences were found by admission status for the other substances of use. Sixteen percent of all youth (n = 75) reported ever receiving drug and/or alcohol treatment services. YMA were more likely to report ever receiving treatment services. Relatively few youth (n = 4) reported ever injecting substances (1%), and no difference was found by admission status.
Data regarding the samples lifetime and recent sexual activity are displayed in Table 3. Overall, 96% reported ever having sexual intercourse in their lifetime. The median age at first intercourse was 13.0 years and the median number of lifetime sex partners was 8.0. Youth with multiple versus first admissions initiated sexual intercourse earlier (mean age 12.2 years versus 12.6 years, p = 0.03) and reported a significantly larger number of lifetime sexual partners (mean number of partners 17.9 versus 10.4, p < 0.001). These differences persisted after controlling for age.
Relatively few youth reported ever having sex with another man (2%), having sex with an injection drug user (3%), or exchanging sex for drugs or money (2%). A larger proportion of all adolescents reported having ever gotten a girl pregnant (31%), ever having a STD (13%), or ever exchanging drugs or money for sex (10%). After adjusting for age, YMA were approximately 50% more likely to report ever exchanging drugs or money for sex and to have ever gotten a girl pregnant. No differences were found between these groups for the other variables assessed.
More than 80% of the sample reported having vaginal and/or anal intercourse within the past 6 months, and 65% reported using a condom with their last sex partner. Forty-four percent of youth reported having insertive oral sex and 14% reported having insertive anal sex over the past 6 months. After adjusting for age, YMA versus YFA were less likely to report using a condom with their last sexual partner.
We looked at the possible effect of previous drug treatment on risk behaviors among all adolescents. Those reporting a history of treatment had uniformly higher drug risk behaviors than those with no history-for example, with respect to recent use of cocaine (19% versus 3%, p < 0.001); crack (7% versus 2%, p = 0.02), PCP (24% versus 16%, p = 0.07), and opiates (10% versus 2%, p < 0.001). We found the same effect when looking at sexual risks, both lifetime (>8 lifetime sex partners, 63% versus 49%, p = 0.03; exchanging drugs or money for sex, 17% versus 9%, p = 0.03) and in a recent time period (condom with last partner, 51% versus 68%, p = 0.009; receptive anal sex in past 6 months, 5% versus 1%, p = 0.05).
The percentage of correct responses to the knowledge questions by admission status is displayed in Table 4. The mean knowledge score (each question had a value of 1.0 and there were 9 items) for all youth was 7.5 (SD = 1.7). YMA had a higher overall mean score as compared with YFA (mean score 7.7 versus 7.2, p = 0.001). The majority of all youth (≥80%) responded correctly to the items pertaining to the use of oral contraception, asymptomatic STD and AIDS, needle sharing, HIV transmission from woman-to-man, and transmission by means of anal sex. However, more than 30% of youth reported that consistent condom use would not provide a high level of protection against HIV. After controlling for age, youth with multiple admissions were more likely to correctly identify a risk of HIV transmission by means of menstruation, deny that you can tell if someone has AIDS just by appearance, identify a risk of HIV transmission by means of anal sex, and correctly deny that douching can prevent HIV infection. No differences were found for the other knowledge variables after controlling for age.
The majority of all youth reported that their risk of HIV infection was low (68%), whereas fewer reported their risk as medium (22%) or high (10%). No differences were found between YMA versus YFA for perceived high (10% versus 10%) or medium risk (25% versus 19%, p = 0.28), respectively. Controlling for age, no differences were found by admission status for perceived high risk (OR 1.23; 95% CI 0.87, 1.73) or medium risk (OR 0.94; 95% CI 0.61, 1.43) for becoming infected.
The goal of this study was to elaborate issues related to sexual activity, substance use, and HIV/STD knowledge among a sample of detained male adolescents. Overall, we found that these youth are at high risk for STD and HIV infections, through sexual activity and substance use, which may lead to high-risk behaviors. Youth with multiple as compared with first admissions differed somewhat in terms of their lifetime sexual activities, their recent sexual activity, and their knowledge regarding HIV and STD. These similarities and differences are highlighted in terms of their implications for HIV/STD interventions.
The HIV seroprevalence rate among youth (both male and female adolescents) at this facility (0.3%) was similar to the median rate (0.3%) found in a study of adolescent detention centers and correctional facilities nationally.6 None of the 486 male youth interviewed as part of this study were seropositive for HIV.
We found a high rate of recent self-reported alcohol and noninjection drug use (mostly marijuana and PCP) among our sample. In contrast, the frequency of recent use of cocaine (crack and cocaine hydrochloride, 6.8%) and injection drug use (1%) overall was low. Other studies also found a high frequency of self-reported marijuana use among similar populations, as well as low rates of injection.1-2,6 Our results agree with urine drug screening surveillance data from the 1996 National Institute of Justice's Drug Use Forecasting program.13 The median rate of recent cocaine, marijuana, and opiates use among male detainees from 12 sites nationally was 7% (range 3% to 13%), 52% (range 36% to 65%), and <1% (range 0% to 4%), respectively.
The prevalence of PCP use among our population is considerably higher as compared with national data from a representative sample of 12th graders, where the self-reported use of PCP in the past year was 2.6%.14 Epidemiologic data suggest that PCP use is not widespread in the United States, particularly among adolescents.15,16 Its use is most often found among post-high school age, African American men in specific geographic regions. Our study may herald findings of increased use among younger African American men. Previous studies among adolescents have found both marijuana and alcohol use, and especially cocaine use, to be markers of increased risk of HIV infection.17-21 Less is known about the sexual risk activities associated with PCP use. Our study suggests that further research is warranted.
A larger proportion of youth with multiple as compared with first admissions reported ever receiving drug and/or alcohol treatment services. The risk behaviors of these youth, including recent risk behaviors, were greater among the treated than nontreated, raising the question as to the efficacy of treatment for this group. We were not able to assess this more finely because of the lack of data on the length of time spent in treatment. Previous studies among adult injection drug users have found that substance use treatment has a protective effect on an individuals' risk of HIV by reducing substance use and sexual risks.22,23 It would seem that adolescent substance use treatment programs have the potential of bringing about similar effects.
Sexual Risk Activity, HIV/STD Knowledge, and Perceptions of Risk for HIV
The majority of detained male youth were sexually experienced and sexually active over the past 6 months. Relatively few youth reported ever having sex with another male, which is comparable to other recent studies among detained males (1.1% and 0.5%).5-6 Our findings on the frequency of insertive anal sex and condom use at last intercourse agrees with other studies on adolescents.1-5,24,25
We found a number of differences in the lifetime and recent sexual risk activities among youth by admission status. Youth with multiple versus first admissions were more likely to initiate sex before age 13, have eight or more lifetime sexual partners, have ever exchanged drugs or money for sex, and have ever gotten a girl pregnant. These youth were also less likely to report using a condom with their last sex partner. Differences were particularly marked in the case of a large number of sexual partners. Thus, YMA were in greater immediate need of interventions to reduce the risk of HIV/STD.
Viewed overall, however, the prevalence of sexual risk behaviors was high among the entire group (not only the multiple admissions subgroup) and argues for safer sex interventions for the entire population aimed particularly at reducing the number of sexual partners and at increasing condom use. Our findings on knowledge and beliefs may guide the way to efficient interventions. For example, YMA with higher levels of riskier activities did not have a higher perceived level of risk for HIV, but the relationship of perceived risk to behavioral change is not clear. Thirty percent or more of the entire sample, however, had doubts about condom efficacy. Condom use has a direct and irrefutable relationship with reducing HIV/STD risk. Our study suggests that interventions for this population would need to focus on strengthening beliefs in condom efficacy (perceived benefits) as one way of increasing condom use.
Finally, a review of recent AIDS risk-reduction interventions among adolescents found that longer intervention duration is associated with positive outcomes.26 Pilot interventions should be undertaken to investigate whether repeated interventions of short duration (thus more adapted to the detention system) could also be effective. Work should build on successful intervention experience with African American youth, as it is not clear that the detained population practice behaviors or have beliefs that are so dissimilar as to warrant an entirely new approach.27 Prison interventions also need to be designed with the big picture in mind. HIV is a disease of the poor and disenfranchised, as is the condition of detention and imprisonment. Humanizing staff and institutions where tremendous and disproportionate numbers of African American spend time will enhance the possibilities not only of promoting changes to safer sex behaviors but also of engendering hope, encouragement, and positive attitudes about mustering the inner and community resources to stay healthy and pursue life goals.28,29 Many structural changes (i.e., changes to policies institutionalized in our society) must occur to reverse the HIV/AIDS epidemic that includes as a centerpiece eliminating discriminating practices and barriers to education, employment opportunities, housing, and good health. Prison/detention center interventions, especially those that facilitate linkages to surrounding community resources, can be seen as a part of that larger goal of bringing about community empowerment.30
Limitations of this Study
There are a number of limitations of this study. Random sampling of youth at this facility was not possible, but our sampling procedures were designed to minimize bias. Available data indicate that youth interviewed as part of the study were similar demographically to the entire population of youth admitted to this facility during the same time period. Second, self-reported data were used to assess the sexual and substance use risks among our sample, raising the ever present concern about data validity. Previous studies among detained male youth have found similar rates of substance use measured by means of urine drug screening as well as self-reported sexual substance use behaviors, except where audio computer-assisted self-interview was used.1-6,12,31 Our self-reported data, like others, may be an under-estimate. Third, neither the frequency of recent substance use nor the level of dependence was assessed. Finally, the duration of drug treatment was not obtained, thus leading to the potential for misclassification of those reporting treatment. This study, however, points the way for more in-depth research on interventions to reduce HIV/STD risk behavior among disaffected youth.
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