HIV risk in adolescents with severe mental illness: literature review

JOURNAL OF ADOLESCENT HEALTH 2001;29:320–329

REVIEW ARTICLE

HIV Risk in Adolescents With Severe Mental Illness: Literature Review MICHAEL D. SMITH, Psy.D.

KEY WORDS:

Adolescent mental health Adolescents HIV Literature review Mental illness Sexual risk behaviors

Surveys of the general adolescent population indicate that teenagers frequently engage in sexual behaviors that place them at risk for human immunodeficiency virus (HIV) [1]. Moreover, many teens use drugs and alcohol, and even moderate levels of drug and alcohol use are associated with higher levels of HIV risk behaviors [2]. Thus, HIV prevention is a pressing concern for American adolescents. HIV prevention takes on added importance for those youths who experience problems that limit their ability to engage in HIV preventive behaviors or that increase the frequency of behaviors related to HIV transmission. Available evidence suggests that it is frequently the most vulnerable and troubled segments of the adolescent population who are most at risk for HIV infection. Adolescents with a severe mental illness (SMI) are one such group. Many SMI youths are at greater HIV risk not only from the direct effects of their mental health condition but also from other problems they encounter more frequently than non-SMI youth, such as delinquency, association in risky social networks, family problems, and From the Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. Address correspondence to: Michael D. Smith, Psy.D., Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 N. Summit Avenue, Milwaukee, WI 53202. E-mail: [email protected]. Manuscript accepted March 29, 2001. 1054-139X/01/$–see front matter PII S1054-139X(01)00265-8

so forth [3]. However, relatively little research has been conducted that examines HIV risk in adolescents with SMI. The purpose of this review is to summarize research that has been conducted with SMI adolescents regarding their risk for infection with HIV. In so doing, it examines studies conducted with related populations, discusses the context of HIV risk for SMI youths, and suggests topics for future research to help prevent the spread of HIV among adolescents with SMI. It begins by placing the HIV risk of SMI youth in its broader context by examining research on HIV risk behaviors in the general adolescent population, youths who are already diagnosed with the virus, and in adults with SMI.

HIV Risk in Related Populations Sexually active young people are at risk for acquiring HIV and other sexually transmitted infections (STIs). Epidemiologic studies suggest that about one-fourth of all STI cases reported in the United States occur in people younger than age 18 years with about 20% of all HIV infections occurring in this age group [4]. One study found an HIV seroprevalence rate of 5.3% in a sample of more than 2600 runaway and homeless adolescents [5]. More than 1800 adolescents were diagnosed with AIDS in 1997 with an additional 1500 in 1998 [6]. According to the Centers for Disease Control and Prevention [6], adolescent girls are primarily infected through heterosexual sexual activity and secondarily by injection drug use. Infection patterns among boys differ somewhat by race. Although infection through homosexual activity is the principal transmission route among adolescent males from all ethnic

© Society for Adolescent Medicine, 2001 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010

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groups, African-American and Hispanic adolescents show relatively more HIV infection through injection drug use and heterosexual sexual activity (about 30% of all infections) than other groups. Moreover, African-American, Hispanic, and economically disadvantaged adolescents have disproportionately high HIV-infection rates compared with other adolescents [6 – 8]. Many young people engage in behavior that places them at risk for HIV infection [1]. Past studies that have examined sexual activity among young people consistently suggest that about two-thirds of adolescents will have had sexual encounters before age 18 years and that many of these teenagers will be sexually active by age 16 years [9 –11]. Rates of pregnancy during adolescence [12,13], STIs among sexually active teens, and adolescent self-reports of unprotected intercourse [10,14] indicate that significant levels of HIV risk behaviors occur in young people. Problems in the family and associations with delinquent peers are significantly related to HIV risk behavior in adolescents. Adolescent sexual risk behavior has been found to be more frequent in those youths whose parents are less available, more coercive, less supportive, and monitor their children less [14 –16]. STIs in teenage girls are associated with negative family interactions and less parental monitoring [17]. Adolescents who have sexually active friends who do not use condoms, who believe that the majority of their peers have sexual encounters, and who view themselves as being less able to engage in HIV-preventive behaviors are more likely to engage in more HIV risk behaviors than youths who do not [18]. Additionally, having delinquent peers has been found to be highly predictive of HIV risk behaviors, particularly in white adolescents [19]. However, most adolescents view sexual intercourse as a normal event in relationships, a view that is even held by youths who are sexually abstinent [20]. Incarcerated, delinquent youths have been found to be at higher risk for HIV than nonadjudicated adolescents. Those adolescents experience onset of sexual intercouse at younger ages, have more partners, and exhibit higher rates of pregnancy [21]. Condoms are not frequently used by delinquent youths, despite larger number of sexual partners [22] and roughly equal knowledge about HIV and AIDS by delinquent youths compared with nondelinquent adolescents [23,24]. Less condom use is consistent with the finding that, in general, adolescents with more sexual partners do not use condoms as often [25].

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Research with HIV-positive adolescents (mostly conducted with minority, urban youth) indicates that adolescents diagnosed with HIV typically experience significant contextual and personal difficulties before acquiring HIV [26]. The majority of HIV-positive adolescents report sexual and physical abuse, and more than one-third have been placed out of the home (e.g., in foster care), have been involved with the criminal justice system, or both [26,27]. HIVpositive youths are significantly more likely than their HIV-negative peers to use drugs and alcohol, to sell sex for drugs or money, and to have anal sex [26]. They also have relatively high numbers of sexual partners and high rates of STIs and pregnancy [28]. Given the stresses that many HIV-positive adolescents confront before and after their HIV diagnosis, it is not surprising that many of them have mental health problems. HIV-positive youths are 2.4 times more likely than HIV-negative adolescents to have been placed in a psychiatric facility; 27% of females and 18% of males have a prior history of psychiatric hospitalization [26]. Pao et al.[28] reported that 85% of their sample qualified for diagnosis of an Axis I mental disorder according to a structured psychiatric interview and history. Moreover, 53% of the sample had been diagnosed with a mental disorder before being identified as HIV-positive. Lyon et al. [26] noted that HIV seropositivity only exacerbated the mental health and other life problems faced by HIV-positive youth before their diagnosis with the virus. This position is also supported by data from surveys of mental health providers in San Francisco who work with HIV-positive teens [29]. In fact, there are a number of similarities between HIV-positive adolescents and adults who have SMIs. SMI adults also frequently exhibit increased HIV risk behaviors associated with multiple sexual partners, sex for money or barter, homosexual contact, low levels of condom use, and drug use along with sexual activity [30]. These factors place SMI adults at much higher HIV risk than other adults [31,32]. Research suggests that many SMI adults do not use condoms during sexual activity and that sexual contact often occurs in the context of riskier social networks for HIV infection [33]. HIV risk for SMI adults, like that of adolescents, differs by gender. Men engage in more injection drug use [31,32] or homosexual sexual activity [34]. Women are at relatively higher risk from heterosexual transmission, especially in the context of powerimbalanced relationships [35]. However, the occurrence of HIV sexual risk behaviors is related to drug use in both genders [32,36]. A review of HIV sero-

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Table 1. Studies Directly Examining HIV Risk and Prevention in Adolescents With Severe Mental Illness (SMI) Study Descriptive Studies Aruffo et al. (1994) [49]

Sample 100 hospitalized, mean age 14.8

Baker & Mossman (1991) [39]

23 hospitalized girls, aged 12–27

Brown et al. (1997a) [44]

100 hospitalized, aged 12–17

DiClemente and Ponton (1993) [41]

76 inpatients compared with CDC school sample of 802 in same city 76 inpatients, aged 12–21

DiClemente et al. (1991) [23] Katz et al. (1995) [24]

167 high school, 166 incarcerated, and 151 placed in severely emotionally disturbed classes

Singh et al. (1994) [43]

220 (120 male, 100 female) placed in severely emotionally disturbed classes, 5th to 12th grades 70, aged 14 –18, in program for severely disturbed youth

Valois et al. (1997) [42] Intervention Studies Brown et al. (1997b) [50]

35 hospitalized, mean age 14.2, recruited consecutively as admitted

Ponton et al. (1991) [38]

76 inpatients, recruited consecutively as admitted

Slonim-Nevo et al. (1991) [48]

54 (aged 10 –18) in 3 residential centers, 2 as treatment and 1 as control group

Focus of Research Relation between HIV knowledge and risk behaviors (esp. substance use) Survey HIV risk behaviors, STI, substance histories Assess associations among HIV-related attitudes and risk behaviors; examine sexual communication skills Compare HIV risk behaviors of SMI youth with community sample Frequency and correlates of selfcutting Compare HIV knowledge and attitudes between community, incarcerated, and mentally ill adolescent samples Assess HIV knowledge and attitudes

Assess frequency and correlates of HIV sexual risk behaviors 10-session cognitive-behavioral group with group discussion, role plays, and instruction; measures before and after 8-session cognitive-behavioral group with discussion, instruction, drama/ art, talk with PWA; measures before and after 90-minute educational program; and 1-month follow-up measures before and after

PWA ⫽ person with HIV.

prevalence studies suggests that 5% to 8% of SMI adults (possibly as many as 15% to 23%, especially among the homeless) have HIV [37].

HIV Research With SMI Adolescents Studies examining HIV risk in SMI adolescents have mainly focused on identifying the frequency of behaviors known to be involved in HIV transmission. The connections between these behaviors, their similarity or difference with those of non-SMI youth and adults with SMI, and the context of their occurrence have not been well-documented. A review of available databases and published articles revealed 11 studies examining HIV risk factors and prevention efforts with adolescents who have SMI (Table 1). Eight of the studies were descriptive in nature; the other three studies described preliminary work in

primary HIV prevention among SMI youth. For the purposes of this review, an adolescent was defined as anyone between the ages of 13 and 21 years, and an SMI was characterized as a persistent mental illness (such as schizophrenia or recurrent major depression) that has required specialized educational or psychiatric placement because of its severe impairment of adaptive functioning. Descriptive Research Most of the studies in Table 1 are descriptive studies that examine HIV risk in SMI adolescents. SMI adolescents face increased HIV risk because of an increased frequency of sexual risk behaviors, higher rates of substance use (including injection drug use), and association in social networks with increased HIV risk (e.g., delinquent youth and prostitutes).

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SMI adolescents have less accurate knowledge about HIV transmission and AIDS than non-SMI or delinquent youth, and they exhibit greater denial of their vulnerability for HIV infection [24]. Mentally ill adolescents engage in more HIV risk behaviors. Research with SMI adolescents suggests that they are at substantially higher risk for HIV than non-SMI youths [3]. SMI adolescents often exhibit several HIV risk factors at the same time, placing them at higher risk than other groups [38]. Furthermore, SMI adolescent girls exhibit increased rates of STIs [39]. SMI youth have been found to initiate intercourse at an earlier age than other adolescents [40], with 40% to 50% reporting first intercourse before age 13 years [41,42], compared with about 5% in the general adolescent population [10]. SMI adolescents with early onset of sexual intercouse have higher numbers of sexual partners and less condom use than their non-SMI peers [39]. When compared with SMI adolescents with onset of sexual intercouse after age 13 years, the early onset SMI group has higher rates of STI, more unintended pregnancies, and twice as many sexual partners [42]. Early onset of sexual intercouse in SMI adolescents also is associated with more negative attitudes toward HIV prevention and less accurate knowledge about HIV transmission and prevention [3]. Younger SMI youths in general, and especially African-American youths younger than age 15 years, have less accurate knowledge about HIV and its prevention [43]. Valois et al. [42] found that carrying a gun was strongly associated with onset of first sexual intercourse before age 13 years, suggesting that there may be a tendency toward conduct disorder and delinquency in the early initiation subgroup. In their review of the literature on HIV and SMI adolescents, Brown et al. [3] reported that SMI adolescents are more likely than other youth to be involved in social networks in which risk factors are prominent, such as those that include delinquent youths. Those authors concluded that the risk behaviors exhibited by SMI youths can be directly attributed to the effects of mental illness on decisionmaking, reality testing, impulsivity, and social interaction, all of which influence the adolescent’s ability to make decisions about health and sexual behaviors. Many SMI adolescents are the victims of sexual abuse. For example, one-third of the SMI adolescents sampled by Brown et al. [44] had experienced sexual abuse. In the non-SMI population, sexual abuse has

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been linked to HIV risk behaviors [45]. Therefore, it is not surprising that sexual abuse has been found to be related to a number of sexual and other risk factors in SMI adolescents, such as early onset of sexual intercousre, greater numbers of sexual partners, lower rates of condom use, and difficulties in effectively communicating and negotiating safer sex needs with partners [44]. Hussey and Singer [46] found that sexually abused SMI adolescents reported higher levels of substance abuse relative to psychiatrically hospitalized youths who had not been sexually abused. Aside from the sexual and drug behaviors, those adolescents were not significantly different from other SMI youths. Another HIV risk behavior associated with sexual abuse is the sharing of implements used in self-cutting behaviors. DiClemente et al. [47] identified the sharing of self-cutting implements as a potential HIV risk for SMI adolescents. Among their sample of 76 inpatient adolescents, 61.2% engaged in self-cutting, and 36.7% reported that they shared cutting implements. Self-mutilation was associated with a history of sexual abuse but was not related to gender or psychiatric diagnosis. Prostitution and drugs increase HIV risk for SMI youths. Prostitution and drug use pose significant HIV risks for SMI youths. Some SMI adolescents not only engage in providing sex for money, drugs, and other resources [41] but also buy sex from commercial sex workers. In their study of 54 youths (aged 10 –18 years) placed in a residential facility for mentally ill and delinquent adolescents, Slonim-Nevo et al. [48] found that the males in their sample were likely to have sexual contact with prostitutes and others who could be linked to the sexual networks of injection drug users. SMI adolescents in their sample used injection drugs at a higher rate than other teens. Aruffo et al. [49] also noted higher levels of injection drug use among SMI youths. Alcohol consumption and use of noninjection drugs among SMI youth are associated with increased sexual risk behaviors. SMI adolescents who use alcohol before age 13 years are more likely to also engage in first intercourse before that age [42]. In another study directly examining substance use and HIV risk with SMI youths, Aruffo et al. [49] surveyed alcohol and substance use and HIV risk in 100 adolescents (mean age, 14.8 years) hospitalized in a psychiatric facility. They found levels of sexual activity commensurate with other adolescents but higher rates of lifetime substance use (95% to 98%), mainly alcohol and marijuana. In that sample, 56%

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reported having unprotected intercourse and 20% reported having intercourse after drinking. Prevention Studies Three HIV prevention studies with SMI youth have been published [38,48,50]. Slonim-Nevo et al. [48] conducted an HIV prevention study with youths in residential placement. Treatment was provided by a 90-minute educational program that included HIV/ AIDS education, group discussion, and transmission and prevention information. Fifty-four youths (34 male, 20 female), aged 10 –18 years, residing in three residential centers participated in the study. Two of the centers received the intervention (30 participants), whereas the third center (24 participants) served as the control group. Measurements of HIV knowledge, attitudes, and risk behaviors were taken before and immediately after intervention and again 1 month after the intervention (80% of participants were located and assessed at follow-up). HIV/AIDS knowledge was generally high at pretest. However, misconceptions about HIV and AIDS were observed. For example, 15% of the sample believed that exercise can help people avoid getting infected with HIV. A majority (72%) had engaged in sexual behaviors and most had engaged in high-risk behaviors. The intervention produced no significant changes in HIV knowledge or risk behavior either within groups or between the control and treatment groups. Significant improvements in attitudes toward HIV preventive behaviors were noted within groups, but there was no significant difference in such attitudes between the intervention and control conditions. Ponton et al. [38] implemented an eight-session cognitive-behavioral group intervention with hospitalized youths over a 4-week period. The study was run in a psychiatric facility as part of the unit’s regular sexuality education programming. The intervention used group discussions, classroom presentations, conversations with an HIV-positive person, and drama and art therapy sessions to improve awareness, knowledge, and attitudes about HIV and AIDS. Over the 6 months during which groups were run, 76 adolescents (ages and genders not provided) participated in the HIV program. Measures were administered before and immediately after the conclusion of the 4-week program. Pre-intervention measures indicated that the adolescents already possessed a high level of HIV knowledge. No change was detected in HIV knowledge over the course of the program nor was there

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significant change in the participants’ perceived risk of acquiring HIV through their behaviors. However, misconceptions about transmission risk owing to casual contact decreased significantly at postintervention. Among participants reporting at least one risk behavior before the intervention, intentions to engage in risk behaviors were lower after attending the group program. However, this decreased intention to engage in risk behaviors was not found with SMI adolescents who used injection drugs. The third HIV prevention study with SMI adolescents was conducted by Brown et al. [50]. They delivered their intervention to 35 adolescents (mean age, 14.2 years) placed in a psychiatric hospital. The intervention consisted of a 10-session cognitive-behavioral program that used group support, roleplaying, and instruction to build HIV skills and knowledge, to increase personal concern, and to reduce risk behaviors by encouraging preventive attitudes. Assessments of HIV knowledge, attitudes, and behaviors were administered before intervention, immediately after intervention, and 3 months after the program. Following the intervention, participants showed significant improvement in HIV-related knowledge, tolerance of people with AIDS, and self-efficacy beliefs regarding safer sex behaviors. Participants with a history of sexual abuse showed less improvement in self-efficacy than did other SMI youths in the treatment program. All outcome measures had returned to baseline levels at the 3-month follow-up assessment. However, a trend toward increased condom use was reported at follow-up. Although these three studies represent important initial efforts to address the need for HIV prevention research with SMI youth, there are several limitations that restrict their broad applicability. First, only Slonim-Nevo et al. [48] employed a control group in their evaluation of treatment effectiveness. Thus, in the other two studies, one cannot determine if reported gains resulted from the HIV prevention effort or from more general effects owing to programming in the treatment facility. Second, it would have been helpful to have more information about relevant participant characteristics. One study did not report the age or gender of its participants [38]; two did not provide data on participant diagnoses [38,48]; and none gave information on family background, cognitive limitations, and other potentially important characteristics that could affect treatment outcome. Third, more comprehensive measurement of HIV risk behavior would have been helpful in these studies. None of the studies assessed HIV risk from

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oral sex, and only Slonim-Nevo et al. [48] examined needle-sharing behaviors. Brown et al. [50] did not assess any sexual risk behaviors in evaluating intervention outcomes. Last, all three studies used psycho-educational interventions primarily designed to improve HIV knowledge, to promote positive attitudes about HIV prevention, and to increase intentions to engage in safer behavior relative to HIV infection. However, even in the studies in which improvements in these areas were reported, it is unclear as to whether this improvement would transfer into reduced HIV risk behaviors. Given what is known about the complexity of HIV-relevant behaviors and the powerful influence of situational factors with SMI adolescents, it does not seem likely that such psycho-educational interventions alone would be sufficient to produce behavior change after termination of treatment. Indeed, neither of two studies conducting follow-up measures [48,50] reported maintenance of treatment gains. Longer term, socially embedded risk behaviors will probably require more intensive and individually tailored interventions if prevention efforts are to be effective.

Summary and Conclusions Evidence from the existing research on SMI adolescents indicates that this population is highly vulnerable to HIV infection. If HIV seroprevalence rates match those found in SMI adults and runaway adolescents, about 1 in 20 youths with an SMI could already be infected with the virus. Youths with SMI are at increased HIV risk owing to a constellation of social, family, peer, and contextual influences. A history of negative family interactions, insufficient parenting, delinquency, victimization experiences (especially sexual abuse), and mental illness seem to identify those adolescents at greatest risk for HIV infection. Not surprisingly, many of these factors are interrelated. For example, conflicted parent– child interactions and a lack of parental monitoring have been associated with delinquent behaviors in the community and at school [51,52], as well as with increased HIV risk behaviors. These problems further expose SMI youth to social networks with higher levels of HIV risk behavior. Trauma and delinquency histories are related to out-of-family placement, which can disrupt existing social support for SMI adolescents and can lead to increased association in risky social networks. Sociocultural and economic concerns can also re-

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sult in higher HIV risk among SMI adolescents. Economically disadvantaged SMI adolescents may be caught in the double bind of having less effective or timely mental health treatment, combined with residence in communities where fewer resources have been provided to address the spread of HIV. The lack of treatment for mental health problems may be a factor that places SMI youth at greater risk for HIV infection. Research has shown that treatment for mental health problems decreases HIV risk behaviors in adolescents, with such gains measurable into young adulthood [53]. It may be that HIV risk in SMI adolescents cannot be separated from the life context in which such teenagers find themselves. For example, Atwood [54] described a multisystemic model for explaining how various aspects of an adolescent’s social environment (e.g., peers, media, family, etc.) interact to influence HIV-relevant behaviors and attitudes. Hovell et al. described HIV risk behavior in similar terms within a behavioral-ecological model [55]. However, in addition to the effect of multiple social systems on HIV risk behavior, this model incorporated antecedents and consequences to risk behavior and added cognitive variables (such as assertiveness, self-efficacy, and HIV prevention knowledge), relationship factors (like communication and influences from the partner), and consequences (such as orgasm, pregnancy, and disease). In both models, adolescents often must interpret conflicting messages from their environments, which can lead to inappropriate decisions regarding safer sex and drug use behaviors, especially when judgment is impaired, positive role models are lacking, and proximal benefits outweigh distal perceived costs. Applied to SMI adolescents, in which factors such as negative peer influences, impaired and impulsive decision-making, troubled families, and drug involvement frequently occur, these models suggest that greater concordance between such influences, especially in the absence of health-promoting factors, would lead to increased HIV risk. Consistency in negative messages from multiple sources, susceptibility of the adolescent to those messages, and the low salience of negative consequences (either through ignorance of them or temporal distance) increase HIV risk behavior for youth with SMI. Because these adolescents often lack positive influences to combat these trends, they would be more likely to engage in HIV risk behavior than other teens. These theoretical models also provide a better understanding of how to prevent the spread of HIV

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from those SMI youths already infected with the virus. Research suggests that SMI adolescents have restricted social networks, greater use of drugs and alcohol, multiple sexual partners, and lower rates of condom use. Therefore, it is likely that HIV-positive SMI adolescents will engage in risk behaviors that could spread the virus to their sexual and needlesharing partners unless effective intervention programming is provided at the individual, relationship, and social levels. Yet, no published accounts of secondary prevention programming for HIV-positive SMI adolescents could be found. Even though there is still much about the nature of HIV risk in SMI adolescents that remains to be discovered, some implications for HIV prevention work with this population can be cautiously drawn. For example, SMI adolescents seem to have less accurate HIV knowledge than other teens. Providing them with interesting and personally relevant information about HIV transmission could be helpful in reducing their vulnerability for HIV infection. Additionally, providing SMI adolescents with adequate mental health treatment could be important in reducing their HIV risk. Not only would mental health treatment improve decision-making and social judgment, but it would promote a more positive sense of future wherein long-term consequences of sexual and drug behaviors mattered more to the adolescent. Thus, not only would SMI adolescents have more access to HIV prevention information, but also they might be more motivated to translate this information into behavior. Effective mental health treatment also may improve the ability of SMI adolescents to associate with positive peer groups, to succeed in school, and to engage in prosocial activities. Families and other caregivers could be involved in HIV prevention efforts, and their ability to be positive influences in this area might be enhanced by educational, communication skills, and other family support programs. However, much of this involvement remains speculative. Empirically validated approaches for HIV prevention with SMI adolescents do not exist. Additional research must be conducted to highlight areas in which interventions are most needed and to identify effective HIV prevention strategies.

Directions for Future Research More research is needed to understand the nature of HIV risk in SMI adolescents, as well as to devise effective primary and secondary intervention programs. More extensive, better controlled epidemio-

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logic studies of HIV seroprevalence among SMI youth are needed that account for potential differences in ethnicity, geographic region, and socioeconomic status. Little is known about the characteristics of HIV-positive SMI youths in general, as most studies to date have been conducted with AfricanAmerican females. Little is known about HIV-positive SMI adolescents of Latino or Caucasian descent or about adolescent boys with severe mental illnesses. The available evidence suggests that SMI adolescents engage in HIV risk behaviors more than nonSMI adolescents. Preliminary descriptions of the nature and frequency of these behaviors have been undertaken. However, more work needs to occur in this area to better understand HIV risk in SMI youth, as well as the similarities and differences in HIV risk between SMI and non-SMI youth. For example, even though older non-SMI adolescents appear to have more sexual episodes in a given time period than SMI youth, SMI youth have more partners, engage in riskier activities, and may draw sexual partners from higher risk networks than non-SMI adolescents. Many SMI youth exhibit more than one category of HIV risk behavior [3] and may also exhibit more than one contextual influence on HIV risk; for example, a given SMI youth may engage in delinquent behavior, have early onset of sexual intercourse, and be the victim of sexual abuse. These findings suggest that factors associated with HIV risk and group characteristics are highly intercorrelated, at least for some SMI youths, especially if placed within a theoretical framework, like the behavioral-ecological model [55], which outlines possible connections between such influences. Research exploring the contextual threads that link individuals to clusters of risk behaviors would allow for more effective interventions in group or individual settings. Knowing how certain risk behaviors covary, as well as understanding how different personal and contextual profiles affect HIV risk, would permit prevention programs to be targeted toward specific intervention needs and goals for given individuals or subpopulations. Research designs need to assess enough variables, with sufficient range of possible responses, to capture such potential subtleties. Assessment methods must capture relationship, communication, and decision-making behaviors that influence HIV risk in addition to directly measuring sexual and drug behaviors that could lead to HIV infection. Furthermore, researchers must assess the social environment to explore peer, community, and

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family factors that might affect the risk behaviors of SMI adolescents. Qualitative methods could be used to assess these complex interactions. For instance, a research program that began with qualitative efforts to identify risk behaviors occurring within specific social, peer, family, and individual contexts could provide the initial information needed to undertake quantitative examinations of the inter-relationships between these influences. Formative qualitative research could provide a richer understanding of how cultural, ethnic, socioeconomic, and treatment differences among SMI youth contribute to HIV risk in this population. Several distinctions in risk behaviors for SMI youth already have been suggested in the literature. These distinctions could be used as starting points for future research. First, there may be differences in HIV risk behaviors between SMI youth who exhibit delinquency versus those who do not. For example, delinquent youth may be more likely to inject drugs, to engage in or solicit sex for money and barter, to interact with the legal system, and to have antisocial personality characteristics. Even among nondelinquent SMI youth, there may be significant differences by diagnostic category. For example, adolescents with mood disorders could have very different HIV prevention needs than those with psychosis. Second, SMI youth with early onset of sexual intercourse appear to be distinct from those with a more typical sexual onset. SMI youths with early onset of sexual intercourse are more likely to have a history of sexual victimization. This group will probably need specific treatment for their victimization history for HIV prevention programming to be most effective. SMI youths with early onset of sexual intercourse also tend to have longer histories of sexual activity, at higher levels of risk, than SMI adolescents with later sexual onset. A third distinction present in the literature involves differences in HIV risk and response to prevention messages between SMI youth who inject drugs and those who do not. Although only a relatively small number of SMI youth inject drugs, the proportion is still higher than in the non-SMI population. Additionally, information from the small intervention studies conducted with SMI adolescents suggests that the drug-injecting subgroup may be especially resistant to HIV prevention programming. This suggestion would indicate a need to first address concerns related to the injection drug use by providing drug rehabilitation services. Last, research has identified gender differences in

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HIV risk behaviors for SMI adolescents. Although additional research is needed to more clearly delineate the nature of these differences, adolescent boys seem to be at greater risk from injection drug use, homosexual sex, and purchasing sex. Adolescent girls have more risk from heterosexual contact, especially in the context of exchanging sex for survival needs or in relationships in which they have less ability to negotiate condom use. The existence of such differences would probably require distinct research questions and prevention programming for adolescent boys and girls with SMI. Research also should account for the wide variety of settings in which SMI adolescents live, work, socialize, and receive treatment. It is likely that the nature of HIV risk and the contextual factors associated with risk behaviors change with the type of setting in which SMI adolescents are located. The current preference is to maintain SMI adolescents in the community as much as possible. Many programs exist to facilitate this goal, and public schools have provided services for behaviorally and emotionally disturbed youths for decades. However, most of the research conducted with SMI youth has been with adolescents residing in psychiatric or other institutional placements. For research in this area to be more pertinent, especially with regard to prevention programming, additional data will need to be collected from SMI adolescents in community-based settings such as with youths residing in foster homes, with their families, in group homes, or in homeless shelters. A clearer idea of how HIV risk behaviors are nested within the lives of SMI adolescents could greatly enhance prevention efforts with this population. Attempts to reduce the risk of HIV infection in SMI adolescents need to intervene at multiple levels. Although it is important to educate adolescents with SMI about HIV transmission and prevention, research has shown this education to be insufficient to promote behavior change. Work with SMI adults, for example, suggests that motivation-building, access to prevention resources, attitude change, and so on are all important components of effective prevention programming [56]. These same elements need to be translated into developmentally appropriate and treatment sensitive interventions for teenaged SMI groups. Creative use of music and video, competitions, peer advocacy, and discussion sessions with HIV-positive adolescents would all be ways to bring prevention messages to this population. However, it is unlikely that focusing on SMI youths alone will produce enduring HIV risk-reduc-

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tion. Researchers will need to decide how to address influences from the environment that increase HIV risk. One option would be to provide competing influences in the form of supportive group experiences with other SMI teens, mentorship experiences (like the Big Brother and Big Sister programs), and recreation programs that occur in a prosocial context. A second option would be to directly intervene in the environmental context of SMI youth to improve HIV knowledge, attitudes toward prevention, and HIV prevention resources. This intervention could be done by providing family therapy and other family support, by encouraging the development of positive peer relationships, by educating case workers and child protection service personnel about HIV prevention with SMI adolescents, by using public marketing campaigns to promote safer sex behaviors among teenagers, by improving HIV prevention information and resources in special education programs, and so on. Effective intervention programs will probably incorporate elements that focus both on SMI adolescents and the people and institutions around them. The more HIV prevention programs can be integrated into the daily lives of SMI adolescents, the more effective they are likely to be. Last, relatively little research addressing the prevention, adherence, and other needs of HIV-positive individuals with SMI has been conducted [56]. This research has been especially lacking among SMI youth where no such intervention studies in the published literature could be found. The need to help HIV-positive SMI adolescents adhere to complex medication regimens, adapt emotionally and socially to their HIV diagnosis, and prevent the spread of HIV to sexual and needle-sharing partners are all important areas that need to be addressed in future research and secondary prevention programming. HIV infection appears to occur most frequently in youths who have few resources, who lack supportive families, and who live in disadvantaged communities. These young people often suffer from severe mental illness, have run away from home, have no home, or are involved in delinquent activities. Often, SMI youths experience more than one of these problems that may shift and recombine over the span of their teenage years. As such, it may not be entirely possible to distinguish clearly defined, stable subgroups of youths at risk for HIV, except by the degree to which one set of problems is more prominent than another. Thus, in terms of their HIV risk, this population may represent a relatively homogeneous group, one that is struggling, troubled, and at very high risk for acquiring HIV infection.

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I thank Steven D. Pinkerton, Ph.D., for his kind assistance in critiquing this manuscript. Preparation of this manuscript was supported by center grant P30-MH52776 from the National Institute of Mental Health and by NRSA postdoctoral training grant T32-MH19985.

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