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Predictors of HIV testing among runaway and homeless adolescents
jOURNAL
OF ADOLESCENT
HEALTH
1994;15:566-572
FELLOWSHIF ;RUM
redictors of HIV Testing among Homeless Adolescents
unawayand
ELIZABETH
D.Crim.
GOODMAN,
M.D., AND JOHN
E. BERECOCHEA,
Purpose: Although runaway and homeless adolescents are at high risk for acquiring HIV infection, little is known about which of these youth obtain HIV testing or whether those considered to be at highest risk are being tested. The purpose of our st .dy was to determine demographic characteristics and risk profiles of runaway and homeless adolescents who had obtained an HIV test and compare them to those who had not been tested. Methods: We analyzed data collected by the State of California from a survey of 202 San Francisco Bay area runaway and homeless youth aged 13-18 years conducted in 1990-1991. Adolescents were interviewed about AIDS-related knowledge, attitudes, beliefs, and behaviors, including HIV testing experience. Results: Most subjects were 16 years or older (80%1, white (61%1, sexually active (91%) and heterosexual (82%). Twenty-three percent reported a previous sexually transmitted disease (STD); 27% had used injection drugs. Over half (54%) had been HIV antibody tested. Free/community clinics were the most common site for testing. In a logistic regression model, four variables were independent predictors of having obtained an HIV antibody test: history of an STD (p = 0.011, 5 or more years of sexual activity (p = 0.011, injection drug use (P = 0.041, and age (p = 0.04). Conclusions: Our study demonstrates that many runaway and homeless adolescents have obtained an HIV antibody test and that those with known risk factors are
From the Dizlisim of Adohwt Mediciw, Chi/drerr‘s Hosyifnl, and the /oirlt Progrm it1 !hifh/ Rlld fhh/l, hk0 E~lghd Medical Cerrter, Hnrzmrd School of P~tblrc HwM, Bosh (E.G.) nt~d //le C&@ylio Deprtttmt 01 Health Semite Office of AIDS (/.E.B.). Address correspondewe to: EliznbeU[ Goodrrm~t, M.D., 750 W&Zitl$orf Street, Box 345, Bosto~l, MA 0217 I. This pqwr wns presented in part nt tlrc Atrlericun Plrblic He&/[ Associntioa’s I.?lst Atmrnl Mretirrg, Sm Frmcisco, CA. &t&r 2428th 1993 md the Society for Adolescent Medicitle AIJ~II~~! Meehitlg, LOS Aqeles, CA. M&r 76-20, 1994. Mumscript accepted April 16, 1994. 566 Nm-139xl94/$7.00
more likely to have been tested. These data support the need for community-based expansion of HIV-related services for homeless youth. The effects of HIV antibody testing on subsequent beliefs and behaviors need further study. KEY WORDS:
HIV infections/prevention and control HIV seroprevalence Adolescence Homeless persons Sex behavior Health education
Adolescents are at risk for HIV because experimentation with drugs and sexual activity is common during this developmental period (1,2). Among adolescents, runaway and homeless youth are at significant risk for HIV infection because of their high rates of injection drug use and unprotected sexual activity (3-10). There are an estimated one-half to two million of these youth in the United States (4). Clinic-based studies have demonstrated HIV seroprevalence rates among runaway and hom&ss adolescents ranging from 5.3% to 9.3% (11,121. However, actual prevalence rates ior this population of teenagers and the proportion of teens using HIV testing services are unknown. Because of the increased risk for acquiring HIV infection among homeless adolescents, recommendations have been made to make HIV testing and other related services for these youth more widely available (5,101. However, runaway and homeless adolescents are less likely to utilize conventional
0 Society for Adolescent Medicine, 1994 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
November
1994
sources of health care. Identifying demographic characteristics and risk profiles of runaway and homeless adolescents who obtain HIV testing would help health professionals design comprehensive testing programs and linked services specifically geared to the unmet needs of this high-risk population, which would hopefully include those not currently using available services. We investigated San Francisco Bay area runaway and homeless adolescents to answer two questions: 1) What demographic characteristics and risk profiles of runaway and homeless adolescents are associated with the use of HIV testing services, and 2) Are those adolescents at higher risk for HIV being tested?
Mefhods We analyzed data collected by the California Department of Health Services Office of AIDS regarding AIDS-related Knowledge, Attitudes, Beliefs, Behaviors (KABB) of San Francisco Bay Area adolescents 13-18 years old who were not enrolled in a traditional school program or KABB study. Runaway and homeless teens were recruited for the KABB study from three community-based youth service agencies (“shelter”) and four street sites (“street”) known to be frequented by runaway and homeless adolescents. Youth were considered eligible if they were staying at runaway youth shelters or participating in programs specifically for homeless, runaway, or prostituting teens or if they were known to street outreach workers as living apart from their parents or without a permanent residence. Data were collected by face-to-face structured interviews administered by seven trained interviewers. Informed consent was obtained from all participants, each of whom was given $7.50 worth of “fast-food” coupons. Participants were free to refuse to answer any question. During the 6 month period from October 1990 through April 1991, 206 adolescents completed the interview, representing a response rate of approximateiy 80%. No data are available on non-respondents. Of the 206 subjects, 202 responded to the questions assessing previous HIV antibody testing. These 202 subjects made up the sample used in otir analysis. The survey instrument consisted of close-ended questions assessing five areas: I ) demographics and life history, 2) HIV-related knowledge, 3) attitudes, beliefs and AIDS-relai-ed experience, 4) sexual, alcohol and drug use behaviors, and 5) medical care information, including a history of prior HIV test-
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ing. Only items from these five sections relevant to HIV infection were included in the current study because the small sample size limited the number of variables available for statistical analyses. Demographic variables included in this study were: age, gender, race, education, and site of recruitment. Risk behaviors included age of initiating sexual intercourse, years of sexual activity, number of sexual partners over the past six months, self-reported sexual orientation (“heterosexual”, “homosexual”, “bisexual”, “undecided”), history of injection drug use (IDU), history of a sexually transmitted disease (STD), having engaged in receptive anal intercourse, and condom use (“never, less than half the time, about half the time, more than half the time, always”). Nine items in a “yes, no, don’t know” format assessed HIV-related knowledge. These were then combined into a Knowledge Score which could range from 6 to 18. Beliefs and attitudes included perceived risk and worry. Perceived risk and vorry were each measured. by a single item with an “agree, disagree, don’t know” format: “Things 1 have done in the past have put me at high risk of getting AIDS” and “I am not worried about getting AIDS,” respectively. AIDS-related experience was assessed with single item in a “yes,” “no” format: “have you ever known someone living with AIDS?” Medical care included an item assessing previous testing experience: “Have you ever taken a test for AIDS?” (“Yes, no, don’t know” format). Adolescents were also asked how many times they had been tested and were asked to identify the site of their last HIV test from a list of nine possible choices. Adolescents were not asked to reveal HIV test results, t-herefore seroprevalence data are not known. A detailed description ljf the questionnaire and the methodology used for data collection are available from the State of Califol nia Office of AIDS (13). Two subpopulations were identified from subjects included in the KABB study: adolescents who had used injection drugs and those who reported an additional risk factor for HIV were defined as “Very High Risk Youth.” Additional risk factors included history of an STD, five or more lifetime sexual partners, receptive anal intercourse, never using condoms for vaginal intercourse, and for males, self-reported homosexual or bisexual orientation. There were 43 Very High Risk Youth ,identified in this manner. “Lower Risk Youth” were defined as younger, heterosexual, sexually active less than five years, never having used injection drugs, and no history of an STD. There were, on the basis of these criteria, 21 Lower Risk Youth in the study.
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Statistical Analysis The relationships between having obtained an HIV test and 14 pre-selected variables were assessed with Fisher’s exact tests for analyses with expected counts of less than five in a cell, and chi-square tests for other contingency table analyses. Age and knowledge score were analyzed with Wilcoxon rank sum tests, since these variables were not normally distributed. Means are presented with standard deviations. To determine independent predictors of HIV antibody testing, variables statistically related to HIV antibody testing by univariate analysis were entered into a multiple logistic regression model. Variables entered into the model included age, years of sexual activity, history of an STD, history of IDU, history of receptive anal sex, and knowing a person with AIDS. Gender and site of recruitment were also included in the model to control for confounding. Condom use was not included because 24% of subjects did not answer this question. Male homosexual/bisexual orientation was also excluded owing to collinearity with anal intercourse and gender. Adjusted odds ratios and 95% confidence intervals were calculated from the model’s parsmeter estimates. All analyses were performed using SAS (141, except for determination of relative risk with 95% confidence intervals for univariate analyses which were calculated using Epi Info software (15).
Results Demographics Demographic data for the 202 subjects are presented in Table 1. Our sample was mostly white and most considered themselves heterosexual. Mean age ‘*.vas 16.4, SD -I- 1.1 years. There were no signifif:ant differences between shelter and street popula~:nns for age, gender, sexual risk factors for HIV infeciion, or history of HIV antibody testing. More Hispanic youth and more IVDU’s were interviewed in the shelters.
AIDS-Related Experience
Knowledge,
Attitudes,
Beliefs and
HIV/AIDS knowledge was good in this group. Knowledge score ranged from 10.5 to 15 !vith a mean of 12.8, SD t 0.68. There were no differences in knowledge between adolescents recruited from the shelters and those recruited from the streets. More than half (57%) agreed they were at high risk
for acquiring HIV owing to past behaviors and 81% were worried about getting AIDS. Fifty-six percent of respondents had known someone living with AIDS.
Drug Use and Sexual Behaviors DRUG AND ALCOHOL USE. Many of these adolescents had experience with drugs and alcohol (Table 2). Mean age for initiating alcohol use was 10.2, SD + 3.7 years. Although 18% of IVDUs believed needle sharing between sex partners was “OK”, none of the youths who believed this had actually shared needles in the past.
Table 1. Demographics of Study Population Shelter (n = 125) n (%)
Street (n = 77) n (%)
Total (n = 202) n (%)
Age (Years) 13 14 15 16 17 18
1 (1) 5 (4) 18 (14) 43 (34) 52 (42) 6 (5)
2 (3) 3 (4) 12 (16) 14 (18) 23 (30) 23 (30)
3 (1) 8 (4) 30 (15) 57 (28) 75 (37) 29 (14)
Race Asian Black Hispanic* Native American White Other
2 (2) 10 (8) 19 (15) 3 (2) 76 (61) 15 (12)
5 3 5 46 18
0 (7) (4) (6) (60) (23)
2 (1) 15 (8) 22 (11) 8 (4) 122 (60) 33 (16)
Gender Male
61 (49)
47 (61)
108 (53)
Last Grade Attended in School Below 9 9 10 11
39 37 37 21
24 18 20 15
(31) (30) (22) (17)
(31) (23) (26) (20)
63 55 47 36
(31) (27) (23) (18)
Self-reported Sexual Orientation Heterosexual Homosexual* Bisexual+ Undecided Missing
100 (80) 9 (7) 6 (5) 2 (1) 8 (6)
65 (84) 1 (1) 7 (9) 0 -l(5)
165 (82) 10 (5) 13 (6) 2 (1) 12 (6)
Injection Drug User Yest
41 (33)
14 (18)
55 (27)
HIV Antibody Test Yes
69 (55)
41 (53)
110 (54)
*All were male. +Four were male. *p = 0.01.
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1994
HIL’ TESTING AMONG HOMELESS ADOLESCENTS
VAGINAL INTERCOURSE. The vast majority (91%) of subjects reported vaginal intercourse (Table 2). This cohort initiated sexual activity early and maintained activity at a high level. Mean age of ini.tiating intercourse was 13.0, SD ‘_ 2.3 years. Mean number of years of sexual activity was 3.5, SD + 2.6 years. Forty-two percent had had five or more sexual partners in the past six months. More than one-half of those who engaged in prostitution (“survival sex”) did so to obtain drugs or a place to stay as opposed to being given food or money. Males were more likely than females to report always using condoms during intercourse. When having sex for pleasure, fun or love, 31% of males reported always using condoms compared with 17% of females (p = 0.04). Of the 17 youths who had engaged in survival sex, only 3, all males, reported always using condoms. Fourteen percent of sexually active adolescents reported never using condoms dlrring vaginal intercourse. The percentage of youths reporting never using condoms did not differ between genders. ANAL INTZRCOUR5.E. Twenty (19%) males rclported insertive anal intercourse. Mean age of initiating insertive anal intercourse was 15.0, SD 2 1.4 years. Eight considered themselves homosexual or bisexual, all of whom reported always using con-
Table 2. Recreational Sexual Behaviors
Juvenile Detention Private Hospita: Csunty Clink Other
0
10
5 %
15
20
25
30
Tested
doms during ihis activity. In contrast, 33% of fourteen heterosexual males engaging in insertive anal intercourse reported al,ways uaing cnndoms, while 17% reported never us;-q co:~_~oms during this activity. Receptive anal intercourse was reported by 13 males and 14 females. Seven males reported always using condoms during receptive anal intercourse compared wit’l ? females. Never using condoms was reported by 5 females and DO males (p = 0.04). These 5 females also reported condom use less than half th.P *ime with vaginal intercourse.
Drug and Alcohol Use and
Behavior Drug and Alcohol Use Any drug Crack Alcohol Intravenous Drug Use IIVDU) Ever injected any drug IVDU in past 6 months Ever shared needles Shared needle with a sex partner Vaginal Intercourse For any reason For pleasure, fun, love only For drugs, shelter, food, or money Anal Intercourse Insertive (males only) Receptive*
Very High Risk/Lower n (70) 190 (94) 59 (29) 199 (99) 55 39 23 23
(27) (29) (14) (11)
183 (91) 166 (82) 17 (8) 20 (19) 27 (13)
Condom Use During Vaginal intercourse+ At least half the time
104 (67)
Sexually Transmitted Disease History of an STD
46 (23)
*48% male. +n = 154.
569
Risk Youth
There were 24 very high risk males and 19 very high risk females in this population. Among males, 5 had had an STD, 33 reported five or more sexual partners withir t!le past 6 months, and 8 considered themselves homosexual or bisexual. Among females, 13 had had an STD, 12 reported five or more sexual partner5 within the past 6 months, 6 never used condoms during vaginal intercourse, and 5 reported receptive anal intercourse.
HIV Testing Over one-hali (54%; of the subjects had obtained HIV antibody testing. Forty-four percent of those who had been tested reported being tested once, while 15% had been tested 5 or more times. Free or community clinics were the most common site of testing (Figure 1). There were no significant differences in test site utilization between genders, those with a history of injection drug use, or those adolescents who were sexually active for 5 or more years. However, older adolescents (16 -18 years) were 5
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Table 3. Univariate Analysis of Predictors of WV Testing n tested n With Predictor
Predictor
activity
(% of those with predictor)
48
34 (71)
Injection drug user
55
40 (73)
Had receptive anal intercourse Male homosexual/ bisexual History of an STD
27
20 (74)
25 years sexual
Condom use 2 % time with vaginal sex” Knows someone living with AIDS None of the above
14
11 (79)
46
37 (80)
104
60 (58)
114
72 (63)
21
3 (14)
I95’%‘sl 1.44 11.13, 1.831’ 1.62 11.27, 2.@81*
not associated with testing. Fewer males than females had obtained HIV testing, but the difference was not statistically significant (48% vs 62%, p = 0.054). Logistic regression modeling revealed that history of an STD, 5 or more years of sexual activity, injection drug use, and age were independent predictors of HIV testing (Table 4).
1.46 I1.11. 1.901’ I .%I 11.26. 2.581* 1.73 11.39, 2.161* 1.52 11.03, 2.241‘ I.45 Il.10, 1.911t 0.24 lO.09, 0.69 I*
*0.05 > p r 0.01 ‘0.01 > p > 0.001 ‘p < 0.001 “Data missing for 24% of sample.
times less likely than younger adolescents to be tested at private hospitals or doctors’ offices (p = 0,006). Minority adolescents (African American and Hispanic) were more than 3 times more likely than white adolescents to obtain testing at a county clinic or hospital (p = 0.02). Adolescents with an STD were 2.25 times more likely to go to an adolescent-specific site than other sites for HIV testing (p = 0.02), and those who were recruited from a shelter site were more likely to have been tested at a youth service agency than those recruited from the streets (p = 0.004). Of note, 25% of subjects did not know that adolescents could receive anonymous testing. Fourteen female (74%) and 18 (75%) male very high risk youth had obtained HIV testing. All 8 homosexual/bisexual male IDUs had been tested for HIV, as had nine (75%) female IDUs with 5 or more sexual partners in the past 6 months. Overall, 10 185%) female and 4 (80%) male IDUs with a history of an STD had obtained HIV testing. Univariate analyses for the 7 variables found to be significantly associated with HIV testing are presented in Table 3. Adolescents who obtained testing iYere older (mean age 16.6 yrs vs 16.1 yrs, p = 0.01) and began sexual activity earlier (mean age initiating intercourse 12.9 yrs vs 13.5 yrs, p = 0.01). There were no significant differences in race, education, site of recruitment, and number of sexual partners between those who had been tested and those had not. Perceived risk and worry were also
Discussion This study of runaway and homeless adolescents found that just over half of these teens had obtained HIV testing. Homeless teens engaging in behaviors that put them at higher risk for HIV infection were more likely to have been tested. Because most educational and counseling interventions for runaway and homeless youth, including HIV testing, are based in clinics and social service agencies, previous studies have drawn their samples from these sources 8,11,16-18). However, studies done in shelters may not accurately reflect the risk behaviors and utilization of services by runaway and homeless adolescents because youth from the street are not represented. A contribution made by this study is that this data set included adolescents from both street and shelter sites. This study has several limitations. Because the survey from which these data are drawn was not designed to explore in detail the issue of HIV testing in homeless adolescents, the types of questions which can be answered by this data set are limited. For example, participants were not asked to reveal results or time of HIV testing, so seroprevalence data are not known and the relationship of testing to current behaviors could not be determined. Nor were teens who had not been tested asked why they had not made use of testing services, precluding our ability to address the perceived barriers to care in this population. Because there are no data available on non-participants and recruitment was dependent Table 4. Independent Predictors of HIV Testing from Logistic Model Predictor History of an STD 25 yrs sexual activity Injection Drug User Age
Odds Ratio 195% CI’SI 3.42 12.13, 5.51 I 2.67 Il.81, 3.941 2.31 11.54, 3.461 1.42 i1.20, 1.681
p Value 0.01 b.01 0.04 0.04
November
1994
on interviewer identification of potential subjects at the street sites, there may be a selection bias in the sample, although only 20% of those asked to participate refused to be interviewed. Answers to our survey instrument may have been influenced by social acceptability, given the intimate nature of the questions and the fact that data were collected by interview. However, the percentage of youth reporting risk behaviors such as injection drug use and sexual activity was comparable with other studies (3,6,19). In addition, self-report tends to underestimate actual risks, so the estimates we reported may be conservative. Our sample size reduced statistical power and made sub-group analysis not feasible in many instances. For example, the lack of statistical significance of the finding of less testing among heterosexual males may reflect the small sample size of this subgroup, rather than reality. This trend in gender differences in HIV testing is an area in need of further research, as it identifibs heterosexual males as a group who may not be utilizing available resources. Despite these limitations, these data provide a provocative preliminary glimpse into the level of risk and use of HIV testing among runaway and homeless adolescents. Risk behaviors for HIV were common in our study subjects, and among these adolescents, the number of males who considered themselves homosexual or bisexual and the rates of injection drug use and STDs were similar to those reported by runaway and :nomeless adolescents in other studies (3,6,19). CY.ir fXin:,s support the impression that runaway and homeless adolescents are at greater risk for acquiring HIV than adolescents enrolled in United States high schools, owing to earlier initiation of sexual activity and higher rates of injectio;? drug use (20-22). The proportion of youth engaging in multiple high risk behaviors is alarming and highlights the urgency to identify these youth, assess their risk behaviors and serostatus, and develop effective behavioral change programs. This study documented that, although just over half of these runaway and homeless adolescents had accessed the health care system to obtain HIV testing, those engaging in multiple risk behaviors were more likely to be tested. Some have advocated that HIV testing be used as an intervention to promote behavioral change (23,241. In a review of published reports of the effects of HIV testing, Higgins et al. showed that neither HIV testing nor knowledge of HIV serostatus has consistently been shown to be effective in changing risk behavior (25). Among adolescents,
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Stiffman et al. found no association between HIV testing and behavioral change (26). As an AIDS prevention strategy, interventions aimed at addressing the cultural context of adolescents’ lives and developing specific coping skills may be more effective than information-based programs like those offered by many current testing programs (9,18,24,2628). As stated above, we could not study the association between testing or serostatus and changes in high risk behaviors. Further longitudinal studies are needed to investigate the reasons why adolescents undergo voluntary HIV testing and what the effects of HIV testing on subsequent beliefs and risk behaviors are. Because of rising seroprevalence rates among adolescents, it is also important that we understand what the barriers are to accessing HIV testing services in order to effectively promote HIV testing among adolescents. We were unable to address these vital questions in this secondary data analysis. However, these data provide a valuable starting point for future endeavors. This study also supports recommendations for expansion of services providing HIV testing as well as educational and other comprehensive medical and social services interventions for runaway and homeless adolescents (5,10,29). The data suggest that services which are community-based or directly linked to adolescent-specific programs will be utilized by this group at high risk for HIV infection. The authors wish to thank Frank Cape11 for his conception
for the project from which the data are drawn; Paul Harder and his associates for their dedic&d work in development of the instrument and data collection; Bernard Lo, M.D. for his encouragement and advice, and S. Jean Emans, M.D., Robert H. DuRant, Ph.D., and Eli? beth R. Woob.+, M.D., M.P.H. for their helpful review of this manuscript. This work was supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, NJ, The Henry J. Kaiser Family Foundation, Menlo Park, CA, and project MCJ-MA 259195 from the Maternal and Child Health Rureau (Title V, Social Security Act), Health Resources and Services Administration, DHHS.
References 1. Select Committee
on Children, Youth and Families, A Decade of Denial: Teens and AIDS in America. US House of Representatives, 1992.
2. Hein K. Risky business: adolescents and human immunodcficiency virus. Pediatrics 1991;88:1052-4. 3. Yates GL, Mackenzie RG, Pennbridge J, Cohen E. A risk profile comparison of runaway and non-runaway youth. Am J Public Health 1988;78(7):820-1. 4. Council on Scientific Affairs. Health care needs of homeless and runaway youths. JAMA 1989;262:1358-61.
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5. Athey JL. HIV infection and homeless Welfare 1991;70(5):517-28.
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6. Deisher RW and Rogers W. The medical care of street youth. J Adolesc Health 1991;12(7):500-3.
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19. Selected behaviors that increase risk for HIV infection among high school stud< -%-United States, 1990. MMWR 1992; 41(14):231, 237-40.
ST, Hergenroeder AC, Chacko MR, Parcel CS. immunodeficiency syndrome and adolescents. attitudes, and behaviors of runaway and homeAm J Dis Child 1991;145(4):43l-6.
8. Rotheram-Borus MJ, Becker JV, Koopman C, Kaplan M. AIDS knowledge and beliefs, and sexual behavior of sexually delinquent and non-delinquent (runaway) adolescents. J Adolesc 1991;14(3):229-44. 9. Rotheram-Borus MJ and Koopman C. Sexual risk behaviors, AIDS knowledee. and beliefs about AIDS amone r Y nmawavs. Am J Public H&th 1991;81(2k208-IO.
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20. Yates GL, Pennbritge J, Swofford A, Mackenzie RG. The Los Angeles system of care for runaway/homeless youth. J Adolest Health 1991;12(7):555-60. 21. Sexual behaviors among high school students-United 1990. MMWR 1991;40:885-8.
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22. Alcohol and drue use amone hieh school students-United States, 1990. MMfiR 1991;40:~41,~47-50.
IO. Rotheram-Borus MJ, Koopman C, Ehrhardt AA. Homeless youths and HIV infection. Am Psycho1 199;46(11):1188-97.
23. Remafedi G. Preventing the sexual transmission of AIDS during adolescence. J Adolesc Health Care 1988;9:139-43.
11. Stricof RL, Kennedy JT, Nattel TC, et al. HIV seroprevalence in a facility for runaway and homeless adolescents. Am J Public Health 1991;81(5):50-3,
24. North R. Legal authority for HIV testing of adolescents. Adolesc Health Care 1990;11:176-86.
12. Shalwitz J. Unpublished
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13. HIV Risks Among Out-of-School Youth: Report on a Survey nf AIDS-related Knowledge, Attitudes, Beliefs, and Behaviors among out-of-school youth in the San Francisco Bay area. Sacramento, CA: California Department of Health Services Office of AIDS; May 1992. 14. SAS Institute, Inc. SAS/STAT User’s Guide, Release Edition. Cary, NC: SAS Institute Inc, 1988.
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15. Dean AC, Dean JA, Burton AH, Dicker RC. Epi lnfor, Version 5: a word processing, database, and statistics program for epidemiology on microcomputers. USD, Incorporated, Stone Mountain, GA, :990. 16. Pennbridge JN, Yates GL, David TG, Mackenzie RG. Runaway and homeless youth in Los Angeles County, California. J Adolesc Health Care 1990;11(21:159-65. 17. Rotheram-Borus
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25. Higgins DL, Galvotti C, O’Reilly KR, et al, Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA 1991;266(17):2419-29. 26. Stiffman AR, Earls F, Dore I’, Cunningham R. Changes in acquired immunodeficiency syndrome-related risk behavior after adolescence: relationships to knowledge and experience concerning human immunodeficiency virus infection. Pediatrics 1992;89(S):950-6. 27. Hein K. Commentary on adolescent acquired immunodeficiency syndrome: the next wave of the human immunodcficiency virus epidemic? J Pediatr 1989;114:144-9. 28. Walter HJ, Vaughan RD, Gladis MM, et al. Factors associated with AIDS risk behaviors among high school students in an AIDS epicenter. Am J Pub1 Health 1992;82(4):528-32. 29. Schorr LB. Within our reach: breaking the cycle of disadvantage. New York, Anchor Press/Doubleday, 1988,
OF ADOLESCENT
HEALTH
1994;15:566-572
FELLOWSHIF ;RUM
redictors of HIV Testing among Homeless Adolescents
unawayand
ELIZABETH
D.Crim.
GOODMAN,
M.D., AND JOHN
E. BERECOCHEA,
Purpose: Although runaway and homeless adolescents are at high risk for acquiring HIV infection, little is known about which of these youth obtain HIV testing or whether those considered to be at highest risk are being tested. The purpose of our st .dy was to determine demographic characteristics and risk profiles of runaway and homeless adolescents who had obtained an HIV test and compare them to those who had not been tested. Methods: We analyzed data collected by the State of California from a survey of 202 San Francisco Bay area runaway and homeless youth aged 13-18 years conducted in 1990-1991. Adolescents were interviewed about AIDS-related knowledge, attitudes, beliefs, and behaviors, including HIV testing experience. Results: Most subjects were 16 years or older (80%1, white (61%1, sexually active (91%) and heterosexual (82%). Twenty-three percent reported a previous sexually transmitted disease (STD); 27% had used injection drugs. Over half (54%) had been HIV antibody tested. Free/community clinics were the most common site for testing. In a logistic regression model, four variables were independent predictors of having obtained an HIV antibody test: history of an STD (p = 0.011, 5 or more years of sexual activity (p = 0.011, injection drug use (P = 0.041, and age (p = 0.04). Conclusions: Our study demonstrates that many runaway and homeless adolescents have obtained an HIV antibody test and that those with known risk factors are
From the Dizlisim of Adohwt Mediciw, Chi/drerr‘s Hosyifnl, and the /oirlt Progrm it1 !hifh/ Rlld fhh/l, hk0 E~lghd Medical Cerrter, Hnrzmrd School of P~tblrc HwM, Bosh (E.G.) nt~d //le C&@ylio Deprtttmt 01 Health Semite Office of AIDS (/.E.B.). Address correspondewe to: EliznbeU[ Goodrrm~t, M.D., 750 W&Zitl$orf Street, Box 345, Bosto~l, MA 0217 I. This pqwr wns presented in part nt tlrc Atrlericun Plrblic He&/[ Associntioa’s I.?lst Atmrnl Mretirrg, Sm Frmcisco, CA. &t&r 2428th 1993 md the Society for Adolescent Medicitle AIJ~II~~! Meehitlg, LOS Aqeles, CA. M&r 76-20, 1994. Mumscript accepted April 16, 1994. 566 Nm-139xl94/$7.00
more likely to have been tested. These data support the need for community-based expansion of HIV-related services for homeless youth. The effects of HIV antibody testing on subsequent beliefs and behaviors need further study. KEY WORDS:
HIV infections/prevention and control HIV seroprevalence Adolescence Homeless persons Sex behavior Health education
Adolescents are at risk for HIV because experimentation with drugs and sexual activity is common during this developmental period (1,2). Among adolescents, runaway and homeless youth are at significant risk for HIV infection because of their high rates of injection drug use and unprotected sexual activity (3-10). There are an estimated one-half to two million of these youth in the United States (4). Clinic-based studies have demonstrated HIV seroprevalence rates among runaway and hom&ss adolescents ranging from 5.3% to 9.3% (11,121. However, actual prevalence rates ior this population of teenagers and the proportion of teens using HIV testing services are unknown. Because of the increased risk for acquiring HIV infection among homeless adolescents, recommendations have been made to make HIV testing and other related services for these youth more widely available (5,101. However, runaway and homeless adolescents are less likely to utilize conventional
0 Society for Adolescent Medicine, 1994 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
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sources of health care. Identifying demographic characteristics and risk profiles of runaway and homeless adolescents who obtain HIV testing would help health professionals design comprehensive testing programs and linked services specifically geared to the unmet needs of this high-risk population, which would hopefully include those not currently using available services. We investigated San Francisco Bay area runaway and homeless adolescents to answer two questions: 1) What demographic characteristics and risk profiles of runaway and homeless adolescents are associated with the use of HIV testing services, and 2) Are those adolescents at higher risk for HIV being tested?
Mefhods We analyzed data collected by the California Department of Health Services Office of AIDS regarding AIDS-related Knowledge, Attitudes, Beliefs, Behaviors (KABB) of San Francisco Bay Area adolescents 13-18 years old who were not enrolled in a traditional school program or KABB study. Runaway and homeless teens were recruited for the KABB study from three community-based youth service agencies (“shelter”) and four street sites (“street”) known to be frequented by runaway and homeless adolescents. Youth were considered eligible if they were staying at runaway youth shelters or participating in programs specifically for homeless, runaway, or prostituting teens or if they were known to street outreach workers as living apart from their parents or without a permanent residence. Data were collected by face-to-face structured interviews administered by seven trained interviewers. Informed consent was obtained from all participants, each of whom was given $7.50 worth of “fast-food” coupons. Participants were free to refuse to answer any question. During the 6 month period from October 1990 through April 1991, 206 adolescents completed the interview, representing a response rate of approximateiy 80%. No data are available on non-respondents. Of the 206 subjects, 202 responded to the questions assessing previous HIV antibody testing. These 202 subjects made up the sample used in otir analysis. The survey instrument consisted of close-ended questions assessing five areas: I ) demographics and life history, 2) HIV-related knowledge, 3) attitudes, beliefs and AIDS-relai-ed experience, 4) sexual, alcohol and drug use behaviors, and 5) medical care information, including a history of prior HIV test-
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ing. Only items from these five sections relevant to HIV infection were included in the current study because the small sample size limited the number of variables available for statistical analyses. Demographic variables included in this study were: age, gender, race, education, and site of recruitment. Risk behaviors included age of initiating sexual intercourse, years of sexual activity, number of sexual partners over the past six months, self-reported sexual orientation (“heterosexual”, “homosexual”, “bisexual”, “undecided”), history of injection drug use (IDU), history of a sexually transmitted disease (STD), having engaged in receptive anal intercourse, and condom use (“never, less than half the time, about half the time, more than half the time, always”). Nine items in a “yes, no, don’t know” format assessed HIV-related knowledge. These were then combined into a Knowledge Score which could range from 6 to 18. Beliefs and attitudes included perceived risk and worry. Perceived risk and vorry were each measured. by a single item with an “agree, disagree, don’t know” format: “Things 1 have done in the past have put me at high risk of getting AIDS” and “I am not worried about getting AIDS,” respectively. AIDS-related experience was assessed with single item in a “yes,” “no” format: “have you ever known someone living with AIDS?” Medical care included an item assessing previous testing experience: “Have you ever taken a test for AIDS?” (“Yes, no, don’t know” format). Adolescents were also asked how many times they had been tested and were asked to identify the site of their last HIV test from a list of nine possible choices. Adolescents were not asked to reveal HIV test results, t-herefore seroprevalence data are not known. A detailed description ljf the questionnaire and the methodology used for data collection are available from the State of Califol nia Office of AIDS (13). Two subpopulations were identified from subjects included in the KABB study: adolescents who had used injection drugs and those who reported an additional risk factor for HIV were defined as “Very High Risk Youth.” Additional risk factors included history of an STD, five or more lifetime sexual partners, receptive anal intercourse, never using condoms for vaginal intercourse, and for males, self-reported homosexual or bisexual orientation. There were 43 Very High Risk Youth ,identified in this manner. “Lower Risk Youth” were defined as younger, heterosexual, sexually active less than five years, never having used injection drugs, and no history of an STD. There were, on the basis of these criteria, 21 Lower Risk Youth in the study.
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Statistical Analysis The relationships between having obtained an HIV test and 14 pre-selected variables were assessed with Fisher’s exact tests for analyses with expected counts of less than five in a cell, and chi-square tests for other contingency table analyses. Age and knowledge score were analyzed with Wilcoxon rank sum tests, since these variables were not normally distributed. Means are presented with standard deviations. To determine independent predictors of HIV antibody testing, variables statistically related to HIV antibody testing by univariate analysis were entered into a multiple logistic regression model. Variables entered into the model included age, years of sexual activity, history of an STD, history of IDU, history of receptive anal sex, and knowing a person with AIDS. Gender and site of recruitment were also included in the model to control for confounding. Condom use was not included because 24% of subjects did not answer this question. Male homosexual/bisexual orientation was also excluded owing to collinearity with anal intercourse and gender. Adjusted odds ratios and 95% confidence intervals were calculated from the model’s parsmeter estimates. All analyses were performed using SAS (141, except for determination of relative risk with 95% confidence intervals for univariate analyses which were calculated using Epi Info software (15).
Results Demographics Demographic data for the 202 subjects are presented in Table 1. Our sample was mostly white and most considered themselves heterosexual. Mean age ‘*.vas 16.4, SD -I- 1.1 years. There were no signifif:ant differences between shelter and street popula~:nns for age, gender, sexual risk factors for HIV infeciion, or history of HIV antibody testing. More Hispanic youth and more IVDU’s were interviewed in the shelters.
AIDS-Related Experience
Knowledge,
Attitudes,
Beliefs and
HIV/AIDS knowledge was good in this group. Knowledge score ranged from 10.5 to 15 !vith a mean of 12.8, SD t 0.68. There were no differences in knowledge between adolescents recruited from the shelters and those recruited from the streets. More than half (57%) agreed they were at high risk
for acquiring HIV owing to past behaviors and 81% were worried about getting AIDS. Fifty-six percent of respondents had known someone living with AIDS.
Drug Use and Sexual Behaviors DRUG AND ALCOHOL USE. Many of these adolescents had experience with drugs and alcohol (Table 2). Mean age for initiating alcohol use was 10.2, SD + 3.7 years. Although 18% of IVDUs believed needle sharing between sex partners was “OK”, none of the youths who believed this had actually shared needles in the past.
Table 1. Demographics of Study Population Shelter (n = 125) n (%)
Street (n = 77) n (%)
Total (n = 202) n (%)
Age (Years) 13 14 15 16 17 18
1 (1) 5 (4) 18 (14) 43 (34) 52 (42) 6 (5)
2 (3) 3 (4) 12 (16) 14 (18) 23 (30) 23 (30)
3 (1) 8 (4) 30 (15) 57 (28) 75 (37) 29 (14)
Race Asian Black Hispanic* Native American White Other
2 (2) 10 (8) 19 (15) 3 (2) 76 (61) 15 (12)
5 3 5 46 18
0 (7) (4) (6) (60) (23)
2 (1) 15 (8) 22 (11) 8 (4) 122 (60) 33 (16)
Gender Male
61 (49)
47 (61)
108 (53)
Last Grade Attended in School Below 9 9 10 11
39 37 37 21
24 18 20 15
(31) (30) (22) (17)
(31) (23) (26) (20)
63 55 47 36
(31) (27) (23) (18)
Self-reported Sexual Orientation Heterosexual Homosexual* Bisexual+ Undecided Missing
100 (80) 9 (7) 6 (5) 2 (1) 8 (6)
65 (84) 1 (1) 7 (9) 0 -l(5)
165 (82) 10 (5) 13 (6) 2 (1) 12 (6)
Injection Drug User Yest
41 (33)
14 (18)
55 (27)
HIV Antibody Test Yes
69 (55)
41 (53)
110 (54)
*All were male. +Four were male. *p = 0.01.
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HIL’ TESTING AMONG HOMELESS ADOLESCENTS
VAGINAL INTERCOURSE. The vast majority (91%) of subjects reported vaginal intercourse (Table 2). This cohort initiated sexual activity early and maintained activity at a high level. Mean age of ini.tiating intercourse was 13.0, SD ‘_ 2.3 years. Mean number of years of sexual activity was 3.5, SD + 2.6 years. Forty-two percent had had five or more sexual partners in the past six months. More than one-half of those who engaged in prostitution (“survival sex”) did so to obtain drugs or a place to stay as opposed to being given food or money. Males were more likely than females to report always using condoms during intercourse. When having sex for pleasure, fun or love, 31% of males reported always using condoms compared with 17% of females (p = 0.04). Of the 17 youths who had engaged in survival sex, only 3, all males, reported always using condoms. Fourteen percent of sexually active adolescents reported never using condoms dlrring vaginal intercourse. The percentage of youths reporting never using condoms did not differ between genders. ANAL INTZRCOUR5.E. Twenty (19%) males rclported insertive anal intercourse. Mean age of initiating insertive anal intercourse was 15.0, SD 2 1.4 years. Eight considered themselves homosexual or bisexual, all of whom reported always using con-
Table 2. Recreational Sexual Behaviors
Juvenile Detention Private Hospita: Csunty Clink Other
0
10
5 %
15
20
25
30
Tested
doms during ihis activity. In contrast, 33% of fourteen heterosexual males engaging in insertive anal intercourse reported al,ways uaing cnndoms, while 17% reported never us;-q co:~_~oms during this activity. Receptive anal intercourse was reported by 13 males and 14 females. Seven males reported always using condoms during receptive anal intercourse compared wit’l ? females. Never using condoms was reported by 5 females and DO males (p = 0.04). These 5 females also reported condom use less than half th.P *ime with vaginal intercourse.
Drug and Alcohol Use and
Behavior Drug and Alcohol Use Any drug Crack Alcohol Intravenous Drug Use IIVDU) Ever injected any drug IVDU in past 6 months Ever shared needles Shared needle with a sex partner Vaginal Intercourse For any reason For pleasure, fun, love only For drugs, shelter, food, or money Anal Intercourse Insertive (males only) Receptive*
Very High Risk/Lower n (70) 190 (94) 59 (29) 199 (99) 55 39 23 23
(27) (29) (14) (11)
183 (91) 166 (82) 17 (8) 20 (19) 27 (13)
Condom Use During Vaginal intercourse+ At least half the time
104 (67)
Sexually Transmitted Disease History of an STD
46 (23)
*48% male. +n = 154.
569
Risk Youth
There were 24 very high risk males and 19 very high risk females in this population. Among males, 5 had had an STD, 33 reported five or more sexual partners withir t!le past 6 months, and 8 considered themselves homosexual or bisexual. Among females, 13 had had an STD, 12 reported five or more sexual partner5 within the past 6 months, 6 never used condoms during vaginal intercourse, and 5 reported receptive anal intercourse.
HIV Testing Over one-hali (54%; of the subjects had obtained HIV antibody testing. Forty-four percent of those who had been tested reported being tested once, while 15% had been tested 5 or more times. Free or community clinics were the most common site of testing (Figure 1). There were no significant differences in test site utilization between genders, those with a history of injection drug use, or those adolescents who were sexually active for 5 or more years. However, older adolescents (16 -18 years) were 5
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Table 3. Univariate Analysis of Predictors of WV Testing n tested n With Predictor
Predictor
activity
(% of those with predictor)
48
34 (71)
Injection drug user
55
40 (73)
Had receptive anal intercourse Male homosexual/ bisexual History of an STD
27
20 (74)
25 years sexual
Condom use 2 % time with vaginal sex” Knows someone living with AIDS None of the above
14
11 (79)
46
37 (80)
104
60 (58)
114
72 (63)
21
3 (14)
I95’%‘sl 1.44 11.13, 1.831’ 1.62 11.27, 2.@81*
not associated with testing. Fewer males than females had obtained HIV testing, but the difference was not statistically significant (48% vs 62%, p = 0.054). Logistic regression modeling revealed that history of an STD, 5 or more years of sexual activity, injection drug use, and age were independent predictors of HIV testing (Table 4).
1.46 I1.11. 1.901’ I .%I 11.26. 2.581* 1.73 11.39, 2.161* 1.52 11.03, 2.241‘ I.45 Il.10, 1.911t 0.24 lO.09, 0.69 I*
*0.05 > p r 0.01 ‘0.01 > p > 0.001 ‘p < 0.001 “Data missing for 24% of sample.
times less likely than younger adolescents to be tested at private hospitals or doctors’ offices (p = 0,006). Minority adolescents (African American and Hispanic) were more than 3 times more likely than white adolescents to obtain testing at a county clinic or hospital (p = 0.02). Adolescents with an STD were 2.25 times more likely to go to an adolescent-specific site than other sites for HIV testing (p = 0.02), and those who were recruited from a shelter site were more likely to have been tested at a youth service agency than those recruited from the streets (p = 0.004). Of note, 25% of subjects did not know that adolescents could receive anonymous testing. Fourteen female (74%) and 18 (75%) male very high risk youth had obtained HIV testing. All 8 homosexual/bisexual male IDUs had been tested for HIV, as had nine (75%) female IDUs with 5 or more sexual partners in the past 6 months. Overall, 10 185%) female and 4 (80%) male IDUs with a history of an STD had obtained HIV testing. Univariate analyses for the 7 variables found to be significantly associated with HIV testing are presented in Table 3. Adolescents who obtained testing iYere older (mean age 16.6 yrs vs 16.1 yrs, p = 0.01) and began sexual activity earlier (mean age initiating intercourse 12.9 yrs vs 13.5 yrs, p = 0.01). There were no significant differences in race, education, site of recruitment, and number of sexual partners between those who had been tested and those had not. Perceived risk and worry were also
Discussion This study of runaway and homeless adolescents found that just over half of these teens had obtained HIV testing. Homeless teens engaging in behaviors that put them at higher risk for HIV infection were more likely to have been tested. Because most educational and counseling interventions for runaway and homeless youth, including HIV testing, are based in clinics and social service agencies, previous studies have drawn their samples from these sources 8,11,16-18). However, studies done in shelters may not accurately reflect the risk behaviors and utilization of services by runaway and homeless adolescents because youth from the street are not represented. A contribution made by this study is that this data set included adolescents from both street and shelter sites. This study has several limitations. Because the survey from which these data are drawn was not designed to explore in detail the issue of HIV testing in homeless adolescents, the types of questions which can be answered by this data set are limited. For example, participants were not asked to reveal results or time of HIV testing, so seroprevalence data are not known and the relationship of testing to current behaviors could not be determined. Nor were teens who had not been tested asked why they had not made use of testing services, precluding our ability to address the perceived barriers to care in this population. Because there are no data available on non-participants and recruitment was dependent Table 4. Independent Predictors of HIV Testing from Logistic Model Predictor History of an STD 25 yrs sexual activity Injection Drug User Age
Odds Ratio 195% CI’SI 3.42 12.13, 5.51 I 2.67 Il.81, 3.941 2.31 11.54, 3.461 1.42 i1.20, 1.681
p Value 0.01 b.01 0.04 0.04
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on interviewer identification of potential subjects at the street sites, there may be a selection bias in the sample, although only 20% of those asked to participate refused to be interviewed. Answers to our survey instrument may have been influenced by social acceptability, given the intimate nature of the questions and the fact that data were collected by interview. However, the percentage of youth reporting risk behaviors such as injection drug use and sexual activity was comparable with other studies (3,6,19). In addition, self-report tends to underestimate actual risks, so the estimates we reported may be conservative. Our sample size reduced statistical power and made sub-group analysis not feasible in many instances. For example, the lack of statistical significance of the finding of less testing among heterosexual males may reflect the small sample size of this subgroup, rather than reality. This trend in gender differences in HIV testing is an area in need of further research, as it identifibs heterosexual males as a group who may not be utilizing available resources. Despite these limitations, these data provide a provocative preliminary glimpse into the level of risk and use of HIV testing among runaway and homeless adolescents. Risk behaviors for HIV were common in our study subjects, and among these adolescents, the number of males who considered themselves homosexual or bisexual and the rates of injection drug use and STDs were similar to those reported by runaway and :nomeless adolescents in other studies (3,6,19). CY.ir fXin:,s support the impression that runaway and homeless adolescents are at greater risk for acquiring HIV than adolescents enrolled in United States high schools, owing to earlier initiation of sexual activity and higher rates of injectio;? drug use (20-22). The proportion of youth engaging in multiple high risk behaviors is alarming and highlights the urgency to identify these youth, assess their risk behaviors and serostatus, and develop effective behavioral change programs. This study documented that, although just over half of these runaway and homeless adolescents had accessed the health care system to obtain HIV testing, those engaging in multiple risk behaviors were more likely to be tested. Some have advocated that HIV testing be used as an intervention to promote behavioral change (23,241. In a review of published reports of the effects of HIV testing, Higgins et al. showed that neither HIV testing nor knowledge of HIV serostatus has consistently been shown to be effective in changing risk behavior (25). Among adolescents,
HIV TESTING AMONG HOMELESS ADOLESCENTS
571
Stiffman et al. found no association between HIV testing and behavioral change (26). As an AIDS prevention strategy, interventions aimed at addressing the cultural context of adolescents’ lives and developing specific coping skills may be more effective than information-based programs like those offered by many current testing programs (9,18,24,2628). As stated above, we could not study the association between testing or serostatus and changes in high risk behaviors. Further longitudinal studies are needed to investigate the reasons why adolescents undergo voluntary HIV testing and what the effects of HIV testing on subsequent beliefs and risk behaviors are. Because of rising seroprevalence rates among adolescents, it is also important that we understand what the barriers are to accessing HIV testing services in order to effectively promote HIV testing among adolescents. We were unable to address these vital questions in this secondary data analysis. However, these data provide a valuable starting point for future endeavors. This study also supports recommendations for expansion of services providing HIV testing as well as educational and other comprehensive medical and social services interventions for runaway and homeless adolescents (5,10,29). The data suggest that services which are community-based or directly linked to adolescent-specific programs will be utilized by this group at high risk for HIV infection. The authors wish to thank Frank Cape11 for his conception
for the project from which the data are drawn; Paul Harder and his associates for their dedic&d work in development of the instrument and data collection; Bernard Lo, M.D. for his encouragement and advice, and S. Jean Emans, M.D., Robert H. DuRant, Ph.D., and Eli? beth R. Woob.+, M.D., M.P.H. for their helpful review of this manuscript. This work was supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, NJ, The Henry J. Kaiser Family Foundation, Menlo Park, CA, and project MCJ-MA 259195 from the Maternal and Child Health Rureau (Title V, Social Security Act), Health Resources and Services Administration, DHHS.
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