HIV INFECTION AMONG STREET YOUTH

f."VJCES. 
;Clttlla 
OFFICE OF INSPECTOR GENERAL 
Offce of Evaluation and Inspections 
DECEMBER 199
 . 1'

OFFICE OF INSPECTOR GENERAL 
The mission of the .office of Inspector General (OIG) is to promote the 
efficiency,
effectiveness, and integrty of programs in the United States Department of Health
and Human Servces (HHS). It 
does this by developing methods to detect and 
prevent fraud, waste, and abuse. Created by statute in 1976, the Offce of Inspector
General keeps both the 
Secretary and the Congress fully and currently informed
about programs or management problems and recommends corrective action. 
The
OIG performs its mission by conducting audits, investigations, and inspections with 
approximately 1 400 staff strategically located around the country. 
OFFICE OF EVALUATION AND INSPECTIONS 
This report is produced by the Offce of Evaluation and Inspections (OEI), one of 
the three major offices within the OIG. The other two are the Offce of 
Audit
Servces and the Office of Investigations. Inspections are conducted in accordance 
with professional standards developed by OEI. 
These inspections are 
tyically short-

term studies designed to determine program effectiveness
, efficiency, and vulnerabilty 
to fraud or abuse.

The purpose of this inspection is to determine the scope and nature of the problem 
of HIV infection among street youth. It provides an overvew of the various 
issues 
presented by the epidemic, an understanding of how those issues are being 
addressed, and a set of recommendations for future action. 
The report was
prepared under the direction of Mark R. Yessian
, Ph.  , Regional Inspector General
of Region I, Office of Evaluation and Inspections, and Martha B. Kvaal, Deputy
Regional Inspector General. Participating in this project were the following people: 
Boston Region  Headquarers
Mary Ann Chaffee  Project Leader  Alan S. Levine 
Joyce M. Greenleaf 
David Schrag 
Charles Vann 
Christine N. Owens 
Beth Rubin 
Elizabeth A Wirick 
Eleanor M. Ells  , "
HIV INFECTION AMONG STREET 
YOUTH

RICH 
P. KUSSEROW 
INSPECTOR GENERA 
OEI  DECEMBER 199  EXECUTIVE SUMMARY 
PURPOSE 
The purpose of this inspection is to determine the scope and nature' of the problem 
of HIV infection among street youth and of the servces that address the problem. 
BACKGROUND 
AIS is a major threat to adolescents. Although very few cases of AIS have been 
reported among teenagers, the number of reported cases among 20- to 29-year-olds 
with AIDS suggests a high level of HIV infection (which causes AIS) among 
teenagers. Some adolescents seem to be in more danger than others. They are 
street youth " who have diverged from society s mainstream and have fallen through 
the safety net. Understanding the impact and future threat of HIV among street 
youth is critical for two reasons. First, existing public health strategies for preventing 
and treating HIV infection were initially developed for adult gay men and may have 
limited utilty for this population of young people whose lifestyles suggest more 
specialized approaches. Second, recent medical developments indicate that the use 
AIS 
of  therapies can delay the onset of symptoms among people infected with the 
virus. This makes early identification of infected street youth crucial for improving 
their chances of longer-term survval. 
FINDINGS 
cuen 
Both th rik and  rate of HW infectin are almt cerin highe among street 
youth thn among adlecents in genaL 
Thousands of young people have been infected and street youth are in particular 
danger. While the infection rate for all 
adolescents nationwide appears to be 
less than one percent, for some subpopulations of adolescents the rate may be as 
high as seventy percent. High infection rates among street youth are a 
predictable consequence of the risky behaviors that constitute their lifestyle. The 
most common risk behavior for street youth appears to be unprotected sexual 
intercourse, which in some cases involves sex in exchange for basic survval 
needs. 
Specil need of street youth compromise HW preventin, tetig, and treatmt efort. 
Prevention: Basic survval needs of street youth overwhelm education efforts 
aimed at reducing high-risk behavior. The preventive measures which have 
proven successful in adult populations may be ineffective in this population.  Testig: Youth workers often hesitate to test street youth for HIV because of 
the lack of proper counseling and available follow-up servces. 
Treatment: Traditional medical institutions and street youth don t mix. Street 
youth are unlikely to seek out traditional institutions for care, in part because 
many such facilties actively reject them. 
fight againt HWamong street youth suffer frm gaps in  behavir 
cThh  ange mols seroprevalee, and treatm protools.  reseah  on 
Behavior change models: Researchers and providers lack both basic information 
on street youths' sexual behavior and models for curtailig unsafe sex and drug 
use. 
Seroprevalence: No one knows for sure how many street youth are 
infected. 
Because of insufficient data, attention and money may not be invested where 
they are most needed. 
Treatment protocls: Manifestation of HIV disease in adolescents is an 
understudied phenomenon. One factor hindering progress in this area is the 
dearth of adolescents enrolled in clinical trials of HIV-related therapies. 
At the loallee  categorial reqemts and fragmed pram sttues weake 
sere delier for street youth wih or at rik of HW infectin. 
Even when a range of servces is offered, categorical requirements and other 
access barrers frequently render those servces inaccessible to street youth.

These requirements include money, consent, and age ranges. In addition 
fragmentation of funding sources and different ideological approaches impose 
serious barrers to servce delivery. 
At th Fedallee  the overall resnse to th proble of HW infectin among street 
intely  coordte 
youth is 
foced and 
The breach in coordination has especially severe ramifications for efforts 
involving HIV and street youth, because of the large number of Federal 
agencies
with responsibilty for AIDS, adolescents, or both. In comparison to other 
groups affected by the disease, street youth seem to attract little attention from 
the Department, the public, traditional youth advocates, and Congress.  RECOMMENDATIONS 
Sere 
Puli Heahh 
Th 
The Public Health Servce (PHS), through the Centers for Disease Control (CDC), 
should conduct additional seroprevalence research to measure the scope of the 
epidemic among street youth. 
The PHS should collect baseline data on the sexual behavior patterns of street youth. 
The PHS, through the Alcohol, Drug Abuse, and Mental Health Administration
(ADAM) 
and the CDC, should conduct research on behavior change strategies 
designed to reduce the risk of HIV infection among street youth. 
The PHS should conduct research on the natural history and manifestation of HIV 
infection in adolescents and develop appropriate counseling, testing and clinical 
protocols for treating youth who are infected. 
Puli Heahh Sere and th Ofe of Humn Deelopme Seres 
Th 
The PHS, in collaboration with the Office of Human Development Servces (OHDS), 
should design and implement a strategy to curb HIV infection among street youth in 
six cities with large populations of street youth and high rates of HIV infection. 
COMMENTS 
We received comments on the draft report from the Public Health Servce (PHS), 
the Office of Human Development Servces (OHDS), and the Assistant Secretary for 
Planning and Evaluation (ASPE) within the Department. These comments reflect 
general concurrence with our findings and recommendations. Based on the 
comments we received from PHS and OHDS, we altered our final three 
recommendations. We included the Centers for Disease Control (CDC) among the 
PHS components which should conduct behavioral research among street youth, and 
broadened the scope of our recommendation concerning the manifestation of HIV 
disease among adolescents. We also changed the final recommendation to make it 
more consistent with a pending CDC initiative aimed at preventing HIV infection 
among street youth in six cities. The PHS, rather than OHDS, is now recommended 
as lead agency for the six-city strategy. The detailed comments and our responses to 
them appear in 
appendix A.  ....................................... 
. . . . . . . . . . . . . . . . . ..  .. . . . . .  ...   ...   ...   ....   ...  .. 

 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. ..  ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ... .  . .. .  .. .  . . . . .  . . . . . . .. 
TABLE OF CONTENTS 
EXECUTE SUMMARY

INTODUCTION 
FINDINGS. . . . . . . . . . . . . . . . . . . . . . 
. . . . . . . . . . . . . . . . . . . . . . . . . . . 4 
Both the risk and current rate of HIV infection are almost certainly
higher among street youth than among adolescents in general. 
....... 4 
Special needs of street youth compromise HIV prevention
, testing, and 
treatment efforts. ........................................ 5

The fight against HIV among street youth suffers from gaps in 
research 
on behavior change models
, seroprevalence, and treatment protocols. .. 8 
At the local level, categorical requirements and fragmented program 
structures weaken service delivery for street youth with or at 
risk of HIV 
infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
At the Federal level, the overall response to the problem of HIV 
infection among street youth is inadequately focused and coordinated. 
. 14 
RECOMMENDATIONS 
COMMENTS ON THE DRAFT REPORT 
APPENDIX A 
Detailed Comments on the Draft Report and OIG Response to the 
Comments  . . . . . .. A
APPENDIX B

Methodological Notes 
B-1 
APPENDIX C 
Endnotes 
C-1  " "
INTRODUCTION

PURPOSE 
The purpose of this inspection is to determine the scope and nature of the problem 
of HIV infection among street youth and of the servces 
that address the problem. 
BACKGROUND 
Acquired immunodeficiency syndrome (AIDS) is a major 
threat to adolescents. 
Although only 604 people aged 13-19 have been diagnosed with AIS!, this figure
drastically understates the level of human immunodeficiency virus 
(HIV infection
AIS. 
which causes  The median incubation period for HIV appears to be 
about 10 
years, and may be longer for adolescents than for adults.  This means that only
those teenagers who were infected very young or who progressed from infection to
AIDS very quickly are included in those 604 
cases. Most people infected
teenagers will not develop AIDS before adulthood. 
The number of AIDS cases reported in young adults provides a more accurate
picture of the HIV epidemic among adolescents. Since 1981, 31  AIS 
176 cases of 
have been diagnosed among 20- to 29-year-olds.  This group, many of whom must
have been infected as teenagers, represents 20. 1 percent of all AIDS cases reported
to the CDC since the epidemic began. More than 26 percent 
of all 13- to 29-year
olds who have developed AIDS were diagnosed in the last year. 
Some adolescents seem to be at higher risk than others. 
These youth are the ones
who have become displaced from society s mainstream and have fallen through the
safety net. They are referred to as "
disconnected  disenfranchised " or 
marginalized." Generally out of home, out of school, and out of work, they spend
their days looking for food, shelter, recreation, and money on our urban streets.
They revolve through our system of juvenile courts and jails, mental health facilties
foster care homes, and runaway shelters. We refer to this group as "street youth. 
Street youth lead troubled lives. Data from runaway and homeless shelters indicate 
high rates among this population of physical and sexual abuse, emotional disturbance
including depression and suicide attempts, and ilegal drug use.4 These problems can 
be either the cause or the result of life on the 
streets. 
Our definitional boundaries of street youth are 
intentionally fluid. Strict age limits 
are undesirable because, unlike adolescents in stable residential and educational 
environments, street youth are likely to have peers, sexual contacts, and needle
sharing partners who are older than the traditional cutoff ages of 18 or 21.  , "
he variety of
Definitions based on behaviors are equally problematic because of 
living arrangements and life histories among this population. 
For example, only a
small percentage of street youth visit runaway shelters. A definition 
based on such 
visits would bar from consideration other youth in equally unfortunate situations and 
at equal risk for HIV infection. For purposes of this report, therefore  street youth"
refers to those adolescents and young adults who find their priary 
support systems 
and social structures on city streets rather than at home 
or in school. 
The lack of firm inclusion criteria makes estimating the size of the street youth 
population difficult. However, all people who meet the Federal definition of 
homeless youth, and many who meet the Federal definition of runaway youth, could 
be considered street youth.  Estimates of the number of youth permanently on the 
streets fall between 100 000 and 300 000, with as many as 1  00 to 2 000 000 
running away from home each year. 
Understanding the impact and future threat of HIV among street youth is 
critical for 
two reasons. First, existing public health strategies for preventing and treating HIV 
infection were initially developed for adult gay men and may have limited 
utilty for 
this population of young people whose lifestyles suggest more specialized approaches. 
Second, recent medical developments indicate that use of AIS 
therapies can delay 
the onset of symptoms among people infected with the virus. Ths makes early
identification of infected street youth crucial for improving their chances of longer-
term survval. 
Several operating divisions of the Department of Health and Human Servces 
(DHHS) oversee activities relating to HIV and adolescents. The list includes the 
Office of Human Development Servces (OHDS) and virtually every component of 
the Public Health Servce (PHS): the Alcohol, Drug Abuse, and Mental Health 
Administration (ADAMHA); the Centers for Disease Control (CDC); the Health 
Resources and Servces Administration (HRSA); the Indian Health Servce (IHS); 
the National Institutes of Health (NIH); and the Office of Assistant Secretary for 
Health (OASH). All of these agencies except NIH and IHS target street youth 
specifically. 
For instance, the National Institute of Mental Health (NIMH), within ADAM 
funding research on the prevention and epidemiology of HIV among street youth. 
The OHDS offers technical and financial assistance to local agencies providing 
servces to street youth through the Runaway and Homeless Youth Program and the 
Transitional Livig Program. A more detailed description of Federal activities 
relating to HIV and street youth is contained in a separate report: "HIV Infection 
Among Street Youth: Department of Health and Human Servces Programs and 
Resources " (OEI-01-90-0050l).  METODOLOGY 
The methodology for this study is based on literature searches and intervews. The 
intervews consisted of: (1) formal telephone 
discussions with representatives of 13 
national and 2 local organizations working on issues related to either adolescents or 
HIV; (2) formal telephone discussions with staff from 20 providers of health care 
and social servces to street youth, representing the two providers servg the most 
street youth in each DHHS region of the country; (3) site visits to 3 additional 
servce providers; (4) formal telephone and in-person discussions with 15 DHHS 
offcials involved in adolescent or HIV-related research or programming; and (5) 
supplemental discussions with several researchers, doctors, and government officials. 
In addition, we requested and received wrtten information from several components 
of DHHS documenting their efforts relating to HIV and street youth. A more 
complete explanation of the methodology is contained in appendix B.  FINDINGS 
BOTH THE RISK AND CURRENT RATE OF HIV INFECTION ARE ALOST 
CERTAINLY HIGHER AMONG STREET YOUT THN AMONG 
ADOLESCENTS IN 
GENERAL 
pa 
Thusand of young peple have bee infected and street yout ar in  danger 
Data on seroprevalence (the prevalence of HIV infection in a 
given population)
among some groups of youth are collected by three Federal 
agencies: the Centers for
Disease Control (CDC), the Department of Defense (DoD), and the Job Corps
, all

of which conduct HIV antibody testing.
? The CDC's best estimate is that 74 550 
young people between the ages of 
13 and 24 are currently infected, including those
with AIDS. 
This is a rate of 1.8/1 000.  The rate varies fourfold between 
demographic groups, from 0.8/1 000 for females both 13-18 and 19-24 to 4.1/1 000 for 
19- to 24-year-old males.

Results from other studies and from DoD and Job Corps 
samples suggest that
seroprevalence varies greatly according to geographic and demographic boundaries 
with poor urban youth hit hardest by HIV.  Defense Department statistics show that 
black and Hispanic males have become infected at far higher rates than 
miltary
recruits in general.lO The Job Corps data show that HIV is spreading most rapidly 
in a few metropolitan areas.ll Additional data from 
CDC reveal that specific, high-
risk populations of urban youth face future devastation 
unless a cure for HIV disease 
is found in time. 
In our own survey of direct providers of servces to street youth, we asked for 
estimates of seroprevalence among the client groups served. 
Three of the 
organizations surveyed conduct their own testing and track infection rates as 
a formal 
part of their program. The first is a youth shelter in a large southern city. Its
clients are being tested anonymously, and are testing positive at a 
rate near 30/1 000. 
The second is another non clinical program located on the west coast which tests only 
those clients who request it. Staff of this program report an infection rate of 
110/1,000. The third is a clinical program that serves and tests high-risk youth
referred by other servce providers in a large east coast city. Over the past year, 30
of the 95 youth referred to the program 
have tested positive: a rate of 315/1 000. 
High infectin rates amontgh st reet youth are a predctable conseqe of th riky
behars tht constie 
lifestyle. 
That many adolescents have already been infected with HIV should not come as a 
great shock. Teenagers often become sexually active and begin experimenting with  drugs and alcohol before they have developed the skills 
necessary to moderate such
behavior. Over 60 percent 
of young Americans have sex before their 19th birthday. 
High rates of pregnancy and sexually transmitted diseases (STDs) 
indiCate that most 
teen intercourse is unprotected,13

The behaviors that put street youth at risk for HIV 
infection are no diferent from 
behaviors that are risky for other adolescents, but are probably more frequent and
occur in a different and riskier environment. Eighteen of the 23 servce 
providers
responding to our survey cited unprotected sex as the behavior most likely to place 
their clients at risk. Frequently mentioned contributing factors included sex with 
multiple partners, prostitution, and non-IV substance abuse.14 In general, providers 
believe that high-risk sexual behavior is much more common among their clients than 
IV drug use. On average, respondents reported that slightly less than 8 percent of
their clients engage in IV drug use. 
In contrast, 34 percent consistently engage in 
survval sex  sex in exchange for a broad range of items, including shelter, food
clothing, money, or drugs. 
In addition to behavior-related risks
, physiological factors may further endanger
adolescents. Researchers have noted that 
sexually active adolescents have higher
rates of some STDs than do 
sexually active adults, suggesting that an adolescent'

immunologic response to certain viruses may be weaker than that of an adult. One

question under consideration by physicians is whether the factors 
that put adolescents
at higher risk for STDs also affects their resistance to HIV infection. 
SPECIAL NEEDS OF STREET YOUT COMPROMISE HIV PREVENTON 
TESTING, AND TREATMENT EFFORTS. 
sual 
Prevenn: Bas  need of street youth overhelm edatin efort aim
redg high-
rik behavir. 
Education has long been used as a primary public health prevention 
strategy. In the
context of HIV prevention, education efforts seem to have led to pronounced 
changes in behavior among adult gay  menP  Among street youth, however, there is
compellng evidence that education by itself is inadequate as a prevention technique. 
Nearly all providers we spoke with reported remarkably high 
levels of knowledge
among their clients about how to avoid HIV infection. Most have conducted tests of 
' HIV knowledge before and after educational 
their clients interventions. Estimates 
of the proportion of clients who now know which behaviors are risky ranged as high 
as 100 percent. Ten of 23 
providers reported knowledge rates of 90 percent or 
higher, with an overall average of 81 percent. Nevertheless
, providers consistently
reported that knowledge has little effect on behavior. As described above  youth. 
unprotected sex with multiple partners remains a common practice among street
The reasons for this dissonance are complex and probably apply to most 
adolescents.
But in the case of stteet youth, barrers to behavior change are even more profound
and intractable. Providers reported that the need for food
, shelter, or drugs
displaces knowledge and fear of HIV risks. As one provider stated, "It (HIV
prevention) all fles out the window when they don t have a place to sleep.
" As 
mentioned above, many street youth exchange sex for shelter or 
money, and we
heard anecdotal evidence from providers in several 
cities that their clients receive 
more money for sex without condoms. 
Without exception, the providers we talked with identifed the 
shortage of accessible
survval necessities -- such as housing, food, and drug treatment - as a major
impediment to 
successful prevention efforts. Only 2 of 23 providers surveyed 
believed that existing drug detoxification and rehabiltation 
servces are adequate to
meet clients' needs. Research and advocacy organizations concurred with the 
providers' assessments, stressing the need for basic social support servces. 
In the absence of an adequate supply of such basic servces, most of these providers
rely on prevention techniques that are not 
recognized as particularly effective, even
by those who employ them. Although all providers use pamphlets or other wrtten 
materials and nearly all use educational videos, not one rated either of these 
methods as particularly effective for changing behavior or preventig infection. 
Beyond the barriers to changing a street youth's behavior through education is
another factor that is less frequently recognized but highly relevant to HIV 
prevention among this population: that of general health status and its 
relationship to
transmission. Researchers believe that HIV proliferates 
when the immune system is
active; consequently, a young person who is 
il before she comes in contact with the 
virus may be more likely to become infected. IS Malnutrition and use of drugs 
(including alcohol and tobacco) also compromise general health 
statuS,t9 and there is 
conclusive evidence that lesions associated with some STDs heighten the 
risk of 
transmission. 
Health and mental health problems among street youth result from a number of 
factors, including poor nutrition and hygiene, as well as limited access to preventive
and primary health care servces. The relatively poor health 
status of most street 
youth has been well documented in a study 
conducted under the 
auspices of the
Health Care for the Homeless project. The project 
s findings indicated that the
street youth studied were twce as likely to suffer 
from a chronic disease than a 
control group of youth who were not homeless. Further, the percentage of homeless 
girls with STDs was over three times that of their non-homeless counterparts.20 This  '-I 
suggests that the same behavior may place a street youth at 
significantly greater risk
of HIV infection than her healthy counterpart who is livig at home. 
Testig: Yout work  hete  te 
often  to  street yout for HW becaue of 
an  th lack 
prope counelig  availble follw-up seres. 
Recent findings21 about the abilty of zidovudine (formerly AZT) to prolong the life
of inected but asymptomatic persons have important implications for street youth. 
In order for youth to receive such therapy, however
, their serostatus  (i.  whether or 
not they have been infected) must be determined through testing. 
Despite recognition of the potential value of early identification and treafment of 
inected youth, national organizations and servce providers are highly ambivalent 
about the issue of testing. The source of this ambivalence is the inabilty 
of current
testing sites to deal with the special needs of street youth. 
Five respondents from
research and advocacy organizations expressed serious doubts about HIV testing
because they questioned the resources 
available at or through test sites for youth
who learn they are infected. Direct 
providers communicated the same concern:
of 18 responding felt that 
existing test facilties are not equipped 
to deal with youth. 
By definition, street youth are without traditional social support networks that would 
faciltate access to counseling and other social servces. Ideally, 
such servces should 
be linked to the testing process, particularly when an infection is confirmed. 
In the
absence of such support, a street youth may learn of his infection at a time when he 
has no place to sleep, no connection with family, and no immediate 
prospects for
getting off the street. The counseling that accompanies HIV testing, therefore
, must 
be tailored to recognize such circumstances.

Some providers reported suicidal ideation and actual suicide attempts to be common 
among street youth who learn that they are 
seropositive. There is some 
evidence 
that even youth who attend school and presumably have stronger support 
systems
associate suicide with a positive HIV antibody 
test,22 One provider we intervewed
has documented the incidence of this behavior among its clients who are 
seropositive.
Over a two-year period, 89 percent of these youth have either attempted suicide or
engaged in unusual suicidal ideation. 
Although the link between positive test results
and suicidal behavior is stil being studied, anecdotal evidence such as this makes 
understandable the reluctance of some youth workers to recommend HIV testing for 
street youth. 
This is not to say that providers unanimously oppose testing. Most either provide
some testing servces themselves or refer clients for testing at another site. 
Nevertheless, every provider in this category reported that the 
decision to test is 
made on a case-by-case basis. A number mentioned the availabilty of medical and  suitabilty of testing. 
social servces for an HIV -positive youth as a primary factor in determining the.
inns 
Treatm: Trnal meal  an steet yout don 
The neglect and abuse suffered by street youth can make them distrustful and 
reluctant to engage in treatment. One 
researcher describes the difculties homeless 
youth face in gaining access to servces as follows: "Emotional problems and drug 
abuse problems, often in combination, exacerbate the difficulties of engagig and
assisting them. They may be openly rejecting of servces, particularly those that are 
not easily accessible to them. Thus, they are easy to disregard and ignore. . . .1123 
Street youth are unlikely to seek out traditional institutions for care
, particularly
because many such facilties actively reject them, considerig them poor risks and too 
24 The direct servce 
diffcult to manage. providers we surveyed, most of whom work 
exclusively with street youth, deal with distrust and alienation by employing extensive 
outreach programs. Eighteen of 23 reported using outreach workers to locate and 
engage street youth in servces. But clinical care programs, many of which are 
hospital-based, are less likely to deploy resources for street workers to find infected 
street youth and engage them in care. Many may not have the resources to conduct 
active follow-up with youth who do not keep appointments or have difficulty 
adhering to a prescribed treatment regimen. Every outreach worker we intervewed 
described the problem of youth's alienation from institutional health care as critical 
in the overall HIV effort. 
THE FIGHT AGAINST HIV AMONG STREET YOUT SUFFERS FROM GAPS IN 
RESEARCH ON BEHAVIOR CHANGE MODELS, SEROPREVALENCE, AND 
TREATMENT PROTOCOLS.

Behar  provi 
change mols: Researche and  lack both bas informtin on steet 
sexl  cuilg 
youths'  behavir and mols for  unafe sex and drg use. 
Gaps exist in two areas of behavioral research. The first is purely 
descriptive. 
Although a number of studies have been conducted to assess the nature and 
frequency of youths' sexual behavior , many experts agree that there is limited 
knowledge about how teenagers decide to begin having sex and about the effects of 
family, school, and peer group experiences on sexual behavior.25 Given the lack of 
data on the sexual behavior of adolescents in general, it is not surprising that little is 
known about factors affecting the sexual behavior of street youth in particular. 
Information about these factors could add significantly to the design of prevention 
programs aimed at modifyng behaviors that place street youth at risk of HIV 
infection. The National Institute of Child Health and Human Development 
(NICHD) has prepared the " AIS 
Survey on Health and  Risk Prevalence" to gather  this kind of information about sexual behavior in the general population. But this 
survey will not yield information directly applicable to street youth. The data 
gathered from a survey of this kind directed specifically at street youth could provide 
some of the baseline information necessary for the design of effective prevention 
programs for that population. 
Research has also been sparse in . the more general area of developing and evaluating 
the effectiveness of HIV prevention strategies for youth.26 There is considerable 
debate among researchers and practitioners about the relative merits of various 
behavior change strategies in the context of HIV prevention among adolescents. 
Some evidence suggests that prevention programs in other health 
areas such as 
smoking and teenage pregnancy hold promise for adaptation to HIV prevention. 
There is conflcting evidence about the effectiveness of peer-based education 
strategies. While some practitioners have found peer education to be popular with 
youth and useful in transferrng information, others believe that peers lose their 
credibilty once they are perceived as counselors. 
There is no simple strategy for transferring to younger adolescents behavior change 
strategies that were effective with adult gay men. The need for modifyng behaviors 
was strongly reinforced among older men by familarity with peers who were sick and 
dying of AIDS. But because few infected youth show any symptoms, most street 
AIS. 
youth are unfamilar with the shocking and visible signs of 
inffnt  attn 
Seroprevalee: Because of  data  and mone ma not be inves 
need 
whee the are most 
Because of the lag between infection and onset of symptoms, the President' 
Commission on the Human Immunodeficiency Virus Epidemic recommended in 1988 
that researchers focus on HIV infection rates rather than AIDS case reports to 
28 To date
measure the progress of the epidemic. , no national, statistically reliable 
seroprevalence survey of street youth has been conducted.  , it is unclear 
In fact
whether such a survey is possible, given the relatively low number of subjects and 
their potential unwillngness to participate in such a study. The lack of accurate 
seroprevalence data, however, may have immediate and negative consequences for 
street youth in some cities and the organiztions servng them. 
A new CDC initiative, proposed for Fiscal Year 1991, provides an ilustration of the 
problems facing program designers caused by lack of seroprevalence data. The 
Division of Adolescent and School Health, within CDC, requested $5.2 milion dollars 
to fund as many as six city health departments for the purpose of establishing HIV 
prevention programs for out-of-school youth. To be eligible, cities must have 
reported at least 2 900 AIDS cases to the CDC by December 31, 1989. The eight 
qualifyng cities are Chicago, Houston, Los Angeles, Miami, New York, Newark, San 
Francisco, and Washington, D.  But the number of total AIDS cases
, as discussed above, may be a poor indicator of
HIV prevalence, especially among street youth.  AIS 
By relyig solely on total 
cases, CDC may be . missing some cities with equally high rates or large numbers of 
- cases of HIV infection among street youth in comparison to the eight 
cities just 
mentioned. For example, the list of eight cities with the highest current inection 
among Job Corps applicants does not include Newark, Houston, Los Angeles or 
rates 
Chicago. Instead, Atlanta, Birmingham, Cleveland, and Baltimore are among the top 
of infected Job Corps candidates are considered
eight. Alternatively, if  raw numbers 
the list of eight cities hit hardest by the epidemic 
includes Norfolk, Philadelphia, and
St. Louis. Samples from the Job Corps applicant population
, while not a perfect
substitute, almost certainly give a better indication of the problem among street 
youth than total AIDS cases. 
There are probably a number of reasons for the lack of reliable 
seroprevalence data
on youth. In the course of our study we heard several 
possible explanations
including: 1) because of the small number of AIDS cases among 
adolescents during
the early years of the epidemic, this group was not considered to be at risk; 2) the
transient and secretive nature of this population makes them diffcult to reach 
through traditional 
epidemiologic methods; 3) geographic and ethnographic 
differences among subpopulations of street youth make extrapolation and 
generalization to the population as a whole highly speculative; and 4) researchers
and clinicians were concerned about the ethics of testing this population for a fatal 
and stigmatized disease in the absence of medical interventions and social support 
mechanisms. 
An obvious use for additional seroprevalence data is resource 
allocation. In the 
coming years, budget constraints will likely force public and private managers to
direct money and staff to very specific areas and people. AIS 
case reports are of
very limited utilty in this regard, because they only reflect what was occurrng a
decade ago. On the other hand, HIV antibody status 
yields immediate information
on the spread of the epidemic.

Treatm protocols: Manifestatin of HW diease in adlecen is an
phemen. 
Complicating the problem of getting youth into medical care 
are unanswered 
questions about appropriate clinical protocols for treating youth. Each 
clinical 
provider we intervewed expressed concern about the dearth of knowledge regarding
physiologic and pharmacologic aspects of treating HIV-
infected youth. With the
exception of adolescent hemophilacs, adolescents have not been the subjects of
systematic study in such areas as immune response
, length of the HIV latency period
disease progression, or response to pharmacologic treatment.  , "
As an example, until 1989 there were no adolescents from 13 to 17 years of age 
enrolled in the national clinical trials program.29 By October 1989, only 47
adolescents who were seropositive had been enrolled in trial protocols 
of zidovudine 
and other HIV-related therapies, and most were male hemophilacs.30 Weak 
representation of adolescents among clinical trial subjects can have important 
consequences: data collected during the trial process are used to determine 
appropriate dosage 
levels and schedules for subpopulations of patients. Since gender 
and age-specific factors can affect dosage, effectiveness, and toxicity of drug therapy, 
more information about the pharmacodynamics (what drugs do to the body) and 
pharmacokinetics (what the body does to drugs) of various therapies as applied to 
adolescents could enhance the quality of available treatment. 
Questions about disease progression and ilness rate among 
infected adolescents also 
have critical implications for providing high-quality care. As one clinician who has 
recently begun treating HIV -positive youth in a clinic-based program told us  I need 
to know more about which AIDS-related ilnesses are likely to strie my patients and 
how those ilnesses will manifest themselves in younger people. For example, are my
patients likely to suffer from dementia, and if so, what will dementia look like in a 
teenager and how best can I treat it?" The need for more extensive scientific 
inquiries about the natural history of AIDS among young people has been described 
by other clinicians and experts as "crucial in order to address, in a timely and 
comprehensive manner, the unique problems confronting adolescents with or at risk 
of HIV/AIS."31 
AT THE LOCAL LEEL. CATEGORICAL REQUIREMENTS AND FRAGMENTD 
PROGRA SmUCTURES WEAKEN SERVICE DELIERY FOR SmEET YOUT 
WIT OR AT RISK OF HIV INFECTION.

Even whe a range of serves is offered categorial reqemts and othe acces
barr freqtly renr 
thoe seres inccesle to street youth. 
Even the servces that are offered to street youth on paper may be inaccessible in 
practice. Twenty of the 23 direct servce providers in our survey reported signifcant 
barriers for their clients in accessing existing clinical and social 
servces. The most 
frequently cited barrer (mentioned by 15 providers) is lack of abilty to pay for 
needed servces. 
Not only do street youth lack money to pay for servces, but they are frequently 
denied eligibilty for Medicaid because they do not have Social Security Numbers or 
birth certificates and other required documentation. Sometimes the time and 
patience required to obtain the documentation and fill out forms and paperwork is  ssimyplsy bteeyomnd th.e  capabilties of adolescents weary or afraid of dealing with the
Beyond the cost of care are other barrers, many of which are more complex than 
the payment issue. During each of our site visits, providers and health offcials alike
described a number of serious access barrers to programs that would otherwse 
appear to meet some of the special needs of street youth. The 
following are 
examples: 
Limitations on the rights of minors to consent to their 
Consent Requirements: 

own treatment can create formidable 
obstacles to care. The laws, regulations, and
court decisions that govern consent are highly complex. There is little consistency
among States: some permit minors to enroll themselves in mental health and drug
rehabiltation programs, while others require parental consent. Virtually 
every State
allows minors access to certain servces associated with SID treatment but some 
insist on complicated and time-consuming legal procedures beforehand. 
By our definition, street youth may range in age from early teens up 
Age Limits: 

to about 24 years old. After age 18, however, youths become ineligible for a number
of critical servces. For example, under the Department's Runaway and Homeless 
Youth Program, funds given to shelters may not be used to provide servces to 
youths over age 18. Older street youth may be referred to adult shelters that are 
wet"  (i.  residents are currently using alcohol and other addictive substances).
These shelters house a subpopulation of homeless people very unlike the youths
peer group. In many such cases, sleeping on the street is a more desirable option.
Age may also serve as a barrier to drug therapy for 
youth who are already infected.
One project we visited was funded to provide zidovudine treatment only for 
seropositive youth age 18 or younger. 
Many programs funded to house street youth limit clients 
Length of Stay Limits: 

to 15- or 30-day stays. Designed to serve as temporary placements for emergency 
use, these shelters are increasingly faced with youth who have nowhere 
to go after
this time has elapsed since for many street youth homelessness is not a temporary 
problem. Program managers from across the country expressed frstration with the 
absence of longer-term shelter programs. One project in Los 
Angeles has had a
success rate of over 70 percent (measured by the proportion of youths 
who do not 
return to street life and are able to support themselves) but only among youth who 
were offered structured shelter care for at least seven 
months. 
Other requirements imposed in some programs 
Other Conditions of Partcipation: 

may effectively exclude homeless youth from enrollment. 
At one site we visited 
program staff reported the case of a highly motivated young girl who applied for 
admission to a residential drug program well-known for its high rate of success.  " "
After clearing a morass of legal consent hurdles, they learned that the drug 
program s family-syst  m approach requires that parents, spouses, siblings or
significant others" take an active part in the treatment process, both for immediate 
support purposes and continuity of care after 
discharge. Unfortunately, the young 
girl' s family meribers were completely disengaged from her, and her peers (who
might otherwse have served as 
significant others) were other homeless youth who
were struggling with their own life problems. 
Requirements like this one may have a
sound clinical base, but may also result in exclusion of patients who are not part of
traditional family settings. 
Fragmtin  fug  idloal 
barr  seroef   soures and diferen  apprache impoe serus
to  delier. 
Given the broad and diverse range of problems that street youth have
, the need for
servce coordination and collaboration 
among caregivers cannot be overstated. Yet
during every site visit intervew we conducted
, the issue of servce fragmentation was
identified as a serious problem. To some degree
, fragmentation is the result of 
separate funding streams and program designs, many of which are managed by
DHHS. But poor coordination at the Federal level appears to be only one of a 
range of factors that splinter servce delivery for street 
youth. 
In some respects, the particular 
circumstances of servce fragmentation are unique to
the locality in which servces are delivered. For example, because of their city'
geography, providers in Los Angeles must deal with imposing transportation 
problems when attempting to 
design and coordinate a treatment plan for a street 
youth. Distance alone can serve as a serious barrer to a patient s compliance as
well as to collaboration among care 
givers. But there do appear to be some factors 
that promote fragmentation no matter where the 
programs are located: 
Separate Funding From a  Many providers expressed frstration 
Variety of Sources: 
with the classification of youth into categories such as "runaway,  prostitute " or 
drug abuser." This results from funding programs designed to address discrete 
problems as opposed to the interrelated needs of 
individuals. Exacerbating the
diffculty is that sources of these "problem funds" are at different public and private
levels. The following example, provided by a senior local public health offcial
, may 
serve to ilustrate the potential outcome of fragmented funding streams: Data 
gathered by the local public health department 
showed a significant increase in IV
drug use in a certain sector of the city. At the same time
, seroprevalence rates in
that neighborhood began to increase, according to public hospital and clinic data. 
separate actions, three different organizations (one drug treatment program, one
youth servce agency, and one community-based health clinic) applied for and
received three separate grants from a Federal 
agency, a private foundation, and a
State agency. All three applied for and 
received a major portion of overall funding  , '

designated for outreach workers. In the health official's words  we. had outreach 
workers tripping aU over each other out there. In fact, we probably had more
outreach workers on the streets than clients when all three programs were in 
full 
operation. At the same time, we went beggng for outreach work in other parts of 
the city. 
In some cities that have been 
Competition Among Providers for the Same Funding: 
particularly hard hit by the epidemic, competition among providers for funding can 
be fierce. Many small, community-based agencies believe they are out-
gunned by
larger, more traditional institutions and consequently find themselves in even more 
intense competition with one another for a relatively small 
piece of the funding pie.
This is not to say that such rivalries preclude any cooperation, but they clearly do
not promote the kind of teamwork among providers necessary to maxmize available 
resources. 
Diferent Ideological  Philosophical differences among providers can 
Approaches: 
also be an impediment to coordinated care. The most frequently 
mentioned example
of this phenomenon was in the area of drug treatment. 
Many drug rehabiltation 
programs are premised on a 12-step model that other servce providers believe has 
limited relevance for homeless youth who are addicted to non-
IV drugs. Providers 
told us that "even the language they (drug rehabiltation staff) use is foreign" to other 
social servce workers. 
Similarly, there are differences among servce providers about the relative emphasis 
that should be given to case management and to collocation as methods of 
integrating the delivery of servces to street youth. Through the case management
approach, street youth in need of servces are paired with youth workers who 
can 
help guide them through "the system." Many of those working in this field have 
viewed case management as a core servce that is vital to any sustained effort 
directed to street youth. Indeed, it has become a centerpiece of many demonstration 
and other project grants concerning street youth. 
Yet other servce providers, including many we met with, note that case management
for street youth is frequently duplicated. They 
also note that it can be ineffective 
unless the case managers physically accompany their clients to appointments -- a
practice that can put a severe strain on the supply of time and 
money. These
providers suggest greater emphasis be placed on collocating HIV 
counseling, primary
preventive medical care, and other key servces under one roof. This approach, they
emphasize, would minimize transportation problems and reduce the occurrence of 
missed appointments. However, it would require a considerable capital investment 
and could itself lead to some unnecessary duplication of servces.  AT THE FEDERAL LEEL. THE OVERALL RESPONSE TO THE PROBLEM OF HIV 
INFECTION AMONG STREET YOUT IS INADEQUATELY FOCUSED AND 
COORDINATED. 
Th  breach in coordtin ha especill severe ramifiatins for efort involvig HW 
and street youth. 
Coordination within DHHS is particularly important as far as HIV and street youth 
are concerned. The responsibilty for virtually every piece of the fight against HIV is 
perceived to be shared by more than one Departmental agency. We asked 
Department officials to identify which part of the Department, if any, should have 
responsibilty for nine separate functions related to combating HIV among street 
youth. For all but one function, at least 5 of the 14 respondents identified more 
34 Nine thought that "
than one agency. determining what behaviors most commonly 
lead to the spread of HIV among the street youth population" should be a shared 
35 Eight thought that more than one 
dUty. agency should "design and evaluate 
programs to promote behavior change among street youth."36 The only function that 
seems to lie clearly within a single agency s domain is "determining how many street 
youth are infected, and where they are." Twelve of the fourteen Department 
officials responding thought that this was CDC's responsibilty. Stil , five of the 
respondents named another agency instead of or in addition to CDC. 
The National AIDS Program Office (NAPO) is supposed to "
serve as the Public 
Health Servce focus in coordinating and integrating efforts to prevent and control 
the occurrence and spread of HIV infection and AIDS:'37 Its abilty to perform that 
duty may be hampered, however, by several circumstances. First, Departmental 
bodies which are not part of the PHS have little or no representation at NAPO-
organized meetings. For instance OHDS, which sponsors several programs for street 
youth, does not have an offcial member on the PHS HIV Leadership Group, the 
PHS Executive Task Force on AIDS, the Panel on Women, Adolescents, and 
Children with HIV Infection and AIDS, or the Federal Coordinating Committee on 
the HIV Epidemic. Its absence from the last group is particularly surprising, because 
the Federal Coordinating Committee goes beyond the PHS to include such agencies 
as the Environmental Protection Agency and the National Aeronautics and Space 
Administration. 
Another limit to NAPO's effectiveness may be its emphasis on coordinating PHS 
programs that are directed at people with access to traditional educational and 
medical systems. One former NAPO employee told us that HIV-related activities 
aimed at street youth might be better coordinated through a body focused on the 
homeless rather than on the disease. Finally, NAPO's mandate appears to be 
limited to organizing meetings and "networking." It has no control over resource 
allocation or grant specifications. The decisions on particular programs and policies 
are ultimately left to the individual PHS components.  The exclusion of OHDS from the PHS coordinating process may explain the 
1990
announcement of the Drug Abuse Prevention Program for Runaway and Homeless 
38 This program is sponsored by OHDS'
Youth. s Family and Youth Servce Bureau. 
The announcement acknowledges the link between substance abuse prevention and 
HIV prevention. But the only Federal agencies listed as sources of information on 
HIV and runaway youth are the National Institute on Drug Abuse (NIDA) and the 
Offce of Substance Abuse Prevention (OSAP). Applicants for 
this program could
clearly also benefit from contact with NIMH
, HRSA, and CDC. 
Another example of a coordination gap is the existence of two Federally funded
curricula on HIV prevention for high-risk youth. In 1987, NIDA's Community
Research Branch contracted with Westover 
Consultants to produce and distribute the
AIS 
High Risk Adolescent Prevention currculum. Also in 1987, CDC's Division of 
Adolescent and School Health awarded money to the National Network of 
Runaway
and Youth Servces to develop the "Safe Choices Guide: HIV and AIDS 
Policies and 
Prevention Programs for High-
Risk Youth." Both are aimed at youth servce
organizations, some of which are funded directly by OHDS, and include basic
educational information and suggestions for promoting safe behavior. 
We did not 
investigate thoroughly how or why both projects were funded 
simultaneously. There
may be valid reasons for having two similar curricula
, such as comparing their
relative effectiveness. But it appears that they were not 
originally designed to
complement each other, and on the surface there is no apparent need for both. 
The above discussion aside, there are parts of the Department that seem to be 
making progress in fighting the epidemic among street youth. 
For instance, national
advocacy and research organizations applaud the Centers for Disease Control' 
concern for street youth and other adolescents at high risk of HIV infection. The 
CDC was the agency most often cited by these 
organizations as doing particularly
well in this area. Both the Center for Prevention Servces (CPS) and the Center for 
Chronic Disease Prevention and Health Promotion (CCDPHP) have been supporting 
HIV prevention efforts specifically targeted to out-of-school youth. 
In August 1989
CDC held an internal meeting to identify the most crucial components of HIV
prevention programs for 
out-of-school youth. In October 1989, the Deputy Director
for HIV of CPS served as moderator to a PHS Bi-
Regional Consensus Conference
on HIV and runaway 
and homeless youth. The resulting recommendations from
both gatherings addressed all the key issues raised in this report, including the need
for provision of basic servces to street youth and for 
coalition building between local 
servce providers. Although the General Accounting 
Office recently stated that

CDC has accomplished relatively little in providing HIV education to 
out-of-school 
youth "40 CDC appears to have the knowledge, experience, contacts, and commitment
to promote effective HIV prevention programs for street youth in the future.  Street yout at rik of HW itnrfenctian s eem to attct comparatiely lile attn frm

th Depart th puli  an 
yout advocate  Congres.

Of the many groups who have been hit hard by HIV, street youth seem to have 
been the focus of relatively little publicity and political 
action. Concerted attempts 
to influence public policy on HIV-related issues remain largely the work of the adult 
gay community. Public compassion for people with AIS seems to be directed 
mainly to those who are considered "innocent " such as newborns and recipients of 
infected blood products. For example, the only teenager with AIS who has 
received national attention and sympathy was Ryan White, a hemophilac who died
in April 1990. As one Federal offcial told us
, street youth have "fallen through the
cracks. . . . The 
heartstrings go out to the young children -- not to the 13- or 14
year-old involved in prostitution. 
Street youth may lack sufficiently strong voices in Washington. Two of the most 
well-known and respected advocacy groups for children s issues did not participate in
the survey we conducted for this report. One referred us instead to a publication of 
theirs that was outdated and contained little information directly relevant to street
youth. The other was willng to participate, but felt that they could add little in 
terms of opinions or insight beyond what was contained in their existing publications. 
Again, these publications were clearly focused on younger children in traditional 
settings, and had little to say with regard to street youth. Furthermore, congressional
interest in this population appears limited. The only committee to have held 
hearings on the matter of HIV and street youth recently is the Senate Committee on 
Governmental Afairs, whose mandate to investigate these issues is indirect at best. 
The general absence of focus on street youth may help to explain the Department 
comparatively minimal response to the HIV epidemic in that population. When we 
asked our survey respondents to rate the overall response of the Federal government 
to the epidemic among adolescents, the ratings they offered were consistently lower
in relation to street youth than to youth in general. This was reflected in the 
responses of direct servce providers, national organizations, and even HHS 
offcials. 
In sum, street youth are easily invisible as a group, have no natural advocacy group,
and do not generate the concern directed to other populations most at risk of HIV 
infection. It should not be surprising, therefore, that they have not become a 
primary focus of Federal policy makers' attention in the overall HIV effort.  , I

RECOMMENDATIONS 
THE PUBUC HEATH 
SERVICE 
Ser 
aTh  dPnuali  Healt  thugh th Cers for Diseae Coent~p sh oul condt
serprevalee reseah to mee th  th 
scope of  amng steet
yout 
In order to allocate resources efficiently, policy makers and program 
managers must
have a clearer picture of where and to what extent street youth are 
becoming
infected. Another reason to 
collect seroprevalence data is to demonstrate the
severity of the problem. The long HIV incubation period means there 
will probably
never be a comparatively large number of  AIS 
teenagers diagnosed with  no matter
how many teens become infected with the virus. Many teens who become infected 
will not develop AIDS until they become adults. 
Given the difficulties in generating valid national data on seroprevalence among 
street youth, it seems more appropriate to 
focus on locality-based data. Collecting
such data is necessary if scarce resources for prevention and treatment are 
to be
apportioned effectively. Because infection rates are likely to differ 
significantly
between and perhaps even within metropolitan areas
, a large number of sites must 
be selected for study.

In collecting and analyzing seroprevalence data on street youth
, CDC should make
full use of reliable data collected from other sources, both public and private. The
CDC should make all data easily available to researchers and servce providers. 
This
data should be as detailed as 
possible without jeopardizing individual privacy rights. 
Puli Heahh Sere shoul collct baseli  th sex behar patter
Th 
data  on 
of street youth. 
In response to the call by researchers and practitioners for more and better 
information on factors that encourage high-
risk sexual behavior among street youth
the PHS should move quickly to collect this information. The 
data should be
gathered from several metropolitan areas with large 
concentrations of street youth. 
Th  Puli Heahh Sere, thugh the Akoho~ Drg Abuse, and Menl Heahh
Admtratin 
ansdt trht eCe ers for Diease Cont~ shoul condt reearch on
behar change  degn to rede the rik of HW infectin 
among steet
youth.  In the absence of a vaccine, only behavior change will slow or stop the spread of
HIV. As mentioned previously, interventions developed for smokig cessation and 
pregnancy preventiop may hold promise for HIV prevention efforts, but there has
been little systematic evaluation of such efforts. In the meantime, resources have 
been channeled to traditional education-as-prevention efforts that clearly have limited 
utilty for street youth. .Therefore, behavior change among street youth in particular 
should be a high priority for additional research efforts. What works for adolescents 
in general should not be presumed to work for street youth
, because the physical 
demands and psychological effects of street life inhibit the success of traditional HIV 
risk reduction interventions.

The PHS's research agenda should include modification strategies for all behaviors
that place adolescents at risk, including substance abuse as well as high-risk sexual 
activity. It should continue the search for more effective treatment 
technologies for 
users of current drugs of choice such as "crack" cocaine. Because several ADAM 
components (including NIMH, NIDA, OSAP, and the Office of Treatment 
Improvement) and the CDC have expertise in these areas
, PHS should coordinate 
research initiatives through its Panel on Women, Adolescents, and Children with HIV 
Infection and AIDS. 
Th  Puli Healt Sere shoul condt research on th natul hitory
maniestatin of HW infectin in adlecents  tetig
and deelop approprite counelig, 
clial 
and  protocols for treatig youth who are infected 
Use of zidovudine and other therapies to delay the onset of symptoms among those
infected with HIV represents a major breakthrough in treatment of the 
disease. But 
the use of these therapies for young people may be inhibited by a lack 
information on the progress of the disease and the effects of such treatments on 
adolescents. The PHS should therefore further expand its current research efforts in 
both areas. Disease progression among adolescents should be studied more 
thoroughly and young people, especially young women, should be represented more 
broadly in the clinical trials of therapies designed to treat the disease. Data from 
trials can then be used to guide practitioners in developing treatment protocols and 
determining appropriate dosage levels, dosage schedules, and treatment of adverse 
reactions. 
THE PUBUC HEALTH SERVICE AND THE OFFICE OF HUMAN DEVLOPMENT 
SERVICES 
Puli Heahh Sere, in collboratin wi th Ofe of Hum Deelopm
STh eres shoculi d egn an imple a strteg to cu HW infectin amng street 
si 
yout in  wih large popultins of street yout and high rate of HW infectin.  Local-level servce fragmentation and access problems discussed in this report 
cannot
be resolved completely by Departmental efforts. 
But a combination of technical 
assistance, financial support, and removal of categorical barrers at the Federal level 
would create an environment in which servce delivery reforms could be made. 
We believe that a strategy of focusing on a small number of large urban 
centers with 
high HIV infection rates is warranted for three major reasons. 
One is that by
concentrating on specific localities, the particular tyes of servces and servce 
linkages needed can more readily be identified and implemented. 
A second is that 
by directing an intensified effort at cities with large populations of street youth and 
high rates of HIV infection, the Department can have a sizeable impact on the
national problem. And 
finally, by carefully evaluating the effort, the Department and
others can gain insights on how to respond more effciently and 
effectively to the
needs of street youth throughout the country. 
As noted earlier in this report, the CDC is already planning an initiative for FY 
1991
geared to preventing HIV infection 
among street youth and other youth at high risk. 
The PHS is therefore the most logical agency within the Department to assume lead
responsibilty for implementation of this recommendation. Nevertheless
, the PHS
should not rely on the CDC initiative to fulfill the recommendation. The PHS 
should also ensure that the CDC initiative is planned and carred out 
in collaboration 
with OHDS because of that agency s direct programmatic responsibilty for the street 
youth population, and with other components of the PHS. 
A number of researchers, practitioners, and non-profit organizations have done 
extensive, and in some cases, exemplary work in examining implementation problems 
and testing reform models. Staff of the Robert Wood Johnson Foundation as well as 
participants in the West Coast Scientific Symposium on Health Care of Runaway and
Street Youth are two examples. Therefore, we strongly urge PHS and OHDS to 
ensure that experts from organizations like these participate formally in the planning 
and development of the six-city strategy. 
The HIV prevention strategy should encourage local initiatives; facilitate the 
provision of basic servces that address the survval necessities of street youth; make 
use of existing Federal programs such as the Runaway and Homeless Youth 
Program, the Transitional Living Program, and others; and foster the integration of
servces directed to these 
youth. This would be consistent with the Secretary 
interest in promoting servce integration. 
Making headway against HIV infection among street youth 
will require testing a
number of specialized approaches to servce 
delivery and grant program design. As
we have not had an opportunity to review CDC's plans for its FY 1991 initiative, we
cannot be sure whether the initiative will incorporate 
these approaches. Therefore  . .
we recommend that PHS and OHDS include in their 
strategy, either as part of the
CDC initiative or as an adjunct to it
, evaluations of the following measures: 
The allowance of 
1. 	 waivers to some categorical program requirements.  Such waivers
could be helpful in developing servce 
interventions which respond in a more 
efficient and effective manner to the multiple
, interrelated needs of street youth.
They might also provide a way to serve youth over age 18 if the alternative 
adult" resources are not appropriate for older adolescents. 
2. The allocation of fund for local planning efforts and the requirement that further 
funding depend on demonstrated collaboration among service  The
providers. 
Robert Wood Johnson Foundation has taken this approach recently 
with some 
apparent success. The intent is to foster cooperation among a diverse group of
agencies and professionals who may be otherwse 
inclined to work independently 
or competitively.

The use of a single coordinating or "
anchor" agency within each community.  The 
designation of a single community focal point for organizing the servce 
interventions can faciltate the most efficient and 
effective use of the limited 
resources available. Ideally, such a focal point would be designated through the 
collaborative efforts of the local servce 
providers. 
4. The collocation of some services for street youth.  As we have noted, street youth
are often quite resistant to 
established health and social servces. To the extent 
that such servces are immediately accessible to them, their readiness to use
them and their opportunity to benefit from them may be 
enhanced.  " ,

COMMENTS ON THE DRAFr REPORT

We received comments on the draft report from the 
Public Health Servce (PHS), 
- the Office of Human Development Servces (OHDS), and the Assistant Secretary for
Planning and Evaluation (ASPE). In 
appendix A, we present the detailed comments 
from these Department of Health and Human Servces (HHS) components
, and our
responses to the comments. These comments reflect general concurrence with the 
thrust of our fidings and recommendations
, and contain several suggestions and

technical corrections relating to specific sections of the report  We have

incorporated a number of these suggestions into the text.

We altered the final three recommendations in response to PHS's comments. The 
alterations to the recommendations for behavior change and HIV manifestation 
research were of a technical nature, and are explained in appendix A. 
The change
to the final recommendation deserves further comment. 
In the draft report, our final recommendation called for OHDS, in collaboration with 
PHS, to design and implement a five-city initiative to curb HIV infection among
street youth. In concurring with that recommendation, PHS expressed the desire to
take the lead for that initiative because its Centers for Disease Control (CDC) is 
already planning to implement a new six-city program with the same goal. Given the 
advent of this new initiative (which at the time of our draft report had not been
funded), and given the lack of a comparable new initiative within OHDS
, we have
upon further reflection changed our 
recommendation to make it more compatible 
with PHS' s existing plans. Specifically, we now call for PHS rather than OHDS to 
take the lead in implementing the new initiative, and call for the strategy to be 
implemented in six cities rather than five. We have also revised the text of the 
recommendation to highlight our feeling that certain components of the new 
strategy,
which mayor may not be in CDC's current plans, must be included on at least an

experimental basis.

Both PHS and ASPE commented on our  AIS 
discussion of the National  Program
Office (NAPO). For reasons discussed in appendix A, we believe that an 
evaluation 
of NAPO's mission and performance may be in order.  . .
APPENDIX A 
DETAILED COMMENTS ON THE DRAFT REPORT 
AND OIG RESPONSE TO THE COMMENTS 
In this appendix we present the full comments of all the parties that responded to 
the draft report and our response to each set of comments. We received comments 
on the draft report from the Public Health Servce, the Offce of Human 
Development Servces, and the Assistant Secretary for Planning and Evaluation 
within the Department of Health and Human Servces.  r.  DEPARTMENT OF HEALTH & HUMA SERVICES  Public Helt Seic 
Memorandum 
190 
OCT I 8 

Date 
Assistant Secretary for Health 
From 
Subject  OIG Draft Report "HIV Infection Among Street Youth
OEI-Ol-90-00500 
Inspector General 
, OS

At ta ched are t he PHS commen t s on the subj e c t report 
s finding s

and recommendations. We 
concur with the recommendations and

have taken or plan to take actions to implement them.
suggest slight revision and re-
wording of the last three
recommendations in order to more appropriately elicit the 
scope 
of effort needed to address the report s findings. 
At ta chme nt  ' : .. . - -
COMMENTS OF THE PUBLIC HEATH SERVICE (PHS) ON THE

OFFICE OF INSPECTOR GENERA (OIG) DRAT REPORT " HIV

INFEC'lION AMONG STREET YOUTH, " OEI-01-90-00500

General Comments

This draft report concludes that there is a relative dearth of 
Federal programs targeted to human imunodeficiency virus (HIV)
infection and street youth. 
The term  street youth" 
ruaway, 
encompasses several groups including homeless,  and out
of school youth. 
Al though increased effort in this area can be 
justified, the report should take into consideration the

significant numer of 
Federal programs that are cross-cutting 
with respect to target populations, street youth being only one
of them. 
Programs in many agencies may not be specifically 
titled "Street Youth, " but may have notable impact on that
population. 
A list of programs, many of which are HIV related, specifically 
targeted to street youth was forwarded to OIG at the outset of 
its investigation. These programs have been included in a
companion  directory of programs" to be released in the future. 
We believe that this directory should be included as an 
appendix in this report. It would be misleading to point out a 
dearth of programs in the Federal system and then at a latter 
program targeted 
date release a report with 50 or more Federal 
to HIV and street youth. 
The report interprets data from runaway and homeless shelters 
to indicate that many of the problems of street youth, such as 
physical and sexual abuse, emotional disturbance, and illegal 
streets. 
drug use can be the cause or result of life on the 
However, little in the recommendations addresses the .pre-
, ultimtely, to 
street" phase where many lfiafceto.r s combine  prompt
a youth to enter street  This report should recognize 
that programs to understand and intervene with troubled 
famlies, school-based detection program, and other primry 
prevention activities need to be a priority also. 
The National AIDS Program Office (NAO) is portraye as having
limted 
effectiveness in coordinating the various PHS
components because  it has no control over resource allocation 
or grant specifications. . NAO works directly with the PHS 
agencies and the Assistant Secretary for Health (ASH) in
determning the priority  anual 
areas for Hrv funding on an 
basis, via the budget cycle. Hrv planing initiatives and 
subtted
budget requests of the various agencies must first be 
to NAO for review. Based upon these review,F NuAOe rm,a es 
funding recomendations directly to the ASH.  though
the ASH, NAO exercises its influence in program planning at 
the agency level throughout the year.
 \ .
OIG Recommendation

PHS, through the Centers for Disease Control 
(CDC), should

conduct additional seroprevalence research to measure the

scope of the epidemic among street youth.

PHS Comment

We concur. Through CDC, the Department is already conducting

seroprevalence research to measure the scope of the epidemc
among street youth. CDC collects data from Job Corps entrants,
sexually transmitted disease clinic clientele, women'
s health
clinics, drug treatment centers, adolescent health centers,

sentinel hospitals, family planning clinics, clinics that

specifically serve homeless and street youth, juvenile

detention centers, and other sources that collectively provide

data about seroprevalence among high risk youth, including

street youth.

In addition, CDC has planned an initiative to address street 
youth that is included in the President'
s fiscal year 1991
budget request. Through this initiative, CDC will assist local 
governental and non-governental agencies that serve street
youth in six cities to plan, implement, coordinate, and 
evaluate studies of seroprevalence among street youth, the

prevalence of risk behaviors among these youth, and of factors

that influence the establishment of these behaviors.

OIG Recommendation

PHS should collect baseline data on the sexual behavior

patterns of street youth.

PHS Comment

We concur. Through many different organizations and agencies 
that serve youth, CDC, and hence PHS, collects data abut 
tht 
sexual and other risk behaviors of street youth 
result in 
HIV infection. CDC provides fiscal and technical support to
six national organizations to help youth-serving agencies 
provide HTV education for out-of-school youth. 
The Rational 
Network of Runaway Youth services is one of these 
also directly funds 67 comunty-
organizations. CDC  based 
organizations across the nation to provide HTV education to a
variety of populations, including street youth. 
organizations, 44 target youth populations.  Of the 67
Of these 44, 5 are
working solely in schools, 39 are working with youth in various 
com 
settings in the inner city, mostly minority 
ties, and 5
specifically target homeless or ruaway youth.  In addition, a CDC initiative to address street youth that is

included in the President' s 1991 budget will assist local

governmental and non-governmental agencies that serve street

youth in six cities to plan
, implement, coordinate, and

evaluate the prevalence of risk behaviors among these youth,

and the factors that influence the establishment of these

behaviors. 
Also, CDC' s National Center for Health Statistics plans to

conduct a household-based National Health Interview Surey
Adolescent Supplement in 1992 to assess the comparative

prevalence of the same risk behaviors among a national

probabili ty sample of school- and college-age youth who attend

school or college, and those who do not.

OIG Recommendation

PHS, through the Alcohol, Drug Abuse, and Mental Health

Administration 
(ADAM) , should conduct research on 
behavior change strategies designed to reduce the risk of

HIV infection among street youth.

PHS Comment

We concur with the intent of the recommendation, but suggest 
that it be revised to encompass all PHS agencies. Since
research to assess the effectiveness of behavior change 
strategies designed to reduce the risk of infections among 
various populations, including street youth, is being conducted
by ADAM and 
CDC, we recommend that the recommendation be
revised as follows: 
PHS should ensure collaboration among the various

agencies that conduct research on behavioral change

strategies designed to reduce the risk of HIV infection

among street youth.

ADAM' s efforts in this area have been well-documented. 
CDC
has implemented several research and demonstration projects to 
evaluate behavioral change strategies designed to reduce the 
risk of HIV infection among street youth. In collabration 
Departent of 
with the City of Chicago 
Health, the Heon Street  Center for Youth provides services to homeless and 

ruaway
youth that incorporate HIV risk reduction messages in all 
center activities. 
Peer educators provide HIV education at the
Neon Street drop-in center and on the streets. Behavior
changes are assessed through initial and follow-up interviews

conducted after a 2 month interval. 
Through the Seattle Department of Health, community-
based
AIDS/HIV risk reduction interventions are being implemented in

three hard-to-reach high risk groups, one of which is street

youth. 
These youth are located primarily in two fairly 
isolated areas that can be used for comparison trials of

intervention. The 
object of the study is to assess beliefs

that interfere with adoption of safe sex and drug use

behaviors. 
A demonstration project is underway also in the City of Denver.

This project is an ongoing follow-up of a cohort of 1,

100 men

who have had sex with men to assess seroconversion and changes

in knowledge, attitudes, and behaviors. A cross sectional

analysis will be conducted on the impact of pre- and post-

intervention measures in three communities, one of which is

youth at risk for HIV infection.

OIG Recommendation

PHS should conduct research on the manifestation of 

HTV
infection in adolescents and develop appropriate clinical

protocols for treating youth who are infected.

PHS Comment

tht 
We concur with the recommendation but believe  additional
attention should be focused on the early and subclinical

manifestations of HIV infection, the factors that determne
occurrence of subclinical and clinical outcomes, and the

factors that determne 
access to clinical care by street youth.
We suggest, therefore, that this recommendation be revised as

follows: 
PHS should conduct research on 
the natural history and

infection 
manifestations of 
 HTV  in adolescents and develop
appropriate counseling, testing 
and clinical protocols for

youth who are infected.

Research should not be 
11m ted to the development of clinical

protocols, but should include an examnation of access to early
intervention services by street youth. 
Clinical protocols, no
matter how effective, are of limted 
they have access to care.  use to street youth unless " .
. "
OIG Recommendation

The Office of Human Development Services 

(ORDS), 
collaboration with PHS, should design and 
 plement a

strategy to curb HIV infection among street youth in five

ci ties 
with large populations of street youth and high 
rates of HIV infection. 
PHS Comment

We concur. However, we believe that the recommendation, as

wri tten, could lead to unnecessary fragmentation in the overall

coordination of the national  DS/HIV prevention effort.

Therefore, we suggest that this recommendation be revised as

follows: 
ORDS should collaborate with PHS to design and 
 plement
strategies to curb HIV infection among street youth.

noted on page 9 of the draft report, CDC has already planned

As 
an initiative specifically to prevent HIV infection among

up to six cities with the highest cumulative

street youth  in 
incidence of AIDS. The President'
s budget for fiscal year 1991

requested $5. 
for CDC to implement this initiative.
million 
Wthe ibse leifefvoe rtth.a t CDC should maintain lead responsibility for
governental  CDC, will assist local governental and non
agencies that serve street youth in these cities 
plement, coordinate, and evaluate intensive efforts

to plan, 

to prevent the spread of HIV infection among street youth.

During the past several years CDC has implemented six other 
interrelated national activities to prevent HIV infection among 
out-of-school youth, especially street youth. 
As a result, CDC
has established significant capacity and exprience to 
prevent
the spread of HIV infection among this population. 
We believe

that the best way to reach this population is though the
combined and coordinated capabilities of multiple 
program
wi thin CDC, as well as through other Federal and non-Federal 
agencies. CDC would be pleased to work with OHDS to 
thi s ini tia ti  imlement
ve .  Technical Comments

Page 2
 The acronym for the National Institute for Mental

Health, NIMH, should be introduced here rather than

on page 16. 
Page 9-10  The rates and raw numers of 
Job Corps applicants
infected with HIV in various cities do not reflect

the size of the total populations in those cities

(including the potential size of the street youth

populations in those cities). The numr of 
AIDS
cases diagnosed wi 
thin various cities is a function 
of both the rate of HIV infection within the cities

and the size of the population at risk. Thus, the
numer of 
AIDS cases would be a better criterion to 
use for directing program efforts, than the raw

numers of 
Job Corps entrants infected with  aTV. 
Pages 10
 ADAM " divisions" should be changed to ADAM
and 20
 components. " 
Page 11
 Table 1 may be misleading and we recommend that it be

deleted. The data are based on reports that are 
biased toward major manifestations apparent at the
time of initial diagnosis of AIDS. 
reflect. the clinical  These data do not
course of AIDS. 
The 
distributions may be statistically significant, but 
they are probably not clinically significant. Rather
than reflecting a difference in the distribution of 
manifestations of AIDS between teenagers and adults, 
the table is likely to be a reflection of AIDS among 
teenagers with hemophilia compared to AIDS among 
adul t gay males. 
Page 16
 The acronym for NIDA should be used only after

identifying it as the National Institute on Drug
Abuse. 
Page 16
 NIDA, asAP, and NIM should 
be identified as being
components of ADAM. 
Page 19
 The last sentence of the first paragraph could

confuse readers as written. 
We suggest that it be

revised as follows: 
The long HIV incubation period means there will 
probably never be a comparatively large numr of 
teenagers diagnosed with AIDS, no matter how may
teens become infected with the virus. May teens 
who
become infected will not develop AIDS until they 
become adults.  , "
OIG RESPONSE TO PHS COMMENTS

We thank the PHS for its thoughtful response and appreciate its concurrence with 
our recommendations. We have made the 
revisions to the third and fourth 
recommendations as suggested in the PHS comments. 
As explained in the Comments section of the report, we have also revised the final 
recommendations in response to PHS's comments. We now call for the PHS to take 
lead responsibilty for a six-city initiative and for PHS to collaborate in that effort 
with OHDS. We recognize that CDC's FY 1991 initiative presents a logi.cal vehicle 
for implementation of our recommendation. Unfortunately, we 
have not been able 
to review a current and detailed plan for the CDC initiative, but we assume that it 
resembles the draft of a similar initiative which CDC hoped to implement during FY 
1990. Our review of that draft leads us to believe that while CDC's planned 
initiative is certainly consistent with the intent of our recommendation, it may not be
sufficient. Therefore, we have modified the text accompanying the recommendation 
to reflect our position in that regard. While we originally stated that the planners
for the new strategy should consider taking four steps to reduce categorical program
barrers at the servce delivery level, we now include evaluation of those steps as an 
integral part of the new strategy. The steps we are referrng to are the use of 
eliinate 
waivers to  categorical barrers to servce, linkage of funding to 
demonstrated collaboration among local servce providers, the use of an anchor 
agency within each community, and collocation of servces. We also stress that to 
satisfy the intent of our recommendation, CDC must include OHDS and other PHS 
components in the planning process and must encourage these other agencies to 
consider how their own future initiatives can supplement or complement CDC's. 
We have incorporated the changes suggested in PHS' s technical comments, with one 
exception: we do not agree that the number of AIS 
cases is the best criterion for 
directing program efforts aimed at street youth. It is our belief that the problem of 
HIV infection among street youth may be manifested in a large number of 
metropolitan areas across the country and that the 2900-AIS-case requirement 
proposed by CDC for its new initiative may exclude from consideration many cities 
with equal if not greater need. This belief stems in part from the Job Corps 
seroprevalence data we present in the report. We urge CDC to re-evaluate the 
eligibilty criteria for cities wishing to apply for funding through CDC's new initiative. 
Finally, we offer the following response to PHS's general comments: 
Use of companion report  We agree that publication of the directory of 
programs at a later date would not be timely. We note that the 
companion 
report entitled  HIV Infection Among Street Youth: Department of Health  and Human Servces 
Programs and Resources " has already be  n published'
in final form and is currently available. We 
suggest that publication of the 
edirenctohry aas na fcreee-stasndi ng ireptorts, ra thevr thians ani apbpeindlix tto thyis .rep ort

Broader prevention efforts  We concur with the PHS in its observation that 
prevention of problems that lead young people to live on the streets is a 
worthwhile goal. We would support the PHS in its desire to improve 
primary prevention programs for high-risk familes and would welcome a 
request from PHS to evaluate its efforts in this regard. 
The role of NAPO  We acknowledge that NAPO is given the opportunity to 
comment on allocation proposals. Nevertheless
, based on our research for 
this study we concluded and maintain that NAPO has no clear authority to 
design or coordinate PHS program efforts. Furthermore
, as the Assistant 
Secretary for Planning and Evaluation points out in his comments on this 
report, non-PHS components of the Department are insufficiently 
represented in NAPO-organized working groups. We believe that NAPO' 
current structural limitations hinder its abilty to fulfil its mission and that 
NAPO' s mandate itself may not be sufficiently broad to 
ensure coordination 
and prevent duplication within the Department. As this inspection was not
designed as an evaluation of NAPO' s mission or performance, and as we are 
not aware of any formal evaluations of NAPO, we are not making any 
formal recommendations to PHS regarding that office. Given
, however, the
critical nature of the epidemic
, the visibilty of the office, and the need for 
coordination of Departmental efforts to prevent the spread of 
HIV infection 
such an evaluation may be in order.  ., 
\U,VICIS" 
11 
HETH " HUN  Ofice Of 
OF  SERVICE 
Human Development ServicE 
i: DEPARTMNT 

ol"  Asistant Secretary
4JO 
Washington DC 20201-0001 
SEP 3 0

TO:  Richard P. Kusserow 
Inspector General 
FROM:  Assistant Secretary 
for Human Development Services 
SUBJECT:  Office of Inspector General Draft Report on "HIV 
Infection Among Street Youth" (OEI-Ol-90-00500) 
Thank you for the opportunity to review the draft report

developed by the Office of Inspector General on "
HIV Infection

Among Street Youth.  The report effectively describes the need

for increased interagency efforts as well as research in order to

better address the needs of street youth infected with human

immunodeficiency virus (HIV). As such, it should be useful to

policyrakers both within and outside the Department of Health and 
Human Services. While we concur with the ' 
thrust of the report,
we have several comments. 
First, the report should advocate for coordination beyond that 
involving just the Public Health Service 
(PHS) and the Office of
Human Development Services (OHDS). An examination of the extent 
to which the categorical programs administered by other Federal
agencies 
, such as the Departments of Education and Labor, could 
be extended to serve this population is also needed. 
Wi th 
respect to collaboration between OHDS and PHS
, however, some
efforts are already underway. In Region IX, for example, the two
agencies are cooperatively developing a data collection effort to 
assess the health and medical needs of runaway and homeless
youth. 
Second , while the report discusses barriers to the provision of 
needed services to street youth, such as the denial of

eligibility for Medicaid benefits and the need for parental

consent prior to treatment (pages 11-13), it does not address

potential ways to remove these barriers. 
Street youth, because

they are not in family settings, are in limbo and are ineligible

for most Federal benefits to which many of them had previously 
bfeaemn illiinekse.d  when residing with their natural, foster or other
These programs include Titles IV-A 
(Aid to Families
With Dependent Children), IV-B (Child Welfare Services),
 Page 2 - Richard P. Kusserow

IV-E (Foster 
Care) and, particularly relevant to street youth
XIX (Medicaid). 
Needed remedies include advocating for the 
extension of coverage for benefits such as Medicaid to this

. population and working with the states to liberalize emancipation
requirements. 
Moreover, as the report describes,  survival 
It ' 
sex '" (and we would add drug abuse) are the behaviors which put
street youth at high risk of HIV infection 
(page 5). If the
basic needs of these youth for food
, shelter and other assistance 
are met, we may be able to reduce these behaviors. 
And by
linking street youth to Medicaid and by assuring that medical 
psychological and psychiatric providers treat them if they are
emancipated 
, the resistance to HIV testing by youth service 
workers may be reduced (page 7). 
Third, while the report discusses the need for programs which are

directed towards older street youth and which offer lengths of 
stay beyond thirty days (pages 12-13), no mention is made of
programs , such as the new Transitional Living Program for
Homeless Youth , which address these voids. Grants under the 
Transitional Living Program, to be awarded for the first time in 
fiscal year 1990 , will support the provision of a wide range of 
services (including shelter, health promotion and treatment) to
homeless youth 
, aged 16-21, for periods of up to eighteen months. 
Again , thank you for the opportuni ty to review this report. 
ila Gall
 , "
OIG RESPONSE TO OHDS COMMENTS 
We thank OHDS for reviewing our report and for its concurrence with our 
recommendations. We feel that OHDS has 
accurately identified the need for
increased coordination within and outside DHHS
, and for additional flexibilty in the
administration of assistance programs. We hope that our report can provide the
impetus for future efforts by OHDS in these areas. In 
response to OHDS' s thid
point, we point out that the Transitional Living Program is indeed mentioned at the 
end of the Introduction and in the text accompanying the final recommendation
, as
well as in the companion report 
HIV Infection Among Street Youth: Department
of Health and Human Servces 
Programs and Resources.  ~~~~ \/ =

"''' =- 
.r0 
DEPARTMENT OF HEALTH 
&. HUMAN SERVICES 	 OfIC of th Seetay 
J-' 
4'O  .shirt 
SEP  - PDIG  . D.C. 20201 
/0:)"'  IG 
DIG-AS 
Richard P. Kusserow	 DIG-EI 
DIG.
Inspector General  or 
Gr"n 0 
AIG-MP 	
OGC/IG 
FROM	 Assistant Secretary for 
EX SEO 

Planning and Evaluation 
DATE 

SD 
SUBJECT: 
OIG Draft Report: 
"HIV Infection Among Street Youtq;" 
OEI-01-90-00S00 --
COMM 
I appreciate the opportunity to review and comment on the above

named report. I think that the report will prove useful in that

it helps to bring greater attention to a group of  are
infection. In  Y011th who 
at particular risk of HIV 
addition, I think the
finding that "basic survival needs of street youth overwhelm

education efforts aimed at reducing high-risk behavior" is

particularly 
important, and encourage you to give greater 
emphasis to this finding and its relationship to your specific

recommendations. 
While this study reports remarkabl 
high levels of knowledge

among street youth about how to avoid HIV infection
, many other

studies have found that a high degree of ignorance about HIV

infection exists among adolescents. 
This apparent inconsistency

should be addressed, even though the main message is that

knowledge alone is not sufficient to prevent high risk behavior

in this population.

While HIV infection can be effectively prevented through the use 
of condoms and avoidance of high risk behaviors, these methods 
are not being effectively transmitted to street youth or other 
infection. 
adolescents at high risk of 
Therefore, I think one of
the study' s primary recommendations should be to encourage the

research and development of educational strategies for

adolescents that will change high risk behaviors.

I have several other comments, as well as some specific technical

suggestions. 
Comments 
Reasons for Understandina the ImDact and Future Threat of

The third paragraph on page 2 states that this is critical

for two reasons: because of improving the chances of long-

term survival due to recent medical breakthroughs and

because a large 
numer of 
 ftet youth eventually return to
 . '
mainstream 
society, unknowingly spreading HIV 
infection.
While these reasons are important, I think the primary

reason should be to prevent HIV infection in this group and

the general- population.

I suggest retaining the first justification but only

secondary reason. There  as a

is no way to make those who 
contracted the virus " have
well" with medical treatment. 
language that street youth may eventually return to  The 
mainstream society should be dropped because of the
insensitivity it reflects for those with the disease. 
treatment and prevention should be provided to all groupAsID S
wi thout regard to their present or future contact with the 
general" population, however that is defined. 
Data Collection on Hiah Risk Sexual Activity

and 19 , the report recommends data collection -o nO ns epxaugaels
 8 
activity of street youth. 
Surveying street youth on sexual

activity has many of the same methodological difficulties as

are cited under the discussion for seroprevalence 

studies.
Consequently, the use of a national survey approach such as
the "
Survey on Health and AIDS Risk Prevalence 
to be very difficult.  " might prove
I agree with the recommendation that

gathering data from several metropolitan areas with large 
concentrations of street youth is preferable to a national
survey. 
This approach of performing in-depth studies at
selected sites has been used to look at HIV risk behavior in

IV drug abusing populations

population.  , another hard to reach 
Case Management Versus Collocation

- On pages 14 and 15
report raises an interesting issue on the effectiveness ,o ft
he

using case management versus collocation or "

one stop
shopping" in getting services to street youth. 

issue that merits further investigation Is this an

your office would recommend that further,  raensde aornceh  fboer  dwohniec?h


Local Coordination 
- The first paragraph on page 14 is

principally directed at fragmented funding streams.
However 
, it is also an example of the need for localities to
do better coordination.

DS Re resentation on 
APO Coord ' nated G ou s - I think that
this study appropriately has identified a need for NAPO to

better incorporate the non-PHS components of the Department

in their coordinating activities. 

want to make a specific recommendatiIo ns urgegleastte dt htaot  tyhoius 
might

finding. 
DAM esi 
nation of a Sin Ie Unit to Coordi ate 
on Street Youth  esearch 
- I am concerned that, as now 
recommendation could be misinterpreted to mean stthaet ecdr,e atthieo nI
G
 ...
role. 
of a new organizational entity or individual 
Research 
ot unique in needing collaboration and
con ostreoet ryoduthi ins 
ation. 
ADAM has 
many issues in which there is a
need for coordination among its Institutes and Offices. 
you think it is important to recommend a coordinating 
function, I suggest that you provide more flexibility to the
ADAM Administrator to 
determine how to achieve that
coordination. 
Technical Comments

1, second paragraph. 
Page i and page 
It would be more 
accurate if the background information spoke about the

reported 
cases of AIDS among adolescents and those 
numer of 

in the 20- to 29-year-old categories. The statement,
"Although very few teenagers have developed AIDS, ... 
should read, 'Although very few cases of AIDS have been 
reported among teenagers numer of 
, the  reported cases among
20- to 29-year-olds suggests a high level of HIV infection 
(which causes AIDS) among teenagers. 
While the general observations in the document regarding

disease prevalence are probab 
y true, it is likely that

significant underreporting of both HIV infection and AIDS

occurs in these age groups
, and it would be preferable to

use the more precise language in the background statement.

2. 
1, third paragraph. 
' Page  As now drafted, the paragraph
potentially could give the impression that the 13- 29-
year
olds with AIDS are not predominantly male. 
Yet the data in
the endnotes indicate that even in the younger age groups 
males are significantly overrepresented. This discussion,
combined with the use of the female gender pronouns or 
female examples when discussing the street youth, gives the 
impression that female street youth are more at risk. 
Page 6, first paragraph. The phrase "
we heard anecdotal 
evidence from providers in several cities that their clients 
are willing to pay more for sex without condoms 
" perhaps
needs redrafting. As currently written, it implies that the

street youth, themselves, are willing to pay more for sex

without condoms. Is this the intent of this sentence?

Page 10, "Treatment Protocols.  While representation of
adolescents in clinical trials is a legitimate concern, the 
paragraph should point out that one of the obstacles has 
been the size of the pool of potential participants. 
1\ Page 13, "Other Conditions of Participation.  . As now 
drafted, the paragraph implies that the youth was excluded 
from the treatment program because she did not have a 
supportive partner. Is this in fact the case, or is it that 
the girl did not successfully complete treatment? This 
point needs clarification because many substance abusers
drop out of treatment programs. 
If the young girl was
admi tted to the program but did not successfully complete 
treatment, then this particular requirement is not a good 
example of program requirements that may be barriers to 
street youth. 
Martin H. Gerry
 OIG RESPONSE TO ASPE COMMENTS

We thank the Assistant Secretary for his thoughtful comments and his support for 
recommendations contained in our report. 
We agree about the importance of our
fiding that the basic survval needs of street youth overwhelm education efforts 
geared to reducing high-risk behavior. Our final recommendation is aimed at 
addressing the issue of basic survval needs. Our hope is that by restructurig 
servces and using waivers to eliminate access barrers, the Department wi be able 
to address the basic needs of street youth more effectively. We also 
concur about 
the value of educational strategies to change high-
risk behaviors among adolescents.
Our third recommendation directed to the PHS 
addresses this issue specifically. 
We have made nearly all the changes suggested in the Assistant Secretary 
s general
and technical comments. We strongly agree with the concern about the need for 
NAPO to better incorporate the non-PHS components of the Department in its 
coordinating activities. We suggest in our response to PHS' s comments that a formal 
evaluation of NAPO's mission and performance may be in order.  APPENDIX B

METHODOLOGICAL NOTES 
The methodology for the study included the following: 
The study team conducted a literature review of popular 
1.  Literature review. 
professional and government publications. We reviewed articles and reports on 
issues such as epidemiology; behavior modification models; HIV education 
prevention, and intervention; adolescent health; HIV knowledge, attitudes, beliefs 
and behaviors; and clinical treatment. 
2. 
Federal survey.  The study team examined current Federal policy and actions on 
the issue of HIV infection among street youth through a review of Departmental 
documents and intervews with relevant staff in offices engaged in AIS-related 
activities. 
In response to a formal request for information, eight Departmental offices 
provided a summary of ongoing activities relevant to HIV infection among 
adolescents for our review. Six other offices added supplemental information. 
We relied on the documents to formulate a profie of Departmental efforts and 
looked for signs of internal duplication and omissions. 
Following a review of these documents, we conducted intervews with 15 Federal 
employees who had significant experience with either HIV infection or street 
youth or both. The intervews garnered information on: the employees 
perceptions of the strengths and weaknesses of Departmental efforts; suggestions 
for strengthening the Department' s overall approach; coordination of activities 
within the Department; and mechanisms for sharing of information among offices 
and divisions. 
We analyzed the qualitative data collected in intervews with Departmental staff 
to identify barrers to communication and coordination within and among 
organizational components and ways to enhance collaboration. We reviewed 
Departmental efforts and strategies in the context of major research findings and 
lessons learned at the servce delivery level. 
3. 
Research and advocacy organization  Telephone intervews were conducted 
survey. 
with offcials from 2 local and 13 national independent organizations who 
perform research and provide advocacy servces. The organizations selected 
either receive Federal funding for HIV-related activities, or were identified 
through the literature or word-of-mouth as playing a major role in this area.  The 
discussion guide used for the telephone intervews elicited information on 
such issues as coordination among advocacy and direct 
servce organizations on
the issue of HIV infection; their stance on HIV 
testing; their perceptions of the 
F:ederal response to HIV among street youth; and their ideas about successful 
prevention, testing, and treatment programs for this population. 
4. 
Infomiation was obtained from direct servce 
Direct service provider survey. 
providers that serve street youth
, through a telephone survey of 20 organizations
and site visits to 3 selected providers. The Office of Human Development
Servces provided a list of candidates for the 
survey. From this list we selected 
23 organizations on the basis of caseload size and geographical 
diversity (each
region of the country yielded at least 2 participants). The site viits took 
place
in three major urban areas with a relatively large population of street youth and 
a selection of programs that serve them. 
We conducted the telephone intervews with the 
executive directors of these 
organizations, or their designees. A 
discussion guide was used to ask them about
issues that affect servce delivery for street youth; lessons learned from 
experiences with servce delivery; and perceptions of Federal efforts. A protocol
incorporating the issues covered in the telephone intervew 
and elaborating upon
them, was used for the site visits. 
The telephone intervews and site visits were used to develop profiles of 
programs that are providing innovative servces, to create an inventory of positive 
and negative lessons learned at the servce delivery level, and to identify 
areas of 
consensus regarding opportunities to improve Departmental efforts. 
A list of participating offices and organizations follows: 
Federal offces responding to a formal request for 
Alcohol, Drug Abuse
information: 
and Mental Health Administration; Centers for Disease Control; Food and Drug
Administration; Health Resources and Servces 
Administration; Health Care 
Financing Administration; National AIDS Program 
Office; National Institutes of
Health; and Offce of Human Development Servces. 
Offces providing supplemental information:  Bureau of Prisons; Indian Health Servce; 
Job Corps; Office of Assistant Secretary of Defense for Health Afairs; Offce of
Disease Prevention and Health Promotion; and Offce 
of Minority Health. 
National and local 
American Foundation for 
research and advocacy organizations: 
AIDS Research; Association for the Care of Children s Health; Boston AIS 
Consortium; Center for Population Options; National AIDS Network; National  Coalition of Advocates for Students; National Coalition of Hispanic Health and 
Human Servces Organizations; National Commission on Correctional Health Care; 
National Education AgencylHealth Information Network; National Minority AIDS 
Council; National Network of Runaway and Youth Servces; National 
Organization of
Black County Officials; Planned Parenthood (of Washington
, D.C.); Society for
Adolescent Medicine; and U.S. Conference of Mayors. 
Direct service organizations: 
 Adolescent AIDS Program, Bronx, NY; Avance Human
Servces, Los Angeles, CA; Bridge Over Troubled Waters
, Boston, MA; Casa Shelter
YMCA, Dallas, TX; Comitis Crisis Center, Aurora, CO; Covenant House, Ft.
Lauderdale, FL; The Door, New York, NY; Gay and Lesbian Community Servce
Center, Los Angeles, CA; Janice Youth Programs, Portland, OR; L.A. Children
Hospital, Los Angeles, CA; L.A. Network, Los Angeles, CA; Larkin Street, San
Francisco, CA; Middle Earth Unlimited, Austin, TX; Neon Street Shelter, Chicago
IL; New Beginnings, Lewiston, ME; Sasha Bruce Youthworks, Washington, DC;
Streetwork Project, New York, NY; Synergy House, Parkvlle, MO; Teen Livig,
Chicago, IL; Volunteers of America, Denver, CO; Youth Care, Seattle, WA; Youth
Emergency, Philadelphia, P A; and Youth Emergency Shelter and Servces
, Des
Moines, IA.  '" ,

, "
APPENDIX C 
ENDNOTES 
1. 
Centers for Disease Control  HW/AIDS Surveillance Report  November 1990. 
Figures through October 31, 1990. Teenagers represent less than 0.4 percent of 
AIS 
the total number of  cases. 
2. 
Centers for Disease Control  Strategic Plan for the Prevention of Human 
Immunodeficiency Viru (HIV  Centers for 
Infection: 1990 and Beyond (Draft), 
Disease Control, 1990. For adolescent vs. adult incubation period, see Goedert 
, et aI.  A Prospective Study of Human Immunodeficiency Virs Type 1
Inection and the Development of AIDS in Subjects with Hemophila  New 
England Journal of Medicine 
 321(17):1141-1148, 1989. 
3. 
Centers for Disease Control  HW/AIDS Swveilance Report  November 1990. 
Figures through October 31
, 1990. 
4. See, for example, U. S. General Accounting Offce  Homelessness: Homeless and 
Runaway Youth Receiving Services at Federally Funded  HRD-90
Shelters, 
December 1989. 
5. A runaway youth is a person under 18 years old who absents himself or herself 
from home or place of legal residence without the permission of parents or legal 
guardians. A homeless youth is a person under 18 years old who is in need of
servces and without a place of shelter 
where he or she can receive supervsion 
55(44):8086, March 6
and care. See  Federal Regiter 
 , 1990. 
6. 
Figures from the National Network of 
Runaway and Youth Servces, cited in U. 
S. General Accounting Office AIDS Education: Programs for Out-of-school Youth 
HRD-90-111, May 1990
Slowly Evolving, 
 , p. 2. 
7. The Department of Defense, whose test results are often cited as evidence of 
the infection rate among 
young Americans, has actually witnessed a decline in 
the incidence of HIV antibodies among applicants since 1985. This may be due 
however, to self-selection bias caused by knowledge of HIV testing requirements 
and by recent publicity surrounding DoD's policy of excluding homosexuals from 
miltary servce. Furthermore, the miltary is not likely to attract many street
youth. Unlike miltary recruits, 97 percent of all Job Corps entrants are under 
21 years old and are primarily from low-income familes and urban settings.
Although the Job Corps sample certainly taps the street youth population more 
regularly than the miltary sample, it too may underestimate the true 
incidence of  , "
HIV among street youth. The Job Corps s testing requirements are also well 
known, and the Corps tests only those street youth who are motivated to enter a 
strictly regimented program. 
8. Response to OIG request from Deputy Director (HIV), Centers for Disease 
Control, May 1990. These estimates are derived from 
seroprevalence data 
gathered at 26 sentinel hospitals, which are part of CDC's efforts to determine 
the progress of the epidemic nationwide. The CDC was unable to 
provide any 
demographic information other than age range and sex to accompany this 
estimate. 
9. For a review of published epidemiological data concerning AIS, HIV, and 
adolescents, see National Research Council Committee on AIS Research and 
the Behavioral, Social, and Statistical Sciences  AIDS: The Second Decade 
Washington: National Academy Press, 1990, pp. 147-167. 
10. Between October and December 1989, miltary recruits tested positive for HIV 
at a rate of 0.2/1 000 for 17- to 20-year-olds, and 1.6/1 000 for 21- to 25-year
olds. For Hispanic 17- to 20-year-old males, however, the rate was 1.2/1 000, and 
for black 21- to 25-year-old males, the rate was 6.2/1 000. Figures provided 
response to OIG request from Offce of Assistant Secretary of Defense for 
Health Afairs, Department of Defense, March 1990. 
11. While the seroprevalence rate for Job Corps applicants nationwide between 
October 1, 1987, and October 31, 1989, was 3.88/1 000, several cities experienced 
much higher rates. Examples include San Francisco (13.91/1 000), Miami 
(12.98/1 000), and New York City (10.42/1 000). Figures provided in response to 
OIG request from Director, Office of Job Corps, Department of Labor, March 
1990. 
12. According to the Public Health Servce 
s draft of the  Year 2000 National Health 
Objectives  1987 seroprevalence rates among 18- to 25-year-old homosexual men 
seeking treatment for sexually transmitted diseases were as high as 700/1 000 
while for people in the same age group 
seeking treatment for intravenous drug 
use they ranged up to 600/1 000. Preliminary data from a seroprevalence survey 
of homeless youth in New York City, provided to us by CDC's Center for 
Infectious Diseases, indicate an infection rate of 70/1,000. 
13. Brooks-Gunn , Boyer, C.B., and Hein, K.  Preventing HIV Infection and AIS 
, J.
in Children and Adolescents: Behavioral Research and Intervention Strategies 
American Psychologit  43(11):958-964, 1988. 
14. Non-IV substance abuse, while not considered risky for HIV transmission in 
itself, is thought to stimulate sexual activity and interfere with the cognitive 
functioning necessary for safer sex.  . . ,,  "" ,,,   """ , " , "
15. This is a weighted average, with weight added in proportion to the number 

clients served.

16. Personal communication with Diane Sondheimer, National Institute of Mental

Health, March 1990.

AIS 
17. Becker, M.  , and Joseph and Behavioral Change to Reduce Risk: 
, J. 
A Review  78(4):394-410
American Journal of Public Health 
 , 1988.
18. National Institute on Drug Abuse	 AIDS High Rik Adolescent Prevention Project: 
Partcipant's Manual  , pp. 2-10. 
19. Ibid. 
20. Wright, J.  Povert, Homelessness, Health, Nutrition and Children 
Homeless Children and Youth: 
unpublished paper delivered at conference on 
Washington, D.  , May 1989. 
Coping with a National Tragedy, 

21. National Institute of Allergy and Infectious Diseases  Recommendations for 
Zidovudine: Early Infection  JAM  263(12):1606-1609, 1990.
22. Goodman, E., and Cohall, A.  Acquired Immunodeficiency Syndrome and 
Adolescents: Knowledge, Attitudes, Beliefs, and Behaviors in a New York City 
Adolescent Minority Population  84(1):36
Pediatrics 	 , 1989. 
23. Athey, Jean	 HIV Infection and Homeless Adolescents " unpublished manuscript 
1990
, p. 7. 
24. Ibid. 
25. Brooks-Gunn Adolescent Sexual Behavior  American 
, J., and Furstenberg, 	
Psychologit  44(2):249-257, 1989. 
26. D'Angelo, L.J., and Sondheimer, D.  Adolescents and HIV Infection: 
Struggling Not to Be Forgotten  in press. See also the Offce of
Pediatrc AIDS, 

Technology Assessment Staff Paper  How Effective is AIDS Education?
, 1988. 
AIS 
27. Flora, J.  , and Thoresen, C.E.  Reducing the Risk of  in Adolescents 
American Psychologit  43(11):965-970
, 1988. 
28. Watkins, J.  , et aI.  Report of the Presidential Commission on the Human 
Immunodeficiency Viru Epidemic 1988
, p. 3. 
29. Pediatric AIDS Coalition  1990 Legilative Agenda 
p. 12.  , "
\I 
30. Personal communication with Diane Sondheimer, National Institute of Mental 
Health, May 1990. 
31. Ibid. 
32. English, A.  Adolescents and AIDS: Legal and Ethical Questions Multiply," in 
Quackenbush, M., Nelson, M., and Clark, K.  The AIDS Challenge, Prevention 
Education for Young People Santa Cruz, CA: Network Publications, 1988. 
33. Yates, G., Testimony before the Little Hoover Commission on California State 
Government Organization & Economy, December 13, 1989. Also personal 
communication with Gary Yates, March 1990. 
34. For the purposes of this question, we considered each major component of the 
Public Health Servce plus OHDS and HCFA to be a separate agency. 
Subcomponents such as the National Institute of Mental Health and the National 
Institute on Drug Abuse were not 
considered separate agencies. 
ADAM 
35. The particular agencies named most often were CDC (11 mentions), 
(5 mentions), and NIH (5 mentions). 
36. Here the most commonly cited agencies were CDC (10 mentions), ADAMHA 
mentions), HRSA ( 4 mentions), NIH (4 mentions), and OHDS (3 mentions). 
37. National AIDS Program Office, unpublished document, June 1989. 
55(92):19832- , May 11
38. Federal Regiter 
 , 1990. 
39. Now that both have been completed and are being implemented across the 
country, OHDS is making efforts to ensure coordination between agencies and 
contractors. 
40. U.S. General Accounting Office AIDS Education: Programs for Out-of-School 
HRD-90-111, May 1990
Youth Slowly Evolving, 
 , p. 1. 
41. We asked for ratings of the overall response on a scale of 1- , with 1 meaning 
poor and 10 meaning excellent. The mean responses were as follows: Prom 
direct servce providers, 2.4 for street youth and 3.4 for youth in general; from 
research and advocacy organizations, 2.4 for street youth and 4.0 for youth in 
general; from DHHS officials 7 for street youth and 5.9 for youth in general. 
, 3.