U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

DEPARTMENT OF JUSTICE

OFF ICE OF JUSTICE PROGRAMS

BJA NI J OJJDP BJS OVC

R e s e a r c h i n B r i e f

Jeremy Travis, Director April 1996

continued . . .

HIV/AIDS and STDs in Juvenile Facilities

By Rebecca Widom and Theodore M. Hammett

Sexually transmitted diseases (STDs), including HIV/AIDS, pose serious challenges to administrators of both adult and

juvenile justice systems. Although extensive literature exists on HIV/AIDS and

sexually transmitted diseases among incarcerated adults,1

 little research has focused

on HIV and STDs among confined juveniles. High rates of HIV risk behaviors

have been documented among high school

students and adolescents not in school.2

Juveniles in confinement are likely to be

disproportionately at risk for HIV, STDs,

and other health problems linked to substance abuse, unprotected sexual contact,

and poor access to preventive and primary

health care. Although most training

schools and juvenile detention centers

currently report few confined juveniles

with HIV or AIDS, HIV infection may be

spreading among this population. Further,

significant rates of STD infection and unplanned pregnancy among confined youths

are cause for concern in and of themselves

and as indicators of the prevalence of

HIV-risk activities.

Thus, even though most terms of juvenile

confinement are short, juvenile justice systems have an opportunity to help improve

the health of an underserved and vulnerable segment of society. Moreover, intervention during confinement can benefit

those whom juveniles will encounter once

they are released.

Issues and Findings

Discussed in this Brief: The findings of a 1994 survey by the National Institute of Justice (NIJ) and

Centers for Disease Control and

Prevention (CDC) of policies, programs, and data regarding HIV/

AIDS and sexually transmitted diseases (STDs) in State and local juvenile justice detention centers and

training schools.

Key issues: Although much research has been conducted among

incarcerated adults on HIV/AIDS

and sexually transmitted diseases,

little has been done among confined juveniles. NIJ and CDC sponsored this survey of State and city/

county juvenile justice systems to

gather information about their HIV

and STD education and prevention

measures. Although youths have

basic knowledge about how HIV

and STDs are transmitted, confined

juveniles often lack a sense of personal risk and its consequences

when engaging in high-risk

behavior.

Key findings: Although only about

1 percent of individuals diagnosed

with AIDS between 1993 and 1994

were between 13 and 19 years old,

many youths engage in high-risk

behavior that puts them in danger

of contracting HIV and STDs.

Among the survey’s findings:

● Many detention centers and

training schools offer instructor-led

The 1994 National Institute of Justice

(NIJ) and Centers for Disease Control and

Prevention (CDC) survey asked State and

city/county juvenile justice systems to report on their policies, programs, and data

regarding HIV/AIDS and sexually transmitted diseases. In order to gauge the accuracy of central office reports, samples of

training schools in selected State systems

also completed an abbreviated questionnaire that focused on policies regarding

HIV/AIDS and STDs.

Forty-one State juvenile justice systems,

32 city or county detention centers, and 27

State training schools responded to the

questionnaire. Responses to the NIJ/CDC

survey do not constitute a random sample

of juvenile justice systems or facilities.

However, the data are extensive enough to

support some preliminary findings. This

Research in Brief outlines current knowledge regarding HIV and STD risk behaviors among youths, epidemiological data on

HIV/AIDS and STDs from the NIJ/CDC

survey and other sources, and NIJ/CDC

survey findings on education, preventive

measures, and testing policies.

Epidemiological data

Patterns of HIV/AIDS among adolescents in the United States. Relatively

few adolescents have been diagnosed with

AIDS in the United States; however, a

National Institute of Justice
2

R e s e a r c h i n B r i e f

Exhibit 1: AIDS Cases in the U.S., 1993 and 1994

Ages 13–19 Ages 20–24 Total in U.S.

1993 586 (1%) 3,910 (4%) 103,228

1994 417 (1%) 2,684 (3%) 78,126

Percentage of adolescents with AIDS by race/ethnic background

Caucasian 37%

African American 42%

Hispanic 19%

Native American or Asian/Pacific Islander 2%

People with AIDS by age and sex

All Age Groups 14% female/86% male

Adolescents 34% female/66% male

Source: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report: U.S. HIV

and AIDS Cases Reported Through December 1994, Year End Edition 6(2).

Issues and Findings

continued . . .

R e s e a r c h i n B r i e f

larger minority of people with AIDS have

been diagnosed in their early twenties.

Because an individual can be infected

with HIV for 3 to 5 years or more before

showing symptoms, many of those diagnosed with AIDS in their early twenties

were probably infected with HIV as

teenagers.3 Adolescent girls are more at

risk for HIV infection than women in

other age groups, and adolescents of

color comprise a majority of adolescents

with AIDS (see exhibit 1). Eighty percent of female adolescents with AIDS

are African American and/or Hispanic.

Among the 239 males 13 to 19 years old

in the United States diagnosed with

AIDS in 1994, 26 percent were infected

through sex with other males, 5 percent

through injection drug use (IDU), 3 percent through sex with other males and

injection drug use, and 5 percent

through heterosexual contact.4 Among

the 1,857 males 20 to 24 years old diagnosed with AIDS in the United States in

1994, approximately 80 percent were infected through sex with other men and/or

injection drug use.5 Since more than

half the adolescents diagnosed with

AIDS in the United States were diagnosed in 1993 or 1994 6

 and in light of

documented risk activities among adolescents, an increase in the number of

adolescents with HIV/AIDS is expected.

AIDS cases among confined juveniles. Respondents to the NIJ/CDC survey reported a cumulative total of 60

juveniles with AIDS (50 boys and 10 girls,

54 in State systems and 6 in city/county

systems out of a total of 73 systems responding). Cumulative totals included

cases among confined juveniles, those who

had been released, and those who had

died while confined. Only four currently

confined juveniles with AIDS were reported: Three State systems and one city/

county detention center each reported having one boy with AIDS. Four juveniles

(three boys and one girl, two in State systems and two in city/county systems) had

died from AIDS while confined.

Seven percent of the respondents did not

know either how many juveniles with

AIDS were currently in their systems, had

died while confined, or had been released

with AIDS. Maintaining records of the

number of juveniles with AIDS released

from juvenile systems appeared to be particularly difficult. Further, respondents reported almost no information on racial

breakdowns among confined juveniles

education about HIV. Out of the total

respondents to the survey, 53 systems provided complete data. Of

these, approximately three-quarters

offered HIV prevention counseling in

juvenile facilities.

● Although some juvenile justice systems have comprehensive HIV education and prevention programs, many

do not provide extensive information

because of societal pressure and juvenile justice agency regulations

against delivering explicit messages

and distributing materials such as

condoms.

● State systems, more than county

and city systems, include such topics

as safer sex practices, negotiating

skills, self-perception of risk, the

meaning of HIV/STD tests, and

proper condom use in their education programs.

● Only 2 of the 73 systems that responded to the survey conduct mandatory HIV screening of all incoming

juveniles (11 more systems screen

pregnant girls). Most systems provide

HIV, STD, and pregnancy testing on a

voluntary basis and/or when juveniles

exhibit clinical indications of disease

or pregnancy.

● If voluntary testing is to be successful, it must be easily accessible

and include provision of confidential

services, extensive education, and

quality medical care.

Target audience: Juvenile justice

system administrators, State commissioners of corrections, State and local

policymakers, health professionals,

and researchers.
3

R e s e a r c h i n B r i e f

with AIDS. Of those systems that had

detained youths with AIDS, approximately half of the cases were reported

as race unknown.

HIV seropositivity7

 among confined adolescents. Currently, HIV

seropositivity among confined juveniles appears to be infrequent. Blinded

studies of confined juveniles in Colorado, Texas, and San Bernardino

County, California, found no HIV positive juveniles in their samples.8

 Studies in Alabama and Illinois found HIV

seropositivity rates of 0.7 percent and

0.1 percent, respectively. Screening of

all incoming juveniles in New Mexico

found no HIV positive adolescents

among 1,053 boys and 260 girls

tested. Similarly, screening of all incoming juveniles from September

1992 through October 1994 in Mississippi revealed only one girl to be HIV

positive. All responses from other jurisdictions indicated that HIV testing

for other purposes, including testing

juveniles upon request and testing

pregnant girls, resulted in less than 1

percent seropositivity among confined

juveniles.

Risk behaviors among

adolescents

Although relatively few adolescents with

HIV have been identified, it appears

that many adolescents have engaged in

risky behavior. Most research on risk

behavior among adolescents has focused

on those in school, somewhat less has

dealt with youths not in school, and very

little has considered confined juveniles.

Studies to date on risky behavior among

adolescents have produced somewhat

disparate results, but they generally support the conclusion that sexual activity

among adolescents has increased over

time.

One study found relatively stable levels of sexual activity and drug use

among adolescents between 1990 and

1993.9

 Other research documented increases in sexual activity, rates of

STDs, and unintended pregnancy

among high school students since the

1970’s and an increase in HIV infection among high school students since

the 1980’s.10 Survey data from a

sample of 12,272 representative high

school students across the United

States led to the following estimates:

● Sixty-nine percent of high school

students had sexual intercourse during

the 3 months preceding the survey.

● Nineteen percent had sexual intercourse with four or more partners during their lifetimes.

● Of those currently sexually active,

46 percent used a condom during their

previous sexual encounter.

● Two percent had used injection

drugs.11

Adolescents not in school, including

confined juveniles, appear to be at

even more serious risk. According to

the CDC, “[o]ut-of-school adolescents

aged 14 to 19 years were significantly

more likely than inschool adolescents

to report ever having had sexual intercourse (70.1 percent versus 45.4 percent) and to have had four or more

sexual partners (36.4 percent versus

14.0 percent).”12 Confined juveniles

represent what may be a particularly

at-risk subpopulation of adolescents

not in school because of the

overrepresentation among them of

youths with histories of high-risk behavior and poor access to health care

and prevention services.

STD and pregnancy testing results.

According to recent research, some of

the highest rates of gonorrhea during

the 1980’s were found among adolescents 15 to 19 years old, and rates increased or remained the same among

adolescents throughout the 1980’s

even while decreasing for other

groups. Further, confined youths

tended to have higher rates of STDs

than adolescents in the community, indicating significant risk for HIV

among confined youths.13

Slightly over half of the jurisdictions

responding to the NIJ/CDC survey provided data on results from testing done

on a routine or voluntary basis or when

clinically indicated. Most systems reported testing juveniles who requested

it or who exhibited symptoms. In contrast to rates of HIV infection under 1

percent, the mean reported rates were

2 percent (median 7 percent, standard

deviation 5 percent) for syphilis and

14 percent (median 5 percent, standard deviation 22 percent) for gonorrhea.14 These estimates do not

accurately indicate seroprevalence for

gonorrhea or syphilis because some jurisdictions tested only adolescents who

were most likely to have been exposed.

However, because most systems reporting results tested a total of 400 to

500 juveniles, this indicates that a

large number of confined juveniles

have syphilis or gonorrhea.

Similarly, some juvenile systems tested

confined girls who requested pregnancy

tests or demonstrated clinical indications of pregnancy, while others reported

conducting routine pregnancy testing.

Among the systems that provided routine pregnancy testing, the mean pregnancy rate was 14 percent (total tested:

2,230). Among systems that provided

pregnancy tests on request of the juvenile or upon clinical indications, the

mean pregnancy rate was 19 percent

(total tested: 1,091).
4

R e s e a r c h i n B r i e f

Exhibit 2: HIV/AIDS Education and Prevention for Confined Juveniles

State Juvenile Justice Systems City/County Detention Centers

 (N=41) (N=32)

Testing Policies Number of Percent Number of Percent

Systems Systems

Instructor-Led

Education a, b 38 93 27 84

Peer Education

Programs b 10 24 5 16

Audiovisuals b 35 85 25 78

Written

Materials b 37 90 25 78

a

 Instructor-led education involves the participation of a trained leader in some substantial

part of a session.

b Programs provided in at least one facility in the system.

Source: NIJ/CDC questionnaire responses.

HIV and STD education and

preventive measures

Information alone is not sufficient to

induce or sustain changes in the often

ingrained or addictive behaviors that

place adolescents (and others) at risk

for HIV infection. Effective HIV prevention requires addressing the complex circumstances in which high-risk

behaviors occur and persist. Leading

researchers have proposed a two-level

prevention program comprising universal and targeted elements. The universal components include:

● Basic information on HIV/AIDS and

risk-reduction methods.

● Efforts to reduce discrimination

against people living with HIV.

● Removal of restrictions on access to

condoms, sterile needles, and other

materials needed to implement guidelines for safer behavior.

In addition, communities with a high

prevalence or risk of HIV should receive intensive interventions addressing the “physiologic, emotional,

interpersonal, and cultural contexts”

lead to HIV transmission, confined

adolescents were not as motivated to

change their behavior, and youths in

school were more likely to identify

condom use as a way to prevent transmission.16

Another study found significant differences in perceived risk and personal

consequences between confined and

nonconfined adolescents. Because

confined youths are more likely than

other adolescents to have lived in poverty, they may simply need better access to health services to obtain basic

information.17 However, their lack of a

sense of personal risk and responsibility is of equal concern.

Types of HIV education and

prevention programs

Most systems responding to the NIJ/

CDC survey reported providing

instructor-led education, audiovisual

materials, and written materials, but

only a few offer peer education programs (see exhibit 2). Rates of agreement between systems and their

facilities were generally quite high

(see exhibit 3).

Instructor-led programs. In many

juvenile training schools, HIV/STD

education is offered as part of the

health component of the regular education curriculum. However, the turnover in the population may mean that

many youths are not exposed to the

portion of the curriculum dealing with

HIV and STDs.

A particularly well-conceived HIV/

STD education program is offered by

the Massachusetts Department of

Youth Services (MDYS).18 Two fulltime educators, funded through CDC’s

HIV prevention cooperative agreement

with the State’s Department of Public

of behavior and emphasizing face-toface communication, changes in social

norms regarding sex and drug use, and

distribution of materials necessary for

safer behavior.15

Because of high rates of HIV risk behaviors among confined adolescents,

juvenile facilities may be prime settings for intensive HIV/STD education. Further, since virtually all

confined juveniles are eventually discharged, behavioral interventions

could benefit not only the youths

themselves but persons they encounter

once released.

Prevention knowledge among

adolescents. Research on adolescents’ knowledge of HIV and STD

transmission has produced somewhat

mixed results. One study found similar

and impressive levels of knowledge

about HIV transmission among confined youths and adolescents in school

but also found differences in the particular knowledge between the two

groups and in their motivation to act

on what they knew. Although both

confined and inschool youths recognized that sexual intercourse could
5

R e s e a r c h i n B r i e f

valuable information they could apply

to their own lives. The MDYS educator

noted that the interview session did

not work well unless the youths were

given a previous session on interviewing skills and an opportunity to consider and discuss questions they might

ask of the guest.

Finally, the Massachusetts program

places a heavy emphasis on educating

staff. In addition to building support

for the program, education in HIV and

sexuality issues better equips staff to

provide information and followup in

the facility during the majority of

hours when the HIV educator is not

present.

Peer-led programs. Several juvenile

systems have implemented HIV peer

education programs. In New Mexico,

HIV prevention education is part of a

peer drug and alcohol prevention education program, started 7 years ago as

part of the Drug-Free Schools Program.19 Approximately 20 confined juveniles act as peer educators each

year. In one session in this series, confined juveniles learn how HIV is transmitted and how to practice safer sex,

discuss their fears of HIV, and receive

referrals for HIV testing.20

In Los Angeles County, the Peer HIV

Education Research Project (PHERP)

was designed to compare the effectiveness of peer and adult educators.21

Peer educators team-teach classes

with adult teachers and cover prevention and transmission of HIV, including safer sex and injection practices,

alcohol and drug abuse, STD symptoms and treatment, and negotiation

skills regarding condom use. Students

participate in role-playing exercises

and listen to a guest speaker discuss

what it is like to be HIV positive. At

the beginning and end of the program,

Exhibit 3: HIV/AIDS Education and Prevention for Confined Juveniles: Results

of the Validation Study (VS)

Systems in VS Facilities in VS Percent

with This Policy (N=27) in Agreement

 (N=18)

Instructor-Led 4 6 100

Mandatory for All

 Incoming Juveniles 11 15 73

Mandatory for All

Releasees 6 6 67

Peer-Led 0 a n/a n/a

Prevention Counseling 3 5 b 100

Audiovisual Materials 4 6 100

Written Materials 4 6 c 100

a

 Although no systems in the validation study reported peer education in all facilities,

three systems reported having peer education programs in some of their facilities.

b In systems reporting that some facilities provide prevention counseling, only one facility

reported not providing prevention counseling.

c

 In systems reporting some or all facilities provide written materials, all facilities reported

providing written materials.

Source: NIJ/CDC questionnaire responses.

Health, cover HIV and STD issues in

the context of a comprehensive sexuality education program.

As part of the site visits conducted for

this study, sessions conducted by one

of the MDYS educators were observed

at three Massachusetts juvenile facilities: a long-term care facility and a

shelter care facility for boys, and a

short-term detention center for girls.

The MDYS educator was both respectful and sensitive to the youths’ diverse

learning levels, emotional states, and

cultural backgrounds. Rather than lecturing, she used an innovative, interactive style that was youth-centered.

The educator spent significant time

bonding with her students and listening to their concerns. She appeared to

develop trusting relationships with the

youths, even during one-time sessions

in detention facilities.

In longer term facilities, the educator offered a series of four 11

/2-hour sessions.

During the first session, the youths selected issues they wanted to address.

This approach, while taking into account the juveniles’ feelings and concerns, was also flexible enough for the

educator to cover important points she

had prepared. She also created exercises and materials addressing the topics selected by the adolescents. In an

environment with little opportunity for

choice, this educator has found an important way to win the youths’ support

for the program by offering them the

chance to voice their preferences.

Another important feature of the MDYS

four-session series was a visit from an

HIV-positive guest who, rather than

simply relating his/her story and drawing appropriate lessons about risk behavior, was interviewed by the juveniles.

The youths “owned” the session and

could ask any questions they wished as

long as they were respectful of the guest.

In the observed session, the youths

asked many candid and important questions, and the guest responded with
6

R e s e a r c h i n B r i e f

Exhibit 4: Systems Providing Multicultural HIV Prevention Materials

State Juvenile Justice Systems City/County Detention Centers

 (N=40)a (N=31)a

Number of Percent Number of Percent

Systems Systems

African American 19 48 12 39

Latino 22 55 14 45

Asian/Pacific

 Islander 7 18 4 13

Girls 28 70 19 61

Available in

 Spanish 12 30 8 26

a

 One State system and one city/county detention center did not answer this question.

Percentages are based on the number of respondents who answered the question.

Source: NIJ/CDC questionnaire responses.

participants are surveyed on their HIV

knowledge.

Three peer educators were trained and

team-taught HIV prevention classes,

and the project coordinator was able to

report some preliminary evaluation results. Her initial assumption was that

peer educators would be much more

effective than adult educators, but initial evaluation results suggest that

each type of educator has different

strengths. Although differences were

quite small, peer-led groups showed

more positive changes in attitude and

behavior, while adult-led groups demonstrated higher levels of HIV-related

knowledge.22

Written materials. In order to implement effective HIV prevention education, a system must provide appropriate materials that confined youths are

able to read and understand. Participating systems reported using HIV

education materials with an average of

a sixth-grade reading level. Four jurisdictions reported using materials with

reading levels of tenth to twelfth

grades, and one reported using materials with a third-grade reading level.

Since people of color are overrepresented in confined populations and

among adolescents with AIDS, culturally specific HIV prevention materials

should be available to meet their needs.

Similarly, confined juveniles whose first

language is not English should have access to HIV prevention materials in their

primary language. Materials specifically

addressing issues facing girls also

should be available. Juvenile justice

systems have had mixed success in this

regard (see exhibit 4).

Topics covered in HIV and STD

education. To date, most HIV prevention programs in juvenile facilities

have emphasized provision of information. Practical risk-reduction techniques have been insufficiently

addressed in juvenile and adult systems’ HIV education programs, often

because authorities have been reluctant to teach about proscribed behaviors such as sex and drug use and to

provide the means to render such activities safer. (Similar concerns have

also limited HIV prevention programs

for nonconfined adolescents.) Providing effective HIV prevention programs

to confined juveniles is made difficult

by a central tension: The best programs are explicit about precautionary

and preventive measures, yet public

opinion and the regulations of juvenile

justice agencies often prohibit such

explicit messages. Additionally, most

systems forbid distribution of materials, such as condoms and bleach,

needed to put HIV prevention messages into practice.

Discussing sex with youths is always

complicated and controversial, which is

why the CDC has encouraged input from

parents and communities in developing

HIV prevention curriculums for public

schools.23 Obtaining meaningful input

from the parents of confined juveniles

into education for these youths may be

more difficult. However, because HIV

prevention depends on individual behavior, frank and honest discussion of

how HIV is transmitted is essential.

Although some juvenile justice systems

have implemented comprehensive HIV

education and prevention programs,

many systems have only minimal programs. Some justify this lack of programs by citing the very low HIV

seropositivity among confined youths,

but this disregards evidence of substantial levels of high-risk behaviors and

STD infection in these populations.

All but one responding State system

and most city/county systems reported

covering basic HIV and STD information in their education programs. Many

more State systems than city/county

systems reported covering such topics

as safer sex, the meaning of tests for

HIV or STDs, negotiating skills, condom use, and self-perception of risk

(see exhibit 5). The fact that juveniles

remain in city/county detention centers for much less time than in State

training schools may explain some of

this discrepancy. In light of the research cited above, however, topics
7

R e s e a r c h i n B r i e f

Exhibit 5: Topics Covered in HIV and STD Education

State Juvenile Justice Systems City/County Detention Centers

 (N=41) a (N=32) a

Number of Percent Number of Percent

Systems Systems

Basic Information 40 98 23 74

Meaning of HIV

Test 37 90 19 63

Meaning of STD

Tests 39 95 24 80

Safer Sex

Practices 40 98 24 77

Negotiating

Skills 33 83 16 52

Condom Use 37 90 22 73

Tattoo Risk 39 98 16 52

Alcohol/Drug

Issues 40 98 22 73

Self-Perception

of Risk 36 88 18 60

Barriers to

Change 35 90 16 52

Referrals 35 88 19 66

a

 Some respondents did not answer the questions pertinent to the items listed in the table.

The percentages given are based on the number of respondents who answered each question.

Source: NIJ/CDC questionnaire responses.

Exhibit 6: Summary of Correctional Policies on HIV Antibody Testing of

Confined Juvenilesa

State Juvenile Justice Systems City/County Detention Centers

(N=41) (N=32)

Testing Policies Number of Percent Number of Percent

Systems Systems

Mandatory Testing of

All Incoming

 Juveniles 2 5 0 _

All Releasees 0 _ 0 _

Pregnant Girls 8 20 3 9

Testing Available to

All Confined

 Juveniles on Request 39 95 27 84

Testing if Clinical

Indications b 34 83 28 88

Other Testing c 19 46 20 63

a

 The categorization is not mutually exclusive.

b Clinical signs or symptoms of HIV infection or AIDS.

c

 Examples of other policies include court order and high-risk conduct.

Source: NIJ/CDC questionnaire responses.

such as self-perception of risk and efficacy of prevention activities seem

particularly important.

Condom distribution. Only two jurisdictions (Alameda and San Mateo

counties in California) reported making condoms available to confined juveniles for use within the facility, and

only one additional jurisdiction (Miami, Florida) reported future plans to

distribute condoms. However, 40 percent of State systems and 32 percent of

city/county systems reported that they

made condoms available to juveniles

upon release. Although none of the

systems in the validation study reported distributing condoms, one facility within one of the systems did report

doing so.

HIV and STD testing policies

HIV mandatory screening. Few jurisdictions have implemented mandatory mass screening for HIV. Instead,

most provide voluntary testing and/or

test for HIV when juveniles show

clinical symptoms of disease (see exhibit 6).

Only two State systems (5 percent) reported mandatory screening of incoming juveniles. No city/county juvenile

detention centers reported screening

all incoming juveniles, which is not

surprising in light of the high rate of

turnover in these facilities. Juvenile

justice systems may have several purposes in mind in implementing mandatory mass screening policies. They

may screen to isolate infected individuals. Of the two systems that reported screening all incoming

juveniles, only one housed juveniles

with HIV disease24 apart from other juveniles. Two other systems segregate

juveniles with AIDS but did not report
8

R e s e a r c h i n B r i e f

Exhibit 7: HIV Antibody Testing of Confined Juveniles: Hierarchical Categorization with Validation Study

Results a

State Juvenile Justice Systems City/County Validation Study (VS)

(N=41) Detention Centers (N systems=18)

(N=32) (N facilities=27)

Number Percent Number Percent b Systems Percent

of of in VS with Facilities in AgreeSystems Systems This Policy in VS ment

Mandatory

Testing c 9 22 3 9 2 3 33

Voluntary 31 76 26 81 11 18 89

Clinical

Indications d 1 2 2 6 0 _ _

Missing or

Other e 0 _ 1 3 5 6 n/a

Total 41 100 32 99 18 27 _

a

 Includes actual and planned policies. This is a hierarchical categorization: Jurisdictions and facilities that do mass screening are placed in

the uppermost category, regardless of whether they also test for other purposes. Those that offer voluntary or on-request screening but

do no mass screening are placed in the voluntary category regardless of whether they also test when clinically indicated.

b Percentages do not add to 100 because of rounding error.

c

 Includes mandatory mass screening of all incoming juveniles, releasees, and/or pregnant juveniles.

d Clinical indications include lowered CD4 (T4) counts, opportunistic infections, and TB positivity or active TB.

e

 Five systems with six facilities participating in the validation study did not respond to the system questionnaire. Four of the facilities in

these systems reported a policy of voluntary testing; the other two reported mandatory screening.

Source: NIJ/CDC questionnaire responses.

mass screening policies. Others might

implement mass screening policies in

order to ensure early detection and

treatment of HIV disease. However, in

part because of discrimination against

people with HIV disease and in part

because of the cost of mass screening

policies, most jurisdictions prefer to

educate confined youths and allow

them to choose whether or not to be

tested for HIV.

None of the responding jurisdictions

reported screening releasees. However, eight (19 percent) State systems25

and three (9 percent) city/county systems26 reported a policy of screening

all pregnant girls. All of the city/

county detention centers with this

policy were located in California,

whose State system also reported mandatory testing of all pregnant girls.

This will be an important policy to

monitor in view of recent evidence that

treatment of HIV-positive pregnant

women with zidovudine (ZDV) reduces

the risk of perinatal transmission. Most

facilities participating in the validation

study reported testing policies consistent with those reported by their systems; however, facilities and systems

with policies of testing on request

showed higher rates of agreement than

those with mass screening policies

(see exhibit 7).

Voluntary HIV testing. It is often

assumed that persons who know they

are at elevated risk for HIV or believe

they are infected will volunteer for

HIV testing. However, many high-risk

individuals may not come forward to

be tested out of fear of the results.27

Early treatment—including prophylaxis for Pneumocystis carinii pneumonia or other opportunistic infections,

immunizations, and counseling regarding diet and food preparation to avoid

food-borne pathogens—may lengthen

and improve the quality of life for

HIV-infected juveniles.

Voluntary HIV testing for juveniles

may be complicated by parental consent requirements. Having to acknowledge high-risk behavior to their

parents may discourage juveniles from

pursuing voluntary testing. Thirtyseven State systems (90 percent) and

25 city/county systems (78 percent) reported that juveniles do not need parental consent in order to be tested for

HIV infection. Only five States (California, Colorado, Iowa, Michigan, and

Washington) explicitly allow minors to
9

R e s e a r c h i n B r i e f

Exhibit 8: Summary of Policies on Testing Confined Juveniles for STDs

Syphilis Gonorrhea Chlamydia

 State City/County State City/County State City/County

(N=41) a (N=32)a (N=41)a (N=32)a (N=41)a (N=32)a

All Incoming

Girls 30 (81%) 10 (32%) 23 (64%) 14 (44%) 21 (60%) 6 (20%)

All Incoming

Boys 26 (65%) 10 (32%) 13 (33%) 9 (28%) 11 (28%) 2 (7%)

All HIV

Positive Juveniles 21 (66%) 9 (35%) 17 (53%) 8 (31%) 15 (48%) 4 (16%)

Clinical

Indications 35 (95%) 29 (91%) 36 (95%) 29 (94%) 35 (95%) 30 (94%)

Voluntary 31 (84%) 31 (97%) 30 (81%) 32(100%) 29 (81%) 30 (94%)

a

 Some respondents did not answer the questions pertinent to the items listed in the table. The percentages given are based on the

number of respondents who answered each question.

Source: NIJ/CDC questionnaire responses.

consent to HIV testing.28 To implement successful voluntary HIV testing

programs, administrators must consider how to make testing accessible in

addition to providing confidential services, extensive education, and quality

medical care.

Confidentiality and disclosure. Ensuring confidentiality of HIV test results is one of the most important ways

to encourage youths to be tested, but

this can be complicated and extremely

difficult. Although by official policy

only 25 percent of systems notify parents or guardians of their children’s

HIV status, parents often have general

access to their children’s medical

records. Parents have good reasons for

wanting to know the HIV status of

their children, particularly if their

children are at high risk for HIV infection. Adolescents, however, may also

have valid concerns about informing

their parents of their HIV status. Juvenile justice systems should carefully

consider all ramifications before informing parents or guardians of HIV

status without the consent of the juvenile. In many jurisdictions, such disclosure without consent may be illegal.

Almost all systems reported a policy of

notifying the juvenile (96 percent), her

or his doctor (85 percent), and the local public health department (80 percent) of HIV status. Half or more

systems also reported policies of notifying other medical staff (63 percent),

institution management (50 percent),

and spouses or sexual partners of HIVinfected youths (49 percent). A partner

notification policy might mean that the

confined juvenile notifies the

partner(s) directly, that juvenile justice staff notify the partner(s), or that

public health authorities are notified

and follow up with the partner(s). Only

20 percent of responding systems reported a policy of notifying nonmedical

juvenile justice staff. Validation study

results on notification policies show a

high rate of agreement between central

offices and individual facilities.

HIV pretest and posttest

counseling

Pretest and posttest counseling are

critical components of programs dealing with HIV in juvenile justice systems. Fifty-nine percent of State

systems and 22 percent of city/county

systems reported providing HIV prevention counseling in some or all of

their facilities. (There may have been

uncertainty regarding the meaning of

the survey questions that dealt with

“HIV prevention counseling.” The

questions were intended to refer to ongoing prevention counseling, but most systems probably answered in terms of

pretest and posttest counseling.) Overall,

questionnaire responses indicate that

approximately two-thirds of all facilities

provide HIV prevention counseling.

In order to maintain confidentiality,

counseling must be individualized. By

offering increased individual attention,

such counseling can encourage youths

to express their feelings honestly. However, limited resources among juvenile

justice systems often preclude offering

this service. Sixty-two percent of State

systems and 38 percent of city/county

systems reported providing individual

HIV counseling. More than half of the

participating State juvenile justice systems reported providing HIV counseling

that covered the meaning of HIV antibody test results, safer sex practices,

condom use, effects of alcohol and drug

use on HIV risk, self-perception of risk,

and/or referrals to other services.
10

R e s e a r c h i n B r i e f

STD testing and notification

Many more systems perform routine

screening for syphilis, gonorrhea, and

chlamydia than for HIV (see exhibit

8). STD testing on request and in cases

of clinical symptoms also appear at

least officially available in the vast

majority of juvenile justice systems.

Similarly, more systems require that

sexual partners be notified of a

juvenile’s syphilis, gonorrhea, or

chlamydia infection than of HIV infection. Approximately 80 percent of participating systems reported having

policies requiring sexual partner notification of syphilis and gonorrhea infection, and 75 percent of systems

reported having a policy requiring

sexual partner notification of chlamydia infection. However, only 5 percent

of State systems and 13 percent of

city/county systems said they officially

require notification of parents or

guardians when a confined juvenile

tests positive for an STD.

Pregnancy testing. Sixty-four percent of State juvenile justice systems,

compared with 19 percent of city/

county systems, reported routine pregnancy testing policies. This difference

may be due to youths’ short length of

stay in detention centers. However, 94

percent of all systems, both State and

local, reported testing girls demonstrating symptoms of pregnancy, and

94 percent of all systems reported providing voluntary pregnancy testing.

Conclusion

Many juveniles in confinement have

engaged in activities that place them

at elevated risk for HIV and STDs.

Nevertheless, HIV has not yet become

as widespread as STDs among adolescents in detention centers and training

schools. Thus, a unique opportunity

exists to prevent HIV infection, improve public health, and provide important preventive and therapeutic

services for youths who may have no

other means of accessing them. Most

juvenile systems have implemented

some form of prevention program, including HIV/STD education, but there

is still considerable work to be done to

improve education and prevention. If

juvenile justice systems do not seize

this opportunity, HIV infection among

confined juveniles will likely escalate.

In order to take full advantage of this

opportunity, more juvenile systems

should make counseling, education,

and voluntary HIV testing available.

Further research, especially on the

prevalence of HIV and STDs among

confined juveniles and on the efficacy

of various behavioral interventions,

would also be of value.

Notes

1. Hammett, T., R. Widom, J. Epstein,

M. Gross, S. Sifre, and T. Enos, 1994

Update on HIV/AIDS and STDs in Correctional Facilities, Washington, D.C.:

U.S. Department of Justice, National

Institute of Justice, 1995.

2. The following reports were cited in

DeClemente, R.J., M.M. Lanier, P.F.

Horan, and M. Lodico, “Comparison of

AIDS Knowledge, Attitudes, and Behaviors among Incarcerated Adolescents and a Public School Sample in

San Francisco,” American Journal of

Public Health, 81(5) (May 1991):

628–630; Alexander-Rodriguez, T.,

and S.H. Vermund, “Gonorrhea and

Syphilis in Incarcerated Urban Adolescents: Prevalence and Physical

Signs,” Pediatrics, 80 (1987):561–564;

Bell, T.A., J.A. Farrow, W.E. Stamm,

C.W. Critchlow, and K.K. Holmes,

“Sexually Transmitted Diseases in Females in a Juvenile Detention Center,”

Sexually Transmitted Diseases, 12

(1985):140–144; and Council on Scientific Affairs, “Health Status of Detained and Incarcerated Youths,”

Journal of the American Medical Association (JAMA), 263 (1990):987–991.

3. Centers for Disease Control and

Prevention (CDC), “Guidelines for Effective School Health Education to

Prevent the Spread of AIDS,” Morbidity and Mortality Weekly Report

(MMWR), 37(S–2) (January 29,

1988):1–14.

4. Of males 13 to 19 years old diagnosed with AIDS in 1994, 48 percent

were at risk through hemophilia/coagulation disorder or receipt of a blood

transfusion, and 13 percent did not

have a risk category reported or identified. CDC, HIV/AIDS Surveillance Report: U.S. HIV and AIDS Cases

Reported Through December 1994,

Washington, D.C.: U.S. Department of

Justice, National Institute of Justice,

6(2) Year End Edition.

5. Ibid.

6. Ibid.

7. HIV seropositivity indicates the

presence of HIV antibodies in the

blood.

8. Blinded epidemiological studies

and mass screening both avoid selection bias, which provides the best estimates of seroprevalence.

9. “Trends in Sexual Risk Behavior

Among High School Students—United

States, 1990, 1991, and 1993,” MMWR,

44(7) (February 24, 1995): 124, 131–

132.

10. “Selected Behaviors that Increase

Risk for HIV Infection, Other Sexually

Transmitted Diseases, and Unintended Pregnancy Among High School
11

R e s e a r c h i n B r i e f

Students—United States, 1991,”

MMWR, 41(50) (December 18,

1992):945–950.

11. Ibid.

12. “Health Risk Behaviors Among

Adolescents Who Do and Do Not Attend School—United States, 1992,”

MMWR, 43(08) (March 4, 1994):129–

132.

13. Morris, R.E., C.J. Baker, and S.

Huscroft, “Incarcerated Youth at Risk

for HIV Infection,” in Adolescents and

AIDS: A Generation in Jeopardy, ed.

R.J. DeClemente, Newbury Park, CA:

Sage Publications, 1992:52–69.

14. On average, systems reporting results on syphilis seroprevalence tested

approximately 500 juveniles. On average, systems reporting results on gonorrhea seroprevalence tested

approximately 400 juveniles.

15. DesJarlais, D.C., N.S. Padian, and

W. Winkelstein, “Targeted HIV-Prevention Programs,” New England

Journal of Medicine, 331 (November

24, 1994):1451–1453.

16. DeClemente, R.J., M.M. Lanier,

P.F. Horan, and M. Lodico, “Comparison of AIDS Knowledge, Attitudes,

and Behaviors among Incarcerated

Adolescents and a Public School

Sample in San Francisco,” American

Journal of Public Health, 81(5) (May

1991):628–630.

17. Morris, Baker, and Huscroft, “Incarcerated Youth at Risk for HIV Infection,” 52–69.

18. For information on the Massachusetts program, contact Gary Shostak,

Director of Health Services, Massachusetts Department of Youth Services, 27–43 Wormwood Street, Suite

400, Boston, MA 02210.

19. For more information on the New

Mexico program, contact Dorothy

Martinez, Children, Youth, and Families Department, P.O. Box 38,

Springer, NM 87747.

20. Dorothy Martinez, New Mexico

State Juvenile Justice System, personal communication, May 12, 1995.

21. For more information on the Los

Angeles County program, contact

Maureen Valentine, Peer HIV Education Research Project Coordinator, Los

Angeles Juvenile Court Health Services, 1925 Daly Street, Los Angeles,

CA 90033.

22. Jace Anderson, Peer HIV Education Research Project Coordinator,

personal communication, May 12 and

16, 1995; and Morris, R.E., C. Baker,

J. Anderson, and M. Valentine, “A

Comparison of Peer, Adult, and Mixed

(Adult and Peer) HIV Prevention Educators for Probationary Youth,” abstract presented to the Society for

Adolescent Medicine, 1996.

23. CDC, “Guidelines for Effective

School Health Education to Prevent

the Spread of AIDS,” MMWR, 37(S–2)

(January 29, 1988):1–14.

24. HIV (human immunodeficiency virus) disease refers to the spectrum of

disease from the incubation period

(usually with no obvious symptoms but

HIVseropositivity) to the stage of serious disease (active AIDS—acquired

immunodeficiency syndrome).

25. Arkansas, California, Illinois,

Michigan, Mississippi, South Carolina,

Tennessee, and Wyoming.

26. Alameda, Riverside, and Ventura,

California.

27. Behrendt, C., et al., “Voluntary

Testing for HIV in Prison Populations

with a High Prevalence of HIV,”

American Journal of Epidemiology,

139 (1994):918–926.

28. Morris, Baker, and Huscroft, “Incarcerated Youth at Risk for HIV Infection,” 62.

This research was conducted by

Abt Associates Inc. The study

team consisted of Rebecca

Widom, research assistant, and

Theodore M. Hammett, vice

president.

Prepared under contract OJP–89–C–009

to Abt Associates Inc. from the National Institute of Justice, Office of

Justice Programs, U.S. Department of

Justice. Findings and conclusions of

the research reported here are those of

the authors and do not necessarily reflect the official position or policies of

the U.S. Department of Justice.

The National Institute of Justice is

a component of the Office of Justice

Programs, which also includes the

Bureau of Justice Assistance, Bureau of Justice Statistics, Office of

Juvenile Justice and Delinquency

Prevention, and the Office for Victims of Crime.

NCJ 155509
U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

Washington, D.C. 20531

Official Business

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