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 

of AIS 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 

Both th rik and cuen 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. 

Th fight againt HWamong street youth suffer frm gaps in reseah behavir 

change mols seroprevalee, and treatm protools. 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 

youth is intely foced and coordte 

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 

Th Puli Heahh Sere 

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. 

Th Puli Heahh Sere and th Ofe of Humn Deelopme Seres 

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. 
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. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . .. 

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 . . . . . .. AAPPENDIX 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 which causes AIS. 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, 31 176 cases of AIS 

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. 
, 

Definitions based on behaviors are equally problematic because of he variety 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 longerterm 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 

Thusand of young peple have bee infected and street yout ar in pa 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 among street youth are a predctable conseqe of th riky behars tht constie th 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. 

Prevenn: Bas sual 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 

their clients' HIV knowledge before and after educational 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 
unprotected sex with multiple partners remains a common practice among street youth. 

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 often hete to te street yout for HW becaue of th lack 

prope counelig an 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 
social servces for an HIV -positive youth as a primary factor in determining the. suitabilty of testing. 

Treatm: Trnal meal inns 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 

diffcult to manage.24 The direct servce 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 change mols: Researche and provi lack both bas informtin on steet 

youths' sexl behavir and mols for cuilg 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 "Survey on Health and AIS 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 

youth are unfamilar with the shocking and visible signs of AIS. 

Seroprevalee: Because of inffnt data attn and mone ma not be inves 

whee the are most need 

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 

measure the progress of the epidemic.28 To date, no national, statistically reliable 

seroprevalence survey of street youth has been conducted. In fact, it is unclear 

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. By relyig solely on total AIS 

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 rates among Job Corps applicants does not include Newark, Houston, Los Angeles or 

Chicago. Instead, Atlanta, Birmingham, Cleveland, and Baltimore are among the top eight. Alternatively, if raw numbers of infected Job Corps candidates are considered 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 
simply beyond the capabilties of adolescents weary or afraid of dealing with the system. 

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: 

Consent Requirements: 
 Limitations on the rights of minors to consent to their 

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. 

Age Limits: 
 By our definition, street youth may range in age from early teens up 

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. 

Length of Stay Limits: 
 Many programs funded to house street youth limit clients 

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 Conditions of Partcipation: 
 Other requirements imposed in some programs 

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 of fug soures and diferen idloal apprache impoe serus barr to sere 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 Variety of Sources: Many providers expressed frstration 

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. 

Competition Among Providers for the Same Funding: In some cities that have been 

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 Approaches: Philosophical differences among providers can 

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 

than one agency.34 Nine thought that "determining what behaviors most commonly 

lead to the spread of HIV among the street youth population" should be a shared 

dUty.35 Eight thought that more than one 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 NAPOorganized 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 

Youth.38 This program is sponsored by OHDS'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 infectin seem to attct comparatiely lile attn frm
 th Depart th puli trna yout advocate an 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 

Th Puli Healt Ser thugh th Cers for Diseae Cont~ shoul condt adna serprevalee reseah to mee th scope of th ep 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 teenagers diagnosed with AIS 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. 

Th Puli Heahh Sere shoul collct baseli data on th sex behar patter 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 and th Ceers for Diease Cont~ shoul condt reearch on behar change strte 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 and deelop approprite counelig, tetig and clial 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 

Th Puli Heahh Sere, in collboratin wi th Ofe of Hum Deelopm Seres shoul degn an imple a strteg to cu HW infectin amng street 

yout in si ci 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: 

1. 	 The allowance of 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 providers. The 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 discussion of the National AIS 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. 
DEPARTMENT OF HEALTH & HUMA SERVICES Public Helt Seic 

r. 

190 Memorandum OCT I 8 


Date 

From Assistant Secretary for Health 

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 

of effort needed to address the report s findings. scope 

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" 

encompasses several groups including homeless, ruaway, 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 

date release a report with 50 or more Federal program targeted 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 

drug use can be the cause or result of life on the streets. 

However, little in the recommendations addresses the .pre- street" phase where many factors combine , ultimtely, to prompt a youth to enter street life. 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 areas for Hrv funding on an anual 

basis, via the budget cycle. Hrv planing initiatives and 

budget requests of the various agencies must first be subtted to NAO for review. Based upon these review, NAO maes 

funding recomendations directly to the ASH. Fuer, 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 sexual and other risk behaviors of street youth tht 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 

organizations. CDC also directly funds 67 comunty-based organizations across the nation to provide HTV education to a variety of populations, including street youth. Of the 67 organizations, 44 target youth populations. Of these 44, 5 are working solely in schools, 39 are working with youth in various 

settings in the inner city, mostly minority com 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 

with the City of Chicago Departent of 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


We concur with the recommendation but believe tht 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
 manifestations of 
 HTV infection 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 

intervention services by street youth. examnation of access to early Clinical protocols, no matter how effective, are of limted use to street youth unless they have access to care. 
. . 

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.


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


an initiative specifically to prevent HIV infection among


street youth in up to six cities with the highest cumulative


incidence of AIDS. The President' s budget for fiscal year 1991
 requested $5. million for CDC to implement this initiative. We believe that CDC should maintain lead responsibility for this effort. CDC, will assist local governental and non­ governental agencies that serve street youth in these cities to plan, 
 plement, coordinate, and evaluate intensive efforts


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 

wi thin CDC, as well as through other Federal and non-Federal program

agencies. CDC would be pleased to work with OHDS to imlement thi s ini tia ti ve . 
Technical Comments


Page 2


Page 9-10 

Pages 10


and 20


Page 11


Page 16


Page 16


Page 19


The acronym for the National Institute for Mental


Health, NIMH, should be introduced here rather than


on page 16. 

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. 

ADAM " divisions" should be changed to ADAM components. " 

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. These data do not reflect. the clinical 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. 

The acronym for NIDA should be used only after


identifying it as the National Institute on Drug

Abuse. 

NIDA, asAP, and NIM should be identified as being components of ADAM. 

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 

waivers to eliinate 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 

directory as a free-standing report, rather than an appendix to this report enhances its visibilty. 


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. 
., 

11 \U,VICIS" 

OF HETH " HUN SERVICE 

Ofice Of 

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 

been linked when residing with their natural, foster or other families. 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, It ' survival 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 

SEP - PDIG .shirt . D.C. 20201 

/0:)"' IG 

DIG-AS 

DIG-EI 

Richard P. Kusserow	 DIG. or 

Inspector General G" AIG-MP 	 rn 0 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 Y011th who are at particular risk of HIV infection. In 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 

adolescents at high risk of infection. 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 

While these reasons are important, I think the primary
 infection.

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 groups 

wi thout regard to their present or future contact with the 

general" population, however that is defined. 

AIDS

Data Collection on Hiah Risk Sexual Activity


and 19 , the report recommends data collection on sexual
 activity of street youth. - On pages 8 

Surveying street youth on sexual
 activity has many of the same methodological difficulties as


are cited under the discussion for seroprevalence 


Consequently, the use of a national survey approach such as studies. 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 of
 , the


using case management versus collocation or "


shopping" in getting services to street youth. 
 one stop

issue that merits further investigation Is this an


your office would recommend that further research be done?
 , and one for which


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 recommendation related to this
 I suggest that you might


finding. 

DAM esi nation of a Sin Ie Unit to Coordi ate 

on Street Youth - I am concerned that, as now esearch 

recommendation could be misinterpreted to mean the creation
 stated, the IG

...

of a new organizational entity or individual role. Research on street youth is 
 ot unique in needing collaboration and coordination. 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


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


numer of 
 reported cases of AIDS among adolescents and those 

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 , the numer of 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. ' Page 1, third paragraph. 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: 

1. Literature review. The study team conducted a literature review of popular 

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 survey. Telephone intervews were conducted 

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. Direct service provider survey. Infomiation was obtained from direct servce 

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 information: Alcohol, Drug Abuse 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 research and advocacy organizations: American Foundation for 

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 

the total number of AIS cases. 

2. Centers for Disease Control Strategic Plan for the Prevention of Human 

Immunodeficiency Viru (HIV Infection: 1990 and Beyond (Draft), Centers for 

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 Shelters, HRD-90­

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 

and care. See Federal Regiter 
 55(44):8086, March 6, 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 Slowly Evolving, 
 HRD-90- 111, May 1990, 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-yearolds. 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, J., Boyer, C.B., and Hein, K. Preventing HIV Infection and AIS 

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.


17. Becker, M. , and Joseph, J. AIS and Behavioral Change to Reduce Risk: 

A Review American Journal of Public Health 
 78(4):394-410, 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 

unpublished paper delivered at conference on Homeless Children and Youth: 

Coping with a National Tragedy, 
 Washington, D. , May 1989. 

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 Pediatrics 	 84(1):36­ , 1989. 

23. Athey, Jean	 HIV Infection and Homeless Adolescents " unpublished manuscript 

1990, p. 7. 

24. Ibid. 

25. Brooks-Gunn, J. , and Furstenberg, 	 Adolescent Sexual Behavior American Psychologit 44(2):249-257, 1989. 

26. D'Angelo, L.J., and Sondheimer, D. Adolescents and HIV Infection: 

Struggling Not to Be Forgotten Pediatrc AIDS, 
 in press. See also the Offce of

Technology Assessment Staff Paper How Effective is AIDS Education?, 1988. 

27. Flora, J. , and Thoresen, C.E. Reducing the Risk of AIS 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. 

35. The particular agencies named most often were CDC (11 mentions), ADAM 

(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. 

38. Federal Regiter 
 55(92):19832- , May 11, 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 

Youth Slowly Evolving, 
 HRD-90-111, May 1990, 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, 3.7 for street youth and 5.9 for youth in general.