5. Pathways to STI Risk for Adolescents in Foster Care: Evidence From a Longitudinal Study of Youth Transitioning Out of Care

Purpose: Among other health disparities, adolescents in foster care are at a disproportionately high risk of sexually transmitted infections (STIs) compared with their peers. We sought to determine overall fit and identify important pathways to STI risk for foster youth using a theoretically-driven conceptual model which included: (1) past abuse and foster care experiences, (2) mental health and relational factors in late adolescence, and (3) STI risk variables in young adulthood. Methods:We performed path analysis using data from a longitudinal cohort study of 732 youth transitioning out of foster care in 3 Midwestern states. Datawere collected between ages 17-25 at 2 year intervals (5 waves; 81-82% response for all follow-up waves). Exposure variables (retrospectively measured at Waves 1-2) included: history of physical/sexual abuse, total, group, and kinship care placements, and whether the participant ever had very close relationship with foster caregiver. Mediators (Wave 1) included: current symptoms of post-traumatic stress disorder (PTSD), depression, and/or substance use, delinquency behaviors, attachment style, and whether the youth participated in extended care past age 18. Outcomes (Waves 2-5) included inconsistent condom use, 5 or more partners, and/or having sex for money in the past year at any wave, and report of STI diagnosis in partner or self. Covariates included gender, race, and an inverse probabilityweight to account formissing data. We also performed moderation analyses evaluating models constrained and unconstrained by gender. Results: Thirty percent of the youths reported STI diagnosis in a partner or self; probability of the other outcomes ranged from9% (sex for money) to 79% (inconsistent condom use). Overall model fit was good (Standardized Root Mean Squared Residual ’SRMR’ 0.042). We detected multiple significant pathways to STI risk involving a history of physical/sexual abuse and two foster care variables: total and group placements. Most pathways were mediated by late adolescent symptoms of PTSD and/or delinquent behaviors. Both having a very close relationship with a foster caregiver and participation in extended foster care decreased STI risk. Gender moderation analyses revealed better model fit in unconstrained models compared with the constrained model (SRMR 0.043 and 0.038 for men and women-only models vs. 0.069 for the gender-constrained model), although minimal significant differences were detected in individual path coefficients when gender-specific models were compared. Conclusions: Findings suggest several potential strategies to decrease STI risk in foster youth. Specifically: (1) therapeutic interventions addressing existing internalizing (i.e., PTSD) and externalizing (i.e., delinquency) trauma sequelae, (2) preventive interventions emphasizing core emotion regulation and interpersonal skills to decrease risk of these trauma-related symptoms (either alone or in combinationwith traditional behavioral STI curricula), and (3) policy changes promoting placement stability, youth-caregiver relationship building, and/or which extend care past age 18 may be effective approaches to reduce STIs in this population. Sources of Support: The principal investigator was supported by NIH K23 award 1K23MH90898 and a New Investigator Award from the University of Washington Center for AIDS Research. The parent study was conducted with funding from from the William T. Grant Foundation and the Illinois, Wisconsin, and Iowa state human services departments.