feel you're alone in the world, that leads you to a lot of dangerous behaviors."45 46 While national studies have not been conducted, small scale studies indicate that gay and lesbian youth are at increased risk of alcohol and other drug abuse and school failure." These indicators subsequently reduce the likelihood that HIV prevention messages will be heard or heeded.47 Rejected by friends and family, some gay and lesbian youth turn to life in the streets for emotional and financial support. 48 An estimated 25% of all youth living on the streets are gay, lesbian, bisexual, or transsexual.49 (See "HIV-Related Needs of Runaway and Homeless Youth" in this chapter for further analysis of the risks associated with this high-risk situation.) Suicide is the third leading cause of death among males and females ages 15-24, accounting for 8% of deaths among women and 15% of deaths among men in this age group in 1988.50 In 1989, the U.S. Department of Health and Human Services (DHHS) found that gay and lesbian youth are two to three times more likely to attempt suicide than their peers, comprising up to 30% of completed youth suicides annually.51 A more recent study supports the DHHS findings. A 1991 study found that among nearly 140 males from Minnesota and Washington State who identified themselves as gay or bisexual, 30% reported at least one suicide attempt at a mean age of 15.5 years. Nearly one-half of those who had attempted suicide also reported other attempts to take their lives. One-third of first attempts occurred in the same year that the participants identified their sexual orientation. Eighty-five percent of attempters also reported illicit drug use, and 22% had undergone chemical dependency treatment." 52 Social and Resource Barriers to Reaching Youth Who Practice As described in Chapter II, successful HIV prevention programs must be culturally sensitive and instill precise information, a sense of vulnerability and self-efficacy, and skills. These "protect yourself" messages should be reinforced by parents, schools, peers, churches and other community organizations. With respect to efforts aimed at gay adolescents: The effectiveness of AIDS prevention efforts for gay As has been mentioned previously, many HIV prevention programs, particularly those offered in schools, do not address the needs specific to lesbian and gay youth.54 In 1989, the National Education Association took an important step in addressing this problem, by adopting a resolution which stated: All persons, regardless of sexual orientation, should be However, this commitment is not widespread among service providers from the juvenile justice, child welfare, and health care services who have historically neither identified nor addressed the special needs of this population.56 Moreover, most schools and youth-serving agencies do not have policies, programming, or staff training to help these youth develop strong self-esteem and a sense of self-efficacy to prevent or reduce HIV-related risk-taking behaviors.57 Other political barriers include a lack of Federal resources dedicated to HIV prevention serving gay and lesbian youth. This is particularly disturbing, given the high proportion of AIDS cases among youth that are linked to homosexual behavior, and data that indicate that many of these youth engage in sexual and drug use behaviors that put them at risk of HIV.58 Additionally, Federal restrictions on explicit information about safer sex practices for these youth make it difficult to provide the information they need to protect themselves and their partners from HIV.59 Several Model Programs Making Inroads to Prevent HIV Among Gay and Bisexual Male Youth Several model programs providing HIV prevention services to gay male youth exist and are noteworthy because they have overcome many of the barriers addressed above. One model HIV prevention program, at the HIV Center for Clinical and Behavioral Studies at Columbia University, has produced significant reductions in risky behavior among nearly 150 predominantly Hispanic (51%) and African-American (31%) gay males ages 14-19. This program provides intensive HIV prevention services, including individual risk assessment and counseling, coping skills training sessions, and facilitated access to comprehensive medical and social services. After one year, 57% of program participants reported increased condom use. An additional 18% of participants reported decreases in unprotected sex and then relapsed. Improvements were greater for AfricanAmerican youths than for Hispanic youths who engaged in significantly fewer risk acts initially, but made fewer behavior changes over time." 60 A second model program targeting gay male youth is conducted by the Department of Pediatrics at the University of Minnesota. The Youth and AIDS Project (YAP) provides comprehensive outreach, risk reduction counseling, peer education, case management, referral for medical and psychosocial services, and longitudinal follow-up to youth who self-identify as gay or bisexual. Program participants include 140 males ages 1421, more than half of whom grew up in non-urban areas, principally in Minnesota.61 Initial data from YAP indicate that 75% engaged in unprotected anal intercourse and/or needle sharing, nearly onefifth (18%) were chemically dependent, and the same number (18%) of participants reported a history of sexually transmitted diseases. Additionally, 83% of participants did not know that HIV can be transmitted through oral sex, 16% denied any risk for HIV, and 12% were unaware of the HIV antibody test. 62 After participating in YAP for three months, the young men reported a sharp increase in consistent use of condoms during anal intercourse (from 44% to 73%), and were significantly less likely to report oral sex and symptoms of dysfunctional substance abuse.63 Perceived personal vulnerability to HIV increased by 15% among YAP participants and denial of any personal risk for HIV decreased from 16% to 6%. Additionally, regular use of alcohol in sexual situations diminished from 17% to 4%, involvement in prostitution decreased from 8% to 0%, and consistent use of condoms with new partners more than doubled from 30% to 65%.64 B. HIV-RELATED NEEDS OF HOMELESS AND RUNAWAY YOUTH Estimates of the Number of Homeless and Runaway Youth Vary, But Too Many Teens Forced to Survive on the Streets Adolescents live on the streets for a variety of reasons. Many children run away from home each year, while others are literally "thrown away" or abandoned by their families. The Office of Juvenile Justice and Delinquency Prevention (OJJDP) estimates that in 1988, 450,700 youth ran away from their homes or juvenile institutions across the United States. Of this group, nearly 130,000 youth were without a secure and familiar place to stay. Additionally, OJJDP estimates that in 1988 more than 127,000 children were thrown away or abandoned by parents or guardians, and more than 59,000 youth did not have a secure and familiar place to stay during some portion of the time they spent away from their homes.65 66 Other studies indicate higher estimates of homeless and runaway youth. The National Network on Youth and Runaway Services estimates that the number of youth permanently living on the streets ranges from 100,000 to 300,000, with as many as 1,300,000 to 2,000,000 running away from home each year. Community and youth shelter surveys suggest that each year between 1,000,000 - 1,300,000 adolescents live on the streets or receive services from emergency shelters. A large portion of these adolescents are runaways. 67 Another study estimates that the actual number of adolescents on the streets and in emergency shelters may be closer to 500,000.68 Although estimates on the number of runaway and homeless youth vary, it is clear that each year significant numbers of youth are forced to survive living on the streets. Rate of HIV Infection Among Runaway and Homeless Youth Unknown, Rates High Among Youth in Shelters The extent of HIV infection among runaway and homeless adolescents is unknown. However, several youth shelters have collected HIV seroprevalence data from youth whom they serve. These studies indicate a wide range of infection rates. One study of nearly 2,700 youth who received services at Covenant House in New York City between October 1987 and 1989 found that more than 5% were infected with HIV. Data from this study indicate that the longer an adolescent was homeless, the more likely he or she was to be infected with HIV the average rate of HIV infection for youth age 20 was 8.6%. Another anonymous seroprevalence study conducted at a New York health clinic for runaway youth noted that 7% of the youth tested were infected with HIV.? 70 Additionally, a 1991 survey conducted by the Inspector General of the DHHS found that HIV seroprevalence varies by city. Among youth served by a clinical program in a large east coast city, three of every ten were infected with HIV, compared with three of every 100 tested among youth served by a shelter in a large southern city.71 Successful HIV Prevention Among Homeless and Runaway Youth Faces Formidable Barriers Numerous barriers impede successful HIV prevention for runaway and homeless youth. These include: Stressful situations encountered by living on the street; lack of education, job skills, medical care, and social services; increased drug and alcohol use; and unrealistic stereotypes about these youth. As noted by Rotheram-Borus: The lack of supportive resources and the existence of multiple |