materials, STD and AIDS hotlines, individual and group counseling, media campaigns, condom distribution and needle exchange and bleach programs exist, but very few have been evaluated for effectiveness.96 It is also unclear to what extent the community programs consider and serve the needs of runaway and homeless youth.97 Because they live on the streets, runaway and homeless youth fail to receive prevention messages through the mail and television.98 Other resources necessary for preventing HIV may also be unavailable to runaway and homeless youth. For example, although they may know that cleaning needles and syringes in a chlorine solution will sterilize them, runaway and homeless youth often lack access to bleach or a private place where they can clean these items." 99 Moreover, various studies have found that runaway and homeless youth often fail to attend school.100 One study found that more than seven in ten boys and almost five in ten girls who live on the streets either drop out or are expelled from school. 101 Many health care institutions also provide HIV prevention materials, including condoms, but these services are rarely accessible to runaway and homeless youth. The Office of the Inspector General found that due to lack of funds or the inability to meet eligibility requirements, many homeless and runaway youth are unable to gain access to health care and social services.102 Also, traditional health care institutions often reject runaway and homeless youth, "considering them to be either a poor risk or to carry problems too complex to handle."103 The 1991 Inspector General study highlighted various problems that inhibit HIV prevention, testing, and treatment efforts on behalf of runaway and homeless youth. Even when services are apparently available to youth in the community, requirements such as money, parental consent and age restrictions, fragmentation of funding sources, and different ideological approaches "weaken service delivery for runaway and homeless youth with or at risk of HIV infection."104 As discussed elsewhere in this report, although early detection of HIV can reduce the spread of the infection, shelter staff remain reluctant to test youth at risk of infection due to the lack of proper counseling and available follow-up services. Many studies have also found that Federal and state policies impede the participation of runaway and homeless youths' participation in AIDS clinical trials, particularly requirements for parental consent. 105 Stereotypes About Homeless and Runaway Youth Thwart Prevention It is important to note that while many runaway and homeless youth are faced with difficult and dangerous situations, health care providers and policymakers often have inaccurate beliefs about the lives of these youth. Recently, in testimony before the Select Committee on Children, Youth, and Families, Mary Jane Rotheram-Borus observed that: The stereotypes do not focus on the fact that 25% of these 106 GAO confirms this observation, finding that media portrayals of runaway and homeless youth which highlight drug abuse or prostitution are often exaggerated. According to GAO, "The majority of homeless youth were not reported to have such problems (i.e., drug abuse and prostitution). Approximately one in five was reported as having a drug or alcohol problem, while approximately one in seven females had to deal with pregnancy or venereal disease."107 The stereotype that homeless and runaway youth are beyond help inhibits many prevention and health care providers from serving runaway and homeless youth. Rotheram-Borus criticizes the widely held opinion of one reviewer for the Journal of the American Medical Association, who wrote that the "bleak and hopeless future" of runaway and homeless youth and concludes that "the problem is so huge, so inevitable; nothing can be done. "108 Model HIV Prevention Programs for Runaway and Homeless Youth Are Intensive, Combine Skills Development with Access to Comprehensive Health Care Services When the special needs of runaway and homeless youth are addressed in long-term intervention sessions, risk-taking behavior of runaway and homeless youth decreases. A 1991 study examined the high-risk behavior of 145 runaways at residential shelters and evaluated the impact of comprehensive intervention (up to 30 sessions) on their behavior. Sessions included discussions of general knowledge of HIV/AIDS, coping skills, access to resources and individual counseling to reduce barriers to safer sex. Youth who received the comprehensive intervention reported an increase in condom use and a decrease in high-risk behavior, 109 In testimony before the Select Committee, the program's Director, Rotheram-Borus compared her program with teenage pregnancy, substance abuse, and smoking prevention efforts that have produced behavior change: These programs share several characteristics: a) Interventions Prior to entering the shelters, fewer than one in four runaways reported consistent condom use in the last three months, and among sexually active youth, almost one in four reported engaging in high-risk sexual behavior, defined by the number of partners and sexual encounters, as well as condom use. After six months of intervention, more than six in ten youth reported consistent condom use. No youth reported participating in high-risk behaviors, defined as infrequent condom use (condom use during 0-49% of sexual encounters) combined with ten or more sexual encounters and/or with three or more sexual The "Safe Choices" project sponsored by the National Network of Runaway and Youth Services provides HIV prevention training to community-based agencies that serve youth in high-risk situations, including homeless and runaway youth. Components of the Safe Choices project include train-the-trainer workshops, technical assistance to community-based organizations regarding model program components, policy development, funding sources, and new materials, and various hotlines and publications which include a model training manual. 112 Experts Recommend Comprehensive HIV Prevention and Services for Runaway and Homeless Youth In 1991, the American Medical Association identified the following needs and recommendations regarding the health care of runaway and homeless adolescents: Funding should be provided by an appropriate Conduct a pilot study of the health care needs of Establish a protocol to be used in the evaluation and Disseminate information on the lack of treatment Encourage state medical societies to determine the Encourage local medical societies to develop and 113 In addition, a 1991 literature review of homeless youth and HIV infection included several recommendations about serving homeless and runaway youth. The authors found that standard one- or two-day "AIDS 101" sessions have little effect on the behavior of runaway and homeless youth. They also recommended providing comprehensive care, including case management, to HIV-infected adolescents specifically targeted to homeless youth, and proposed increased Federal and state funding of HIV prevention programs in temporary shelters, foster care and group home settings, and other social service agencies.114 Strategies have been outlined to improve service delivery to runaway and homeless youth who are infected with HIV. These include a holistic and comprehensive approach to service delivery provided by multi-agency coordinated care and "wrap-around" services. Multi-agency coordinated care would address the problems caused by incomplete and fragmented care by providing a comprehensive system of care which uses "interagency committees, multi-disciplinary teams, and 'blended funding', accompanied by case management." Wrap-around services would assure that if a particular youth's needs are not being met by the system, a program will be designed to meet the specific needs of that youth. 115 C. HIV-RELATED NEEDS OF INCARCERATED AND DETAINED YOUTH Although studies of limited samples indicate that large percentages of youth who reside in corrections facilities have engaged in behavior that puts them at risk of HIV infection, no regular or periodic assessment of HIV infection or of high-risk behavior is conducted in these settings. Little is known about |