While providing compelling descriptions of many of the risks that these youth face, Marquis notes that, since analyses are preliminary, findings should not be generalized to all youth in juvenile facilities nationwide.131

A 1991 study compared AIDS-related knowledge, attitudes, and behaviors among incarcerated youth with adolescents in public schools in San Francisco.132 While both groups demonstrated high levels of general knowledge about the transmission of AIDS, incarcerated youth were less likely to have information regarding risk-reduction strategies. Among youth enrolled in school, 85% correctly identified condom use as a means of reducing the risk of HIV transmission, compared with three-fourths of incarcerated youth. Moreover, only 62% of incarcerated youth (compared with 80% of school youth) recognized that sexual abstinence reduces the risk of HIV infection. Similarly, only 56% of incarcerated youth identified not having sexual partners who use intravenous drugs as a strategy to reduce risk of HIV transmission, compared with 72% of school youth. Incarcerated youth were significantly more likely to perceive themselves as susceptible to infection (69% VS. 45%).

Table 8 summarizes the substantial differences in sexual and drug-related behaviors between the two study groups. Youth in detention had engaged in the highest risk behaviors at more than three times the rate of youth enrolled in public school.

Table 8:

Prevalence of Sexual and Drug-Related Behaviors Among
Detained Youth and Youth Enrolled in Public School(k)

These findings are similar to those from a 1988 study which compared knowledge and attitudes about AIDS among nearly 1,600 urban, suburban, gay, and incarcerated youth. This study found that incarcerated youth demonstrated significantly poorer knowledge about AIDS, lower agreement with health guidelines, lower perceived personal threat, lower perceived norms about safer sex practices, and lower personal efficacy in avoiding infection than the other three groups studied.133

Several studies indicate that youth in correctional facilities initiate sexual activity earlier than their counterparts in the general population, and are more likely to have STDs. Hein, et al., found that the average age of first intercourse among females in one detention center (n=378) was 12 years.

134

Virtually all

(k)

DiClemente, R.J., et al. "Comparison of AIDS Knowledge, Attitudes, and Behaviors
Among Incarcerated Adolescents and a Public School Sample in San Francisco."
American Journal of Public Health. Vol. 81. No. 5. May 1991. Table 3.

(1)

Among sexually active, defined as always using condoms.

(m)

Proportion reporting intravenous drug use at lease once.

females in this sample were sexually active. Rates of STDs in female juveniles ranged from 6% to 20% in various facilities.135

In one study of 306 incarcerated male youth, the median age of first intercourse was 11 years. Ninety-six percent were sexually active at the time of the study, 19% reported male/female anal sex, 14% had sex with an IV drug user, 11% had a history of STDs, and 37% reported never using condoms.136

A 1987 study of sexual activity and STDs by the Los Angeles County Department of Health Services, which had an average daily population of 1,850 minors, reported that 75% of the male population was sexually active, with high numbers of sexual partners. Three percent of males tested were found to have gonorrhea, and 13% had asymptomatic chlamydia. Among females, who represented 12% of the juvenile population, 98% were sexually active, 10% were pregnant at the time of the examination, 33% had chlamydia, 10% had gonorrhea, and 28% had trichomoniasis.

137

High rates of STDs among female offenders illustrate a point made by a key informant in a Select Committee survey about the special needs of females which are often overlooked within the juvenile justice system:

[We] make a special effort to reach out to girls who have
often neglected themselves and have a difficult time dealing
with partners...there is far less resistance on the part of males
to at least say that using a condom is OK...girls are afraid to
even bring the subject up...there is an exceptionally high
probability that they will be infected by their older partners.
Sex and babies are powerful ways to feel important to
someone at least for a short time. The girls get STDs all the
time and don't get treatment."

138

Despite Clear Evidence of High-Risk Behavior, Medical and AIDS-Related Services for Juvenile Offenders Are Few and Largely Unevaluated

In 1990, the Council on Scientific Affairs of the American Medical Association found that youth who come to correctional facilities are a medically underserved population that often arrives

with substantial existing physical and emotional problems caused by a variety of factors, including past physical or psychosocial insults, lifestyle habits, and lack of prior health care.

139

As was noted previously, little is known about the quality and availability of primary and preventive health care to youth in custody. Studies indicate, however, that adult inmates are more likely than juvenile offenders to receive HIV education.140 A 1988 study found that all adult prison inmates and approximately two-thirds of surveyed jail inmates received some AIDS education.141 In the same year, the American Correctional Association (ACA) found that 14 state systems of juvenile correction provided no AIDS education for youth, and seven provided only staff training. Of the 29 detention facilities that responded to the ACA survey, nine provided no instruction for young offenders, and two provided no programming for staff.142

Moreover, the Select Committee is unaware of any systematic attempts to evaluate existing HIV prevention and related services programs in correctional facilities serving youth. This apparent failure is underscored by the lack of baseline data about high-risk behavior that is required to inform prevention planners. The Director of the National Institute of Justice, James Stewart, clarified specific information needs:

Correctional administrators thus continue to face tough
decisions about institutional management, the best and most
equitable means of identifying and treating inmates with HIV
disease, potential legal issues, and the costs of medical care.
Policy makers and corrections officials cannot afford to wait
until medical science produces an ultimate answer. Το
address the problem effectively today, they need the most
accurate and up-to-date information available.

143

Approaches that have been shown to be effective in public schools may not be useful with juvenile offenders. According to Gary Shostak, Director of Health Services for the Massachusetts Department of Youth services:

It's difficult to measure the long-term impact of the
[prevention] program...to know if what matters most is what
is said, or who said it. It's difficult for adults who have little

in common with the youth to translate what they know into
something the youth take to heart and make sense of for
themselves.

One program that appears to have made progress overcoming this "culture gap" between juvenile offenders and adult AIDS educators was developed by YouthCare, Inc. for the Seattle-King County Department of Public Health. An evaluation of this program found that YouthCare's curriculum, which includes activities jointly designed by staff and detained youth, produced knowledge gains and increased intentions to behave safely.144 Additional suggestions for effective ways to involve detained youth in program design have been offered, but not evaluated.

145

In the absence of sufficient data about what works in reducing risk in juvenile offenders, an effort has been made to develop a general policy for serving these youth based on a consensus of experienced providers. The National Commission on Correctional Health Care has published standards to assist correctional facilities in designing HIV-related procedures. These standards include recommendations in the following policy areas: education and counseling; prevention; HIV-antibody testing and counseling; confidentiality; nondiscrimination/segregation in housing; and practice of universal precautions.146

Barriers to provision of AIDS services to juvenile offenders have also been identified by the NCCHC. These range from fear of contagion to inadequate agency policy. Suggestions for overcoming these barriers are NCCHC's Health Education Curriculum for Incarcerated Youth: Training Manual, and include, for example, networking with agencies experienced with HIV/AIDS issues and becoming educated about current health matters.147

Incarceration and Detention Present Unique Opportunities for Providing Prevention and Services to Hard-to-Reach Youth

Despite the challenges enumerated above, the period of incarceration or detention offers an important opportunity to provide medical assistance, including HIV prevention services, to