Runaway and street youth at risk for HIV infection: legal and ethical issues in access to care

Runaway Youth: Caring for the Nation's Largest Segment of Missing Children

The largest segment of missing children in the United States includes runaways, children who run away from home, and thrownaways, children who are told to leave or stay away from home by a household adult. Although estimates vary, as many as 1 in 20 youth run away from home annually. These unaccompanied youth have unique health needs, including high rates of trauma, mental illness, substance use, pregnancy, and sexually transmitted infections. While away, youth who run away are at high risk for additional trauma, victimization, and violence. Runaway and thrownaway youth have high unmet health care needs and limited access to care. Several populations are at particular high risk for runaway episodes, including victims of abuse and neglect; lesbian, gay, bisexual, transgender, and questioning youth; and youth in protective custody. Pediatricians and other health care professionals have a critical role to play in supporting runaway youth, addressing their unique health needs, fostering positive relationships within their families and with other supportive adults, and connecting them with available community resources. This report provides clinical guidance for pediatricians and other health care professionals regarding (1) the identification of adolescents who are at risk for running away or being thrown away and (2) the management of the unique medical, mental health, and social needs of these youth. In partnership with national, state, and local resources, pediatricians can significantly reduce risk and improve long-term outcomes for runaway youth.

Strategies for conducting adolescent health research in the clinical setting: the Mount Sinai Adolescent Health Center HPV experience

BACKGROUND

Clinical research with adolescents can be challenging due to issues of informed consent, parental involvement, institutional review board requirements, and adolescent psychosocial development. These requirements present a dilemma, particularly in the area of sexual health research, as adolescents are disproportionately affected by sexually transmitted infections such as human papillomavirus (HPV). To successfully conduct adolescent research in the clinical setting, one requires an awareness of state statutes regarding adolescent confidentiality and consent for medical care, and a close partnership with the IRB.

CASE STUDY

In 2007, the Mount Sinai Adolescent Health Center in collaboration with the Albert Einstein College of Medicine developed a longitudinal research study to examine the natural history of oral, cervical, and anal HPV in an adolescent female population engaged in high-risk sexual behaviors. We use this research project as a case study to explore the ethical, methodological, and clinical issues related to conducting adolescent health research.

SUMMARY AND CONCLUSIONS

Several strategies were identified to promote adolescent study participation, including: (1) building a research team that is motivated to work with adolescents; (2) combining research and patient care visits to avoid duplication of services; and (3) establishing a personalized communication network with participants. Using these methods, adolescent sexual health research can successfully be integrated into the clinical setting. While retaining a prospective cohort of adolescents has its challenges, a persistent and multi-disciplinary approach can help improve recruitment, sustain participation, and acquire critical data that will lead to improved healthcare knowledge applicable to understudied populations of adolescents.

Exploring the Ethics of Observational Research: The Case of an HIV Study in Tanzania

BACKGROUND

Observational studies have generally been viewed as incurring minimal risk to participants, resulting in fewer ethical obligations for investigators than intervention studies. In 2004, the lead author (AN) carried out an observational study measuring sexual behavior and the prevalence of HIV, syphilis, and herpes simplex virus type 2 (HSV-2), among Tanzanian agricultural plantation residents (results reported elsewhere). This article uses an ethical lens to consider the consequences of the observational study and explore what, if any, effects it had on participants and their community.

METHODS

Using a case study approach, we critically examine three core principles of research ethics-respect for persons/autonomy; beneficence/nonmaleficence; and distributive justice-as manifested in the 2004 observational study. We base our findings on three sources: discussions with plantation residents following presentations of observational research findings; in-depth interviews with key informants; and researcher observations.

RESULTS

The observational research team was found to have ensured confidentiality and noncoercive recruitment. Ironically, maintenance of confidentiality and voluntary participation led some participants to doubt study results. Receiving HIV test results was important for participants and contributed to changing community norms about HIV testing.

CONCLUSIONS

Observational studies may act like de facto intervention studies and thus incur obligations similar to those of intervention studies. We found that ensuring respect for persons may have compromised the principles of beneficence and distributive justice. While in theory these three ethical principles have equal moral force, in practice, researchers may have to prioritize one over the others. Careful community engagement is necessary to promote well-considered ethical decisions.

Research on tobacco use among teenagers: ethical challenges

Recent increases in adolescent smoking portend upcoming public health challenges as the majority of smokers initiate long-term addiction during youth, but experience major health consequences later in life. To effectively address this important teenage and adult health issue, critical research information and early interventions are needed, yet conducting tobacco research with teen smokers poses substantial challenges, including several ethical dilemmas. This paper reviews some of the ethical issues presented in etiologic and clinical treatment research addressing adolescent smoking. Common problems and possible solutions are presented. Issues of parent/guardian involvement, decision-making ability of teens, the need to maintain confidentiality are discussed, along with the specific problems of recruitment, compensation, and ethical challenges that arise in group treatment settings. Context-specific ethical adjustments and alternative perspectives are likely to be needed if we are to overcome procedural difficulties in conducting teen smoking studies.

Adolescent research recruitment issues and strategies: application in a rural school setting

This report discusses adolescent research recruitment strategies in general and specifically, those developed by a research team for a rural school setting. Recruitment of adolescent subjects involves the consideration of several complex issues. These issues include adolescent development, ethical and legal guidelines, and access to school settings. Specific strategies are discussed regarding access and culture of the rural setting, collaboration, and recruitment procedures in relation to their use to recruit adolescent subjects from rural schools.

HIV testing, behaviors, and knowledge among adolescents at high risk

PURPOSE

We examined HIV testing behavior and its predictors among adolescents considered at high risk for HIV.

METHODS

Self-reports of HIV testing, knowledge, attitudes, and high-risk acts were examined among 272 adolescents aged 13-23 years (M = 18.7; SD = 2.3) attending community-based agencies that serve youth at high risk for HIV in Los Angeles, New York City, and San Francisco.

RESULTS

Evidence of adolescents' risk for HIV is reflected in a rate of 4.8% seropositivity, 24% injecting drug use, a mean of 4.3 (SD = 11.6) sexual partners during the previous 3 months, and 71% condom use during vaginal/ anal sex. HIV testing was common (63%) and often repeated (M = 3.6, SD = 4.0). Knowledge of the meaning and consequences of testing was high (84% correct). Contrary to service providers' expectations, youth were likely to return for their test results (90% returned). Youth who were older, labeled themselves gay or bisexual, lived in Los Angeles or San Francisco, and those who injected drugs were significantly more likely, compared to peers, to get tested for HIV.

CONCLUSIONS

These results suggest a need for more detailed observational studies of HIV testing behavior that include evaluation of characteristics of the youth, the testing site, and the attitudes and beliefs of providers offering HIV testing.

A profile of human immunodeficiency virus-infected adolescents receiving health care services at selected sites in the United States

OBJECTIVE

To determine the demographic/clinical profile of human immunodeficiency virus (HIV)-infected adolescents in care at selected sites.

METHODS

We mailed surveys requesting prevalence data from physicians in government-funded HIV research and care programs on HIV-infected youth (10-21 years) receiving care.

RESULTS

A total of 49% responses yielded information on 978 subjects. Vertical, blood, and sexual were predominant transmission modes. Three-quarters were of an ethnic/racial minority; 50% were female. The earliest median CD4 count was 0.467 x 10(9)/liter (467/microliter). Percent asymptomatic varied by transmission: vertical (16%), blood products (40%), male-male sexual (67%) and female-male sexual (M:73%) (F:74%). Clinical indicated Pneumocystis carinii pneumonia prophylaxis was differentially prescribed: vertical (96%), blood (89%), and sexually (male-male-47%) (female-male: M: 36% and F: 56%). Of these youth 78% are not represented in national AIDS case data.

CONCLUSIONS

Examination of numerator data from selected sites indicates three transmission-driven adolescent HIV epidemics with different characteristics. Minority youth are disproportionately represented; many vertically infected infants are surviving to adolescence; sexual activity is a significant transmission avenue. HIV-infected youth appear to enter care with considerable immunosuppression. Clinical profiles and treatment patterns appear to differ by transmission mode. Further study is needed on adolescent HIV disease progression and determinants of access to care and treatment.

Health risks of homeless adolescents. Implications for holistic nursing

Although the exact number of homeless adolescents is unknown, it is estimated that this population may exceed 2 million. Literally living on the streets, homeless youth are at risk for a variety of physical, psychosocial, and spiritual health problems. Many engage in "survival sex," exchanging sexual favors for necessities of food, clothing, and shelter. Such risky sexual behaviors make them vulnerable to sexually transmitted diseases, including human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and unintended pregnancies. Many have serious, diagnosable mental health problems, whereas others suffer various consequences of substance abuse. There is a need for comprehensive and holistic health care services, for which the majority of homeless youth have very limited access. Holistic nursing can provide creative interventions for thus vulnerable population.

Characteristics of troubled youths in a shelter

The purposes of this descriptive study were to: (a) describe the identifiable characteristics of a population of runaway youths; (b) describe certain aspects of the youths' current and past situations, such as alcohol and drug use/abuse and a history of physical or sexual abuse; (c) identify significant life events by means of the Coddington Life Events Scale (LES); and (d) examine possible ways in which health and mental health practitioners can best assist these youths and their families through times of crisis. A convenience sample of 78 runaway youths was drawn from an available population of 780 youths who were admitted to a runaway shelter, during the 7-month period of the study. The shelter is located in a semiurban community in north central Florida. Data collection instruments included the Structured Clinical Interview Instrument and the LES. These were administered to volunteer youth participants during the face-to-face interviews. Data from the current study support the assertion that many runaway youths live in abusive situations and are exposed to drugs and alcohol from a variety of sources. Furthermore, the high scores on the LES show insurmountable levels of stressful life events that occur at any given time. Researchers recommend that prevention programs focusing on the antecedents of runaway behavior be developed to prevent future runaway episodes.

Logical Responses to Youth Who Run Away From Home: Implications for Psychiatric Mental Health Nursing

1. Runaway youths do not fit into a typical profile; they are adolescents of every race, ethnic group, and religious orientation; they are representative of every socioeconomic status and geographic location in America. 2. Psychosocial events including physical and sexual abuse are common antecedents to runaway behaviors. 3. Implications for psychiatric mental health nursing practice include working with community programs focused on reducing runaway episodes; implementing preventive measures focused on strengthening parenting and problem-solving skills for reducing conflict with families with adolescent children; and promoting responsible sexuality through adequate and responsible sex education and counseling.

Sexual risk profiles of delinquent and homeless youths

Relatively little is know about the sexual behaviors of high-risk adolescents, such as delinquent and homeless youths. Having secured data from medical examinations, this study provides sexual risk profiles for a sample of delinquent (N = 245) and homeless (N = 160) youths in San Francisco, California. The study found several indicators of high-risk behaviors, such as high levels of STDs, trading sex for money or drugs, and unprotected sexual relations with multiple partners. The study suggests that communities provide better sex education and medical services to high-risk adolescents through multi-service health clinics, public health clinics, and street outreach.

A substance use profile of delinquent and homeless youths

The overall health status of delinquent and homeless youths is of increasing concern. These high-risk youth populations have a variety of health problems, including relatively high levels of substance abuse. This study provides empirical data on the substance use behaviors of a sample of delinquent and homeless youths in San Francisco, California. The data, secured within the context of medical examinations, indicate that both samples use tobacco, alcohol, and illicit drugs at higher rates than the general adolescent population. The study concludes that drug education and prevention programs must be tailored to fit the needs and lifestyles of these two populations, and that the programs should be provided within the broader context of adolescent health care.