Street Youths Are the Only High-Risk Group for HIV in a Low-Prevalence South American Country

Sex and the streets: the open secret of sexual abuse among Pakistan's two million street children

BACKGROUND

About two million children live on the streets in Pakistan. Their complicated past and dire living conditions make them susceptible to many psychological and physical problems, including sexual abuse.

MAIN BODY

With little research on the topic, the prevalence of sexual intercourse among street children is reported to be as high as 88% in Pakistan. With commercial sex a common practice among the street children, public places such as bus terminals and parks have become foci of prostitution and sexual exploitation. A growing concern is the spread of HIV/AIDS among the affected children due to a general lack of awareness about the disease and its prevention and high prevalence of unsafe sexual practices. The generally apathetic attitude of the society towards this issue and the affected children, combined with a lack of commitment and limited resource allocation by the government, has contributed in deteriorating the situation further.

CONCLUSIONS

A comprehensive multi-pronged strategy involving government, societal and international stakeholders is crucial to tackle the current crisis.

Exploring readiness for implementing best practices: A mixed methods study

RATIONALE

Evidence-based practice (EBP) can improve health care in underprivileged countries. Bolivia's EBP movement is nascent and the factors contributing to better implementation in nursing are unknown.

AIM

To explore Bolivian nurses' readiness to engage in EBP while highlighting the facilitators and barriers for pursuing EBP.

METHOD

The study used a sequential explanatory mixed methods study. First, general trends were disclosed via a survey of 170 nurses in La Paz, Bolivia, holding at least a baccalaureate regarding their perceived beliefs about EBP. The survey identified facilitators and barriers for implementing EBP in acute and ambulatory settings. Second, qualitative data was gathered via a focus group of nine nurses with the purpose of enhancing the survey results.

RESULTS

The survey results showed that nurses believe that engaging in EBP can improve their clinical practice. However, the nurses' research behaviors were found to be infrequent. Lack of support from the nurses' clinics and hospitals and from non-nursing professionals were identified as barriers for engaging in EBP. The qualitative results revealed underlying limitations to nurses' clinical practice, including "feeling undervalued".

CONCLUSIONS

There is a dearth of EBP knowledge among Bolivian nurses stemming from a lack of preparation in EBP environments, including EBP training opportunities. This situation affects nurses' professional dimensions of relational work, power, and collaboration. Collaborative research among educators, professional nursing societies, and local and international organizations could provide initiatives for implementing EBP, based on local health profiles.

Domestic Minor Sex Trafficking Patients: A Retrospective Analysis of Medical Presentation

STUDY OBJECTIVE

To describe the clinical characteristics of patients referred for domestic minor sex trafficking (DMST) to improve identification and intervention.

DESIGN

Retrospective cohort study.

SETTING

The Lawrence A. Aubin, Sr Child Protection Center at Hasbro Children's Hospital where patients are evaluated by child abuse pediatricians in outpatient, emergency department, and inpatient settings.

PARTICIPANTS

A total of 41 patients younger than the age of 18 years referred for the evaluation of DMST involvement between August 1, 2013 and March 30, 2015.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We collected demographic, social-environmental, medical, and psychiatric variables from the medical records of patients referred for evaluation who have self-disclosed, been reported with evidence, and/or have histories that place them at high risk for DMST involvement.

RESULTS

Children had frequent contact with medical providers, with 81% seen in the year before referral for DMST. Childhood maltreatment and family dysfunction were identified (sexual abuse, 21/37 or 57%; parental substance abuse, 22/37 or 60%) in the 41 patients. Children had medical problems (eg, sexually transmitted infection, 13/41 or 32%), psychiatric needs (eg, acute suicidality, 8/41 or 20%; at least 1 previous psychiatric admission, 19/41 or 46%), and substance use (36/41 or 88%). Although 26/41 (63%) had runaway and 17/41 (42%) lived in a group home placement, 28/41 (68%) currently lived at home and 29/41 (71%) presented with a parent/guardian or relative.

CONCLUSION

Children referred for DMST present frequently to physicians and have complex medical and psychiatric needs. Medical providers' increased awareness of this health issue would inform victim identification and intervention.

HIV prevalence in children and youth living on the street and subject to commercial sexual exploitation: a systematic review

The aim of this review was to describe HIV prevalence in children and youth living on the street and subject to commercial sexual exploitation, and the studies' characteristics in terms of place, time, population, and sample design. This was a systematic review, not a meta-analysis, based on an article search in 10 electronic databases: Science Direct, MEDLINE, OVID, LILACS, Wiley InterScience, MD Consult, Springer Link, Embase, Web of Science, and Ebsco. A complementary search was also performed in the libraries of schools of public health and webpages of U.N. agencies, besides the reference lists from the selected articles. We selected observational studies focused on children and youth living on the street and subject to commercial sexual exploitation, ranging in age from 10 to 20 years, with the results for HIV prevalence rates. A total of 9,829 references were retrieved, of which 15 met the inclusion criteria and comprise this descriptive summary. Of these 15 articles, 12 were conducted in children and youth living on the street and three in children subject to commercial sexual exploitation. All 15 were cross-sectional studies. HIV prevalence in children and youth living on the street ranged from 0% in Dallas, USA and Cochabamba, Bolivia to 37.4% in St. Petersburg, Russia. In children and youth living subject to commercial sexual exploitation, prevalence ranged from 2% in Toronto, Canada to 20% in Kolkata, India. In conclusion, HIV infection is present in children and youth living on the street and subject to commercial sexual exploitation. Measures are needed for prevention, diagnosis, and treatment as a public health priority and an ethical responsibility on the part of governments and society.

The health diagnoses of homeless adolescents: a systematic review of the literature

BACKGROUND

Homelessness during adolescence impacts negatively upon young people's physical and mental wellbeing. To be effective, programs aimed at addressing the health needs of this population must include knowledge of both the presenting and underlying acute and chronic conditions that characterise this high risk group of youth.

METHODS

We undertook a systematic review of the international literature for studies that used validated instruments and techniques to diagnose prevalence rates of physical and mental health disorders in homeless adolescents.

RESULTS

Twenty-one studies fulfilled the selection criteria. Of these, nine studies examined mental health diagnoses including depression, post-traumatic stress disorder, anxiety and substance abuse disorders. With one exception, the remaining twelve studies all related to sexually transmitted infections.

CONCLUSION

Homeless adolescents are diagnosed with widely varying rates of mental health disorders and high rates of sexually transmitted infection. Other likely chronic and acute physical conditions appear to be neglected in the published research.

The health status of street children and youth in low- and middle-income countries: a systematic review of the literature

The health of the tens of millions of street children globally is understudied. We undertook a systematic review of the existing quantitative literature regarding the health status of street children and youth in low- and middle-income countries to summarize available knowledge, identify underexplored areas of research, and inform the future research agenda regarding the health of this population. A total of 108 articles met our inclusion criteria. Demographic data and structural factors associated with street life are summarized. Although data in specific regions or diseases are sparse, the literature review illustrates that youth's survival behaviors and the exposures associated with poor shelter have resulted in disproportionate morbidity in the areas of infectious illness, psychiatric disease, reproductive health, and perhaps to a lesser extent, growth. Vast areas of health that may disproportionately affect street children in childhood or later on as adults have not been investigated, including chronic diseases and cognitive deficits. Studies of specific diseases or conditions vary considerably by region. Strengths and limitations of the literature are discussed and principles for future research in this area are proposed.

Reaching youth with out-of-facility HIV and reproductive health services: a systematic review

PURPOSE

Many young people, particularly those who are marginalized and most at risk for HIV and reproductive health-related problems, cannot or will not seek traditional facility-based health services. Policies and programs are being implemented to provide them with these health services in the community. We sought to review the effectiveness of such approaches in increasing HIV and reproductive health service use.

METHODS

A systematic literature review was undertaken to identify policies promoting or programs delivering HIV or reproductive health services in the community. We reviewed studies that evaluated uptake of services or commodities. Data from studies meeting inclusion criteria were qualitatively analyzed.

RESULTS

Twenty studies met inclusion criteria, including 10 containing comparative data (e.g., before and after study or control study design). The studies generally demonstrated positive impact, although results varied across settings and approaches. The most successful approaches included mail-based chlamydia screening in the Netherlands, condom distribution via street outreach in Louisiana, home-based HIV counseling and testing in Malawi, and promotion of over-the-counter access to emergency contraception in various countries.

CONCLUSION

Overall, this review suggests that out-of-facility approaches can be important avenues to reach youth. Continued evaluation is necessary to better understand specific approaches that can successfully deliver health services.

HIV knowledge and sexual risk behavior among street adolescents in rehabilitation centres in Kinshasa; DRC: gender differences

BACKGROUND

Street children, common in Africa, are increasingly vulnerable to alcohol and drugs of abuse and lack access to both healthcare and knowledge about HIV and AIDS. Hence, this study assessed the level of knowledge about sexually transmitted infections (STIs), including HIV, among street adolescents in the Democratic Republic of the Congo (DRC).

METHODS

A random sampling of 200 street children (10-25 years of age) were selected from 17 rehabilitation centres in Kinshasa, and a structured questionnaire was administered to all participants in their respective centres. High knowledge, knowledge or awareness of condom was defined when a participant gave more than 67% of correct responses. Chi square analysis was used to test differences between sexes.

RESULTS

The knowledge level of respondents was high. 54.3% of males and 45.7% of girls have heard about HIV), and few participants cited unprotected sex as mode of transmission (42.9% for males and 57.1% for females). A high number of children reported a previous sexual experience. Satisfying a natural bodily need was the main reason for having sex. However, the use of condoms is still low in both genders (26.2 versus 59.3%, p<0.01). Neither gender reported a reason why they are not using a condom.

CONCLUSION

This study highlights the high knowledge about HIV, which contrasts with low condom use and high past sexual experiences with the high number of sexual partners and sexual contacts. Policies targeting these findings are warranted to reverse such trends.

Multicity HIV seroprevalence in street youth, Ukraine

We conducted the first systematic, community-based, multicity assessment outside the USA of HIV seroprevalence, risk factors and linkage into clinical services among 929 street youth. After city-wide mapping, we used time-location sampling and randomly selected 74 venues in Odesa, Kyiv and Donetsk, Ukraine. Rapid HIV testing with post-test counselling was offered to all eligible youths aged 15-24 years. Overall, 18.4% (95% confidence interval 16.2-20.2) were HIV positive and 85% had previously unknown status. Rates were identical by sex. Subgroups with highest rates included orphans (26%), youths with histories of exchanging sex (35%), sexually transmitted infections (STIs) (37%), injection drug use (IDU) (42%) and needle sharing (49%). Independent predictors, similar across age groups and city, included being orphaned, time on the street, history of anal sex, STIs, exchanging sex, any drug use, IDU and needle sharing. Two-thirds (68%) of HIV-positive youths were linked to services. This high-risk population has many immediate needs.

Interventions to modify sexual risk behaviours for preventing HIV in homeless youth

BACKGROUND

Homeless youth are at high risk for HIV infection as a consequence of risky sexual behaviour. Interventions for homeless youth are challenging. Assessment of the effectiveness of interventions to modify sexual risk behaviours for preventing HIV in homeless youth is needed.

OBJECTIVES

To evaluate and summarize the effectiveness of interventions for modifying sexual risk behaviours and preventing transmission of HIV among homeless youth.

SEARCH STRATEGY

We searched electronic databases (CENTRAL, MEDLINE, EMBASE, AIDSearch, Gateway, PsycInfo, LILACS), reference lists of eligible articles, international health agency publication lists, and clinical trial registries. The search was updated January 2010. We contacted authors of published reports and other key role players.

SELECTION CRITERIA

Randomised studies of interventions to modify sexual risk behaviour (biological, self-reporting of sexual-risk behaviour or health-seeking behaviour) in homeless youth (12-24 years).

DATA COLLECTION AND ANALYSIS

Data from eligible studies were extracted by two reviewers. We assessed risk of bias per the Cochrane Collaborations tool. None of the eligible studies reported any primary biological outcomes for this review. Reports of self-reporting sexual risk behaviour outcomes varied across studies precluding calculation of summary measures of effect; we present the outcomes descriptively for each study. We contacted authors for missing or ambiguous data.

MAIN RESULTS

We identified three eligible studies after screening a total of 255 unique records. All three were performed in the United States of America and recruited substance-abusing male and female adolescents (total N=615) through homeless shelters into randomised controlled trials of independent and non-overlapping behavioural interventions. The three trials differed in theoretical background, delivery method, dosage (number of sessions,) content and outcome assessments. Overall, the variability in delivery and outcomes precluded estimation of summary of effect measures. We assessed the risk of bias to be high for each of the studies. Whilst some effect of the interventions on outcome measures were reported, heterogeneity and lack of robustness in these studies necessitate caution in interpreting the effectiveness of these interventions. 

AUTHORS' CONCLUSIONS

The body of evidence does not permit conclusions on the impact of interventions to modify sexual risk behaviour in homeless youth; more research is required. While the psychosocial and contextual factors that fuel sexual risk behaviours among homeless youth challenge stringent methodologies of RCT's, novel ways for program delivery and trial retention are in need of development. Future trials should comply with rigorous methodology in design, delivery, outcome measurement and reporting.

Street-based adolescents at high risk of HIV in Ukraine

Background

Ukraine has the highest HIV prevalence in Europe, with young people disproportionately represented among populations at high risk. One particularly vulnerable group comprises adolescents who live or work on the streets. This study aimed to measure the extent and distribution of HIV risk behaviours among street-based adolescents in four Ukrainian cities as part of a regional UNICEF HIV prevention programme for most-at-risk adolescents.

Methods

A cross-sectional behavioural survey was conducted of 805 adolescents (aged 10–19 years) in the cities of Kiev, Donetsk, Dnepropetrovsk and Nikolaev. Using location-based network and convenience sampling, 200 adolescents were reached in each site and were administered a standardised questionnaire on drug use, sexual behaviour, condom use, HIV knowledge, access to prevention services, experience of violence and contact with state institutions and police.

Results

Considerable levels of HIV risk behaviour were found, including injecting drug use among 15.5% of the sample. Almost three-quarters of adolescents had experienced sexual debut, most before the age of 15 years. Male-to-male sexual behaviour was reported by just under 10% of boys. Condom use was low although varied by partner type. There were high rates of forced sex, and 75.5% of respondents reported police harassment.

Conclusions

Street-based adolescents in Ukraine are at significant risk of contracting HIV due to involvement in injecting drug use and unprotected sex in personal and commercial exchanges, including male-to-male sex. This group initiates risk behaviours at early ages, and does not appear to have good access to prevention and other health services.

AIDS in Latin America: assessing the current status of the epidemic and the ongoing response

BACKGROUND

This article provides a summary of the current status of the HIV/AIDS epidemic in Latin America, as well as an outline of the diverse responses to it.

METHODS

A search of international databases (Pubmed and ISI-Web of Science), regional databases (Scielo and Lilacs), regional and national documents and UNAIDS reports. Data are presented according to subregion.

RESULTS

In Mexico HIV remains concentrated among urban men who have sex with men (MSM), and has been growing among injecting drug users (IDU) and in rural areas in relation to migration. An increasing proportion of women among those affected is observed in all countries in Central America, the most affected region, as well as increasing the impact on other vulnerable groups, such as indigenous populations. The Andean Countries have urban epidemics concentrated among MSM. In Peru, non-traditional vulnerable populations were identified. In the Southern Cone heterosexual transmission became more relevant, probably in connection with IDU epidemics and is increasingly affecting lower income groups. Incidence rates have been declining since 2002 in Brazil, the first country to guarantee free, universal access to antiretrovirals, where one-third of drug-naïve patients are still initiating treatment at an advanced stage. Generally, access to treatment has improved as a result of support from the Global Fund and other initiatives, but there are concerns regarding coverage, equity and sustainability.

CONCLUSIONS

HIV is still concentrated among MSM in Latin America. Non-traditional vulnerable groups such as migrants and lower income populations, usually considered part of the general population, deserve attention. Programmes confronting sexual exclusion are still needed. Access to treatment has improved over time, but inequalities persist.

HIV seroprevalence in street youth, St. Petersburg, Russia

BACKGROUND

Reliable data on HIV infection among Russian street youth are unavailable. The purpose of this study was to assess HIV seroprevalence among street youth in St Petersburg and to describe social, sexual, and behavioral characteristics associated with HIV infection.

METHODS

A cross-sectional assessment conducted during January-May 2006 included city-wide mapping of 41 street youth locations, random selection of 22 sites, rapid HIV testing for all consenting 15-19-year-old male and female street youth at these sites, and an interviewer-administered survey. Adjusted odds ratios (AOR) were calculated using logistic regression, accounting for intracluster homogeneity.

RESULTS

Of 313 participants, 117 (37.4%, 95% confidence interval 26.1-50.2%) were HIV infected. Subgroups with the highest seroprevalences included double orphans (64.3%), those with no place to live (68.1%), those previously diagnosed with a sexually transmitted infection (STI; 70.5%), those currently sharing needles (86.4%), and those currently using inhalants (60.5%) or injection drugs (78.6%), including Stadol (82.3%) or heroin (78.1%). Characteristics independently associated with HIV infection included injecting drugs (AOR 23.0), sharing needles (AOR 13.3), being a double or single orphan (AOR 3.3 and 1.8), having no place to live (AOR 2.4), and being diagnosed with a STI (AOR 2.1). Most HIV-infected street youth were sexually active (96.6%), had multiple partners (65.0%), and used condoms inconsistently (80.3%).

DISCUSSION

Street youth aged 15-19 years in St Petersburg, Russia, have an extraordinarily high HIV seroprevalence. In street youth who are injection drug users, HIV seroprevalence is the highest ever reported for eastern Europe and is among the highest in the world.

The global epidemiology of HIV/AIDS

HIV infected nearly 5 million and killed more than 3 million people in 2005. Whereas traditional epidemics have been limited to high-risk populations, in many regions, it has generalized to the at-large population, with heterosexual sex being the predominant source of transmission. The virus has hit sub-Saharan Africa the hardest, although major epidemics are now transpiring in Asia, Eastern Europe, and the Caribbean. The United Nations and World Health Organization have produced targeted prevention strategies to control the pandemic that focus on comprehensive prevention activities and universal access to care.