REVIEW ARTICLE
HIV Prevention in Street Youth
ANDREW S. WALTERS, Ph.D., M.P.H.
Homeless adolescents have remained an underserved
population throughout the human immunodeficiency/
acquired immune deficiency syndrome epidemic. This
article reviews the recent literature investigating human
immunodeficiency virus (HIV) risk behavior among
street youth. Prevalence rates of both adolescent home-
lessness and HIV seropositivity are unknown. However,
data from a number of samples document a high preva-
lence of HIV risk behavior, sexually transmitted dis-
eases, and alcohol/drug use among homeless adolescents.
A number of individual and social factors, often associ-
ated with street survival, propel adolescents toward high-
risk behavior. For some adolescents, testing HIV positive
is perceived as advantageous in the procurement of basic
needs such as food and shelter. HIV risk-reduction
interventions must take into consideration the cause of
homelessness, access to and participation in shelter ser-
vices, and individual factors (such as the effects of sexual
orientation and ethnicity) that frequently have not been
systematically included in previous research. HIV risk
for many homeless adolescents stems directly from their
state of homelessness. National policies and funding
are needed to address the health needs of these youth.
© Society for Adolescent Medicine, 1999
KEY WORDS
:
HIV
Adolescents
Homelessness
Street youth
Infection with human immunodeficiency virus (HIV)
and its progression to a diagnosis of acquired immu-
nodeficiency syndrome (AIDS) pose a number of
risks at the individual and public health levels. In
1996, AIDS became the leading cause of death among
all Americans aged 25–44 years (1) and is unique
among major causes of mortality because of the
overrepresentation of adolescents and young adults,
its link to behavioral factors leading to infection, and
its irreversibility (2–7). In addition, the social stigma
attached to HIV disease has produced a number of
negative consequences (e.g., discrimination) that fre-
quently are not associated with other diseases.
The actual seroprevalence of HIV positivity in the
United States is unknown. Epidemiologic studies
estimate that approximately 40,000 new seroconver-
sions occur in the United States each year (8,9).
Seroprevalence estimates for the United States range
from the earlier and most frequently cited figure of
1.5 million (10) to more recent and mathematically
modeled estimates of 650,000–700,000 (8,11). From
1981 through June 1998, 665,357 cases of AIDS were
reported in the United States, and of these, 401,028
persons have died (1).
Individuals are not uniformly at risk for HIV.
Because HIV is transmitted sexually or through
contamination with infected blood or body fluids,
seroprevalence rates have been shown to recede
following reduction of high-risk behavior. For exam-
ple, research has shown that studies of men who
have sex with other men (i.e., the group comprising
the majority of HIV cases in developed countries)
substantially reduced HIV seroconversion by imple-
menting multi-leveled interventions and maintain-
ing effective risk-reduction strategies (12,13). Com-
munity-based interventions for injection drug users
have also reported moderate to large for reductions
in HIV seroconversion (14). Nevertheless, HIV infec-
tion continues to affect disproportionately the urban
poor, members of ethnic minority groups, and youth.
Thus, although behavior change programs have been
successful for some high-risk populations, others,
From the Department of Psychology, Hobart and William Smith
Colleges, Geneva, New York, USA.
Address reprint requests to: Andrew S. Walters, Department of
Psychology, Hobart and William Smith Colleges, Geneva, NY 14456.
Manuscript accepted July 8, 1998.
JOURNAL OF ADOLESCENT HEALTH 1999;25:187–198
© Society for Adolescent Medicine, 1999
Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/99/$–see front matter
PII S1054-139X(98)00155-4