JOURNAL OF ADOLESCEW
MARY
GOULART,
F.N.P.,
M.S.N.,
AND
SCOTT
Larkin Street Youth Center (LSYC) is a multidisciplinary sewice center for homeless youth in San Francisco. ‘IThis article describes the strategies developed by the medical clinic at LSYC for the prevention of human irilmunodeficiency virus infection. KBY WORDS:
Adolescents Homeless youth Human immunodeficiency Health care
virus
Many of us who work with homeless youth are attempting to find successful interventions to prevent the spread of human immunodeficiency visu:$(HIV) infection. This is often a frustrating and difficult task. The high-risk behaviors of runaway and homeless youth coupled with limittid practical HIV information place them at‘greater risk for HIV infection. In addition, many homeless youths have a colnstellation of other problems, such as substance abuse, histories of physical and/or sexual nbuse, low selfesteem, depression, suicidal behaviors, sexual identity formation problems, and mistrust of adults. Eecause of these serious behavioral and emotional problems, there are greater barriers to the d.evelopment of healthier and safer behaviors. Adolescents in general and street you;h specifically are in a time of life characterized by many developmental changes, turmoil, anal experimentation. Their focus is on thr: present, on survival, and not on the future, and they feel invulnerable.
From the Larkin Street Youih Center, San Francisco, Califirnia. Address reprint requests ia: Mary Goulart, F. N. P., M.S. N., Medical Director, Larkin Street Youik Center, 1044 Larkirr St., Surf Fran:isco, CA 94109. Mmwript accepted Novemb 20, 1990.
8 Society for Adoksmnt
MADOVER,
of
Ph.D.
For the majority of youths, acquired immunodeficiency syndrome (AIDS) is not perceived as a personal threat. In 1987, four pan& of you,*!-,; in Washington, D.C., discussed adoiescent attitudes on sexuality and sexual behavior:> as they related to AIDS (a). Five major themes emerged: 1) Youth are not changing their sexual behaviolj; 2) abstinence was rejected universally; 3) youths were skeptical about monogamy; 4) they were ambivalent about condom use; and 5) even though they had information about the transmission of the virus, they did not gen?craSlyperceive a risk of becoming infected themselves. Research has sEown that adolescents nave made little behavioral change since the AIDS epidemic began. Strunin and Mingson (2) found that 70% of 860 randomly selected adolescents, aged 16-19 years, were sexual+ active. Over 50% did not worry about S. Only 15% made any changes in sexual behavior because of AIDS. In S988, DiClemente, Zorn, and Temoshok (unpublished obs?rvations) r:*ported a lack of knowledge about AIDS anzor.ig San Francisco adolescents. Only 60% were awr,re that condom use might prevent transmission of HIV, and about 33% thought that one could catch AIDS by shaking hands with 0%touching someone who was infected. This article focuses on prevention as well as the interventions employed by the medic& clinic at Larkin Street Youth Center (LSYC:) with HIV-infected youth and screened youth.
l%gram Description LSYC is a multidisciplinary center for homeless
youths. The medical clinic at LSYC is dircrcted by a nurse practitioner and provides primary medical care to ho*meless/runaway youth in San Francisco.
Medicine, 1991
Published by Elsevier Science Publishing Co., IK., 655 Avenw
KEALTH 1991;12:573-575
the Americas, New York, NY l(lc10
573 1054-139x191/$3.50
574
GOLJLART AND MADOVER
It is funded through the San Francisco Department of public Health and is currently one of the few confidential HIV-testing sites in California for Street youth. There are a variety of medical services and HIVprevention strategies offered by the different professionals of the center. For example, the outreach team walks the streets where homeless youth congregate, dispenshg condoms and bleach and discussing HIV ~~formadon. In the drop-in center, an HIV questionfiaire is a useful tool for evaluating a youths level ot understanding about HIV terminology, mutes of transmission, high-risk behaviors, prevention siysregieo, HIV testing, HIV-incubation periods, and HIV-test results and their meaning. All questionnaires are reviewed with a staff person to ensure that youth understand the facts of HIV. In addition, a weekly staff HIV-prevention group meeting is held in the medical clinic. There is easy access to HIVrelated posters and pamphlets, as well as condoms and bleach, at the clinic and adjoining drop-in center. The nurse practitioner is responsible for the preand posttest counseling appointments for LSYC youth. At least two pretest counseling sessions are offered by the nurse practitioner. Before the HIV test, each youth reads and signs two consent forms that review for the youth all of the vital pretest information. After the test, the youth has an a! pointment in 2 weeks time to go over the test results. During this period, the youth receives psychosocial support. The klurse practitioner is tkle anly person who has access to the coded test results. A positive test result can be disclosed to other staff members only by the youth or after the youth has signed a consent form authorizing the release of HIV-status information to B cific staff persons. The nurse practitioner encourages all youths to discuss their HIV status with a trusted adult staff member at LSYC. Doing so ensures additional support and reinforces an ac-urate interpretation of the HIV-test results, For those youth who are HIV infected, the rtdrse pra&tioner follows a standard protocol for followup medical care and treatment; Once a---youth signs the consent-for-release form, the HIV clinical team meets and a treatment plan is developed, The multidiscipIinary HIV clinical team meets bimonthly and is facilitated by the nurse practitioner. Imluded in the team are the program director, clinical psychologist, clinical coordina!or, substance abuse coor.linator, outreach worker, and a &Op-in COUI~OFT. k!flare trained in HIV-& ted issues pAOr to their in;rolvement on the team. Any information
JOURNAL OF ADOLESCENT HEALTri x cd. 12, No. 7
discussed by the HIV-clinical team remains confidential. The team not only discusses the cases of HIV-infected youths, but also gives attention to the needs of HIV-negative youths1 Team members also discuss strategies to encourage some high-risk youths to agree to testing and to take steps to prevent the spread of HIV. The clinical psychologist collaborates with the nurse practitioner in regard to HIV test@ and the education and counseling of youth. Education includes instruction in safe sex practices and safe needle-use techniques. HIV-infected youths meet with thlp clinical psychologist, the nurse practitioner, a ca:e manager, or other center staft members for courrsellr~~~as needed. On ;dk?ni# .ng weeks, the clinical psychologist facilitates the HIV support group for staff. Madover (unpublished observations) found th,?t psychotherapists who work with persons with P:.rDS/ARC have their own concerns that are important to address, for example, fears of their owrl mortality, fears of contagimi, and homophobia, as well as feelings of guilt, ;Icspair, and anger. The support group is a place for staff members to receive and give support to each other in helping to cope with WV-related issues. HIV disease in young people bings an additional Iaver of in+sity to working w:th an already challenging population. This i- a time when staff membe:-s can talk in a confidential setting about their own feelings regarding clients. This support group has b:en an extremely useful resource that helps the staff work more effectively with HIV-infected youth ;i:ind redrrces burnout. All members make a commitment to the group. One of the most important commitments for the group is maintaining the confidentiality of shared information. This is the only way to build safety and trust within thle group, Individual clients are not discussed, because not all members of the group are on the MI’Vclinical team. The focus is on professional and personal issues. Central themes include increased codependent feelings, feelings of failure when no adequate solutions are found for HIVinfected youth, feelings of anger, bes$air, and @lt, issues related to staff members’ own sexual behaviors, and fears of one’s own mort~Jity_ These issues tend to not be unique and can be shared and processed within the group. Learriing to give and receive support with a staff merriber can appear to be easy, but in fact call be quite challen@ng. Monthly HIV eciucational sessions are offered to all LSYC staff :w~2,:lezs. For example, presenters might discuss death and dying, neurological com-
November
1991
plications of HIV disease, and gaykbianksexual issues.
Conclusion There is controversy about whether to do HIV testing at youth centers. We have found this to be, for the most part, an appropriate means of intervention for homeless youth, especially in an AIDS epicenter where these youth are at serious risk for HIV infection. A center that offers community-based, primary health care services by a sensitive and concerned staff is probably the most accessible and acceptable site fey these youth to receive confidential HIV test-
AIDS PREVENTl\3N
575
ing and counseling. These activities must be combined with other comprehensive medical a .Id social services. Thus, it is important that such s trvices be provided by a clinical team that represents mul$‘pJre grofessionai disciplines. Team members working tosether can develop and implement the best interventions for any specific client.
References 1. Haffner DW. AIDS and adolescents: [he time for prevennon is now. Washington, DC: Ce&er for Population Options, 1987.
Hillgson R. AIDS and adolescents: Knowledge, beliefs, attitudes and behavlars. Pediatrics 1987;79:825-8.
2. Strunin C,
MARY
GOULART,
F.N.P.,
M.S.N.,
AND
SCOTT
Larkin Street Youth Center (LSYC) is a multidisciplinary sewice center for homeless youth in San Francisco. ‘IThis article describes the strategies developed by the medical clinic at LSYC for the prevention of human irilmunodeficiency virus infection. KBY WORDS:
Adolescents Homeless youth Human immunodeficiency Health care
virus
Many of us who work with homeless youth are attempting to find successful interventions to prevent the spread of human immunodeficiency visu:$(HIV) infection. This is often a frustrating and difficult task. The high-risk behaviors of runaway and homeless youth coupled with limittid practical HIV information place them at‘greater risk for HIV infection. In addition, many homeless youths have a colnstellation of other problems, such as substance abuse, histories of physical and/or sexual nbuse, low selfesteem, depression, suicidal behaviors, sexual identity formation problems, and mistrust of adults. Eecause of these serious behavioral and emotional problems, there are greater barriers to the d.evelopment of healthier and safer behaviors. Adolescents in general and street you;h specifically are in a time of life characterized by many developmental changes, turmoil, anal experimentation. Their focus is on thr: present, on survival, and not on the future, and they feel invulnerable.
From the Larkin Street Youih Center, San Francisco, Califirnia. Address reprint requests ia: Mary Goulart, F. N. P., M.S. N., Medical Director, Larkin Street Youik Center, 1044 Larkirr St., Surf Fran:isco, CA 94109. Mmwript accepted Novemb 20, 1990.
8 Society for Adoksmnt
MADOVER,
of
Ph.D.
For the majority of youths, acquired immunodeficiency syndrome (AIDS) is not perceived as a personal threat. In 1987, four pan& of you,*!-,; in Washington, D.C., discussed adoiescent attitudes on sexuality and sexual behavior:> as they related to AIDS (a). Five major themes emerged: 1) Youth are not changing their sexual behaviolj; 2) abstinence was rejected universally; 3) youths were skeptical about monogamy; 4) they were ambivalent about condom use; and 5) even though they had information about the transmission of the virus, they did not gen?craSlyperceive a risk of becoming infected themselves. Research has sEown that adolescents nave made little behavioral change since the AIDS epidemic began. Strunin and Mingson (2) found that 70% of 860 randomly selected adolescents, aged 16-19 years, were sexual+ active. Over 50% did not worry about S. Only 15% made any changes in sexual behavior because of AIDS. In S988, DiClemente, Zorn, and Temoshok (unpublished obs?rvations) r:*ported a lack of knowledge about AIDS anzor.ig San Francisco adolescents. Only 60% were awr,re that condom use might prevent transmission of HIV, and about 33% thought that one could catch AIDS by shaking hands with 0%touching someone who was infected. This article focuses on prevention as well as the interventions employed by the medic& clinic at Larkin Street Youth Center (LSYC:) with HIV-infected youth and screened youth.
l%gram Description LSYC is a multidisciplinary center for homeless
youths. The medical clinic at LSYC is dircrcted by a nurse practitioner and provides primary medical care to ho*meless/runaway youth in San Francisco.
Medicine, 1991
Published by Elsevier Science Publishing Co., IK., 655 Avenw
KEALTH 1991;12:573-575
the Americas, New York, NY l(lc10
573 1054-139x191/$3.50
574
GOLJLART AND MADOVER
It is funded through the San Francisco Department of public Health and is currently one of the few confidential HIV-testing sites in California for Street youth. There are a variety of medical services and HIVprevention strategies offered by the different professionals of the center. For example, the outreach team walks the streets where homeless youth congregate, dispenshg condoms and bleach and discussing HIV ~~formadon. In the drop-in center, an HIV questionfiaire is a useful tool for evaluating a youths level ot understanding about HIV terminology, mutes of transmission, high-risk behaviors, prevention siysregieo, HIV testing, HIV-incubation periods, and HIV-test results and their meaning. All questionnaires are reviewed with a staff person to ensure that youth understand the facts of HIV. In addition, a weekly staff HIV-prevention group meeting is held in the medical clinic. There is easy access to HIVrelated posters and pamphlets, as well as condoms and bleach, at the clinic and adjoining drop-in center. The nurse practitioner is responsible for the preand posttest counseling appointments for LSYC youth. At least two pretest counseling sessions are offered by the nurse practitioner. Before the HIV test, each youth reads and signs two consent forms that review for the youth all of the vital pretest information. After the test, the youth has an a! pointment in 2 weeks time to go over the test results. During this period, the youth receives psychosocial support. The klurse practitioner is tkle anly person who has access to the coded test results. A positive test result can be disclosed to other staff members only by the youth or after the youth has signed a consent form authorizing the release of HIV-status information to B cific staff persons. The nurse practitioner encourages all youths to discuss their HIV status with a trusted adult staff member at LSYC. Doing so ensures additional support and reinforces an ac-urate interpretation of the HIV-test results, For those youth who are HIV infected, the rtdrse pra&tioner follows a standard protocol for followup medical care and treatment; Once a---youth signs the consent-for-release form, the HIV clinical team meets and a treatment plan is developed, The multidiscipIinary HIV clinical team meets bimonthly and is facilitated by the nurse practitioner. Imluded in the team are the program director, clinical psychologist, clinical coordina!or, substance abuse coor.linator, outreach worker, and a &Op-in COUI~OFT. k!flare trained in HIV-& ted issues pAOr to their in;rolvement on the team. Any information
JOURNAL OF ADOLESCENT HEALTri x cd. 12, No. 7
discussed by the HIV-clinical team remains confidential. The team not only discusses the cases of HIV-infected youths, but also gives attention to the needs of HIV-negative youths1 Team members also discuss strategies to encourage some high-risk youths to agree to testing and to take steps to prevent the spread of HIV. The clinical psychologist collaborates with the nurse practitioner in regard to HIV test@ and the education and counseling of youth. Education includes instruction in safe sex practices and safe needle-use techniques. HIV-infected youths meet with thlp clinical psychologist, the nurse practitioner, a ca:e manager, or other center staft members for courrsellr~~~as needed. On ;dk?ni# .ng weeks, the clinical psychologist facilitates the HIV support group for staff. Madover (unpublished observations) found th,?t psychotherapists who work with persons with P:.rDS/ARC have their own concerns that are important to address, for example, fears of their owrl mortality, fears of contagimi, and homophobia, as well as feelings of guilt, ;Icspair, and anger. The support group is a place for staff members to receive and give support to each other in helping to cope with WV-related issues. HIV disease in young people bings an additional Iaver of in+sity to working w:th an already challenging population. This i- a time when staff membe:-s can talk in a confidential setting about their own feelings regarding clients. This support group has b:en an extremely useful resource that helps the staff work more effectively with HIV-infected youth ;i:ind redrrces burnout. All members make a commitment to the group. One of the most important commitments for the group is maintaining the confidentiality of shared information. This is the only way to build safety and trust within thle group, Individual clients are not discussed, because not all members of the group are on the MI’Vclinical team. The focus is on professional and personal issues. Central themes include increased codependent feelings, feelings of failure when no adequate solutions are found for HIVinfected youth, feelings of anger, bes$air, and @lt, issues related to staff members’ own sexual behaviors, and fears of one’s own mort~Jity_ These issues tend to not be unique and can be shared and processed within the group. Learriing to give and receive support with a staff merriber can appear to be easy, but in fact call be quite challen@ng. Monthly HIV eciucational sessions are offered to all LSYC staff :w~2,:lezs. For example, presenters might discuss death and dying, neurological com-
November
1991
plications of HIV disease, and gaykbianksexual issues.
Conclusion There is controversy about whether to do HIV testing at youth centers. We have found this to be, for the most part, an appropriate means of intervention for homeless youth, especially in an AIDS epicenter where these youth are at serious risk for HIV infection. A center that offers community-based, primary health care services by a sensitive and concerned staff is probably the most accessible and acceptable site fey these youth to receive confidential HIV test-
AIDS PREVENTl\3N
575
ing and counseling. These activities must be combined with other comprehensive medical a .Id social services. Thus, it is important that such s trvices be provided by a clinical team that represents mul$‘pJre grofessionai disciplines. Team members working tosether can develop and implement the best interventions for any specific client.
References 1. Haffner DW. AIDS and adolescents: [he time for prevennon is now. Washington, DC: Ce&er for Population Options, 1987.
Hillgson R. AIDS and adolescents: Knowledge, beliefs, attitudes and behavlars. Pediatrics 1987;79:825-8.
2. Strunin C,
