Sexual risk behavior and condom use among street youth in Hollywood

Because much sexual risk-taking occurs during adolescence and young adulthood,(1) many programs designed to prevent the spread of the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) are oriented toward teenagers and adults in their early 20s. Prevention programs have specifically targeted youth in high-risk situations, including homeless youth, runaways and youth supporting themselves through the street economy of drugs, prostitution and crime.

Although street youth are a priority for HIV prevention programs, in part because of concern that these youth may link the general population to the HIV epidemic, reliable data about the characteristics and behavior of high-risk youth are scarce. Representative surveys, such as the National Survey of Family Growth and the National Survey of Adolescent Males, provide information about youth living in households, and the Youth Risk Behavior Survey contains data about those attending high school. However, representative data on high-risk youth are more difficult to obtain because their lifestyle excludes them from sampling flames usually used to obtain probability samples.

Surveys conducted of this population are usually drawn from homeless shelters or clinics.(2) Obtaining meaningful data from interviews with these youth requires special sensitivity. Research in Los Angeles has shown that runaway youth who become acculturated to the streets generally adopt one of three dominant street subcultures--hustlers, druggies and rebels.(3) Members within these groups share common values, attitudes and beliefs, use distinctive language, have unique dress codes and clearly defined hang-outs, and use different survival strategies. These factors, as well as the emotional responses to life on the streets, must be considered when studying the behaviors of these youth.

The data reported in this article are from a survey of youth who attended drop-in centers in Hollywood, Calif., in 1990-1991. The survey was conducted by the Department of Adolescent Medicine at Children's Hospital of Los Angeles, with the collaboration of a coalition of agencies that provide services to street youth in the area. These services include overnight shelter, day programs and street outreach. This study examines the prevalence of sexual risk behavior and correlates of condom use in this population. The data can be used in planning interventions to provide more effective support services and reduce risky behavior among street youth.

METHODOLOGY

The survey was conducted at five drop-in centers in the Hollywood area: Covenant House, Gay and Lesbian Community Services Center, Los Angeles Youth Network, Teen Canteen and The Way In. These agencies provide services for youth aged 12-23, which is the age range used by the Division of Adolescent Medicine of Children's Hospital when providing adolescent services. Among the agencies participating in this survey, the Los Angeles Youth Network and the Teen Canteen serve primarily young people who are trying to move off the streets. Youth aged 18 and older tend to prefer the Teen Canteen, while those aged 12-17 frequent the Los Angeles Youth Network. Covenant House and The Way In serve young people who have been on the street longer and are more acculturated to it; Covenant House primarily serves older youth and The Way In provides services to younger teenagers. The Gay and Lesbian Community Services Center serves gay and lesbian teenagers and adults of all ages.

To obtain the most representative sample possible of all youth using the centers, we based the number interviewed in each center on the number of clients who used that center during the previous three months, according to program records. After determining the number of clients to be interviewed in each center, we interviewed all youth aged 13-23 who came to each center until the quotas were filled; interviewing occurred during a 21-month period from 1990 to 1991. An $8.00 fastfood voucher was provided as an incentive to participate in the survey. Among 641 youth approached for interviews, 28 refused and three interviews were not completed; this yielded an overall response rate of 95%.

In this article, we present the estimated proportions of survey respondents who engaged in risky behaviors. We hypothesized that men and women would have different experiences, so we analyzed them separately. Bivariate statistical significance was determined using one-way analysis of variance. We conducted a multivariate analysis of condom use among respondents by using multiple logistic regression analysis with stepwise methods to reduce the models; only variables significant at the p

RESULTS

As Table 1 shows, 73% of respondents interviewed were male. Female respondents tended to be younger than male respondents: About one-half of the women and one-fourth of the men were aged 18 or younger. On average, the young men had been away from home longer than had the young women; 53% of men and 32% of women had left home at least two years prior to the survey. Many respondents reported not having had a stable living situation for some time: Six months or longer had elapsed for 43% of respondents since they had spent at least three months in the same house, apartment or room, and 35% had been living on the streets or in shelters during the past three months.

As Table 2 shows, nearly all respondents (97% of men and 96% of women) had had sex, many before age 15 (69% of men and 56% of women). More than half of the young women had been pregnant. The reported frequency of risk factors for HIV and other STDs was high. One-half of the young men and one-third of the young women had engaged in "survival sex," defined as exchanging sex for anything needed, including money, food, clothes, a place to stay or drugs. Drug use was common among respondents: Fifty-one percent of the men and 42% of the women reported having used cocaine; 46% of men and 35% of women reported having used crack; and 25% of men and 15% of women had injected illegal drugs at some time in their lives. Many respondents (57% of men and 38% of women) reported having had sex when buying drugs.

TABLE 1. PERCENTAGE DISTRIBUTION OF HIGH-RISK YOUTH, BY SELECTED` CHARACTERISTICS, ACCORDING TO GENDER, HOLLYWOOD, 1990-1991` ` Characteristic Total Male Female` (N=610) (N=446) (N=164)` ` Race or Ethnicity` White 42.1 44.5 35.6` Black 22.6 21.9 24.5` Hispanic 14.0 12.6 17.8` Other 21.3 21.0 22.1` ` Age (in years)` 13-16 11.6 5.2 29.3` 17-18 23.8 20.6 32.3` 19-20 33.6 37.2 23.8` 21-23 31.0 37.0 14.6` ` Time since left home` =2 years 47.2 52.9 31.7` ` Time since stable` residence(*)` =6 months 42.6 43.9 39.1` ` Time lived in street or` shelter(**)`

Regarding STDs, 67% of respondents had been tested for HIV, and 5% of the men said they had been diagnosed as HIV-positive. Nearly one-third of the youth interviewed said they had been told by a health care provider that they had an STD. Among men, 17% identified themselves as homosexual and 12% as bisexual. Among the women, 6% identified themselves as homosexual and 11% as bisexual.

Despite the prevalence of risk behaviors, only a minority of these street youth felt they had a medium or greater chance of having or becoming infected with HIV. About one-fourth described themselves as quite or extremely worried about AIDS. Although consistent condom use may reduce the risk of HIV infection, only 45% of men and 30% of women reported using a condom the last time they had had sex.

The factors related to condom use differ for men and women. Table 3 (page 24) shows that men who had been tested for HIV and those who were diagnosed as HIV-positive were significantly more likely than other men to report using condoms. Among HIV-positive men, 78% reported using a condom the last time they had had sex, compared with 43% of HIV-negative men or men who had not been tested. Young men who had finished the 10th grade or higher and those who identified themselves as homosexual were more likely than other men to use condoms. However, men who said they had a medium or greater chance of having HIV were less likely than other men to use condoms.

Among women, significantly higher rates of condom use were associated with having sex in exchange for money, food or lodging, and with having survival sex (which also includes exchanging sex for drugs or other items needed). The youngest women (aged 13-14) were most likely to use condoms. Women who had ever been pregnant had low rates of condom use at last sex, probably indicating that those who did not use condoms in the past (and became pregnant) may be less likely to be using condoms currently.

Results of the multiple logistic regression analysis, presented in Table 4 (page 25), indicate which variables remained significantly related to condom use when all other factors were controlled. All variables listed are significant at the p

TABLE 2. PERCENTAGE OF RESPONDENTS WITH SELECTED BEHAVIORAL CHARACTERISTICS` AND STANDARD ERRORS, BY GENDER` ` Characteristic Male Female` % SE % SE` ` Ever had sex 96.9 0.8 96.3 1.5` Had sex before age 15(*) 68.7 2.2 55.7 4.0` Had been pregnant na na 59.8 3.8` Had children(*) 14.5 1.7 22.6 3.3` Had sex for money,` food or lodging(*) 40.9 2.3 29.3 0.6` Had survival sex(*)(**) 51.5 2.4 32.3 0.7` Used cocaine 50.5 2.4 42.1 3.9` Used crack(*) 45.6 2.4 35.4 3.7` Had sex when selling drugs(*) 17.3 1.8 2.4 1.2` Had sex when buying drugs(*) 57.4 2.3 38.4 3.8` Injected illegal drugs(*) 25.2 2.1 14.6 2.8` Was tested for HIV 66.9 2.2 66.5 3.7` Was diagnosed HIV-positive(*) 5.2 1.0 0.0 0.0` Had an STD 29.6 2.2 33.5 3.7` Was currently in school(*) 8.5 1.3 17.7 3.0` Completed =>10th grade(*) 80.9 1.9 67.7 3.7` Identified as heterosexual(*) 67.8 2.2 81.1 3.1` Identified as homosexual(*) 16.9 1.8 6.1 1.9` Identified as bisexual 11.7 1.5 11.0 2.4` Believed had medium or greater` chance of having HIV 17.5 1.9 12.3 2.6` Believed had medium or greater` chance of getting HIV(*) 23.4 2.1 13.5 2.7` Was extremely worried` about AIDS 24.7 2.1 26.8 3.5` Used condom at last sex(*) 45.0 2.4 30.4 3.7` ` * Difference between males and females is significant at p

Among women, younger age was strongly related to condom use: For each additional year of age, the odds of using condoms decreased by a factor of 0.71. Having been pregnant in the past, perhaps indicating a tendency not to use condoms consistently, was also strongly related to not using condoms at last sex. Having sex in exchange for money, food or lodging was strongly associated with greater condom use (odds ratio 3.16), possibly indicating that women who put themselves at risk of STDs are trying to protect themselves by using condoms.

DISCUSSION

A relatively small proportion of AIDS cases have come from adolescent age-groups; one study found that only 1% of AIDS cases were from the 13-21 age-group, with at least half of these youth acquiring HIV through sexual contact.(5) However, HIV infection has been found among adolescents undergoing antibody tests, such as military recruits (0.3 per 1,000 were infected)(6) and Job Corps applicants (3.6 per 1,000).(7) Because AIDS symptoms may not occur until 8-11 years after HIV infection,(8) the small number of reported AIDS cases among adolescents does not accurately reflect the epidemic's impact on this age-group; persons who developed AIDS as adults may have been infected during adolescence.

Nearly all of the youth (96%) interviewed in this survey had had sex. The level of sexual experience reported by the respondents in this survey contrasts with that reported by young persons interviewed in surveys of the general adolescent population. In household-based surveys of 15-19-year-old respondents, 45-60% were sexually experienced and 60-80% were sexually active by age 19.(9) In surveys of high school students, 50-60% of 9th-12th graders(10) and 70-80% of college students(11) reported having had sex.

The rates of condom use reported by respondents in our study are similar to rates of other youth.(12) None of the rates found in surveys reaches the national health promotion and disease prevention goal for the year 2000, which calls for 60% of women and 75% of men aged 15-19 years old who are sexually active to have used condoms at their last intercourse.(13)

Our results confirm the results of earlier studies of homeless or runaway youth: Sexual activity is high, but condom use is relatively low.(14) As did a previous study of youth in New York City, our study found that young men were more likely than young women to have had sex in exchange for money or drugs.(15) Because young people who use drop-in services include many who never use overnight shelters, our sample contains a broader range of high-risk youth than many previous studies, which have taken samples from homeless shelters or other institutional settings. Unlike youth who attend drop-in centers while living in the streets, shelter residents are seeking a stable environment (at least for the night) and must be willing to abide by certain rules, such as no drug or alcohol use in the shelter.

Since the factors related to condom use differed for men and for women, intervention messages should have a different focus. Among the women in our study, the youngest respondents were more likely to have used condoms at their last sexual encounter. This may indicate a cohort effect, in which more recent cohorts have adopted condoms at a greater rate, or it may indicate that because younger women have not been on the street as long, they have had fewer partners in fewer situations, and thus have been able to use condoms more consistently. Women who had been pregnant were less likely to have used condoms at their last sexual encounter; thus, condom use should be promoted among women for pregnancy prevention as well as disease prevention.

Programs to encourage high-risk youth to adopt healthier behavior must consider a number of factors that can affect an individual's ability to change. Some of these factors, developed by the AIDS Community Demonstration Projects, which are funded by the Centers for Disease Control and Prevention, include acknowledging personal risk of HIV infection from unprotected sex, understanding the potential benefits of condom use, perceiving that others in the community are using condoms, feeling confident about using condoms consistently and acquiring the interpersonal skills needed to adopt consistent condom use.(16)

Individuals may be placed on a continuum regarding their ability to adopt healthier behavior, from those who are not even thinking about behavior change to those who are thinking about change, those who are ready to change, those who have begun to change their behavior and those who are maintaining these changes. To plan more effective interventions and to determine which factors promote moving from one stage to the next, programs must determine which stage of behavior potential clients have reached. While the survey we presented was not designed to measure these stages of change, our results suggest that many individuals are thinking about their vulnerability to disease.

TABLE 3. PERCENTAGE OF RESPONDENTS WHO USED A CONDOM AT THEIR LAST SEXUAL` ENCOUNTER AND STANDARD ERRORS, BY GENDER, ACCORDING TO SELECTED CHARACTERIS` ` Characteristic Males Females` N % SE N % SE` ` Had sex when` selling drugs` Yes 77 36.4 5.5 (**) (**) (**)` No 354 46.9 2.7 154 29.9 3.7` ` Had sex for` money, food or` lodging` Yes 182 47.3 3.7 48 43.8(*) 7.2` No 249 43.4 3.1 110 24.5 4.1` ` Had survival sex` Yes 229 44.5 3.3 53 43.4(*) 6.9` No 202 45.5 3.5 105 23.8 4.2` ` Was tested for` HIV` Yes 290 50.0(*) 2.9 107 32.7 4.6` No 140 34.3 4.0 51 25.5 6.2` ` Was diagnosed` HIV-positive` Yes 23 78.3(*) 8.8 (**) (**) (**)` No 408 43.1 2.5 158 30.4 3.7` ` Was currently` in school` Yes 36 30.6 7.8 24 29.2 9.5` No 395 46.3 2.5 134 30.6 4.0` ` Completed 10th` grade or higher` Yes 349 49.3(*) 2.7 109 25.7 4.2` No 82 26.8 4.9 49 40.8 7.1` ` Identified as` heterosexual` Yes 290 42.1 2.9 128 28.1 4.0` No 140 50.7 4.2 30 40.0 9.1` ` Identified as` homosexual` Yes 72 58.3(*) 5.9 (**) (**) (**)` No 358 42.2 2.6 148 30.4 3.8` ` Identified as` bisexual` Yes 52 42.3 6.9 (**) (**) (**)` No 378 45.2 2.6 140 27.9 3.8` ` Believed had` medium or` greater chance` of having HIV` Yes 72 31.9(*) 5.5 20 30.0 10.5` No 325 45.8 2.8 137 30.7 4.0` ` Age-group` 13-14 22 18.2 8.4 43 46.5(*) 7.7` 17-18 88 46.6 5.3 53 34.0 6.6` 19-20 158 48.1 4.0 38 18.4 6.4` 21-23 163 44.8 3.9 24 12.5 6.9` ` Left home 2 or` more years ago` Yes 236 45.8 3.2 52 19.2(*) 5.5` No 195 44.1 3.6 106 35.8 4.7` ` Had been pregnant` Yes na na na 98 20.4(*) 4.1` No na na na 60 46.7 6.5` ` * p

Our results are subject to a number of limitations. They are based on the reports of young persons attending drop-in centers; street youth who do not attend these centers may differ from those who do. A related study indicated that among 47 street youth approached in the Hollywood area, 25% had not visited a drop-in center in the past year.(17) This suggests that although our survey excludes a segment of high-risk youth, it includes most of the target population. Data collected by outreach programs indicate that persons who use drop-in centers are similar in age and sex to persons outreach workers see on the streets, but that they are less likely than street contacts to be black or Hispanic.(18)

TABLE 4. RESULTS OF LOGISTIC REGRESSION ANALYSIS SHOWING ODDS RATIO (AND 95` CONFIDENCE INTERVAL) FOR USING A CONDOM AT LAST SEX, BY GENDER AND` CHARACTERISTIC` ` Gender and Coefficient SE Odds ratio` characteristic` ` Males` Tested for HIV 0.65 0.22 1.91 (1.25-2.93)` Completed grade 10 or` higher 0.97 0.27 2.63 (1.53-4.50)` Intercept -1.44` ` Females` Age -0.35 0.10 0.71 (0.58-0.86)` Had been pregnant -1.31 0.40 0.27 (0.12-0.60)` Had sex for money,` food or lodging 1.15 0.42 3.16 (1.37-7.27)` Intercept 5.71`

Another limitation is that our sample came from a relatively limited area; street youth in Hollywood may not be representative of high-risk youth elsewhere. Further, since condom use rates are based on respondents' self-reports, they are subject to reporting errors.

By any standard, the street youth interviewed in this survey are at high risk of HIV infection and other STDs, as well as unplanned pregnancy. Many have additional risk related to drug use. Because of their life-style, these youth are difficult to reach for service delivery and for the data collection needed to evaluate and plan programs. Programs that seek to prevent the transmission of STDs among street youth through behavior change should address all of their needs, including food, shelter, drug treatment, medical care and reproductive health services, and must have the resources to help young people get off the streets and into more stable living environments.

REFERENCES

1. W. Cates, "Teenagers and Sexual Risk Taking: The Best of Times and the Worst of Times," Journal of Adolescent Health, 12:84-94, 1991.

2. G. L. Yates et al., "A Risk Profile Comparison of Runaway and Non-Runaway Youth," American Journal of Public Health, 78:820-821, 1988; S. T. Sugarman et al., "Acquired Immunodeficiency Syndrome and Adolescents: Knowledge, Attitudes, and Behaviors of Runaway and Homeless Youth," American Journal of Diseases in Children, 145: 431-435, 1991; and M. J. Rotheram-Borus and C. Koopman, "Sexual Risk Behaviors, AIDS Knowledge, and Beliefs About AIDS Among Runaways," American Journal of Public Health, 81:208-210, 1991.

3. S. R. LaFrance et al., "A Typology of Street Youth at Risk for HIV and Its Implications for Service Providers in Los Angeles, California," unpublished paper, Division of Adolescent Medicine, Children's Hospital of Los Angeles, 1993.

4. D. W. Hosmer, S. Taber and S. Lemeshow, "The Importance of Goodness of Fit of Logistic Regression Models: A Case Study," American Journal of Public Health, 81: 1630-1635, 1991.

5. S. H. Vermund et al., "Acquired lmmunodeficiency Syndrome in Adolescents: Case Surveillance Profiles in New York City and the Rest of the United States," American Journal of Diseases in Children, 143:1220-1225, 1989.

6. D. S. Burke et al., "Human Immunodeficiency Virus Infections in Teenagers: Seroprevalence Among Applicants for US Military Service," Journal of the American Medical Association, 263: 2074-2077, 1990.

7. M. E. St. Louis et al., "Human Immunodeficiency Virus Infection in Disadvantaged Adolescents," Journal of the American Medical Association, 266:2387-2391, 1991.

8. K. J. Lui, W. W. Darrow and G. W. Rutherford, "A Model-Based Estimate of the Mean Incubation Period for AIDS in Homosexual Men," Science, 240:1333-1335, 1988; and A. Munoz et al., "Acquired Immunodeficiency Syndrome (AIDS)-Free Time After Human Immunodeficiency Virus Type 1 (HIV-1) Seroconversion in Homosexual Men," American Journal of Epidemiology, 130:530-539, 1989.

9. J. R. Kahn, W. D. Kalsbeek and S. L. Hofferth, "National Estimates of Teenage Sexual Activity: Evaluating the Comparability of Three National Surveys," Demography: 25:189-204, 1988; S. L. Hofferth, J. R. Kahn and W. Baldwin, "Premarital Sexual Activity Among U. S. Teenage Women over the Past Three Decades," Family Planning Perspectives, 19:46-53, 1987; Centers for Disease Control (CDC), "Premarital Sexual Experience Among Adolescent Women--United States, 1970-1988," Morbidity and Mortality Weekly Report, 39:929-932, 1991; W. D. Mosher, "Contraceptive Practice in the United States, 1982-1988," Family Planning Perspectives, 22:198-205, 1990; and F. L. Sonenstein, J. H. Pleck and L. C. Ku, "Sexual Activity, Condom Use and AIDS Awareness Among Adolescent Males," Family Planning Perspectives, 21:152-158, 1989.

10. J. E. Anderson et al., "HIV/AIDS Knowledge and Sexual Behavior Among High School Students," Family Planning Perspectives, 22:248-255, 1990; and CDC, "Sexual Behavior Among High School Students--United States, 1990," Morbidity and Mortality Weekly Report, 40:885-888, 1991.

11. J. M. Reinisch et al., "High Risk Sexual Behavior Among Heterosexual Undergraduates at a Midwestern University," Family Planning Perspectives, 24:116-121 & 145, 1992; and N. E. MacDonald et al., "High Risk STD/HIV Behavior Among College Students," Journal of the American Medical Association, 263:3155-3159, 1990.

12. S. M. Kegeles, N. E. Adler and C. E. Irwin, "Sexually Active Adolescents and Condoms: Changes over One Year in Knowledge, Attitudes and Use," American Journal of Public Health, 78:460-461, 1988; W. D. Mosher, 1990, op. cit. (see reference 9); F. L. Sonenstein, J. H. Pleck and L. C. Ku, 1989, op. cit. (see reference 9); J. E. Anderson et al., 1990, op. cit. (see reference 10); and CDC, 1991, op. cit. (see reference 10).

13. U. S. Department of Health and Human Services, Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U. S. Government Printing Office, Washington, D. C., 1990.

14. G. L. Yates et al., 1988, op.cit. (see reference 2); S. T. Sugarman et al., 1991, op. cit. (see reference 2); and M. J. Rotheram-Borus and C. Koopman, 1991, op. cit. (see reference 2).

15. M. J. Rotheram-Borus et al., "Lifetime Sexual Behaviors Among Runaway Males and Females," Journal of Sex Research, 29:15-29, 1992.

16. Behavioral and Prevention Research Branch, National Center for Prevention Services, "What We Have Learned From the AIDS Community Demonstration Projects," CDC, Atlanta, June 15, 1992.

17. S. R. LaFrance, M. D. Kipke and J. N. Pennbridge, "AIDS Evaluation of Street Outreach Project (AESOP): Final Comprehensive Report--Street Outreach to Youth in High Risk Situations: Los Angeles County, California," report to CDC, Los Angeles Oct. 31, 1992.

18. Unpublished data from the Division of Adolescent Medicine, Children's Hospital of Los Angeles, 1992.

John E. Anderson is chief of the Behavioral Studies Section, Behavioral and Prevention Research Branch, Division of STD/HIV Prevention, National Center for Prevention Services, Centers for Disease Control and Prevention, Atlanta. Thomas E. Freese is project coordinator for the Division of Adolescent Medicine, Children's Hospital of Los Angeles. Julia N. Pennbridge is program officer for the California Wellness Foundation, Woodland Hills.

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