Three years after their detention, delinquent youth, irrespective of diagnostic group, had high prevalence rates of many HIV/STI sexual risk behaviors. One-quarter to one-half of youth reported engaging in unprotected vaginal sex at baseline and follow-up interviews. At baseline, over two-fifths of the sample reported engaging in sex while drunk or high, and almost two-thirds of the sample reported this behavior at the follow-up interview.
Our findings are difficult to compare with general population studies, such as the Youth Risk Behavior Survey (YRBS) and National Longitudinal Survey of Adolescent Health (ADD Health), because they define risk behaviors differently. We asked about behaviors in the past three months; the YRBS and ADD Health asked respondents about their last
sexual intercourse. In the general population, approximately 9% to 12% of youth use substances during sexual intercourse.11,33,34
In our sample, the prevalence of this behavior was much higher -- 33% to 92% -- depending on the diagnostic group. For some risk behaviors, the direction
of the differences between our sample and general population studies varied by diagnostic group. For example, in our sample, fewer youth with MMD (10%) than general population youth (22% to 35%) reported not using a condom in past three months2,34
; however, the prevalence of this behavior in our sample of youth with SUD (49%) or with MMD+SUD (62%) was substantially higher than general population rates.
Overall, behaviors with the highest prevalence at baseline were most likely to persist at follow-up. In all diagnostic groups, the most persistent behaviors were being sexually active, having vaginal sex, engaging in sex while drunk or high, and having unprotected sex while drunk or high. Of particular concern is the persistence of sexual behaviors involving substance use. These youth, regardless of their diagnosis, place themselves at risk for contracting HIV/STIs through use of drugs or alcohol.
As delinquent youth age, which diagnostic groups predict HIV/STI risk behaviors three years later? Compared with other diagnostic groups, SUD at baseline increases subsequent risk of engaging in sexual risk behaviors: unprotected vaginal sex, oral sex, and sex with multiple partners. Approximately three-quarters of youth with SUD at baseline engaged in 5 or more sexual risk behaviors at follow-up compared with about one-half of those with MMD. This pattern is consistent with previously published findings from the study’s baseline interview; SUD was then the disorder most strongly associated with HIV/STI sexual risk behaviors reported prior to detention.8
Taken together, these findings suggest that substance use is both directly and indirectly related to HIV/STI risk behaviors, a relationship that continues as youth age. Intoxication can increase the likelihood of unplanned sexual activity, and sex while drunk or high can decrease the likelihood of using condoms and impair one’s ability to negotiate safe sex practices.35
Alcohol and drugs are indirectly related to HIV/STI risk behaviors because their use increases exposure to deviant peers and risky sexual partners.36,37
Moreover, addiction may cause persons to engage in risky sexual behavior to obtain substances.
Some of our findings do not replicate those of other cross-sectional and longitudinal studies that show youth with mental illness engage in higher rates of HIV/STI risk behaviors.11,12,38–41
Our findings may differ for two reasons. First, unlike prior longitudinal studies -- which examined only psychiatric symptoms11,12,38
-- we focused on disorders.
The relationship between MMD and HIV/STI risk behaviors may be substantially different. Second, prior longitudinal studies11,12,42
conflated mental illness and comorbid SUD. In contrast, the current study differentiated youth with only MMD from those with comorbid MMD and
SUD. The higher rates of HIV/STI risk behaviors among youth with mental illness found in prior studies may be a result of comorbid SUD, not MMD.
For many high-risk behaviors -- such as sex with high-risk partners, unprotected anal sex, or unprotected sex while intoxicated -- there were no significant differences by diagnostic category. This may reflect that, especially in these vulnerable populations, other variables -- a history of sexual abuse, sexual orientation, the lack of parental involvement, and delinquent peer groups -- may play a more important role in determining HIV/STI risk behaviors.
The study has several limitations. Our findings, drawn from one site (CCJTDC), are generalizable to youth who were detained during adolescence in urban detention centers of similar demographic composition. We examined HIV/STI risk behaviors during only 2 periods of our subjects’ lives. The study does not address causal mechanisms underlying HIV/STI risk, nor does this study examine the impact of treatment or other services during the years between assessments. Risk behaviors were assessed according to a dichotomous variable denoting presence or absence of the behavior; no data are available on changes in the frequency or intensity of behaviors. When examining changes in prevalence rates between the baseline and follow-up interviews (), there were too few incarcerated youth to examine simultaneously the effects of incarceration and diagnostic group. The MMD group (n=34) and the MMD+SUD group (n= 72) may have been too small to detect some differences. The MMD group was composed primarily of youth with a major depressive disorder because other MMDs were uncommon. The group with neither MMD nor SUD may have had other psychiatric disorders -- such as posttraumatic stress disorder -- which may have elevated the group’s prevalence of risk behaviors. Finally, the data are subject to the limitations of self-reporting.
Despite these limitations, this study has implications for future research and for improving the treatment of youth involved with the juvenile justice system. We recommend research in the following areas:
- Longitudinal studies of patterns of multiple substances used and HIV/STI risk behaviors. Prior studies have examined the effects of specific substances (e.g., alcohol, marijuana, cocaine) on HIV/STI risk behaviors.34,43 The effects on HIV/STI risk behaviors vary by the type of substance used and the amount used over time.44 Far fewer investigations examine how concurrent and sequential use of multiple substances (e.g., alcohol and marijuana) affect HIV/STI risk behaviors as high-risk youth age into adulthood. Longitudinal studies will identify the patterns of use that are associated with the highest-risk behaviors.
- Studies of SUDs and HIV/STI risk behaviors. Most studies of adolescent and young adults examine substance use; far fewer studies examine SUDs. Studies examining only substance use are problematic because definitions vary widely across studies, often not differentiating experimentation from problem use. Moreover, compared with substance use, SUDs have different developmental sequences, different risk and protective factors, and worse outcomes45–47.
- Studies of the context of HIV/STI risk behaviors. HIV/STI risk behaviors were common in our sample, irrespective of diagnostic group. The next generation of research must address how risk and protective factors moderate and mediate the relationships among mental disorders, SUDs, and HIV/STI risk behaviors. To successfully intervene, we must understand the mechanisms and context of environmental risk.48
- Comprehensive longitudinal studies of psychiatric disorders and HIV/STI risk. To date, most prior longitudinal studies11,14,15,38 have examined psychiatric symptoms or a limited number of disorders such as depression and substance use. Yet, the related cross-sectional literature suggests that other disorders such as eating disorders and antisocial personality disorder are also associated with elevated rates of HIV/STI risk behavior.9,40 Studies are needed of youth at high risk for HIV (e.g., homeless youth, youth in treatment) as well as youth in community.
Our findings also have important clinical and policy implications. It is essential to provide HIV/STI preventive interventions for delinquent youth when they are detained and after they return to their communities. We recommend that the pediatric and psychiatric communities address the HIV epidemic in the following ways:
- Include HIV/STI preventive interventions in mental health and substance abuse treatment programs. More than one-half of participants had SUD, MMD, or both. HIV/STI interventions integrated into treatment programs can decrease HIV/STI risk behaviors in youth and adults.49,50 In addition, incorporating targeted HIV/STI preventive interventions in detention centers and in the community is a powerful and cost-effective tool to prevent the spread of HIV and other STIs.51
- Provide innovative interventions and outreach in the community. To reach the more than 90% of detained youth who do not receive needed mental health services after their release into the community,52 we must provide outreach and prevention efforts in settings where these youth are more likely to be found: free clinics, hospital emergency departments, and juvenile homeless shelters.53–55 Interventions must include information on the risk of using drugs or alcohol within a sexual context. Providing on-site education, preventive interventions, HIV/STI testing services, pretest and posttest counseling, and condoms to youth in these settings may reduce HIV/STI risk behaviors.
In conclusion, HIV/STI risk behaviors in delinquent youth are prevalent and persist as youth age into adulthood. Substance use disorders increase sexual risk behaviors. Because detained youth have a median stay of approximately 2 weeks, their HIV/STI risk behaviors subsequently become a community health problem. Pediatricians and child psychiatrists must collaborate with corrections professionals to develop HIV/STI interventions and ensure that programs started in detention centers continue after youth are released into the community.