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Overcoming Barriers to HIV Prevention Education in the Juvenile by arm77214


									                           Overcoming Barriers to
                    HIV Prevention Education in the
                           Juvenile Justice System

                                       by: Julie Taylor
                                       ETR Associates
                                      4 Carbonero Way
                                   Scotts Valley, CA 95066

HIV Prevention Education for adolescents in the juvenile justice system is more important than
ever because it is estimated that one in every four new HIV infections happen to people 22 or
younger. In addition to these high percentages, incarcerated youth tend to take more risks than
the average teen. Therefore, the purpose of this article is assist juvenile justice facilities to
implement effective HIV Prevention programs by articulating the common barriers they face and
offering concrete strategies for addressing each challenge. In addition, readers will learn about
national resources to help them with their HIV Prevention programming.
HIV Prevention Education for adolescents in the juvenile justice system is more important than
ever because it is estimated that one in every four people newly infected with HIV are younger
than 22.1 Since an individual can be infected with HIV for 3-5 years or more before showing
symptoms, many individuals presenting with AIDS in their early twenties are probably being
infected as teenagers.

In addition to these high percentages of infection among young people, incarcerated youth tend
to take more risks than the average teen as illustrated by a Health Risk Behavior Survey of
youth in confinement conducted in 1991 by the National Commission on Correctional Health
Care.2 The survey of five states found that:

       93% of teens reported having had consensual sex before the age of 16;
       62% had their first sexual encounter before the age of 13;

       66% had 6 or more partners and 34% had 20 or more partners their entire life;

       87% had used alcohol and other drugs before the age of 15;
       39% had used alcohol and/or other drugs before sex;
       64% had not used a barrier form of protection during last intercourse.

These unusually high rates of HIV related risk behaviors demonstrate an urgent need for
effective HIV prevention interventions for youth in the juvenile justice setting. Effective HIV
Prevention education needs to provide: 1) basic information about how the disease is and is not
transmitted, 2) information about protection including abstinence from sex and drugs as well as
using condoms and cleaning needles, and 3) information about and practice in communication
and protection skills.
To compound this problem, there seems to be a growing apathy among the general population
regarding the seriousness of the HIV epidemic. Some of this apathy is in response to the
success of the new HIV/AIDS treatment options including protease inhibitors. While these
treatments are more effective than earlier drugs, they come with serious costs both in dollars
and in the side effects which often get worse over time.

During the last two years, ETR Associates has been working intently with juvenile justice staff
and facilities nationwide to improve HIV prevention education. While individual facilities are
interested in implementing effective interventions, they often encounter barriers to achieving this
goal. The purpose of this article is to articulate the common barriers facilities face and to offer
concrete strategies for addressing each in an effort to increase the implementation of HIV
prevention education in juvenile justice settings.
Common Barriers To HIV Prevention

The juvenile justice system and its staff are often over-burdened with the needs of the
adolescents they work with, the demands of the judicial and correctional system in which they
work, and the shortage of resources to carry out the responsibilities assigned to them. Each of
these pressures creates specific barriers to implementing effective HIV prevention programs in
their facilities. Some of the most common barriers and strategies for addressing them are
described below.
Inadequate materials and prevention interventions. Although many facilities are providing some
type of HIV education to their confined youth, the duration, content and implementation of these
interventions varies widely and no formal evaluation is being conducted to assess the
effectiveness of these programs in changing HIV-related risk behaviors.34 In addition, because
facilities vary widely in size, type, staffing and the population of youth they house, there needs
to be a variety of interventions available that address the needs of youth in different detention
and residential settings. Interventions need to be developed that are effective with youth who
are in a facility for less than a week, those who are detained for a month or two, and those who
are serving a longer sentence in a correctional facility. In other words, no one intervention will
work for all settings.

Several resources do currently exist that provide interventions for the various needs of detention
centers and training schools. The Centers for Disease Control and Prevention (CDC) has
provided funding for several programs to prevent HIV infection among youth in the juvenile
justice system. These programs include:
       Survive Outside: Effective HIV Prevention for Juvenile Justice. ETR Associates, in
       collaboration with the National Juvenile Detention Association, provides free training and
       intervention materials to direct care staff in juvenile detention and correction facilities
       nationwide through its Survive Outside project. Survive Outside offers three types of
       effective HIV prevention interventions including a one-on-one HIV Counseling Session,
       videos and discussion guides that assist educators in leading discussions about HIV
       topics and research-based, multi-session curricula which provide HIV education and
       skills training. For more information about free training and HIV prevention materials,
       contact Alison Wakefield at (831) 438-4060.

       HIV Education and Prevention for Incarcerated Youth. The National Commission on
       Correctional Health Care, through its HIV Education and Prevention for Incarcerated
       Youth program, provides two-day intensive trainings to service providers working with
       juveniles housed in various correctional facilities nationwide. The training provides
       participants with helpful information and techniques for reducing the risk of HIV infection
       among youth they serve. The trainings include units on HIV and AIDS, sexuality, alcohol
       and other drug use, risk reduction assessments, HIV treatment and testing, counseling
       techniques and peer education. For more information about free training and HIV
       prevention materials, contact Mindy Ferguson at (773) 880-1460.

       POWER Moves: A Situational Approach to HIV Prevention for High Risk Youth. Seven
       western state HIV education directors, Rocky Mountain Center for Health Promotion and
       Education and staff from the Universities of Colorado and Utah have developed POWER
       Moves, a 12 session education intervention targeting youth residing in juvenile
       correctional facilities. The Colorado Department of Education, in collaboration with the
       University of Colorado and CDC, is currently conducting an evaluation of the program to
       determine if it is more effective than the usual HIV education being provided to
       incarcerated youth in Colorado. For more information about this program contact Rocky
       Mountain Center at (303) 239-8428.
In addition to these programs, CDC funds HIV Prevention Coordinators in all 50 state
departments of education. These HIV coordinators have up to date information on promising
and research-based HIV prevention programs and can provide assistance to schools in the
juvenile justice system in their state. Another resource available to local facilities is the HIV
Community Planning Group (CPG). These planning groups set priorities for HIV prevention
within their state or local jurisdiction. For information about the CPG in your area call your state
or local health department and ask for the AIDS Director or the person in charge of HIV
Prevention for your community.

Lack of time and money to implement interventions. As mentioned earlier, juvenile justice staff
are often over-burdened with the demands of their jobs, the multitude of risk-taking behaviors of
the adolescents they work with and the shortage of staff to assume these responsibilities.
These challenges make it difficult to find the time and the money to teach HIV prevention
difficult. Staff can do several things to reduce the amount of time and the money spent on this
important health issue. First, staff can reduce time spent in developing an HIV Prevention
program for their youth by seeking out already developed programs such as those described
above. Two of these programs provide free training and program materials, thus reducing
costs. Second, staff can seek out short programs that take minimal staff time to implement.
The Survive Outside program has identified two HIV Prevention videos that provide basic
information and are easy to implement. Third, staff can review their current health education
efforts to determine where HIV prevention can be integrated into the existing program. For
example if drug and alcohol use is addressed, staff can include a discussion about the risks of
IV drug use and how alcohol and drug use increases risk of HIV infection by reducing
inhibitions. Fourth, staff can use community health educators to implement HIV prevention
programs. These health educators are trained in HIV prevention education and can minimize
the time and money staff need to invest in the program. Community resources can include local
health departments, local college programs, AIDS Projects, family planning agencies, etc.
Lack of support from facility administrators. Administrators experience many of the same
demands and pressures as line staff with the added responsibility of finding solutions to day to
day problems of running a facility. Administrators are usually supportive of HIV prevention
programming if the problems of time and cost can be addressed (see above). Providing
information about how incarcerated youth tend to take more risks than the average teen can
help administrators see why HIV prevention needs to be a priority in their facility. The data from
the Health Risk Survey of youth in confinement described above can be used to inform a
resistant administrator. In addition, many states require HIV prevention programming as part of
the school curriculum. Some facility accreditation standards also require that HIV/AIDS be
addressed. These mandates help support administrators to implement worthwhile programs. A
sample of such standards can be found in the Standards For Health Services in Juvenile
Detention and Confinement Facilities, published by the National Commission on Correctional
Health Care.

Inadequate HIV prevention policies and standards. In order for individual facilities to do an
effective job of HIV prevention education, they need to have policies in place that provide: 1)
standards for HIV prevention education programs, 2) guidelines for protecting the confidentiality
of staff and youth who are HIV positive while protecting the health of other staff and youth in the
facility, 3) guidelines for teaching harm reduction techniques such as condom use and cleaning
works and 4) guidelines for condom distribution while youth are incarcerated as well as at the
time of their release. Sample policies for these issues are available from the National
Commission on Correctional Health Care at (773) 880-1460.
Lack of support from co-workers. When an individual staff member has the sole responsibility
for implementing HIV prevention education it is easy for them to get discouraged or
overwhelmed by other responsibilities. Therefore, it is strongly recommended that at least two
staff take responsibility for the development and implementation of the program. This type of
collaboration provides: 1) support in dealing with the sensitive issues youth may discuss; 2)
support in problem solving when difficulties arise; 3) more flexibility in scheduling; 4) more
opportunity for youth to receive instruction and counseling in reducing their specific HIV risk
Staff discomfort with the sensitive material addressed in HIV prevention programs. In order to
implement effective HIV prevention, counselors and educators need to be able to talk
comfortably about such topics as sexuality, sexual practices, IV drug use, condom use, sexual
abuse, etc. If staff are uncomfortable with these topics it is often because they lack practice and
confidence in discussing them. For most staff, their comfort and confidence can be greatly
increased through effective training. Effective training should include modeling of effective ways
to discuss such topics as well as time for participants to improve their skills and comfort through
practice. Free or low-cost training is available from some of the CDC-funded programs
described above. Another option is to have staff team teach with a health educator from a
community- based organization until they become comfortable with the subject matter.

Several efforts need to be undertaken to enhance the HIV prevention education that is provided
to youth in the juvenile justice system. First, facilities need to be made aware of the current
programs already available to them through national and state initiatives. Second, more
resources need to be invested into the development and evaluation of programs for a wide
variety of juvenile justice settings. Third, line staff need policies and support from facility
administrators to make the HIV prevention education work. Finally, staff need support from
each other because a team effort puts less burden on one person or department within the
Despite the difficulties juvenile justice staff face in doing their jobs, there are rewards in knowing
you have made a change in some aspect of a youth’s risk taking. Effective HIV programs can
make that difference.
    Rosenburg, P.S., Biggar, R.J., Goedert, J.J. (1994). Declining age at HIV infection in the Unites States
    (letter). New England Journal of Medicine, 330, 789-790.
    Health risk behavioral survey from 39 juvenile correctional facilities in the United States. (1995). Journal
    of Adolescent Health, 17, 334-344.
    National Institute of Justice. (1996). HIV/AIDS and STDs in juvenile facilities.
    American Public Welfare Association. (1997, April). Public juvenile justice initiatives in HIV prevention
    for adolescents.

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