Overcoming Barriers to HIV Prevention Education in the Juvenile Justice System by: Julie Taylor ETR Associates 4 Carbonero Way Scotts Valley, CA 95066 ABSTRACT 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 behaviors. 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. Conclusion 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 facility. 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. 1 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. 2 Health risk behavioral survey from 39 juvenile correctional facilities in the United States. (1995). Journal of Adolescent Health, 17, 334-344. 3 National Institute of Justice. (1996). HIV/AIDS and STDs in juvenile facilities. 4 American Public Welfare Association. (1997, April). Public juvenile justice initiatives in HIV prevention for adolescents.
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