Kristen Underhill & Don Operario Department of Community Health

1. Preventing HIV among juvenile offenders: Evidence from randomized and quasi-randomized controlled trials Kristen Underhill & Don Operario Department of Community Health Brown University, Providence, RI, USA

2. Overview • Background and research objectives • Systematic review methods • Inclusion criteria • Search • Analysis • Results • Limitations • Conclusions and future directions

3. Youth involved in the juvenile justice system • Juvenile offenders: legal minors charged with offenses that would be crimes if they were adults. • Typically aged 12-18, although legal systems vary (Hartjen 2008). • Global increases in juvenile offending past 20 years, but difficult to estimate international rates (UN 2003). • UNODC surveys number of juveniles brought into formal contact with the justice system, per 100,000 inhabitants per year (UNODC 2005). • Austria 267.91 Kuwait 106.4 Saudi Arabia 48.90 • Italy 27.64 Mexico 16.92 Romania 70.27 • Japan 112.15 USA 478.22 Peru 5.75

4. Need for HIV prevention services among juvenile offenders • Cross-sectional studies from many jurisdictions document elevated rates of HIV and other STIs in this group, compared to other adolescents. (Belenko et al. 2009, citing studies; Belenko et al. 2008; Johnson et al. 2008; Murray et al. 2003; Rowe et al. 2008.) • Social justice imperatives to reduce HIV risk among young offenders, especially incarcerated youth. • Convention on the Rights of the Child, Comment on HIV/AIDS and the Rights of the Child, 2003 • WHO Guidelines on HIV Infection and AIDS in Prisoners, 1993 • International Guidelines on HIV/AIDS and Human Rights, 1998

5. Risk factors for HIV infection among juvenile offenders • Risky sexual behaviors (early first sex, condom nonuse, number of partners, substance use during sex, transactional sex) • Drug use (injection / noninjection) and alcohol use • Mental health issues • Poverty, family effects, neighborhood effects, partner age, unstable housing, peer networks including gang membership • History of physical/sexual abuse (associated with substance use, depression, sexual activity) • Poor overall health status, including untreated STIs • Gender, race, age • References: Bright & Jonsen-Reid 2008; Butler 2008; Crosby et al. 2003; Dembo et al. 2007; Elkington et al. 2008; Fazel et al. 2008; Forrest et al. 2000; Golzari et al. 2006; Gover 2004; Mason et al. 1998; Morris 2004; Morris et al. 1995; Otto-Salaj et al. 2002; Pack et al. 2000; Poulin et al. 1997; Robertson et al. 2005; Romero et al. 2007; Rosengard et al. 2008, summarizing studies; Rowe et al. 2008; St. Lawrence et al. 2008; Teplin et al. 2003; Tolou-Shams et al. 2007; Tolou-Shams et al. 2008; UN World Youth Report 2003

6. Harnessing the justice system as a point of intervention • Contacts/opportunities: Arrest; adjudication or court contact (family, juvenile, drug, or truancy court); incarceration; parole; probation/supervision; alternative dispositions. • Young offenders may be less likely to access services in other venues, such as school-based or community programming.

7. What works? Past Reviews • Behavioral interventions have shown efficacy • For youth in the juvenile justice system • Tolou-Shams et al. 2010 (7 RCTs in juvenile justice settings) • Robin et al. 2004 (24 studies; 2 juvenile justice) • Mullen et al. 2002 (20 studies; 2 juvenile justice) • For youth generally • Kirby et al. 2007 (83 studies worldwide) • Johnson et al. 2003 (44 studies worldwide) • For adults in the criminal justice system • Bryan et al. 2006 (7 studies in prisons) • Lichtenstein & Malow 2010 (5 studies among incarcerated women) • Jürgens et al. 2009 (6 strategies for reducing IDU risk in prisons)

8. Research Objective • To identify, appraise, and summarize the evidence for HIV prevention programs among youth involved with juvenile justice systems. • Differences from past reviews • Systematic search of the criminal justice and social services literature, as well as medicine and psych. • Limited to trials in which all participants are juvenile offenders. • Intervention could take place in any setting. • Cochrane review methods.

9. Systematic Review Methods • Goal: Bring together all the most rigorous evidence • 2 independent researchers complete analysis • Define exactly what studies are of interest • Pre-specify where and how to find them • Search for published/unpublished studies • Appraise methodological quality • Synthesize the evidence (narrative or quantitative synthesis) to identify program effects on HIV risk behaviors and biological outcomes

10. Inclusion Criteria • Study design: Randomized & quasi-randomized controlled trials, using any comparison group. • Participants: All participants are minors defined by local laws, reporting least one formal contact with the juvenile justice system (e.g., arrest). Not known to be HIV+. • Interventions: Any intervention aiming to prevent HIV infection. Includes behavioral intervention, structural intervention, substance use treatment focusing on HIV. • Outcomes: Behavioral or biological HIV risk outcomes (e.g., STI incidence, unprotected sex) were reported.

11. Search Strategy = 27,043 abstracts • 16 electronic databases, (ending December 2009) • Medical: PubMed, PsycINFO, EMBASE, CENTRAL, CINAHL, AMED, Global Health Abstracts • Social services: ASSIA, ERIC, Sociological Abstracts, Political Science Abstracts, Social Services Abstracts, Social Sciences Citation Index • Criminal justice: National Criminal Justice Reference Service, Criminal Justice Abstracts • Unpublished literature: Dissertation Abstracts • Cross-referenced reviews and papers • Searched conference abstracts • Contacting authors in the field (in progress)

12. 27,043 Records recovered 507 Appeared relevant 12Full text unavailable 495 Sufficient data obtained 4Duplicates 5Ongoing 475 Did not meet criteria 11 included papers, reporting 7 separate evaluations Search Results

13. 7 Included Studies: Participants • N=2595 youth, age range 12-19, median 15.8 • 6 studies in US (mostly coastal), 1 in Canada. Mix of rural and urban settings. • 2 studies were 100% male, others majority male (range 54% to 89.5%, median 82%) • Race/ethnicity mixed in all studies. Median 65% nonwhite. • 2 studies reported small percentages of LGBT participants • All participants incarcerated; most were pre-adjudication and short-term facilities. • Offenses rarely reported, large majority of participants had previously been in custody, prior sexual experience

14. Included Studies: Interventions • All interventions were psychosocial • 4 stated theoretical basis • Programs delivered in groups (3), one-on-one (1), or used both formats (3) • Median duration 6.5 hours, range 2 to 18+ hours • 3 included contact after release: extensive case management (2) or short boosters (1) • All delivered by adults; 1 also used peer educators • 4 explicitly incorporated substance use; 2 integrated intervention into reentry plan

15. Included Studies: Methodology • 6 RCTs, 1 quasi-RCT (assignment by alternation). 1 randomized blocks of participants. • 3 reported significant group differences at baseline, controlled in analyses. • Control groups included usual care (3 studies), attention (2), and information about HIV (2). • Median follow-up was 6 months after release, (range 3-24 mo). Median retention 75% (range 60% to 97%). 4 studies analyzed attrition. 1 full ITT analysis. • Outcomes by ACASI (1), written survey (2), interview (4). 1 study analyzed biological specimens.

16. Results: Sexual Behavior Outcomes

17. Results: Sexual Behaviors, continued

18. Other Results: Cost, Acceptability, Drug Use Outcomes • No cost data reported • Where reported, acceptability was high (4 studies) for participants and their families • Drug use • 4 studies reported drug use outcomes (n=1612). 1 reported protective effects (family therapy vs. usual care, n=154) • No studies reported an impact on alcohol use.

19. Some characteristics of programs with protective effects • No clear patterns among the 4 trials demonstrating efficacy • Formats varied (1 group, 1 individual, 2 both) • All used adult facilitators and monitored fidelity • 3 focused on substance use along with HIV (alcohol, marijuana, or all drug use) • 2 had contact with participants after release from incarceration (booster sessions or case management) • 1 family-centered, case management program involved parents • 2 other trials found large pre-post differences in both trial arms, but no significant group differences; possible contamination or effective control conditions.

20. Notable Excluded Studies • 3 excluded because some participants were not offenders • 2 led to safer sexual behaviors among youth in alternative education (Coyle 2006; Lightfoot 2007) • 1 had no effect among delinquent and abused youth (Slonim-Nevo 1996). • 4 studies ongoing (1 focusing on female youth). • Nonrandomized studies outside North America -- UK, Israel, Hong Kong, France, Australia, Russia, Pakistan, Brazil, South Africa, Israel, China.

21. Limitations of the Review • Possible publication bias or missed trials. • Limited generalizability to North American youth. • Relatively small n=2595, small number of trials, all in North America, considerable attrition. • Limitations of included trials. • Rare use of biological outcome measures • Reliance on self-reported outcomes (as reliable as community samples) (Kenny & Grant 2007). • Underreporting of key methodological details: method of randomization, allocation concealment, blinding of assessors. • Results could not be quantitatively synthesized due to missing data and heterogeneity.

22. Conclusions: Policy and Practice • Social justice imperatives to acknowledge and reduce HIV risk among juvenile offenders. • Several intervention strategies are promising; too few to discern consistent themes. • Substance use is an important co-factor in HIV risk, and it should be addressed in intervention design and delivery. • Contact after release from incarceration may also be helpful, although not every case management program was efficacious. • Reducing HIV risk among juvenile offenders is feasible and necessary. Need funded expansion of services and access to research.

23. Future Research Directions • Research questions • Programs that take place in community settings (probation, parole); for incarcerated offenders, need programs targeting time immediately after release. • Programs specific to female juvenile offenders. • Programs incorporating mental health services. • Few trials have investigated peer education approaches. None has examined structural interventions. • Research methods • Use of biological outcome measurements. • Larger participant samples spanning multiple sites, minimizing possibility of contamination among trial arms. • Cost-effectiveness, acceptability, and implementation research.

24. Acknowledgements • Internal support from Brown University Department of Community Health, Center for Alcohol and Addictions Studies. • This review did not receive external funding. KU is supported by NIH grant 5T32 AA07459-24. • This review overlaps with our ongoing Cochrane review of HIV prevention programs for criminal offenders in community settings, which is overseen by the Cochrane HIV/AIDS Group. • We are very grateful to the investigators who have responded to our inquiries about unpublished papers.

25. References: Included Studies 1. Bryan AD, Schmiege SJ, Broaddus MR. HIV risk reduction among detained adolescents: a randomized, controlled trial. Pediatrics. Dec 2009;124(6):e1180-1188. 2. Gillmore MR, Morrison DM, Richey CA, Balassone ML, et al. Effects of a skill-based intervention to encourage condom use among high risk heterosexually active adolescents. Aids Educ. Prev. Feb 1997;9(1, Suppl):22-43. 3. Goldberg E, Millson P, Rivers S, et al. A human immunodeficiency virus risk reduction intervention for incarcerated youth: a randomized controlled trial. J Adolesc Health. Feb 2009;44(2):136-145. 4. Needels K, James-Burdumy S, Burghardt J. Community case management for former jail inmates: its impacts on rearrest, drug use, and HIV risk. J Urban Health. Sep 2005;82(3):420-433. 5. Rosengard C, Stein LA, Barnett NP, Monti PM, Golembeske C, Lebeau-Craven R. Randomized clinical trial of motivational enhancement of substance use treatment among incarcerated adolescents: post-release condom non-use. Journal of HIV/AIDS Prevention in Children and Youth. 2007;8:45-64. 6. St Lawrence JS, Crosby RA, Belcher L, Yazdani N, Brasfield TL. Sexual risk reduction and anger management interventions for incarcerated male adolescents: A randomized controlled trial of two interventions. Journal of Sex Education & Therapy. 1999(1-2):9-17. 7. Marvel F, Rowe CL, Colon-Perez L, DiClemente RJ, Liddle HA. Multidimensional family therapy HIV/STD risk-reduction intervention: an integrative family-based model for drug-involved juvenile offenders. Fam Process. Mar 2009;48(1):69-84. 8. Schmiege SJ, Broaddus MR, Levin M, Bryan AD. Randomized trial of group interventions to reduce HIV/STD risk and change theoretical mediators among detained adolescents. J Consult Clin Psychol. Feb 2009;77(1):38-50. 9. Liddle HA. Family-based therapy for drug using adolescent offenders: Multidimensional Family Therapy in the CJ DATS Detention-to-Community RCT. NIDA Addiction Science & Clinical Practice (formerly, Science & Practice Perspectives). In press. • Liddle HA, Dakof GA, Henderson CE, Rowe CL. Implementation outcomes of a comprehensive cross-context, family-based community reintegration therapy for drug-using juvenile detainees. J Experimental Criminol. in press • Liddle HA, Dakoff GA, Henderson CE, Rowe CL. Implementation outcomes of Multidimensional Family Therapy–Detention to Community: A reintegration program for drug-using juvenile detainees. International Journal of Offender Therapy and Comparative Criminology. 2010;in press.

26. Other References • Belenko S, Dembo R, Weiland D, Rollie M, Salvatore C, Hanlon A, Childs K. Recently Arrested Adolescents Are at High Risk for Sexually Transmitted Diseases. Sex Transm Dis. 2008;35(8): 758-763. • Belenko S, Dembo R, Rollie M, Childs K, Salvatore C. Detecting, preventing, and treating sexually transmitted infections among adolescent arrestees: An unmet public health need. Am J Public Health. 2009;99(6):1032-41. • Bright CL, Jonson-Reid M. Onset of juvenile court involvement: Exploring gender-specific associations with maltreatment and poverty. Child Youth Serv Rev. 2008;30(8):914-927. • Bryan A, Robbins RN, Ruiz MS, O'Neill D. Effectiveness of an HIV prevention intervention in prison among African Americans, Hispanics, and Caucasians. Health Educ & Behav. 2006;33:154-177. • Butler T, Belcher JM, et al. The physical health status of young Australian offenders. Australian and New Zealand Journal of Public Health 2008;32(1):73-79. • Coyle KK, Kirby DB, Robin LE, Banspach SW, Baumler E, Glassman JR. All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students. AIDS Educ Prev. 2006;18(3):187-203. • Crosby RA, Diclemente RJ, Wingood GM, Rose E, Levine D. Adjudication history and African American adolescents' risk for acquiring sexually transmitted diseases: An exploratory analysis. Sex Transm Dis. 2003;30(8): 634-638. • Dembo R, Schmeidler J, Childs K. Correlates of male and female offender abuse experiences. J Child Sex Abus. 2007;16(3)75-94. • Elkington KS, Teplin LA, Mericle AA, Welty LJ, Romero EG, Abram KM. HIV/sexually transmitted infection risk behaviors in delinquent youth with psychiatric disorders: a longitudinal study. J Am Acad Child Adolesc Psychiatry. 2008;47(8):901-11. • Fazel S, Doll H, Langstrom N. Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1010-9.

27. Other References II • Forrest CB, Tambor E, Riley AW, Ensminger ME, Starfield B. The health profile of incarcerated male youths. Pediatrics. 2000;105(1 pt 3):286-91. • Golzari M, Hunt SJ, Anoshiravani A. The health status of youth in juvenile detention facilities. J Adolesc Health. 2006;38(6):776-82. • Gover AR. Childhood sexual abuse, gender, and depression among incarcerated youth. Int J Offender Ther Comp Criminol. 2004;48(6):683-96. • Hartjen CA. Youth, Crime and Justice: A Global Inquiry. Piscataway,, NJ: Rutgers University Press, 2008. • Johnson BT, Carey MP, Marsh KL, Levin KD, Scott-Sheldon LA. Interventions to reduce sexual risk for the human immunodeficiency virus in adolescents, 1985-2000: A research synthesis. Arch PediatrAdolesc Med. 2003;157(4):361-368. • Johnson CC, Jones EH, Goldberg M, Asbel LE, Salmon ME, Waller CL. Screening for Chlamydia trachomatis and Neisseriagonorrhoeae among adolescents in Family Court, Philadelphia, Pennsylvania. Sex Transm Dis. 2008;11(35):S24-27. • Jurgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect Dis. 2009;9(1):57-66. • Kenny DT, Grant J. Reliability of self-report of health in juvenile offenders. Vulnerable Children & Youth Studies. 2007;2(2):127-141. • Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world. J Adolesc Health. 2007;40(3):206-217. • Lichetenstein B, Malow R. A critical review of HIV-related interventions for women prisoners in the United States. J Assoc Nurses AIDS Care. 2010; in press. • Lightfoot M, Comulada S, Stover G. Computerized HIV preventive intervention for adolescents: Indications of efficacy. Am J Public Health. 2007;97:1027-1030. • Mason W, Zimmerman L, Evans W. Sexual and physical abuse among incarcerated youth: implications for sexual behavior, contraceptive use, and teenage pregnancy. Child Abuse Negl. 1998;22(10):987-95.

28. Other References III • Morris RE. Health status of incarcerated adolescents: Implications for juvenile justice decision-making. Juvenile and Family Court Journal. 2004;55(1):49-62. • Morris RE, Harrison EA, Knox GW, Tromanhauser E, Marquis DK, Watts LL. Health risk behavioral survey from 39 juvenile correctional facilities in the United States. J Adolesc Health. 1995;17:334-44. • Mullen PD, Ramirez G, Strouse D, Hedges LV, Sogolow E. Meta-analysis of the effects of behavioral HIV prevention interventions on the sexual risk behavior of sexually experienced adolescents in controlled studies in the United States. J Acquir Immune DeficSyndr. 2002;31(suppl 1):S94-S105. • Murray KF, Richardson LP, Morishima C, Owens JW, Gretch DR. Prevalence of hepatitis C virus infection and risk factors in an incarcerated juvenile population: a pilot study. Pediatrics 2003; 111:153-157. • Otto-Salaj LL, Gore-Felton C, McGarvey E, Canterbury RJ, II. Psychiatric function and substance use: factors associated with HIV risk among incarcerated adolescents. Child Psychiatry and Human Development. 2004;33(2):91-106. • Pack RP, DiClemente RJ, Hook EW, Oh MK. High prevalence of asymptomatic STDs in incarcerated minority male youth: A case for screening. Sex Transm Dis. 2000;27(3):175-177. • Poulin C, Alary M, Ringuet J, Frappier JY, Roy E, Lefebvre J. Prevalence of chlamydial infection and frequency of risk behaviours for STDs and HIV infection among adolescents in public juvenile facilities in the province of Quebec. Can J Public Health. 1997;88(4):266-70. • Robertson AA, Thomas CB, St Lawrence JS, Pack R. Predictors of infection with Chlamydia or gonorrhea in incarcerated adolescents. Sex Transm Dis. 2005;32(2):115-22. • Robin L, Dittus P, Whitaker D, Crosby R, Ethier K, Mezoff J, Miller K, Pappas-Deluka K. Behavioral interventions to reduce incidence of HIV, STD, and pregnancy among adolescents: A decade in review. J Adolesc Health. 2004;34(1):3-26. • Romero, E. G., Teplin, L. A., McClelland, G. M., Abran, K. M., Welty, L. J., & Washburn JJ. A longitudinal study of the prevalence, development, and persistence of HIV/sexually transmitted infection risk behaviors in delinquent youth: Implications for health care in the community. Pediatrics. 2007; 119(5):1126-1141.

29. Other References IV • Rowe CL, Wang W, Greenbaum P, Liddle HA. Predicting HIV/STD risk level and substance use disorders among incarcerated adolescents. J Psychoactive Drugs. 2008;40(4):503-512. • Slonim-Nevo V, Auslander WF. The long-term impact of AIDS-preventive interventions for delinquent and abused adolescents. Adolescence. 1996;31(122):409-421. • St Lawrence JS, Snodgrass CE, Robertson A, Baird-Thomas C. Minimizing the risk of pregnancy, sexually transmitted diseases, and HIV among incarcerated and adolescent girls: Identifying potential points of intervention. Criminal Justice and Behavior. 2008;35(12):1500-1514. • Teplin LA, Mericle AA, McClelland GM, Abram KM. HIV and AIDS risk behaviors in juvenile detainees: Implications for public health policy. Am J Public Health. 2003;93(6):906-12. • Tolou-Shams M, Brown LK, Houck C, Lescano CM, Project SHIELD Study Group. The association between depressive symptoms, substance use, and HIV risk among youth with an arrest history. J Stud Alcohol Drugs. 2008;69(1);58-64. • Tolou-Shams M, Brown LK, Gordon G, Fernandez I, Project SHIELD Study Group. Arrest history as an indicator of adolescent/young adult substance use and HIV risk. Drug Alcohol Depend. 2007;88(1):87-90. • Tolou-Shams M, Stewart A, Fasciano J, Brown LK. A review of HIV prevention interventions for juvenile offenders. J Pediatr Psychol. 2010;35(3):250-261. • United Nations Office on Drugs and Crime. Eighth United Nations Survey of Crime Trends and Operations of Criminal Justice Systems. Geneva, Switzerland: UNODC, 2005. http://www.unodc.org/unodc/en/data-and-analysis/Eighth-United-Nations-Survey-on-Crime-Trends-and-the-Operations-of-Criminal-Justice-Systems.html. • United Nations Secretary-General, World Youth Report 2003. Geneva, Switzerland: UN, 2003. http://www.un.org/esa/socdev/unyin/wyr03.htm.