STD Quarterly: Take it to the streets: Reach homeless teens
STD quarterly
Take it to the streets: Reach homeless teens
How can homeless youth be reached with services for sexually transmitted diseases (STDs)? New research indicates good results can be achieved through field-based STD testing, field-delivered therapy, and patient-delivered partner therapy.1,2
If you think homeless youth aren't a problem in your community, think again; homelessness among young people in the United States is becoming more common, with an estimated annual prevalence of at least 5% for those ages 12 to 17.3
These adolescents are at increased risk for STDs, says Colette Auerswald, MD, MS, assistant professor of pediatrics in the division of adolescent medicine at University of California, San Francisco (UCSF) and lead author of the current study. Runaway and homeless youth often engage in survival sex (the exchange of sex for financial or other resources such as shelter, food, or clothing); at the same time, these young people seek care less often than teens in stable situations.4
Much less likely to trust clinics
Many homeless adolescents may not seek clinic-based care due to previous poor relationships with authority, notes Auerswald. As children, they may have been entrusted to authority figures, such as parents, foster parents, or the juvenile justice system, and been failed by them, she notes.
"They are much less likely to trust a clinic, to trust a nurse, to go someplace and reach out for help, because in the past when they have done that, they have gotten slapped," observes Auerswald. "By meeting people in an environment that is their turf, it makes it more likely that they will accept service."
Through a collaborative partnership of the San Francisco Department of Public Health, UCSF, and Larkin Street Youth Services, a San Francisco community-based agency, outreach workers have been trained through the Street START (Street Testing and Rapid Testing) Program. They test homeless youth for chlamydia and gonorrhea, and they dispense field-delivered therapy and patient-delivered partner therapy.
"We think that it is important to reach out to the segment of homeless youth most at risk for infection and least likely to access clinics: street youth," says Dina Wilderson, PhD, director of research, evaluation, and technology at Larkin Street Youth Services, which provides services to San Francisco's homeless and runaway youth. "By providing both screening and treatment as part of a street outreach program, we are able to provide services to a high-risk group least likely to come into a clinic setting for care."
Review the results
In a longitudinal study, funded in part through a grant from the National Institute of Child Health and Development, researchers enrolled 218 ethnically diverse homeless youth, ages 15-24, recruited from street sites in San Francisco.
Study participants completed a computer-administered self-interview survey and provided a first-void urine sample for testing for chlamydia and gonorrhea. Those youth who tested positive for infection were offered field-delivered therapy and patient-delivered partner therapy. A random subset of 157 youth was followed prospectively; 110 (70%) were interviewed, and 87 (55%) were retested at six months.
At baseline, 99% of youth in the study consented to STD testing; 6.9% and 0.9% tested positive for chlamydia and gonorrhea, respectively. Ninety-four percent of positive youth were treated, 50% within one week. The incidence rate for chlamydia was 6.3 per 100 person-years [95% confidence interval (CI): 1.3-18.4], and the rate for gonorrhea was 4.2 per 100 person-years (95% CI: 0.5-15.2). None of the youth treated by study staff and tested six months later had an STD infection.1
The experience in the longitudinal study is being translated to practice in the Street START Project led by Wilderson and Auerswald.2 Larkin Street Youth Services and UCSF received an award to train outreach workers serving homeless youth in San Francisco to provide street-based testing and treatment. To date, 159 youth have been tested in the outreach setting. All positive youth have been treated, Auerswald reports.
With nucleic acid amplification tests, single-dose treatment regimens, and patient-delivered partner therapy, clinics can expand their services outside the walls of their facilities, say the researchers. The Street START program has been successful because it has been able to use street outreach workers who have the skills to locate and evaluate youth on the street. The workers have received training in STD testing, field-delivered therapies, and research principles to help them test and treat youth at risk.
"The transient nature of this group can make it hard to locate youth who test positive; however our outreach team has a great deal of experience tracking youth to conduct check-ins as part of their larger activities," says Wilderson. "In addition, the San Francisco Department of Public Health has been able to help us locate youth who might otherwise be lost."
References
- Auerswald CL, Sugano E, Ellen JM, et al. Street-based STD testing and treatment of homeless youth are feasible, acceptable, and effective. J Adolesc Health 2006; 38:208-212.
- Wilderson DM, Sugano E, Klausner JD, et al. Meeting homeless youth where they're at: Integrating STI testing and treatment into a street outreach program. Presented at the 2006 National STD Prevention Conference. Jacksonville, FL; May 2006.
- Robertson M, Toro P. Homeless youth: Research, intervention, and policy. Presented at the 1998 National Symposium on Homeless Research. Arlington, VA; October 1998. Accessed at: http://aspe.hhs.gov/progsys/homeless/symposium/3-Youth.htm.
- American Social Health Association. State of the Nation 2005: Challenges Facing STD Prevention Among Youth — Research, Review, and Recommendations. Research Triangle Park, NC; 2005.
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