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Adherence to antiretroviral therapy (ART) among youth remains low. We piloted an adapted active visualization device that demonstrates how ART works in the body. Youth living with HIV were randomized to: (1) standard care (n = 14) or the (2) adapted active visualization intervention (n = 14) and 71% of the sample (n = 19) were re-assessed on viral load, adherence behaviors, and illness perceptions 2.5months later. Intervention youth had lower viral loads, reported less difficulty in adhering to ART, and more motivation and control over their HIV than standard care at follow-up. Active visualization may be an acceptable tool to address ART adherence among youth.

Background Tenofovir disoproxil fumarate (TDF) decreases bone mineral density (BMD). We hypothesized that vitamin D3 (VITD3) would increase BMD in youth receiving TDF. Methods This was a randomized, double-blind, placebo-controlled trial of directly observed VITD3 vs placebo every 4 weeks for 48 weeks in youth aged 16-24 years with HIV, RNA load

Background Gay, bisexual, transgender, and homeless youth are at risk of sexually transmitted infections. As part of an adolescent human immunodeficiency virus prevention study, we provided same-day Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing and treatment. We aimed to evaluate the feasibility and effectiveness of same-day CT and NG treatment on the proportion of participants receiving timely treatment. Methods We recruited adolescents with high sexual risk behaviors aged 12 to 24 years from homeless shelters, lesbian, gay, bisexual, and transgender organizations, and community health centers in Los Angeles, California, and New Orleans, Louisiana from May 2017 to June 2019. Initially, participants were offered point-of-care pharyngeal, rectal, and urethral/vaginal CT and NG testing and referral to another clinic for treatment. After March 2018 in Los Angeles and November 2018 in New Orleans, we provided same-day treatment (and partner treatment packs) for study participants. We measured the proportion of participants who received same-day treatment and the median time to treatment. We collected frequency of partner treatment and any reported adverse treatment-related events. Results The proportion of participants receiving same-day CT and NG treatment increased from 3.6% (5/140) to 21.1% (20/95; Δ17.5%; 95% confidence interval, 9.2%-26.9%) after implementation of same-day testing and treatment. The median time to treatment decreased from 18.5 to 3 days. Overall, 36 participants took a total of 48 partner treatment packs. There were no reported treatment-related adverse events. Conclusions Providing sexually transmitted infection treatment to adolescents at the same visit as testing is feasible and safe, and can increase the proportion of individuals receiving timely treatment.

Author(s): Shannon, Chelsea L; Keizur, Erin M; Fehrenbacher, Anne; Wood-Palmer, Drew; Ramos, Wilson; Koussa, Maryann; Fournier, Jasmine; Lee, Sung-Jae; Patel, Dhara; Akabike, Whitney N; Abdalian, Sue Ellen; Rotheram-Borus, Mary Jane; Klausner, Jeffrey D; Adolescent Trials Network (ATN) CARES Team | Abstract: BackgroundGay, bisexual, and transgender youth and homeless youth are at high risk for sexually transmitted infections (STIs). However, little recent data exist describing STI positivity by anatomical site among those groups. We determined the positivity of Chlamydia trachomatis (CT) infection, Neisseria gonorrhoeae (NG) infection, and syphilis antibody reactivity among lesbian, gay, bisexual, transgender, and homeless youth.MethodsWe recruited 1,264 adolescents with high risk behavior aged 12 to 24 years from homeless shelters, lesbian, gay, bisexual, and transgender organizations, community health centers, and using social media and online dating apps in Los Angeles, California and New Orleans, Louisiana from May 2017 to February 2019. Participants received point-of-care pharyngeal, rectal, and urethral/vaginal CT and NG testing and syphilis antibody testing. We calculated STI positivity by anatomical site and compared positivity by participant subgroups based on human immunodeficiency virus (HIV) status, sex assigned at birth, and gender identity.ResultsCT and NG positivity and syphilis antibody reactivity was higher among HIV-infected adolescent men who have sex with men (MSM) than HIV-uninfected adolescent MSM (40.2% vs. 19%, P l 0.05), particularly CT or NG rectal infection (28% vs. 12.3%, P l 0.05). Of participants with positive CT or NG infections, 65% had extragenital-only infections, 20% had both extragenital and urogenital infections, and 15% had urogenital-only infections.ConclusionsSexually transmitted infection positivity was high, particularly among transgender women and MSM. The high proportion of rectal and pharyngeal infections highlights the importance of both urogenital and extragenital STI screening. More accessible STI testing is necessary for high-risk adolescent populations.

Background Human Papillomavirus (HPV) is common and is linked to cancer in both males and females. Efforts are underway to increase uptake of the vaccine (Gardasil) that is now recommended for youth and adults up to age 45. However, little is known about the role of gender identify on vaccination, particularly among youth at increased risk for contracting and spreading the virus. Methods We analyzed data (N=1070) from a longitudinal study of high-risk HIV negative youth and youth living with HIV aged 12–24. Data were collected in Los Angeles, CA and New Orleans, LA from clinic and community settings. We examined self-reports of HPV vaccination as well as predictors of vaccination. Results Cis-gender females (CGFs) had the highest proportion of youth reporting vaccination (52.7%) followed by transgender youth (45.9%), gender non-conforming youth (44.2%), and MSM (39.0%). Cis-gendered, heterosexual males (CGHMs) reported the lowest proportion (32.9%). However, 18.8% of youth did not know if they had received the vaccine. In our multivariate logistic model examining predictors of vaccination, gender identity was only significant for CGHMs. Other significant variables included age, some education higher than a high school diploma or completing higher education compared to less than high school, ever being tested for Hepatitis C, currently having a healthcare provider, always using condoms, and Latino or other race/ethnicity compared to African-American. Conclusion Results suggest that despite national efforts to increase the uptake of the vaccine, many youth at high-risk for HPV have not received it or did not know if they had. CGFs appear to have the highest uptake, but CGMs are a group for whom increased efforts targeting vaccination are needed. Demographic and health care factors may also impact vaccination rates. Research is needed on barriers to vaccination and new interventions that go beyond education and promotion such as policy initiatives. Disclosure No significant relationships.

Background Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) disproportionately affect adolescents, however, many adolescents receive infrequent sexually transmitted infection (STI) testing. Gay, bisexual, transgender, and homeless youth are at increased risk for STIs. Currently, the Centers for Disease Control and Prevention recommend only annual screening of CT/NG for all sexually active gay, bisexual, and other men who have sex with men (MSM). Methods We recruited adolescents aged 12–24 years from homeless shelters, lesbian, gay, bisexual, transgender, and queer (LGBTQ) organizations, and community health centers in Los Angeles, California and New Orleans, Louisiana from May 2017-January 2019. All participants received point-of-care pharyngeal, rectal, and urethral/vaginal CT/NG testing using the Cepheid GeneXpert (Sunnyvale, CA). We measured the proportion of participants with CT/NG infections every 4 months for 12 months. We compared the proportion of STI positivity at each time point to the baseline visit using a McNemar’s test. Results Overall, 156 participants received testing (53 MSM/transgender women, 56 heterosexual men, 47 heterosexual women). Baseline prevalence of CT/NG among MSM and transgender women was 18.9%. At the 4 month visit, prevalence was 5.7% (Δ = 13.2%, P-value = 0.04). At the 8 month visit, prevalence was 15.1% (Δ = 3.8%, P-value = 0.99). At the 12 month visit, prevalence of CT/NG was 3.8%, a 15.1% decrease from baseline (P-value = 0.02). There was no significant difference in prevalence among heterosexual men between their baseline visit (5.4%) and their 12-month visit (8.9%) (Δ = 3.5%, P-value = 0.82). There was no significant difference in prevalence among heterosexual women between their baseline visit (10.6%) and their 12-month visit (8.5%) (Δ = 2.1%, P-value = 0.99). Conclusion Providing regular testing among adolescent MSM and transgender women may be beneficial in reducing the prevalence of CT/NG infections. Reasons for failure to reduce prevalence among heterosexual men and women require further study. Disclosure No significant relationships.

Author(s): Nielsen-Saines, Karin; Mitchell, Kate; Kerin, Tara; Fournier, Jasmine; Kozina, Leslie; Andrews, Brenda; Cortado, Ruth; Bolan, Robert; Flynn, Risa; Rotheram, Mary Jane; Abdalian, Sue Ellen; Bryson, Yvonne; Adolescent Medicine Trials Network (ATN) CARES Team; Mobilizing Minds Research Group | Abstract: BackgroundEarly treatment studies have shown that prompt treatment of HIV with combination antiretroviral therapy (cART) can limit the size of latent viral reservoirs, thereby providing clinical and public health benefits. Studies have demonstrated that adolescents have a greater capacity for immune reconstitution than adults. Nevertheless, adolescents who acquired HIV through sexual transmission have not been included in early treatment studies because of challenges in identification and adherence to cART.ObjectiveThis study aimed to identify and promptly treat with cART youth aged 12 to 24 years in Los Angeles and New Orleans who have acute, recent, or established HIV infection, as determined by Fiebig stages 1 to 6 determined by viral RNA polymerase chain reaction, p24 antigen presence, and HIV-1 antigen Western blot. The protocol recommends treatment on the day of diagnosis when feasible. Surveillance and dedicated behavioral strategies are used to retain them in care and optimize adherence. Through serial follow-up, HIV biomarkers and response to antiretroviral therapy (ART) are assessed. The study aims to assess viral dynamics, decay and persistence of viral reservoirs over time, and correlate these data with the duration of viral suppression.MethodsA total of 72 youth (36 acutely infected and 36 treatment naive controls) are enrolled across clinical sites using a current community-based strategy and direct referrals. Youth are prescribed ART according to the standard of care HIV-1 management guidelines and followed for a period of 2 years. Assessments are conducted at specific time points throughout these 2 years of follow-up for monitoring of adherence to ART, viral load, magnitude of HIV reservoirs, and presence of coinfections.ResultsThe study began enrolling youth in July 2017 across study sites in Los Angeles and New Orleans. As of September 30, 2018, a total of 37 youth were enrolled, 12 with recently acquired, 16 with established HIV infection as determined by Fiebig staging, and 9 pending determination of Fiebig status. Recruitment and enrollment are ongoing.ConclusionsWe hypothesize that the size of the HIV reservoir and immune activation markers will be different across groups treated with cART, that is, those with acute or recent HIV infection and those with established infection. Adolescents treated early who are virally suppressed will have diminished HIV reservoirs than those with established infection. These youth may be potential candidates for a possible HIV vaccine and additional HIV remission intervention trials. Our study will inform future studies of viral remission strategies.International registered report identifier (irrid)DERR1-10.2196/10807.

Background: Sexually transmitted infection (STI) rates are increasing in the United States, with approximately half of new infections occurring among adolescents aged 15-24 years. Gay, bisexual, and transgender youth (GBTY), homeless youth, and youth with histories of drug use, mental health disorders, and incarceration are all at uniquely high risk for STIs. However, these adolescents often lack access to sexual health services. Objective: This study aims to use point-of-care STI tests in community-based settings to screen for and treat STIs in adolescents. Methods: We are recruiting 1500 HIV-uninfected youth and 220 HIV-infected youth from homeless shelters, GBTY organizations, and community health centers in Los Angeles, California and New Orleans, Louisiana. Study participants will receive STI screening every 4 months for 24 months. STI screening includes rapid HIV, syphilis, Chlamydia trachomatis, Neisseria gonorrhoeae, and Hepatitis C virus testing. Trained paraprofessionals will conduct all STI testing. When a participant screens positive for an STI, they are either linked to a partner medical clinic or provided with same-day antibiotic therapy and expedited partner therapy. We will monitor STI prevalence among study participants as well as point-of-care test performance, linkage to care, and treatment outcomes. Results: The project was funded in 2016, and enrollment will be completed in 2019. Preliminary data analysis is currently underway. Conclusions: As STI rates continue to rise, it is important to improve access to screening and treatment services, particularly for high-risk adolescents. In this study, we aim to evaluate the use of point-of-care STI diagnostic tests in community-based organizations. We hope to determine the prevalence of STIs among these adolescents and evaluate the acceptability and feasibility of community-based STI screening and treatment. Trial Registration: ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833 International Registered Report Identifier (IRRID): DERR1-10.2196/10795

Background: Over 20% of HIV diagnoses in the United States are among youth aged 12-24 years. Furthermore, youth have the lowest rates of uptake and adherence to antiretroviral (ARV) medications and are least aware of their HIV status. Objective: Our objective was to design a set of interrelated studies to promote completion of each step of the HIV Prevention Continuum by uninfected youth at high risk (YHR), as well as completion of steps in the Treatment Continuum by youth living with HIV (YLH). Methods: Gay, bisexual, and transgender youth; homeless youth; substance-abusing youth; youth with criminal justice contact; and youth with significant mental health challenges, particularly black and Latino individuals, are being recruited from 13 community-based organizations, clinics, drop-in centers, and shelters in Los Angeles and New Orleans. Youth are screened on the basis of self-reports and rapid diagnostic tests for HIV, drug use, and sexually transmitted infections and, then, triaged into one of 3 studies: (1) an observational cohort of YLH who have never received ARV medications and are then treated—half initially are in the acute infection period (n=36) and half with established HIV infection (n=36); (2) a randomized controlled trial (RCT) for YLH (N=220); and (3) an RCT for YHR (N=1340). Each study contrasts efficacy and costs of 3 interventions: an automated messaging and weekly monitoring program delivered via text messages (short message service, SMS); a peer support intervention delivered via social media forums; and coaching, delivered via text message (SMS), phone, and in-person or telehealth contacts. The primary outcomes are assessing youths’ uptake and retention of and adherence to the HIV Prevention or Treatment Continua. Repeat assessments are conducted every 4 months over 24 months to engage and retain youth and to monitor their status. Results: The project is funded from September 2016 through May 2021. Recruitment began in May 2017 and is expected to be completed by June 2019. We expect to submit the first results for publication by fall 2019. Conclusions: Using similar, flexible, and adaptable intervention approaches for YLH and YHR, this set of studies may provide a roadmap for communities to broadly address HIV risk among youth. We will evaluate whether the interventions are cost-efficient strategies that can be leveraged to help youth adhere to the actions in the HIV Prevention and Treatment Continua. International Registered Report Identifier (IRRID): DERR1-10.2196/10759

Introduction Future HIV vaccine efficacy trials with adolescents will need to ensure that participants comprehend study concepts in order to confer true informed assent. A Hepatitis B vaccine trial with adolescents offers valuable opportunity to test youth understanding of vaccine trial requirements in general. Methods Youth reviewed a simplified assent form with study investigators and then completed a comprehension questionnaire. Once enrolled, all youth were tested for HIV and confirmed to be HIV-negative. Results 123 youth completed the questionnaire (mean age=15 years; 63% male; 70% Hispanic). Overall, only 69 (56%) youth answered all six questions correctly. Conclusions Youth enrolled in a Hepatitis B vaccine trial demonstrated variable comprehension of the study design and various methodological concepts, such as treatment group masking.

Purpose: To characterize sexual behaviors and sociodemographic factors that are associated with douching among geographically diverse adolescent women with and without HIV infection. Methods: HIV infected subjects recruited preferentially and behaviorally comparable high-risk HIV uninfected subjects were enrolled in a prospective HIV study from 15 sites in 13 U.S. cities. Baseline interview data from 1996 to 1999 for females aged 12 to 19 years were analyzed using one-way analysis of variance and multiple logistic regression. Results: Among the 342 females/young women, 74.9% were black (non-Hispanic), 11.1% Hispanic/Latina, and 14.0% white or other race/ethnicity; 63.5% were HIV infected. Young women who had dropped out of high school comprised 23.4% of subjects. In the 3 months before the interview, 179 (52.3%) adolescents had douched at least once. In a multivariable logistic regression model, recent douching was more common among sexually active females (OR = 2.2; 95% CI: 1.2–4.2), Blacks (OR = 2.2; 95% CI: 1.2–4.1 vs. Hispanics/Whites/others), females who dropped out of high school (OR = 2.1; 95% CI: 1.2–3.7), and HIV infected females (OR = 1.7; 95% CI: 1.04–2.7). Conclusions: In this nationwide study, adolescents who are sexually active, African-American, dropped out of high school, and HIV infected were most likely to douche. Interventions to discourage douching should pay special attention to these populations.

Purpose: To describe disclosure of HIV serostatus by infected youth to parents and sexual partners and to examine the association of disclosure with subject characteristics. Methods: Baseline data on 317 HIV infected adolescents in national 15 site study were examined. Data sources included direct and computer-assisted interview, laboratory studies, and chart reviews. Examination of parental disclosure was restricted to subjects without parental permission requirements. Concordance in parental disclosure/support used McNemar's test. Associations between disclosure to parent(s) and subject characteristics were examined using logistic regression analysis. Repeated measure analysis was used for sexual partner disclosure. Results: Subjects of both genders more often disclosed their HIV infection status to mothers than to their fathers (77% vs. 47%, p Conclusions: Although subjects were more likely to reveal their status to their mothers, parental support was perceived as high after disclosure to either parent. Since "time since diagnosis" was associated with parental disclosure, support systems are necessary for youth until such a disclosure can occur.

This seroprevalence report examines serologic evidence of hepatitis B immunization or infection and associated demographic/behavioral factors in adolescent (aged 12-20) subjects enrolled in a nonth...

Purpose: There is limited information regarding the clinical manifestations of human immunodeficiency virus (HIV) infection among adolescents. To better define the clinical presentation and course of HIV disease in this population, a retrospective review of all HIV-infected persons age 13–21 years at entry into a public, inner-city HIV outpatient clinic in New Orleans, Louisiana, was undertaken. Results: A total of 141 adolescents were included in this study. The cohort was predominantly female (65%) and African-American (83%), and acquired HIV infection through sexual contact (89%). As many as 75% of the females and 48% of the males were diagnosed with at least one sexually transmitted disease (STD), respectively, and young African-American females with a CD 4 cell count > 500/mm 3 were at highest risk. The proportions of female adolescents having a gravida ≥ 1 and 2 were 82% and 20%, respectively. A total of 55% of females were diagnosed with squamous intraepithelial lesions (SIL) at least once. Similar to adults, the majority of opportunistic processes occurred in adolescents with a CD 4 cell count 3 . Known HIV-related symptoms (oral hairy leukoplakia, thrush, and zoster) were significantly predictive ( p Conclusions: Although HIV-related symptoms and infections do not appear to be unique in the adolescent population, it is clear that STDs and pregnancies are common among female adolescents. Our results emphasize the need for aggressive STD and contraceptive protection counseling, and surveillance screening for STDs and cervical dysplasia.

Future HIV vaccine efficacy trials with adolescents will need to ensure that participants comprehend study concepts in order to confer true informed assent. A Hepatitis B vaccine trial with adolescents offers valuable opportunity to test youth understanding of vaccine trial requirements in general.Youth reviewed a simplified assent form with study investigators and then completed a comprehension questionnaire. Once enrolled, all youth were tested for HIV and confirmed to be HIV-negative.123 youth completed the questionnaire (mean age=15 years; 63% male; 70% Hispanic). Overall, only 69 (56%) youth answered all six questions correctly.Youth enrolled in a Hepatitis B vaccine trial demonstrated variable comprehension of the study design and various methodological concepts, such as treatment group masking.

Objectives. Chlamydia trachomatis is the most prevalent bacterial sexually transmitted disease (STD) in the United States, with the highest rates reported among adolescents. Chlamydia has severe consequences including pelvic inflammatory disease and infertility, and is believed to be a cofactor in human immunodeficiency virus transmission. Given that chlamydia is predominantly asymptomatic, most cases are identified through routine screening in health care settings. Over time, screening and treatment appear to be associated with a decrease in the prevalence of disease in areas with consistent chlamydia control programs. The new availability of sensitive and specific urine tests for chlamydia (polymerase chain reaction [PCR] and ligase chain reaction [LCR]) provides the opportunity to screen large numbers of at-risk youth in a noninvasive manner. We used PCR/LCR testing to investigate the feasibility of a school-based chlamydia control program and to determine the prevalence of chlamydia infection among junior and senior high school students.Design. At three junior/senior high schools, all students, regardless of symptoms or sexual history, were given the opportunity to be tested for chlamydia using urine-based PCR or LCR testing. Only students with parental consent were eligible. Parents could not obtain test results, except if their children told them. During the five 3-week testing periods, throughout the day, classes were escorted to the testing area and each student was individually counseled regarding the opportunity to participate in the testing.Setting. Three urban public schools in Louisiana.Participants. A total of 1933 students in grades 7 through 12, including 861 girls and 1072 boys.Intervention. All students were informed about the test and taught about chlamydia during the homeroom period. Students were asked to provide a first-void urine specimen of not more than 30 mL. Specimens were refrigerated and delivered to the laboratory on the same day. Infected students were counseled and offered treatment with azithromycin, 1 g orally. They were also referred for or offered additional STD and human immunodeficiency virus testing. Infected students were asked to refer their sex partners to the city STD clinic for treatment.Main Outcome Measure. Prevalence of C trachomatis infection by grade and gender.Results. Parental consent was obtained for 2849 (86.9%) of the 3278 matriculated students in grades 7 through 12. Fifty-one parents (1.6%) returned consent forms refusing permission for their child to participate in this screening and treatment program. The remaining 378 (11.5%) could not be reached by mail or telephone. Among all students with consent, 1933 (67.8% of those consented and 59.0% of those matriculated) were tested. Girls were less likely to be tested than boys (861/1363 [63.2%] vs 1072/1465 [73.2%]).The overall prevalence of C trachomatis was 6.5%, with rates among girls more than twice that of boys (9.7% vs 4.0%). Generally, rates of infection increased with age. The prevalence rates among boys were for 7th grade, 2/208 (1%); 8th grade, 2/196 (2%); 9th grade, 10/236 (4.2%); 10th grade, 12/185 (6.5%); 11th grade, 8/146 (5.5%); and 12th grade, 9/101 (8.9%). For boys 15 to 19 year old, the prevalence of chlamydia was 5.7%. Among girls, the prevalence rates were 7th grade, 0/105 (0%); 8th grade, 11/166 (6.6%); 9th grade, 23/218 (10.6%); 10th grade 23/146 (15.8%); 11th grade, 13/118 (11%); and 12th grade, 13/107 (12.1%). Among girls 15 to 19 years old, 12.7% were infected. Of 126 infected students, treatment was provided to 111 (88%).For this project, the laboratory cost of LCR testing was $17.76 per test. Without considering clinical staff time to collect the specimens, the average laboratory cost per infected student identified was $272. For students 15 to 19 years of age, of whom 104 (8.9%) of 1170 were infected, the laboratory cost was $200 per case identified.Conclusion. School-based chlamydia screening and treatment is feasible, acceptable, relatively inexpensive, and has a high yield. The higher prevalence among girls might be explained in part by greater incidence of symptoms among boys, prompting earlier diagnosis and treatment. Also, girls may have older, more experienced partners and may have greater exposure to chlamydia early in their sexual lives. The fact that girls are probably more susceptible to infection than boys could play a role as well.DNA amplification technology as represented by PCR and LCR, the two types of tests currently available, offers the pediatrician who deals with adolescents greater flexibility in diagnosing chlamydia infections. Because the majority of chlamydia infections are asymptomatic and the disease can only be controlled through screening programs, urine-based screening may be the only practical way to accomplish this on a large scale. Schools are settings that can be used to reach the majority of adolescents.Urine-based screening for chlamydia in school settings should be considered a routine part of programs to control STDs nationally. Because, over time, screening and treatment appear to be associated with a decrease in the prevalence of disease in areas with consistent chlamydia control programs, a national school-based chlamydia control program conceivably could lead to eradication of endemic C trachomatis in the United States.

Several studies have found HIV infected adult women particularly those immunosuppressed are at higher risk than non-HIV infected women for cervical dysplasia. Although these results can probably be generalized to adolescent women there are few data pertaining to cervical dysplasia in this age group. To better understand the epidemiology of squamous intraepithelial lesions (SIL) in this population a retrospective study of 62 HIV infected adolescent women from 13-21 years of age enrolled in the HIV Outpatient Program at the Medical Center of Louisiana at New Orleans was undertaken. Demographic and clinical data in this cohort have been previously published. This study is a further analysis of the Papinicoulau (Pap) smear data. Subjects were defined as progressors either if they progressed from a Pap smear not demonstrating SIL to SIL or from low grade SIL to high grade SIL. Rapid CD4 cell count loss was defined as a loss of at least 25% of the baseline CD4 cell count in a period of 6 months. SPSS software was utilized for analyses (SSPS Statistical Software Chicago IL). Significant differences between selected characteristics were determined by Chi-square methods. (excerpt)

THE WORDS “STREET YOUTH” CONJURE DIFFERENT IMages for each reader based on experience or suppositions. Clinicians who are newly introduced to a group of homeless or marginally housed adolescents and young adults are invariably surprised by what they had never noticed before. They begin to recognize young people on the street they had previously ignored and identify street youth among their own patients. Street youth are often invisible, blending into the urban, suburban, or rural landscape. To complicate matters, street youth do not identify themselves as homeless or marginally housed unless such identifiers provide a specific advantage. Even then, street youth often resist the label because they stereotype homeless people as substance-abusing adults who should be avoided as dangerous, not individuals with whom to identify. Alternatively, street youth often depict themselves as adventurers and self-determined individualists who are living life on their own terms. Even those with a long history of neglect and abuse rarely tolerate being treated like dependents or objects of pity. The study of mortality among Montreal street youth by Roy et al in this issue of JAMA is a reminder of the vulnerability of street youth that belies their bravado. In this prospective study, 1013 street youth aged 14 to 25 years were followed every 6 months, with an average follow-up of 33.4 months between January 24, 1995, and September 30, 2000. Twenty-six of these young individuals died. The high mortality rate, more than 11 times that of the general youth population in Montreal, is consistent with other investigators’ reports of elevated mortality ratios in other cities in Canada and the United States. Unlike earlier investigations of the mortality of homeless populations, this study treated homelessness as a time-dependent variable, permitting the authors to further conclude that mortality risk is increased during homeless periods; thus, homelessness in itself, not just being a street youth with tenuous housing and risky behavior, is an independent predictor of death. Factors mediating the effect of homelessness on the death rate could not be defined in this study but are certainly suggested by the leading causes of death: suicide and drug overdose. Infection with human immunodeficiency virus (HIV) was the strongest predictor of mortality in this study, with an adjusted hazard ratio of 5.6. This is not surprising given the rates of HIV and HIV behavior risk reported in the Montreal cohort. In a recent study of HIV-positive youth aged 12 to 18 years at baseline who were infected through sex or injection drug use and were receiving routine health care, fully 27% of both females and males reported having been homeless. Mortality was due to the complications of HIV and its treatment. For 90 male youth followed for a total of 203.3 person-years (mean follow-up time, 2.26 years), the observed death rate was 490 per 100000 person-years over the observation period; for 262 females followed for 634.4 person-years (mean follow-up time, 2.42 years), the observed death rate was 1100 per 100000 person-years (a rate much greater than the 2001 death rate of 80.7 per 100000 youth aged 15-24 years). Depression occurred in 43% of these individuals. Depression and health anxiety were related to substance abuse in this HIV-infected cohort. In the study by Roy et al, the death of 1 HIV-infected street youth was attributed to complications of HIV; 2 of the other 3 deaths among HIV-infected youth were drug overdoses. Although Roy et al did not gather specific information on depression, it is likely that depressive disorder and substance abuse coupled with HIV could increase the effect of an already high HIV death rate on mortality. The ability of Roy et al to follow 1013 street youth for an average of 33.4 months per participant is noteworthy. Tracking street youth for this length of time is difficult. The mobility of unattached youth and their friends, some of whom may be nomadic and travel to other cities over the observation period, as well as the mobility of family and other “stationary” contacts makes tracking highly dependent on relationship-building with youth, their contacts, and with organizations providing youth services. While the study participants were given $20 per visit, this amount, although respectable, will not induce many youth to make an unusual effort to participate in a study, as evidenced by the 12% refusal rate of youth approached for enrollment. The characteristics of street youth who do not participate, particularly

Human immunodeficiency virus (HIV)-infected adolescents are faced with serious psychosocial problems. It is vital that clinicians be aware of this aspect of management given the increasing rates of infected youths. To describe these problems a retrospective chart review of all HIV-infected persons 13-21 years of age at entry into a public HIV outpatient clinic in New Orleans Louisiana between November 1 1989 and February 1 1994 was conducted. Psychosocial data were collected retrospectively through medical chart review by trained abstractors. Of the 141 adolescents studied 65% were female and 83% were African-American. Median age and CD4 cell count were 18 (range 14-21 years) and 565 (range 5-1469) respectively. Clinical features of this cohort have been previously described. Fifty-two percent acquired HIV through sex 9% through injection drug use and 2% through infected blood products and 37% were unable to identify their risk factor. The majority of females (44%) were recruited into care from prenatal screening and 13% had a subsequent pregnancy during the follow-up period. Median follow-up time for the cohort was 24 months. Broken appointments were frequent averaging 1.9 missed visits/person-year or 24% of scheduled visits. (excerpt)

• Chlamydial disease in adolescent women is a serious public health problem, but secondary preventive efforts through early detection and treatment are encumbered by the cost and complexity of mass screening. This study was undertaken to identify clinical predictors of infection that might narrow the scope of screening adolescent populations. Demographic/clinical data and endocervical smears for the direct-specimen fluorescein-conjugated monoclonal antibody test for Chlamydia trachomatis were collected from 244 consecutive women, 21 years of age or less, attending an adolescent health clinic. Positive direct-specimen fluorescein-conjugated monoclonal antibody test for C trachomatis results were associated with a past history of chlamydial infection, multiple sexual partners, sexual contact with men with urethritis, nonuse of condoms, metrorrhagia, exocervicitis, mucopurulent endocervical discharge, abnormal cervical cytologic features, and isolation of Neisseria gonorrhoeae from the endocervix. These variables were entered into a discriminant analysis to predict direct-specimen fluorescein-conjugated monoclonal antibody test for C trachomatis results. The discriminant function was statistically significant but explained only 17% of between-group variance. Two variables alone, exocervicitis and partners with urethritis, correctly predicted direct-specimen fluoresceinconjugated monoclonal antibody test for C trachomatis results in 79% of all cases (negative predictive value 90%; positive predictive value 35%). When routine screening with reliable laboratory tests is not feasible, selective testing or empirical treatment of adolescent women with either risk factor may be cost-effective alternatives. ( AJDC. 1989;143:1437-1442)