Ways to reduce risky sexual behaviour in homeless youth to prevent HIV

There have been a limited number of  rigorously conducted interventions to modify the sexual behaviour of homeless youth 12-24 years of age to prevent them from acquiring HIV.  More research is required to identify effective strategies for this population. In this review, we systematically searched published and unpublished accounts of interventions that had been rigorously tested . We found three eligible independently conducted randomised controlled trials testing three different interventions. All three were conducted in the United States, amongst a total of 615 homeless, male and female youth. Due to the varied delivery of interventions, outcome measurement and reporting, we were unable to aggregate outcomes to estimate summary of effect measures. The significant risk of bias associated with the three included studies and their heterogeneity necessitate caution in interpreting the effectiveness of interventions to modify sexual risk behaviour for preventing HIV in homeless youth. While studies among homeless youth are highly challenging, future trials should comply with rigorous methodology in design, delivery, outcome measurement and reporting as well as consider the changing facets of homeless youth when designing HIV prevention tools.

Authors' conclusions: 

The body of evidence does not permit conclusions on the impact of interventions to modify sexual risk behaviour in homeless youth; more research is required. While the psychosocial and contextual factors that fuel sexual risk behaviours among homeless youth challenge stringent methodologies of RCT's, novel ways for program delivery and trial retention are in need of development. Future trials should comply with rigorous methodology in design, delivery, outcome measurement and reporting.

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Background: 

Homeless youth are at high risk for HIV infection as a consequence of risky sexual behaviour. Interventions for homeless youth are challenging. Assessment of the effectiveness of interventions to modify sexual risk behaviours for preventing HIV in homeless youth is needed.

Objectives: 

To evaluate and summarize the effectiveness of interventions for modifying sexual risk behaviours and preventing transmission of HIV among homeless youth.

Search strategy: 

We searched electronic databases (CENTRAL, MEDLINE, EMBASE, AIDSearch, Gateway, PsycInfo, LILACS), reference lists of eligible articles, international health agency publication lists, and clinical trial registries. The search was updated January 2010. We contacted authors of published reports and other key role players.

Selection criteria: 

Randomised studies of interventions to modify sexual risk behaviour (biological, self-reporting of sexual-risk behaviour or health-seeking behaviour) in homeless youth (12-24 years).

Data collection and analysis: 

Data from eligible studies were extracted by two reviewers. We assessed risk of bias per the Cochrane Collaborations tool. None of the eligible studies reported any primary biological outcomes for this review. Reports of self-reporting sexual risk behaviour outcomes varied across studies precluding calculation of summary measures of effect; we present the outcomes descriptively for each study. We contacted authors for missing or ambiguous data.

Main results: 

We identified three eligible studies after screening a total of 255 unique records. All three were performed in the United States of America and recruited substance-abusing male and female adolescents (total N=615) through homeless shelters into randomised controlled trials of independent and non-overlapping behavioural interventions. The three trials differed in theoretical background, delivery method, dosage (number of sessions,) content and outcome assessments. Overall, the variability in delivery and outcomes precluded estimation of summary of effect measures. We assessed the risk of bias to be high for each of the studies. Whilst some effect of the interventions on outcome measures were reported, heterogeneity and lack of robustness in these studies necessitate caution in interpreting the effectiveness of these interventions. 

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