Angulique Y. Outlaw

Characteristics associated with retention among African American and Latino adolescent HIV-positive men: results from the outreach, care, and prevention to engage HIV-seropositive young MSM of color special project of national significance initiative.

Background:Surveillance points to an urgent public health need for HIV prevention, access, and retention among young men of color who have sex with men (YMSM). The purpose of this multisite study was to evaluate the association between organizational- and individual-level characteristics and retention in HIV care among HIV-positive YMSM of color. Methods:Data were collected quarterly via face-to-face interviews and chart abstraction between June 2006 and September 2008. Participants were aged 16-24 years, enrolled at 1 of 8 participating youth-specific demonstration sites, and engaged or reengaged in HIV care within the last 30 days. Generalized estimating equations were used to examine factors associated with missing research and care visits. Stata v.9.0se was used for analysis. Results:Of 224 participants, the majority were African American (72.7%), 19-22 years old (66.5%), had graduated high school or equivalent (71.8%), identified as gay or homosexual (80.8%), and disclosed having had sex with a man before HIV diagnosis (98.2%). Over the first 2¼ years of the study, only 11.4% of visits were missed without explanation or patient contact. Characteristics associated with retention included being <21 years old, a history of depression, receipt of program services, and feeling respected at clinic; those associated with poorer retention included having a CD4 count <200 at baseline and being Latino. Conclusions:Special Projects of National Significance programs were able to achieve a high level of retention over time, and individual and program characteristics were associated with retention. Latino YMSM, those not receiving services, and those not perceiving respect at the clinic were at increased risk of falling out of care. Retention is essential to providing HIV+ adolescents with treatment, including reducing antiretroviral resistance development. Innovative programs that address the needs of the YMSM of color population may result in improved retention.

Age of MSM Sexual Debut and Risk Factors: Results from a Multisite Study of Racial/Ethnic Minority YMSM Living with HIV

The average reported age of sexual debut for youth in the United States is 14.4 years, with approximately 7% reporting their sexual debut prior to age 13. While the research literature on sexual debut for youth addresses gender and ethnic differences (with males and African-American youth experiencing earlier sexual debut), there is limited data regarding factors associated with sexual debut for young men who have sex with men (YMSM). Early sexual debut poses potential health risks, such as contracting HIV with an increased risk of unprotected intercourse. Given current high HIV infection rates for racial/ethnic minority YMSM, learning more about their sexual debuts and associated risk factors of this population is of great importance. This study investigated risk behaviors and emotional distress, and their association with MSM sexual debut for a multisite cohort of racial/ethnic minority YMSM living with HIV. We hypothesized that a MSM sexual debut younger than age 16 would be associated with engagement in more high-risk sexual behaviors (unprotected sex and exchange sex), substance use, and emotional distress than a MSM sexual debut at age 16 or older. Results indicated that participants having a MSM sexual debut before the age of 16 reported more exchange sex; drug use (specifically marijuana); emotional/psychological problems related to substance use; and a history of suicide attempts, compared to participants with later MSM sexual debuts. Comprehensive interventions that are racially/ethnically sensitive, inquire about initial sexual experiences, and focus on sexual health and healthy relationships are needed to improve health outcomes for this population.

Motivational interviewing by peer outreach workers: a pilot randomized clinical trial to retain adolescents and young adults in HIV care

Abstract Youth living with HIV (YLH) are at particularly high risk for poor retention in HIV primary care. This study utilized Motivational Interviewing (MI) to improve youth retention in primary care and compared the fidelity and outcomes of peer outreach workers (POW) to masters level staff (MLS). Eighty-seven YLH were randomized to receive two MI sessions from POW or MLS. YLH were aged 16–29 and 92% were African American. Thirty-seven audiotaped sessions were coded with the Motivational Interviewing Treatment Integrity (MITI) coding system. Retention in care was assessed by review of medical records. POW had higher fidelity on two MITI scales, and did not differ from MLS on remaining three scales. While both groups improved the regularity of primary care appointments, the effect size for POW on retention in care and intervention dose was larger than that of MLS. The results suggest that POW can provide MI with quality comparable to MLS with adequate training and supervision. MI provided by POW to improve retention in health care services may increase the cost-effectiveness of evidence-based practices in urban settings.

Early linkage and retention in care: Findings from the outreach, linkage, and retention in care initiative among young men of color who have sex with men

Early linkage and retention in HIV clinical care is essential for optimal disease management, promotion of health, and receipt of secondary prevention messages to decrease onward transmission of HIV. Youth, specifically racial/ethnic minority young men who have sex with men (YMSM), continue to acquire new HIV infections and have been shown to be less likely to engage in regular HIV care and adhere to scheduled medical visits. The goal of the current study was to evaluate the characteristics of participants and program delivery that were associated with early linkage and retention in HIV care among HIV-infected YMSM of color enrolled in an outreach, linkage, and retention study. Of the 334 patients included in the linkage analysis, 72% were linked to care within 30 days of diagnosis, 81% within 60 days, and 87% within 90 days. While no patient-level characteristics were associated with early linkage, having the person who provided the positive HIV test result refer the patient to HIV care (p=0.048), specifically calling to make the appointment (p=0.009), was associated with earlier linkage. Retention of Latino participants (96.2%) was significantly higher than for the African-American (79.9%) youth (p=0.006). Overall, 221 participants had at least 1 year of possible follow-up and 82.8% of these participants were retained at 1 year. While unique challenges exist in the care of adolescents infected with HIV from identification to engagement and retention in clinical care, programs that are responsive and dedicated to the needs of these youth can be successful in retaining them in care.

Racial and sexual identity-related maltreatment among minority YMSM: prevalence, perceptions, and the association with emotional distress

Bullying is a form of violence characterized as an aggressive behavior that is unprovoked and intended to cause harm. Prior studies have found that lesbian, gay, bisexual, and transgender (LGBT) youth experience high levels of bullying related to their sexuality and this harassment can lead to engagement in risk behaviors, depression, and suicide. Ethnic/racial minority young men who have sex with men (YMSM) may experience dual levels of stigma and maltreatment due to both their sexuality and their race. The aim of the current study was to assess the prevalence and perceptions of racial and sexual identity-based abuse among a sample of minority YMSM, and whether this maltreatment plays a role in the emotional distress of these youth. We found that overall 36% and 85% of participants experienced racial and sexuality-related bullying, respectively. There was a significant association between experiencing a high level of sexuality-related bullying and depressive symptomatology (p=0.03), having attempted suicide (p=0.03), and reporting parental abuse (p=0.05). We found no association between racial bullying and suicide attempts. In a multivariable logistic regression model, experiencing any racial bullying and high sexuality-related bullying were significant predictors of having a CES-D score ≥16; adjusted odds ratio (OR) 1.83 and 2.29, respectively. These findings contribute to the existing literature regarding the negative experiences and daily stressors facing LGBT youth with regard to both their minority status and LGBT identities. Future interventions for racial/ethnic minority YMSM should provide assistance to achieve a positive view of self that encompasses both their racial and sexual identities.

Using motivational interviewing in HIV field outreach with young african american men who have sex with men: A randomized clinical trial

OBJECTIVES We sought to determine whether field outreach with motivational interviewing, as compared with traditional field outreach, leads to increases in HIV counseling and testing and rates of return for test results among young African American men who have sex with men (MSM). METHODS In a randomized, 2-group, repeated-measures design, 96 young African American MSM completed a motivational interviewing-based field outreach session and 92 young African American MSM completed a traditional field outreach session. The percentages of participants agreeing to traditional HIV counseling and testing (an oral swab of the cheek) and returning for test results were the primary outcome measures. RESULTS More of the participants in the motivational interviewing condition than the control condition received HIV counseling and testing (49% versus 20%; chi(2)(1) = 17.94; P = .000) and returned for test results (98% versus 72%; chi(2)(1) = 10.22; P = .001). CONCLUSIONS The addition of motivational interviewing to field outreach is effective in encouraging high-risk young African American MSM to learn their HIV status. Also, peer outreach workers can be effectively trained to reduce health disparities by providing evidence-based brief counseling approaches targeting high-risk minority populations.

Motivational Enhancement System for Adherence (MESA): Pilot Randomized Trial of a Brief Computer-Delivered Prevention Intervention for Youth Initiating Antiretroviral Treatment

OBJECTIVE To pilot test a two-session computer-delivered motivational intervention to facilitate adherence among youth with HIV newly prescribed antiretroviral treatment (ART). METHODS Youth (N = 76) newly prescribed ART were recruited from 8 sites, and were randomized to the intervention or an active nutrition and physical activity control. Primary outcomes were HIV-1 viral load at baseline, 3 months, and 6 months, and self-reported adherence at 3 and 6 months. RESULTS Satisfaction ratings were high. Effect sizes suggested that the intervention group showed a greater drop than controls in viral load from baseline to 6 months (Cohens d = 0.39 at 3 months; d = 0.19 at 6 months), and had greater percent undetectable by 6 months (d = 0.28). Effects sizes were medium to large for 7-day and weekend adherence. CONCLUSIONS A brief computer-delivered motivational intervention showed promise for youth starting ART and is ready to be tested in a full-scale clinical trial.

Patterns of HIV Disclosure and Condom Use Among HIV-Infected Young Racial/Ethnic Minority Men Who Have Sex with Men

Recent findings highlight the continued rise in cases of HIV infection among racial/ethnic minority young men who have sex with men (YMSM). In adults, disclosure of HIV status has been associated with decreased sexual risk behaviors but this has not been explored among YMSM. In this study of 362 HIV-infected racial/ethnic minority YMSM, rates of disclosure were high, with almost all disclosing their status to at least one person at baseline. The majority had disclosed to a family member, with higher disclosure rates to female relatives compared with males. After adjustment for site, disclosure to sex partners and boyfriends was associated with an increase in condom use during both oral and anal sex. Future studies should consider skills training to assist youth in the disclosure process, facilitate how to determine who in their family and friend social network can be safely disclosed to and support family-based interventions.ResumenLos resultados recientes destacan el continuo aumento de los casos de infección por VIH entre los hombres de las minorías raciales/étnicas jóvenes que tienen sexo con hombres (YMSM). En los adultos, la revelación del estado de VIH se ha asociado con una disminución de las conductas sexuales de riesgo, pero esto no ha sido explorado entre YMSM. En este estudio de 362 infectados por el VIH YMSM minoría racial/étnico, las tasas de revelación fueron altas, con casi toda revelación de su estado al menos una persona en la línea base. La mayoría había revelado a un miembro de la familia, con tasas más altas de divulgación a familiares mujeres en comparación con los varones. Después del ajuste para el sitio, la revelación a las parejas sexuales y los novios se asoció con un aumento en el uso del condón durante el sexo oral y anal. Los estudios futuros en cuenta la formación profesional para ayudar a los jóvenes en el proceso de divulgación, facilitar la forma de determinar quién en su familia y la red social puede ser amigo de forma segura y compartida con las intervenciones de apoyo basadas en la familia.

Ancillary services and retention of youth in HIV care.

Abstract The purpose of this prospective study was to test the relationship between receipt of ancillary services (case management, advocacy, counseling) over six months and retention of youth in HIV care in the subsequent six months. Medical records of 75 youth (ages 16–25) enrolled in a comprehensive HIV care program at a university-affiliated medical center in Detroit, Michigan were reviewed for receipt of services in a 12-month period. The youth program offered medical and ancillary services in a one-stop-shopping model. The expectation for medical care for youth was at least quarterly medical appointments. A three-point scale was constructed with a score of ‘0’ indicating no gaps (at least one medical care appointment every three months in a six-month period), a score of ‘1’ indicating one gap (no appointment in one of the two quarters) and a score of ‘2’ indicating two gaps (no appointments in six months). Increased receipt of ancillary services in the first six months predicted lower gap scores in the second six months, even controlling for gap scores in the first six months. Counseling appointments were the strongest predictor. Preliminary results suggest the continued need for resources allocated to ancillary services to support retention in care.

Sexual behaviors of racial/ethnic minority young men who have sex with men

We assessed changes in sexual behaviors from baseline to 12-month follow-up among a multisite cohort of HIV-positive racial/ethnic minority young men who have sex with men enrolled in an outreach, linkage, and retention study. In the 3 months prior to their baseline interview, more than three-quarters of participants (78.5%) reported sex with at least one man (mean: 2.3 partners). Among sexually active participants, 44.2% had one partner; 50.5% had 2-9 partners; and 5.3% had 10 or more partners. Over three-quarters (77.5%) reported engaging in sex with at least one steady partner, 43.5% with at least one casual partner, and 29.5% with both casual and steady partners. Exchanging sex for money, drugs, or other needs was reported by 13.2%. Use of condoms during oral and anal sex increased significantly from baseline to 12-month follow-up (oral sex: 29.1-42.5%, p=0.02; anal sex: 67.8-76.2%, p=0.05). While unprotected anal sex significantly decreased among individuals who were new to care (34.8-18.3%, p<0.0001), it significantly increased among individuals who were previously in care (26.7-37.5%, p=0.03). Overall, exchange sex decreased from 13.3% at baseline to 5.0% at 12 months (p=0.001). Despite reductions in unprotected sexual encounters and exchange sex through one year of follow-up, many participants continued to engage in high-risk sexual behaviors. Retention within this study appeared to be associated with decreases in high-risk sexual behaviors, especially among participants who were new to care, although more research is needed. Future studies should investigate sexual network characteristics and the prevalence of behaviors such as serosorting.