Brittany D. Chambers

Transitioning HIV-infected adolescents to adult care at 14 clinics across the United States: using adolescent and adult providers’ insights to create multi-level solutions to address transition barriers

ABSTRACT HIV-infected adolescents have disproportionately low rates of care retention and viral suppression. Approximately half disengage from care while transitioning to adult clinics, in part due to fragmented care systems and lack of streamlined protocols. We conducted 58 qualitative interviews with social service and health care providers across 14 Adolescent Trials Network clinics (n = 28) and 20 adult clinics that receive transitioning adolescents (n = 30) from August 2015–June 2016. We used the constant comparative approach to examine processes, barriers, and facilitators of adult care transition. Transition barriers coalesced around three levels. Structural: insurance eligibility, transportation, and HIV-related stigma; Clinical: inter-clinic communication, differences in care cultures, and resource/personnel limitations; and Individual: adolescents’ transition readiness and developmental capacity. Staff-initiated solutions (e.g., grant-funded transportation) were often unsustainable and applied individual-level solutions to structural-level barriers. Comprehensive initiatives, which develop collaborative policies and protocols that support providers’ ability to match the solution and barrier level (i.e., structural-to-structural), are sorely needed. These initiatives should also support local systematic planning to facilitate inter-clinic structures and communication. Such approaches will help HIV-infected adolescents transition to adult care and improve long-term health outcomes.

Using the Multiphase Optimization Strategy (MOST) to Develop an Optimized Online STI Preventive Intervention Aimed at College Students: Description of Conceptual Model and Iterative Approach to Optimization

This chapter describes some aspects of an application of the multiphase optimization strategy (MOST) to optimize and evaluate itMatters, an online intervention that targets the intersection of alcohol use and sexual behaviors to reduce sexually transmitted infections (STIs) among college students. The chapter emphasizes two aspects of this application. First, we describe the development of a detailed conceptual model during the preparation phase of MOST. This conceptual model guided decisions such as the choice of outcome variables. Second, we describe an iterative approach to experimentation during the optimization phase of MOST. The objective of the iterative approach is to build a highly effective intervention by using repeated optimization trials to evaluate which intervention components meet a given criterion for effectiveness and which do not. Revisions are undertaken to improve the components that do not meet the criterion, and then a subsequent optimization trial is used to reevaluate the components. This iterative approach has the potential to enable the investigator to develop more effective, efficient, economical, and scalable interventions.

Using Index of Concentration at the Extremes as Indicators of Structural Racism to Evaluate the Association with Preterm Birth and Infant Mortality-California, 2011-2012.

Disparities in adverse birth outcomes for Black women continue. Research suggests that societal factors such as structural racism explain more variation in adverse birth outcomes than individual-level factors and societal poverty alone. The Index of Concentration at the Extremes (ICE) measures spatial social polarization by quantifying extremes of deprived and privileged social groups using a single metric and has been shown to partially explain racial disparities in black carbon exposures, mortality, fatal and non-fatal assaults, and adverse birth outcomes such as preterm birth and infant mortality. The objective of this analysis was to assess if local measures of racial and economic segregation as proxies for structural racism are associated and preterm birth and infant mortality experienced by Black women residing in California. California birth cohort files were merged with the American Community Survey by zip code (2011–2012). The ICE was used to quantify privileged and deprived groups (i.e., Black vs. White; high income vs. low income; Black low income vs. White high income) by zip code. ICE scores range from − 1 (deprived) to 1 (privileged). ICE scores were categorized into five quintiles based on sample distributions of these measures: quintile 1 (least privileged)–quintile 5 (most privileged). Generalized linear mixed models were used to test the likelihood that ICE measures were associated with preterm birth or with infant mortality experienced by Black women residing in California. Black women were most likely to reside in zip codes with greater extreme income concentrations, and moderate extreme race and race + income concentrations. Bivariate analysis revealed that greater extreme income, race, and race + income concentrations increased the odds of preterm birth and infant mortality. For example, women residing in least privileged zip codes (quintile 1) were significantly more likely to experience preterm birth (race + income ICE OR = 1.31, 95% CI = 1.72–1.46) and infant mortality (race + income ICE OR = 1.70, 95% CI = 1.17–2.47) compared to women living in the most privileged zip codes (quintile 5). Adjusting for maternal characteristics, income, race, and race + income concentrations remained negatively associated with preterm birth. However, only race and race + income concentrations remained associated with infant mortality. Findings support that ICE is a promising measure of structural racism that can be used to address racial disparities in preterm birth and infant mortality experienced by Black women in California.

The Promise of Intersectional Stigma to Understand the Complexities ofAdolescent Pregnancy and Motherhood

For decades, adolescent pregnancy prevention strategies focused on proximal determinants. These strategies resulted in impressive declines in US adolescent pregnancy and birth rates, reaching historic lows in 2014. However, disparities in adolescent birth rates by race/ethnicity and socioeconomic status persist. Further, not only are adolescents of color and those who live in underserved communities more likely to become pregnant, they are also more likely than their white and more affluent peers to experience negative health and social consequences of pregnancy and parenthood. More distal or “upstream” factors, such as social stigma, may cause these persistent disparities. This paper aims to build upon a nascent framework, intersectional stigma, and show how it may shape efforts to address the needs of adolescent mothers. Stigma is defined as a deeply discrediting attribute that marginalizes groups of people as “other.” Intersectional stigma posits that individuals may experience stigma resulting from the dynamic interaction of multiple marginalized social identities. Adolescent pregnancy and motherhood often cross multiple oppressed identities (e.g., minority race/ethnicity, single motherhood, low socioeconomic status), resulting in intersectional stigma. This stigma is experienced at school, in healthcare and social services, through media, and in public. As a result, adolescent mothers describe experiencing shame, guilt, and unhealthy coping strategies including avoiding the locations and institutions involved in their experience of stigma. Doing so can lead to repeat births and delinquent behaviors. The intersectional stigma framework provides a guide to the development of interventions to reduce stigma and improve outcomes for pregnant and parenting adolescents.

The Intersection Between Women’s Reproductive Desires and HIV Care Providers’ Reproductive Health Practices: A Mixed Methods Analysis

Background HIV-positive women in the United States can have healthy pregnancies and avoid transmitting HIV to their children. Yet, little is known about the extent to which HIV care providers’ reproductive health practices match women’s pregnancy desires. Accordingly, we explored young HIV-positive women’s pregnancy desires and reproductive health behaviors and examined reproductive health information offered by HIV care clinics. Methods A mixed-method analysis was conducted using data from a 14-site Adolescent Medicine Trials Network (ATN) study. We conducted descriptive statistics on data from 25 HIV-positive women (e.g., demographics, pregnancy desires, and sexual- and health-related behaviors). Qualitative interviews with 58 adolescent and adult clinic providers were analyzed using the constant comparative method. Results About half of the women reported using reproductive health care services (i.e., contraception and pregnancy tests) (n = 12) and wanted a future pregnancy (n = 13). Among women who did not desire a future pregnancy (n = 5), three used dual methods and two used condoms at last sexual encounter. Qualitative themes related to clinics’ approaches to reproductive health (e.g., “the emphasis…is to encourage use of contraceptives”) and the complexity of merging HIV and reproductive care (e.g., “We [adolescent clinic] transition pregnant moms from our care back and forth to adult care”). Discussion Despite regular HIV-related medical appointments, HIV-positive women may have unaddressed reproductive health needs (e.g., pregnancy desire with providers focused on contraceptive use). Findings from this study suggest that increased support for young HIV-positive women’s reproductive health is needed, including supporting pregnancy desires (to choose when, how, and if, to have children).

Testing the Association Between Traditional and Novel Indicators of County-Level Structural Racism and Birth Outcomes among Black and White Women

Despite decreases in infants born premature and at low birth weight in the United States (U.S.), racial disparities between Black and White women continue. In response, the purpose of this analysis was to examine associations between both traditional and novel indicators of county-level structural racism and birth outcomes among Black and White women. We merged individual-level data from the California Birth Statistical Master Files 2009–2013 with county-level data from the United States (U.S.) Census American Community Survey. We used hierarchical linear modeling to examine Black-White differences among 531,170 primiparous women across 33 California counties. Traditional (e.g., dissimilarity index) and novel indicators (e.g., Black to White ratio in elected office) were associated with earlier gestational age and lower birth weight among Black and White women. A traditional indicator was more strongly associated with earlier gestational age for Black women than for White women. This was the first study to empirically demonstrate that structural racism, measured by both traditional and novel indicators, is associated with poor health and wellbeing of infants born to Black and White women. However, findings indicate traditional indicators of structural racism, rather than novel indicators, better explain racial disparities in birth outcomes. Results also suggest the need to develop more innovative approaches to: (1) measure structural racism at the county-level and (2) reform public policies to increase integration and access to resources.

The Association Between the Intersection of Immigrant Status and Insurance with Adverse Birth Outcomes Among Mexican Women Residing in the San Joaquin Valley: A Mediation Analysis of Late Initiation or No Prenatal Care

Latinos are the largest growing population and have the highest fertility rates in the US. In response, this study assessed if late initiation of or no prenatal care (PNC) mediated the relationship among adverse birth outcomes and interactions between immigrant and insurance status. This study used cross-sectional data (2002–2004) limited to 109,399 women of Mexican ethnicity who had singleton births in the San Joaquin Valley, California. We conducted hierarchical mediation analyses. US-born Mexican women who used private or public insurance for PNC were more likely to have infants born at low-birth weight and premature compared to Mexican first generation immigrant women. Nonetheless, initiation of late or no PNC positively mediated the relationship between infants born premature to Mexican first generation immigrant women who used public insurance (ab/se(ab) = 2.123, p = .034). Findings from this study support acculturation theory and the need for multilevel approaches to address PNC among women of Mexican ethnicity.

Healthcare Transition for Youth Living With HIV: Outcomes from a Prospective Multi-site Study

PURPOSE Youth living with HIV (YLHIV) in the United States (U.S.) account for nearly one-third of new HIV infections and face significant barriers to care engagement; only 25% are virally suppressed. Healthcare transition (HCT) from pediatric/adolescent to adult-oriented care can be particularly disruptive. Accordingly, we prospectively examined HCT processes at 14 distinct geographical sites across the U.S. METHODS We collected Audio Computer-Assisted Self-Interviews data and abstracted electronic medical records from 135 HCT-eligible YLHIV at baseline and 9-month follow-up. Descriptive analyses and multilevel modeling were conducted. Data also included qualitative interviews with 28 adolescent and 30 adult providers across 14 adolescent and 20 adult clinics, respectively. Interviews were analyzed using the constant comparative method; this analysis focused on specific HCT recommendations. RESULTS At baseline, youth were primarily age 24 (78.8%), male (76.8%), black (78.0%), identified as a sexual minority (62.9%), had attended an HIV appointment in the past 3 months (90.2%), had Medicaid for insurance (65.2%), and were always or mostly always adherent to their antiretroviral therapy (65.9%). At the 9-month follow-up only 37% of YLHIV successfully transitioned to adult care. Both individual-level (insurance status and disclosure-related stigma) and clinic-level (adolescent clinic best practices) factors were significant. Adolescent and adult clinic staff offered recommendations to support HCT; these focused primarily on clinical changes. CONCLUSIONS This study highlights the complex set of individual- and clinic-level factors associated with HCT. Addressing these key factors is essential for developing streamlined, comprehensive, and context-specific HCT protocols to support continuous care engagement for YLHIV.

Individual and structural factors influencing HIV care linkage and engagement: Perceived barriers and solutions among HIV-positive persons

ABSTRACT To meet the National HIV/AIDS Strategy’s goals of reducing and preventing HIV transmission, understanding factors that shape HIV-positive persons’ care-seeking behaviors is critical. Accordingly, this study examined factors that affect HIV care linkage and engagement. Six focus groups were conducted with 33 HIV-positive persons living in North Carolina. A variety of factors influenced care behaviors, including: structural and policy factors, relationship with HIV care systems, and individuals’ personal characteristics. Participants also provided solutions for addressing specific factors to care. Improving clinical services and utilizing context-specific strategies can help facilitate greater care linkage and engagement.