Donna Futterman

The REACH (Reaching for Excellence in Adolescent Care and Health) project: study design, methods, and population profile

The Reaching for Excellence in Adolescent Care and Health (REACH) Project was designed as an observational study aimed to achieve a better understanding of HIV disease progression and co-morbidity in adolescents in the US. Direct interviews among 242 HIV-infected females and 83 males and 131 high-risk HIV-uninfected females and 40 males aged 12-18 years were conducted to examine the pathogenesis of HIV infection and its spectrum of disease in adolescents. The study also aimed to examine potential immunologic markers in peripheral blood for disease progression specific to adolescents infected with HIV. Results showed that HIV infection predominates among females and youths with poor knowledge on sexual risk behaviors. It was also shown that the seroconversion rate in the homosexual/bisexual male cohort was 7.7/100 person-years while there were no seroconversions among the HIV-uninfected females. Distribution of CD4+ T-cell numbers suggested a progression of the disease among the infected cohorts. Based on the findings the risk behaviors among HIV-infected cohorts demonstrate the need for theory-based development of secondary prevention programs for HIV-positive youth.

Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa

Abstract Nearly 30% of pregnant women in South Africa are estimated to be HIV seropositive, yet adherence to guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) is often low. A pilot study was developed to see whether PMTCT services provided by the South African Government could be enhanced by the Mamekhaya program, a combination of the mothers2mothers peer-mentoring program and a culturally adapted cognitive-behavioral intervention (CBI) from the USA. Pregnant women attending two maternity clinics offering PMTCT in Gugulethu and Vanguard Townships, Cape Town, South Africa, were invited to participate in the study. Women at the intervention site (Gugulethu) received the support of a mentor mother and also attended an eight-session Mamekhaya CBI. At the control site (Vanguard), women received standard services provided by midwives and counselors. Baseline assessments were completed by all participants at enrollment (n=160), and follow-ups were completed six months later by 44% of participants. Self-reports of adherence to PMTCT practices were high across both sites (90% or more engaging in the core practices). Women at the Mamekhaya site showed significantly greater improvement in establishing social support and reducing depression scores than women at the control site. Mamekhaya participants also showed trends for better attendance at follow-up medical visits, and greater improvements in positive coping. The greatest effect of the Mamekhaya program was to increase HIV knowledge scores, particularly with regard to understanding the meaning and importance of viral load and CD4 test results. Results from this pilot study show promise that augmenting basic PMTCT services with mentor mothers and a culturally adapted CBI can be effective in conveying information and in improving the emotional outlook and hopefulness of HIV-positive pregnant women in South Africa.

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.

Serologic response to hepatitis B vaccine in HIV infected and high-risk HIV uninfected adolescents in the REACH cohort

PURPOSE To evaluate hepatitis B (HBV) vaccine response rates in HIV infected and high-risk HIV uninfected youth and examine associations with responsiveness in the HIV infected group. METHODS Cohorts within the Reaching for Excellence in Adolescent Care and Health (REACH) study population were defined based on receipt of HBV vaccine both retrospectively and prospectively. Sero-responsiveness was determined by HBsAb measurements. Testing was done for HBsAg, HBsAb, and HBcAb. For HBsAb, a value of > 10 International Units per liter was considered a positive response, and the data were collected as either positive or negative from each of the reporting laboratories. Covariates of responsiveness were explored in univariate and multivariate models for each cohort. RESULTS Sixty-one subjects had received a three-dose vaccination course at the time of entry into REACH. HIV uninfected subjects had significantly higher rates of response by serology compared with HIV infected subjects (70% vs. 41.1%; chi(2) = .05; RR = .586, 95% CI: .36-.96). By the time of an annual visit 43 subjects had received three vaccinations with at least one occurring in the study period. The rates of response were similar for the HIV infected and uninfected groups (37.1% vs. 37.5%) in this cohort. Univariate and multivariate analysis in the prospective HIV infected group (N = 35) found an association between elevated CD8(+)/CD38(+)/HLA-DR(+) T cells and lack of HBV vaccine responsiveness (6.7% vs. 60%; chi(2) = .03; RR = .12, 95% CI: .02- .55). CONCLUSIONS The poor HBV vaccine response rate in the HIV uninfected high-risk adolescents was unexpected and suggests that HBV vaccination doses have not been optimized for older adolescents. This is the first report of decreased responsiveness in HIV infected subjects being associated with elevated CD8(+)/CD38(+)/HLA(-)DR(+) T cells and suggests that ongoing viral replication and concomitant immune system activation decreases the ability of the immune system in HIV infected subjects to respond to vaccination.

HIV and AIDS in adolescents

HIV infection in adolescents continues to challenge health providers, policymakers, and advocates for youth. There will be no relief from its complexities soon. Primary care providers are in a unique position to use effective HIV prevention and care interventions. Successful programs move beyond moralism to realism. They show a willingness to engage young people and their families in a sensitive dialogue about the needs of youthful sexual development. Youth at high risk for HIV should be identified and referred to comprehensive care and counseling as soon as possible. HIV-positive youth need intensive individual and group interventions to remain healthy and reduce transmission to others. To protect their patient population, health care providers will need to commit time and effort to making adolescents services visible, flexible, affordable, confidential, culturally appropriate, and universally available.

A profile of human immunodeficiency virus—Infected adolescents receiving health care services at selected sites in the United States

OBJECTIVE To determine the demographic/clinical profile of human immunodeficiency virus (HIV)-infected adolescents in care at selected sites. METHODS We mailed surveys requesting prevalence data from physicians in government-funded HIV research and care programs on HIV-infected youth (10-21 years) receiving care. RESULTS A total of 49% responses yielded information on 978 subjects. Vertical, blood, and sexual were predominant transmission modes. Three-quarters were of an ethnic/racial minority; 50% were female. The earliest median CD4 count was 0.467 x 10(9)/liter (467/microliter). Percent asymptomatic varied by transmission: vertical (16%), blood products (40%), male-male sexual (67%) and female-male sexual (M:73%) (F:74%). Clinical indicated Pneumocystis carinii pneumonia prophylaxis was differentially prescribed: vertical (96%), blood (89%), and sexually (male-male-47%) (female-male: M: 36% and F: 56%). Of these youth 78% are not represented in national AIDS case data. CONCLUSIONS Examination of numerator data from selected sites indicates three transmission-driven adolescent HIV epidemics with different characteristics. Minority youth are disproportionately represented; many vertically infected infants are surviving to adolescence; sexual activity is a significant transmission avenue. HIV-infected youth appear to enter care with considerable immunosuppression. Clinical profiles and treatment patterns appear to differ by transmission mode. Further study is needed on adolescent HIV disease progression and determinants of access to care and treatment.

Guidelines for adolescent participation in research: current realities and possible resolutions.

morbidity in adolescents from drug abuse, preventable injury, violence, and unprotected sexual activity continues to increase. Moreover, with AIDS this generation of adolescents is threatened by an epidemic of potentially devastating proportions. This epidemic requires that the origins of risk-taking behaviors be understood in appropriate developmental and behavioral terms and that every opportunity be seized to learn what programs are effective in adolescent risk reduction and health mainte-

HIV infection and AIDS during adolescence.

It is clear from the evidence that a growing number of adolescents are acquiring HIV infection and developing AIDS. The impact this epidemic will have on all teenagers is overwhelming. Given the high prevalence of risk-related sexual behaviors, many adolescents are likely to become HIV infected, thus requiring extensive medical and psychosocial services. Other adolescents will lose a parent, relative, or friend to AIDS, and these adolescents will similarly require special services and psychological counseling. Thus, there is an immediate need for the development of methods for (1) providing all adolescents with age-appropriate and culturally relevant interventions for prevention and risk reduction, (2) identifying high-risk adolescents and triaging them to different levels of care and risk reduction counseling, and (3) providing ongoing medical and psychosocial treatments. Accessing adolescents at risk for HIV infection will require networking between the health care system and youth-serving and community-based agencies, particularly agencies servicing high-risk adolescents. We must begin addressing these needs now, in order to prevent further infection and to provide appropriate care for those adolescents who are or will become infected with HIV.

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.

Serologic examination of hepatitis B infection and immunization in HIV-positive youth and associated risks

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 nontherapeutic clinical trial at 43 Pediatric AIDS Clinical Trials Group (PACTG) clinical centers. Subjects (n = 94) infected with the human immunodeficiency virus (HIV) through sexual activity were categorized as hepatitis B virus (HBV)-immunized, HBV-infected, or nonimmune by hepatitis B serology performed on specimens collected within the subjects first 48 weeks on study (1993-1995). Sixteen percent of the 94 serologically classified subjects were immunized; 19% HBV-infected; 65% nonimmune. Of the three risk factor scores examined (sociodemographic, sexual, and substance abuse), substance use alone demonstrated a significant difference among groups (despite virtually no reported injecting drug behavior), with the sexual risk score exhibiting marginally significant differences. Logistic regression analysis (restricted to nonimmunized subjects) showed that male-male sexual activity raised the odds of HBV infection by a factor of 5.14 (95% confidence interval [CI]: 1.45-18. 23) relative to heterosexual activity; and that for every one point increase on the substance abuse risk scale the odds of infection increased 5% (95% CI: 0.99-1.10). The HBV infection rate in PACTG 220 HIV-positive females is twice United States population-based rates; the rate in PACTG 220 HIV-positive males is nearly seven times higher. Past immunization efforts in this population appear to have been based on sexual activity volume without regard to injecting-drug use in sex partners.