Morgan M. Philbin

“Youth friendly” clinics: Considerations for linking and engaging HIV-infected adolescents into care

Linkage and engagement in care are critical corollaries to the health of HIV-infected adolescents. The adolescent HIV epidemic and adolescents unique barriers to care necessitates innovation in the provision of care, including the consideration of the clinical experience. Little research has addressed how “youth friendly” clinics may influence care retention for HIV-infected youth. We conducted 124 interviews with providers, outreach workers, and case managers, at 15 Adolescent Medicine Trials Network clinics. Photographs of each clinic documented the characteristics of the physical space. Constant comparison and content and visual narrative methods were utilized for data analysis. Three elements of youth friendliness were identified for clinics serving HIV-infected youth, including: (1) role of target population (e.g., pediatric, adolescent, HIV); (2) clinics physical environment; and (3) clinics social environment. Working to create ‘youth friendly’ clinics through changes in physical (e.g., space, entertainment, and educational materials) and social (e.g., staff training related to development, gender, sexual orientation) environments may help reduce HIV-infected adolescents unique barriers to care engagement. The integration of clinic design and staff training within the organization of a clinical program is helpful in meeting the specialized needs of HIV-infected youth.

Linking HIV-positive adolescents to care in 15 different clinics across the United States: Creating solutions to address structural barriers for linkage to care

Linkage to care is a critical corollary to expanded HIV testing, but many adolescents are not successfully linked to care, in part due to fragmented care systems. Through a collaboration of the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC) and the Adolescent Trials Network (ATN), a linkage to care outreach worker was provided to ATN clinics. Factors related to linkage were explored to better understand how to improve retention rates and health outcomes for HIV-positive adolescents. We conducted 124 interviews with staff at 15 Adolescent Trials Network clinics to better understand linkage to care processes, barriers, and facilitators. Content analysis was conducted focusing on structural barriers to care and potential solutions, specifically at the macro-, meso-, and micro-levels. Macro-level barriers included navigating health insurance policies, transportation to appointments, and ease of collecting and sharing client-level contact information between testing agencies, local health departments and clinics; meso-level barriers included lack of youth friendliness within clinic space and staff, and duplication of linkage services; micro-level barriers included adolescents readiness for care and adolescent developmental capacity. Staff initiated solutions included providing transportation for appointments and funding clinic visits and tests with a range of grants and clinic funds while waiting for insurance approval. However, such solutions were often ad hoc and partial, using micro-level solutions to address macro-level barriers. Comprehensive initiatives to improve linkage to care are needed to address barriers to HIV-care for adolescents, whose unique developmental needs make accessing care particularly challenging. Matching the level of structural solution to the level of structural barriers (i.e., macro-level with macro-level), such as creating policy to address needed youth healthcare entitlements versus covering uninsured patients with clinic funds is imperative to achieving the goal of increasing linkage to care rates for newly diagnosed adolescents.

Hepatitis B and liver cancer among three Asian American sub-groups: a focus group inquiry.

Prevalence of hepatitis B among Asian Americans is higher than for any other ethnic group in the United States. Since more than 50% of liver cancer is hepatitis B related, the burden of morbidity and mortality is extremely high among Asian Americans, highlighting the need for culturally appropriate interventions. We conducted focus groups (nxa0=xa08) with a total of 58 Korean, Vietnamese, and Chinese immigrants in Maryland to explore knowledge, awareness and perceived barriers toward hepatitis B screening and vaccinations. Thematic analysis uncovered generally low levels of knowledge and awareness of hepatitis B risks, screening, and vaccination; inter-generational differences; and barriers to prevention. Some differences arose across ethnic groups, particularly toward perceived orientation to preventive activities and the role of religious groups. High rates of hepatitis B infection among Asian Americans highlight the need for tailored interventions. These findings may assist policy strategists in implementing interventions that will facilitate the integration and scale-up of hepatitis B education, screening, and vaccination campaigns.

How physicians test: clinical practice guidelines and HIV screening practices with adolescent patients.

The aim of this study is to examine how physicians use clinical practice guidelines that call for routine HIV screening in a general adolescent medicine clinic and to determine how adolescent patients respond to routine screening. Physicians offered screening to 116 of 217 patients (53%) aged 13-21 who completed a survey. Physicians offers conformed to the latest Centers for Disease Control and Prevention (CDC) guidelines with 73% of patients because some patients not offered a test had been screened within the last year. Physicians were three times more likely (OR = 3.0; 95% CI = 1.3-6.8) to offer HIV screening to sexually active adolescents than to adolescents who reported no sexual history. Adolescent medicine physicians and their patients endorse the idea of routine screening as embodied in the latest CDC recommendations, but adolescents with no sexual history are less likely than other adolescents to accept screening when it is offered and to support a clinic policy of routine screening. Both physicians and their adolescent patients continue to test based on risk assessments.

Linking HIV-Positive Adolescents Into Care: The Effects of Relationships Between Local Health Departments and Adolescent Medicine Clinics

The fragmentation of HIV-related diagnostic and treatment services, especially for youth, is a significant barrier for engaging in care. The authors identified key elements that affected care linkage efforts and conducted 64 interviews across 15 clinical sites. The constant comparative method was used. Primary linkages to care processes are illustrated through three geographically diverse case studies. Factors included interagency relationships, data-sharing protocols, and service duplication concerns. Program improvement strategies were discussed. A strong, citywide network is helpful in coordinating care linkage services. These partnerships will be critical in effectively realizing the goals of the National HIV/AIDS Strategy.

Exploring stakeholder perceptions of facilitators and barriers to accessing methadone maintenance clinics in Yunnan Province, China

Abstract Injection drug use is an ongoing public health crisis in China and one of the largest contributors to the transmission of HIV/AIDS. Though the government has rapidly scaled up methadone maintenance treatment clinics, they have not been extensively evaluated to analyze factors influencing rates of attendance. We explored the facilitators and barriers to accessing methadone maintenance clinics in Kunming City, Yunnan Province, China. Using in-depth qualitative interviews conducted from February 2008 to June 2008 with 35 informants – injection drug users (IDUs) and key stakeholders – we explored factors that determine whether drug users decide to present at methadone clinics. Interviews were digitally recorded with consent, transcribed verbatim, and translated. Content analysis was conducted to identify themes which included general attitudes toward methadone treatment, barriers and challenges to access, and suggestions for improvement. Within these, topics included responses to methadone, its side effects, and fear of discrimination, loss of privacy, and police interference. Respondents also listed numerous suggestions for improvement including raising awareness of harm reduction both among drug users and the community, providing additional support in the form of psychological counseling, job training and behavioral therapy, and increasing communication between police, government, and public health officials. High rates of HIV infection among IDUs in China have prompted public health responses including the scale up of methadone maintenance clinics. Our results may inform policy strategists in implementing social–structural changes to create enabling environments that facilitate an increase in access to methadone clinics among IDUs in Kunming.