Peter M. Keenan

Outreach, Mental Health, and Case Management Services: Can They Help to Retain HIV-Positive and At-Risk Youth and Young Adults in Care?

Objectives: To assess the impact of outreach, mental health, and case management services on retention in primary care of HIV+ and at-risk youth and young adult clients of the Boston HAPPENS program, a comprehensive adolescent HIV prevention and care network of agencies. Methods: Providers at 8 urban sites used standard data forms at each visit to collect background and service receipt information on at-risk clients aged 12–24 years. Data were aggregated across all visits for each client to create summary variables for the number of times each client received each type of service. The retention measure was the number of days between a clients first and last visits during the 4-year data collection period. Kaplan–Meier survival curve and Cox proportional hazards regression analyses were used to assess the association between receipt of the support services of interest and the retention measure. Results: The median retention times were 21 days for male clients (range, 0–1406, N = 512), and 26 days for female clients (range, 0–1577, N = 914). Among males, 45% were retained beyond a month, 24% beyond a year, and 10% beyond 2 years. Similar proportions of females were retained beyond a month and a year, but more females were retained beyond 2 years (15%). After adjusting for other covariates, both male and female clients had significantly longer retention times if they received ≥q2 outreach contacts, or case management at ≥q3 visits. Among males, receipt of mental health counseling at ≥q2 visits also increased retention times. Conclusions: These findings suggest that provision of outreach, mental health, and case management services can improve retention in care of at-risk youth and young adults.

Boston HAPPENS Program: A model of health care for HIV-positive, homeless, and at-risk youth

The Boston HAPPENS [Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services] Program is a project supported by Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration, which provides a network of care for homeless, at-risk, and HIV-positive youth (ages 12-24 years), involving eight agencies. The program has provided services to 1301 youth, including 46 who are HIV-positive. Boston HAPPENS provides a citywide network of culturally and developmentally appropriate adolescent-specific care, including: (a) outreach and risk-reduction counseling through professional and adult-supervised peer staff, (b) access to appropriate HIV counseling and testing support services, (c) life management counseling (mental health intake and visits as part of health care and at times of crisis), (d) health status screening and services needs assessment, (e) client-focused, comprehensive, multidisciplinary care and support, (f) follow-up and outreach to ensure continuing care, and (g) integrated care and communication among providers in the metropolitan Boston area. This innovative network of youth-specific care offers a continuum from street outreach to referral and HIV specialty care that crosses institutional barriers.

Primary care experiences and preferences of urban youth

There are few qualitative studies that assess the experiences and preferences of urban youth with regard to use of primary care. The purpose of this pilot survey was to identify positive and negative influences and underlying issues for adolescents leading to seeking and returning for primary health care. Four focus groups totaling 20 diverse adolescents ranging in age from 13 to 21 years were conducted between April 1994 and June 1994. Participants were recruited through existing peer leadership groups that meet regularly at community health centers or afterschool programs. Urban adolescents are most concerned with being respected and treated well by primary care providers. They want to be listened to, to have their problems taken seriously, and to be treated with dignity and respect. Participants expressed strong preferences regarding sex, sexual orientation, and language of providers, but not for race or ethnicity. Qualitative methods such as focus groups give a voice to youth to advocate for access to adolescent-specific health services. Further research is needed to corroborate the results of this study, to expand our understanding of existing problems, and to investigate the predictors of health care use by vulnerable youth.

Initiation of Services in the Boston HAPPENS Program: Human Immunodeficiency Virus-Positive, Homeless, and At-Risk Youth Can Access Services

This study evaluates the factors associated with initiation of services in the Boston HAPPENS Program, which is a collaborative network of care consisting of multiservice outreach agencies, community health centers and hospitals, for human immunodeficiency virus (HIV)-positive and hard to reach youth who are 12-24 years old. The program served 2116 youth who were 19.8 +/- 2.9 years old; 64% female; 45% youth of color; 16% gay/lesbian, bisexual, or undecided; and 10% homeless or runaway. At first contact with the program, 56% received outreach services; and 91% received a health intervention. Among those receiving a health intervention, 55% had HIV counseling and testing services, 49% medical care, 24% case management, and 9% mental health services. HIV-positive youth needed more contacts before a first medical visit than those who were HIV-negative or untested (p < 0.001). Different kinds of service sites reached different populations of at-risk youth. Logistic regression modeling showed that for young women, older age, lesbian-bisexual orientation, substance use, high-risk sexual behaviours, and receiving outreach services at first contact were independent predictors of initiation of services at outreach agencies; however, unprotected sex with males, and pregnancy were associated with a greater likelihood of care at hospitals or community health centers. For young men, older age, Asian/other ethnicity, and substance abuse were associated with care at outreach agencies; however, positive HIV status and unprotected sex with females were associated with care at hospitals or community health centers. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect underserved youth to health care.

The Boston HAPPENS program: needs and use of services by HIV-positive compared to at-risk youth, including gender differences

Objective: The Boston HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program is a linked services network of care for HIV-positive, homeless, and at risk youth in Metropolitan Boston funded by the Special Projects of National Significance Program. This report studies the needs and use of services by HIV-positive youth compared with negative and untested at-risk youth, including gender differences. Design: Providers collected information prospectively at outreach and services encounters, including demographic information, risk behaviors, and service utilization data. Results: Youth (N=1044) were 19.6±3.0 years old; 38% male; 43% youth of color; and 4% self-identified as gay/lesbian/bisexual and 11.0% as homeless and/or runaway youth. HIV-positive clients (N=26) were more likely to use a range of network related health services. HIV-positive young women were more likely to report previous pregnancy (21% vs 5%, p=0.04) or sexual contact with high risk partners such as an injection drug user (57% vs 6%, p=0.0009), an HIV-positive person (p<0.00001), or survival sex (33% vs 8%, p=0.04) than the other young women. HIV-positive young men were more likely to be youth of color (75% vs 43%, p=0.04) and self-identify as gay or bisexual (42% vs 4%, p=0.005), and to report same sex partners (80% vs 29%, p=0.03) and substance use (100% vs 26%, p=0.006) than other young men. Youth seen at an outreach site were 10 times as likely to access medical care through the program (95% CI, 6.9–14.6). Conclusions: HIV-positive youth are accessing coordinated care and there are gender differences in the needs for services. Health care policies should facilitate the development and evaluation of comprehensive, youth-specific health services for these hard to reach populations.

Evaluation of a Targeted HIV Testing Program for At-Risk Youth

With the advent of new therapies for HIV, case identification through HIV counseling and testing (CTS) has become critically important. Young women, youth of color, and disenfranchised youth are at significant risk of acquiring HIV. This study describes clients who access CTS at a program of comprehensive care for high-risk youth (aged 12 to 24 years), and assessed, using logistic regression analyses, whether youth at highest risk utilized CTS. Most of the 531 youth were female (72 percent) and nonwhite (60 percent). Sixty-eight percent received CTS. Logistic regression modeling revealed that white race and receiving care at the teaching hospital were the only independent predictors of testing. Data indicate that, despite targeted, youth-specific, developmentally appropriate and culturally sensitive outreach and intervention efforts, youth of color and high-risk youth are poorly accessing CTS. A greater understanding of the barriers to and cultural norms regarding CTS is needed.

HIV Testing Experience of a Model of Care for High Risk Youth: Testing the Worried Well ♦ 12

The Boston HAPPENS program is an innovative model of care for street youth and youth at high risk for HIV which has been providing services for 2 years. HIV testing is a major focus of the program. Voluntary confidential and anonymous HIV testing is available at the 8 program sites. This report describes clients who are accessing these services and evaluates whether youth at highest risk are using testing services. 1576 clients have been contacted by the program, 1044 (66%) of whom provided enough information for this report. Since 90% came from 3 of the 8 sites, analyses was restricted to these 942 subjects. 60% were female, 54% white, 19% black, 15% hispanic, 4% asian, 3% multi-ethnic. Mean age=21.1+2.9yrs, range 10.8 - 31.5 yrs. 4% (N=36) self-identified as gay/lesbian or bisexual (g/l/b). 176 had had an STD, 49 substance abuse problems. 24 reported survival sex, 16 sex with an injection drug user (IDU), 13 sex with an HIV+ partner. 14 had been pregnant, 4 had shared needles. 23 were HIV+, all of whom knew their HIV status before contacting the program, 2 of whom were retested by the program. 20% (N=186) reported previous HIV testing. Those who were older (p<0.001), g/l/b(p=0.001), white (p<0.0001) and had problems with substance abuse (p=0.001) were more likely to have been tested in the past. Those who had had an STD were less likely to have been previously tested (p<0.0001). 52% received pretest counseling, 48% received HIV testing, and 28% received posttest counseling through the program. No new cases of HIV infection have been diagnosed through the programs HIV testing efforts. Those who received testing were more likely to have been tested in the past (p<0.001), and be white (p<0.001). Those who had had an STD (p<0.001), sex with an IDU(p=0.003), survival sex (p=0.001), or substance use problems (p=0.04) were less likely to receive testing. These data indicate that though teens are using HIV testing services, high risk youth are not accessing HIV testing despite targeted, youth specific, developmentally appropriate and culturally sensitive outreach and intervention efforts. More research on the barriers to using HIV testing among teenagers needs to be performed so that youth at highest risk can and will access services.