When can get my assignment back?
visadeewa
msm_4.pdf
A youth-focused case management intervention to engage and retain young gay men of color
in HIV care
Amy Rock Wohl a *, Wendy H. Garland
a , Juhua Wu
b , Chi-Wai Au
b , Angela Boger
b , Rhodri Dierst-Davies
a ,
Judy Carter b , Felix Carpio
c and Wilbert Jordan
d
a Los Angeles County Department of Public Health, HIV Epidemiology Program, Los Angeles, CA, USA;
b Los Angeles County
Department of Public Health, Office of AIDS Programs and Policy, Los Angeles, CA, USA; c AltaMed Health Services
Corporation, Daniel V. Lara Clinic, Los Angeles, CA, USA; d Los Angeles County MLK-MACC, OASIS Clinic, Los Angeles,
CA, USA
(Received 5 April 2010; final version received 18 November 2010)
HIV-positive Latino and African-American young men who have sex with men (YMSM) have low rates of engagement and retention in HIV care. An evaluation of a youth-focused case management intervention (YCM) designed to improve retention in HIV care is presented. HIV-positive Latino and African-American YMSM, ages
18�24, who were newly diagnosed with HIV or in intermittent HIV care, were enrolled into a psychosocial case management intervention administered by Bachelor-level peer case managers at two HIV clinics in Los Angeles County, California. Participants met weekly with a case manager for the first two months and monthly for the
next 22 months. Retention in HIV primary care at three and six months of follow-up was evaluated as were factors associated with retention in care. From April 2006 to April 2009, 61 HIV-positive participants were enrolled into the intervention (54% African-American, 46% Latino; mean age 21 years). At the time of
enrollment into the intervention, 78% of the YMSM had a critical or immediate need for stable housing, nutrition support, substance abuse treatment, or mental health services. Among intervention participants (n �61), 90% were retained in primary HIV care at three months and 70% at six months. Among those who had previously been in intermittent care (n �33), the proportion attending all HIV primary care visits in the previous six months increased from 7% to 73% following participation in the intervention (pB0.0001). Retention in HIV care at six months was associated with increased number of intervention visits (p �0.05), more hours in the intervention (p �0.02), and prescription of HAART. These data highlight the critical needs of HIV-positive African-American and Latino YMSM and demonstrate that a clinic-based YCM can be effective in stabilizing hard-to-reach clients and retaining them in consistent HIV care.
Keywords: adolescents; MSM; HIV/AIDS; Latinos; African-Americans; interventions
Introduction
National HIV and AIDS rates are elevated for
African-American and Latino youth which is consis-
tent with 2008 behavioral surveillance data in Los
Angeles County in which HIV prevalence rates were
17% for African-American and 13% for Latino
18�24-year-old young men who have sex with men (YMSM) (Bingham & Sey, 2009; Centers for Disease
Control and Prevention [CDC], 2008). Youth are also
known to test late for HIV, delay seeking care for an
HIV infection following a positive HIV test, are at high
risk for dropping out of HIV care and have poor
adherence to antiretroviral treatment regimens (Cen-
ters for Disease Control and Prevention [CDC], 2005;
Johnson, Sorvillo et al., 2003; Rao, Kekwaletswe,
Hosek, Martinez, & Rodriguez, 2007; Rudy, Murphy,
Harris, Muenz, & Ellen, for the Adolescent Trials
Network for HIV/AIDS Interventions, 2009; Valleroy
et al., 2000). In addition, among a national sample of
HIV-positive 15�22-year-old YMSM, only 15% were receiving HIV medical care and 8% were on antire-
troviral medications (Valleroy et al., 2000). Given the difficulties faced by HIV-positive
youth, targeted interventions are needed to help
YMSM access and attend regularly scheduled pri-
mary HIV care appointments. The successful man-
agement of HIV disease requires frequent lifelong
appointments with an HIV primary care provider and
uninterrupted medication use, requirements that im-
pose substantial lifestyle changes for all HIV-positive
persons (Department of Health and Human Services
[DHHS], 2008). Given the many competing chal-
lenges that HIV-positive minority YMSM face in
their daily lives including cultural and community
stigma toward their sexual orientation and HIV
status, sexual identity issues, substance abuse, mental
illness, and basic subsistence concerns regarding
employment, education, transportation, and housing,
*Corresponding author. Email: [email protected]
AIDS Care Vol. 23, No. 8, August 2011, 988�997
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2011 Taylor & Francis
DOI: 10.1080/09540121.2010.542125
http://www.informaworld.com
it is not surprising that additional support is needed
to help them manage their HIV infection (Eastwood
& Birnbaum, 2007; Mustankski, Garafalo, Herrick, &
Donenberg, 2007; Rao et al., 2007; Swendeman,
Rotheram-Borus, Comulada, Weiss, & Ramos,
2006; Valleroy et al., 2000). Several interventions have helped at-risk youth
access and remain in general medical care and several
models of integrated medical care for HIV-positive
youth have been developed (Harris et al., 2003; Huba
& Melchior, 1998; Johnson, Sorvillo et al., 2003;
Schneir, Kipke, Melchior, & Huba, 1998; Woods
et al., 1998). There are few quantitative evaluations
of interventions, however, that target HIV-positive
Latino and African-American YMSM with the goal of
improving engagement and retention in HIV care. One
intervention that included primarily HIV-negative
at-risk youth (98%) used a combination of outreach,
mental health and case management services and
reported that retention in care was correlated with
more outreach and case management contacts (Harris
et al., 2003). Another case management program
found that addressing barriers related to concrete
needs helped improve retention in HIV care for a
mostly female and young African-American sample
(Johnson, Botwinick et al., 2003). In 2004, the Health Resource and Services Ad-
ministration (HRSA) HIV/AIDS Bureau, Special
Projects of National Significance (SPNS) program
funded eight demonstration sites to identify, imple-
ment, and evaluate new models to provide outreach
and interventions for HIV-positive Latino and Afri-
can-American YMSM (Magnus et al., 2010). As one
of the demonstration sites, the Los Angeles County
Department of Public Health developed and evalu-
ated a clinic-based, youth-focused case management
intervention (YCM) to engage and retain Latino and
African-American YMSM in HIV primary care
services.
Methods
Participants were recruited from April 2006 through
April 2009 from HIV testing sites, sexually trans-
mitted disease clinics, support groups, community
colleges, clubs/bars, and two predominantly African-
American or Latino public HIV clinics in Los Angeles
County. Eligibility criteria included ages 13 to 23,
confirmed HIV-positive status, African-American or
Latino race/ethnicity, and biologically male. In addi-
tion, eligible participants had to be new to HIV care
or in intermittent care with less than two HIV
primary care visits in the previous six months.
YCM combined psychosocial case management, treatment education/adherence support and HIV risk reduction counseling to provide a client-centered intervention through which care was coordinated (Garland, Wohl, Boger, Carter, & Wu, 2006). The clinic-based intervention was administered by two para-professional, Bachelor-level case managers who were trained and supervised by a licensed clinical social worker to deliver the intervention in a non- judgmental and culturally appropriate manner. The participants met weekly with a case manager for the first two months and monthly for the next 22 months.
At the first meeting, the case managers conducted a comprehensive assessment to evaluate the partici- pant’s medical, physical, psychosocial, environmental, and financial needs. Using the stages of change model, the case manager evaluated whether participants were in one of the following stages with respect to initiation and utilization of HIV care: pre-contemplation, con- templation, preparation, action, or maintenance (Coury-Doniger, Levenkron, McGrath, Knox, & Urban, 2000; Elder, Ayala, & Harris, 1999). The case manager and the participant developed an individualized treatment plan to address identified barriers to engagement and retention in HIV care corresponding to their stage of change. To reduce barriers to care, necessary referrals for services were identified. Participants were provided $25 quar- terly for their participation in the evaluation totaling $200 for the 24-month intervention.
Participants were administered a standardized baseline survey at enrollment by the case managers to assess demographic and psychosocial characteris- tics, sexual risk behaviors, substance use, depression, and HIV testing and care history (Magnus et al., 2010; Radloff 1977). Data on prescribed antiretrovir- al therapy regimens, CD4 counts, and attendance to HIV care appointments were abstracted from medical records.
The primary study outcome was the proportion of YMSM retained in HIV care at six months. For the purposes of analysis, retention in care was defined as attending two or more HIV care appointments in the past six months which was based on the DHHS treatment guideline recommendation during the study period of at least one HIV medical care visit every three�four months (DHHS, 2008). Odds ratios (ORs), 95% confidence intervals (CI) and t-tests were calculated to compare demographic and beha- vioral characteristics for Latino vs. African-American YMSM. Data on attendance and time in the inter- vention, referrals provided and referrals completed were compared using a binomial test of proportions. Referral data were used to construct a dichotomous composite variable to indicate whether a client had a
AIDS Care 989
critical and immediate need for housing, nutrition,
substance abuse treatment, and/or mental health
services, characteristics identified in other studies of
HIV-positive youth (Eastwood & Birnbaum, 2007;
Johnson, Botwinick et al., 2003). Data on mean number of HIV care visits, missed
visits, percent of scheduled visits attended, and
retention in care were compared at three and six
months for all 61 patients. The same measures were
compared at baseline and six months for the 33
patients who had been in intermittent care prior to
enrollment in the intervention. These comparisons
were conducted using paired t-tests and McNemar’s
test for paired data. Finally, logistic regression
modeling was conducted to identify factors associated
with retention in HIV care at six months and the
unadjusted ORs and 95% CIs are presented. All
statistical analyses were performed with SAS version
9.1 (SAS 2007). The study was approved by the
institutional review boards at all of the participating
organizations and all clients provided written in-
formed consent in English or Spanish.
Results
The majority of the 61 participants were enrolled via
referral from friends who were in the intervention
(28%); 26% were enrolled through clinic in-reach by
the case manager to re-engage patients who had been
lost to care at the clinics; 18% were enrolled by clinic
providers and staff; 16% were enrolled by referral
from local HIV testing programs; 5% through out-
reach activities, and 7% from other programs. As shown in Table 1, 54% of the participants were
African-American, 46% were Latino, and the mean
age at enrollment was 21. Participants identified
themselves as male (91%), transgender (3%), female
(3%), or other/refused to identify (3%). Sixty-one
percent identified as homosexual, 21% as bisexual,
and 11% as heterosexual. Almost half (43%) of the participants reported
that they were still in school and more than three
quarters (84%) reported that they had completed at
least high school. Compared to Latinos, African-
Americans were significantly more likely to have
completed at least high school (OR �3.5, 95% CI �1.03, 11.8). Overall, 42% were currently em- ployed, with no statistical differences between Afri-
can-Americans and Latinos. Most participants
reported living with their family (57%) or friends
(29%) and African-Americans were significantly
more likely to report living with friends compared
to Latinos (OR �6.4, 95% CI �1.6�25.4).
Based on the CES-D screening tool administered at time of enrollment, 66% of participants had depressive symptoms, with CES-D scores of 16 or more. In addition, African-Americans were three times more likely to have depressive symptoms at time of enrollment compared to Latinos (OR �3.5, 95% CI �1.01, 12.4).
Among African-Americans, 52% reported life- time drug use and 54% of Latinos reported any lifetime drug use. Although not shown in Table 1, 46% of the overall sample reported lifetime marijua- na use, 13% stimulant use, 8% inhalant use, and 23% other drugs.
As shown in Table 2, one (2%) participant exited the study early and seven (11%) were lost to follow- up. The participant who left the study early changed his primary HIV care to another location; the seven participants who were lost to follow-up were also lost to care at the clinic and included five who moved out of the area, one in jail and one whose whereabouts was unknown.
Participants attended an average of 5.1 scheduled YCM appointments, had on average 1.1 drop-in visits, 0.9 telephone contacts, and 2.3 missed YCM appointments. Overall, participants attended 61% of scheduled YCM appointments. Participants received a mean of 7.3 hours of the intervention with Latino YMSM receiving statistically more hours of the intervention compared to African-Americans (p �0.001). The average YCM appointment lasted 67 minutes and the length of the appointment was significantly longer for Latinos compared to African- Americans (p �0.0003).
There were 238 total referrals provided in the first six months of the intervention. The majority of referrals were for housing (29%), mental health services (13%), risk reduction education (11%), and transportation assistance (8%). By the end of six months, 163 of the 238 (68%) referrals were completed. Of these, 78% of the housing, 65% of the mental health, 77% of risk reduction education, and 68% of transportation referrals were completed.
African-Americans were more likely to receive referrals for housing (pB0.0001) and transportation (pB0.0001) compared to Latinos, and Latinos were more likely than African-Americans to receive refer- rals for risk reduction services (p �0.007), support groups (p�0.03), and substance abuse services (p �0.03).
At time of enrollment into the intervention, 86% of the African-Americans and 71% of the Latinos had a critical need for housing, nutrition, substance abuse treatment, or mental health services.
From months 1�3, participants attended an average of 2.2 HIV primary care appointments,
990 A.R. Wohl et al.
Table 1. Demographic characteristics of HIV-positive 18�24-year-old men who have sex with men who participated in a youth-focused case management intervention (N �61).
African- Americans
(N�33) Latinos
(N�28) Total
(N�61) N (%) N (%) N (%) OR (95% CI)
Sexual orientation Homosexual/gay 20 (61) 17 (61) 37 (61) Referent Heterosexual 1 (3) 6 (21) 7 (11) 0.2 (0.02�1.5) Bisexual 10 (30) 3 (11) 13 (21) 2.5 (0.7�9.2) Other/refused 2 (6) 2 (7) 4 (7) 1.0 (0.1�7.7)
Gender identity
Male 29 (88) 26 (93) 55 (91) Referent Female 2 (6) 0 (0) 2 (3) � Transgender 1 (3) 1 (4) 2 (3) 1.0 (0.6�16.2) Other/refused 1 (3) 1 (4) 2 (3) 1.0 (0.1�16.2)
Education a
Less than high school 5 (16) 11 (39) 16 (27) Referent High school or more 27 (84)* 17 (61)* 44 (84)* 3.5 (1.03�11.8)*
Currently in school b
No 17 (55) 16 (59) 33 (57) Referent Yes 14 (45) 11 (41) 25 (43) 1.2 (0.4�3.4)
Currently employed c
No 20 (67) 13 (48) 33 (58) Referent Yes 10 (33) 14 (52) 24 (42) 0.4 (0.2�1.4)
Housing status d
Family 17 (53) 15 (63) 32 (57) Referent Friends 13 (41)** 3 (12)** 17 (29)** 6.4 (1.6�25.4)** On own 2 (6) 5 (21) 7 (12) 0.5 (0.1�3.1) Homeless/shelter 0 (0) 1 (4) 1 (2) �
Depression � CES-De
No 6 (22) 10 (50) 16 (34) Referent
Yes 21 (78)*** 10 (50)*** 31 (66)*** 3.5 (1.01�12.4)*** History of drug use
f
No 16 (48) 13 (46) 29 (48) Referent
Yes 17 (52) 15 (54) 32 (52) 0.9 (0.3�2.5) Mode of HIV exposure MSM 32 (100) 22 (78) 55 (90) Referent MSM-IDU/IDU 0 (0) 1 (4) 1 (2) � Heterosexual 0 (0) 3 (11) 3 (5) � Other/NIR 0 (0) 2 (7) 2 (3) �
HIV care history
Previously in care 21 (64) 13 (46) 34 (56) Referent New to care 12 (36) 15 (54) 27 (44) 2.0 (0.7�5.6)
Disclosed HIV status to friends g
No 7 (23) 10 (36) 17 (29) Referent Yes 24 (77) 18 (64) 42 (71) 1.9 (0.6�5.9)
Disclosed HIV status to family h
No 14 (44) 15 (54) 29 (48) Referent Yes 18 (56) 13 (46) 31 (52) 1.5 (0.5�4.1)
Disclosed HIV status to no one i
No 25 (81) 20 (71) 45 (76) Referent
Yes 6 (19) 8 (29) 14 (24) 0.6 (0.2�2.0)
Mean (SD) Mean (SD) Mean (SD) t-Test p
Mean age (SD) 21 (1.4) 22 (1.7) 21 (1.6) �1.67 0.10 Mean age at first sexual intercourse (SD)
j 14.2 (2.5) 14.2 (2.6) 14.3 (2.5) 0.05 0.96
Mean number of partners in past 3 months (SD) k
2 (2.2) 2 (2.2) 2 (3.1) �0.3 0.76
AIDS Care 991
attended 76% of scheduled HIV care appointments, and 90% were retained in care (Table 3). During months four through six, participants attended an average of 1.7 HIV care appointments, attended 51% of scheduled appointments, and 70% were retained in care. There were statistically significant decreases in all of the HIV care measurements between three and six months.
Among the 33 participants who had been in intermittent care, the average number of HIV care visits increased from 0.2 to 5.5 between baseline and six months (pB0.0001) (Table 4). In addition, the percentage of scheduled HIV care visits attended increased from 7% to 73% between baseline and six months (pB0.0001) and 82% of those who had been in intermittent care were retained in consistent primary HIV care at six months.
The main factors associated with retention in HIV care at six months was prescription of HAART, increased number of intervention appointments and more hours in the intervention (Table 5). A signifi- cant dose-response trend was observed between retention in HIV care and increasing number of hours in the intervention (p �0.02) and increasing number of intervention appointments (p �0.05).
Discussion
This is one of the first studies to evaluate the impact of a youth-focused clinic-based intervention on retention in HIV care for HIV-positive Latino and African-American YMSM. Not only was the inter- vention effective in engaging YMSM in consistent HIV care, but two of the main factors associated with retention in HIV care at six months were related to the quantity or dose of the intervention received. These data suggest that a time-intensive intervention delivered by a non-judgmental and culturally compe- tent peer is very effective in engaging at-risk Latino and African-American YMSM in consistent HIV care, particularly during the early months of HIV
care. Our findings are consistent with a study of
primarily HIV-negative at-risk youth that found that
more case management contact was associated with
improved retention in care (Harris et al., 2003). The finding that YMSM who were prescribed
HAART were more likely to be retained in care is
a new finding as there are few similar interventions
that have been evaluated with respect to retention in
care. Given that the intervention was associated with
retention in care, intervention participants were also
probably more likely to be prescribed HAART by a
physician. Several studies have noted the difficulties
and challenges that youth face with adherence to
HAART, and it is likely that the skills needed for
YMSM to adhere to HAART are the same as those
needed to adhere to HIV care (Rao et al., 2007; Rudy
et al., 2009). It is notable that the percentage of
intervention participants on HAART (69%) was
considerably greater than that reported among
a national sample of HIV-positive YMSM (8%)
(Valleroy et al., 2000). A large proportion of the YMSM were in a state
of crisis at time of entry into the intervention,
underscoring the strong need for youth-focused
interventions to help address barriers to engagement
and retention in HIV care. The severe subsistence and
psychosocial needs of the study group are consistent
with data from other studies of HIV-positive YMSM
in which a critical need for housing, substance abuse,
and mental health treatment were identified (East-
wood & Birnbaum, 2007; Johnson, Botwinick et al.,
2003; Mustankski et al., 2007; Valleroy et al., 2000).
Housing referrals were most common for the YMSM
which is consistent with other research in adolescent
and general HIV patient populations that has shown
that housing challenges are an obstacle to retention in
consistent HIV care and that housing assistance can
result in improved medical outcomes (Aidala, Lee,
Abramson, Messeri, & Siegler, 2007; Eastwood &
Birnbaum, 2007).
Table 1 (Continued )
Mean (SD) Mean (SD) Mean (SD) t-Test p
Average months between HIV diagnosis and intervention enrollment (SD)
l 11.6 (19.5) 20.0 (29.9) 15.3 (24.7) �1.16 0.23
Mean CD4 cell count at enrollment (cells/mm 3 ) d
381 (180) 419 (213) 397 (194) �0.7 0.43
a Data missing on one participant;
b Data missing on three participants;
c Data missing on four participants;
d Data missing on five participants;
e Data missing on 14 participants;
f Includes marijuana, methamphetamine, amyl nitrate, and other drugs;
g Data missing on two participants;
h Data missing on one participant;
i Data missing on two participants;
j Data missing on nine participants;
k Data missing on six
participants; and l Data missing on nine participants. *p-value�0.04; **p-value�0.009; ***p-value�0.046
Note: OR, odds ratio; CI, confidence interval; MSM, men who have sex with men; IDU, injection drug use; NIR, no identified risk; IQR, interquartile range.
992 A.R. Wohl et al.
Other research has described the impact that an
HIV diagnosis can have on the mental health of gay
youth and given all of the psychosocial challenges
related to sexual identity, stigma and alienation by
friends and family, and the general vulnerabilities
attached to YMSM, it is not surprising that the
high rates of depression were observed (Donenberg
& Pao, 2005). The high prevalence of depression in
the African-Americans in the study group is con-
sistent with other research and underscores the
critical need for mental health interventions for
YMSM of color (Flicker et al., 2005; Johnson,
Botwinick et al., 2003; Lam, Naar-King, & Wright,
2007). The prevalence of any lifetime drug use among
this group of YMSM was high (52%), but consistent
with the prevalence of lifetime substance use reported
in an adolescent HIV clinic population in Los Angeles
(44%) (Schneir et al., 1998). The proportion of
YMSM in the current study reporting marijuana
and methamphetamine use is also consistent with
individual drug use reported for HIV-positive YMSM
in California, however it was lower than lifetime drug
use reported from the eight sites participating in this
Table 2. Participation and referrals for 18�24-year-old HIV-positive Latino and African-American MSM who participated in a youth-focused case management intervention (YCM).
African-Americans
n �33 Latinos
n �28 Total
n�61 p-Valuea
Six month study status, n (%) Completed 28 (85) 25 (89) 53 (87) 0.52 Exited study 1 (3) 0 (0) 1 (2) 0.32
Lost to follow-up 4 (12) 3 (11) 7 (11) 0.72
Six month YCM attendance (mean) n �33 n �28 n �61 p-Valueb
Scheduled appointments attended 4.0 5.8 5.1 0.15 Drop-in visits 1.7 0.4 1.1 0.02 Telephone contacts 0.2 1.5 0.9 0.01
Missed appointments 1.2 3.5 2.3 0.003 Percent of scheduled appointments attended
60% 63% 61% 0.77
Total hours of YCM received (mean) 5.1 9.7 7.3 0.001
Average duration of YCM appointment (mean minutes)
52 84 67 0.0003
Total referrals provided, n (%) N�73 N�165 N�238 p-Value b
Mental health services 6 (8) 26 (16) 32 (13) 0.12 Substance abuse services 0 (0) 10 (6) 10 (4) 0.03 Nutrition/food counselling 3 (4) 13 (8) 16 (7) 0.28
Housing 40 (55) 29 (18) 69 (29) B0.0001 Transportation 14 (20) 5 (3) 19 (8) B0.0001 Family/child related issues 0 (0) 2 (1) 2 (B1) 0.34
Financial/benefits 3 (4) 5 (3) 8 (3) 0.67 Employment assistance 0 (0) 5 (3) 5 (2) 0.13 Legal issues 0 (0) 5 (3) 5 (2) 0.13 Risk reduction education 2 (3) 24 (15) 26 (11) 0.007
Treatment advocate/pharmacy 2 (3) 12 (7) 14 (6) 0.17 Support groups 0 (1) 10 (6) 10 (4) 0.03 Dental services 1 (1) 2 (1) 3 (1) 0.92
General education 0 (0) 1 (B1) 1 (B1) 0.50 Other HIV care services 0 (0) 3 (2) 3 (1) 0.25 Other needs 2 (3) 14 (8) 16 (7) 0.23
Referrals completed at 6 months, n (%)
55 (75) 108 (65) 163 (68) 0.13
Critical need for housing, nutrition, substance abuse and/or mental health services at time
of enrollment, n (%)
30 (86) 24 (71) 54 (78) 0.13
Prescribed HAART during intervention, n (%) 25 (76) 17 (61) 42 (69) 0.21
a Proportions compared using a binomial test of proportions. b Means compared using a t-tests.
AIDS Care 993
SPNS initiative (Magnus et al., 2010; Ruiz, Facer, & Sun, 1998). Although substance use was common among this study group of YMSM, drug use was not associated with retention in primary HIV care once a client was enrolled in the intervention.
The intervention was designed to include weekly visits for the first two months followed by monthly visits for the subsequent four months for a total of 12 case management visits. The average number of visits was seven, however, suggesting that weekly visits are not feasible for YMSM and that monthly visits are more realistic for this population, given that many of the YMSM were employed or in school. However, the HIV care measures were statistically worse at six months compared to three months, suggesting that the intervention was most effective when the contact with the case manager was most intense during the early months of the intervention, lending support for weekly visits up to at least six months. To facilitate YCM attendance, the case managers had to be flexible with intervention appointment times and the clinics became flexible with HIV care visit appointments as the YMSM would often miss scheduled appointments and show up when no appointment had been scheduled. Flexible scheduling has been reported as a strategy to help YMSM keep their appointments to clinical care and case
management (Johnson, Botwinick et al., 2003; Magnus et al., 2010). These data suggest that clinic scheduling flexibility will improve clinical care atten- dance and health outcomes.
In addition to having flexible appointment times, the case managers had multiple strategies for staying in contact with their clients. They conducted a large part of their communication with the YMSM using cell phones and text messaging which was the most effective communication strategy. While these meth- ods of communication were not specifically evaluated in this study, they have been found to be effective in improving clinic attendance among general clinic populations (Chen, Fang, Chen, & Dai, 2008; Leong et al., 2006; O’Brien & Lazebnik, 1998). The $25 incentive was also helpful in motivating clients to come to the appointments and incentives have been demonstrated to improve retention in a variety of health care interventions (Giuffrida & Torgerson, 1997).
The limitations to this study include the relatively small sample of YMSM which prevented the calcula- tion of adjusted OR estimates. Identification of HIV- positive Latino and African-American YMSM both locally and nationally for this SPNS initiative was extremely challenging, even when using multiple outreach strategies. Second, the YMSM in this study
Table 3. Retention in HIV care at 3 and 6 months among HIV-positive 18�24-year-old MSM in a youth-focused case management intervention (n �61).
3 months 6 months p-Value
Mean number of HIV care visits in the past
3 months
2.2 1.7 0.04 a
Mean missed HIV care visits in past 3 months
0.6 1.0 0.06 a
Percent of scheduled HIV care visits attended in the past 3 months
76% 51% B0.0001 b
Percent retained in HIV care in past 3 months
90% 70% 0.0005 b
a p-Value for paired t-test;
b p-Value for McNemar’s test for paired data.
Table 4. Retention in HIV care at 6 months among 18�24-year-old HIV-positive MSM in a youth-focused case management intervention who had been in intermittent care (n �33).
Baseline (n �33) 6 months (n �33) p-Valuea
Mean attended HIV care visits in past 6 months
0.2 5.5 B0.0001
Mean missed HIV care visits in past
6 months
0.4 2.0 0.0001
Percent of scheduled HIV care visits attended in past 6 months
7% 73% B0.0001
Percent retained in HIV care at 6 months
0% 82% �
a p-Value from results of paired t-test.
994 A.R. Wohl et al.
were recruited using a convenience sampling ap-
proach and the findings may not be representative
of all HIV-positive African-American and Latino
YMSM. In addition, while there was no control
group for comparison, participants served as their
own controls when the analyses of outcomes pre and
post intervention were conducted. Finally, the sus-
tainability of the intervention beyond the 6 months of
follow-up is important but has not been evaluated to
date. Given the growing number of HIV-positive
YMSM and the challenges that they face in testing
early for HIV and accessing and staying in consistent
care, innovative, culturally appropriate care retention
interventions are necessary. The data presented here
demonstrate that it is possible to create an effective,
clinic-based intervention to address the barriers that
YMSM encounter in engaging in consistent HIV care.
Acknowledgements
This study was supported by the Health Resources and
Services Administration (HRSA) Special Projects of Na-
tional Significance Initiative H97HA03783-04-00 and
California HIV/AIDS Research Program grant CH05-
LAC-617. The authors would like to acknowledge the
study staff who delivered the project intervention: Amin
Lewis, Christopher Moore, and Kathy Bouch. In addition,
the authors would like to acknowledge and thank the study
participants and medical providers for their time.
References
Aidala, A.A., Lee, G., Abramson, D.M., Messeri, P., & Siegler, A. (2007). Housing need, housing assistance, and connection to HIV medical care. AIDS and Behavior, 11, 101�115. doi:10.1007/s10461-007-9276-x
Bingham, T.A., & Sey, K.A. (2009, August). Sexual network characteristics and HIV risk among African American men who have sex with men. Paper presented
at the National HIV Prevention Conference, Atlanta, GA.
Centers for Disease Control and Prevention. (2005). HIV
prevalence, unrecognized infection and HIV testing among men who have sex with men � five US cities, June 2004�April 2005. Morbidity and Mortality Weekly Report, 54, 597�601. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5424a2. htm
Centers for Disease Control and Prevention. (2008). Trends
in HIV/AIDS diagnoses among men who have sex with men � 33 States, 2001�2006. Morbidity and Mortality Weekly Report, 57, 681�686. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a2. htm
Table 5. Odds ratios and 95% confidence intervals for factors associated with retention in HIV care
a at 6 months
among YMSM (n �61) in a youth-focused case manage- ment (YCM) intervention in Los Angeles County, 2006� 2009.
Characteristic Unadjusted OR (95% CI)
Race/ethnicity
African-American 0.8 (0.2�2.9) Latino Referent
Age 18�20 years 2.4 (0.5�12.4) 21�24 years Referent
Education More than high school 1.0 (0.2�4.5) Less than high school Referent
Currently in school Yes 1.1 (0.3�4.7) No Referent
Currently employed Yes 1.1 (0.3�4.5) No Referent
Housing status Live on own/with friends 0.8 (0.2�3.1) Live with family Referent
Depression Moderate or severe 0.2 (0.03�2.0) None Referent
History of drug use Yes 0.7 (0.2�2.6) No Referent
CD4 cell count B200 cells/mm
3 0.7 (0.1�7.0)
]200 cells/mm 3
Referent
Critical need at baseline b
Yes 2.0 (0.5�7.8) No Referent
Prescribed HAART
Yes 11.7 (2.7�51.4)* No Referent
New to HIV care
Yes 1.1 (0.3�4.1) No Referent
Number of YCM appointments c
9 or more visits 10.5 (1.1�96.6)** 5�8 visits 2.8 (0.7�11.5) 0�4 visits Referent
Number of YCM hours d
10 or more hours 6.6 (1.1�38.7)*** 5�9 hours 6.0 (1.3�28.3) 1�4 hours Referent
a Retention in care was defined as two or more HIV primary care visits in the previous 6 months. b Critical need at baseline was defined as immediate need for housing, nutrition, substance abuse, or mental health treatment. c The chi-square test for trend�6.01, p-Value �0.05. d The chi-square test for trend�7.83, p-Value �0.02. *p-value�0.0003; **p-value�0.038; ***p-value�0.036.
AIDS Care 995
Chen, Z.W., Fang, L.Z., Chen, L.Y., & Dai, H.L. (2008).
Comparison of an SMS text messaging and phone
reminder to improve attendance at a health promotion
center: A randomized controlled trial. Journal of
Zhejiang University SCIENCE B, 9, 34�38. doi:10.1631/jzus.B071464
Coury-Doniger, P.A., Levenkron, J.C., McGrath, P.L.,
Knox, K.L., & Urban, M.A. (2000). From theory to
practice: Use of stage of change to develop an STD/
HIV behavioral intervention, phase 2: Stage-based
behavioral counseling strategies for sexual risk reduc-
tion. Cognitive and Behavioral Practice, 7, 395�406. doi:10.1016/S1077-7229(00)80050-4
Department of Health and Human Services (DHHS).
(2008). Panel on antiretroviral guidelines for adults
and adolescents. Guidelines for the use of antiretroviral
agents in HIV-1-infected adults and adolescents.
Washington, DC: Department of Health and Human
Services (DHHS). November 3, 1�139. Retrieved from http://www.aidsinfo.nih.gov/ContentFiles/Adult
andAdolescentGL.pdf
Donenberg, G.R., & Pao, M. (2005). Youths and HIV/
AIDS: Psychiatry’s role in a changing epidemic.
Journal of the American Academy of Child and
Adolescent Psychiatry, 44, 728�747. doi:10.1097/ 01.chi.0000166381.68392.02
Eastwood, E.A., & Birnbaum, J.M. (2007). Physical and
sexual abuse and unstable housing among adolescents
with HIV. AIDS and Behavior, 11, S116�S127. doi:10.1007/s10461-007-9236-5
Elder, J.P., Ayala, G.X., & Harris, S. (1999). Theories and
intervention approaches to health-behavior change in
primary care. American Journal of Preventive Medicine,
17, 275�284. doi:10.1016/S0749-3797(99)00094-X Flicker, S., Skinner, H., Read, S., Veinot, T., McClelland,
A., Saulnier, P., & Goldberg, E. (2005). Falling
through the cracks of the big cities: Who is meeting
the needs of HIV-positive youth. Canadian Journal of
Public Health, 96, 308�312. Garland, W.G., Wohl, A.W., Boger, A., Carter, J., &
Wu, J. (2006, May). One-stop shopping: Using
an integrated case management model to improve
retention in HIV care among young men who have
sex with men. Paper presented at the 18th annual
national conference on Social Work and HIV/AIDS,
Miami, FL.
Giuffrida, A., & Torgerson, D.J. (1997). Should we pay the
patient? Review of financial incentives to enhance
patient compliance. British Medical Journal, 315,
703�707. Harris, S.K., Samples, C.L., Keenan, P.M., Fox, B.S.,
Melchiono, M.W., Woods, E.R., & Boston HAPPENS
Program Collaborators. (2003). Outreach, mental
health, and case management services: Can they help
to retain HIV-positive and at-risk youth and young
adults in care? Maternal and Child Health Journal, 7,
205�218. doi:10.1023/A:1027386800567
Huba, G.J., & Melchior, L.A. (1998). A model for
adolescent-targeted HIV/AIDS services. Journal of
Adolescent Health, 23(Suppl. 1), 11�27. doi:10.1016/ S1054-139X(98)00052-4
Johnson, D.F., Sorvillo, F.J., Wohl, A.R., Bunch, J.G.,
Carruth, A., Castillon, M., & Jimenez, B. (2003).
Frequent failed early HIV detection in a high pre-
valence area: Implications for prevention. AIDS Pa-
tient Care and STDs 2003, 17, 277�282. doi:10.1089/ 108729103322108148
Johnson, R.L., Botwinick, G., Sell, R.L., Martinez, J.,
Siciliano, C., Friedman, L.B., . . . Bell, D. (2003). The utilization of treatment and case management
services by HIV-infected youth. Journal of Adoles-
cent Health, 33(Suppl. 1), 31�38. doi:10.1016/S1054- 139X(03)00158-7
Lam, P.K., Naar-King, S., & Wright, K. (2007). Social
support and disclosure and predictors of mental health
in HIV-positive youth. AIDS Patient Care and STDs,,
21, 20�29. doi:10.1089/apc.2006.005 Leong, K.C., Chen, W.S., Leong, K.W., Matura, I., Mimi,
O., Sheikh, M.A., . . .Teng, C.L. (2006). The use of text messaging to improve attendance in primary care:
A randomized controlled trial. Family Practice, 23,
699�705. doi:10.1093/fampra/cml044 Magnus, M., Jones, K., Phillips, G., Binson, D., Hightow-
Weidman, L., Richards-Clark, C., & Wohl, A.R.
(2010). 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 projects of national significance.
urnal of Acquired Immune Deficiency Syndromes, 53(4),
529�536. doi:10.1097/QAI.0b013e3181b56404 Mustankski, B., Garofalo, R., Herrick, A., & Donenberg,
G. (2007). Psychosocial health problems increase risk
for HIV among urban young men who have sex with
men: Preliminary evidence of a syndemic in need of
attention. Annals of Behavioral Medicine, 34, 37�45. doi:10.1080/08836610701495268
O’Brien, G., & Lazebnik, R. (1998). Telephone call
reminders and attendance in an adolescent clinic.
Pediatrics, 101(6), E6.
Radloff, L.S. (1977). The CES-D scale: A self-report
depression scale for research in the general population.
plied Psychological Measurement, 1, 385�401. doi:10.1177/014662167700100306
Rao, D., Kekwaletswe, T.C., Hosek, S., Martinez, J., &
Rodriguez, F. (2007). Stigma and social barriers to
medication adherence with urban youth living
with HIV]. AIDS Care, 19, 28�33. doi:10.1080/ 09540120600652303
Rudy, B.J., Murphy, D.A., Harris, D.R., Muenz, L., &
Ellen, J., for the Adolescent Trials Network for HIV/
AIDS Interventions. (2009). Patient-related risks for
non-adherence to antiretroviral therapy among HIV-
infected youth in the United States: A study of
996 A.R. Wohl et al.
prevalence and interactions. AIDS Patient Care and STDs, 23, 185�194. doi: 10.1089/apc.2008.0162
Ruiz, J., Facer, M., & Sun, R.K. (1998). Risk factors for
human immunodeficiency virus infection and unpro- tected anal intercourse among young men who have sex with men. Sexually Transmitted Diseases, 25,
100�107. SAS. (2007). (Version 8.2) Computer software. Cary, NC:
SAS Institute.
Schneir, A., Kipke, M.D., Melchior, L.A., & Huba, G.J. (1998). Childrens hospital Los Angeles: A model of integrated care for HIV-positive and very high-risk youth. Journal of Adolescent Health, 23(Suppl. 1), 59� 70. doi:10.1016/S1054-139X(98)00054-8
Swendeman, D., Rotheram-Borus, M.J., Comulada, S., Weiss, R., & Ramos, M.E. (2006). Predictors of HIV-
related stigma among young people living with HIV. Health Psychology, 25, 501�509. doi:10.1037/0278- 6133.25.4.501
Valleroy, L.A., MacKellar, D.A., Karon, J.M, Rosen, D.H., McFarland, W., Shehan, D.A., . . . Jansen, R.S. for the Young Men’s Survey Study Group.
(2000). HIV prevalence and associated risks in young men who have sex with men. Journal of the American Medical Association, 284, 198�204. doi:10.1001/ jama.284.2.198
Woods, E.R., Samples, C.L., Melchiono, M.W., Keenan, P.M., Fox, D.J., Chase, L., . . . Goodman, E. (1998). Boston HAPPENS Program: A model of health care
for HIV-positive, homeless, and at-risk youth. Journal of Adolescent Health, 23(Suppl. 1), 37�48. doi:10.1016/ S1054-139X(98)00048-2
AIDS Care 997
Copyright of AIDS Care is the property of Routledge and its content may not be copied or emailed to multiple
sites or posted to a listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.
