1 predictors of retention in care among hiv+ and at-risk youth sion kim harris, phd cathryn l....
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Predictors of Retention in CareAmong HIV+ and At-Risk Youth
Sion Kim Harris, PhD
Cathryn L. Samples, MD, MPH
Peter Keenan, RN, C-PNP
Durrell J. Fox, BS
Maurice W. Melchiono, RN, MS, C-FNP
Elizabeth R. Woods, MD, MPH
Boston HAPPENS Program Participants
Children’s Hospital Boston, Harvard Medical School
Society for Adolescent Medicine Annual Meeting 2002
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Study Grant Support• Special Projects of National Significance Program
(SPNS) #BRH 970155-05-0, HRSA, DHHS
• Leadership in Adolescent Health Project #5T 71 MC 00009-10, MCH Bureau, HRSA, DHHS
• W.T. Grant Foundation
• Children’s Hospital’s Aerosmith Fund for HIV Care and Prevention
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Background
• At-risk youth are hard to engage and retain in care
• Ancillary services such as outreach, case management, and mental health services believed to enhance retention in care
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Study Aims
• Describe retention in care of youth clients of a comprehensive adolescent HIV care program (Boston HAPPENS Program)
• Assess impact of outreach, case management, mental health services on likelihood of retention over time, adjusted for potential confounding factors
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Program Description
• Boston HIV Adolescent Provider and Peer Education Network for Services (HAPPENS)
• Coordinated network of 8 agencies serving at-risk youth ages 12-24
• Comprehensive care including HIV CTS, outreach, nurse case management, mental health services, and medical care
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Study Population
• HAPPENS clients seen during data collection period (4.5 years)
• Clients excluded from analysis if had no more than two standard HIV counseling and testing visits
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Data Collection Method
• Standard forms used by all 10 SPNS programs
• “Contact” form: used at client enrollment or street/phone contact to record demographic and HIV risk info, outreach services provided
• “Intervention” form: used at each health visit to record health care, case management, mental health services provided
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Data Analyses MethodSurvival analysis:
• Retention measure
– Number of days between first and last visits during data collection period
• Censored cases
– Clients with at least one visit during last program year
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Key Predictor Variables
• Number of outreach contactsCategories: 0, 1, >2 times
• Number of mental health service visitsCategories: 0, 1, >2 times
• Number of case management visitsCategories: 0, 1-2, >3 times
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Other Potential Predictors
• Age• Gender• Race/ethnicity• HIV status• Mental health system
involvement• Homeless/runaway• Self-identified sexual
orientation
• Ever pregnant • Ever had STD• Any unprotected sex• Any survival sex, sex with
HIV+ or injection drug using partner (high risk sex)
• Any substance abuse, injection drug use, or needle-sharing
Client Demographic and HIV Risk Factors:
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• Type of site of initial care– Multi-service outreach agency
– Community health center
– Hospital
Other Potential Predictors (cont’d)
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Statistical Tests
• All analyses were gender-stratified
• Descriptive analyses:– Kaplan-Meier survival curve analysis
• Bivariate analyses:– Log-rank test to assess group
differences in retention times
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Statistical Tests (cont’d)
• Multivariate Cox Proportional Hazards (PH) regression modeling– Variables related to retention at p<0.10 entered
into model, including age, HIV status– Adjusted Hazard Ratio (AHR) and 95% CI
• PROC SURVIVAL in SUDAAN® used to account for potential intra-cluster correlation within sites
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Client Characteristics by Gender (Total N=1426)
Males FemalesGender
differencen % n % p-value
Number of Clients 512 36 914 64 –––
Age (mean years + SD) 20 ± 3 19 ± 2 <0.001
Race/Hispanic ethnicity:
White non-Hispanic 275 57 401 45 0.002
Black non-Hispanic 91 19 207 23
Hispanic 83 17 194 22
Asian/Other 34 7 81 9
HIV positive 21 4 16 2 0.007
Gay, lesbian, bisexual orundecided
112 22 63 7 <0.001
Homeless and/or runaway 77 15 131 14 NS
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Overall Program Retention
• Retention times ranged from 0-1406 days for males, 0-1577 for females
• About two-thirds of clients returned for at least a second visit (males=64.3%, females=70.0%)
• 25% in both gender groups retained for more than a year
• 10% of males and 15% of females retained for more than two years
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Probability of Retention Over Timeby Number of Outreach Contacts
MALES FEMALES
>2 contacts*
0
1
>2 contacts*
0
1¥
Number of days between first and last visits
Cum
Pro
babi
li ty
of R
ete n
tion
Log-rank test: *p<0.001; ¥p=0.002
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Probability of Retention Over Timeby Number of Mental Health Visits
MALES FEMALES
Cum
Pro
babi
li ty
of R
ete n
tion
Number of days between first and last visits
>2 visits*
0
1
>2 visits*
0
1¥
Log-rank test: *p<0.001; ¥p=0.03
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Probability of Retention Over Timeby Case Management Visits
Cum
Pro
babi
li ty
of R
ete n
tion
Number of days between first and last visits
MALES
>3 visits*
0
1-2
>3 visits*
0
1-2
FEMALES
Log-rank test: *p<0.001
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Cox PH Modeling Results, MalesAdjustedHazardRatio* (95% CI) p-value
Outreach contacts0 Reference Reference1 1.38 (1.14-1.68) 0.005
>2 0.64 (0.57-0.73) <0.001
Mental health counseling visits0 Reference Reference1 0.83 (0.61-1.13) NS
>2 0.66 (0.54-0.80) <0.001
Case management visits0 Reference Reference
1-2 1.08 (0.92-1.26) NS>3 0.57 (0.46-0.69) <0.001
* Adjusted for age, HIV status, race/ethnicity, sexual orientation, homelessness, MH-system involvement, and high risk sex behaviors
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Cox PH Modeling Results, FemalesAdjustedHazardRatio* (95% CI) p-value
Outreach contacts0 Reference Reference1 1.32 (1.09-1.61) NS
>2 0.72 (0.61-0.85) 0.002
Mental health counseling visits0 Reference Reference1 0.95 (0.61-1.50) NS
>2 0.59 (0.18-1.92) NS
Case management visits0 Reference Reference
1-2 1.06 (0.75-1.50) NS>3 0.54 (0.34-0.84) 0.013
* Adjusted for age, HIV status, race/ethnicity, sexual orientation, any pregnancy, and any unprotected sex with males
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Discussion
• Some hard-to-reach, at-risk youth can be retained in care, with intensive efforts
• Increased outreach and case management associated with retention (adjusted for client demographic and risk factors)
• Mental health counseling related to retention of male clients
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Study Limitations
• HAPPENS clients may not be representative of all at-risk youth
• Visits to providers outside of program not included
• Variability in quality, completeness of data across sites
• Cell sizes for some variables small
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• Other client and program factors related to retention unmeasured
Study Limitations (cont’d)
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Implications
• Comprehensive services help retain at-risk youth in care
• Ancillary services such as outreach, case management, mental health services need to be more consistently funded for all at-risk youth, not just HIV+