Transitioning Adolescents and Young Adults With HIV Infection to Adult Care: Pilot Testing the "Movin' Out" Transitioning Protocol.

BACKGROUND: Advances in care and treatment of adolescents/young adults with HIV infection have made survival into adulthood possible, requiring transition to adult care. Researchers have documented that the transition process is challenging for adolescents/young adults. To ensure successful transition, a formal transition protocol is needed. Despite existing research, little quantitative evaluation of the transition process has been conducted. PURPOSE: The purpose of the study was to pilot test the "Movin' Out" Transitioning Protocol, a formalized protocol developed to assist transition to adult care. METHOD: A retrospective medical/nursing record review was conducted with 38 clients enrolled in the "Movin' Out" Transitioning Protocol at a university-based adolescent medicine clinic providing care to adolescents/young adults with HIV infection. RESULTS: Almost half of the participants were able to successfully transition to adult care. Reasons for failure to transition included relocation, attrition, lost to follow-up, and transfer to another adult service. Failure to transition to adult care was not related to adherence issues, X(2) (1, N=38)=2.49, p=.288; substance use, X(2) (1, N=38)=1.71, p=.474; mental health issues, X(2) (1, N=38)=2.23, p=.322; or pregnancy/childrearing, X(2) (1, N=38)=0.00, p=.627). CONCLUSIONS: Despite the small sample size, the "Movin' Out" Transitioning Protocol appears to be useful in guiding the transition process of adolescents/young adults with HIV infection to adult care. More research is needed with a larger sample to fully evaluate the "Movin' Out" Transitioning Protocol.

Evaluation of the effect of human immunodeficiency virus-related structural interventions: the connect to protect project.

IMPORTANCE: With the emphasis on structural-level interventions that target social determinants of human immunodeficiency virus (HIV) transmission to curb the HIV epidemic, there is a need to develop evaluation models that can detect changes in individual factors associated with HIV-related structural changes. OBJECTIVE: To describe whether structural changes developed and achieved by community coalitions are associated with an effect on individual factors associated with the risk of contracting HIV. DESIGN, SETTING, AND PARTICIPANTS: In this serial cross-sectional survey design, data were collected from 8 cities during 4 rounds of annual surveys from March 13, 2007, through July 29, 2010. Study recruitment took place at venues where the population of focus was known to congregate, such as clubs, bars, community centers, and low-income housing. The convenience sample of at-risk youth (persons aged 12-24 years) included 5337 individuals approached about the survey and 3142 (58.9%) who were screened for eligibility. Of the 2607 eligible participants, 2559 (98.2%) ultimately agreed to participate. INTERVENTIONS: Achievement of locally identified structural changes that targeted public and private entities (eg, federal agencies, homeless shelters, and school systems) with the goal of fostering changes in policy and practice to ultimately facilitate positive behavioral changes aimed at preventing HIV. MAIN OUTCOMES AND MEASURES: Number of sexual partners, partner characteristics, condom use, and history of sexually transmitted infections and HIV testing. RESULTS: Exposure to structural changes was not statistically significantly associated with any of the outcome measures, although some results were in the direction of a positive structural change effect (eg, a 10-unit increase in a structural change score had an odds ratio of 0.88 [95% CI, 0.76-1.03; P = .11] for having an older sexual partner and an odds ratio of 0.91 [95% CI, 0.60-1.39; P = .39] for using a condom half the time or less with a casual partner). CONCLUSIONS AND RELEVANCE: This study evaluated a broad representation of at-risk individuals and assessed the effect of numerous structural changes related to various HIV risk factors. No structural changes as measured in this study were associated with a statistically significant reduction in risk behaviors. These null findings underscore the need for a long-term approach in evaluating structural interventions and the development of more nuanced methods of quantifying and comparing structural-change initiatives and determining the appropriate strategies for evaluating effect.

Development of a protocol for transitioning adolescents with HIV infection to adult care.

As HIV infection in childhood and adolescence has evolved from a terminal to a chronic illness, new challenges are posed for both medical and psychosocial teams serving these clients. Although specialized programs for transition to adult care have been reported for persons with cystic fibrosis, diabetes mellitus, sickle cell disease, and other chronic illnesses, there are few published reports of integral programs designed to transition adolescents who were infected with HIV during the adolescent period to adult HIV services. This article describes a model of transition from a University-based, federally funded adolescent HIV program to adult HIV services, addresses barriers to transition, and provides strategies and recommendations for improving adherence to the transition process.

The effect of a structured exercise program on nutrition and fitness outcomes in human immunodeficiency virus-infected children.

The feasibility and effectiveness of a hospital-based exercise-training program followed by a home-based program for improving fitness, strength, and changes in body composition in children and adolescents with HIV were evaluated. Subjects participated in nonrandomized 24-session, hospital supervised exercise training program followed by an 314 unsupervised home-based maintenance program. Outcome measurements included muscular strength/endurance, flexibility, relative peak VO(2), body composition, and lipids. Seventeen subjects (eight females) with a median age of 15.0 years (range: 6.0-22.6) and BMI z-score of 0.61 (range: -1.70-2.57) at entry completed the intervention. After 24 training sessions, the median increases in muscular strength were between 8% and 50%, depending on muscle group. The median increases in muscle endurance, relative peak VO(2), and lean body mass were 38.7% (95% CI: 12.5-94.7; p = 0.006), 3.0 ml/kg/min (95% CI: 1.5-6.0; p < 0.001), and 4.5% (95% CI: 2.4-6.6; p < 0.001), respectively. Twelve children completed the home-based maintenance program. Median changes in these outcomes between completion of the hospital-based intervention and a follow-up after completion of the home-based program were near zero. No adverse events occurred during the intervention. A supervised hospital-based fitness program is feasible, safe, and effective for improving general fitness and strength as well as lean body mass in children with HIV.

Renal manifestations of sexually transmitted diseases: sexually transmitted diseases and the kidney.

The adolescent population is particularly vulnerable to STDs. Those that cause significant kidney disease are of viral origin. The primary VVD are HIV-1, HBV, and HCV. Screening of high-risk populations should include quantitation of proteinuria, including total protein and microalbumin, to assess severity of renal damage and potential for progression. Renal biopsy is indicated for diagnosis and for planning important treatment interventions if there is significant proteinuria or decreased renal function. Causes of acute renal failure are frequently reversible and should be treated aggressively. These include HUS, vaso-motor or ischemic acute tubular necrosis, and drug toxicities. The spectrum of chronic kidney disease associated with VVD is broad and may include systemic manifestations of vasculitis. HIV-associated nephropathy is the prototype, with the most prevalent lesion remaining FSGS. Progression occurs in up to 15% of the patients, who are overwhelmingly of African lineage. Significant advances in management include ongoing development of HAART, angiotensin antagonists to control proteinuria, and novel immune-modulating drugs such as MMF, CsA, and rituximab. Dialysis therapies have offered improved survival, especially in pediatric patients. Moreover, transplantation is no longer considered experimental and should be offered to select patients.

Case finding for HIV-positive youth: a special type of hidden population.

PURPOSE: To describe the HIV case finding strategies used by the Special Projects of National Significance (SPNS), Adolescent HIV Outreach and Treatment programs, the populations of youth they were able to reach, and the populations of HIV-positive youth they were able to identify. METHODS: Program specifications from five programs located in four major metropolitan centers were contrasted. Four of the programs also provided outcome data for HIV counseling and testing outcome numbers, demographic and risk profile data for youth who underwent HIV testing, and mode of infection of HIV-positive youth. RESULTS: The program outcomes were discussed in terms of similarities and differences in outreach methods (e.g., peer workers, time of outreach, etc.), geographic settings (i.e., mobile van, institutional settings, community locations), individual characteristics (e.g., pregnant women) and youth subcultures (i.e., gay/transgendered, incarcerated juveniles, homeless). CONCLUSIONS: Because HIV-positive adolescents will constitutionally remain a "hidden population," a great deal of time and effort will continue to need to go into the front end of outreach, counseling and testing. Specific guidance and recommendations for locating HIV-positive youth were provided to program designers for each type of outreach strategy.

Transitioning youths into care: linking identified HIV-infected youth at outreach sites in the community to hospital-based clinics and or community-based health centers.

PURPOSE: To describe and analyze the process of transitioning HIV-infected youths from the point of HIV diagnosis into HIV treatment. Rather than simply offering HIV positive youths a list of referrals, the youth-focused SPNS grantees (AWAC) found it vital that youths were immediately assisted with linkage to a medical provider. METHODS: From February 1997 to December 2000, 107 identified HIV-infected youths from the five adolescent SPNS projects were surveyed on needs and barriers. The time interval between HIV testing and youth linkage to care was also noted. RESULTS: Nine percent of youth reported perceived barriers to accessing health care. Perceived needs were identified as Mental Health (44.9%; n = 48); Alcohol and drug treatment (14%; n = 15); transportation to health care settings (40.2%; n = 43); and housing (46.7%; N = 50). At sites tracking linkage to care, the time of being transitioned into a medical setting ranged from 5 to 55 days (average 26 days). CONCLUSIONS: The period of transitioning identified HIV-infected youths into care can be reduced from 1-5 years to as short as 5-55 days. Success with linking these youth to care involves establishing a series of contacts at outreach sites wherein program staff seeks to build trusting relationships with youths, is able to track these youths and identify and address perceived needs.

The utilization of treatment and case management services by HIV-infected youth.

PURPOSE: This article describes the essential components for effective and comprehensive HIV care for youth who have tested positive and have been linked to HIV treatment. Descriptive profile data are also presented that detail the demographics, risk behaviors and health care barriers of youth served in the five Special Projects of National Significance (SPNS), which focused on adolescents and young adults. METHODS: Data presented are from the core multi-site data set, which was standardized across the five youth-oriented SPNS projects. Substance use and mental health symptoms were gathered using the Personal Problem Questionnaire (PPQ) screener, which was an adaptation of the PRIME-MD. In-depth qualitative interviews with enrolled HIV-positive youth were also conducted by several Projects. RESULTS AND CONCLUSIONS: Medical care alone is not enough and cannot be effective without supportive program components such as flexible scheduling, and a multi-disciplinary team approach that includes assertive case management. Case Managers help enrolled youth with concrete service needs such as housing, emergency financial assistance for food/utilities, transportation, child care, coverage for prescriptions, and public entitlements. They also help isolated youth to connect with a personal support system. Addressing those needs helps to facilitate and reinforce treatment adherence and retention. In addition to other identified needs such as stable housing and transportation, a significant number of enrolled youth self-reported having experienced physical, sexual, and/or emotional abuse in their lives and articulated a need for mental health services. Therefore, effective HIV care for youth must be multi-faceted; it must consist of more than a medical component.

Retention, adherence, and compliance: special needs of HIV-infected adolescent girls and young women.

PURPOSE: To demonstrate that whereas all HIV-infected youth evidence complex factors that challenge retention in care and adherence to treatment, HIV-infected females have additional issues that are gender-specific. METHODS: Preliminary data from a subset of 21 adolescent/young women under age 25 from the Whole Life mental health-perinatal HIV care project were analyzed to illustrate the needs of these patients. RESULTS: Of the 21 young women assessed, all but one was of minority background, and a sizeable majority had limited education (

Making waves: systems change on behalf of youth with HIV/AIDS.

PURPOSE: To document the effects of five Special Projects of National Significance (SPNS), funded by the Health Resources and Services Administration (HRSA), on HIV care, related service systems, policy, planning, and funding for youth with HIV/AIDS. METHODS: Literature on services and systems integration and technology transfer is used as a conceptual framework for the examination of HIV-informed, youth-specific changes at the local, state, and national levels. The Principal Investigators for each project and/or the Project Evaluators were interviewed several times to capture "snapshots" of evolving results from the Projects' varied activities in New York City; Newark, New Jersey; Chicago; and Miami. Some changes were consciously targeted, and others occurred serendipitously. This work covers the funding period from 1996 through 2000. RESULTS AND CONCLUSIONS: There were many "ripple" effects that emanated from these Projects' presence and activities. Important lessons were learned about why systems change is necessary to effectively serve youth with HIV, how to make constructive changes happen, and how to sustain changes once they are achieved. Successful strategies included, but were not limited to, consensus-building among stakeholders, participatory planning and decision-making, collaborative referral and linkage agreements, staff sharing, co-locating services, providing technical assistance, consultation, cross-training, and engaging consumers as partners in communicating new technologies and in advocating for change.

The reciprocal effects of program evaluation on service delivery for the SPNS adolescent HIV outreach and treatment programs.

PURPOSE: To describe the contexts within which the Special Projects of National Significance (SPNS) Adolescent HIV Outreach and Treatment programs were evaluated, the effects their evaluations had on their respective programs and, in turn, the effects the program delivery had on the evaluations. METHODS: The full range of process evaluation heuristics were used to analyze the bi-directional effects of conducting field-based, service delivery data collection. Although data collection efforts sometimes interfered with service delivery, and vice versa, several notable positive effects were disclosed. CONCLUSIONS: Specific guidance and recommendations were provided to program designers, behavioral researchers and institutional funding decision makers. Primary amongst them was a call for research evaluation designs that allow for maximum flexibility.