Empirical Development of a Behavioral Intervention for African American/Black and Latino Persons with Unsuppressed HIV Viral Load Levels: An Application of the Multiphase Optimization Strategy (MOST) Using Cost-Effectiveness as an Optimization Objective.

We used results from an optimization randomized controlled trial which tested five behavioral intervention components to support HIV antiretroviral adherence/HIV viral suppression, grounded in the multiphase optimization strategy and using a fractional factorial design to identify intervention components with cost-effectiveness sufficiently favorable for scalability. Results were incorporated into a validated HIV computer simulation to simulate longer-term effects of combinations of components on health and costs. We simulated the 32 corresponding long-term trajectories for viral load suppression, health related quality of life (HRQoL), and costs. The components were designed to be culturally and structurally salient. They were: motivational interviewing counseling sessions (MI), pre-adherence skill building (SB), peer mentorship (PM), focused support groups (SG), and patient navigation (short version [NS], long version [NL]. All participants also received health education on HIV treatment. We examined four scenarios: one-time intervention with and without discounting and continuous interventions with and without discounting. In all four scenarios, interventions that comprise or include SB and NL (and including health education) were cost effective (< $100,000/quality-adjusted life year). Further, with consideration of HRQoL impact, maximal intervention became cost-effective enough to be scalable. Thus, a fractional factorial experiment coupled with cost-effectiveness analysis is a promising approach to optimize multi-component interventions for scalability. The present study can guide service planning efforts for HIV care settings and health departments.

Effects of Behavioral Intervention Components for African American/Black and Latino Persons Living with HIV with Non-suppressed Viral Load Levels: Results of an Optimization Trial.

There is an urgent need for efficient behavioral interventions to increase rates of HIV viral suppression for populations with serious barriers to engagement along the HIV care continuum. We carried out an optimization trial to test the effects of five behavioral intervention components designed to address barriers to HIV care continuum engagement for African American/Black and Latino persons living with HIV (PLWH) with non-suppressed HIV viral load levels: motivational interviewing sessions (MI), focused support groups (SG), peer mentorship (PM), pre-adherence skill building (SB), and navigation with two levels, short (NS) and long (NL). The primary outcome was HIV viral suppression (VS) and absolute viral load (VL) and health-related quality of life were secondary outcomes. Participants were 512 African American/Black and Latino PLWH poorly engaged in HIV care and with detectable HIV viral load levels in New York City, recruited mainly through peer referral. Overall, VS increased to 37%, or 45% in a sensitivity analysis. MI and SG seemed to have antagonistic effects on VS (z = - 1.90; p = 0.057); the probability of VS was highest when either MI or SG was assigned, but not both. MI (Mean Difference = 0.030; 95% CI 0.007-0.053; t(440) = 2.60; p = 0.010) and SB (Mean Difference = 0.030; 95% CI 0.007-0.053; t(439) = 2.54; p = 0.012) improved health-related quality of life. This is the first optimization trial in the field of HIV treatment. The study yields a number of insights into approaches to improve HIV viral suppression in PLWH with serious barriers to engagement along the HIV care continuum, including chronic poverty, and underscores challenges inherent in doing so.

Exploring behavioral intervention components for African American/Black and Latino persons living with HIV with non-suppressed HIV viral load in the United States: a qualitative study.

BACKGROUND: The persistence of racial/ethnic inequities in rates of engagement along the HIV care continuum signals the need for novel approaches. We developed six behavioral intervention components for use in an optimization trial, grounded in a model that integrates critical race theory, harm reduction, and self-determination theory, designed to address various barriers that African American/Black and Latino persons living with HIV (PLWH) experience to the HIV care continuum. The components were: health education, motivational interviewing sessions, pre-adherence skill building, peer mentorship, focused support groups, and navigation. The present qualitative exploratory study describes participants' perspectives on the components' acceptability, feasibility, and impact. METHODS: Participants were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City. From a larger trial, we randomly selected 46 participants for in-depth semi-structured interviews. Interviews were audio-recorded and transcribed verbatim, and data were analyzed using directed content analysis. Quantitative data on sociodemographic and background characteristics and components' acceptability and feasibility were also collected. RESULTS: On average, participants were 49 years old and had lived with HIV for 19 years. Most were cisgender-male and African American/Black. Participants reported a constellation of serious social and structural challenges to HIV management including chronic poverty, unstable housing, and stigma. Across components, a non-judgmental and pressure-free approach and attention to structural and cultural factors were seen as vital to high levels of engagement, but lacking in most medical/social service settings. Prominent aspects of individual components included establishing trust (health education); developing intrinsic motivation, goals, and self-reflection (motivational interviewing sessions); learning/practicing adherence strategies and habits (pre-adherence skill building); reducing social isolation via peer role models (peer mentorship); reflecting on salient goals and common challenges with peers without stigma (focused support groups); and circumventing structural barriers to HIV management with support (navigation). Components were found acceptable and feasible. Findings suggested ways components could be improved. CONCLUSIONS: The present study advances research on interventions for African American/Black and Latino PLWH, who experience complex barriers to engagement along the HIV care continuum. Future study of the components is warranted to address racial/ethnic health inequities in HIV.

Block by block: Building on our knowledge to better care for LGBTQIA+ patients.

Background: Emergency physicians need to recognize the diversity of identities held by sexual and gender minorities, as well as the health implications and inequities experienced by these communities. Identities such as lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, aromantic, and many others fall under the LGBTQIA+ acronym. This wide spectrum is seldom discussed in emergency medicine but nonetheless impacts both patient care and patient experience in acute and critical care settings. Aims: This commentary aims to provide a brief but nonexhaustive review of LGBTQIA+ identities and supply a critical framework for applying this understanding to patient encounters in the emergency department, as well as describe the challenges and educational aims at the level of medical school, residency, and postresidency. Materials and Methods: The commonly used and widely accepted definitions of LGBTQIA+ terms are described, as well as implications for patient care and emergency physician education. The authors of this writing group represent the Society for Academic Emergency Medicine, LGBTQ Task Force of the Academy of Diversity Inclusion in Medicine. Results: LGB terms are addressed, with LGBTQIA+ adding "intersex," "asexual," and "+," to include other gender identities and sexual orientations which are not already included. This paper also addresses the terms "transition," "nonbinary," "polyamorous." "two-spirit," "queer," and others. These acronyms and terms continually expand and evolve in the pursuit of inclusivity. Additionally, with some health issues potentially related to medications, hormones, surgery, or to internal or external genitalia, important EM physician tools include gathering an "organ inventory," asking about sexual history, and conducting a physical exam. Discussion: Most persons have congruent biological sex, gender identity, and attraction to the "opposite" gender. However, humans can have every imaginable variation and configuration of chromosomes, genitalia, gender identities, sexual attractions, and sexual behaviors. Terms and definitions are constantly changing and adapting; they may also vary by local culture. Obtaining relevant medical history, conducting an "organ inventory," asking about sexual history in a nonjudgmental way, and conducting a physical exam when warranted can all be important in delivering best possible medical care. Although there has been increased focus on education at the medical school, residency, and faculty level on LGBTQIA+ patient care in the ED, much work remains to be done. Conclusion: Emergency physicians should feel confident in providing a model of care that affirms the sexual and gender identities of all the patient populations we serve. Optimal patient-centric care requires a deeper understanding of the patient's biology, gender identity, and sexual behavior encapsulated into the ever-growing acronym LGBTQIA+.

Emergency care of LGBTQIA+ patients requires more than understanding the acronym.

Emergency physicians (EPs) frequently deliver care to members of the LGBTQIA+ community in the emergency department. This community suffers from many health disparities important to understand as part of comprehensive care, and these disparities are infrequently discussed in emergency medicine education. Previous data also suggest a need for broader education to increase the comfort of EPs caring for LGBTQIA+ patients. A group of content experts identified key disparities, opportunities for expanded education, and strategies for more inclusive care of LGBTQIA+ patients.

Advancing behavioral interventions for African American/Black and Latino persons living with HIV using a new conceptual model that integrates critical race theory, harm reduction, and self-determination theory: a qualitative exploratory study.

BACKGROUND: Rates of participation in HIV care, medication uptake, and viral suppression are improving among persons living with HIV (PLWH) in the United States. Yet, disparities among African American/Black and Latino PLWH are persistent, signaling the need for new conceptual approaches. To address gaps in services and research (e.g., insufficient attention to structural/systemic factors, inadequate harm reduction services and autonomy support) and improve behavioral interventions, we integrated critical race theory, harm reduction, and self-determination theory into a new conceptual model, then used the model to develop a set of six intervention components which were tested in a larger study. The present qualitative study explores participants' perspectives on the study's acceptability, feasibility, and impact, and the conceptual model's contribution to these experiences. METHODS: Participants in the larger study were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City (N = 512). We randomly selected N = 46 for in-depth semi-structured interviews on their experiences with and perspectives on the study. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using directed qualitative content analysis. RESULTS: On average, participants were 49 years old (SD = 9) and had lived with HIV for 19 years (SD = 7). Most were male (78%) and African American/Black (76%). All had taken HIV medication previously. Challenging life contexts were the norm, including poverty, poor quality/unstable housing, trauma histories exacerbated by current trauma, health comorbidities, and substance use. Participants found the study highly acceptable. We organized results into four themes focused on participants' experiences of: 1) being understood as a whole person and in their structural/systemic context; 2) trustworthiness and trust; 3) opportunities for self-reflection; and 4) support of personal autonomy. The salience of nonjudgment was prominent in each theme. Themes reflected grounding in the conceptual model. Participants reported these characteristics were lacking in HIV care settings. CONCLUSIONS: The new conceptual model emphasizes the salience of systemic/structural and social factors that drive health behavior and the resultant interventions foster trust, self-reflection, engagement, and behavior change. The model has potential to enhance intervention acceptability, feasibility, and effectiveness with African American/Black and Latino PLWH.

Using the multiphase optimization strategy (MOST) framework to optimize an intervention to increase COVID-19 testing for Black and Latino/Hispanic frontline essential workers: A study protocol.

BACKGROUND: Among those at highest risk for COVID-19 exposure is the large population of frontline essential workers in occupations such food service, retail, personal care, and in-home health services, among whom Black and Latino/Hispanic persons are over-represented. For those not vaccinated and at risk for exposure to COVID-19, including frontline essential workers, regular (approximately weekly) COVID-19 testing is recommended. However, Black and Latino/Hispanic frontline essential workers in these occupations experience serious impediments to COVID-19 testing at individual/attitudinal- (e.g., lack of knowledge of guidelines), social- (e.g., social norms), and structural-levels of influence (e.g., poor access), and rates of testing for COVID-19 are insufficient. METHODS/DESIGN: The proposed community-engaged study uses the multiphase optimization strategy (MOST) framework and an efficient factorial design to test four candidate behavioral intervention components informed by an integrated conceptual model that combines critical race theory, harm reduction, and self-determination theory. They are A) motivational interview counseling, B) text messaging grounded in behavioral economics, C) peer education, and D) access to testing (via navigation to an appointment vs. a self-test kit). All participants receive health education on COVID-19. The specific aims are to: identify which components contribute meaningfully to improvement in the primary outcome, COVID-19 testing confirmed with documentary evidence, with the most effective combination of components comprising an "optimized" intervention that strategically balances effectiveness against affordability, scalability, and efficiency (Aim 1); identify mediators and moderators of the effects of components (Aim 2); and use a mixed-methods approach to explore relationships among COVID-19 testing and vaccination (Aim 3). Participants will be N = 448 Black and Latino/Hispanic frontline essential workers not tested for COVID-19 in the past six months and not fully vaccinated for COVID-19, randomly assigned to one of 16 intervention conditions, and assessed at 6- and 12-weeks post-baseline. Last, N = 50 participants will engage in qualitative in-depth interviews. DISCUSSION: This optimization trial is designed to yield an effective, affordable, and efficient behavioral intervention that can be rapidly scaled in community settings. Further, it will advance the literature on intervention approaches for social inequities such as those evident in the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05139927 ; Registered on 11/29/2021. Protocol version 1.0. May 2, 2022, Version 1.0.

African American/Black and Latino Adults with Detectable HIV Viral Load Evidence Substantial Risk for Polysubstance Substance Use and Co-occurring Problems: A Latent Class Analysis.

Substance use problems are highly prevalent among persons living with (PLWH) in the United States and serve as serious barriers to engagement in HIV care. Yet, in contrast to studies of single substances, little is known about patterns of polysubstance use in this population. Moreover, other risk factors (e.g., financial hardship, incarceration, homelessness, and mental health distress) are also prevalent and complicate HIV management. The present study drew on a cross-sectional survey with African American/Black and Latino (AABL) adult PLWH from low socioeconomic status backgrounds in New York City who were insufficiently engaged in HIV care and evidenced detectable HIV viral load (N = 512). We used latent class analysis (LCA) to explore patterns of polysubstance use and their relationships to financial hardship, incarceration, homelessness, and mental health. LCA yielded three substance use classes: Class 1, a high polysubstance use/high-risk substance use class (9%); Class 2, a polysubstance use/moderate substance use risk class (18%); and Class 3, a moderate polysubstance use/moderate-to-low-risk substance use class (74%). Mental health symptoms were prevalent in all classes, but Class 1 had greater mental health distress than the other two classes. Current homelessness was more prevalent in Classes 1 and 2. We cannot end the HIV epidemic without engaging and treating AABL PLWH who have serious barriers to engagement along the HIV care continuum, and who evidence polysubstance use along with co-occurring risk factors. Clinical settings can develop outreach and engagement approaches to bring this subpopulation of PLWH into care settings, and further, specialized services are needed to successfully screen, treat, and retain them.

Black and Latino Persons Living with HIV Evidence Risk and Resilience in the Context of COVID-19: A Mixed-Methods Study of the Early Phase of the Pandemic.

The COVID-19 pandemic has great potential to disrupt the lives of persons living with HIV (PLWH). The present convergent parallel design mixed-methods study explored the early effects of COVID-19 on African American/Black or Latino (AABL) long-term survivors of HIV in a pandemic epicenter, New York City. A total of 96 AABL PLWH were recruited from a larger study of PLWH with non-suppressed HIV viral load. They engaged in structured assessments focused on knowledge, testing, trust in information sources, and potential emotional, social, and behavioral impacts. Twenty-six of these participants were randomly selected for in-depth semi-structured interviews. Participants were mostly men (64%), African American/Black (75%), and had lived with HIV for 17 years, on average (SD=9 years). Quantitative results revealed high levels of concern about and the adoption of recommended COVID-19 prevention recommendations. HIV care visits were commonly canceled but, overall, engagement in HIV care and antiretroviral therapy use were not seriously disrupted. Trust in local sources of information was higher than trust in various federal sources. Qualitative findings complemented and enriched quantitative results and provided a multifaceted description of both risk factors (e.g., phones/internet access were inadequate for some forms of telehealth) and resilience (e.g., "hustling" for food supplies). Participants drew a direct line between structural racism and the disproportional adverse effects of COVID-19 on communities of color, and their knowledge gleaned from the HIV pandemic was applied to COVID-19. Implications for future crisis preparedness are provided, including how the National HIV/AIDS Strategy can serve as a model to prevent COVID-19 from becoming another pandemic of the poor.

Stopping, starting, and sustaining HIV antiretroviral therapy: a mixed-methods exploration among African American/Black and Latino long-term survivors of HIV in an urban context.

BACKGROUND: Although periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. Yet, little is known about factors that contribute to such ART non-persistence among long-term HIV survivors. The present study applied a convergent parallel mixed-methods design to explore the phenomena of stopping/starting and sustaining ART, focusing on low-socioeconomic status African American or Black and Latino persons living with HIV (PLWH) who face the greatest challenges. METHODS: Participants (N = 512) had poor engagement in HIV care and detectable HIV viral load. All received structured assessments and N = 48 were randomly selected for in-depth interviews. Quantitative analysis using negative binomial regression uncovered associations among multi-level factors and the number of times ART was stopped/started and the longest duration of sustained ART. Qualitative data were analyzed using a directed content analysis approach and results were integrated. RESULTS: Participants were diagnosed 18.2 years ago on average (SD = 8.6), started ART a median five times (Q1 = 3, Q3 = 10), and the median longest duration of sustained ART was 18 months (Q1 = 6, Q3 = 36). Factors associated with higher rates of stops/starts were male sex, transgender identity, cannabis use at moderate-to-high-risk levels, and ART- and care-related stigma. Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU). Factors associated with longer durations of sustained ART were Latino/Hispanic ethnicity, motivation for ART and care, and recent IDU. Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support. Qualitative results uncovered a convergence of intersecting risk factors for stopping/starting ART and challenges inherent in managing HIV over decades in the context of poverty. These included unstable housing, which contributed to social isolation, mental health distress, and substance use concerns, the latter prompting selling ("diverting") ART. Primarily complementary quantitative and qualitative findings described mechanisms by which risk/protective factors operated and ways PLWH successfully restart and/or sustain ART. CONCLUSIONS: The field focuses substantially on ART adherence, but greater attention to reducing the frequency of ART non-persistence is needed, along with creating social/structural conditions favorable for sustained ART.

Understanding Medical Distrust Among African American/Black and Latino Persons Living With HIV With Sub-Optimal Engagement Along the HIV Care Continuum: A Machine Learning Approach.

Medical distrust is a potent barrier to participation in HIV care and medication use among African American/Black and Latino (AABL) persons living with HIV (PLWH). However, little is known about sociodemographic and risk factors associated with distrust. We recruited adult AABL PLWH from low socio-economic status backgrounds with insufficient engagement in HIV care (N = 512). Participants completed structured assessments on three types of distrust (of health care providers, health care systems, and counter-narratives), HIV history, and mental health. We used a type of machine learning called random forest to explore predictors of trust. On average, participants were 47 years old (SD = 11 years), diagnosed with HIV 18 years prior (SD = 9 years), and mainly male (64%) and African American/Black (69%). Depression and age were the most important predictors of trust. Among those with elevated depressive symptoms, younger participants had less trust than older, while among those without depression, trust was greater across all ages. The present study adds nuance to the literature on medical distrust among AABL PLWH and identifies junctures where interventions to build trust are needed most.

Long-Term Mental Health Effects of a Devastating Wildfire Are Amplified by Sociodemographic and Clinical Antecedents in College Students.

OBJECTIVES: The aim of this study is to assess prevalence of major depressive disorder (MDD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) in students of Keyano College 18 months after a wildfire and to determine the predictors of likely MDD, GAD, and PTSD in the respondents. METHODS: A quantitative cross-sectional survey was used to collect data through self-administered, paper-based questionnaires to determine likely MDD, GAD, and PTSD using the PHQ 9, GAD-7, and the PTSD Checklist for DSM 5, Part 3, respectively. Data were analyzed with SPSS version 20 (IBM Corp, Armonk, NY) using univariate analysis with chi-square tests. RESULTS: Eighteen months after the wildfire, the 1-month prevalence rates for MDD, GAD, and PTSD among the college students were 23.4%, 18.7%, and 11.0%, respectively. There were statistically significant associations between multiple sociodemographic variables and the likelihood respondents presented with MDD, GAD, and PTSD 18 months after the wildfire. There were also associations between the likely MDD, GAD, and PTSD and abuse/dependence on alcohol and substances in respondents at 18 months. CONCLUSION: Our study has established prevalence rates for MDD, GAD, and PTDS among college students 18 months after the Fort McMurray wildfires. Further studies are needed to explore the impact of college-based mental health interventions on the long-term mental health effects of the wildfires.

Long-Term Mental Health Effects of a Devastating Wildfire Are Amplified by Socio-Demographic and Clinical Antecedents in Elementary and High School Staff.

OBJECTIVES: To assess the likely prevalence rates of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD) and Post-Traumatic Stress Disorder (PTSD) in staff of Fort McMurray School Districts eighteen months after a May 2016 wildfire, and to determine possible predictors. METHODS: A quantitative cross-sectional survey was used to collect data through self-administered online questionnaires to determine likely MDD, GAD and PTSD using well validated self-report questionnaires. RESULTS: Of 1,446 staff who were sent the online survey link in an e-mail, 197 completed the survey, of which there were 168 females (85%) and 29 males (15%). The one-month prevalence rates for likely MDD, GAD and PTSD among the school staff were 18.3, 15.7 and 10.2% respectively. There were statistically significant associations between multiple socio-demographic and clinical variables likely MDD, GAD and PTSD among respondents. CONCLUSION: Knowledge of key factors for MDD, GAD and PTSD may be helpful for policy makers when formulating population level social and clinical programs, to mitigate the mental health effects of future natural disasters.

Factors influencing medical students and psychiatry residents in Ghana to consider psychiatry as a career option - a qualitative study.

BACKGROUND: Currently, Ghana has 14 actively practicing psychiatrists and about 26 psychiatric residents for a population of over 28 million people. Previous research suggests a lack of interest by Ghanaian medical students and medical graduates in considering psychiatry as a career option. OBJECTIVES: To examine the perception of medical students and psychiatry residents in Ghana about the barriers which hinder Ghanaian medical graduates from choosing careers in psychiatry and how these barriers could be overcome. METHODS: This was a cross-sectional qualitative study with data gathered using focus group discussion. Twenty clinical year medical students were selected through block randomization from the four public medical schools in Ghana and invited to participate in one of two focus group discussions. Also, four psychiatric residents were invited to participate in the focus group discussions. RESULTS: The main barriers identified by participants could be grouped under four main themes, namely: (a) myths and stigma surrounding mental health and patients, (b) negative perceptions of psychiatrists, (c) infrastructure and funding issues, (d) lack of exposure and education. To address the barriers presented, participants discussed potential solutions that could be categorized into five main themes, namely: (a) stigma reduction, (b) educating professionals, (c) addressing deficient infrastructure, (d) risk management, and (e) incentivizing the pursuit of psychiatry among students. CONCLUSION: Health policy planners and medical training institutions could consider implementing proposed solutions to identify barriers as part of efforts to improve the psychiatrist to patient ratio in Ghana.

Understanding Organizations Serving Runaway and Homeless Youth: A Multi-setting, Multi-perspective Qualitative Exploration.

Runaway and homeless youth (RHY) are dependent on the specialized settings that locate, engage, and serve them. Yet, little research has focused on the features of effective settings for RHY. The present qualitative study, grounded in the Youth Program Quality Assessment model, explored characteristics of higher quality organizations for RHY and gaps that remain from staff and RHY perspectives. A total of 29 diverse settings serving RHY in New York State were randomly selected for participation, and ranked on a quantitative program quality index. Within settings, we conducted in-depth semi-structured interviews with program administrators (N=30) and other staff (N=24). Focus group interviews were conducted with RHY (N=13 focus groups; N=84 RHY). Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive, comparing higher to lower quality settings. We found all settings provided vital services and experienced challenges, but higher quality settings ameliorated challenges through 1) a youth-centered program philosophy equally understood by staff and RHY; 2) developmentally appropriate relationships between staff and RHY that promoted autonomy; 3) a focus on short- and long-term goals within anticipated crises; and 4) ongoing internal quality assessment procedures. Within lower-quality settings we found 1) difficulties retaining effective staff and 2) a primary focus on basic services and managing crises, but less attention to emotional support, exacerbated by 3) funding and other challenges emerging from the larger environment. The present study extends the literature on organizations for RHY by identifying characteristics of higher quality settings, and challenges that remain.

Impact of oil recession on community mental health service utilization in an oil sands mining region in Canada.

OBJECTIVES: This retrospective clinical audit compared changes in community mental health service utilization before and during an economic recession in an oil sands region in Canada which was characterized by a doubling of unemployment rates and poor economic outlook. METHODS: Sociodemographic descriptors, psychiatric antecedents, clinical characteristics and follow-up care were compared before and during the recession for newly assessed patients in community mental health clinics located across a Northern Alberta oil mining region. Data were collected retrospectively as part of a clinical audit process and then analysed with descriptive statistics, cross-tabular univariate analyses with chi-square tests using SPSS version 20. RESULTS: A total of 1,465 patients were included. Sociodemographic factors disproportionately elevated during the recession included male sex, Caucasian ethnicity, own home ownership, higher levels of education and unemployment. More patients seeking mental health care were already taking psychotropic medications (e.g. antipsychotics, benzodiazepines and stimulants). At the same time, disproportionately fewer patients engaged in substance abuse or had a prior formal history of mental health problems. The referral reasons during recession were less likely to be associated with substance abuse or mood concerns and more likely for 'other' reasons. The patients seeking psychiatric help during a recession were disproportionately likely to be diagnosed with personality disorders and 'other' less common diagnostic categories and less likely to suffer from mood or trauma-related diagnoses. Referrals for counselling and social services were also disproportionately more common during the recession. CONCLUSION: This study provides a comprehensive description of longitudinal patterns of mental health service utilization before and during a recession. The findings provide important evidence for policy and planning decisions to encourage resource allocation to help promote accessibility of the most needed community mental health resources.

Do Programs for Runaway and Homeless Youth Work? A Qualitative Exploration From the Perspectives of Youth Clients in Diverse Settings.

Runaway and homeless youth (RHY) comprise a large population of young people who reside outside the control and protection of parents and guardians and who experience numerous traumas and risk factors, but few buffering resources. Specialized settings have developed to serve RHY, but little is known about their effects. The present cross-sectional qualitative descriptive study, grounded in the positive youth development approach and the Youth Program Quality Assessment model, addressed this gap in the literature. From a larger sample of 29 RHY-specific settings across New York State, RHY ages 16-21 from 11 settings were purposively sampled for semi-structured in-depth interviews on their transitions into homelessness, experiences with settings, and unmet needs (N = 37 RHY). Data were analyzed with a theory-driven and inductive systematic content analysis approach. Half of participants (54%) were female; almost half (49%) identified as non-heterosexual; and 42% were African American/Black, 31% were Latino/Hispanic, and 28% were White/other. Results indicated that because RHY are a uniquely challenged population, distrustful of service settings and professional adults and skilled at surviving independently, the population-tailored approaches found in RHY-specific settings are vital to settings' abilities to effectively engage and serve RHY. We found the following four major themes regarding the positive effects of settings: (1) engaging with an RHY setting was emotionally challenging and frightening, and thus the experiences of safety and services tailored to RHY needs were critical; (2) instrumental support from staff was vital and most effective when received in a context of emotional support; (3) RHY were skilled at survival on the streets, but benefited from socialization into more traditional systems to foster future independent living; and (4) follow-through and aftercare were needed as RHY transitioned out of services. With respect to gaps in settings, RHY highlighted the following: (1) a desire for better management of tension between youths' needs for structure and wishes for autonomy and (2) lack of RHY input into program governance. This study advances our understanding of RHY, their service needs, and the ways settings meet these needs, as well as remaining gaps. It underscores the vital, life-changing, and even life-saving role these settings play for RHY.

Doing battle with "the monster:" how high-risk heterosexuals experience and successfully manage HIV stigma as a barrier to HIV testing.

BACKGROUND: Annual HIV testing is recommended for populations at-risk for HIV in the United States, including heterosexuals geographically connected to urban high-risk areas (HRA) with elevated rates of HIV prevalence and poverty, who are primarily African American/Black or Hispanic. Yet this subpopulation of "individuals residing in HRA" (IR-HRA) evidence low rates of regular HIV testing. HIV stigma is a recognized primary barrier to testing, in part due to its interaction with other stigmatized social identities. Guided by social-cognitive and intersectionality theories, this qualitative descriptive study explored stigma as a barrier to HIV testing and identified ways IR-HRA manage stigma. METHODS: In 2012-2014, we conducted in-depth qualitative interviews with 31 adult IR-HRA (74% male, 84% African American/Black) with unknown or negative HIV status, purposively sampled from a larger study for maximum variation on HIV testing experiences. Interviews were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive. RESULTS: Stigma was a primary barrier to HIV testing among IR-HRA. In the context of an under-resourced community, HIV stigma was experienced as emerging from, and being perpetuated by, health care organizations and educational institutions, as well as community members. Participants noted it was "better not to know" one's HIV status, to avoid experiencing HIV-related stigma, which could interact with other stigmatized social identities and threaten vital social relationships, life chances, and resources. Yet most had tested for HIV previously. Factors facilitating testing included health education to boost knowledge of effective treatments for HIV; understanding HIV does not necessitate ending social relationships; and tapping into altruism. CONCLUSIONS: In the context of economic and social inequality, HIV stigma operates on multiple, intersecting layers. IR-HRA struggle with an aversion to HIV testing, because adopting another stigmatized status is dangerous. They also find ways to manage stigma to engage in testing, even if not at recommended levels. Findings highlight strategies to reduce HIV stigma at the levels of communities, institutions, and individuals to improve rates of annual HIV testing necessary to eliminate HIV transmission and reduce HIV-related racial and ethnic health disparities among IR-HRA.

Cost-Effectiveness of Peer- Versus Venue-Based Approaches for Detecting Undiagnosed HIV Among Heterosexuals in High-Risk New York City Neighborhoods.

INTRODUCTION: We used a computer simulation of HIV progression and transmission to evaluate the cost-effectiveness of a scale-up of 3 strategies to seek out and test individuals with undiagnosed HIV in New York City (NYC). SETTING: Hypothetical NYC population. METHODS: We incorporated the observed effects and costs of the 3 "seek and test" strategies in a computer simulation of HIV in NYC, comparing a scenario in which the strategies were scaled up with a 1-year implementation or a long-term implementation with a counterfactual scenario with no scale-up. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression, calibrated to NYC epidemiological data from 2003 to 2015. The 3 approaches were respondent-driven sampling (RDS) with anonymous HIV testing ("RDS-A"), RDS with a 2-session confidential HIV testing approach ("RDS-C"), and venue-based sampling ("VBS"). RESULTS: RDS-A was the most cost-effective strategy tested. When implemented for only 1 year and then stopped thereafter, using a societal perspective, the cost per quality-adjusted life-year (QALY) gained versus no intervention was $812/QALY, $18,110/QALY, and $20,362/QALY for RDS-A, RDS-C, and VBS, respectively. When interventions were implemented long term, the cost per QALY gained versus no intervention was cost-saving, $31,773/QALY, and $35,148/QALY for RDS-A, RDS-C, and VBS, respectively. When compared with RDS-A, the incremental cost-effectiveness ratios for both VBS and RDS-C were dominated. CONCLUSIONS: The expansion of the RDS-A strategy would substantially reduce HIV-related deaths and new HIV infections in NYC, and would be either cost-saving or have favorable cost-effectiveness.