Predictors of Retention in Care Among HIV+ and At-Risk Youth

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Data Analyses Method Survival 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

9. Key Predictor Variables • Number of outreach contacts Categories: 0, 1, >2 times • Number of mental health service visits Categories: 0, 1, >2 times • Number of case management visits Categories: 0, 1-2, >3 times

10. 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 Other Potential Predictors Client Demographic and HIV Risk Factors:

11. Type of site of initial care Multi-service outreach agency Community health center Hospital Other Potential Predictors (cont’d)

12. 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

13. 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

14. Client Characteristics by Gender(Total N=1426)

15. 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

16. Probability of Retention Over Timeby Number of Outreach Contacts MALES FEMALES >2 contacts* Cum Probability of Retention >2 contacts* 0 0 1¥ 1 Number of days between first and last visits Log-rank test: *p<0.001; ¥p=0.002

17. Probability of Retention Over Timeby Number of Mental Health Visits MALES FEMALES >2 visits* >2 visits* Cum Probability of Retention 1¥ 1 0 0 Number of days between first and last visits Log-rank test: *p<0.001; ¥p=0.03

18. Probability of Retention Over Timeby Case Management Visits MALES FEMALES >3 visits* >3 visits* Cum Probability of Retention 1-2 1-2 0 0 Number of days between first and last visits Log-rank test: *p<0.001

19. Cox PH Modeling Results, Males * Adjusted for age, HIV status, race/ethnicity, sexual orientation, homelessness, MH-system involvement, and high risk sex behaviors

20. Cox PH Modeling Results, Females * Adjusted for age, HIV status, race/ethnicity, sexual orientation, any pregnancy, and any unprotected sex with males

21. 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

22. 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

23. Study Limitations (cont’d) • Other client and program factors related to retention unmeasured

24. 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+