Outreach, mental health, and case management services: can they help to retain HIV-positive and at-risk youth and young adults in care?

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

A Digital Platform to Support HIV Case Management for Youth and Young Adults: Mixed Methods Feasibility Study

BACKGROUND

Advances in medical treatments in recent years have contributed to an overall decline in HIV-related opportunistic infections and deaths in youth; however, mortality and morbidity rates in perinatally and nonperinatally infected adolescents and young adults (AYA) living with HIV remain relatively high today.

OBJECTIVE

The goal of this project was to assess the use, utility, and cost-effectiveness of PlusCare, a digital app for HIV case management in AYA living with HIV. The app supports routine case management tasks, such as scheduling follow-up visits, sharing documents for review and signature, laboratory test results, and between-visit communications (eg, encouraging messages).

METHODS

We conducted a single-group mixed methods pre-post study with HIV case management programs in 2 large urban hospitals in the Boston metro area. Case management staff (case managers [CMs], N=20) and AYA living with HIV participants (N=45) took part in the study with access to PlusCare for up to 15 and 12 months, respectively.

RESULTS

The CMs and AYA living with HIV reported mean System Usability Scale scores of 51 (SD 7.9) and 63 (SD 10.6), respectively. Although marginally significant, total charges billed at 1 of the 2 sites compared with the 12 months before app use (including emergency, inpatient, and outpatient charges) decreased by 41% (P=.046). We also observed slight increases in AYA living with HIV self-reported self-efficacy in chronic disease management and quality of life (Health-Related Quality of Life-4) from baseline to the 12-month follow-up (P=.02 and P=.03, respectively) and increased self-efficacy from the 6- to 12-month follow-up (P=.02). There was no significant change in HIV viral suppression, appointment adherence, or medication adherence in this small-sample pilot study.

CONCLUSIONS

Although perceived usability was low, qualitative feedback from CMs and use patterns suggested that direct messaging and timely, remote, and secure sharing of laboratory results and documents (including electronic signatures) between CMs and AYA living with HIV can be particularly useful and have potential value in supporting care coordination and promoting patient self-efficacy and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03758066; https://clinicaltrials.gov/ct2/show/NCT03758066.

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology-such as gaming platforms, mobile phone applications, and wearable devices-suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care.

The experiences of emergency department use by street-involved youth: Perspectives of health care and community service providers

Street-involved (SI) youth represent a significant proportion of urban homeless populations. While previous research has identified SI youth as substantial users of emergency department (ED) services and has examined their experiences of ED care, little is known about the experiences and perceptions of the service providers who assist these youth with health care related issues. Using grounded theory, individual interviews and focus groups were conducted with 20 community agency staff serving SI youth, 17 health service providers, two hospital administrators, and two hospital security personnel regarding their experiences in providing or facilitating ED care for SI youth. Results identify differences in expectations between SI youth and hospital staff, along with service issues and gaps, including relational barriers and resource constraints. Implications for practice and policy development are offered.

High rates of retention and viral suppression in the US HIV safety net system: HIV care continuum in the Ryan White HIV/AIDS Program, 2011

BACKGROUND

In the human immunodeficiency virus (HIV) care continuum, retention in HIV medical care and viral suppression are key goals to improve individual health outcomes and reduce HIV transmission. National data from clinical providers are lacking.

METHODS

HIV providers funded by the Ryan White HIV/AIDS Program (RWHAP) annually report demographic, service, and clinical data using encrypted unique client identifiers, and data are processed and de-duplicated to create a single record for each client. We calculated retention and viral suppression for clients who received RWHAP-funded HIV medical care in 2011. We conducted multivariate logistic regression to identify factors associated with these outcomes.

RESULTS

In 2011, an estimated 512 911 HIV-infected clients received at least 1 RWHAP-funded non-AIDS Drug Assistance Program service. Of these, 317 458(61.8%) were seen for at least 1 HIV medical care visit. Of these, 82.2% were retained in HIV medical care, and 72.6% achieved viral suppression. Viral suppression was higher among retained clients (77.7%) vs clients who were not retained (58.3%). The lowest levels of retention and viral suppression were among individuals aged 13-34 years.

CONCLUSIONS

The RWHAP provides HIV medical care and support services for more than half a million poor and underinsured individuals living with HIV in the United States. Rates of retention and viral suppression are relatively high compared with other national estimates but demonstrate room for improvement, especially among youth and racial minorities. Additional improvements in retention and viral suppression will contribute to achieving the goals of the National HIV/AIDS Strategy and improve individual and public health.

Factors associated with returning to HIV care after a gap in care in New York State

BACKGROUND

Retention in HIV care has important implications. Few studies examining retention include comprehensive and heterogeneous populations, and few examine factors associated with returning to care after gaps in care. We identified reasons for gaps in care and factors associated with returning to care.

METHODS

We extracted medical record and state-wide reporting data from 1865 patients with 1 HIV visit to a New York facility in 2008 and subsequent 6-month gap in care. Using mixed effect logistic regression, we examined sociodemographic, clinical, and facility characteristics associated with returning to care.

RESULTS

Most patients were men (63.2%), black (51.4%), had Medicaid (53.9%). Many had CD4 counts >500 cells per cubic millimeter (34.4%) and undetectable viral loads (45.0%). Most (55.9%) had unknown reasons for gaps in care; of those with known reasons, reasons varied considerably. After a gap, 54.6% returned to care. Patients who did (vs. did not) return to care were more likely to have stable housing, longer duration of HIV, high CD4 count, suppressed viral load, antiretroviral medications, and had facilities attempt to contact them. Those who returned to care were less likely to be uninsured and have mental health problems or substance use histories.

CONCLUSION

Over half of our sample of patients in New York with 1 HIV visit and subsequent 6-month gap in care returned to care; no major reasons for gaps emerged. Nevertheless, our findings emphasize that stabilizing patients' psychosocial factors and contacting patients after a gap in care are key strategies to retain HIV-positive patients in care in New York.

Interventions to promote linkage to and utilization of HIV medical care among HIV-diagnosed persons: a qualitative systematic review, 1996-2011

This qualitative systematic review examined interventions that promote linkage to or utilization of HIV care among HIV-diagnosed persons in the United States. We conducted automated searches of electronic databases (i.e., MEDLINE, EMBASE, PsycINFO, CINAHL) and manual searches of journals, reference lists, and listservs. Fourteen studies from 19 published reports between 1996 and 2011 met our inclusion criteria. We developed a three-tier approach, based on strength of study design, to evaluate 6 findings on linkage to care and 18 findings on HIV care utilization. Our review identified similar strategies for the two outcomes, including active coordinator's role in helping with linking to or utilizing HIV care; offering information and education about HIV care; providing motivational or strengths-based counseling; accompanying clients to medical appointments and helping with appointment coordination. The interventions focused almost exclusively on individual-level factors. More research is recommended to examine interventions that address system and structural barriers.

Conformity of pediatric/adolescent HIV clinics to the patient-centered medical home care model

The patient-centered medical home (PCMH) has been introduced as a model for providing high-quality, comprehensive, patient-centered care that is both accessible and coordinated, and may provide a framework for optimizing the care of youth living with HIV (YLH). We surveyed six pediatric/adolescent HIV clinics caring for 578 patients (median age 19 years, 51% male, and 82% black) in July 2011 to assess conformity to the PCMH. Clinics completed a 50-item survey covering the six domains of the PCMH: (1) comprehensive care, (2) patient-centered care, (3) coordinated care, (4) accessible services, (5) quality and safety, and (6) health information technology. To determine conformity to the PCMH, a novel point-based scoring system was devised. Points were tabulated across clinics by domain to obtain an aggregate assessment of PCMH conformity. All six clinics responded. Overall, clinics attained a mean 75.8% [95% CI, 63.3-88.3%] on PCMH measures-scoring highest on patient-centered care (94.7%), coordinated care (83.3%), and quality and safety measures (76.7%), and lowest on health information technology (70.0%), accessible services (69.1%), and comprehensive care (61.1%). Clinics moderately conformed to the PCMH model. Areas for improvement include access to care, comprehensive care, and health information technology. Future studies are warranted to determine whether greater clinic PCMH conformity improves clinical outcomes and cost savings for YLH.

Dental case manager encounters: the association with retention in dental care and treatment plan completion

Little is known about dental case managers as few programs have been scientifically evaluated. The goal of this study was to explore the impact of dental case manager on retention in dental care and completion of treatment plans, while specifically exploring the number of dental case manager encounters. Fourteen programs enrolled people with HIV/AIDS (PLWHA) in dental care and a longitudinal study between 2007 and 2009. The 758 participants had a total of 2715 encounters with a dental case manager over twelve months: 29% had a single encounter; 21% had two; 27% had 3-4 and; 23% had 5-29 encounters. Adjusting for baseline characteristics, participants receiving more encounters were significantly more likely to complete their Phase 1 treatment plan, be retained in dental care, and experience improvements in overall oral health status. Organizations considering efforts to improve the oral health of vulnerable, hard-to-engage populations should consider these findings when planning interventions.

Outreach with street-involved youth: a quantitative and qualitative review of the literature

Outreach workers meet with street-involved youth in their environment, and attempt to engage them in services vital to their well-being. The goal of this study is to conduct a systematic review of both the quantitative and qualitative research that explores outreach with street-involved youth. Using 16 outreach programs with quantitative information, our meta-analysis found that 63% of youth who are contacted through outreach later participate in the offered service. Our meta-synthesis of 31 qualitative articles on outreach uncovered 13 themes across 4 conceptual domains of interest. Themes pertaining to the therapeutic relationship, flexibility, and youth-centric programming had a large presence among the majority of the articles. Outreach with street-involved youth, when characterized through a strong bond between worker and youth, is an effective strategy for involving youth in agency services.

A scoping literature review of collaboration between primary care and public health

AIM

The purpose of this scoping literature review was to determine what is known about: 1) structures and processes required to build successful collaborations between primary care (PC) and public health (PH); 2) outcomes of such collaborations; and 3) markers of their success.

BACKGROUND

Collaboration between PC and PH is believed to enable more effective individual and population services than what might be achieved by either alone.

METHODS

The study followed established methods for a scoping literature review and was guided by a framework that identifies systemic, organizational and interactional determinants for collaboration. The review was restricted to articles published between 1988 and 2008. Published quantitative and qualitative primary studies, evaluation research, systematic and other types of reviews, as well as descriptive accounts without an explicit research design, were included if they addressed either the structures or processes to build collaboration or the outcomes or markers of such collaboration, and were published in English.

FINDINGS

The combined search strategy yielded 6125 articles of which 114 were included. Systemic-level factors influencing collaboration included: government involvement, policy and fit with local needs; funding and resource factors, power and control issues; and education and training. Lack of a common agenda; knowledge and resource limitations; leadership, management and accountability issues; geographic proximity of partners; and shared protocols, tools and information sharing were influential at the organizational level. Interpersonal factors included having a shared purpose; philosophy and beliefs; clear roles and positive relationships; and effective communication and decision-making strategies. Reported benefits of collaboration included: improved chronic disease management; communicable disease control; and maternal child health. More research is needed to explore the conditions and contexts in which collaboration between PC and PH makes most sense and potential gains outweigh the associated risks and costs.

A youth-focused case management intervention to engage and retain young gay men of color in HIV care

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 (p<0.0001). 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.

Keeping them in "STYLE": finding, linking, and retaining young HIV-positive black and Latino men who have sex with men in care

Young men who have sex with men (YMSM) of color are at particularly increased risk for HIV infection compared to white MSM. National data highlight the need to link YMSM of color to care to improve their overall health and stem further infections, yet, there is limited data on interventions and clinical outcomes focused on engaging and retaining youth, specifically HIV-infected YMSM of color in care. To address the medical care needs of this underserved population, in 2005, the Health Research and Services Administration (HRSA) created the YMSM of Color Initiative. Utilizing a social marketing campaign targeting youth and members of their sexual and social networks, testing and outreach on college campuses and within the broader community, and a tightly linked medical-social support network, we created STYLE (Strength Through Youth Livin' Empowered), a novel intervention that sought to diagnose, engage, and retain HIV-positive black and Latino YMSM in HIV primary care services. Over a 3-year period, 81 men were either newly diagnosed or reengaged in care. Overall, 63% of the cohort was retained in clinical care; defined as attending at least one medical visit every 4 months. Compared to the 3 years prior to STYLE, the odds ratio for whether or not someone attended a clinic visit was 2.58 (95% confidence interval [CI] 1.34-4.98) if enrolled in STYLE. We conclude that compared to a pre-STYLE cohort, STYLE was an effective intervention that increased HIV diagnoses, provided efficient and timely engagement in care for both those newly diagnosed and those who had fallen out of care and improved overall retention.

Strategies to improve access to and utilization of health care services and adherence to antiretroviral therapy among HIV-infected drug users

We review five innovative strategies to improve access, utilization, and adherence for HIV-infected drug users and suggest areas that need further attention. In addition, we highlight two innovative programs. The first increases access and utilization through integrated HIV and opioid addiction treatment with buprenorphine in a community health center, and the second incorporates adherence counseling for antiretroviral therapy in methadone programs. Preliminary evaluations demonstrated that these strategies may improve both HIV and opioid addiction outcomes and may be appropriate for wider dissemination. Further refinement and expansion of strategies to improve outcomes of HIV-infected drug users is warranted.

Linking urban families to community resources in the context of pediatric primary care

INTRODUCTION

Pediatric guidelines emphasize the importance for healthcare providers to view children in the context of family and community, and promote community resources at visits. In 2006, a Family Help Desk (FHD) was established in an urban academic-based clinic in Baltimore, MD to assist healthcare providers in educating families about available community-based resources.

METHODS

A longitudinal cohort pilot study was conducted during a 6-week period in 2007 to evaluate the impact of the FHD in connecting at-risk families to community resources.

RESULTS

Overall, 6% of parents (n=59) who brought their child for a scheduled clinic visit accessed the FHD. Parents had a mean of 1.7 social needs, including after-school programs and childcare (29%), employment (13%), housing (12%), and food (11%). Most parents who utilized the FHD (64%) contacted a community resource or service within 6 months of their clinic visit. Nineteen parents (32%) who utilized the FHD enrolled in community programs.

CONCLUSION

A clinic-based multi-disciplinary model can empower families to connect with community-based resources for basic social needs.

PRACTICE IMPLICATIONS

The Family Help Desk model has great potential for addressing family psychosocial needs, and educating families about community resources within the context of pediatric primary care.

Revisiting "Who gets care?": health equity as an arena for nursing action

This article revisits and reaffirms Patricia Steven's earlier work on access to healthcare as an important arena for nursing action. Many of the conditions that affect access to healthcare, such as racism and oppression, also shape inequities in health outcomes. We propose a conceptualization of social justice that is consistent with addressing the conditions that influence health inequities. We also discuss the implications of a critical and feminist conception of social justice for nursing action, education, practice, research, and policy.

Case management and health-related quality of life outcomes in a national sample of persons with HIV/AIDS

OBJECTIVE

To examine whether having a case manager is associated with better physical and mental health scores.

BACKGROUND

HIV/AIDS is a condition characterized by a variety of medical and social needs that vary between individuals and over time. Case management has been advocated as a means to improve problems of access, cost and outcomes of HIV/AIDS care.

METHODS

We analyzed data from a nationally representative sample of 2,251 HIV-positive persons receiving care in the in the HIV Costs and Services Utilization Study (HCSUS). Participants were interviewed at baseline and approximately 18 months later. Data were collected on use of case management, sociodemographics, antiretroviral therapy and health-related quality of life. We examined bivariate and multivariate associations of case management at baseline with change in self-reported physical health and mental health at follow-up.

RESULTS

We found that having contact with a case manager at baseline significantly predicted improvement in physical health (regression coefficient=1.02, p<0.05) among those not receiving HAART. We found no association of case management with mental health among those not receiving HAART and those receiving HAART in multivariate analysis.

CONCLUSIONS

Our findings support a beneficial relationship between case managers and physical health for patients with HIV but only among those not already receiving recommended treatment with HAART.

Medical and support service utilization in a medical program targeting marginalized HIV-infected individuals

BACKGROUND

One strategy to facilitate HIV health care services utilization is to incorporate support services with medical services. We developed a program that delivers HIV medical care and support services to marginalized people, and evaluated the association between support and medical services utilization.

METHODS

We extracted data on 218 newly enrolled program participants 3 months prior to through 6 months after program enrollment, and analyzed associations between support and medical services.

RESULTS

Case management visits (AOR=1.95, 95% CI 1.04-3.67) and group visits (AOR=2.59, 95% CI 1.30-5.16) were associated with greater odds of quarterly medical visits. Outreach visits were associated with greater odds of having a medical visit in a traditional medical setting (AOR=2.31, 95% CI 1.15-4.67).

CONCLUSION

Case management, support groups, and outreach were associated with HIV medical visits. Further research exploring how integration of support services into HIV medical programs can improve health care delivery is crucial for health policy and program development.

Psychiatric morbidity in HIV-infected children

After the introduction of antiretroviral therapy, HIV infection in children has been transformed from an acute to a chronic illness. The number of HIV-infected children has also increased in recent years. The routes of transmission and clinical manifestation of HIV infection in children are unique and different from those of adults. There are a number of biological, psychological and social factors associated with HIV-infected child that may predispose him/her to develop psychiatric illness. However, there are very few studies on psychiatric morbidity in HIV-infected children. In the existing studies, a number of psychiatric illnesses including: depression, anxiety, disruptive disorders and hyperactive disorders have been observed in HIV-infected children. A number of variables have a bearing on psychiatric morbidity, including experience and expression of physical illness as well as adherence to medications. The physician dealing with HIV-infected children should be aware of the psychological manifestations so that appropriate interventions and referral may be made as needed.

"Getting me back on track": the role of outreach interventions in engaging and retaining people living with HIV/AIDS in medical care

This qualitative study investigated the process of engagement in HIV medical care from the perspective of people living with HIV/AIDS (PLWHA). In-depth interviews were conducted with 76 participants in six cities. All participants were considered underserved because of histories of substance use, mental illness, incarceration, homelessness, or cultural barriers to the traditional health care system. A semistructured interview guide elicited narratives related to health care and the role of program interventions in facilitating access to care. Data analysis revealed that participants cycled in and out of care, a process that was influenced by (1) their level of acceptance of being diagnosed with HIV, (2) their ability to cope with substance use, mental illness, and stigma, (3) their health care provider relationships, (4) the presence of external support systems, and (5) their ability to overcome practical barriers to care. Outreach interventions played a role in connecting participants to care by dispelling myths and improving knowledge about HIV, facilitating access to HIV care and treatment, providing support, and reducing the barriers to care. The findings suggest that outreach programs can interrupt this cyclical process and foster sustained, regular HIV care for underserved PLWHA by conducting client-centered risk assessments to identify and reduce sources of instability and improve the quality of provider relationships; implementing strategies that promote healthy practices; creating a network of support services in the community; and supporting adherence through frequent follow-ups for medication and appointment keeping.

Prevalence and correlates of human immunodeficiency virus testing and posttest counseling among outpatients with serious mental illness

This study examined the prevalence and correlates of receipt of human immunodeficiency virus (HIV) testing, test results, and posttest counseling among outpatients with serious mental illness at 3 public-sector facilities in Connecticut (N = 487). A substantial proportion (41.9%) reported never having been tested for HIV, including fully one-third of those who were "very afraid" of getting acquired immune deficiency syndrome. Independent correlates of HIV testing included younger age, felony criminal history, stronger therapeutic alliance with one's primary clinician, and increased drug problems and psychological distress. Of those tested, nearly all (96.5%) reported receiving the test results; however, only half (50.5%) reported receiving any posttest counseling. Independent correlates of posttest counseling included higher educational level, felony criminal history, and receipt of community-based case management services. Greater efforts are needed to increase HIV testing and counseling among persons with serious mental illness to better identify and care for HIV-positive individuals and potentially reduce future transmission of the virus in this vulnerable, at-risk population.

Implementing an HIV and Sexually Transmitted Disease Screening Program in an Emergency Department

STUDY OBJECTIVE

We assess the feasibility, effectiveness, and cost of routinely recommended HIV/sexually transmitted disease screening in an urban emergency department (ED).

METHODS

From April 2003 to August 2004, patients aged 15 to 54 years were offered rapid HIV testing, and those aged 15 to 25 years were also offered gonorrhea and chlamydia testing (nucleic acid amplification), Monday through Friday, 11 am to 8 pm. Infected patients were referred for treatment and care. Prevalence, treatment rates, and cost were assessed.

RESULTS

Among 3,030 patients offered HIV testing, 1,447 (47.8%) accepted, 8 (0.6%) tested positive, and 3 (37.5%) were linked to care. Among 791 patients offered sexually transmitted disease testing, 386 (48.8%) accepted, 320 provided urine (82.9%), 48 (15.0%) tested positive, and 42 (87.5%) were treated for gonorrhea or chlamydia. The program cost was $72,928. Costs per HIV-infected patient identified and linked to care were, respectively, $9,116 and $24,309; cost per sexually transmitted disease-infected patient treated was $1,736. The program cost for HIV/sexually transmitted disease screening was only $14,340 more than if we screened only for HIV.

CONCLUSION

Through ED-based HIV/sexually transmitted disease screening, we identified and treated many sexually transmitted disease-infected patients but identified few HIV-infected patients and linked even fewer to care. However, sexually transmitted disease screening can be added to HIV screening at a reasonable cost.

Emotional Distress and Mental Health Service Use Among Urban Homeless Adolescents

The Expanded Behavioral Model for Vulnerable Populations was used to examine the predisposing, enabling, and need factors associated with mental health service use in a homeless adolescent sample (N = 688). Among all youth, 32% perceived a need for help with mental health problems and 15% met Brief-Symptom Inventory (BSI) criteria for emotional distress. The rate of mental health service use in our sample was 32%. One enabling factor, having a case manager/discussed mental health concerns, and one need factor, which met criteria for BSI, were found to be associated with mental health service use in the past 3 months. The majority of youth who used mental health services had obtained services from crisis centers. Among those who perceived a need for help with mental health problems but who did not use services, the most common barrier was not knowing where to go or what service to use (57%). These findings suggest that due to the high prevalence of mental health problems among homeless youth, it would be helpful for service providers coming into contact with youth to make them aware of existing community resources for mental health services; making youth aware of these resources may in turn decrease the rate of crisis center use and instead allow youth to receive mental health services in outpatient settings that provide continuity of care.

Unmet need for medical care among homeless adults with serious mental illness

OBJECTIVE

The objective of this study was to determine the rates and predictors of unmet medical needs among homeless adults with serious mental illness entering a community-based case management program and those of receipt of medical care in the subsequent 3-month period.

METHODS

We analyzed baseline and follow-up data for 7213 homeless clients in the multisite Access to Community Care and Effective Services and Supports program.

RESULTS

Overall, 43.6% of the sample reported having an unmet need for medical care at baseline; of these subjects, only 36.1% received medical services during the 3 months following program entry. Using multivariate logistic regression modeling, we found that, at baseline, independent correlates of an unmet medical need included lower educational level, increased depressive and psychotic symptoms and greater number of potentially competing needs. None of these variables, however, adversely affected the likelihood of receiving medical care during follow-up. Factors associated with receiving medical services in the 3 months following program entry included receiving outpatient psychiatric services and reporting stronger therapeutic alliance with one's case manager.

CONCLUSIONS

Collaborative case management may play an important role in meeting mentally ill homeless persons' medical needs. Greater efforts are needed to identify and link at-risk clients with appropriate medical services.