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A youth-focused case management intervention to engage and retain young gay men of color in HIV care Amy Rock Wohl a*, Wendy H. Garland a, Juhua Wu b, Chi-Wai Au b, Angela Boger b, Rhodri Dierst-Davies a, Judy Carter b, Felix Carpio cand Wilbert Jordan d aLos Angeles County Department of Public Health, HIV Epidemiology Program, Los Angeles, CA, USA; bLos Angeles County Department of Public Health, Office of AIDS Programs and Policy, Los Angeles, CA, USA; cAltaMed Health Services Corporation, Daniel V. Lara Clinic, Los Angeles, CA, USA; dLos Angeles County MLK-MACC, OASIS Clinic, Los Angeles, CA, USA (Received 5 April 2010;final version received 18 November 2010) 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 (pB0.0001). 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. Keywords:adolescents; MSM; HIV/AIDS; Latinos; African-Americans; interventions Introduction National HIV and AIDS rates are elevated for African-American and Latino youth which is consis- tent with 2008 behavioral surveillance data in Los Angeles County in which HIV prevalence rates were 17% for African-American and 13% for Latino 18 24-year-old young men who have sex with men (YMSM) (Bingham & Sey, 2009; Centers for Disease Control and Prevention [CDC], 2008). Youth are also known to test late for HIV, delay seeking care for an HIV infection following a positive HIV test, are at high risk for dropping out of HIV care and have poor adherence to antiretroviral treatment regimens (Cen- ters for Disease Control and Prevention [CDC], 2005; Johnson, Sorvillo et al., 2003; Rao, Kekwaletswe, Hosek, Martinez, & Rodriguez, 2007; Rudy, Murphy, Harris, Muenz, & Ellen, for the Adolescent Trials Network for HIV/AIDS Interventions, 2009; Valleroy et al., 2000). In addition, among a national sample ofHIV-positive 15 22-year-old YMSM, only 15% were receiving HIV medical care and 8% were on antire- troviral medications (Valleroy et al., 2000).

Given the difficulties faced by HIV-positive youth, targeted interventions are needed to help YMSM access and attend regularly scheduled pri- mary HIV care appointments. The successful man- agement of HIV disease requires frequent lifelong appointments with an HIV primary care provider and uninterrupted medication use, requirements that im- pose substantial lifestyle changes for all HIV-positive persons (Department of Health and Human Services [DHHS], 2008). Given the many competing chal- lenges that HIV-positive minority YMSM face in their daily lives including cultural and community stigma toward their sexual orientation and HIV status, sexual identity issues, substance abuse, mental illness, and basic subsistence concerns regarding employment, education, transportation, and housing, *Corresponding author. Email: [email protected] AIDS Care Vol. 23, No. 8, August 2011, 988 997 ISSN 0954-0121 print/ISSN 1360-0451 online #2011 Taylor & Francis DOI: 10.1080/09540121.2010.542125 http://www.informaworld.com it is not surprising that additional support is needed to help them manage their HIV infection (Eastwood & Birnbaum, 2007; Mustankski, Garafalo, Herrick, & Donenberg, 2007; Rao et al., 2007; Swendeman, Rotheram-Borus, Comulada, Weiss, & Ramos, 2006; Valleroy et al., 2000).

Several interventions have helped at-risk youth access and remain in general medical care and several models of integrated medical care for HIV-positive youth have been developed (Harris et al., 2003; Huba & Melchior, 1998; Johnson, Sorvillo et al., 2003; Schneir, Kipke, Melchior, & Huba, 1998; Woods et al., 1998). There are few quantitative evaluations of interventions, however, that target HIV-positive Latino and African-American YMSM with the goal of improving engagement and retention in HIV care. One intervention that included primarily HIV-negative at-risk youth (98%) used a combination of outreach, mental health and case management services and reported that retention in care was correlated with more outreach and case management contacts (Harris et al., 2003). Another case management program found that addressing barriers related to concrete needs helped improve retention in HIV care for a mostly female and young African-American sample (Johnson, Botwinick et al., 2003).

In 2004, the Health Resource and Services Ad- ministration (HRSA) HIV/AIDS Bureau, Special Projects of National Significance (SPNS) program funded eight demonstration sites to identify, imple- ment, and evaluate new models to provide outreach and interventions for HIV-positive Latino and Afri- can-American YMSM (Magnus et al., 2010). As one of the demonstration sites, the Los Angeles County Department of Public Health developed and evalu- ated a clinic-based, youth-focused case management intervention (YCM) to engage and retain Latino and African-American YMSM in HIV primary care services.

Methods Participants were recruited from April 2006 through April 2009 from HIV testing sites, sexually trans- mitted disease clinics, support groups, community colleges, clubs/bars, and two predominantly African- American or Latino public HIV clinics in Los Angeles County. Eligibility criteria included ages 13 to 23, confirmed HIV-positive status, African-American or Latino race/ethnicity, and biologically male. In addi- tion, eligible participants had to be new to HIV care or in intermittent care with less than two HIV primary care visits in the previous six months.YCM combined psychosocial case management, treatment education/adherence support and HIV risk reduction counseling to provide a client-centered intervention through which care was coordinated (Garland, Wohl, Boger, Carter, & Wu, 2006). The clinic-based intervention was administered by two para-professional, Bachelor-level case managers who were trained and supervised by a licensed clinical social worker to deliver the intervention in a non- judgmental and culturally appropriate manner. The participants met weekly with a case manager for the first two months and monthly for the next 22 months.

At the first meeting, the case managers conducted a comprehensive assessment to evaluate the partici- pant’s medical, physical, psychosocial, environmental, and financial needs. Using the stages of change model, the case manager evaluated whether participants were in one of the following stages with respect to initiation and utilization of HIV care: pre-contemplation, con- templation, preparation, action, or maintenance (Coury-Doniger, Levenkron, McGrath, Knox, & Urban, 2000; Elder, Ayala, & Harris, 1999). The case manager and the participant developed an individualized treatment plan to address identified barriers to engagement and retention in HIV care corresponding to their stage of change. To reduce barriers to care, necessary referrals for services were identified. Participants were provided $25 quar- terly for their participation in the evaluation totaling $200 for the 24-month intervention.

Participants were administered a standardized baseline survey at enrollment by the case managers to assess demographic and psychosocial characteris- tics, sexual risk behaviors, substance use, depression, and HIV testing and care history (Magnus et al., 2010; Radloff 1977). Data on prescribed antiretrovir- al therapy regimens, CD4 counts, and attendance to HIV care appointments were abstracted from medical records.

The primary study outcome was the proportion of YMSM retained in HIV care at six months. For the purposes of analysis, retention in care was defined as attending two or more HIV care appointments in the past six months which was based on the DHHS treatment guideline recommendation during the study period of at least one HIV medical care visit every three four months (DHHS, 2008). Odds ratios (ORs), 95% confidence intervals (CI) andt-tests were calculated to compare demographic and beha- vioral characteristics for Latino vs. African-American YMSM. Data on attendance and time in the inter- vention, referrals provided and referrals completed were compared using a binomial test of proportions.

Referral data were used to construct a dichotomous composite variable to indicate whether a client had aAIDS Care989 critical and immediate need for housing, nutrition, substance abuse treatment, and/or mental health services, characteristics identified in other studies of HIV-positive youth (Eastwood & Birnbaum, 2007; Johnson, Botwinick et al., 2003).

Data on mean number of HIV care visits, missed visits, percent of scheduled visits attended, and retention in care were compared at three and six months for all 61 patients. The same measures were compared at baseline and six months for the 33 patients who had been in intermittent care prior to enrollment in the intervention. These comparisons were conducted using pairedt-tests and McNemar’s test for paired data. Finally, logistic regression modeling was conducted to identify factors associated with retention in HIV care at six months and the unadjusted ORs and 95% CIs are presented. All statistical analyses were performed with SAS version 9.1 (SAS 2007). The study was approved by the institutional review boards at all of the participating organizations and all clients provided written in- formed consent in English or Spanish.

Results The majority of the 61 participants were enrolled via referral from friends who were in the intervention (28%); 26% were enrolled through clinic in-reach by the case manager to re-engage patients who had been lost to care at the clinics; 18% were enrolled by clinic providers and staff; 16% were enrolled by referral from local HIV testing programs; 5% through out- reach activities, and 7% from other programs.

As shown in Table 1, 54% of the participants were African-American, 46% were Latino, and the mean age at enrollment was 21. Participants identified themselves as male (91%), transgender (3%), female (3%), or other/refused to identify (3%). Sixty-one percent identified as homosexual, 21% as bisexual, and 11% as heterosexual.

Almost half (43%) of the participants reported that they were still in school and more than three quarters (84%) reported that they had completed at least high school. Compared to Latinos, African- Americans were significantly more likely to have completed at least high school (OR 3.5, 95% CI 1.03, 11.8). Overall, 42% were currently em- ployed, with no statistical differences between Afri- can-Americans and Latinos. Most participants reported living with their family (57%) or friends (29%) and African-Americans were significantly more likely to report living with friends compared to Latinos (OR 6.4, 95% CI 1.6 25.4).Based on the CES-D screening tool administered at time of enrollment, 66% of participants had depressive symptoms, with CES-D scores of 16 or more. In addition, African-Americans were three times more likely to have depressive symptoms at time of enrollment compared to Latinos (OR 3.5, 95% CI 1.01, 12.4).

Among African-Americans, 52% reported life- time drug use and 54% of Latinos reported any lifetime drug use. Although not shown in Table 1, 46% of the overall sample reported lifetime marijua- na use, 13% stimulant use, 8% inhalant use, and 23% other drugs.

As shown in Table 2, one (2%) participant exited the study early and seven (11%) were lost to follow- up. The participant who left the study early changed his primary HIV care to another location; the seven participants who were lost to follow-up were also lost to care at the clinic and included five who moved out of the area, one in jail and one whose whereabouts was unknown.

Participants attended an average of 5.1 scheduled YCM appointments, had on average 1.1 drop-in visits, 0.9 telephone contacts, and 2.3 missed YCM appointments. Overall, participants attended 61% of scheduled YCM appointments. Participants received a mean of 7.3 hours of the intervention with Latino YMSM receiving statistically more hours of the intervention compared to African-Americans (p 0.001). The average YCM appointment lasted 67 minutes and the length of the appointment was significantly longer for Latinos compared to African- Americans (p 0.0003).

There were 238 total referrals provided in the first six months of the intervention. The majority of referrals were for housing (29%), mental health services (13%), risk reduction education (11%), and transportation assistance (8%). By the end of six months, 163 of the 238 (68%) referrals were completed. Of these, 78% of the housing, 65% of the mental health, 77% of risk reduction education, and 68% of transportation referrals were completed.

African-Americans were more likely to receive referrals for housing (pB0.0001) and transportation (pB0.0001) compared to Latinos, and Latinos were more likely than African-Americans to receive refer- rals for risk reduction services (p 0.007), support groups (p 0.03), and substance abuse services (p 0.03).

At time of enrollment into the intervention, 86% of the African-Americans and 71% of the Latinos had a critical need for housing, nutrition, substance abuse treatment, or mental health services.

From months 1 3, participants attended an average of 2.2 HIV primary care appointments, 990A.R. Wohlet al. Table 1. Demographic characteristics of HIV-positive 18 24-year-old men who have sex with men who participated in a youth-focused case management intervention (N 61).

African- Americans (N 33)Latinos (N 28)Total (N 61) N(%)N(%)N(%) OR (95% CI) Sexual orientation Homosexual/gay 20 (61) 17 (61) 37 (61) Referent Heterosexual 1 (3) 6 (21) 7 (11) 0.2 (0.02 1.5) Bisexual 10 (30) 3 (11) 13 (21) 2.5 (0.7 9.2) Other/refused 2 (6) 2 (7) 4 (7) 1.0 (0.1 7.7) Gender identity Male 29 (88) 26 (93) 55 (91) Referent Female 2 (6) 0 (0) 2 (3) Transgender 1 (3) 1 (4) 2 (3) 1.0 (0.6 16.2) Other/refused 1 (3) 1 (4) 2 (3) 1.0 (0.1 16.2) Education a Less than high school 5 (16) 11 (39) 16 (27) Referent High school or more 27 (84)* 17 (61)* 44 (84)* 3.5 (1.03 11.8)* Currently in school b No 17 (55) 16 (59) 33 (57) Referent Yes 14 (45) 11 (41) 25 (43) 1.2 (0.4 3.4) Currently employed c No 20 (67) 13 (48) 33 (58) Referent Yes 10 (33) 14 (52) 24 (42) 0.4 (0.2 1.4) Housing status d Family 17 (53) 15 (63) 32 (57) Referent Friends 13 (41)** 3 (12)** 17 (29)** 6.4 (1.6 25.4)** On own 2 (6) 5 (21) 7 (12) 0.5 (0.1 3.1) Homeless/shelter 0 (0) 1 (4) 1 (2) Depression CES-D e No 6 (22) 10 (50) 16 (34) Referent Yes 21 (78)*** 10 (50)*** 31 (66)*** 3.5 (1.01 12.4)*** History of drug use f No 16 (48) 13 (46) 29 (48) Referent Yes 17 (52) 15 (54) 32 (52) 0.9 (0.3 2.5) Mode of HIV exposure MSM 32 (100) 22 (78) 55 (90) Referent MSM-IDU/IDU 0 (0) 1 (4) 1 (2) Heterosexual 0 (0) 3 (11) 3 (5) Other/NIR 0 (0) 2 (7) 2 (3) HIV care history Previously in care 21 (64) 13 (46) 34 (56) Referent New to care 12 (36) 15 (54) 27 (44) 2.0 (0.7 5.6) Disclosed HIV status to friends g No 7 (23) 10 (36) 17 (29) Referent Yes 24 (77) 18 (64) 42 (71) 1.9 (0.6 5.9) Disclosed HIV status to family h No 14 (44) 15 (54) 29 (48) Referent Yes 18 (56) 13 (46) 31 (52) 1.5 (0.5 4.1) Disclosed HIV status to no one i No 25 (81) 20 (71) 45 (76) Referent Yes 6 (19) 8 (29) 14 (24) 0.6 (0.2 2.0) Mean (SD) Mean (SD) Mean (SD)t-Testp Mean age (SD) 21 (1.4) 22 (1.7) 21 (1.6) 1.67 0.10 Mean age at first sexual intercourse (SD) j 14.2 (2.5) 14.2 (2.6) 14.3 (2.5) 0.05 0.96 Mean number of partners in past 3 months (SD) k 2 (2.2) 2 (2.2) 2 (3.1) 0.3 0.76 AIDS Care991 attended 76% of scheduled HIV care appointments, and 90% were retained in care (Table 3). During months four through six, participants attended an average of 1.7 HIV care appointments, attended 51% of scheduled appointments, and 70% were retained in care. There were statistically significant decreases in all of the HIV care measurements between three and six months.

Among the 33 participants who had been in intermittent care, the average number of HIV care visits increased from 0.2 to 5.5 between baseline and six months (pB0.0001) (Table 4). In addition, the percentage of scheduled HIV care visits attended increased from 7% to 73% between baseline and six months (pB0.0001) and 82% of those who had been in intermittent care were retained in consistent primary HIV care at six months.

The main factors associated with retention in HIV care at six months was prescription of HAART, increased number of intervention appointments and more hours in the intervention (Table 5). A signifi- cant dose-response trend was observed between retention in HIV care and increasing number of hours in the intervention (p 0.02) and increasing number of intervention appointments (p 0.05).

Discussion This is one of the first studies to evaluate the impact of a youth-focused clinic-based intervention on retention in HIV care for HIV-positive Latino and African-American YMSM. Not only was the inter- vention effective in engaging YMSM in consistent HIV care, but two of the main factors associated with retention in HIV care at six months were related to the quantity or dose of the intervention received.

These data suggest that a time-intensive intervention delivered by a non-judgmental and culturally compe- tent peer is very effective in engaging at-risk Latino and African-American YMSM in consistent HIV care, particularly during the early months of HIVcare. Our findings are consistent with a study of primarily HIV-negative at-risk youth that found that more case management contact was associated with improved retention in care (Harris et al., 2003).

The finding that YMSM who were prescribed HAART were more likely to be retained in care is a new finding as there are few similar interventions that have been evaluated with respect to retention in care. Given that the intervention was associated with retention in care, intervention participants were also probably more likely to be prescribed HAART by a physician. Several studies have noted the difficulties and challenges that youth face with adherence to HAART, and it is likely that the skills needed for YMSM to adhere to HAART are the same as those needed to adhere to HIV care (Rao et al., 2007; Rudy et al., 2009). It is notable that the percentage of intervention participants on HAART (69%) was considerably greater than that reported among a national sample of HIV-positive YMSM (8%) (Valleroy et al., 2000).

A large proportion of the YMSM were in a state of crisis at time of entry into the intervention, underscoring the strong need for youth-focused interventions to help address barriers to engagement and retention in HIV care. The severe subsistence and psychosocial needs of the study group are consistent with data from other studies of HIV-positive YMSM in which a critical need for housing, substance abuse, and mental health treatment were identified (East- wood & Birnbaum, 2007; Johnson, Botwinick et al., 2003; Mustankski et al., 2007; Valleroy et al., 2000).

Housing referrals were most common for the YMSM which is consistent with other research in adolescent and general HIV patient populations that has shown that housing challenges are an obstacle to retention in consistent HIV care and that housing assistance can result in improved medical outcomes (Aidala, Lee, Abramson, Messeri, & Siegler, 2007; Eastwood & Birnbaum, 2007).

Table 1 (Continued) Mean (SD) Mean (SD) Mean (SD)t-Testp Average months between HIV diagnosis and intervention enrollment (SD) l 11.6 (19.5) 20.0 (29.9) 15.3 (24.7) 1.16 0.23 Mean CD4 cell count at enrollment (cells/mm 3)d 381 (180) 419 (213) 397 (194) 0.7 0.43 aData missing on one participant; bData missing on three participants; cData missing on four participants; dData missing on five participants; eData missing on 14 participants; fIncludes marijuana, methamphetamine, amyl nitrate, and other drugs; gData missing on two participants; hData missing on one participant; iData missing on two participants; jData missing on nine participants; kData missing on six participants; and lData missing on nine participants. *p-value 0.04; **p-value 0.009; ***p-value 0.046 Note: OR, odds ratio; CI, confidence interval; MSM, men who have sex with men; IDU, injection drug use; NIR, no identified risk; IQR, interquartile range. 992A.R. Wohlet al. Other research has described the impact that an HIV diagnosis can have on the mental health of gay youth and given all of the psychosocial challenges related to sexual identity, stigma and alienation by friends and family, and the general vulnerabilities attached to YMSM, it is not surprising that the high rates of depression were observed (Donenberg & Pao, 2005). The high prevalence of depression in the African-Americans in the study group is con- sistent with other research and underscores the critical need for mental health interventions for YMSM of color (Flicker et al., 2005; Johnson,Botwinick et al., 2003; Lam, Naar-King, & Wright, 2007).

The prevalence of any lifetime drug use among this group of YMSM was high (52%), but consistent with the prevalence of lifetime substance use reported in an adolescent HIV clinic population in Los Angeles (44%) (Schneir et al., 1998). The proportion of YMSM in the current study reporting marijuana and methamphetamine use is also consistent with individual drug use reported for HIV-positive YMSM in California, however it was lower than lifetime drug use reported from the eight sites participating in this Table 2. Participation and referrals for 18 24-year-old HIV-positive Latino and African-American MSM who participated in a youth-focused case management intervention (YCM).

African-Americans n 33Latinos n 28Total n 61p-Value a Six month study status,n(%) Completed 28 (85) 25 (89) 53 (87) 0.52 Exited study 1 (3) 0 (0) 1 (2) 0.32 Lost to follow-up 4 (12) 3 (11) 7 (11) 0.72 Six month YCM attendance (mean)n 33n 28n 61p-Value b Scheduled appointments attended 4.0 5.8 5.1 0.15 Drop-in visits 1.7 0.4 1.1 0.02 Telephone contacts 0.2 1.5 0.9 0.01 Missed appointments 1.2 3.5 2.3 0.003 Percent of scheduled appointments attended60% 63% 61% 0.77 Total hours of YCM received (mean) 5.1 9.7 7.3 0.001 Average duration of YCM appointment (mean minutes)52 84 67 0.0003 Total referrals provided,n(%)N 73N 165N 238p-Value b Mental health services 6 (8) 26 (16) 32 (13) 0.12 Substance abuse services0 (0) 10 (6) 10 (4) 0.03 Nutrition/food counselling 3 (4) 13 (8) 16 (7) 0.28 Housing40 (55) 29 (18) 69 (29)B0.0001 Transportation14 (20) 5 (3) 19 (8)B0.0001 Family/child related issues 0 (0) 2 (1) 2 (B1) 0.34 Financial/benefits 3 (4) 5 (3) 8 (3) 0.67 Employment assistance 0 (0) 5 (3) 5 (2) 0.13 Legal issues 0 (0) 5 (3) 5 (2) 0.13 Risk reduction education2 (3) 24 (15) 26 (11) 0.007 Treatment advocate/pharmacy 2 (3) 12 (7) 14 (6) 0.17 Support groups0 (1) 10 (6) 10 (4) 0.03 Dental services 1 (1) 2 (1) 3 (1) 0.92 General education 0 (0) 1 (B1) 1 (B1) 0.50 Other HIV care services 0 (0) 3 (2) 3 (1) 0.25 Other needs 2 (3) 14 (8) 16 (7) 0.23 Referrals completed at 6 months, n(%)55 (75) 108 (65) 163 (68) 0.13 Critical need for housing, nutrition, substance abuse and/or mental health services at time of enrollment,n(%)30 (86) 24 (71) 54 (78) 0.13 Prescribed HAART during intervention,n(%) 25 (76) 17 (61) 42 (69) 0.21 aProportions compared using a binomial test of proportions.bMeans compared using at-tests. AIDS Care993 SPNS initiative (Magnus et al., 2010; Ruiz, Facer, & Sun, 1998). Although substance use was common among this study group of YMSM, drug use was not associated with retention in primary HIV care once a client was enrolled in the intervention.

The intervention was designed to include weekly visits for the first two months followed by monthly visits for the subsequent four months for a total of 12 case management visits. The average number of visits was seven, however, suggesting that weekly visits are not feasible for YMSM and that monthly visits are more realistic for this population, given that many of the YMSM were employed or in school. However, the HIV care measures were statistically worse at six months compared to three months, suggesting that the intervention was most effective when the contact with the case manager was most intense during the early months of the intervention, lending support for weekly visits up to at least six months. To facilitate YCM attendance, the case managers had to be flexible with intervention appointment times and the clinics became flexible with HIV care visit appointments as the YMSM would often miss scheduled appointments and show up when no appointment had been scheduled. Flexible scheduling has been reported as a strategy to help YMSM keep their appointments to clinical care and casemanagement (Johnson, Botwinick et al., 2003; Magnus et al., 2010). These data suggest that clinic scheduling flexibility will improve clinical care atten- dance and health outcomes.

In addition to having flexible appointment times, the case managers had multiple strategies for staying in contact with their clients. They conducted a large part of their communication with the YMSM using cell phones and text messaging which was the most effective communication strategy. While these meth- ods of communication were not specifically evaluated in this study, they have been found to be effective in improving clinic attendance among general clinic populations (Chen, Fang, Chen, & Dai, 2008; Leong et al., 2006; O’Brien & Lazebnik, 1998). The $25 incentive was also helpful in motivating clients to come to the appointments and incentives have been demonstrated to improve retention in a variety of health care interventions (Giuffrida & Torgerson, 1997).

The limitations to this study include the relatively small sample of YMSM which prevented the calcula- tion of adjusted OR estimates. Identification of HIV- positive Latino and African-American YMSM both locally and nationally for this SPNS initiative was extremely challenging, even when using multiple outreach strategies. Second, the YMSM in this study Table 3. Retention in HIV care at 3 and 6 months among HIV-positive 18 24-year-old MSM in a youth-focused case management intervention (n 61).

3 months 6 monthsp-Value Mean number of HIV care visits in the past 3 months2.2 1.7 0.04 a Mean missed HIV care visits in past 3 months0.6 1.0 0.06 a Percent of scheduled HIV care visits attended in the past 3 months76% 51%B0.0001 b Percent retained in HIV care in past 3 months90% 70% 0.0005 b ap-Value for pairedt-test; bp-Value for McNemar’s test for paired data. Table 4. Retention in HIV care at 6 months among 18 24-year-old HIV-positive MSM in a youth-focused case management intervention who had been in intermittent care (n 33).

Baseline (n 33) 6 months (n 33)p-Value a Mean attended HIV care visits in past 6 months0.2 5.5B0.0001 Mean missed HIV care visits in past 6 months0.4 2.0 0.0001 Percent of scheduled HIV care visits attended in past 6 months7% 73%B0.0001 Percent retained in HIV care at 6 months0% 82% ap-Value from results of pairedt-test.

994A.R. Wohlet al. were recruited using a convenience sampling ap- proach and the findings may not be representative of all HIV-positive African-American and Latino YMSM. In addition, while there was no control group for comparison, participants served as their own controls when the analyses of outcomes pre and post intervention were conducted. Finally, the sus- tainability of the intervention beyond the 6 months of follow-up is important but has not been evaluated to date.

Given the growing number of HIV-positive YMSM and the challenges that they face in testing early for HIV and accessing and staying in consistent care, innovative, culturally appropriate care retention interventions are necessary. The data presented here demonstrate that it is possible to create an effective, clinic-based intervention to address the barriers that YMSM encounter in engaging in consistent HIV care.

Acknowledgements This study was supported by the Health Resources and Services Administration (HRSA) Special Projects of Na- tional Significance Initiative H97HA03783-04-00 and California HIV/AIDS Research Program grant CH05- LAC-617. The authors would like to acknowledge the study staff who delivered the project intervention: Amin Lewis, Christopher Moore, and Kathy Bouch. In addition, the authors would like to acknowledge and thank the study participants and medical providers for their time.

References Aidala, A.A., Lee, G., Abramson, D.M., Messeri, P., & Siegler, A. (2007). Housing need, housing assistance, and connection to HIV medical care.AIDS and Behavior,11, 101 115. doi:10.1007/s10461-007-9276-x Bingham, T.A., & Sey, K.A. (2009, August).Sexual network characteristics and HIV risk among African American men who have sex with men. Paper presented at the National HIV Prevention Conference, Atlanta, GA.

Centers for Disease Control and Prevention. (2005). HIV prevalence, unrecognized infection and HIV testing among men who have sex with men five US cities, June 2004 April 2005.Morbidity and Mortality Weekly Report,54, 597 601. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5424a2.

htm Centers for Disease Control and Prevention. (2008). Trends in HIV/AIDS diagnoses among men who have sex with men 33 States, 2001 2006.Morbidity and Mortality Weekly Report,57, 681 686. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a2.

htm Table 5. Odds ratios and 95% confidence intervals for factors associated with retention in HIV care aat 6 months among YMSM (n 61) in a youth-focused case manage- ment (YCM) intervention in Los Angeles County, 2006 2009.

Characteristic Unadjusted OR (95% CI) Race/ethnicity African-American 0.8 (0.2 2.9) Latino Referent Age 18 20 years 2.4 (0.5 12.4) 21 24 years Referent Education More than high school 1.0 (0.2 4.5) Less than high school Referent Currently in school Yes 1.1 (0.3 4.7) No Referent Currently employed Yes 1.1 (0.3 4.5) No Referent Housing status Live on own/with friends 0.8 (0.2 3.1) Live with family Referent Depression Moderate or severe 0.2 (0.03 2.0) None Referent History of drug use Yes 0.7 (0.2 2.6) No Referent CD4 cell count B200 cells/mm 3 0.7 (0.1 7.0) ]200 cells/mm 3 Referent Critical need at baseline b Yes 2.0 (0.5 7.8) No Referent Prescribed HAART Yes 11.7 (2.7 51.4)* No Referent New to HIV care Yes 1.1 (0.3 4.1) No Referent Number of YCM appointments c 9 or more visits 10.5 (1.1 96.6)** 5 8 visits 2.8 (0.7 11.5) 0 4 visits Referent Number of YCM hours d 10 or more hours 6.6 (1.1 38.7)*** 5 9 hours 6.0 (1.3 28.3) 1 4 hours Referent aRetention in care was defined as two or more HIV primary care visits in the previous 6 months.

bCritical need at baseline was defined as immediate need for housing, nutrition, substance abuse, or mental health treatment.

cThe chi-square test for trend 6.01,p-Value 0.05.dThe chi-square test for trend 7.83,p-Value 0.02.

*p-value 0.0003; **p-value 0.038; ***p-value 0.036. AIDS Care995 Chen, Z.W., Fang, L.Z., Chen, L.Y., & Dai, H.L. (2008).

Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: A randomized controlled trial.Journal of Zhejiang University SCIENCE B,9,34 38.

doi:10.1631/jzus.B071464 Coury-Doniger, P.A., Levenkron, J.C., McGrath, P.L., Knox, K.L., & Urban, M.A. (2000). From theory to practice: Use of stage of change to develop an STD/ HIV behavioral intervention, phase 2: Stage-based behavioral counseling strategies for sexual risk reduc- tion.Cognitive and Behavioral Practice,7, 395 406.

doi:10.1016/S1077-7229(00)80050-4 Department of Health and Human Services (DHHS).

(2008).Panel on antiretroviral guidelines for adults and adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.

Washington, DC: Department of Health and Human Services (DHHS). November 3, 1 139. Retrieved from http://www.aidsinfo.nih.gov/ContentFiles/Adult andAdolescentGL.pdf Donenberg, G.R., & Pao, M. (2005). Youths and HIV/ AIDS: Psychiatry’s role in a changing epidemic.

Journal of the American Academy of Child and Adolescent Psychiatry,44, 728 747. doi:10.1097/ 01.chi.0000166381.68392.02 Eastwood, E.A., & Birnbaum, J.M. (2007). Physical and sexual abuse and unstable housing among adolescents with HIV.AIDS and Behavior,11, S116 S127.

doi:10.1007/s10461-007-9236-5 Elder, J.P., Ayala, G.X., & Harris, S. (1999). Theories and intervention approaches to health-behavior change in primary care.American Journal of Preventive Medicine, 17, 275 284. doi:10.1016/S0749-3797(99)00094-X Flicker, S., Skinner, H., Read, S., Veinot, T., McClelland, A., Saulnier, P., & Goldberg, E. (2005). Falling through the cracks of the big cities: Who is meeting the needs of HIV-positive youth.Canadian Journal of Public Health,96, 308 312.

Garland, W.G., Wohl, A.W., Boger, A., Carter, J., & Wu, J. (2006, May). One-stop shopping: Using an integrated case management model to improve retention in HIV care among young men who have sex with men. Paper presented at the 18th annual national conference on Social Work and HIV/AIDS, Miami, FL.

Giuffrida, A., & Torgerson, D.J. (1997). Should we pay the patient? Review of financial incentives to enhance patient compliance.British Medical Journal,315, 703 707.

Harris, S.K., Samples, C.L., Keenan, P.M., Fox, B.S., Melchiono, M.W., Woods, E.R., & Boston HAPPENS Program Collaborators. (2003). Outreach, mental health, and case management services: Can they help to retain HIV-positive and at-risk youth and young adults in care?Maternal and Child Health Journal,7, 205 218. doi:10.1023/A:1027386800567Huba, G.J., & Melchior, L.A. (1998). A model for adolescent-targeted HIV/AIDS services.Journal of Adolescent Health,23(Suppl. 1), 11 27. doi:10.1016/ S1054-139X(98)00052-4 Johnson, D.F., Sorvillo, F.J., Wohl, A.R., Bunch, J.G., Carruth, A., Castillon, M., & Jimenez, B. (2003).

Frequent failed early HIV detection in a high pre- valence area: Implications for prevention.AIDS Pa- tient Care and STDs 2003,17, 277 282. doi:10.1089/ 108729103322108148 Johnson, R.L., Botwinick, G., Sell, R.L., Martinez, J., Siciliano, C., Friedman, L.B.,...Bell, D. (2003).

The utilization of treatment and case management services by HIV-infected youth.Journal of Adoles- cent Health,33(Suppl. 1), 31 38. doi:10.1016/S1054- 139X(03)00158-7 Lam, P.K., Naar-King, S., & Wright, K. (2007). Social support and disclosure and predictors of mental health in HIV-positive youth.AIDS Patient Care and STDs,, 21, 20 29. doi:10.1089/apc.2006.005 Leong, K.C., Chen, W.S., Leong, K.W., Matura, I., Mimi, O., Sheikh, M.A.,...Teng, C.L. (2006). The use of text messaging to improve attendance in primary care:

A randomized controlled trial.Family Practice,23, 699 705. doi:10.1093/fampra/cml044 Magnus, M., Jones, K., Phillips, G., Binson, D., Hightow- Weidman, L., Richards-Clark, C., & Wohl, A.R.

(2010). Characteristics associated with retention among African American and Latino adolescent HIV-positive men: Results from the outreach, care, and prevention to engage HIV-seropositive young MSM of color special projects of national significance.

urnal of Acquired Immune Deficiency Syndromes,53(4), 529 536. doi:10.1097/QAI.0b013e3181b56404 Mustankski, B., Garofalo, R., Herrick, A., & Donenberg, G. (2007). Psychosocial health problems increase risk for HIV among urban young men who have sex with men: Preliminary evidence of a syndemic in need of attention.Annals of Behavioral Medicine,34,37 45.

doi:10.1080/08836610701495268 O’Brien, G., & Lazebnik, R. (1998). Telephone call reminders and attendance in an adolescent clinic.

Pediatrics,101(6), E6.

Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the general population.

plied Psychological Measurement,1, 385 401.

doi:10.1177/014662167700100306 Rao, D., Kekwaletswe, T.C., Hosek, S., Martinez, J., & Rodriguez, F. (2007). Stigma and social barriers to medication adherence with urban youth living with HIV].AIDS Care,19,28 33. doi:10.1080/ 09540120600652303 Rudy, B.J., Murphy, D.A., Harris, D.R., Muenz, L., & Ellen, J., for the Adolescent Trials Network for HIV/ AIDS Interventions. (2009). Patient-related risks for non-adherence to antiretroviral therapy among HIV- infected youth in the United States: A study of 996A.R. Wohlet al. prevalence and interactions.AIDS Patient Care and STDs,23, 185 194. doi: 10.1089/apc.2008.0162 Ruiz, J., Facer, M., & Sun, R.K. (1998). Risk factors for human immunodeficiency virus infection and unpro- tected anal intercourse among young men who have sex with men.Sexually Transmitted Diseases,25, 100 107.

SAS. (2007).(Version 8.2) Computer software. Cary, NC:

SAS Institute.

Schneir, A., Kipke, M.D., Melchior, L.A., & Huba, G.J.

(1998). Childrens hospital Los Angeles: A model of integrated care for HIV-positive and very high-risk youth.Journal of Adolescent Health,23(Suppl. 1), 59 70. doi:10.1016/S1054-139X(98)00054-8 Swendeman, D., Rotheram-Borus, M.J., Comulada, S., Weiss, R., & Ramos, M.E. (2006). Predictors of HIV-related stigma among young people living with HIV.

Health Psychology,25, 501 509. doi:10.1037/0278- 6133.25.4.501 Valleroy, L.A., MacKellar, D.A., Karon, J.M, Rosen, D.H., McFarland, W., Shehan, D.A.,...Jansen, R.S. for the Young Men’s Survey Study Group.

(2000). HIV prevalence and associated risks in young men who have sex with men.Journal of the American Medical Association,284, 198 204. doi:10.1001/ jama.284.2.198 Woods, E.R., Samples, C.L., Melchiono, M.W., Keenan, P.M., Fox, D.J., Chase, L.,...Goodman, E. (1998).

Boston HAPPENS Program: A model of health care for HIV-positive, homeless, and at-risk youth.Journal of Adolescent Health,23(Suppl. 1), 37 48. doi:10.1016/ S1054-139X(98)00048-2 AIDS Care997 Copyright of AIDS Care is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.