Infectious Diseases Among the Homeless Pediatric Population
Boston HAPPENS program: HIV-positive, homeless, and at-risk youth can access care through youth-oriented HIV services☆,☆☆,★,★★

https://doi.org/10.1053/spid.2003.127217Get rights and content

Abstract

The Boston HAPPENS Program is a collaborative network of care consisting of multiservice outreach agencies; community health centers; and hospitals for HIV-positive, homeless, and hard-to-reach youth. In four years of data collection, the program served more than 2,000 youth, including 54 HIV-positive youth. The youth were 19.9 ± 2.9 years old; 64 percent female; 45 percent youth of color; 11 percent gay/lesbian, bisexual, or undecided; and 13 percent homeless or runaway. Homeless youth were much more likely to have been involved with a mental health system (47% vs. 12%, P < 0.001), the criminal justice system (20% vs. 2%, P < 0.001), high-risk sexual behaviors (21% vs. 3%, P < 0.001), and substance abuse (25% vs. 6%, P < 0.001) than were other youth served by the program. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect under-served youth to health care. Outreach and human immunodeficiency virus (HIV) counseling and testing services can offer important portals of entry into health services for at-risk youth. Support services such as outreach, case management, and mental health services are needed to complement medical services by all youth at-risk for contracting HIV. Support services are necessary for the initiation and retention of youth in care so that early case identification and complex treatment regimens can be initiated and tailored to the individual. © 2003 Elsevier Inc. All rights reserved.

Section snippets

Epidemiology of HIV and AIDS in adolescent and young adult populations

Data from the Centers for Disease Control and Prevention (CDC) indicate that as of June, 2001, 793,026 cases of AIDS were reported in the United States,19 with 4219 in the 13- to 19-year-old age group and 27,880 cases in the 20- to 24-year-old age group.19 Secondary to the long delay in developing symptoms associated with HIV, most of these young adults were infected during adolescence. These data include an increasing proportion of women with HIV in the younger age groups and high rates of HIV

Boston HAPPENS program

The Boston HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program was designed as a model of collaborative care and outreach to meet the needs of youth in Boston. The network linked nine core agencies and institutions, including three teaching hospitals (two private and one public), three multiservice outreach agencies, and three community health centers, and more than 27 other affiliated agencies in Metropolitan Boston (see Fig 1).23, 36

. Relationship of core agency

Retention in care for HIV-positive, homeless, and at-risk youth

Once adolescents have initiated primary or HIV care, additional attention is needed to retain youth in healthcare programs.37 For adolescents to sustain adherence to complex, highly active, antiretroviral therapy (HAART) regimens,67 case management and coordinated care are needed. In our project, we found that once care was initiated, additional outreach, case management, and mental health services were needed to retain these youth (see Fig 2).37 Regular medical care also contributed to the

Funding for health services

Funding for these support services should be available to all at-risk youth and not just those who are HIV-positive to optimally retain them in care.37 Unfortunately, these services are not funded by most insurance plans. Funds from Ryan White Titles usually focus on HIV-positive individuals and do not provide services for at-risk vulnerable populations. These services are particularly critical for youth who are at risk for acquiring HIV, as well as those living with HIV. Comprehensive care

Survey evaluation of the network needs and structure

Interviews were performed with staff from 22 youth-serving agencies to evaluate the need for services and the structure of the network.63 Participants identified a particular need for HIV-specific services; access to clinical trials and additional mental health and substance abuse services oriented to youth; and vocational training, housing, and dental services in Boston.23, 63 The Boston site for the Adolescent Trials Network was developed in response to these needs. Substance abuse and mental

Issues in HIV counseling and testing services for adolescents

Adolescents need to be aware of the availability of HIV CTS in youth-oriented, confidential settings.43 Adolescents may need more extensive HIV counseling than do their adult counterparts. Some of the adolescents at greatest risk for acquiring HIV may choose not to test despite the health benefits of early intervention.41 HIV CTS needs to be offered in a variety of settings and should be normalized as part of routine care. More research is needed concerning the barriers to seeking HIV testing

Policy and public health issues

From this evaluation and the lessons learned by the 9 national Adolescent HIV programs supported by SPNS (1993-1998), seven policy issues have been identified:43

  • 1.

    A variety of outreach approaches is needed to engage hard-to-reach youth through employment of youth and adult staff.

  • 2.

    Collaborative networks of care are needed to link local youth-oriented resources.

  • 3.

    Case management is the cornerstone for coordinated care that crosses institutional barriers.

  • 4.

    Youth-oriented HIV counseling and testing

Conclusions

To optimize access and care, youth-serving agencies need to link together to provide the range of services needed for at-risk, homeless, and HIV-positive youth.23, 36, 50, 51, 53, 54 The profile of the youth served at each agency varies with the target population and goals of the agency. Comprehensive linked-services networks of agencies can offer a broad range of services beyond the ability of one agency or institution.51, 63, 71, 72 These service networks have demonstrated increased

Acknowledgements

We would like to thank Abby Reidy, MS, for her help with the preparation of the manuscript. Copies of the data forms used for the data collection for the Special Projects of National Significance Program's Adolescent HIV Care Projects, Health Resources and Services Administration can be obtained by writing to: The Measurement Group, 5811A Uplander Way, Culver City, CA 90230, or available on their web site (www.themeasurementgroup.com).

References (72)

  • RW Pfeifer et al.

    A study of HIV seroprevalence in a group of homeless youth in Hollywood, California

    J Adolesc Health

    (1997)
  • SA Ryan et al.

    Utilization of ambulatory health services by urban adolescents

    J Adolesc Health

    (1996)
  • ER Woods et al.

    The Boston HAPPENS Program: needs and use of services by HIV-positive compared to at-risk youth, including gender differences

    Eval Program Plann

    (2000)
  • MW Kline

    Vertically acquired human immunodeficiency virus infection

    Semin Pediatr Infect Dis

    (1999)
  • ER Woods

    Overview of the Special Projects of National Significance Program's 10 models of adolescent HIV care

    J Adolesc Health

    (1998)
  • SL Rosenfeld et al.

    Youth perceptions of comprehensive adolescent health services through the Boston HAPPENS program

    J Pediatr Health Care

    (2000)
  • GJ Huba et al.

    A model for adolescent-targeted HIV/AIDS services: conclusions from 10 adolescent-targeted projects funded by the Special Projects of National Significance Program of the Health Resources and Services Administration

    J Adolesc Health

    (1998)
  • T Bettencourt et al.

    Bay Area Young Positives: A model of a youth-based approach to HIV/AIDS services

    J Adolesc Health

    (1998)
  • R Feudo et al.

    Bridgeport's Teen Outreach and Primary Services (TOPS) project: A model for raising community awareness about adolescent HIV risk

    J Adolesc Health

    (1998)
  • A Schneir et al.

    Childrens Hospital Los Angeles: A model of integrated care for HIV- positive and very high-risk youth

    J Adolesc Health

    (1998)
  • B Bourdon et al.

    Health Initiatives for Youth: A model of youth/adult partnership approach to HIV/AIDS services

    J Adolesc Health

    (1998)
  • ER Wright et al.

    Indiana Youth Access Project: A model for responding to the HIV risk behaviors of gay, lesbian, and bisexual youth in the heartland

    J Adolesc Health

    (1998)
  • AD Tenner et al.

    Seattle YouthCare's prevention, intervention, and education program: A model of care for HIV-positive, homeless, and at-risk youth

    J Adolesc Health

    (1998)
  • MS Sturdevant et al.

    The University of Alabama Teenage Access Project: A model for prevention, referrals, and linkages to testing for high-risk young women

    J Adolesc Health

    (1998)
  • G Remafedi

    The University of Minnesota Youth and AIDS Projects' Adolescent Early Intervention Program: A model to link HIV-seropositive youth with care

    J Adolesc Health

    (1998)
  • MS Hymel et al.

    The Walden House Young Adult HIV project: Meeting the needs of multidiagnosed youth

    J Adolesc Health

    (1998)
  • MD Kipke et al.

    Substance use among youth seen at a community-based health clinic

    J Adolesc Health

    (1993)
  • TA DiLorenzo et al.

    The evaluation of targeted outreach in an adolescent HIV/AIDS program

    J Adolesc Health

    (1993)
  • AS Rogers et al.

    A profile of human immunodeficiency virus-infected adolescents receiving health care services at selected sites in the United States

    J Adolesc Health

    (1996)
  • MD Kipke et al.

    Acquired immunodeficiency syndrome (AIDS) in adolescents

    Adolesc Med State of the Art Rev

    (1990)
  • MA Morey et al.

    Health care needs of homeless adolescents

    Curr Opin Pediatr

    (1993)
  • MJ Rotheram-Borus et al.

    Promoting early detection of human immunodeficiency virus infection among adolescents

    Arch Pediatr Adolesc Med

    (2000)
  • GL Yates et al.

    The Los Angeles system of care for runaway/homeless youth

    J Adolesc Health

    (1991)
  • J Noell et al.

    Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population

    Sex Transm Dis

    (2001)
  • C Ryan et al.

    Lesbian and gay youth: Care and counseling

    Adolesc Med: State of the Art Rev

    (1997)
  • MA Morey et al.

    Voluntary HIV testing in adolescents: a comparison of two urban sites

    • Cited by (0)

    ☆

    *Other Boston HAPPENS Program participants include Peter M. Keenan, RN, MS, PNP, Durrell J. Fox, BS, Louise H. Chase, MSW, LICSW, Michelle A. Burns, PNP, MPH, Virginia A. Price, MEd, Jan Paradise, MD, Rebecca O'Brien, MD, Richard A. Claytor, Jr., BA, and Robyn Brooke, RN, MSN, C-FNP

    ☆☆

    Supported in part by the W.T. Grant Foundation and Special Projects of National Significance Program Project #BRH 970155-05-0 and the Leadership Education in Adolescent Health Project #6 T71 MC 0000909 from the Maternal and Child Health Bureau (Title 5, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. This publication's contents are solely the responsibility of the authors and do not necessarily represent the official view of the funding agencies.

    ★

    Address reprint requests to Elizabeth R. Woods, MD, MPH, Division of Adolescent/Young Adult Medicine Children's Hospital Boston, LO-306, 300 Longwood Avenue, Boston, MA 02115; e-mail: [email protected]

    ★★

    1045-1870/03/1401-0007$30.00/0

    View full text
    Copyright © 2003 Elsevier Inc. All rights reserved.