Expanding Psychiatric Treatment in Primary Care Settings: Improved Care Through the Wisconsin Child Psychiatry Consultation Program.

The national shortage of child psychiatrists has resulted in the necessity of primary care providers (PCPs) managing increased mental health concerns of youth. The Wisconsin Child Psychiatry Consultation Program (WI CPCP) is one of several programs throughout the United States which provide PCPs with education, consultation, and resource support related to pediatric mental health. To evaluate initial impact of the program, data from 190 pediatricians and family practitioners from the Wisconsin Health Information Organization (WHIO) were analyzed. Enrollment in the WI CPCP was associated with a significant increase in rates of mental health diagnoses within primary care visits. In addition, the number of providers who made any mental health diagnosis increased from 56% of PCPs pre-enrollment to over 99% post-enrollment. These data provide additional support for pediatric psychiatry consultation programs within primary care.

Perceptions of HIV Research Participation Among Gay, Bisexual, and Other Men who Have Sex with Men and Transgender and Nonbinary Adults: Results From a Midwest Pride Event.

Human immunodeficiency virus (HIV) continues to disproportionately affect gay, bisexual, and other men who have sex with men (GBM) and transgender and nonbinary (trans/NB) individuals. This study investigated attitudes toward participation in HIV survey research, guided by Emanuel's framework for ethical clinical research (e.g., risk-benefit ratio, fair participant selection, respect for participants, social value, and collaborative partnership). GBM (n = 294) and trans/NB (n = 86) persons recruited at a Pride event in Milwaukee completed a survey assessing risks and benefits of participation in, and comfort responding to, sexual health surveys. Participants reported few ethical concerns (e.g., privacy and confidentiality), with notable differences by race, sexual orientation and gender identity, and prior research experiences. Implications for HIV research with GBM and trans/NB individuals are discussed.

"Running Trains" and "Sexing-In": The Functions of Sex Within Adolescent Gangs.

Gang members are exposed to unique sexual risks, yet little work has explored the influence of gang social norms. This study examines the functions and meanings of sex within gangs, with a specific focus on the ways in which sex is used to reinforce gang membership and norms, gender roles, and group cohesion. We conducted 58 semi-structured interviews with adolescent members of six gangs. Data were analyzed using thematic content analysis and constant comparative method in MAXQDA. Sexual risk behaviors within gangs are upheld and reinforced through unspoken norms and expectations. These high-risk sexual practices increase group cohesion and reinforce gender norms and power differences. Despite the prevalence of such practices, many gang members felt regret and remorse over their participation but noted it was just part of "the life." Our findings highlight the need for interventions to address the norms of the gang that reinforce sexual risk behavior.

HIV Testing and Mistaken Beliefs about Immigration Laws.

Evidence suggests that migrants may underutilize USA health care because of misconceptions about immigration-related consequences of health care use. This study aimed to explore whether common misconceptions about the immigration consequences of seeking health care, receiving an HIV test, and being diagnosed with HIV were associated with participant self-report of never having received an HIV test. The study sample comprised 297 adult, sexually active, documented and undocumented Spanish-speaking Latino migrants. Participants completed a cross-sectional survey via ACASI. In multiple logistic regression analyses controlling for sociodemographic variables and HIV stigma, misconceptions about laws emerged as a strong predictor of never having received an HIV test (p < .001). Associations between participants' endorsement of misconceptions and their HIV testing history suggest that incorrect perceptions of laws do deter some subgroups of USA Latino migrants from HIV testing. Identifying misconceptions about negative immigration consequences of engaging in important health behaviors should be a community health research priority.

"I don't have to do this all by myself": Systems Navigation to Ensure Continuity of HIV Care for Persons Leaving Prison.

Ensuring continuity of and retention in care after release from prison is critical for optimizing health outcomes among people living with HIV. As part of a large federal initiative, we conducted qualitative interviews (n = 24) with individuals living with HIV and recently released from prison in four states to understand their experiences in different navigation interventions to improve access to HIV care post-release. Interventions were delivered only in prison, only in the community, or in both settings. While the interventions varied by design, overall, participants appreciated the breadth of support received from interventionists, including health system navigation, case management and social support. Even when individuals leaving prison were returning to clinics that they were familiar with, systems navigation supported continuity of care. Our findings elucidate why navigational support was instrumental, and underscore the value of a variety of types of navigation programs in facilitating continuity of care and reintegration post-prison.

Implementing a Standardized Social Networks Testing Strategy in a Low HIV Prevalence Jurisdiction.

Alternative HIV testing strategies are needed to engage individuals not reached by traditional clinical or non-clinical testing programs. A social networks recruitment strategy, in which people at risk for or living with HIV are enlisted and trained by community-based agencies to recruit individuals from their social, sexual, or drug-using networks for HIV testing, demonstrates higher positivity rates compared to other non-clinical recruitment strategies in some jurisdictions. During 2013-2015, a social networks testing protocol was implemented in Wisconsin to standardize an existing social networks testing program. Six community-based, non-clinical agencies with multiple sites throughout the state implemented the protocol over the 2-year period. Both quantitative and qualitative data were collected. The new positivity rate (0.49%) through social networks testing did not differ from that of traditional counseling, testing, and referral recruitment methods (0.48%). Although social networks testing did not yield a higher new positivity rate compared to other testing strategies, it proved to be successful at reaching high risk individuals who may not otherwise engage in HIV testing.

Lessons Learned from Applying a Modified Learning Collaborative Model to Promote Change in Regional and Statewide HIV Care Systems.

The Health Resources and Services Administration Special Projects of National Significance launched the Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative in 2011. Six state departments of health were funded to utilize a modified Learning Collaborative model to develop and/or adapt HIV testing, linkage to care and retention in care system-level interventions. More than 60 Learning Sessions were held over the course of the Learning Collaborative. A total of 22 unique interventions were tested with 18 interventions selected and scaled up. All interventions were created to impact services at a systems level, with standardized protocols developed to ensure fidelity. Our findings provide key lessons and present considerations for replication for use of a modified Learning Collaborative to achieve state-level systems change.

Patient acceptability of receiving short message services from an HIV patient-centered medical home.

Patient-centered medical homes (PCMH) are a key component in addressing the comprehensive physical and psychosocial needs of persons living with HIV. The AIDS Resource Center of Wisconsin (ARCW) is a PCMH that has become a nationally recognized leader in addressing barriers to HIV retention in care. Recently, ARCW has become interested in the use of short message services (SMS), as SMS have been found to have positive impacts on treatment adherence, CD4+ counts, viral load, and appointment attendance. The purpose of this research was to evaluate patient acceptability of receiving SMS from an HIV specific PCMH, in addition to evaluating patient privacy concerns and practical details of incorporating SMS into clinical care. These constructs were evaluated through a survey of 180 ARCW patients recruited from several ARCW waiting rooms. Patients were most interested in receiving SMS from medical, dental, and pharmacy services and message content regarding appointment and medication refill reminders. Participants did not indicate the presence of significant privacy concerns and were divided nearly in half over whether ARCW should refer to itself as "ARCW" or "Your medical/dental clinic." Prior to implementation of SMS at ARCW, further evaluation into the optimization of language into concise and easy to understand messages that maximize confidentiality and minimize patient anxiety is needed.

"It's Almost Like a Crab-in-a-Barrel Situation": Stigma, Social Support, and Engagement in Care Among Black Men Living With HIV.

Social support is associated with improved health outcomes for people living with HIV (PLWH), including initiation and engagement in HIV care and antiretroviral therapy (ART) adherence. Yet, stigma may negatively affect the availability and utilization of social support networks, especially among African American PLWH, subsequently impacting HIV care and health out-comes. This qualitative study examines the relationship between stigma and social support relationships among African American PLWH. We conducted 23 interviews with Black men living with HIV who reported being out of care or non-adherent to ART. Thematic content analysis revealed three primary themes including variation in social support, experiences of stigma and discrimination, and coping mechanisms used to deal with stigma. Findings reveal that although social support may be protective for some men, many African American PLWH face challenges in harnessing and sustaining needed social support, partly due to stigma surrounding HIV and homo-sexuality.

Effectiveness of an evidence-based HIV prevention intervention when implemented by frontline providers.

Carefully conducted randomized trials have established that sexual behavior change interventions can significantly reduce intervention participants' risk of acquiring HIV. Establishing the effectiveness of these evidence-based interventions when implemented by frontline HIV prevention service providers is increasingly important in order to achieve maximum public health impact. This study sought to assess the effectiveness of an evidence-based intervention when implemented by frontline HIV prevention service providers. We evaluated Sisters Informing Sisters on Topics about AIDS (SISTA), an HIV prevention intervention for heterosexual African American women, as implemented by four AIDS service organizations. Women enrolled in HIV counseling, testing, and referral (CTR) at each agency served as contemporaneous controls. Measures included self-reported number of occasions of unprotected vaginal intercourse and number of vaginal sex partners in the previous 90 days. 1,262 participants completed baseline and follow-up assessments across both conditions (SISTA = 537 [57%]; CTR = 725 [62%]). In the full sample of HIV-negative women, CTR participants' odds of having had unprotected sex decreased over time by 38% while SISTA participants' odds of having had unprotected sex did not change. Similar results were found among only those participants who had sex at baseline. Hypothesized interaction effects indicating positive changes in sexual risks over time for SISTA participants were not observed.

The Development and Psychometric Properties of the Immigration Law Concerns Scale (ILCS) for HIV Testing.

To develop, pilot test, and conduct psychometric analyses of an innovative scale measuring the influence of perceived immigration laws on Latino migrants' HIV-testing behavior. The Immigration Law Concerns Scale (ILCS) was developed in three phases: Phase 1 involved a review of law and literature, generation of scale items, consultation with project advisors, and subsequent revision of the scale. Phase 2 involved systematic translation- back translation and consensus-based editorial processes conducted by members of a bilingual and multi-national study team. In Phase 3, 339 sexually active, HIV-negative Spanish-speaking, non-citizen Latino migrant adults (both documented and undocumented) completed the scale via audio computer-assisted self-interview. The psychometric properties of the scale were tested with exploratory factor analysis and estimates of reliability coefficients were generated. Bivariate correlations were conducted to test the discriminant and predictive validity of identified factors. Exploratory factor analysis revealed a three-factor, 17-item scale. subscale reliability ranged from 0.72 to 0.79. There were significant associations between the ILCS and the HIV-testing behaviors of participants. Results of the pilot test and psychometric analysis of the ILCS are promising. The scale is reliable and significantly associated with the HIV-testing behaviors of participants. Subscales related to unwanted government attention and concerns about meeting moral character requirements should be refined.

Fostering a "Feeling of Worth" Among Vulnerable HIV Populations: The Role of Linkage to Care Specialists.

To address barriers to adequate engagement in medical care among people living with HIV, Wisconsin's AIDS/HIV Program created a new position, the Linkage to Care (LTC) Specialist. Specialists provide intensive, short-term case management and patient navigation services for small caseloads of individuals at high risk of disengaging with medical care. Clients are eligible if they are newly diagnosed with HIV or new to medical care, recently released from incarceration, recently out of care, nonadherent to scheduled medical care visits, or have detectable viral load while in care. Interviews with 30 clients of Specialists were conducted to understand experiences with the program and medical care. Common themes included the ability of Specialists to navigate complex systems of care and support services, the unique role Specialists played in their clients' lives, and the challenges of transitioning out of the program. Although the primary goal of Specialists is to address barriers to medical care, they often adopted a holistic approach that also included housing, financial assistance, and other social determinants of health. Descriptions of the Specialist's role in implementation manuals focus on their functional roles and the services provided. However, clients often discussed the emotional support they received, especially for clients without strong social support networks. Many clients also desired an ongoing relationship with their Specialists even after discharge, but had been able to establish independence and self-efficacy. The LTC Specialists are resource-intensive considering their small caseloads, but fill an important gap in existing, often overtaxed case management systems.

Acceptability of HIV Prevention Information Delivered Through Established Geosocial Networking Mobile Applications to Men Who Have Sex With Men.

Geosocial networking (GSN) applications could disseminate HIV prevention information to thousands of men who have sex with men (MSM); however, acceptability of the type of information, methods, and frequency of information delivery are unknown. Acceptability of these constructs were assessed through a survey of 224 MSM at the Milwaukee Pridefest. All types of information were found acceptable. A sexual health section and self-seeking information were the most acceptable method and frequency of delivery. Demographics and differences in app usage did not correlate to acceptability. Continued research focusing on the feasibility of incorporating HIV prevention information into GSN applications is needed.

Convention Versus Deviance: Moral Agency in Adolescent Gang Members' Decision Making.

BACKGROUND: Adolescent gang members are a source of concern due to their involvement in criminal activity, violence, substance use, and high-risk sexual behaviors. Adolescent gang theories hypothesize that social institutions, including the family and school, fail to meet the needs of adolescents who therefore feel less attachment to these institutions and find an unconventional institution (i.e. the gang) to meet these needs through the gang. OBJECTIVES: In this paper, we will examine the extent to which social disorganization and social control theories, in particular the rejection of conventional norms and aspirations, match adolescents' subjective reasons for their decisions and their future aspirations. METHODS: Between 2012 and 2013, we conducted in-depth interviews with 58 gang members between the ages of 14 to 19. Interviews were coded for key themes using the constant comparison method. RESULTS: Social disorganization and social control theories have both value and limitations in explaining reasons why adolescents join gangs and engage in criminal behaviors. Participants saw many of their aspirations blocked by negative school experiences and limited economic opportunities. Gangs provided a social organization in which to sell drugs. However, gang members did not reject conventional norms and aspirations. Rather, they view themselves as making decisions to survive in the present while recognizing that these strategies will not continue to work in the future. CONCLUSIONS: Gang members value education and aspire to obtain legal employment. Thus, interventions to help adolescent gang members with the immediate financial pressures that lead them to sell drugs may be particularly effective.

Gang masculinity and high-risk sexual behaviours.

High-risk sexual behaviours include practices such as relationship violence and substance use, which often cluster together among young people in high-risk settings. Youth gang members often show high rates of such behaviours, substance use and relationship violence. This paper draws on data from in-depth interviews with male and female gang members from six different gangs to explore the role of powerful socialising peer groups that set gender, sexual and relationship roles and expectations for their male and female members. High-risk sexual behaviours among gang members included sex with multiple partners and group sex. Gang norms included the belief that male members were sexually insatiable with multiple sexual partners and that female gang members should be sexually available to male members. Alcohol and drugs were seen to have a large influence on sexual desire and the inability to use condoms. Much sexual behaviour with gangs, such as group sex, was viewed with ambivalence and seen as somewhat coercive. Finally, gendered sexual expectations (boys as sexually insatiable and girls as sexually available) made forming long-term romantic relationships problematic for gang members. The influence of gang norms such as these must be addressed in future programmes and interventions with gang members.

The Uses of Texting in Sexual Relationships Scale: Associations With Risky Sexual Behavior Among At-Risk African American Emerging Adults.

Qualitative and quantitative research was used to create the Uses of Texting in Sexual Relationships scale. At-risk, predominantly African American emerging adults participated in qualitative interviews (N = 20) and quantitative surveys (N = 110) about their uses of text messaging within romantic and sexual relationships. Exploratory factor analysis of items generated from interviews resulted in four subscales: Sexting, Relationship Maintenance, Relationship Development, and Texting for Sexual Safety. Exploratory analyses indicated associations of Sexting with more instances of condomless sex, and Texting for Sexual Safety with fewer instances of condomless sex, which was moderated by relationship power. Further research on the connections between text messaging in relationships and sexual behavior among high-risk and minority young adults is warranted, and intervention efforts to decrease sexual risks need to incorporate these avenues of sexual communication.

A qualitative analysis of the concepts of fidelity and adaptation in the implementation of an evidence-based HIV prevention intervention.

Continued debate about the relative value of fidelity versus adaptation, and lack of clarity about the meaning of fidelity, raise concerns about how frontline service providers resolve similar issues in their daily practice. We use SISTA ('Sisters Informing Sisters on Topics about acquired immune deficiency syndrome'), an evidence-based human immunodeficiency virus (HIV) prevention intervention for African American women, to understand how facilitators and program directors interpret and enact implementation fidelity with the need for adaptation in real-world program delivery. We conducted 22 in-depth, semi-structured interviews with service providers from four agencies implementing SISTA. Facilitators valued their skills as group leaders and ability to emotionally engage participants as more critical to program effectiveness than delivering the intervention with strict fidelity. Consequently, they saw program manuals as guides rather than static texts that should never be changed and, moreover, viewed the prescriptive nature of manuals as undermining their efforts to fully engage with participants. Our findings suggest that greater consideration should be given to understanding the role of facilitators in program effectiveness over and above the question of whether they implement the program with fidelity. Moreover, training curricula should provide facilitators with transferable skills through general facilitator training rather than only program-specific or manual-specific training.

Partnership-Level Analysis of African American Women's Risky Sexual Behavior in Main and Non-Main Partnerships.

The majority of research on risky sexual behavior in African American women has examined global associations between individual-level predictors and behavior. However, this method obscures the potentially significant impact of the specific relationship or relationship partner on risky sexual behavior. To address this gap, we conducted partnership-level analysis of risky sexual behavior among 718 African American women recruited from HIV counseling, testing, and referral sites in four states. Using mixed model regressions, we tested relationships between condomless vaginal intercourse with men and variables drawn from the Theory of Planned Behavior, Theory of Gender and Power, and previous research specifically on sexual risks among African American women. Significant associations with risky sexual behavior indicate the need for continued emphasis on condom attitudes, condom negotiation behaviors, and overcoming partner resistance to condoms within both main and non-main partnerships when implementing interventions designed to address HIV and sexually transmitted infection risks among African American women.

Audit Culture: Unintended Consequences of Accountability Practices in Evidence-Based Programs.

Evaluation has become expected within the nonprofit sector, including HIV prevention service delivery through community-based organizations (CBOs). While staff and directors at CBOs may acknowledge the potential contribution of evaluation data to the improvement of agency services, the results of evaluation are often used to demonstrate fiscal prudence, efficiency, and accountability to funders and the public, rather than to produce information for the organization's benefit. We conducted 22 in-depth, semistructured interviews with service providers from four agencies implementing the same evidence-based HIV prevention intervention. We use the lens of "audit culture" to understand how the evaluation and accountability mandates of evidence-based program implementation within HIV prevention service provision affect provider-client relations, staff members' daily work, and organizational focus in natural settings, or contexts without continuous support and implementation monitoring. We conclude with recommendations for improving the use and methods of evaluation within HIV prevention service delivery.

The Association of Attitudes about Contraceptives with Contraceptive Use in a Random Sample of Colorado Women.

CONTEXT: Research regarding unintended pregnancy often focuses on how women make decisions about whether or not to use contraceptives, and structural barriers to contraception. Less research examines how multidimensional attitudinal characteristics may be associated with effective contraceptive use. METHODS: In fall 2007, we conducted a random telephone survey of 801 sexually active women in Colorado to assess associations of the attitudinal dimensions of Planning, Partner Communication, and Stigma and Misinformation with contraceptive use. We also examine demographic differences on hypothesized predictors. RESULTS: Stigma and Misinformation is higher in Latina women, women on Medicaid or with no insurance, women with less than a college degree, and women living in small towns or rural areas. Partner Communication attitudes are most positive among those with a bachelor's degree, and those with less than a high school degree, while they are most negative among those living in small towns and rural areas. In multivariate analysis, planning to use contraceptives is associated with greater likelihood of more effective contraceptive use. Higher levels of planning and partner communication are associated with greater likelihood of any contraceptive use. DISCUSSION: In addition to addressing structural barriers to contraception, interventions to address the need to plan for contraception are vital to mitigate the high prevalence of unintended pregnancies in the United States.