More than just Reminders: Using text Messaging to Improve HIV care Outcomes Among Youth and Young Adults Living with HIV.

This study evaluated engagement, satisfaction, and efficacy of an automated and live two-way text messaging intervention that linked youth and young adults at high risk for poor HIV outcomes to their medical case managers, with the aims of increasing viral load suppression rates and improving medical visit attendance. Participants (N = 100) were an average age of 22-23 years old. Most were Black (93%) and men who have sex with men (82%). A total of 89,681 automated text messages were sent to participants; and 62% of participants engaged in monthly text-message exchanges with medical case managers. McNemar's test results indicated that a significantly greater proportion of intervention participants were virally suppressed at 6 and 12 month follow-up than at enrollment. Adjusted odds ratio results showed a significant association between likelihood of achieving viral suppression at 6 and 12 months, and a greater number of participant responses to automated text messages. Future research should prospectively compare outcomes between usual care case management and usual care plus text-messaging to test for significant differences between groups.

RESUMEN: La presente investigación evaluó el compromiso, la satisfacción y la eficacia de una intervención de mensajes de texto bidireccional automatizada y en vivo que vinculó a jóvenes y adultos jóvenes con altos riesgos de resultados deficientes del VIH con sus administradores de casos médicos, con el objetivo de aumentar las tasas de supresión de la carga viral y mejorar la asistencia a las visitas médicas. Los participantes (n = 100) tenían una edad promedio de 22 a 23 años. La mayoría eran negros (93,0%) y hombres que tienen sexo con hombres (82,0%). Un total de 89.681 mensajes de texto automatizados fueron enviados a los participantes; y 62,0% de los participantes participaron en intercambios de mensajes de texto mensuales con los administradores de casos médicos. Los resultados de la prueba de McNemar indicaron que una proporción significativamente mayor de participantes de la intervención fueron suprimidos viralmente a los 6 y 12 meses de seguimiento que al momento de la inscripción. Los resultados del índice de probabilidad ajustado mostraron una asociación significativa entre la probabilidad de lograr la supresión viral a los 6 y 12 meses, así como un mayor número de respuestas de los participantes a los mensajes de texto automatizados. Las investigaciones futuras deben comparar prospectivamente los resultados entre la gestión de casos de atención habitual y la atención habitual más mensajes de texto para evaluar las diferencias significativas entre los grupos.

Direct and Indirect Cost Savings From Sexually Transmitted Infection Testing, Treatment, and Counseling Among Foster Youth.

BACKGROUND: Sexually transmitted infection (STI) prevention programs can decrease the economic burden of STIs. Foster youth have higher rates of STIs compared with their peers; however, information on direct costs and indirect costs averted by STI testing, treatment, and counseling among foster youth is lacking. METHODS: This study used data from a comprehensive medical center for foster youth over a 3-year study period from July 2017 to June 2020. Direct and indirect costs averted by testing and treatment of chlamydia, gonorrhea, and syphilis, as well as HIV testing and counseling, were calculated based on formulas developed by the Centers for Disease Control and Prevention and adjusted for inflation. RESULTS: Among the 316 youth who received medical services during this time, 206 were sexually active and tested for STIs and/or HIV. Among 121 positive STI test results, 64.5% (n = 78) were positive for chlamydia, 30.6% (n = 37) were positive for gonorrhea, and 5.0% (n = 6) were positive for syphilis. Treatment was provided to all. Overall, $60,049.68 in direct medical costs and $73,956.36 in indirect costs were averted. CONCLUSIONS: Given the rates of STIs among this population and the economic benefit of STI treatment, it is imperative to continue to provide intensive and comprehensive, individualized sexual health care for foster youth. Traditional care management may miss the opportunity to prevent, identify, and treat STIs that comprehensive wraparound care can achieve. This study suggests that comprehensive wraparound care is a cost-effective way to identify, treat, and prevent STIs among foster youth.

E-VOLUTION: A Text Messaging-Powered Intervention-Connection, Support, and HIV Eradication.

This longitudinal, nonexperimental, quantitative study examined the acceptability, feasibility, and efficacy of a texting intervention that was added to medical case management for youth and young adults at high risk for poor HIV outcomes. The intervention, E-VOLUTION, sent automated text messages to youth participants living with HIV that reminded them to take prescribed medication and attend medical visits. Automated texts also asked clients about mood, housing, and ability to pay bills. Client responses to automated texts that indicated challenges triggered alerts for their medical case manager, who then followed up to address the issue. Participants (N = 100) were an average age between 22 and 23 years and most were Black (95%) and men who have sex with men (82%). Over a period of 26 months 89,681 automated texts were sent, resulting in 450 alerts. Additionally, clients and medical case managers exchanged more than 17,000 texts. Results of Spearman correlations indicated significant associations between greater frequency of alerts triggered and greater likelihood of kept medical appointments (p < .05). Findings also showed significant associations between greater frequency of texting with a medical case manager and greater likelihood of viral load suppression and kept medical visits at 12-month follow-up (p < .01). More frequent substance use was associated with more alerts triggered (p < .01). Use of text messaging was acceptable to the participants and is a culturally responsive way to engage youth participants living with HIV in care. Future research may examine the use of structured behavioral health assessments in the automated texting framework, as well as compare outcomes between automated and two-way texting groups.

Characteristics of youth agreeing to electronic sexually transmitted infection risk assessment in the emergency department.

OBJECTIVES: Adolescents and young adults are at high risk for sexually transmitted infections (STIs). We previously reported an increase in STI testing of adolescents in our ED by obtaining a sexual history using an Audio-enhanced Computer-Assisted Self-Interview (ACASI). We now examine associations among demographics, sexual behaviour, chief complaint and willingness to be tested. METHODS: This was a prospective study conducted in a paediatric ED between April and December 2011. After triage, eligible patients between 15 and 21 years presenting with non-life-threatening conditions were asked to participate in the study. Consenting participants used an ACASI to provide their demographic data and answer questions about their sexual history and willingness to be tested. Our primary outcome was the association of demographics, chief complaint and ACASI recommendation with the participant's willingness to be tested. RESULTS: We approached 1337 patients, of whom 800 (59%) enrolled and completed the ACASI. Eleven who did not answer questions related to their sexual history were excluded from analysis. Of 789 participants, 461 (58.4%) were female and median age was 16.9 years (IQR 16.0-17.8); 509 (64.5%) endorsed a history of anal, oral and/or vaginal intercourse. Disclosing a sexual history and willingness to be tested did not differ significantly by gender. 131 (16.6%) had a chief complaint potentially referable to an STI; among the 658 participants with non-STI-related complaints, 412 (62.6%) were sexually active, many of whom disclosed risky behaviours, including multiple partners (46.4%) and inconsistent condom use (43.7%). The ACASI identified 419 patients as needing immediate STI testing; the majority (81%) did not have a chief complaint potentially related to STIs. 697 (88.3%) participants were willing to receive STI testing. Most (94.6%) of the patients with STI-related complaints were willing to be tested, and 92.1% of patients with a recommendation for immediate testing by the ACASI indicated a willingness to be tested. CONCLUSIONS: Adolescents were willing to disclose sexual activity via electronic questionnaires and were willing to receive STI testing, even when their chief complaint was not STI related. The ACASI facilitated identification of adolescent ED patients needing STI testing regardless of chief complaint.

HIV and Sexually Transmitted Infection Testing Among High-Risk Youths: Supporting Positive Opportunities With Teens (SPOT) Youth Center.

OBJECTIVES: We investigated the development of and service utilization at Supporting Positive Opportunities with Teens (SPOT)-a community-based health and social service facility in St. Louis, Missouri, for youths that focuses on increasing HIV and sexually transmitted infection (STI) testing. METHODS: We identified the US-based, co-located youth health and social service models that guided the establishment of the SPOT. We analyzed the first 5 years (2008-2013) of service delivery and utilization data. RESULTS: During the study period, the SPOT provided services for 8233 youths in 37,480 visits. The 5 most utilized services included HIV and STI screening, food, transportation, contraception, and case management. A total of 9812 gonorrhea and chlamydia screenings revealed 1379 (14.1%) cases of chlamydia and 437 (4.5%) cases of gonorrhea, and 5703 HIV tests revealed 59 HIV infections (1.0%); 93.0% of patients found to have an STI were treated within a 5-day window. CONCLUSIONS: Co-locating health and social services in informal community settings attracts high-risk youths to utilize services and can prove instrumental in reducing STI burden in this population.

Impact of human immunodeficiency virus on neurocognition and risky behaviors in young adults.

Previous studies have identified cognitive impairments due to human immunodeficiency virus (HIV) in adults. However, few studies have examined the impact of HIV on cognition in young adults (18-24 years old). Yet, this group is one of the largest populations of individuals with new HIV infection. Young adulthood is also an important developmental window because the brain has not fully matured and individuals are prone to engage in risky behavior. The purpose of the present study was to examine the impact of HIV on neurocognition and risky behaviors. We hypothesized that HIV+ young adults (n = 23) would exhibit greater cognitive impairment and risky behaviors compared to seronegative controls (n = 21). In addition, we predicted that self-reported risky behavior as assessed by the Risk Assessment Battery (RAB) would covary with cognitive performances. Results revealed poorer executive function in HIV+ young adults compared to seronegative (HIV-) controls. HIV+ young adults exhibited significantly greater risk scores on the RAB (p < 0.01) compared to HIV- young adults. However, there were no relationships between risky behavior and cognitive performance. Overall, our results suggest that HIV is associated with poorer cognition and increased risky behaviors in young adults.

Computerized self-interviews improve Chlamydia and gonorrhea testing among youth in the emergency department.

STUDY OBJECTIVE: National guidelines recommend annual Chlamydia trachomatis and Neisseria gonorrhoeae screening for sexually active youth at risk for infection. These infections have serious sequelae in women if untreated, and methods to improve testing are needed. We hypothesize that an electronic method of identifying at-risk youth will significantly increase testing for these sexually transmitted infections during emergency department (ED) visits. METHODS: We developed an audio-enhanced computer-assisted self-interview (ACASI) to obtain sexual histories from ED patients and an embedded decision tree to create a sexually transmitted infection testing recommendation. ED health care providers were prompted by the electronic medical record to review the participant answers and testing recommendations, and to offer testing to at-risk youth. Patients aged 15 to 21 years and visiting the St. Louis Children's Hospital ED, regardless of complaint, were eligible for participation. RESULTS: Sexually transmitted infection testing among all 15- to 21-year-old ED patients increased from 9.3% in the 3 months before the ACASI to 17.8% during the 8-month period the ACASI was available and diminished to 12.4% in the 3 months after ACASI withdrawal (P<.001). During the ACASI period, we approached 51.4% of eligible patients and enrolled 59.8% (800/1,337) of those approached. Among ACASI participants, 52.4% (419/800) received a recommendation to receive sexually transmitted infection testing. Of these patients, 52.7% (221/419) received testing in the ED and 18.1% (40/221) of those tested had positive results for chlamydia or gonorrhea, 55% of whom (22/40) had chief complaints unrelated to sexually transmitted infections. Most participants (89%) rated the ACASI easy to use. CONCLUSION: Sexually transmitted infection testing in the ED significantly increased during ACASI use and diminished after withdrawal. The ACASI was well accepted by youth and holds promise for enhancing sexually transmitted infection testing in the ED.

Pediatric Primary Care Provider Perspectives on Universal Suicide Screening.

INTRODUCTION: Given the increase in youth mental health concerns, the American Academy of Pediatrics (AAP) recommends universal suicide screening for ages 12 and older, with positive screens followed by a brief suicide risk assessment. However, it is unclear how pediatric clinicians incorporate this recommendation into practice. Therefore, the objective of this qualitative study was to identify pediatric clinicians' current practice, attitudes, and barriers to implement the updated universal suicide screening recommendation in primary care. METHODS: Community-based pediatric primary care providers (PCPs) in the St. Louis Metropolitan area who by self-report provide mental health care for patients participated. Participants completed a 30-minute semi-structured interview with invitations extended through an electronic listserv in a local Pediatric PCP Learning Collaborative. Interviews were transcribed and analyzed using consensual deductive and inductive approaches until data saturation. RESULTS: Eighteen PCPs participated in the interviews. Interviews described themes related to acceptability of the recommendations, PCPs' current screening practices, and perceived barriers for implementing the recommendations. Overall, PCPs agreed with, but expressed hesitancy about, the recommendation. Frequently mentioned barriers to suicide screening included time, training, and inadequate access to resources for follow-up care for at-risk patients. Yet, PCPs were optimistic they could learn with support and were interested in working in this subject area through quality improvement interventions. CONCLUSIONS: PCPs agree with the AAP recommendation about suicide screening but need support to implement into practice. Specifically, PCPs need time sensitive strategies, resources, training, and practice change support to assist these efforts.

Improving Follow-Up for Adolescents With Depression in Primary Care.

BACKGROUND: Few adolescents with depression receive treatment in accordance with national guidelines. This quality improvement project took place in 11 primary care practices with the primary aim of increasing the percentage of teens with depression who received follow-up care within 6 weeks of diagnosis and within 3 months, once stable. METHODS: The primary strategy was external practice facilitation for 12 months. The change process used goal setting and plan-do-study-act cycles to identify and implement change ideas. A preanalysis and postanalysis was completed to evaluate process change, provider confidence, and patient improvement. RESULTS: Randomly selected samples of 199 and 217 charts of teens newly diagnosed with depression were reviewed before and after the intervention, respectively. Chart data for these measurements was provided by 10 and 9 practices, respectively. The percentage of patients with follow-up care within 6 weeks after diagnosis increased from 40% to 81% (P < .001), the percentage with a follow-up visit within 3 months once stable increased from 30% to 60% (P < .001), and the percentage in remission at 6 months increased from 7% to 21% (P < .001). Providers reported increased confidence to diagnose and manage depression, assess severity, provide pharmacotherapy, and educate families. CONCLUSIONS: Practices improved follow-up care for teens with depression. In addition, providers experienced an improvement in their confidence to diagnose and manage depression. Working with a facilitator, each practice implemented standardized systems to provide effective care in the medical home, increase providers' confidence to address this common problem, and improve patient outcomes.

Help Is Available: Supporting Mental Wellness Through Peer Health Navigation with Young Black Men Who Have Sex with Men with HIV.

Young black men who have sex with men (YBMSM) with HIV experience disproportionate rates of trauma, incarceration, poverty, racial discrimination, and homophobia. The synergistic effects of these adverse experiences, along with increased rates of mental health disorders, increase their risk for poor health. To address this need, the study authors adapted a current HIV service model to include a peer-health navigation intervention (WITH U) to attend to behavioral health, health literacy, linkage to services, and psychosocial support for YBMSM with HIV. This longitudinal, mixed-methods, nonexperimental study reports on the mental health burden among participants and the association between participation in WITH U and mental wellness outcomes. Participants (N = 65) were an average age of 25-26 years (mean = 25.48, standard deviation = 2.51). Over 25% of participants reported clinically significant depression and/or anxiety symptoms and nearly half the participants reported experiencing post-traumatic stress symptoms that were at least moderately difficult to handle. Quantitative analyses indicated no significant positive association between intervention engagement and mental health symptoms; however, reporting a greater number of depression symptoms was associated with attending fewer intervention sessions. Qualitative data analysis revealed that participants' mental wellness was positively impacted by participating in the intervention and that participants preferred to receive mental wellness support from peer health navigators (HNs) rather than licensed mental health professionals. Yet, peer HNs did not feel adequately prepared to address participants' mental wellness concerns. Increased training for peer HNs and development of a linkage process to more formalized mental health services with community input may strengthen mental wellness support.

Primary care experiences of providing mental healthcare for children in the USA during the COVID-19 pandemic: a qualitative study.

BACKGROUND: The increased demand for mental healthcare associated with the COVID-19 pandemic adds to the already high unmet mental health needs among paediatric patients, resulting in a declared 'mental health emergency'. The study objective was to describe paediatric primary care providers (PCPs') experience of meeting their patients' needs for mental healthcare during the pandemic and to identify opportunities to optimise care. METHODS: 19 paediatricians and 2 nurse practitioners completed a 30 min video interview in May 2021. Interviews were recorded and transcribed, and transcripts were analysed using consensual qualitative research methods. RESULTS: Participants reported marked increases in patient mental health needs during the COVID-19 pandemic. These included new diagnoses of anxiety and depression and increased treatment needs for patients with a prior mental health diagnosis. They identified that the mental health needs of their patients were greater, more severe and more challenging to manage with the resources currently available. While they were frustrated with the lack of communication and support from their mental health colleagues, and felt isolated and overwhelmed, they approached the increased demand for mental healthcare with a growth mindset. This outlook included providing care, seeking help to improve their skills and engaging with local resources such as the Child Psychiatry Access Project (CPAP). CONCLUSIONS: Our findings suggest that urgent action is needed to better support paediatric PCPs to provide mental healthcare in our community. Providers identified an ongoing need for timely access to and effective communication with mental health providers to guide care in the medical home. This need could be addressed immediately by providing training for new and experienced clinicians, expanding the scope of CPAP programmes to include patient assessment and supporting implementation of integrated behavioural health programmes into the medical home.

Making a Difference With Mental Health During Adolescence in a Global Pandemic.

Anxiety and depression are common in adolescence and have increased during the coronavirus disease 2019 pandemic. The isolation from shutdowns and loss of school, loved ones, and typical activities left many children and youth with increased mental health needs. Standardized mental health screening, diagnosis, and treatment with close follow-up care can be done within the framework of the medical home, which is accessible to patients and caregivers. Best practices and a decision tree, a decision support tool, are offered to help meet the growing need. Even with current longer wait times for therapists and psychiatry provider shortages, teenagers and families can be helped in meaningful ways to achieve remission, recovery, and well-being. [Pediatr Ann. 2021;50(12):e494-e497.].

Collaborating to Advocate in Primary Care for Children During COVID-19.

The St Louis Regional Pediatric Learning Collaborative of pediatric primary care providers and infectious diseases specialists formed in March 2020 to address the needs of children and families during the coronavirus disease 2019 (COVID-19) pandemic. More than 400 pediatric primary care providers participated, using a listserv to discuss care and organize webinars to provide updates on local and national data and plan next steps. To inform local decision-making about care and testing for severe acute respiratory syndrome coronavirus 2, 95 providers from 26 practices partnered with the local practice-based research network to rapidly collect and share data about children with COVID-19-like symptoms. Of 2162 children tested for severe acute respiratory syndrome coronavirus 2, 9% had positive test results. Test result positivity was 33% if a patient was exposed to a confirmed case of COVID-19 and 4% if they had COVID-19-like symptoms and no exposure. School or day care attendance was associated with lower rates of positive test results. Although not originally planned, these findings drove local advocacy efforts by the Collaborative for increased access to testing and contact tracing and safe in-person school. Members communicated directly and collectively with local politicians, provided advice and resources for school boards and superintendent groups, and appeared on various media platforms. In these efforts, they shared local data, highlighting the lower rate of positive test results for children in school to support the idea that schools could be safely open. Outreach from trusted pediatricians sharing prospective, timely, local data sustained in-person school for some districts and aided in future in-person openings for other school districts.

Building Community Support Using a Modified World Café Method for Pregnant and Parenting Teenagers in Forsyth County, North Carolina.

STUDY OBJECTIVE: To identify community priorities, foster awareness of existing supports, and recognize barriers and opportunities to enhance support services for pregnant and parenting teens (PPTs). DESIGN AND SETTING: A modified World Café event incorporated parallel, rotating focus groups with semistructured, case-based discussions of salient issues. The event was organized and took place in Forsyth County, North Carolina. PARTICIPANTS: Seventy-eight local health and social service professionals and 15 PPT representatives. INTERVENTIONS AND MAIN OUTCOME MEASURES: Qualitative coding was used to thematically analyze transcript data. Quantitative data pre-/post-event comparisons were made using Fisher exact test. RESULTS: Key community-based support services for PPTs were identified. Qualitative analysis yielded 10 key codes regarding barriers and opportunities to enhance community-based support services, resulting in 4 themes. Themes included maximizing access and efficient delivery of high-quality health care, engaging a 3-generation approach to meet the current and future needs of at-risk families, focusing efforts to meet the unique needs of each teen and his/her family, and emphasizing teen self-advocacy. Pre/post survey responses were overwhelmingly positive regarding use of the modified World Café format for discussion and network building. CONCLUSION: The modified World Café Method offered a platform to collaboratively identify challenges and opportunities and to develop networks to improve health and well-being of PPTs. Engaging multiple stakeholders in meaningful dialogue might foster multidisciplinary, cross-sector collaboration that mitigates risk and enhances resilience among PPTs and their children.

Trading Sex for Money or Compensation: Prevalence and Associated Characteristics from a Sexually Transmitted Infection (STI) Clinic Sample.

The purpose of this study was to determine the prevalence and individual risk factors of people who trade or sell sex among sexually active individuals seeking HIV and sexually transmitted infection (STI) testing. Using electronic agency records, an analysis of the characteristics of 5,029 youth and adults who voluntarily obtained HIV and STI testing was conducted. Multiple imputation procedures for missing data from 3 variables and logistic regression were conducted. A total of 128 individuals reported having traded sex. Nine variables had statistically significant associations with trading sex. Individuals who identified as White and female had lesser odds of trading sex, whereas individuals who were transgender, were living in a shelter, had been sexually assaulted, had a previous STI, had high-risk sex, or used drugs had greater odds of trading sex. Elevated levels of high-risk behavior in addition to sexual trauma should be considered in intervention research and community health practice. Implications for service providers and researchers are discussed.

An Essential Role for Pediatricians: Becoming Child Poverty Change Agents for a Lifetime.

Poverty has profound and enduring effects on the health and well-being of children, as well as their subsequent adult health and success. It is essential for pediatricians to work to reduce child poverty and to ameliorate its effects on children. Pediatricians have important and needed tools to do this work: authority/power as physicians, understanding of science and evidence-based approaches, and first-hand, real-life knowledge and love of children and families. These tools need to be applied in partnership with community-based organizations/leaders, educators, human service providers, business leaders, philanthropists, and policymakers. Examples of the effects of pediatricians on the issue of child poverty are seen in Ferguson, Missouri; Denver, Colorado; and Rochester, New York. In addition, national models exist such as the American Academy of Pediatrics Community Pediatrics Training Initiative, which engages numerous pediatric faculty to learn and work together to make changes for children and families who live in poverty and to teach these skills to pediatric trainees. Some key themes/lessons for a pediatrician working to make changes in a community are to bear witness to and recognize injustice for children and families; identify an area of passion; review the evidence and gain expertise on the issue; build relationships and partnerships with community leaders and organizations; and advocate for effective solutions.

More Than Poverty: The Effect of Child Abuse and Neglect on Teen Pregnancy Risk.

PURPOSE: The purpose of the study was to compare risk for teen pregnancies between children living in poverty with no child protective services (CPS) report history and those in poverty with a history of CPS report. METHODS: Children selected from families in poverty, both with and without CPS report histories were prospectively followed from 1993 to 2009 using electronic administrative records from agencies including CPS, emergency departments, Medicaid services, and juvenile courts. A total of 3,281 adolescent females were followed until the age of 18 years. RESULTS: For teens with history of poverty only, 16.8% had been pregnant at least once by the age of 17 years. In teens with history of both poverty and report of child abuse or neglect, 28.9% had been pregnant at least once by the age of 17 years. Although multivariate survival analyses revealed several other significant factors at the family and youth services levels, a report of maltreatment remained significant (about a 66% higher risk). CONCLUSIONS: Maltreatment is a significant risk factor for teen pregnancy among low income youth even after controlling for neighborhood disadvantage, other caregiver risks and indicators of individual emotional and behavioral problems.

Evidence-based community pediatrics: building a bridge from bedside to neighborhood.

The American Academy of Pediatrics policy statement "The Pediatrician's Role in Community Pediatrics" encourages all pediatricians to partner with their communities to create and disseminate innovative programs that improve child health. This article describes 4 pillars of a bridge to evidence-based community pediatrics for pediatricians interested in pursuing effective community action: (1) collaborate with the community to establish a specific, short-term, health-related goal; (2) identify evidence-based best practice(s) for achieving the shared goal; (3) collaborate with the community to adapt this best practice to the community's unique assets and constraints; and (4) evaluate the project by using appropriate expertise. Practical elements of each pillar are described and illustrated by specific examples from community-based efforts of pediatricians and are accompanied by specific resources to aid pediatricians in their future community health work.