Grantee Spotlight

Focus on Youth Living with HIV: Food insecurity and depression impair treatment adherence; telehealth counseling with youth can help

Drs. Parya Saberi and Carol Dawson Rose and their team are in the fourth year of their CHRP HIV and Health Disparities award and have already published four manuscripts from their research with youth living with HIV (YLWH). Given reductions in engagement in HIV care, reduced antiretroviral therapy adherence, and worse clinical outcomes among YLWH, there is a critical need for research to address health disparities in youth and the tailoring of healthcare delivery to the unique psychosocial and physical needs of YLWH.  Each published article is summarized below, and links to the publications follow each summary.  

Introduction

There is a strong association between younger age and less engagement in HIV care, lower adherence to antiretroviral therapy, and increased risk of virologic failure. Additionally, problematic substance use and untreated mental health challenges frequently occur in YLWH and disrupt the continuum of HIV care. In response to this public health dilemma, our research team is assessing the feasibility and acceptability of videoconferencing along with text messaging for improving engagement in HIV care and decreasing substance use and mental health challenges among YLWH (18-29 years of age). As a result, we have developed an intervention called Youth to Text or Telehealth for Engagement in HIV Care (Y2TEC).

Given the close connection between engagement in HIV care, substance use, and mental health challenges, all three must be addressed concurrently.  Although the evidence-base supporting integrated mental health, substance use, and HIV care adherence counseling is still developing, interventions combining the three aspects appear promising. Y2TEC uses psychoeducation, health education, Motivational Interviewing and brief problem-solving counseling. The intervention development was influenced by trauma-informed care, strengths-based work, and other relevant clinical frameworks. It uses videoconferencing and text messaging to deliver this integrated behavioral health counseling over 12 brief sessions. The Y2TEC intervention focuses on reducing barriers to addressing participant’s health care, mental health, and substance use-related needs, in service of improving their HIV care adherence and overall wellness. If Y2TEC is feasible and acceptable, it can be scaled up for a multi-site randomized trial and ultimately offered in the clinical care of YLWH.

Article One:  What Does it Mean to be “Youth Friendly”? 

Drs. Saberi and Dawson Rose have conducted numerous formative research projects to develop and refine the Y2TEC intervention. Initially, they conducted one-one-one qualitative interviews with healthcare providers and staff at San Francisco Bay Area clinics serving YLWH. The objective of these interviews was to examine the facilitators of and barriers to engagement in care among YLHW at the system and provider/staff level, and the barriers clinics face in using technology-based forms of communication with YLWH. Among the 17 health care providers and staff members, various facilitators of and barriers to engagement in care among YLWH were noted, including the environment of the clinic (e.g., clinic location and service setting); provision of youth-friendly services (e.g., flexible hours and use of technology); and youth-friendly providers/staff (e.g., nonjudgmental approach). In relation to barriers to using technology, interviewees discussed the challenges at the system level (e.g., availability of technology, clinic capacity, and Health Insurance Portability and Accountability Act compliance); provider/staff level (e.g., time constraints and familiarity with technology); and youth level (e.g., changing of cellular telephones and relationship with provider/staff). Therefore, given the need for improved clinical outcomes among YLWH, the results of this study can provide guidance for clinics and institutions providing care for YLWH to enhance the youth-friendliness of their services and examine their guidelines around the use of technology. Results from these interviews can be viewed in their publication titled What does it mean to be youth-friendly? Results from qualitative interviews with health care providers and clinic staff serving youth and young adults living with HIV. Adolesc Health Med Ther. 2018 Apr 24;9:65-75. eCollection 2018.   Parya Saberi, Kristin Ming, Carol Dawson Rose.

Article Two:  Will Videoconferencing Work for Service Delivery with Youth?

Next, the Y2TEC team interviewed YLWH using quantitative surveys (N=101) and qualitative interviews (N=29) to describe the relationship between mental health, substance use, and medication adherence, and explored technology use as an approach to supporting these services. Antiretroviral therapy adherence was significantly negatively associated with depression, trauma, and adverse childhood experiences, and marijuana and stimulants use. Depression was the most important variable in its association with antiretroviral therapy adherence. During in-depth interviews, most participants favored technology use for mental health and substance use service delivery, including videoconferencing with a counselor. Therefore, the team concluded that the provision of ongoing mental health and substance use treatment is an important mechanism to achieving HIV treatment engagement and that technology, particularly videoconferencing, may increase the accessibility of these services. The details of this study are published in an article titled Use of technology for delivery of mental health and substance use services to youth living with HIV: a mixed-methods perspective. AIDS Care 2019. Parya Saberi, Carol Dawson Rose, Angie R. Wootton, Kristin Ming, Dominique Legnitto, Melanie Jeske, Lance M. Pollack, Mallory O. Johnson, Valerie A. Gruber, Torsten B. Neilands. 

Article Three:  Unmet Subsistence Needs and HIV Treatment Adherence among Youth

In addition to mental health and substance use, Dr. Saberi and her team have also examined the relationship between food insecurity and unmet subsistence needs, and their association with antiretroviral therapy adherence among YLWH (N=101). They noted that 51.7% of participants experienced at least one unmet subsistence need (difficulty finding enough to eat [36.6%], clothing [22.8%], place to sleep [21.8%], place to wash [17.8%], and bathroom [15.8%]), and 64.2% reported being food insecure. For every additional unmet need, the risk of very good/excellent adherence was reduced by 15%. The risk of very good/excellent adherence was lowered by 39% among food insecure youth, compared with those who were food secure. These data highlight the need for more research and structural interventions targeting food assistance strategies among YLWH. These results have been published in an article titled Food Insecurity and Unmet Needs Among Youth and Young Adults Living With HIV in the San Francisco Bay Area.  Journal of Adolescent Health, Volume 65, Issue 2, August 2019, Pages 262-266. Christian Reeder, Torsten B. Neilands, Kartika Palar, Parya Saberi.

Article Four:  Implementing a Telehealth and Texting Intervention with Youth Living with HIV

The Y2TEC pilot randomized trial was started in April 2019 and will end about six months later. At the completion of this study, we will have evaluated the feasibility and acceptability of a 12-session 20-30-minute telehealth counseling series provided to YLWH in the San Francisco Bay Area, including education, motivational enhancement, and problem-solving around HIV care, mental health, substance use, and other challenges. During the course of this study, participants also receive text messages for check-ins, appointment reminders, and to improve engagement with care. Participants complete quantitative online surveys at baseline, 4, and 8 months and a qualitative exit interview. Findings will provide information about the benefits and challenges of telehealth counseling for YLWH and will guide the development of new technology-based strategies for care. Details of the study protocol are published in a paper called Telehealth and texting intervention to improve HIV care engagement, mental health and substance use outcomes in youth living with HIV: a pilot feasibility and acceptability study protocol.  BMJ Open 2019.  Angie R. Wootton, Dominique A. Legnitto, Valerie A. Gruber, Carol Dawson Rose, Torsten B. Neilands, Mallory O. Johnson, Parya Saberi.