Initiation of Services in the Boston HAPPENS Program: HIV-Positive, Homeless, and At-Risk Youth Can Access Services

HIV-positive, homeless, and other youth at-risk for HIV present a challenge to those who would connect them to health care. There is a need for more youth-friendly services and street outreach so that hard-to-reach youth will have access to health care, and for early HIV case identification.

Of the 793,026 cases of AIDS the CDC reported in the United States as of June 2001, 4,219 cases fell in the 13-19 age range, and 27,880 cases fell in the 20-24 age group. Many of the young adults were infected during adolescence. The proportion of women with HIV in the younger age groups is increasing, and the African-American and Hispanic adolescent and young adult populations show high rates of HIV. Homeless and runaway youths are especially vulnerable to HIV infection because of substance abuse and/or survival sex (exchanging sex for food, shelter, or drugs).

The Special Projects of National Significance Program (SPNS) of the Health Resources and Services Administration funded the Boston HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program in 1993 as a model of care to help meet the needs of HIV-positive, homeless, and at-risk youth in metropolitan Boston. Nine core agencies and institutions formed the network: three teaching hospitals, three multiservice outreach agencies, and three community health centers.

This study's purpose was to describe the initiation of care among HAPPENS clients. Specifically, the study aimed to evaluate the roles of outreach and HIV counseling and testing services (CTS) in connecting youth to services, describe the kinds of services most frequently obtained at the first encounter, evaluate youth transition from initial contact into medical care, and determine whether there were different types of youth seeking care at different sites.

All sites in the HAPPENS network offered adolescent-oriented HIV counseling and testing services. The program developed a mechanism for communication, collaboration, and integration of adolescent care across sites.

Service providers at participating sites collected program data between 1994 and 1998. HAPPENS served 2,116 youth from 12-24 years old. Sixty-four percent of the subjects were female; 45 percent were youth of color; 16 percent were gay/lesbian, bisexual, or undecided; and 10 percent were homeless or runaways. The mean age of participants was nearly 20; approximately 2 percent of the subjects were confirmed HIV-positive, with young men having double the percentage of young women. Both genders had high rates of unprotected sexual intercourse.

Analyses of this study's data support the findings of other studies: outreach services were instrumental in connecting youth to care, and HIV CTS was crucial to identifying HIV-positive youth who needed care.

In HAPPENS, 56 percent of participants received outreach services at first contact with the program. Compared to those not receiving outreach services, the youth who did included significantly higher proportions of the homeless or runaways, those involved in the mental health system, gay/lesbian, or subjects with a history of sex with IDUs. Outreach services were a critical first step in connecting at-risk youth to other sources of care.

HIV CTS was another entry point into care. Of participants with an intervention service at the first visit, 55 percent received HIV counseling and testing. Hospitals offered HIV CTS to the largest number of young people, followed by outreach agencies, then community health centers. HIV CTS was itself a prevention intervention, the authors say, because the visit included personalized risk assessment and harm reduction counseling. HIV CTS facilitates the success of case identification and early HIV treatment interventions, all the more important now that effective HIV therapies are available.

Different agencies reached different at-risk populations. Outreach agencies, the study shows, were relatively better at reaching males, older youth, gay/lesbian/bisexual, and questioning youth. Hospitals and community health center sites saw a higher proportion of young women, youth with a history of STDs, pregnant women, people of color, and youths engaging in unprotected sex with opposite gender partners. The results indicate that a variety of confidential, comprehensive care sites are needed to optimize access and care for the full range of youth sub-populations.

"Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect underserved youth to health care," the authors stated.

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