title: Factors informing HIV providers' decisions to start antiretroviral therapy for young people living with behaviorally acquired HIV.
abstract: OBJECTIVE
  Young people with behaviorally acquired HIV (BHIV) are less likely than adults to initiate antiretroviral therapy (ART) despite meeting treatment criteria. We explored critical factors involved in healthcare providers' decision making regarding ART initiation for young people with BHIV (aged 12-24 years).
  
  
  METHODS
  Semistructured interviews were conducted with 23 HIV providers from diverse training backgrounds caring for youth with BHIV at four adult clinics and one pediatric clinic in a high prevalence urban city. Interview domains probed clinical and nonclinical patient characteristics, the role of adherence, and provider attitudes working with youth to establish decision-making priorities for ART initiation. The constant comparative approach was used to develop grounded theory on providers' decision making on ART initiation.
  
  
  RESULTS
  Clinical criteria, particularly the CD4 count, and the public health implications of HIV transmission determined the urgency for ART initiation. However, patient-related concerns regarding treatment readiness and adherence hampered the decision to initiate, especially at higher CD4 counts. Providers who acknowledged developmental characteristics of youth (e.g., evolving adult identity and self-efficacy around health management) appeared more cautious in assessing future ART adherence and responded with intensive clinical support. Extensive involvement of multidisciplinary teams was identified as an important strategy to retain youth in care, whereas strengthening youth-targeted approaches may be an unmet need in adult clinics.
  
  
  CONCLUSIONS
  Evaluation of providers' awareness of the developmental features of youth and characteristics of youth-targeted approaches in clinics caring for youth with BHIV may inform interventions to increase youth engagement in care and subsequent decisions to successfully initiate ART.
authors.affiliation: Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland. Electronic address: llee74@jhmi.edu.
authors.forename: Lana
authors.initials: L
authors.lastname: Lee
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Cynthia S
authors.initials: CS
authors.lastname: Rand
authors.affiliation: Department of Pediatrics, Johns Hopkins School of Medicine, All Children's Hospital, St. Petersburg, Florida.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Ellen
authors.affiliation: Division of Adult and Pediatric Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Allison L
authors.initials: AL
authors.lastname: Agwu
mesh_terms: D000293:Adolescent; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D002648:Child; D003657:Decision Making; D005260:Female; D019983:Guideline Adherence; D015658:HIV Infections / Q000188:drug therapy* / Q000635:transmission; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D055118:Medication Adherence; D010349:Patient Compliance; D014505:Urban Population; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: Adolescent health services; Antiretroviral therapy; Guideline adherence; HIV; Medication adherence