Case study: multisystemic therapy for adolescents who engage in HIV transmission risk behaviors.
ABSTRACT To present a case study using multisystemic therapy (MST), an intensive family focused psychotherapy. For the clinical trial from which this case was drawn, MST was adapted to address multiple human immunodeficiency virus (HIV) transmission risk behaviors in HIV-infected youth. Targeted behaviors included medication nonadherence, risky sexual behaviors, and substance use.
One young woman's transmission risk behaviors are described, followed by a description of the MST procedures used to identify and treat the primary drivers of these risk behaviors. Outcome measures were self-report, urine screens, and blood draws.
At discharge, the young woman showed significant improvements in medication adherence and related health status (e.g., reduced HIV viral load), healthier sexual behaviors, and reduced substance use. Importantly, neither her boyfriend nor her newborn tested positive for HIV.
Findings from this case study suggest that MST has the potential to reduce transmission risk behaviors among teens with HIV.
- [Show abstract] [Hide abstract]
ABSTRACT: Abstract Adherence to antiretroviral medication for the treatment of HIV is a significant predictor of virologic suppression and is associated with dramatic reductions in mortality and morbidity and other improved clinical outcomes for pediatric patient populations. Effective strategies for addressing adherence problems in youth infected with HIV are needed and require significant attention to the complex interplay of multiple, interacting causal risk factors that lead to poor self-care. Within the context of a pilot randomized trial, we evaluated the feasibility and initial efficacy of a multisystemic therapy (MST) intervention adapted to address HIV medication adherence problems against a usual care condition that was bolstered with a single session of motivational interviewing (MI). For 34 participating youth, health outcomes (viral load [VL] and CD4 count) were obtained from approximately 10 months pre-baseline through approximately 6 months post-baseline and self-reported medication adherence outcomes were obtained quarterly from baseline through 9 months post-baseline. Using mixed-effects regression models we examined within- and between-groups differences in the slopes of these outcomes. Feasibility was supported, with a 77% recruitment rate and near-maximal treatment and research retention and completion rates. Initial efficacy also was supported, with the MST condition but not the MI condition demonstrating statistically and clinically significant VL reductions following the start of treatment. There was also some support for improved CD4 count and self-reported medication adherence for the MST but not the MI condition. MST was successfully adapted to improve the health outcomes of youth poorly adherent to antiretroviral medications. Replication trials and studies designed to identify the mechanisms of action are important next steps.AIDS Care 08/2012; · 1.60 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Disclosure of serostatus is critical in preventing the transmission of HIV among youth. The purpose of this exploratory study was to describe serostatus disclosure in a multisite study of youth living with HIV. This study investigated serostatus disclosure and its relationship to unprotected sex among 146 youth participating in a multisite study of young people living with HIV who were sexually active within the past 3 months. Forty percent of participants reported a sexual relationship with a partner to whom they had not disclosed their serostatus. Participants with multiple sexual partners were less likely to disclose their serostatus than those with one partner. Disclosure was more frequent when the serostatus of the sexual partner was known. Disclosure was not associated with unprotected sex. Prevention initiatives should focus on both disclosure and condom use in this high-risk population, particularly for youth with multiple sexual partners.Journal of Adolescent Health 03/2012; 50(3):315-7. · 2.75 Impact Factor
- Journal of Pediatric Psychology 09/2011; 36(9):951-8. · 2.91 Impact Factor
Case Study: Multisystemic Therapy for Adolescents Who Engage in
HIV Transmission Risk Behaviors
Elizabeth J. Letourneau,1PHD, Deborah A. Ellis,2PHD, Sylvie Naar-King,2PHD,
Phillippe B. Cunningham,1PHD, and Sandra L. Fowler,1MD
1Medical University of South Carolina, and2Wayne State University
psychotherapy. For the clinical trial from which this case was drawn, MST was adapted to address multiple
human immunodeficiency virus (HIV) transmission risk behaviors in HIV-infected youth. Targeted behaviors
included medication nonadherence, risky sexual behaviors, and substance use.
woman’s transmission risk behaviors are described, followed by a description of the MST procedures used
to identify and treat the primary drivers of these risk behaviors. Outcome measures were self-report, urine
screens, and blood draws.ResultsAt discharge, the young woman showed significant improvements in
medication adherence and related health status (e.g., reduced HIV viral load), healthier sexual behaviors,
and reduced substance use. Importantly, neither her boyfriend nor her newborn tested positive for HIV.
ConclusionsFindings from this case study suggest that MST has the potential to reduce transmission
risk behaviors among teens with HIV.
To present a case study using multisystemic therapy (MST), an intensive family focused
Method One young
Key wordsAdolescence; HIV; multisystemic therapy.
This case study examines the feasibility of using multi-
systemic therapy (MST; Henggeler, Schoenwald, Borduin,
Rowland, & Cunningham, 1998) to address transmission
risk behaviors of adolescents with human immunodefi-
ciency virus (HIV). The most common risk factor for HIV
transmission in adolescents is risky sexual behavior
(Futterman, Chabon, & Hoffman, 2000). A second signifi-
cant risk factor for transmission is drug use which
increases the risk of unprotected or other risky sexual
behaviors and, consequently, for acquiring and trans-
mitting HIV (Strunin & Hingson, 1992). Medication
non-adherence represents a third transmission risk for
HIV. HIV medication regimens can be complex, requiring
high pill burdens and complicated dosing regimens
(Guarinieri & ICoNA Community Advisory Board, 2002).
Even less complex regimens are unrelenting in requiring
daily medications. Strict adherence (i.e., <5% missed
doses) is required to achieve and maintain virologic con-
trol, yet few young people reach this level of adherence
(Murphy et al., 2003). Consequences of poor adherence
include increased risk of HIV transmission in the event of
unprotected sex (Hosseinipour, Cohen, Vernazza, &
Kashuba, 2002). Development of comprehensive programs
that can simultaneously address these common trans-
mission risk behaviors is a research and clinical priority
Youth HIV transmission risk behaviors tend to have
common drivers that coincide with Bronfenbrenner’s
(1979) theory of social ecology. This theory posits that
human behavior is influenced directly or indirectly by the
individual, family, peer, and community systems in which
an individual is embedded. For example, at the ‘‘individual
level,’’ unsafe sexual behaviors and drug use behaviors
have been associated with depression and anxiety
(Murphy et al., 2001) while low medication adherence
has been associated with an unwillingness to disclose
HIV status to others (Mellins et al., 2004). At the ‘‘family
level,’’ all three transmission risk behaviors have been
associated with caregiver substance use (Naar-King et al.,
2006) and low parental monitoring (Duncan, Duncan, &
Stryker, 2000; Donenberg, Wilson, Emerson, & Bryant,
2002; Murphy et al., 2003; Mellins et al., 2004).
All correspondence concerning this article should be addressed to Elizabeth J. Letourneau, Ph.D. Family Services
Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,
Charleston, SC 29425. (843) 876-1800. E-mail: email@example.com
Journal of Pediatric Psychology 35(2) pp. 120–127, 2010
Advance Access publication October 8, 2009
Journal of Pediatric Psychology vol. 35 no. 2 ? The Author 2009. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: firstname.lastname@example.org
At the ‘‘peer level,’’ associating with risk-taking and
deviant peers is one of the strongest correlates of sexual
risk taking behavior and drug use in youth (Madison,
McKay, Paikoff, & Bell, 2000; Bachanas et al., 2002;
Voisin, 2002), while low medication adherence is asso-
ciated with negative censure from peers (Dodds et al.,
2003). At the ‘‘community level,’’ unsafe sexual behavior
has been associated with community level violence (Voisin,
2002); drug use has been associated with high mobility
and disorganization, low community support, and pres-
ence of a criminal subculture (for reviews, see Henggeler,
1997); and low medication adherence has been associated
with poor relationships between health care providers and
caregivers and youth (Ingersoll & Heckman, 2005). While
drivers co-occur across behaviors, the specific pattern
presents differently for individual youth. Thus, effective
strategies for reducing youth transmission risk behaviors
require attention to the complex interplay of multiple,
interacting causal risk factors and benefit from an indivi-
dualized intervention focus (Wechsler et al., 1998;
Chesney et al., 1999; Barnett et al., 2001; Steele &
Grauer, 2003). Yet few interventions attempt to com-
prehensively reduce HIV transmission risk behaviors by
targeting multiple risk factors across ecological levels on
an individualized basis. Rather, available interventions for
pediatric transmission risk behaviors are typically standar-
dized across patients and frequently target just one or
two risk behaviors.
One evidenced-based intervention that targets the
diverse drivers of youth problem behaviors within
youths’ ecological contexts is MST. MST is an intensive,
home- and community-based intervention that has been
identified as an evidenced-based intervention for juvenile
delinquency (US Department of Health and Human
Services, 2001) and juvenile substance abuse (NIDA,
1999). MST therapists are bachelors or masters-level
professionals who work on teams composed of two to
three therapists and a supervisor. Services are delivered
in youths’ homes and other community (e.g., clinic,
school) settings at times convenient to families and thera-
pists are available to respond to crises 24hrs per day.
Therapists carry small caseloads of 4–6 families as a
result of the intensive and individualized nature of MST.
Rather than providing session-by-session protocols for
clinical procedures, nine ‘‘treatment principles’’ are used
to guide therapists’ case conceptualizations, prioritization
of interventions, and implementation of intervention
strategies. The overriding goals of MST are to empower
parents with the skills and resources needed to address
the inevitable difficulties that arise in raising adolescents
and to empower adolescents to cope with familial and
MST is conceptually an excellent fit for intervening
with transmission risk behaviors due to its focus upon
multiple systems that influence youth behavior. Recently,
MST was successfully adapted to address medication non-
adherence in youth with poorly controlled type 1 diabetes
(Ellis et al., 2005) and in youth with HIV (Ellis, Naar-King,
Cunningham, & Secord, 2006). Case studies that emerged
from these projects identified MST’s focus on behavioral
drivers across ecological systems as key to improved
adherence outcomes (Ellis, Naar-King, Frey, Rowland,
Gregor, 2003; Cunningham, Naar-King, Ellis, Pejuan, &
Secord, 2006). The present ‘‘explanatory’’ case study (see
Drotar, La Greca, Lemanek, & Kazak, 1995, p. 551) is the
first to present MST as adapted to address medication
nonadherence as well as other transmission risk behaviors
including substance use, and sexual risk behaviors.
‘‘Sara,’’ a 17-year-old Caucasian young woman diagnosed
with perinatally acquired HIV, was recruited into a ran-
domized clinical trial piloting the use of MST to address
HIV transmission risk behaviors. Sara’s case was selected
for presentation because she presented with all three risk
behaviors targeted by the MST intervention. At study entry,
Sara was 2 months pregnant (per HIV clinic and self
report), on an extended clinic-ordered medication break
due to medication nonadherence (per clinic report),
reported frequent marijuana use (per self-report and con-
firmed by a urine drug test), and had stopped attending
school (per caregiver and youth report and confirmed by
youth’s school). She also was on probation for a prior
truancy charge. In the previous year, Sara’s viral load
varied from 1,033–39,000 copies/ml (per clinic chart
review). The clinic-ordered medication break predated
Sara’s pregnancy and clinic staff were anxious for Sara to
resume antiretroviral medications. The goal of antiretroviral
treatment (ART) for Sara, especially during pregnancy, was
to suppress the viral copy number to as low a level as
possible, preferably to one that was undetectable.
Current ART guidelines reflect the knowledge that high
viral loads are associated with progression of disease, and
with both horizontal and vertical transmission (Perinatal
HIV Guidelines Working Group, 2009). The MST intake
assessment indicated that, in addition to these behavior
problems, Sara had a volatile relationship with her
mother and had struggled with depression since her
preteen years. While not actively suicidal at study entry,
MST for HIV Transmission Risk Behaviors
Sara had been admitted to inpatient settings for threaten-
ing or attempting suicide on three occasions in the preced-
ing 3 years. Sara had minimal contact with her father,
who was drug dependent and had been violent with her
mother when they still were married.
MST intervention goals were developed based on
initial intake information, family priorities, and clinic
goals. These ‘‘overarching goals’’ included (a) improved
medication adherence as evidenced by undetectable viral
load, (b) decreased sexual risk behaviors as evidenced by
demonstrated knowledge of condom usage and an effective
postnatal birth control plan, (c) decreased substance use
as evidenced by clean urine screens, and (4) improved
parenting (of Sara by her mother) as evidence by increased
parental supervision and monitoring and consistent
application of rewards and consequences linked to these
intervention goals. As is typical for MST, the intervention
was provided primarily in Sara’s home although the ther-
apist also attended Sara’s clinic appointments and met
with other stakeholders (e.g., school officials, probation
officer) as needed throughout MST.
Understanding the ‘‘Fit’’ of Sara’s Behavior
At the start of the intervention MST therapists conduct
an ‘‘assessment of fit’’ to identify factors that directly or
indirectly influence the problem behavior (Henggeler et al.,
1998, p. 24). As a staring point, the therapist assesses the
influence of factors identified in the empirical literature as
causative for the problem behavior (e.g., low parental
supervision and monitoring is known to influence medica-
tion adherence) and also identifies idiosyncratic factors
relevant to the specific individual. When conducting fit
assessments, MST therapists rely primarily on interviews
with key informants, and behavioral observations. In Sara’s
case, semi-structured interviews were conducted with Sara
and her mother, Sara’s boyfriend, and members of the HIV
clinic team responsible for Sara’s care. Therapists also
gather data based on direct observation of behavior and
the interactions among family members. Based on these
sources, Sara’s MST therapist identified the specific
combination of behavioral ‘‘fit factors’’ that were maintain-
ing her nonadherence, sexual risk, and substance use
behaviors. This is in contrast to more traditional assess-
ment methods (e.g., standardized questionnaires) that
might assess for common drivers of behavior (e.g., lack
of consistent schedule for medication taking) but miss
less common or idiosyncratic factors that influence the
behavior of a specific youth (e.g., presence of a boyfriend
who supplies marijuana, use of which can interfere with
medication taking as discussed next).
The MST assessment of medication nonadherence
identified several fit factors at the individual level including
Sara’s medication-related nausea, her pattern of going to
bed late and sleeping in most mornings (which interfered
with routine medication dosings), and her belief that
medications were ineffective. Family level factors included
low caregiver supervision and monitoring of medication
taking and a permissive parenting style which contributed
to a lack of limit setting with regard to medication
adherence. Sara’s mother’s permissive parenting was due,
in part, to her feelings of guilt surrounding transmitting
HIV to her daughter and also because she had been advised
by physicians that Sara would die as an infant due to AIDS.
Sara’s mother’s own HIV status and medication adherence
(which had improved in recent years) did not otherwise
Additionally, while her boyfriend knew Sara’s HIV status,
Sara had not disclosed her status to his parents and grand-
parents with whom they often spent the night, making it
difficult for Sara to take her medications due to conceal-
ment. Previous regimen complexity was also found to be a
contributing factor. As depicted in Figure 1, these more
proximal drivers (indicated by boxes) were influenced by
factors that indirectly influenced Sara’s medication adher-
ence (indicated by circles). For example, Sara’s marijuana
use (indirect driver) influenced her sleeping habits (direct
driver) while Sara’s mother’s depression (indirect driver)
influenced parental supervision and monitoring (direct
Several drivers also were identified for Sara’s sexual
risk behaviors. At the individual level, Sara’s sexual risk
taking was influenced by her marijuana use and her
unease with and lack of knowledge about the proper use
of condoms. At the family level, Sara was permitted a
significantamount of unsupervised
boyfriend. At the family and peer levels, teen pregnancy
was modeled by several family members and friends. For
example, Sara’s mother was 19-years-old when she gave
birth to Sara’s older brother; Sara’s older brother also
had a child at the age of 19 years. An indirect driver of
Sara’s sexual risk taking was her boyfriend’s marijuana use.
Regarding Sara’s marijuana use, individual level
drivers included Sara’s boredom and her belief that
marijuana reduced her morning sickness. At the family
level, alcohol and marijuana use were modeled by several
family members (including Sara’s parents) and tacitly per-
mitted by her mother. At the peer level, Sara’s boyfriend
used and supplied marijuana. Indirect drivers of these
main factors included being out of school (which contrib-
uted to boredom) and Sara’s pre-natal nausea (relief from
which she attributed to marijuana).
time with her
Letourneau et al.
Following the identification of behavioral drivers,
interventions were identified to target the primary drivers
for each transmission risk behavior. Interventions were
typically delivered concurrently although the following
description presents the interventions sequentially.
Given the risk of vertical transmission of HIV from Sara
to her fetus and horizontal transmission to her boyfriend
in the event of additional unprotected intercourse,
improved medication adherence was prioritized. High
levels of adherence are necessary to achieve the goals of
antiretroviral therapy, particularly during pregnancy, when
there is the additional goal of preventing transmission of
HIV to the infant (Panel on Antiretroviral Guidelines
for Adults and Adolescents, 2008). When ART is instituted
for prevention of vertical transmission, treatment is
generally started by the beginning of the second trimester
of pregnancy (Perinatal HIV Guidelines Working Group,
To address Sara’s belief that medication was unhelp-
ful, the MST therapist provided education on the effective-
ness of HIV medications and arranged several meetings
between Sara, her mother, and external systems (e.g.,
HIV clinic staff, Sara’s obstetrician) to further address the
risks of nonadherence to both Sara and her fetus. The
therapist used family therapy interventions (e.g., changing
discipline strategies) to empower the mother to take ap-
propriate charge of Sara’s medication regimen, including
directly observing pill taking and tying rewards and
consequences to Sara’s behavior of taking medications
in front of her mother and to viral load test results. The
therapist also helped the mother recruit instrumental
support from friends and family members specifically
mother’s depression negatively influenced her ability to
actively parent Sara, another intervention addressed mater-
nal depression via empirically supported interventions
2003). Toward the end of therapy, Sara’s status was
disclosed to her boyfriend’s family (by a cousin, with
Sara’s consent), making it easier for Sara to maintain
adherence when spending time with her boyfriend’s family.
Sara initially refused to permit her mother to observe
medication taking or the MST therapist to conduct pill
counts. Consequently, weekly pill counts were inconclu-
sive for the first month of MST. Sara responded positively,
however, to a behavior modification plan that included
specific rewards for taking medications when observed by
her mother. By the fourth week of MST, pill counts
indicated 70–80% adherence and this increased to
between 93 and 100% during the final 3 months of
MST. This improved adherence quickly translated into
reduced viral load, which was undetectable after the first
& late curfew
Lack of CG
Figure 1. Fit for poor adherence.
Notes. ‘‘med’’ and ‘‘meds’’ refer to medications; ‘‘CG’’ refers to caregiver.
MST for HIV Transmission Risk Behaviors
month of MST. Sara’s CD4T-cell count remained >400
prior to and throughout MST. The CD4 cell number is the
major marker of immune function in HIV infection, with
a count <200 indicating severe immune deficiency and
a count ?500 considered normal in adults (Panel on
Antiretroviral Guidelines for Adults and Adolescents,
Sexual Risk Behaviors
The MST intervention to reduce sexual risk taking included
educating Sara, her boyfriend, and her mother about the
risks of transmission to others as well as Sara’s risk of
acquiring sexually transmitted infections (STIs) and new
HIV strains (e.g., from new partners). The intervention
quickly focused on engaging Sara’s boyfriend around the
goal of obtaining HIV counseling and testing. Sara and
boyfriend and mother participated in condom use skills
training, which included practical condom use skills
demonstrations, education on HIV/STI prevention, and
prevention of unplanned pregnancies. Barriers to obtaining
condoms and substance use as a driver of unsafe sex also
were addressed. The MST therapist also facilitated an
appointment between Sara and her obstetrician to develop
a post-natal birth control strategy.
Sara and her family were easily engaged around the
goal of reduced sexual risk, due largely to factors associated
with Sara’s current pregnancy (e.g., severe nausea, anxiety
regarding ability to support an infant) and the desire to
avoid future unplanned pregnancies. Over the course of
MST Sara overcame barriers to obtaining condoms, as
evidenced by being able to produce condoms upon
request. She was able to demonstrate correct condom
use using the condom model and to distinguish between
effective disease prevention (i.e., understanding continued
need for ongoing condom use) and pregnancy prevention
(i.e., understanding continued need for primary birth
control methods more effective than condoms). On the
day after delivering her baby, Sara began an interim
regimen of oral contraceptives, with a plan to switch to
an implanted contraceptive when medically indicated.
Several barriers initially presented around the goal of
reducing Sara’s marijuana use. For example, Sara and her
mother believed marijuana to be innocuous and Sara’s
mother was concerned that her own social life would be
negatively impacted if she enforced ‘‘no drinking or
smoking’’ rules in her home. The MST therapist was able
to establish engagement around this intervention goal by
presenting information on state laws that permit removing
infants from mothers who test positive for illicit substances
during pregnancy, engaging obstetricians and genetic
counselors (who already were part of Sara’s obstetric
team due to genetic risk markers identified for the fetus)
who presented information to Sara and her boyfriend
regarding possible fetal consequences of marijuana use,
and by working with Sara’s probation officer to identify
possible consequences if she tested positive during a
probation-ordered drug screen. After achieving Sara’s
engagement to reduce substance use, interventions were
developed, including (a) engaging Sara’s mother around
reducing her own drug use and implementing rules that
forbade marijuana use in the home; (b) engaging Sara’s
boyfriend to eliminate his use; (c) utilizing a contingency
management plan with Sara in which she could earn points
toward rewards for clean urine drug screens; (d) teaching
Sara drug refusal skills, and (e) identifying prosocial peers
and activities to reduce boredom triggers for use.
Sara’s mother made some initial changes to support
Sara’s reduced use (e.g., implemented new household
rules, provided rewards for clean screens) but did not
sustain these changes. Despite these set-backs, Sara
achieved her first clean drug screen in the fifth month of
MST and provided two subsequent (within-therapy) clean
screens as did her boyfriend.
MST Outcome Summary
Sara and her mother were involved in MST for 27 weeks
and received approximately 3.5 hours of MST services per
week. The number of sessions varied by week but occurred
more often early in MST, with decreasing frequency as Sara
and her mother were empowered to make and maintain
intervention gains. Most sessions were conducted in Sara’s
home. Additionally, the MST therapist conducted sessions
with other family members and with other stakeholders
(e.g., clinic staff, probation officer) in other settings.
Treatment progress was slow at first, with the therapist
mediating between frequent family arguments and Sara
missing sessions or unwilling to address treatment goals.
The MST therapist’s persistence and willingness to work
with Sara notwithstanding these negative behaviors even-
tually resulted in strong treatment engagement. Despite the
number and complexity of Sara’s multiple behavioral
problems, she achieved remarkable within-intervention
successes that translated to real reductions in transmission
risks, as well as other important gains. Sara’s mean viral
load across four pre-intervention tests was 12,788 copies/
ml (mean log10¼4.11). Each of her four within-treatment
viral load tests indicated nondetectible viral loads. Sara’s
boyfriend tested negative for HIV and her infant was deliv-
ered at full term without HIV or other health problems and
Letourneau et al.
with significantly less exposure to illicit substances than
might have been the case in the absence of MST.
A myriad of factors contribute to adolescent HIV trans-
mission risk behaviors and these vary by person, thus
requiring a highly flexible and individualized intervention
approach. Interventions that focus on only one transmis-
sion risk behavior or on a limited subset of behavioral
drivers are less likely to reduce a youth’s overall transmis-
sion risk than a more comprehensive approach. Based on
the positive results from this case study, MST appears to
warrant additional investigation as a means of averting
serious health problems in this high-risk population of
young people. Determining whether within-intervention
behavioral changes extend beyond the end of MST—a
principle goal of MST—is an important aim of the pilot
trial and future research.
As noted, MST is an intensive intervention. Family
engagement is enhanced by the availability and persistence
of MST therapists in the event of missed sessions or other
barriers to intervention participation (Cunningham &
Henggeler, 1999). In addition to improved family
engagement, the home-based delivery model offers other
advantages over office-based sessions, including more
thorough and reliable assessment information (e.g., given
therapists’ ability to witness behaviors and interactions in
natural contexts) and improved maintenance and general-
izability of newly acquired skills (e.g., due to practicing
new skills in natural contexts). These strengths of the
MST model also increase the immediate cost of care, rela-
tive to group-based or other less intensive interventions
and potentially increase barriers to ‘‘uptake’’ by providers
whose practices differ significantly from MST (Schoenwald
& Hoagwood, 2001). However, fiscal cost reductions
have been supported in trials of MST with other clinical
(non-HIV) populations. These include youth with poorly
controlled type 1 diabetes, high-risk juvenile offenders, and
youth with substance use disorders. Regarding youth with
poorly controlled type 1 diabetes, youth in the MST con-
dition had a significant decrease in the number of hospital
admissions over a 9-month post-referral period compared
to youth in the control condition and this reduction was
correlated with improved metabolic control (Ellis et al.,
2005). Direct costs for the MST and usual services
groups were equivalent prior to study entry, whereas
direct costs dropped 68% during the study period for
the MST group, and nearly doubled for the usual
services group. Regarding high-risk juvenile offenders, a
comprehensive economic evaluation of juvenile crime
prevention and intervention programs reported that
treating high-risk juvenile offenders with MST resulted in
a net gain or savings to the state of $21,863 per youth
(Aos, Phipps, Barnoski, & Lieb, 1999). Regarding sub-
stance abusing or dependent youth, investigators reported
that, relative to youth treated by usual services, youth
treated in the MST condition evidenced significant
reductions in incarceration and inpatient days across a
12-month post-referral time period, resulting in an incre-
mental cost of MST of $877/youth (Schoenwald, Ward,
Henggeler, Pickrel, & Patel, 1996). The combined evidence
of clinical and cost effectiveness has compelled some
payers to fund MST for juvenile delinquency and youth
substanceabuse (e.g.,there is
Medicaid billing code for MST services). There currently
are no funding mechanisms in place for addressing HIV
transmission risk behaviors with MST. Future research
goals include conducting a larger randomized trial that
will include cost effectiveness analyses. If research
supports the clinical and cost effectiveness of MST as an
intervention for HIV transmission risk behaviors, there is
an existing platform (i.e., 450 MST sites in the USA and 11
other countries) upon which to launch the intervention.
This study was supported by funding from the National
Institute of Mental Health, R34 077550. (R34 077550 to
Conflict of interest: Phillippe B. Cunningham, Deborah
Ellis, and Sylvie Naar-King are co-owners of Evidence
Based Services, Inc., an organization that provides training
and consultation in MST.
Received May 22, 2009; revisions received August 31,
2009; accepted September 2, 2009
Aos, S., Phipps, P., Barnoski, R., & Lieb, R. (1999).
The comparative costs and benefits of programs to reduce
crime: A review of national research findings with
implications for Washington State, State Version 3.0.
Olympia, WA: Washington State Institute for Public
Bachanas, P. J., Morris, M. K., Lewis-Gess, J. K., Sarett-
Causay, E. J., Flores, A. L., Sirl, K. S., et al. (2002).
Psychological adjustment, substance use, HIV
knowledge, and risky behavior in at-risk minority
MST for HIV Transmission Risk Behaviors
females: Developmental differences during
adolescence. Journal of Pediatric Psychology, 27,
Barnett, N. P., Monti, P. M., & Wood, M. D. (2001).
Motivational interviewing for alcohol-involved
adolescents in the emergency room. In E. F. Wagner,
& H. B. Waldron (Eds.), Innovations in adolescent
substance abuse intervention. Kidlington, Oxford, UK:
Bronfenbrenner, U. (1979). The ecology of human
development: Experiments by nature and design.
Cambridge, MA: Harvard University Press.
Chesney, M. A., Ickovics, J., Hecht, F. M., Sikipa, G.,
& Rabkin, J. (1999). Adherence: a necessity for
successful HIV combination therapy. AIDS, 13,
Cunningham, P. B., & Henggeler, S. W. (1999). Engaging
multiproblem families in treatment: Lessons learned
throughout the development of Multisystemic
Therapy. Family Process, 38, 265–281.
Cunningham, P. B., Naar-King, S., Ellis, D. A., Pejuan, S.,
& Secord, E. (2006). Achieving adherence to
antiretroviral medications for pediatric HIV disease
using an empirically supported treatment: A case
report. Developmental and Behavioral Pediatrics, 27,
Dodds, S., Blakley, T., Lizzotte, J. M., Friedman, L. B.,
Shaw, K., Martinez, J., et al. (2003). Retention,
adherence, and compliance: Special needs of
HIV-infected adolescent girls and young women.
Journal of Adolescent Health, 33, 39–45.
Donenberg, G. R., Wilson, H. W., Emerson, E.,
& Bryant, F. B. (2002). Holding the line with a
watchful eye: The impact of perceived parental
permissiveness and parental monitoring on risky
sexual behavior among adolescents in psychiatric care.
AIDS Education and Prevention, 14, 138–157.
Drotar, D., La Greca, A. M., Lemanek, K., & Kazak, A.
(1995). Case reports in pediatric psychology: Uses and
guidelines for authors and reviewers. Journal of
Pediatric Psychology, 20, 549–565.
Duncan, S. C., Duncan, T. E., & Strycker, L. A. (2000).
Risk and protective factors influencing adolescent
problem behavior: a multivariate latent growth curve
analysis. Annals of Behavioral Medicine, 22, 103–109.
Ellis, D. A., Frey, M. A., Naar-King, S., Templin, T.,
Cunningham, P. B., & Cakan, N. (2005). The effects
of multisystemic therapy on diabetes stress in
adolescents with chronically poorly controlled type I
diabetes: Findings from a randomized controlled trial.
Pediatrics, 116, e826–e832.
Ellis, D. A., Naar-King, S., Cunningham, P. B.,
& Secord, E. (2006). Use of multisystemic therapy
to improve antiretroviral adherence and health
outcomes in HIV-infected pediatric patients:
Evaluation of a pilot program. AIDS, Patient Care,
and STD’s, 20, 112–121.
Ellis, D. A., Naar-King, S., Frey, M. A., Rowland, M.,
& Greger, N. (2003). Case study: Feasibility of
multisystemic therapy as a treatment for urban
adolescents with poorly controlled Type 1 diabetes.
Journal of Pediatric Psychology, 28, 287–293.
Ellis, D. A., Naar-King, S., Frey, M., Templin, T.,
Rowland, M. D., & Cakan, N. (2005). Multisystemic
treatment of poorly controlled Type 1 diabetes: Effects
on medical resource utilization. Journal of Pediatric
Psychology, 30, 656–666.
Futterman, D., Chabon, B., & Hoffman, N. D. (2000).
HIV and AIDS in adolescents. Pediatric Clinics of
North America, 47, 171–188.
Guarinieri, M., & ICoNA Community Advisory Board.
(2002). Highly active antiretroviral therapy
adherence: the patient’s point of view. Journal of
Acquired Immune Deficiency Syndromes, 31(Suppl 3),
Henggeler, S. W. (1997). The development of effective
drug abuse services for youth. In J. A. Egertson, D.
M. Fox, & A. I. Leshner (Eds.), Treating drug abusers
effectively (pp. 253–279). New York: Blackwell.
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M.,
Rowland, M. D., & Cunningham, P. B. (1998).
Multisystemic treatment of antisocial behavior in children
and adolescents. New York: Guilford Press.
Hosseinipour, M., Cohen, M. S., Vernazza, P. L.,
& Kashuba, A. D. (2002). Can antiretroviral therapy
be used to prevent sexual transmission of human
immunodeficiency virus type 1? Clinical Infectious
Diseases, 34, 1391–1395.
Hutchinson, M. K., Jemmott, J. B., Jemmott, L. S.,
Braverman, P., & Fong, G. T. (2003). The role of
mother–daughter sexual risk communication in
reducing sexual risk behaviors among urban
adolescent females: A prospective study. Journal of
Adolescent Health, 33, 98–107.
Ingersoll, K. S., & Heckman, C. J. (2005). Patient–clinician
relationships and treatment system effects on HIV
medication adherence. AIDS Behavior, 9, 89–101.
Madison, S. M., McKay, M. M., Paikoff, R., & Bell, C.
(2000). Basic research and community collaboration:
Necessary ingredients for the development of a family-
based HIV prevention program. AIDS Education and
Prevention, 12, 281–298.
Letourneau et al.
Mellins, C. A., Brackis-Cott, E., Dolezal, C., & Abrams, E.
J. (2004). The role of psychosocial and family factors
in adherence to antiretroviral treatment in Human
Immunodeficiency Virus-infected children. The
Pediatric Infectious Disease Journal, 23, 1035–1041.
Murphy, D. A., Durako, S. J., Moscicki, A., Vermund, S.
H., Ma, Y., Schwarz, D. F., et al. Adolescent Medicine
HIV/AIDS Research Network. (2001). No change in
health risk behaviors over time among HIV infected
adolescents in care: Role of psychological distress.
Journal of Adolescent Health, 29S, 57–63.
Murphy, D., Sarr, M., Durako, S., Mosciki, A., Wilson, C.,
& Muenz, L. (2003). Barriers to HAART adherence
among Human Immunodeficiency Virus-infected
adolescents. Archives of Pediatric and Adolescent
Medicine, 157, 249–255.
Naar-King, S., Arfken, C., Frey, M., Harris, M., Secord, E.,
& Ellis, D.A. (2006). Psychosocial factors and
treatment adherence in pediatric HIV. AIDS Care, 18,
National Institutes of Health. (2004). State-of-the-science
conference statement, preventing violence and related
health-risking social behaviors in adolescents. Retrieved
August 26, 2005, from http://consensus.nih.gov/ta/
National Institute on Drug Abuse. (1999). Principles
of drug addiction and treatment: A research-based
guide. NIH Publication No. 99-4180, October
Panel on Antiretroviral Guidelines for Adults and
Adolescents. (2008). Guidelines for the use of
antiretroviral agents in HIV-1-infected adults and
adolescents. Department of Health and Human
Services. (pp. 1–139). Retrieved July 20, 2009 from
Perinatal HIV Guidelines Working Group. (2009). Public
health service task force recommendations for use of
antiretroviral drugs in pregnant HIV-infected women for
maternal health and interventions to reduce perinatal HIV
transmission in the United States (pp. 1–90). Retrieved
July 20, 2009 from http://aidsinfo.nih.gov/
Rotheram-Borus, M. J., Lee, M., Leonard, N., Lin, Y. Y.,
Franzke, L., Turner, E., et al. (2003). Four-year
behavioral outcomes of an intervention for parents
living with HIV and their adolescent children. AIDS,
Rotheram-Borus, M. J., Lee, M. B., Murphy, D. A.,
Futterman, D., Duan, N., Birnbaum, J. M., et al.
(2001). Efficacy of a preventive intervention for youths
living with HIV. American Journal of Public Health, 91,
Schoenwald, S. K., & Hoagwood, K. (2001). Effectiveness,
transportability, and dissemination of interventions:
What matters when? Psychiatric Services, 52,
Schoenwald, S. K., Ward, D. M., Henggeler, S. W.,
& Rowland, M. D. (2000). Multisystemic therapy
versus hospitalization for crisis stabilization of youth:
Placement outcomes 4 months postreferral. Mental
Health Services Research, 20, 3–12.
Steele, R. G., & Grauer, D. (2003). Adherence to
antiretroviral therapy for pediatric HIV infection:
review of the literature and recommendations for
research. Clinical Child & Family Psychology Review, 6,
Strunin, L., & Hingson, R. (1992). Alcohol, drugs, and
adolescent sexual behavior. International Journal of
the Addictions, 27, 129–46.
US Department of Health and Human Services. (2001).
Youth Violence: A report of the Surgeon General.
Retrieved September 18, 2009, from http://www.sur-
Voisin, D. R. (2002). Family ecology and HIV sexual risk
behaviors among African American and Puerto Rican
adolescent males. American Journal of Orthopsychiatry,
Wechsler, H., Dowdall, G. W., Maenner, G., Gledhill-
Hoyt, J., & Lee, H. (1998). Changes in binge drinking
and related problems among American college
students between 1993 and 1997. Results of the
Harvard School of Public Health College Alcohol
Study. Journal of American College Health, 47, 57–68.
Whitfield, G., & Williams, C. (2003). The evidence base
for cognitive-behavioural therapy in depression:
Delivery in busy clinical settings. Advances in
Psychiatric Treatment, 9, 21–30.
MST for HIV Transmission Risk Behaviors