Patient and staff perspectives on the use of a computer counseling tool for HIV and sexually transmitted infection risk reduction

Membrane computing simulation of sexually transmitted bacterial infections in hotspots of individuals with various risk behaviors

The epidemiology of sexually transmitted infections (STIs) is complex due to the coexistence of various pathogens, the variety of transmission modes derived from sexual orientations and behaviors at different ages and genders, and sexual contact hotspots resulting in network transmission. There is also a growing proportion of recreational drug users engaged in high-risk sexual activities, as well as pharmacological self-protection routines fostering non-condom practices. The frequency of asymptomatic patients makes it difficult to develop a comprehensive approach to STI epidemiology. Modeling approaches are required to deal with such complexity. Membrane computing is a natural computing methodology for the virtual reproduction of epidemics under the influence of deterministic and stochastic events with an unprecedented level of granularity. The application of the LOIMOS program to STI epidemiology illustrates the possibility of using it to shape appropriate interventions. Under the conditions of our basic landscape, including sexual hotspots of individuals with various risk behaviors, an increase in condom use reduces STIs in a larger proportion of heterosexuals than in same-gender sexual contacts and is much more efficient for reducing Neisseria gonorrhoeae than Chlamydia and lymphogranuloma venereum infections. Amelioration from diagnostic STI screening could be instrumental in reducing N. gonorrhoeae infections, particularly in men having sex with men (MSM), and Chlamydia trachomatis infections in the heterosexual population; however, screening was less effective in decreasing lymphogranuloma venereum infections in MSM. The influence of STI epidemiology of sexual contacts between different age groups (<35 and ≥35 years) and in bisexual populations was also submitted for simulation.IMPORTANCEThe epidemiology of sexually transmitted infections (STIs) is complex and significantly influences sexual and reproductive health worldwide. Gender, age, sexual orientation, sexual behavior (including recreational drug use and physical and pharmacological protection practices), the structure of sexual contact networks, and the limited application or efficiency of diagnostic screening procedures create variable landscapes in different countries. Modeling techniques are required to deal with such complexity. We propose the use of a simulation technology based on membrane computing, mimicking in silico STI epidemics under various local conditions with an unprecedented level of detail. This approach allows us to evaluate the relative weight of the various epidemic drivers in various populations at risk and the possible outcomes of interventions in particular epidemiological landscapes.

Patient Attitudes on Collection of Sexual Orientation and Gender Identity Data in a Women's Health Clinic with an Embedded Transgender Medicine Program

Purpose: We examined patient attitudes about the collection of sexual orientation and gender identity (SOGI) data in a mixed sample of sexual and gender minority (SGM) and cisgender heterosexual people. Methods: SOGI questions and an evaluation questionnaire were administered to a convenience sample of patients presenting at an academic women's health clinic with an embedded transgender medicine program. Clinic census is ∼10,000 patients, which includes some 1000 cisgender males and 800 transgender patients. Bivariate and multivariate analyses were performed. Our methods expand on prior study in this area through implementing an analysis which divides the sample into three groups; cisgender heterosexual, cisgender sexual minority, and transgender respondents, and includes an intersectional approach to the analysis by income and age range, race/ethnicity, and presence of a non-English language spoken at home. Results: Some 231 respondents participated out of 291 approached, including 149 cisgender heterosexual respondents, 26 cisgender sexual minority respondents, and 56 transgender people of any sexuality. Scores were high regarding ease and accuracy of the SOGI questionnaire, and willingness to answer SOGI questions. Among those identifying as cisgender/heterosexual, non-White respondents had an odds ratio of 5.48 of being offended by sexual behavior questions compared with White respondents. Respondents overwhelmingly preferred to complete questionnaires through confidential electronic or pen-and-paper means. Conclusion: Patients were overwhelmingly willing to complete SOGI data questionnaires in a clinic setting, and preferred to do so using confidential means rather than by live interview by staff or providers.

Association between requests for supportive care assistance and patients' characteristics, prior to treatment in a comprehensive cancer center

Purpose

Patients with cancer experience a wide array of distress symptoms (emotional, practical, physical, and functional), which often hinders their quality of life and survival. Unfortunately, only a small proportion of these patients request assistance for these problems. This study explored the relationship between requests for supportive care assistance and distress of patients newly diagnosed with cancer.

Methods

This study was conducted at city of hope, an NCI‐designated comprehensive cancer center, and included 2658 patients treated between 2009 and 2017. Patients were asked to complete a 30‐item biopsychosocial problem‐related distress survey via SupportScreen^®, prior to any treatment. Correlations between requests for assistance and distress domains were evaluated. Primary types of requests were examined for all patients, and general linear modeling was used to determine the significant predictors of requests for assistance. p‐values <0.05 were considered significant.

Results

Strong correlations were observed between distress subscales and requests for assistance (r ranging from 0.67 to 0.69). The primary types of requests varied by domain: items such as feeling anxious or fearful, finances, and sleep ranked first within the emotional, practical, and physical‐functional domains respectively (∼20% requests for each item). Verbal assistance was generally preferred to the written form of assistance, with the exception of a few items, including finances. Overall, household income of <$100,000 and completing the survey in Spanish were significant predictors of requests for assistance. Regarding the practical and physical‐functional domains, having an advanced stage of disease was significantly related to an increase in demands for assistance. Being older was associated to a decrease in requests for assistance vis‐à‐vis both the emotional and physical functional subscales.

Conclusion

We demonstrated that distress levels were strongly correlated with requests for assistance. Patients' clinical and demographic characteristics such as age, household income, disease stage and survey language were associated with inquiries for psychosocial support, highlighting the importance of targeting interventions towards those most likely to need them, to better aim patients' needs. Therefore, tailoring supportive care assistance to patients' characteristics could help boost the frequency of requests, reduce distress burden, and improve health outcomes.

Technology-Based Interventions to Increase Point-of-Care HIV Testing and Linkage to Care Among Youth in the US: A Systematic Review

HIV testing rates remain low among youth ages 13-24 in the US, with only 55% of HIV-positive youth aware of their serostatus. We conducted a systematic review to assess the utility of technology-based interventions to increase point-of-care youth HIV testing and linkage to care. We searched PubMed, Embase, CINAHL, and Cochrane CENTRAL for randomized controlled trials of technology-based interventions aimed at increasing point-of-care youth HIV testing, published between 2008 and 2020. All identified citations were independently screened for inclusion by two authors, and the Cochrane Risk of Bias Tool for Randomized Controlled Trials was used to assess the quality of included studies. Three studies met all inclusion criteria. Two interventions were effective in increasing HIV testing, while one was effective at linkage to care. Technology-based interventions have the potential to increase youth HIV testing in clinical settings and facilitate linkage to care, possibly reducing undiagnosed HIV among adolescents and emerging adults.

Emotional problem-related distress screening and its prevalence by cancer type: Assessment by patients' characteristics and level of assistance requested

OBJECTIVE

Emotional problem-related distress is a common issue faced by patients with cancer. However, patients suffering with this emotional burden do not typically seek assistance. This study sought to determine the prevalence of emotional problem-related distress by cancer type, and identify factors correlated with the level of assistance requested.

METHODS

Using the SupportScreen®, patients were screened for emotional problem-related distress at their first or second visit to an NCI designated Comprehensive Cancer Center. General Linear Model was used to test the association between emotional problem-related distress and type of cancer, and the relationship between level of assistance requested and patients' characteristics.

RESULTS

A total of 2,421 patients were included in this analysis. Patients were mostly female (62%), diagnosed with breast (24%), gynecological (16%) or gastrointestinal (15%) cancers. Highest levels of emotional problem-related distress were reported by patients diagnosed with lung, gynecological, breast and gastrointestinal cancers. Level of assistance requested were significantly associated with problem-related distress scores (p < 0.001), which were higher among patients with lower household incomes (p < 0.001) and Spanish as primary language (p = 0.001).

CONCLUSION

Our study found an association between Level of assistance requested and emotional problem-related distress, which were heightened by lower income and Spanish-speaking. Intervention strategies should be considered to increase access to psychosocial support services.

Toward a human-centered use of technology: a stakeholder analysis of harm reduction and CBO staff

Background

Technology can enable syringe service programs (SSPs) and other community-based organizations (CBOs) operating under a harm reduction framework to work with an increased number of clients and can also enable organizations to offer services more effectively (e.g., offering HIV testing in ways participants may be more likely to accept). In the current time of COVID-19 social distancing, technology can also help organizations more safely provide services to people with compromised immune systems and to clients who might otherwise not be reached. However, technology projects implemented in harm reduction settings are frequently conceptualized and developed by researchers or technology specialists rather than by SSP staff or clients.

Methods

To more effectively meet the needs of SSPs and other CBOs across the USA, our team conducted qualitative interviews with 16 individuals who have extensive backgrounds working in the field of harm reduction. Interviews were digitally recorded and professionally transcribed, and the transcripts were checked for accuracy by the interviewers. The resulting transcripts were coded and analyzed to determine emerging themes.

Results

Interviewees mentioned the ability of technology to deliver consistent quality messaging to multiple clients at the same time and the potential to customize or tailor technology-based messaging to specific client populations as positive benefits. Clear barriers to technology use also emerged, in particular regarding privacy, data security, and the need to maintain client trust when discussing sensitive issues (e.g., illicit drug use).

Conclusions

Technology offers the potential to deliver consistently high-quality health communication and maintain contact with clients who may have no other access to care. If designed and managed effectively, technology can also address issues related to providing services during times when physical contact is limited due to COVID-19 social distancing measures.

Brief Motivational Interviewing Delivered by Clinician or Computer to Reduce Sexual Risk Behaviors in Adolescents: Acceptability Study

BACKGROUND

Clinicians are expected to screen their adolescent patients for an increasing number of health behaviors and intervene when they uncover risky behaviors, yet, the clinic time allotted to screen, intervene, and provide resources is insufficient. Brief motivational interviewing (MI) offers succinct behavior change counseling; however, for implementation, clinicians need training, skill, and time. Computerized screening and counseling adjuvants may help clinicians increase their scope of behavioral screening, especially with sensitive topics such as sexual health, and provide risk-reduction interventions without consuming provider time during visits.

OBJECTIVE

The objectives of this study were to (1) understand the extent to which health care providers use brief MI for sexual health discussions with adolescent patients and (2) assess the acceptability of incorporating a brief MI-based intervention to reduce sexual risk behaviors into their clinical practice delivered by either themselves or a computer.

METHODS

At a national medical conference, surveys were administered to clinicians who provide sexual health care to adolescents. They were asked about their current use of MI for sexual risk behavior discussions and their willingness to implement computerized sexual health screening and computerized sexual risk behavior interventions into their clinical practice.

RESULTS

The large majority (87.6%, 170/194) of clinicians already used MI with their patients with less than half (72/148, 48.6%) reporting they had been formally trained in MI. Despite all (195/195, 100.0%) clinicians feeling very or completely comfortable discussing sexual risk behaviors with their patients, the large majority (160/195, 82.1%) reported it would be useful, very useful, or extremely useful for a computerized program to do it all: screen their patients, generate risk profiles, and provide the risk-reduction counseling rather than doing it themselves.

CONCLUSIONS

In this study, most clinicians used some form of brief MI or client-centered counseling when discussing sexual risk behaviors with adolescents and are very comfortable doing so. However, the large majority would prefer to implement computerized sexual health screening, risk assessment, and sexual risk behavior interventions into their clinical care of adolescents.

Tablet-based disclosure counselling for HIV-infected children, adolescents, and their caregivers: a pilot study

BACKGROUND

Overwhelmed, under-trained medical staff working in resource-limited settings need efficient resources for HIV disclosure counselling. The objective of this study was to describe providers' experiences using tablet computers for disclosure-related counselling with HIV-infected children and their caregivers in western Kenya, with additional perspectives from adolescents.

METHODS

A qualitative study design was implemented at three HIV clinics in western Kenya (Bumala, Busia and Port Victoria) within the Academic Model Providing Access to Healthcare (AMPATH) partnership. Twenty-one healthcare providers involved with paediatric disclosure were recruited and enrolled in the study. Initial interviews focused on understanding current disclosure practices and barriers. Tablets containing disclosure-related resources were distributed. Resources included short narrative videos created in this context to highlight issues relevant to child HIV disclosure.

RESULTS

Providers reported tablets improved disclosure, child participation, and medication adherence. All reported that reviewing materials increased their knowledge and comfort with disclosure. The most frequently used materials were the narrative videos and an animated video explaining the importance of medication adherence. Time was a major barrier for using the tablet. Clinician self-education persisted at one-year follow-up. Adolescents expressed enjoyment from viewing the tablet resources and had a better understanding of the importance of medication adherence.

CONCLUSIONS

Tablet computers containing resources for disclosure are an acceptable and potentially effective resource to help providers support families with disclosure. Further work is needed to train the clinical providers in using the resources in a developmentally appropriate manner, and to develop new resources on adolescent-specific and HIV-related topics.

Food Insecurity, Weight Status, and Perceived Nutritional and Exercise Barriers in an Urban Youth Population

Food insecurity and overweight/obesity coexist among youth; however, evidence for their association has been mixed. Our objectives were to assess the association between (1) level of food security and weight classification and (2) food insecurity and perceived nutritional and exercise barriers in an urban youth population. Patients aged 15 to 25 years completed a US Department of Agriculture Food Security Survey. Chi-square, Kruskal-Wallis tests, and logistic regression models controlling for age and gender assessed the association between food security level, weight classification, and perceived barriers. Among 376 patients, 122 (32%) were food insecure and 221 (59%) were overweight/obese. There were no significant associations between food security level and weight classification. In adjusted analyses, participants with very low food insecurity reported significantly greater odds of 3 nutritional barriers compared to participants with high food security. Food-insecure youth were more likely to report nutritional barriers, which may lead to overweight/obesity over time.

A Randomized-Controlled Trial of Computer-based Prevention Counseling for HIV-Positive Persons (HPTN 065)

OBJECTIVE

Decreasing the risk of HIV transmission from HIV-positive individuals is an important public health priority. We evaluated the effectiveness of a computer-based sexual risk reduction counseling intervention (CARE+) among HIV-positive persons enrolled in care.

METHODS

HIV-positive eligible participants (N=1075) were enrolled from 11 care sites in the Bronx, NY and Washington, DC and randomized 1:1 to either a tablet-based self-administered CARE+ intervention or standard of care (SOC). The primary outcome was the proportion of participants reporting any unprotected vaginal/anal sex at last sex, among all partners, HIV-negative or HIV-unknown-status partners and for primary and non-primary partners.

RESULTS

At baseline, 7% of participants in both arms reported unprotected sex with an HIV-negative or HIV-unknown-status partner, while 13% in the CARE+ arm and 17% in the SOC arm reported unprotected sex with any partner. Most participants (88%) were on antiretroviral therapy (ART) at baseline. There was no significant difference in changes over time in unprotected vaginal/anal sex between the CARE+ and SOC arms for any partners (p=0.67) or either HIV-negative or HIV-unknown-status partners (p=0.40). At the Month 12 visit, most participants (85%) either strongly agreed or agreed that computer counseling would be a good addition to in-person counseling by a provider.

CONCLUSION

The CARE+ intervention was not effective at reducing sexual risk behaviors among HIV-positive patients in care, most of whom were on ART. Further research may be warranted around the utility of computer-based counseling for HIV prevention.

Differing Experiences with Pre-Exposure Prophylaxis in Boston Among Lesbian, Gay, Bisexual, and Transgender Specialists and Generalists in Primary Care: Implications for Scale-Up

The Centers for Disease Control and Prevention estimates that one in four sexually active men who have sex with men (MSM) could decrease their HIV risk by using HIV pre-exposure prophylaxis (PrEP). Because many MSM access healthcare from primary care providers (PCPs), these clinicians could play an important role in providing access to PrEP. Semistructured qualitative interviews were conducted with 31 PCPs in Boston, MA, to explore how they approach decisions about prescribing PrEP to MSM and their experiences with PrEP provision. Purposive sampling included 12 PCPs from an urban community health center specializing in the care of lesbian, gay, bisexual, and transgender persons ("LGBT specialists") and 19 PCPs from a general academic medical center ("generalists"). Analyses utilized an inductive approach to identify emergent themes. Both groups of PCPs approached prescribing decisions about PrEP as a process of informed decision-making with patients. Providers would defer to patients' preferences if they were unsure about the appropriateness of PrEP. LGBT specialists and generalists were at vastly different stages of adopting PrEP into practice. For LGBT specialists, PrEP was a disruptive innovation that rapidly became normative in practice. Generalists had limited experience with PrEP; however, they desired succinct decision-support tools to help them achieve proficiency, because they considered preventive medicine to be central to their professional role. As generalists vastly outnumber LGBT specialists in the United States, interventions to support PrEP provision by generalists could accelerate the scale-up of PrEP for MSM nationally, which could in turn decrease HIV incidence for this priority population.

Comparing self- and provider-collected swabbing for HPV DNA testing in female-to-male transgender adult patients: a mixed-methods biobehavioral study protocol

Background

Cervical cancer, nearly all cases of which are caused by one of several high-risk strains of the human papillomavirus (hr-HPV), leads to significant morbidity and mortality in individuals with a cervix. Trans masculine (TM) individuals were born with female reproductive organs and identify as male, man, transgender man, or another diverse gender identity different from their female assigned sex at birth. Routine preventive sexual health screening of TM patients is recommended, including screening for cervical cancer and other sexually transmitted infections (STIs); however, as many as one in three TM patients are not up-to-date per recommended U.S. guidelines. Among cisgender (non-transgender) women, self-swab hr.-HPV DNA testing as a primary cervical cancer screening method and self-swab specimen collection for other STIs have high levels of acceptability. No study has yet been conducted to compare the performance and acceptability of self- and provider-collected swabs for hr.-HPV DNA testing and other STIs in TM patients.

Methods

This article describes the study protocol for a mixed-methods biobehavioral investigation enrolling 150 sexually active TM to (1) assess the clinical performance and acceptability of a vaginal self-swab for hr.-HPV DNA testing compared to provider cervical swab and cervical cytology, and (2) gather acceptability data on self-collected specimens for other STIs. Study participation entails a one-time clinical visit at Fenway Health in Boston, MA comprised of informed consent, quantitative assessment, venipuncture for syphilis testing and HIV (Rapid OraQuick) testing, randomization, collection of biological specimens/biomarkers, participant and provider satisfaction survey, and qualitative exit interview. Participants are compensated $100. The primary study outcomes are concordance (kappa statistic) and performance (sensitivity and specificity) of self-collected vaginal HPV DNA specimens vs provider-collected cervical HPV swabs as a gold standard.

Discussion

This study addresses critical gaps in current clinical knowledge of sexual health in TM patients, including comparing alternative strategies for screening and diagnosis of cervical cancer, hr.-HPV, and other STIs. Findings have implications for improving the delivery of sexual health screening to this often overlooked and underserved patient population. Less-invasive patient-centered strategies may also generalize to other at-risk cisgender female populations that face barriers to timely and needed STI and cervical cancer screening.

Trial registration

ClinicalTrials.gov ID: NCT02401867

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2539-x) contains supplementary material, which is available to authorized users.

Design of the HPTN 065 (TLC-Plus) study: A study to evaluate the feasibility of an enhanced test, link-to-care, plus treat approach for HIV prevention in the United States

Background/Aims

HIV continues to be a major public health threat in the United States, and mathematical modeling has demonstrated that the universal effective use of antiretroviral therapy among all HIV-positive individuals (i.e. the “test and treat” approach) has the potential to control HIV. However, to accomplish this, all the steps that define the HIV care continuum must be achieved at high levels, including HIV testing and diagnosis, linkage to and retention in clinical care, antiretroviral medication initiation, and adherence to achieve and maintain viral suppression. The HPTN 065 (Test, Link-to-Care Plus Treat [TLC-Plus]) study was designed to determine the feasibility of the “test and treat” approach in the United States.

Methods

HPTN 065 was conducted in two intervention communities, Bronx, NY, and Washington, DC, along with four non-intervention communities, Chicago, IL; Houston, TX; Miami, FL; and Philadelphia, PA. The study consisted of five components: (1) exploring the feasibility of expanded HIV testing via social mobilization and the universal offer of testing in hospital settings, (2) evaluating the effectiveness of financial incentives to increase linkage to care, (3) evaluating the effectiveness of financial incentives to increase viral suppression, (4) evaluating the effectiveness of a computer-delivered intervention to decrease risk behavior in HIV-positive patients in healthcare settings, and (5) administering provider and patient surveys to assess knowledge and attitudes regarding the use of antiretroviral therapy for prevention and the use of financial incentives to improve health outcomes. The study used observational cohorts, cluster and individual randomization, and made novel use of the existing national HIV surveillance data infrastructure. All components were developed with input from a community advisory board, and pragmatic methods were used to implement and assess the outcomes for each study component.

Results

A total of 76 sites in Washington, DC, and the Bronx, NY, participated in the study: 37 HIV test sites, including 16 hospitals, and 39 HIV care sites. Between September 2010 and December 2014, all study components were successfully implemented at these sites and resulted in valid outcomes. Our pragmatic approach to the study design, implementation, and the assessment of study outcomes allowed the study to be conducted within established programmatic structures and processes. In addition, it was successfully layered on the ongoing standard of care and existing data infrastructure without disrupting health services.

Conclusion

The HPTN 065 study demonstrated the feasibility of implementing and evaluating a multi-component “test and treat” trial that included a large number of community sites and involved pragmatic approaches to study implementation and evaluation.

MOBILE SCREENING TO IDENTIFY AND FOLLOW-UP WITH HIGH RISK, HIV NEGATIVE YOUTH

BACKGROUND

HIV prevalence remains disproportionately high among youth, especially among young men who have sex with men, young people with substance use disorders, and recently incarcerated youth. However, youth may not report behavioral risks because they fear stigma or legal consequences. While routine HIV screening programs have increased testing, current programs are not designed to identify, or provide prevention services to, high-risk patients who test HIV negative.

AIMS

To examine the feasibility and preliminary efficacy of: a tablet-based screening designed to facilitate HIV risk reporting and testing among a sample of young urban emergency department (ED) patients; and a text message-based follow up protocol for patients who test HIV-negative and report increased behavioral risk.

METHODS

100 ED patients aged 18 - 24, who declined HIV tests offered at triage, completed a tablet-based intervention that included a risk screening, an educational video, and offered participants HIV tests. If patients accepted testing and reported increased risk, the tablets offered follow-up text messages.

RESULTS

30 participants accepted HIV tests following the intervention and 21 participants, identified by custom software as high-risk, agreed to receive text messages. Two thirds (66.7%) of text recipients responded to questions at week 6, more than half (57.1%) responded at week 8, one (4.76%) re-tested after week 12.

CONCLUSION

Results indicate our intervention provides a feasible way to facilitate risk reporting, increase HIV testing, and maintain ongoing contact with hard-to-reach youth via tablet computers and text messages.

Food Insecurity and the Burden of Health-Related Social Problems in an Urban Youth Population

PURPOSE

Our study objectives were to (1) determine the prevalence of food insecurity; (2) examine the association between presence and level of food insecurity with other health-related social problems; and (3) assess the predictive values of a two-item food insecurity screen in an urban youth population.

METHODS

Patients aged 15-25 years completed a Web-based screening tool. Validated questions were used to identify problems in seven health-related social domains (food insecurity, health care access, education, housing, income insecurity, substance use, and intimate partner violence). Chi-square and Kruskal-Wallis tests and logistic regression models controlled for age, sex, and race/ethnicity, assessed the association between food insecurity and health-related social problems. Predictive values of a two-item food insecurity screen compared with the United States Department of Agriculture Food Security Survey were calculated.

RESULTS

Among 400 patients (mean age 18 years; 69.2% female; 54.6% black; 58.9% public insurance), 32.5% screened positive for food insecurity. Increasing food insecurity level was significantly associated with cumulative burden of social problems (p < .001). In adjusted analyses, food insecurity was associated with problems with health care access (aOR = 2.6, 95% confidence interval [CI] 1.7-4.1), education (aOR = 2.8, 95% CI 1.6-5.1), housing (aOR = 2.8, 95% CI 1.8-4.4), income insecurity (aOR = 2.3, 95% CI 1.2-4.5), and substance use (aOR = 2.5, 95% CI 1.5-4.3). The two-item screen demonstrated sensitivity of 88.5% and specificity of 84.1%.

CONCLUSIONS

One-third of youth in sample experienced food insecurity, which was strongly associated with presence of other health-related social problems. The two-item screen effectively detected food insecurity. Food insecurity screening may lead to identification of other health-related social problems that when addressed early may improve adolescent health.

Improving Social Determinants of Health: Effectiveness of a Web-Based Intervention

INTRODUCTION

Although patients who experience health-related social problems such as food insecurity are at increased risk for negative health outcomes, there are few systems for screening and intervention. The study aimed to determine whether a web-based intervention can (1) connect youth to services to address these problems and (2) increase their resolution.

DESIGN

Prospective intervention study.

SETTING/PARTICIPANTS

A total of 401 youth, aged 15-25 years, from an urban adolescent/young adult clinic were recruited.

INTERVENTION

A self-administered, web-based tool was developed to screen participants for problems in nine health-related social domains, identify and provide feedback about potential problems, and facilitate a patient-centered selection process of recommended local health and human service agencies to assist in addressing selected problems (conducted in 2008-2010). Follow-up phone calls 1-2 months later determined if patients had contacted recommended agencies and resolved their top-priority problem.

MAIN OUTCOME MEASURES

Outcome measures included prevalence of identified problems, selected problems, and priority problem selected by domain. We also examined frequencies of referral agencies contacted and resolution of priority problem at time of follow-up analysis conducted in 2011-2013.

RESULTS

Seventy-eight percent (313/401) of youth selected at least one problem to address. The most frequent domains selected as priority were income security (21%); nutrition/fitness (15%); and healthcare access (15%). Eighty-three percent (259/313) were reached at follow-up; overall, 40% contacted a selected agency and 47% reported "completely" or "mostly" resolving their priority problem.

CONCLUSIONS

When provided with services to address health-related social problems, the majority of youth choose to receive help, with nearly half successfully addressing their priority concern. Further research to understand the barriers to contacting and utilizing services is needed. A technology-based patient-centered feedback and referral system for social determinants of health can facilitate screening and connect patients with resources to address these problems.

A Randomized Trial to Evaluate the Efficacy of a Web-Based HIV Behavioral Intervention for High-Risk African American Women

The aim of this study was to develop and test a cost-effective, scalable HIV behavioral intervention for African American women. Eighty-three African American women were recruited from a community health center and randomly assigned to either the web-based Safe Sistah program or to a delayed HIV education control condition. The primary outcome was self-reported condom use. Secondary measures assessed other aspects of the gender-focused training included in Safe Sistah. Participants completed self-report assessments prior to randomization, 1- and 4-months after their program experience. Across the entire study period, women in the experimental condition significantly increased their condom use relative to controls (F = 5.126, p = 0.027). Significant effects were also found for sexual communication, sex refusal, condom use after alcohol consumption, and HIV prevention knowledge. These findings indicate that this web-based program could be an important component in reducing the HIV disparities among African American women.

Electronic health records and transgender patients--practical recommendations for the collection of gender identity data

Transgender (Trans, Trans*) persons may have a gender identity and a preferred name that differ from those assigned at birth, and/or those listed on their current legal identification (Gender ID, Birth-assigned Sex, Legal Sex). Transgender people who are referred to in a clinical setting using the wrong pronoun or name may suffer distress, ridicule or even assault by others in the waiting area, and may not return for further care. Furthermore, failure to accurately document (and therefore count) transgender identities has negative implications on quality improvement and research efforts, funding priorities and policy activities. The recent announcement that gender identity data may be included in Meaningful Use Stage 3 has accelerated the need for guidance for both vendors and local implementation teams on how to best record and store these data. A recent study demonstrated wide variation in current practices. This manuscript provides a description of identifiers associated with gender identity, and makes practical and evidence based recommendations for implementation and front-end functionality.

Teens, technology, and health care

Teens are avid users of new technologies and social media. Nearly 95% of US adolescents are online at least occasionally. Health care professionals and organizations that work with teens should identify online health information that is both accurate and teen friendly. Early studies indicate that some of the new health technology tools are acceptable to teens, particularly texting, computer-based psychosocial screening, and online interventions. Technology is being used to provide sexual health education, medication reminders for contraception, and information on locally available health care services. This article reviews early and emerging studies of technology use to promote teen health.

Randomized trial of a novel game-based appointment system for a university hospital venereology unit: study protocol

Background

Chlamydia is the most common reportable sexually transmitted disease (STD) in Norway, and its incidence in the two northernmost counties has been disclosed to be nearly the double of the Norwegian average. The latest publicly available rates showed that 85.6% of the new cases were diagnosed in people under 29 years old.

The information and communication technologies are among the most powerful influences in the lives of young people. The Internet can potentially represent a way to educate on sexual health and encourage young people, and especially youth, to be tested for STDs. If hospital websites include an easy and anonymous system for scheduling appointments with the clinic, it is possible that this could lead to an increase in the number of people tested for STDs.

Methods

The purpose of the study is to assess the impact of a game-based appointment system on the frequency of consultations at a venereology unit and on the use of an educational web app. An A/B testing methodology is used. Users from the city of Tromsø, in North Norway, will be randomized to one of the two versions of the game-style web app on sexual health at www.sjekkdeg.no. Group A will have access to educational content only, while group B will have, in addition, access to a game-based appointment system with automatic prioritization. After one year of the trial, it will be analyzed if the game-based appointment system increases the number of consultations at the venereology unit and if health professionals deem the system useful.

Discussion

This study will explore if facilitating the access to health services for youth through the use of a game-based appointment system integrated in a game-style web app on sexual health education can have an impact on appointment rates.

Trial registration

The trial is registered at clinicaltrials.org under the identifier ClinicalTrials.gov NCT:02128620

Social disparities among youth and the impact on their health

PURPOSE

Social disparities among youth have been recognized as an important influence on disease risk later in the life cycle. Despite this, social problems are seldom assessed in a clinical setting. The primary objective of our study was to evaluate the impact of social disparities on the health of youth.

METHODS

A self-directed, web-based screening system was used to identify social disparities along seven social domains. Participants included youth, aged 15-24 years, recruited from an urban hospital clinic. The main outcome variable, self-rated health, was captured on a 5-point Likert scale. Univariable and multivariable regression models adjusted for sex, age, and race/ethnicity were implemented to assess the association between social problems and self-rated health. Correlation between social disparity problems was estimated using phi coefficient.

RESULTS

Among 383 participants, 297 (78%) reported at least one social problem. The correlation among social disparity problems was low. Social disparities had an independent effect on self-rated health, and, in a fully adjusted model, disparities in health care access and food insecurity remained significant. The presence of even one social problem was associated with a decrease in overall health (β=0.68, P<0.01).

CONCLUSION

There is a high burden of social disparities among our youth urban hospital population. The presence of even one social problem increases the risk of worsening self-rated health. Evaluating the social disparities among youth in the medical setting can help elucidate factors that negatively affect patients' health.

Fully integrated e-services for prevention, diagnosis, and treatment of sexually transmitted infections: results of a 4-county study in California

OBJECTIVES

We examined the acceptability, feasibility, and cost of a fully integrated online system (eSTI) for sexually transmitted infection (STI) testing, treatment, and linkage to care with 4 Northern California health departments.

METHODS

In April 2012, we implemented the eSTI system, which provided education; testing of self-collected vaginal swabs for chlamydia, gonorrhea, and trichomoniasis; e-prescriptions; e-partner notification; and data integration with clinic electronic health records. We analyzed feasibility, acceptability, and cost measures.

RESULTS

During a 3-month period, 217 women aged 18 to 30 years enrolled; 67% returned the kit. Of these, 92% viewed their results online. STI prevalence was 5.6% (chlamydia and trichomoniasis). All participants with STIs received treatment either the same day at a pharmacy (62%) or within 7 days at a clinic (38%). Among participants completing follow-up surveys, 99% would recommend the online eSTI system to a friend, and 95% preferred it over clinic-based testing within a study.

CONCLUSIONS

The fully integrated eSTI system has the potential to increase diagnosis and treatment of STIs with higher patient satisfaction at a potentially lower cost.

Home testing past, present and future: lessons learned and implications for HIV home tests

The recent approval in the United States of the first rapid home test to diagnose HIV raises questions about its potential use and impact. We reviewed the existing literature on the unassisted use of home tests involving self-collection and testing of biological samples by untrained users-including existing HIV self-testing studies-to shed some light on what can be expected from the availability of the HIV home test. The studies reviewed showed that most participants could properly perform home tests, obtain accurate results, and interpret them-yielding high correlations with laboratory and health-professional performed tests. Users often had trouble performing blood-based tests. Participants generally understood the need to confirm positive test results. Materials accompanying HIV home tests should emphasize symptoms of acute infection and the need for additional testing when recent infection is suspected. Different home-test-based screening modalities, personalized HIV-counseling resources and HIV home test impact evaluation methods should be studied.

Computerized counseling reduces HIV-1 viral load and sexual transmission risk: findings from a randomized controlled trial

OBJECTIVE

Evaluate a computerized intervention supporting antiretroviral therapy (ART) adherence and HIV transmission prevention.

DESIGN

Longitudinal randomized controlled trial.

SETTINGS

An academic HIV clinic and a community-based organization in Seattle.

SUBJECTS

In a total of 240 HIV-positive adults on ART, 209 completed 9-month follow-up (87% retention).

INTERVENTION

Randomization to computerized counseling or assessment only, 4 sessions over 9 months.

MAIN OUTCOME MEASURES

HIV-1 viral suppression, and self-reported ART adherence and transmission risks, compared using generalized estimating equations.

RESULTS

Overall, intervention participants had reduced viral load: mean 0.17 log10 decline, versus 0.13 increase in controls, P = 0.053, and significant difference in ART adherence baseline to 9 months (P = 0.046). Their sexual transmission risk behaviors decreased (odds ratio = 0.55, P = 0.020), a reduction not seen among controls (odds ratio = 1.1, P = 0.664), and a significant difference in change (P = 0.040). Intervention effect was driven by those most in need; among those with detectable virus at baseline (>30 copies/mL, n = 89), intervention effect was mean 0.60 log10 viral load decline versus 0.15 increase in controls, P = 0.034. ART adherence at the final follow-up was 13 points higher among intervention participants versus controls, P = 0.038.

CONCLUSIONS

Computerized counseling is promising for integrated ART adherence and safer sex, especially for individuals with problems in these areas. This is the first intervention to report improved ART adherence, viral suppression, and reduced secondary sexual transmission risk behavior.

Youths' health-related social problems: concerns often overlooked during the medical visit

OBJECTIVE

The objectives of this study were to (1) measure the prevalence of health-related social problems among adolescent and young adult primary care patients; (2) estimate previous screening and referral experiences; and (3) examine participant attitudes toward screening and referral.

METHODS

Data were collected as part of a cross-sectional study conducted in an urban young adult clinic. Patients aged 15 to 25 years completed a computerized questionnaire screening for health-related social problems in nine social domains. In addition, participants answered questions about their previous screening experiences, need for referrals, and their experience using the system.

RESULTS

Seventy-six percent (304/401) of youth screened positive for at least one major problem, including healthcare access (37%), housing (34%), and food security (29%). Forty-seven percent (190/401) experienced major problems in two or more social domains. The prevalence of screening in the past year for each domain averaged 26%; 3% were screened in all nine domains in the previous 12 months and 33% were not screened in any domain. Overall, 75% needed a referral within the previous year, and 42% identified at least one unmet referral need. The majority (84%) of participants reported that it was acceptable to screen for these problems.

CONCLUSION

Prevalence of health-related social problems among youth is high. The majority needed at least one referral for a social need in the previous year. Primary care physicians would benefit from improved systems for screening and referral of health-related social problems in order to create a comprehensive medical home for their patients.

Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group

Transgender patients have particular needs with respect to demographic information and health records; specifically, transgender patients may have a chosen name and gender identity that differs from their current legally designated name and sex. Additionally, sex-specific health information, for example, a man with a cervix or a woman with a prostate, requires special attention in electronic health record (EHR) systems. The World Professional Association for Transgender Health (WPATH) is an international multidisciplinary professional association that publishes recognized standards for the care of transgender and gender variant persons. In September 2011, the WPATH Executive Committee convened an Electronic Medical Records Working Group comprised of both expert clinicians and medical information technology specialists, to make recommendations for developers, vendors, and users of EHR systems with respect to transgender patients. These recommendations and supporting rationale are presented here.

Attitudes toward technology-based health information among adult emergency department patients with drug or alcohol misuse

Technology-based screening and interventions are emerging solutions to the challenge of addressing substance use in the emergency department (ED). A standardized questionnaire of adult patients at a large-volume, urban, academic ED assessed interest in, and potential barriers to, technology-based substance use information. Questionnaire topics included substance use, access to technology, preferences for health information, and perceived barriers to technology interventions. Among the 430 participants, mean age was 39 years and 55% were female; 37% reported alcohol misuse and 52% drug misuse. Access to technology was high. Technology was preferred by 46% of alcohol misusers (vs. 43% non-misusers, p=0.65) but only 41.9% of drug misusers (vs. 56% non-drug misusers, p=0.005). In multivariate analyses, drug misuse was associated with decreased interest in receiving technology-based information. Cited barriers included confidentiality, complexity, and time. Our findings suggest that drug misusers in particular may wish to have reassurances about the confidentiality of technology-based interactions.

Assessing and referring adolescents' health-related social problems: qualitative evaluation of a novel web-based approach

We conducted a qualitative study to examine users' perceptions of a web-based screening and referral system for young adults with health-related social problems. The first 50 patients who used the system also took part in semi-structured interviews. There were 20 patients aged 15–17 years and 30 aged 18–25 years. Completing the web-based screening process took an average of 25 min. Ninety percent of participants reported at least one major health-related social problem and a total of 134 referrals were selected for further assistance. Ninety-six percent of participants said they would recommend the system to a friend or peer, and 80% supported its use for annual screening. Perceived strengths of the system were novelty, privacy, ease of use, relevance, motivation, variety and proximity of referrals, and clinic staff support. Perceived shortcomings were length, sensitivity, navigation challenges and agency availability. The system complemented provider visits and preserved privacy while improving attention to patient needs. Computerized screening and referral tools have potential to improve the quality of care in vulnerable young adults.

Emergency department patients' preferences for technology-based behavioral interventions

STUDY OBJECTIVE

To assess emergency department (ED) patients' preferences for technology-based behavioral interventions, and the demographic factors associated with these preferences.

METHODS

A cross-sectional survey of a random sample of urban ED patients (≥13 years) from a representative sample of shifts, with oversampling of adolescents/young adults (aged 13 to 24 years). Participants self-administered the survey about baseline technology use, concerns about technology-based interventions, and preferred intervention format for 7 behavioral health topics. We performed descriptive statistics and multivariate logistic regression (controlling for demographics and then additionally for baseline technology use) to identify factors differentially associated with technology preference for each behavioral topic.

RESULTS

Of patients presenting during research assistant shifts, 1,429 (≈59%) were screened and 664 (68.2% of eligible) consented to participate. Mean age was 31 years (SD 0.69); 54.5% were female, 64.1% were white, 23.2% were Hispanic, and 46.6% reported low income. Baseline use of computers (91.2%), Internet (70.7%), social networking (66.9%), mobile phones (95.0%), and text messaging (73.8%) was high. Participants reported interest in receiving interventions on each behavioral topic. Ninety percent preferred a technology-based intervention for at least 1 topic. Patients expressed greatest concerns about Internet (51.5%) and social networking (57.6%), particularly about confidentiality. Adjusting for sex, race, ethnicity, and income, younger age associated with preference for technology-based interventions for unintentional injuries (odds ratio 0.63 for technology preference if adult versus youth; 95% confidence interval 0.45 to 0.89) and peer violence (odds ratio 0.63 if adult; 95% confidence interval 0.43 to 0.92). Additionally adjusting for baseline technology usage, only baseline usage was associated with preference for technology-based interventions.

CONCLUSION

ED patients reported high baseline technology use, high interest in behavioral health interventions, and varying preferences for technology-based interventions. Future studies should address actual feasibility and acceptability of technology-based interventions in a more generalized population and ways to alleviate concerns about these interventions.

The influence of substance use, social sexual environment, psychosocial factors, and partner characteristics on high-risk sexual behavior among young Black and Latino men who have sex with men living with HIV: A qualitative study

Understanding the sexual risk behaviors of youths living with HIV/AIDS is critical to secondary prevention of HIV. As part of a larger qualitative study of youths living with HIV, in-depth interviews were conducted with 27 African American and Latino, HIV-infected young men who have sex with men, aged 16-24 years, living in New York City. The study explored the role of substance use, the social-sexual-environmental, and psychological contexts in which sexual risk behaviors occurred. Since learning of their HIV infection, the majority of participants had reduced their risky sexual behaviors; however, a subset (26%) of participants continued to have unprotected sex, in most cases with multiple partners. Substance use, the social environmental context of the sexual encounter, the psychological impact of HIV on sexual behavior, and partner characteristics were associated with high-risk sexual behaviors in this group. Among high-risk participants, factors associated with risky sexual behaviors clustered, with 57% reporting two or more factors. More intensive interventions are needed for this subset of youths living with HIV, including assessment and treatment for substance use and mental health issues, strategies for stress reduction, and partner interventions.

Test-retest reliability in a computer-based medical history

The authors developed a computer-based medical history for patients to take in their homes via the internet. The history consists of 232 'primary' questions asked of all patients, together with more than 6000 questions, explanations, and suggestions that are available for presentation as determined by a patient's responses. The purpose of this research was to measure the test-retest reliability of the 215 primary questions that have preformatted, mutually exclusive responses of 'Yes,' 'No,' 'Uncertain (Don't know, Maybe),' 'Don't understand,' and 'I'd rather not answer.' From randomly selected patients of doctors affiliated with Beth Israel Deaconess Medical Center in Boston, 48 patients took the history twice with intervals between sessions ranging from 1 to 35 days (mean 7 days; median 5 days). High levels of test-retest reliability were found for most of the questions, but as a result of this study the authors revised five questions. They recommend that structured medical history questions that will be asked of many patients be measured for test-retest reliability before they are put into widespread clinical practice.

From questionnaire to conversation: a structural intervention to improve HIV test counseling

OBJECTIVE

We describe the effects of structural intervention to enhance the quality of HIV test counseling interaction with men who have sex with men (MSM) in San Francisco.

METHODS

Audio recordings of 28 rapid HIV test sessions by seven counselors were collected in two phases: before and after implementation of a waiting room intervention prior to the session. The sessions were analyzed using sequence maps to visualize and compare the sequence and distribution of four activities: counseling, information delivery, data collection, and sample collection.

RESULTS

Prior to the intervention, counselors and clients often oriented to data collection about the client's past risk as if it were a survey. In sessions recorded after the intervention, questions about past risk were dispersed throughout the session and embedded within an elaborated discussion of the client's particular life circumstances.

CONCLUSION

Direct observation with the aid of sequence maps illuminates the ways that counselors and clients collaboratively orient to various tasks.

PRACTICE IMPLICATIONS

We demonstrated the feasibility of a structural intervention that improved the quality of both counseling and the accuracy of client risk data without requiring additional session time or counselor training.

Using technology to improve adolescent healthcare

PURPOSE OF REVIEW

To provide an overview of current technologies available for use in a primary healthcare setting, common indications for their use, and their effects on clinical practice.

RECENT FINDINGS

Technologies such as the internet and cell phones are an integral part of the daily lives of most adolescents. Many young people are comfortable using technology as part of their healthcare visits, especially when addressing sensitive issues. Over the past 5 years, a significant body of research has emerged introducing a variety of technologic modalities that screen for health-risk behaviors, educate patients about chronic diseases, promote preventive efforts, and provide interventions in the adolescent population. Findings suggest that integrating technology with clinical practice can improve quality of patient care.

SUMMARY

Technology can be used as an effective medium for the delivery of health information and interventions in an efficient, organized, and effective manner. Sharing knowledge of innovative tools, systems and programs will help develop further interventions and strategies to ensure optimal healthcare in young people.

Effectiveness of increasing emergency department patients' self-perceived risk for being human immunodeficiency virus (HIV) infected through audio computer self-interview-based feedback about reported HIV risk behaviors

OBJECTIVES

Prior research has demonstrated that emergency department (ED) patient acceptance of human immunodeficiency virus (HIV) screening is partially dependent on patients' self-perceived risk of infection. The primary objective of this study was to determine the effectiveness of audio computer-assisted self-interview (ACASI)-based feedback. The intervention aimed to increase patient's self-perceived risk of being HIV infected by providing immediate feedback on their risk behaviors.

METHODS

This 1-year, randomized, controlled trial at a U.S. ED enrolled a random sample of 18- to 64-year-old subcritically ill or injured adult patients who were not known to be HIV infected. All participants completed an anonymous, ACASI-based questionnaire about their HIV risk behaviors related to injection drug use and sex, as well as their self-perceived risk for being HIV infected. Participants were randomly assigned to one of two study groups: an intervention group in which participants received immediate ACASI-based feedback in response to each of their reported risk behaviors or a no-intervention group without feedback. Participants were asked to indicate their level of HIV risk on a five-point scale before and after they answered the questions. Change in level of self-perceived HIV risk was calculated and compared by study group using Pearson's chi-square test. An HIV risk behavior score that summarized reported HIV risk behavior was devised. Because HIV risk behaviors differ by sex, scores were calculated separately for each sex. Linear regression models that adjusted for study group and same subject covariance were employed to determine if higher HIV risk behavior scores were associated with an increase in self-perceived HIV risk.

RESULTS

Of the 566 trial participants, the median age was 29 years (interquartile range [IQR] = 22-43 years), 62.2% were females, and 66.9% had been tested previously for HIV. After answering the reported HIV risk behavior questions, 12.6% of participants had an increase, 79.9% had no change, and 7.5% had a decrease in self-perceived HIV risk. Of the 46.6% of participants who initially indicated that they were not at risk for HIV, 11.4% had an increase in self-perceived HIV risk after answering the reported HIV risk behavior questions. Change in self-perceived HIV risk did not differ by study group (p = 0.77). There were no differences in reported HIV risk scores between the intervention and no-intervention groups for females (p = 0.78) or males (p = 0.86). In the linear regression models, a greater increase in self-perceived HIV risk was associated with higher reported HIV risk behavior scores for females (beta = 0.59, 95% confidence interval [CI] = 0.15, 1.04) but not for males (beta = 1.00, 95% CI = -0.13 to 2.14).

CONCLUSIONS

Some ED patients can be moved, although modestly, to recognize their risk for being HIV infected by asking about their HIV risk behaviors. However, ACASI-based feedback messages about HIV risk behaviors do not increase subjects' self-perceived HIV risk. Female ED patients appear to increase their self-perceived HIV risk more than males when queried about their HIV risk behaviors.

+CLICK: harnessing web-based training to reduce secondary transmission among HIV-positive youth

Adolescents and young adults account for over 10 million HIV infections worldwide. Prevention of secondary transmission is a major concern as many HIV-positive youth continue to engage in risky sexual behavior. This study pilot-tested " + CLICK", an innovative, web-based, sexual risk reduction intervention for HIV-positive youth as an adjunct to traditional clinic-based, self-management education. The theory-based application, developed for perinatally and behaviorally infected youth 13-24 years of age, provides tailored activities addressing attitudes, knowledge, skills, and self-efficacy related to sexual risk reduction. HIV-positive youth (N=32) pilot-tested " + CLICK" to assess usability (ease of use, credibility, understandability, acceptability, motivation) and short-term psychosocial outcomes (importance and self-efficacy related to abstinence and condom use) using a single group, pre-/post-test study design in a hospital-based pediatric clinic and community locations. A subsample of participants (n=20) assessed feasibility for clinic use. Participants were 62.5% female, 68.8% Black, and 28.1% Hispanic. Mean age was 17.8 years (SD = 2.55), 43.8% were infected behaviorally, 56.2% perinatally, and 68.8% were sexually experienced. Usability ratings were high: 84.4% rated the application very easy to use; 93.8% perceived content as trustworthy; 87.5% agreed most words were understandable; 87.5% would use the application again. Short-term psychosocial outcomes indicate a significant increase in condom use self-efficacy (p=0.008) and positive trends toward importance (p=0.067) and self-efficacy (p=0.071) for waiting before having sex. Regarding feasibility, participants accessed " + CLICK" during waiting periods (average time, 15 minutes) in their routine clinic visit. Clinic staff rated " + CLICK" highly in providing consistent, confidential, and motivational sexual health education without significant disruption to clinic flow. Results suggest that the application is a feasible tool for use in the clinic and has the potential to affect psychological antecedents to sexual behavior change. Further research on long-term and behavioral effects is indicated prior to broader dissemination into clinical practice.

HIV risk associated with gay bathhouses and sex clubs: findings from 2 seattle surveys of factors related to HIV and sexually transmitted infections

OBJECTIVES

We studied the HIV risk behaviors of patrons of the 3 commercial sex venues for men in Seattle, Washington.

METHODS

We conducted cross-sectional, observational surveys in 2004 and 2006 by use of time-venue cluster sampling with probability proportional to size. Surveys were anonymous and self-reported. We analyzed the 2004 data to identify patron characteristics and predictors of risk behaviors and compared the 2 survey populations.

RESULTS

Fourteen percent of respondents reported a previous HIV-positive test, 14% reported unprotected anal intercourse, and 9% reported unprotected anal intercourse with a partner of unknown or discordant HIV status during the current commercial sex venue visit. By logistic regression, recent unprotected anal intercourse outside of a commercial sex venue was independently associated with unprotected anal intercourse. Sex venue site and patron drug use were strongly associated with unprotected anal intercourse at the crude level. The 2004 and 2006 survey populations did not differ significantly in demographics or behaviors.

CONCLUSIONS

Patron and venue-specific characteristics factors may each influence the frequency of HIV risk behaviors in commercial sex venues. Future research should evaluate the effect of structural and individual-level interventions on HIV transmission.

Feasibility of using computer-assisted interviewing to enhance HIV test counseling in community settings

OBJECTIVES

Significant advances in the treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) place a premium on early detection and linkage to care. Recognizing the need to efficiently yet comprehensively provide HIV counseling, we assessed the feasibility of using audio computer-assisted self-inventory (A-CASI) in a community-based HIV counseling and testing facility.

METHODS

A convenience sample of 50 adults presenting for HIV testing was recruited to complete an 85-item computerized HIV Assessment of Risk Inventory (HARI) containing domains of demographics, sexual behaviors, alcohol and substance use, emotional well-being, past experiences with HIV testing, and attitudes about taking HARI.

RESULTS

Client acceptance rate was limited by the completion time outlined during the intake process. However, the majority of respondents who completed HARI felt that it took only a short to moderate time to complete and was easy to understand. A majority also reported a preference for using a computerized format in the future. Further, HARI identified a number of risk-taking behaviors, including unprotected anal sex and substance use prior to past sexual encounters. Additionally, more than half of the sample reported moderate to severe depressive symptoms.

CONCLUSIONS

Those respondents who had time to complete the survey accepted the A-CASI interview, and it was successful at identifying a substantial level of risk-taking behaviors. A-CASI has the potential to guide HIV counselors in providing risk-reduction counseling and referral activities. However, results suggested the need to shorten the instrument, and further studies are needed to determine applicability in other HIV testing sites.

Defining, designing, implementing, and evaluating phase 4 HIV prevention effectiveness trials for vulnerable populations

The efficacy of behavioral HIV prevention interventions has been convincingly demonstrated in a large number of randomized controlled phase 3 research outcome trials. Little research attention has been directed toward studying the effectiveness of the same interventions when delivered by providers to their own clients or community members, however. This article argues for the need to conduct phase 4 effectiveness trials of HIV prevention interventions that have been found efficacious in the research arena. Such trials can provide important information concerning the impact of interventions when applied in heterogeneous "real-world" circumstances. This article raises design issues and methodologic questions that need to be addressed in the conduct of phase 4 trials of behavioral interventions. These issues include the selection and training of service providers engaged in such trials, maintenance of fidelity to intervention protocol in provider-delivered interventions, determination of intervention core elements versus aspects that require tailoring, selection of relevant phase 4 study outcomes, interpretation of findings indicative of field effectiveness, sustainability, and other aspects of phase 4 trial design.