NIMH Collaborative HIV/STD Prevention Trial Group. The feasibility of audio computer-assisted self-interviewing in international settings

Human-Centered Design of an mHealth Tool for Optimizing HIV Index Testing in Wartime Ukraine: Formative Research Case Study

BACKGROUND

Assisted partner services (APSs; sometimes called index testing) are now being brought to scale as a high-yield HIV testing strategy in many nations. However, the success of APSs is often hampered by low levels of partner elicitation. The Computer-Assisted Self-Interview (CASI)-Plus study sought to develop and test a mobile health (mHealth) tool to increase the elicitation of sexual and needle-sharing partners among persons with newly diagnosed HIV. CASI-Plus provides client-facing information on APS methods and uses a standardized, self-guided questionnaire with nonjudgmental language for clients to list partners who would benefit from HIV testing. The tool also enables health care workers (HCWs) to see summarized data to facilitate partner tracking.

OBJECTIVE

The formative research phase of the CASI-Plus study aimed to gather client and HCW input on the design of the CASI-Plus tool to ensure its acceptability, feasibility, and usability.

METHODS

This study gathered input to prioritize features and tested the usability of CASI-Plus with HCWs and clients receiving HIV services in public health clinics in wartime Ukraine. The CASI-Plus study's formative phase, carried out from May 2023 to July 2024, adapted human-centered design (HCD) methods grounded in principles of empathy, iteration, and creative ideation. The study involved 3 steps: formative HCD, including in-depth individual interviews with clients, such as men who have sex with men and people who inject drugs, and internet-based design workshops with HCWs from rural and urban HIV clinics in Chernihiv and Dnipro; software platform assessment and heuristic evaluation, including assessment of open-source mHealth platforms against CASI-Plus requirements, prototype development, and testing of the REDCap (Research Electronic Data Capture) prototype based on usability heuristics; and usability walk-throughs, including simulated cases with HCWs and clients.

RESULTS

The formative phase of the CASI-Plus study included in-depth individual interviews with 10 clients and 3 workshops with 22 HCWs. This study demonstrated how simplified HCD methods, adapted to the wartime context, gathered rich input on prioritized features and tool design. The CASI-Plus design reflected features that are both culturally sensitive and in alignment with the constraints of Ukraine's wartime setting. Prioritized features included information about the benefits of HIV index testing; a nonjudgmental, self-guided questionnaire to report partners; client stories; and bright images to accompany the text. Two-way SMS text messaging between clients and HCWs was deemed impractical based on risks of privacy breaches, national patient privacy regulations, and HCW workload.

CONCLUSIONS

It was feasible to conduct HCD research in Ukraine in a wartime setting. The CASI-Plus mHealth tool was acceptable to both HCWs and clients. The next step for this research is a randomized clinical trial of the effect of the REDCap-based CASI-Plus tool on the number of partners named and the rate of partners completing HIV testing.

Digital Health Screening in People With HIV in Uganda to Increase Alcohol Use Reporting: Qualitative Study on the Development and Testing of the Self-administered Digital Screener for Health

Background

Alcohol consumption is a critical driver of the HIV epidemic worldwide, particularly in sub-Saharan Africa, where unhealthy alcohol use and HIV are prevalent. Brief alcohol interventions are effective in reducing alcohol use; however, they depend on effective screening for unhealthy alcohol use, which is often underreported. Thus, there is a need to develop methods to improve reporting of unhealthy alcohol use as an essential step toward referral to brief alcohol interventions. Self-administered digital health screeners may improve reporting.

Objective

This study aimed to develop and test a digital, easy-to-use self-administered health screener. The health screener was designed to be implemented in a busy, underresourced HIV treatment setting and used by patients with varying levels of literacy.

Methods

We conducted a qualitative study at the Immune Suppression Syndrome (ISS) Clinic of Mbarara Regional Referral Hospital in Uganda to develop and test a digital self-administered health screener. The health screener included a training module and assessed behaviors regarding general health, HIV care, and mental health as well as sensitive topics such as alcohol use and sexual health. We conducted focus group discussions with clinicians and patients with HIV of the Mbarara ISS Clinic who consumed alcohol to obtain input on the need for and content, format, and feasibility of the proposed screener. We iteratively revised a tablet-based screener with a subset of these participants, piloted the revised screener, and conducted individual semistructured in-depth interviews with 20 participants who had taken part in our previous studies on alcohol and HIV, including those who had previously underreported alcohol use and with low literacy.

Results

A total of 45 people (n=5, 11% clinicians and n=40, 89% Mbarara ISS Clinic patients) participated in the study. Of the patient participants, 65% (26/40) were male, 43% (17/40) had low literacy, and all (40/40, 100%) had self-reported alcohol use in previous studies. Clinicians and patients cited benefits such as time savings, easing of staff burden, mitigation of patient-provider tension around sensitive issues, and information communication, but also identified areas of training required, issues of security of the device, and confidentiality concerns. Patients also stated fear of forgetting how to use the tablet, making mistakes, and losing information as barriers to uptake. In pilot tests of the prototype, patients liked the feature of a recorded voice in the local language and found the screener easy to use, although many required additional help and training from the study staff to complete the screener.

Conclusions

We found a self-administered digital health screener to be appealing to patients and clinicians and usable in a busy HIV clinic setting, albeit with concerns about confidentiality and training. Such a screener may be useful in improving reporting of unhealthy alcohol use for referral to interventions.

Comparison of audio computer-assisted self-interview (ACASI) to other survey modes in sexual behaviour surveys in Asia and Sub-Saharan Africa: A systematic literature review (Preprint)

Background

Reliable data about sexual behaviors is fundamental in the prevention and control of HIV, hepatitis, and other sexually transmitted infections. Generally, sexual behaviors are regarded as a sociocultural taboo in Africa and Asia, and this results in biased sexual behavior survey data due to social desirability. Various modes of survey delivery, including audio computer-assisted self-interviews (ACASIs), have been investigated to improve data quality.

Objective

This study aimed to review studies that compared the ACASI mode to other survey modes in sexual behavior surveys in Asia and sub-Saharan Africa to ascertain the impact of survey mode on responses to sexual behavior questions.

Methods

A systematic literature review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis. The review protocol was registered at PROSPERO (International Prospective Register of Systematic Reviews). Six databases were searched.

Results

A total of 21 papers were included. The face-to-face interview (FTFI) mode was the survey mode most frequently compared to the ACASI mode. Among the most commonly reported outcome variable groups, ACASI participants were more likely to report sexual behaviors, such as “forced sex,” “multiple partners,” “transactional sex,” and “ever had sex,” as compared to FTFI participants. In addition to the survey mode effect, other factors were found to have had an impact on data quality, for example, participant characteristics, social norms, study design, and data collection setting.

Conclusions

Use of ACASIs for administering sexual behavior surveys among populations in Asia and sub-Saharan Africa demonstrated higher reports for some sexual behaviors than the use of FTFIs. More studies that compare the ACASI mode to other survey modes would improve our understanding of the usefulness of ACASIs in sexual behavior surveys in these regions.

Evaluating the effects of two alcohol reduction counseling interventions on intimate partner violence perpetration: secondary analysis of a three-arm randomized controlled trial among Vietnamese men with HIV

BACKGROUND AND AIMS

Evidence suggests that alcohol reduction interventions decrease intimate partner violence (IPV) perpetration, although this remains untested in low- and middle-income countries and among men with human immunodeficiency virus (HIV). This study evaluates the effectiveness of alcohol reduction counseling interventions on IPV perpetration among men on anti-retroviral therapy (ART) and tests whether alcohol use explains the intervention effects.

DESIGN

Secondary analysis of data from a three-arm randomized controlled trial among ART patients with hazardous alcohol use. Participants were recruited from March 2016 to May 2017.

SETTING

Thai Nguyen, Vietnam.

PARTICIPANTS, INTERVENTIONS AND COMPARATORS

Male participants (n = 426). Participants received a two-session brief intervention (BI), a six-session combined intervention (CoI) or the standard of care (SOC), comprising alcohol treatment referrals. Alcohol reduction counseling interventions were guided by cognitive-behavioral therapy and motivational enhancement therapy delivered by psychosocial counselors over 3 months.

MEASUREMENTS

IPV perpetration was measured using the shortened Conflict Tactics Scale 2 and alcohol use was measured using timeline followback.

FINDINGS

BI and CoI participants reported reduced IPV perpetration at 3 months compared with SOC participants [BI: adjusted odds ratio (aOR) = 0.27, 95% confidence interval (CI) = 0.11, 0.65; CoI: aOR = 0.50, 95% CI = 0.22, 1.13]; the association was only significant for the BI group. Intervention effects were not sustained at 6 and 12 months. There was little evidence that alcohol use acted as a mediator (indirect effect, BI: aOR = 0.84, 95% CI = 0.63, 1.04; indirect effect, CoI: aOR = 0.86, 95% CI = 0.66, 1.03).

CONCLUSIONS

Among Vietnamese men receiving anti-retroviral therapy, alcohol reduction counseling interventions appeared to reduce intimate partner violence perpetration immediately post-intervention, but reductions were not sustained at 6 and 12 months and were not explained by alcohol reduction.

You Know What I Know: Interviewer Knowledge Effects in Subjective Expectation Elicitation

Directly eliciting individuals' subjective beliefs via surveys is increasingly popular in social science research, but doing so via face-to-face surveys has an important downside: the interviewer's knowledge of the topic may spill over onto the respondent's recorded beliefs. Using a randomized experiment that used interviewers to implement an information treatment, we show that reported beliefs are significantly shifted by interviewer knowledge. Trained interviewers primed respondents to use the exact numbers used in the training, nudging them away from higher answers; recorded responses decreased by about 0.3 standard deviations of the initial belief distribution. Furthermore, respondents with stronger prior beliefs were less affected by interviewer knowledge. We suggest corrections for this issue from the perspectives of interviewer recruitment, survey design, and experiment setup.

Electronic self-administered screening for substance use in adult primary care patients: feasibility and acceptability of the tobacco, alcohol, prescription medication, and other substance use (myTAPS) screening tool

BACKGROUND

The TAPS Tool is a substance use screening and brief assessment instrument that was developed for use in primary care medical settings. It is one of the first screening instruments to provide rapid assessment of all commonly used substance classes, including illicit and prescription opioids, and is one of the only available screeners designed and validated in an electronic self-administered format (myTAPS). This secondary analysis of data from the TAPS Tool validation study describes the feasibility and acceptability of the myTAPS among primary care patients.

METHODS

Adult patients (N = 2000) from five primary care clinics completed the TAPS Tool on a tablet computer (myTAPS), and in an interviewer-administered format. Requests for assistance and time required were tracked, and participants completed a survey on ease of use, utilization of audio guidance, and format preference. Logistic regression was used to examine outcomes in defined subpopulations, including groups that may have greater difficulty completing an electronic screener, and those that may prefer an electronic self-administered approach.

RESULTS

Almost all participants (98.3%) reported that the myTAPS was easy to use. The median time to complete myTAPS screening was 4.0 min (mean 4.48, standard deviation 2.57). More time was required by participants who were older, Hispanic, Black, or reported non-medical prescription drug use, while less time was required by women. Assistance was requested by 25% of participants, and was more frequently requested by those who with lower education (OR = 2.08, 95% CI 1.62-2.67) or age > 65 years (OR = 2.79, 95% CI 1.98-3.93). Audio guidance was utilized by 18.3%, and was more frequently utilized by participants with lower education (OR = 2.01, 95% CI 1.54-2.63), age > 65 years (OR = 1.79, 95% CI 1.22-2.61), or Black race (OR = 1.30, 95% 1.01-1.68). The myTAPS format was preferred by women (OR = 1.29, 95% CI 1.00-1.66) and individuals with drug use (OR = 1.43, 95% CI 1.09-1.88), while participants with lower education preferred the interviewer-administered format (OR = 2.75, 95% CI 2.00-3.78).

CONCLUSIONS

Overall, myTAPS screening was feasible and well accepted by adult primary care patients. Clinics adopting electronic screening should be prepared to offer assistance to some patients, particularly those who are older or less educated, and should have the capacity to use an interviewer-administered approach when required.

Risk and protective factors of posttraumatic stress disorder among African American women living with HIV

We sought to examine risk and protective factors for Posttraumatic Stress Disorder (PTSD) among African American women living with HIV. This is a cross-sectional analysis of baseline data from a randomized trial of an HIV stigma reduction intervention. We examined data from two-hundred and thirty-nine African American women living with HIV. We examined whether age, marital status, level of education, internalized HIV-related stigma, and social support as potential protective and risk factors for PTSD symptoms using logistic regression. We analyzed bi-variate associations between each variable and PTSD symptoms, and constructed a multivariate logistic regression model adjusting for all variables. We found 67% reported clinically significant PTSD symptoms at baseline. Our results suggest that age, education, and internalized stigma were found to be associated with PTSD symptoms (p < 0.001), with older age and more education as protective factors and stigma as a risk factor for PTSD. Therefore, understanding this relationship may help improve assessment and treatment through evidence- based and trauma-informed strategies.

Social Desirability Response Bias and Other Factors That May Influence Self-Reports of Substance Use and HIV Risk Behaviors: A Qualitative Study of Drug Users in Vietnam

The accuracy of self-report data may be marred by a range of cognitive and motivational biases, including social desirability response bias. The current study used qualitative interviews to examine self-report response biases among participants in a large randomized clinical trial in Vietnam. A sample of study participants was reinterviewed. The vast majority reported being truthful and emphasized the importance of rapport with the study staff for achieving veridical data. However, some stated that rapport may lead to under reporting of risk behaviors in order not to disappoint study staff. Other factors that appeared to influence accuracy of self-reports include fear that the information may be divulged, desire to enroll in the study, length of the survey, and memory. There are several methods that can be employed to reduce response biases, and future studies should systematically address response bias and include methods to assess whether approaches and survey items are effective in improving accuracy of self-report data.

HIV Risk Behavior Among Methamphetamine Users Entering Substance Abuse Treatment in Cape Town, South Africa

South Africa is experiencing a growing methamphetamine problem, and there is concern that methamphetamine use may accelerate HIV transmission. There has been little research on the HIV prevention needs of methamphetamine users receiving substance abuse treatment in South Africa. This study assessed the prevalence and correlates of HIV risk behaviors among 269 methamphetamine users entering substance abuse treatment in two clinics in Cape Town. The prevalence of sexual risk behaviors was high among sexually active participants: 34 % multiple partners, 26 % unprotected intercourse with a casual partner, and 24 % sex trading for money/methamphetamine. The strongest predictor of all sexual risk behaviors was concurrent other drug use. Over half had not been HIV tested in the past year, and 25 % had never been tested, although attitudes toward HIV testing were overwhelmingly positive. This population of primarily heterosexual, non-injecting methamphetamine users is a high-risk group in need of targeted HIV prevention interventions. Substance abuse treatment is an ideal setting in which to reach methamphetamine users for HIV services.

Assessing Stigma among African Americans Living with HIV

PURPOSE

In the present study, we validated a culturally adapted stigma scale designed to assess stigma among African Americans living with HIV.

METHODS

We collected data on the scale using an audio computer assisted self-interview (ACASI) format. We validated the scale with a sample of 62 African American participants living with HIV.

RESULTS

Findings demonstrated that stigma can be measured succinctly and effectively in a 14-item scale with two subscales measuring enacted and internalized stigma.

DISCUSSION

We identified many advantages to using the scale, which demonstrated good psychometric properties when used with an audio computer assisted self-interview format and with an African American sample. We recommend this scale's use in both clinical practice and research study of HIV-stigma reduction interventions with African American populations.

Feasibility and acceptability of an audio computer-assisted self-interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients

BACKGROUND

This study explores the feasibility and acceptability of a computer self-administered approach to substance use screening from the perspective of primary care patients.

METHODS

Forty-eight patients from a large safety net hospital in New York City completed an audio computer-assisted self-interview (ACASI) version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and a qualitative interview to assess feasibility and acceptability, comprehension, comfort with screening questions, and preferences for screening mode (interviewer or computer). Qualitative data analysis organized the participants' feedback into major themes.

RESULTS

Participants overwhelmingly reported being comfortable with the ACASI ASSIST. Mean administration time was 5.2 minutes (range: 1.6-14.8 minutes). The major themes from the qualitative interviews were (1) ACASI ASSIST is feasible and acceptable to patients, (2) Social stigma around substance use is a barrier to patient disclosure, and (3) ACASI screening should not preclude personal interaction with providers.

CONCLUSIONS

The ACASI ASSIST is an appropriate and feasible approach to substance use screening in primary care. Because of the highly sensitive nature of substance use, screening tools must explain the purpose of screening, assure patients that their privacy is protected, and inform patients of the opportunity to discuss their screening results with their provider.

High prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infections in anal and pharyngeal sites among a community-based sample of men who have sex with men and transgender women in Lima, Peru

OBJECTIVES

This study aimed to characterise the epidemiology of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru.

SETTING

Cross-sectional study in Lima, Peru.

PARTICIPANTS

We recruited a group of 510 MSM and 208 TW for a subsequent community-based randomised controlled trial. The presence of CT and NG were evaluated using Aptima Combo2 in pharyngeal and anal swabs. We also explored correlates of these infections.

PRIMARY AND SECONDARY OUTCOME MEASURES

Study end points included overall prevalence of C. trachomatis and N. gonorrhoeae in anal and pharyngeal sites.

RESULTS

Overall prevalence of CT was 19% (95% CI 16.1% to 22.1%) and 4.8% (95% CI 3.3% to 6.6%) in anal and pharyngeal sites, respectively, while prevalence of NG was 9.6% (95% CI 7.5% to 12.0%) and 6.5% (95% CI 4.8% to 8.5%) in anal and pharyngeal sites, respectively.

CONCLUSIONS

The prevalence of each infection declined significantly among participants older than 34 years (p<0.05). Efforts towards prevention and treatment of extraurogenital chlamydial and gonococcal infections in high-risk populations like MSM and TW in Lima, Peru, are warranted.

TRIAL REGISTRATION NUMBER

NCT00670163; Results.

SANKOFA: a multisite collaboration on paediatric HIV disclosure in Ghana

With the scale-up of effective antiretroviral therapy in resource-limited settings, many HIV-infected children are now able to survive into adulthood. To achieve this potential, children must navigate normative developmental processes and challenges while living with an unusually complex, stigmatizing, potentially fatal chronic illness and meeting the demands of treatment.Yet many of these children, especially preadolescents, do not know they are HIV-infected. Despite compelling evidence supporting the merits of informing children of their HIV status, there has been little emphasis on equipping the child's caregiver with information and skills to promote disclosure, particularly, when the caregiver faces a variety of sociocultural barriers and is reluctant to do so. In this study, we present the background, process and methods for a first of its kind collaboration that is examining the efficacy of an intervention developed to facilitate the engagement of caregivers in the process of disclosure in a manner suitable to the sociocultural context and developmental age and needs of the child in Ghana. We also report preliminary data that supported the design of the intervention approach and currently available domains of the data system. Finally, we discuss challenges and implications for future research.

Decreased injecting is associated with increased alcohol consumption among injecting drug users in northern Vietnam

BACKGROUND

Reducing injecting frequency may reduce the risk of HIV infection and improve health outcomes among injection drug users (IDUs). However, the reduction of one risk behavior may be associated with an increase in other risk behaviors, including the use of other risk-associated substances. Our objective was to determine if an association exists between a reduction in injecting and level of alcohol use among IDU.

METHODS

We conducted a longitudinal analysis of data collected for a randomized controlled trial examining the efficacy of a peer education intervention in reducing HIV risk among IDU and their network members in Thai Nguyen, Vietnam. Our analysis included active male injectors (n = 629) who were study participants and attended both baseline and 3-month visits. Frequency of alcohol consumption was assessed as the number of alcoholic drinks in the past 30 days. Change in risk and outcome behaviors was calculated as the difference in frequencies of behaviors between baseline and 3-month follow-up visits. The outcome of interest was concurrent decreased drug injection and increased alcohol consumption.

RESULTS

The mean difference between baseline and 3-month follow-up of alcohol consumption and injection frequency in the past 30 days was 19.03 drinks (93.68 SD) and 20.22 injections (35.66 SD), respectively. Participants who reported reduced injection frequency were almost three times as likely to report increased alcohol consumption (OR 2.8; 95% CI, 2.0, 4.0). The proportion that both decreased injecting and increased alcohol by any amount in the past 30 days was 35.6%. In multivariate analysis higher education was significantly associated with an increase in alcohol and decrease in injecting of any amount.

CONCLUSION

Male IDU may be at risk for increasing alcohol consumption when they reduce injection frequency. Interventions with male IDU that encourage reduction of injection may need to review specific strategies to limit alcohol consumption.

Color-coded audio computer-assisted self-interviews (C-ACASI) for poorly educated men and women in a semi-rural area of South India: "good, scary and thrilling"

It is challenging to collect accurate and complete data on sensitive issues such as sexual behaviors. Our objective was to explore experience and perceptions regarding the use of a locally programmed color-coded audio computer-assisted self interview (C-ACASI) system among men and women in a semi-rural setting in south India. We conducted a mixed-methods cross-sectional survey using semi-structured interviews among 89 truck drivers and 101 truck driver wives who had participated earlier in the C-ACASI survey across a predominantly rural district in Tamil Nadu. To assess the color-coded format used, descriptive quantitative analysis was coupled with thematic content analysis of qualitative data. Only 10% of participants had ever used a computer before. Nearly 75% did not report any problem in using C-ACASI. The length of the C-ACASI survey was acceptable to 98% of participants. Overall, 87% of wives and 73% of truck drivers stated that C-ACASI was user-friendly and felt comfortable in responding to the sensitive questions. Nearly all (97%) participants reported that using C-ACASI encouraged them to respond honestly compared to face-to-face personal interviews. Both the drivers and wives expressed that C-ACASI provided confidentiality, privacy, anonymity, and an easy mechanism for responding truthfully to potentially embarrassing questions about their personal sexual relationships. It is feasible and acceptable to use C-ACASI for collecting sensitive data from poorly computer-literate, non-English-speaking, predominantly rural populations of women and men. Our findings support the implementation of effective and culturally sensitive C-ACASI for data collection, albeit with additional validation.

Relationship between alcohol consumption prior to sex, unprotected sex and prevalence of STI/HIV among socially marginalized men in three coastal cities of Peru

This article presents data about the relationship between alcohol consumption prior to sex and unprotected sex and the prevalence of at least one sexually transmitted infection (STI) including HIV among socially marginalized men in three coastal Peruvians cities. During an epidemiological survey with 2,146 men, we assessed their STI prevalence, frequency of alcohol consumption prior to sex, unprotected sex and other sexual risk behaviors. The overall prevalence of at least one STI/HIV was 8.5 % (95 % CI 7.3-9.7), the prevalence of unprotected sex was 79.1 % (95 % CI 77.8-80.3) and alcohol consumption prior to sex with any of the last five sex partners in the previous 6 months was 68.9 % (95 % CI 66.9-70.9). Bivariate and multivariate analysis showed that alcohol consumption of participants or their partners prior to sex were associated with the prevalence of at least one STI, adjusted Prevalence Ratio (aPR) = 1.3 (95 % CI 1.01-1.68). Unprotected sex was significantly associated with alcohol consumption prior to sex when both partners used alcohol, aPR = 1.15 (95 % CI 1.10-1.20) or when either one of them used alcohol aPR = 1.14 (95 % CI 1.09-1.18). These findings concur with previous literature suggesting a relationship between alcohol consumption prior to sex and STI and HIV. These data improve our understanding of this relationship in this context and could be used to enhance STI and HIV prevention strategies for socially marginalized men in Peru.

Effect of computer-assisted interviewing on self-reported sexual behavior data in a microbicide clinical trial

In a microbicide safety and effectiveness trial (HPTN 035) in Malawi, 585 women completed the same questionnaire through a face-to-face interview (FTFI) and an audio computer-assisted self-interview (ACASI). Concordance between FTFI and ACASI responses ranged from 72.0 % for frequency of sex in the past week to 95.2 % for anal intercourse (AI) in the past 3 months. Reported gel and condom use at last sex act were marginally lower with ACASI than FTFI (73.5 % vs. 77.2 %, p = 0.11 and 60.9 % vs. 65.5 %, p = 0.05, respectively). More women reported AI with ACASI than FTFI (5.0 % vs. 0.2 %, p < 0.001). Analyses of consistency of responses within ACASI revealed that 15.0 % of participants in the condom-only arm and 28.7 % in the gel arm provided at least one discrepant answer regarding total sex acts and sex acts where condom and gel were used (19.2 % reported one inconsistent answer, 8.1 % reported two inconsistent answers, and 1.4 % reported three inconsistent answers). While ACASI may provide more accurate assessments of sensitive behaviors in HIV prevention trials, it also results in a high level of internally inconsistent responses.

Prevalence of HCV risk behaviors among prison inmates: tattooing and injection drug use

Hepatitis C virus (HCV) is the most common blood-borne chronic viral infection in the United States and it is over represented in incarcerated populations. This study estimates if in prison tattooing is associated with self reported HCV infection in a probabilistic sample of 1,331 sentenced inmates in Puerto Rico prisons anonymously surveyed in 2004, who had previously been tested for HCV. Analysis were carried out with the total sample and among non-injectors (n=796) to control for injection drug use (IDU) and other confounders. Nearly 60% of inmates had acquired tattoos in prison. HCV was reported by 27% of subjects in the total sample and by 12% of non-injectors who had undergone tattoos in prison. IDU was the strongest predictor of HCV in the total sample (OR=5.6, 95% CI=3.2-9.7). Among non injectors, tattooing with reused needles or sharp objects and/ or reusing ink was positively associated with HCV self-report (OR=2.6, 95% CI=1.3-5.5). Tattooing is a common occurrence in this prison setting. Findings suggest that preventive interventions are required to reduce the risk of HCV transmission through unsterile tattooing and injection practices.

A systematic review and meta-analysis of quantitative interviewing tools to investigate self-reported HIV and STI associated behaviours in low- and middle-income countries

OBJECTIVE

Studies identifying risks and evaluating interventions for human immunodeficiency virus (HIV) and other sexually transmitted infections often rely on self-reported measures of sensitive behaviours. Such self-reports can be subject to social desirability bias. Concerns over the accuracy of these measures have prompted efforts to improve the level of privacy and anonymity of the interview setting. This study aims to determine whether such novel tools minimize misreporting of sensitive information.

METHODS

Systematic review and meta-analysis of studies in low- and middle-income countries comparing traditional face-to-face interview (FTFI) with innovative tools for reporting HIV risk behaviour. Crude odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Cochran's chi-squared test of heterogeneity was performed to explore differences between estimates. Pooled estimates were determined by gender, region, education, setting and question time frame using a random effects model.

RESULTS

We found and included 15 data sets in the meta-analysis. Most studies compared audio computer-assisted self interview (ACASI) with FTFI. There was significant heterogeneity across studies for three outcomes of interest: 'ever had sex' (I(2) = 93.4%, P < 0.001), non-condom use (I(2) = 89.3%, P < 0.001), and number of partners (I(2) = 75.3%, P < 0.001). For the fourth outcome, 'forced sex', there was homogenous increased reporting by non-FTFI methods (OR 1.47; 95% CI 1.11-1.94). Overall, non-FTFI methods were not consistently associated with a significant increase in the reporting of all outcomes. However, there was increased reporting associated with non-FTFI with region (Asia), setting (urban), education (>60% had secondary education) and a shorter question time frame.

CONCLUSION

Contrary to expectation, differences between FTFI and non-interviewer-administered interview methods for the reported sensitive behaviour investigated were not uniform. However, we observed trends and variations in the level of reporting according to the outcome, study and population characteristics. FTFI may not always be inferior to innovative interview tools depending on the sensitivity of the question as well as the population assessed.

How to improve the validity of sexual behaviour reporting: systematic review of questionnaire delivery modes in developing countries

OBJECTIVES

To systematically review comparative research from developing countries on the effects of questionnaire delivery mode.

METHODS

We searched Medline, EMbase and PsychINFO and ISSTDR conference proceedings. Randomized control trials and quasi-experimental studies were included if they compared two or more questionnaire delivery modes, were conducted in a developing country, reported on sexual behaviours and occurred after 1980.

RESULTS

A total of 28 articles reporting on 26 studies met the inclusion criteria. Heterogeneity of reported trial outcomes between studies made it inappropriate to combine trial outcomes. Eighteen studies compared audio computer-assisted survey instruments (ACASI) or its derivatives [personal digital assistant (PDA) or computer-assisted personal interview (CAPI)] against another self-administered questionnaires, face-to-face interviews or random response technique. Despite wide variation in geography and populations sampled, there was strong evidence that computer-assisted interviews lowered item-response rates and raised rates of reporting sensitive behaviours. ACASI also improved data entry quality. A wide range of sexual behaviours were reported including vaginal, oral, anal and/or forced sex, age of sexual debut, condom use at first and/or last sex. Validation of self-reports using biomarkers was rare.

CONCLUSIONS

These data reaffirm that questionnaire delivery modes do affect self-reported sexual behaviours and that use of ACASI can significantly reduce reporting bias. Its acceptability and feasibility in developing country settings should encourage researchers to consider its use when conducting sexual health research. Triangulation of self-reported data using biomarkers is recommended. Standardizing sexual behaviour measures would allow for meta-analysis.

Pilot study assessing HIV vaccine trial readiness among female sex workers, injection and non-injection drug users, and men who have sex with men in Spain

The purpose of this study was to assess HIV risk and willingness to participate in HIV vaccine trials in three high risk populations in Spain. Eight hundred and forty-four participants, comprising female sex workers, injection and non-injection drug users (IDUs and NIDUs, respectively), and men who have sex with men were tested for HIV and surveyed for risk and willingness to participate in future preventive HIV vaccine trials. HIV seroprevalence was 3.8% (95% CI: 2-11). HIV infection was associated with transgender identification, IDU in the past year, and sex with an IDU or other drug-using partner. The majority (82%) expressed their willingness to participate in HIV vaccine trials. Substantial sexual and parenteral risk in all groups and concomitant willingness to participate in vaccine trials was found, particularly among women and IDUs. Additional longitudinal cohort studies in Spain are needed to plan future vaccine efficacy trials.

Results of the NIMH collaborative HIV/sexually transmitted disease prevention trial of a community popular opinion leader intervention

OBJECTIVE

To determine whether community populations in community popular opinion leader intervention venues showed greater reductions in sexual risk practices and lower HIV/sexually transmitted disease (STD) incidence than those in comparison venues.

METHODS

A 5-country group-randomized trial, conducted from 2002 to 2007, enrolled cohorts from 20 to 40 venues in each country. Venues, matched within country on sexual risk and other factors, were randomly assigned within matched pairs to the community popular opinion leader intervention or an AIDS education comparison. All participants had access to condoms and were assessed with repeated in-depth sexual behavior interviews, STD/HIV testing and treatment, and HIV/STD risk-reduction counseling. Sexual behavior change and HIV/STD incidence were measured over 2 years.

RESULTS

Both intervention and comparison conditions showed declines of approximately 33% in risk behavior prevalence and had comparable diseases incidence within and across countries.

CONCLUSIONS

The community-level intervention did not produce greater behavioral risk and disease incidence reduction than the comparison condition, perhaps due to the intensive prevention services received by all participants during the assessment. Repeated detailed self-review of risk behavior practices coupled with HIV/STD testing, treatment, HIV risk-reduction counseling, and condom access can themselves substantially change behavior and disease acquisition.

Socio-demographic and behavioral correlates of herpes simplex virus type 1 and 2 infections and co-infections among adults in the USA

OBJECTIVES

Although herpes simplex virus (HSV)-1 and HSV-2 may co-exist and interact, some epidemiologic features including geographical distribution, secular trends, route of transmission, and established risk factors may distinguish these HSV sub-types. With recent data indicating a link between genital herpes and either strain, a re-evaluation of risk factors for HSV-1/HSV-2 infection and co-infection is needed.

METHODS

We used the 1999-2004 National Health and Nutrition Examination Study (NHANES) data and logistic regression modeling to identify socio-demographic and behavioral risk factors that can independently predict HSV-1/HSV-2 infection and co-infection.

RESULTS

Approximately 48% were positive for HSV-1 alone, 7% were positive for HSV-2 alone and 12% were co-infected with HSV-1 and HSV-2. History of genital herpes was found in individuals infected with either or both HSV sub-types. Whereas age, sex, race, and level of education independently predicted all three outcomes, lifetime sexual activity as well as use of tobacco products and recreational drugs mainly correlated with HSV-2 infection and HSV-1/HSV-2 co-infection. Lifetime use of alcohol was not consistently associated with HSV-1/HSV-2 infection and co-infection.

CONCLUSIONS

Sexual activity played an important role for HSV-2 and was potentially important for HSV-1, with implications for healthcare practice and vaccine development.

Test-retest reliability of a sexual behavior interview for men residing in Brazil, Mexico, and the United States: the HPV in Men (HIM) Study

Understanding the natural history of sexually transmitted infections requires the collection of data on sexual behavior. However, there is concern that self-reported information on sexual behavior may not be valid, especially if study participants are culturally and linguistically distinct. The authors completed a test-retest reliability study of 1,069 men recruited in Brazil, Mexico, and the United States in 2005 and 2006. All of the men completed the same computer-assisted self-interview approximately 3 weeks apart. Refusal rates, kappa coefficients, and intraclass correlation coefficients were calculated for the full sample and by country, age, and lifetime number of female sex partners. Reliability coefficients for each study site and the combined population were high for almost all questions. With few exceptions, the authors found high test-retest reliability with a computer-assisted self-interview on sexual behavior used in 3 culturally and linguistically distinct countries.

Effects of Survey Mode on Results of a Patient Satisfaction Survey at the Observation Unit of an Acute Care Hospital in Singapore

Introduction: Over the years, surveys have become powerful tools for assessing a wide range of outcomes among patients. Healthcare managers and professionals now consider patient satisfaction as an outcome by itself. This study aims to determine if results of a patient satisfaction survey are affected by the manner by which the survey instrument is administered. Materials and Methods: A patient satisfaction survey was conducted from May 2006 to October 2007 in a tertiary level acute care facility. All patients admitted to the observation unit during the study period were invited to participate. Using a contextualised version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey, data was collected through either a phone interview, face to face interview or self-administered questionnaire. Each of these survey modes was administered during 3 different phases within the study period. Results: Eight hundred thirty-two (832) patients were included in the survey. Based on results of univariate analysis, out of the 18 questions, responses to 11 (61.1%) were related to survey mode. Face-to- face interview resulted in the greatest proportion of socially desirable responses (72.7%), while phone interview yielded the highest proportion of socially undesirable responses (63.3%). After controlling for possible confounders, logistic regression results showed that responses to 55.6% of the questions were affected by survey mode. Variations in response between phone interview and self-administered questionnaire accounted for 87.5% of the observed differences. Conclusions: Researchers must be aware that the choice of survey method has serious implications on results of patient satisfaction surveys. Key words: Methods, Patient satisfaction, Surveys

Is audio computer-assisted self-interview (ACASI) useful in risk behaviour assessment of female and male sex workers, Mombasa, Kenya?

Background

Audio computer-assisted self-interview (ACASI) may elicit more frequent reporting of socially sensitive behaviours than face-to-face (FtF)-interview. However, no study compared responses to both methods in female and male sex workers (FSW; MSW) in Africa.

Methodology/Principal Findings

We sequentially enrolled adults recruited for an HIV-1 intervention trial into a comparative study of ACASI and FtF-interview, in a clinic near Mombasa, Kenya. Feasibility and acceptability of ACASI, and a comparative analysis of enrolment responses between ACASI and FtF on an identical risk assessment questionnaire were evaluated. In total, 139 women and 259 men, 81% of eligible cohort participants, completed both interviews. ACASI captured a higher median number of regular (2 vs. 1, p<0.001, both genders) and casual partners in the last week (3 vs. 2, p = 0.04 in women; 2 vs. 1, p<0.001 in men). Group sex (21.6 vs. 13.5%, p<0.001, in men), intravenous drug use (IDU; 10.8 vs. 2.3%, p<0.001 in men; 4.4 vs. 0%, p = 0.03 in women), and rape (8.9 vs. 3.9%, p = 0.002, in men) were reported more frequently in ACASI. A surprisingly high number of women reported in ACASI that they had paid for sex (49.3 vs. 5.8%, p<0.001). Behaviours for recruitment (i.e. anal sex, sex work, sex between males) were reported less frequently in ACASI. The majority of women (79.2%) and men (69.7%) felt that answers given in ACASI were more honest. Volunteers who were not able to take ACASI (84 men, and 37 women) mostly lacked reading skills.

Conclusions/Significance

About 1 in 5 cohort participants was not able to complete ACASI, mostly for lack of reading skills. Participants who completed ACASI were more likely to report IDU, rape, group sex, and payment for sex by women than when asked in FtF interview. ACASI appears to be a useful tool for high risk behaviour assessments in the African context.

Alcohol-related disorders in Beijing, China: prevalence, socio-demographic correlates, and unmet need for treatment

BACKGROUND

The study aimed to determine the prevalence of alcohol use, episodic heavy drinking, and alcohol dependence and their socio-demographic correlates in Beijing, China. methods: A total of 5,926 subjects were randomly selected in Beijing and interviewed using the Composite International Diagnostic Interview (CIDI 1.0). Data on basic socio-demographic and current major medical conditions were also collected.

RESULTS

The 12-month prevalence of alcohol use and episodic heavy drinking were 32.5 and 13.8%, respectively. The 12-month and lifetime prevalence of alcohol dependence were 1.7 and 4.3%, respectively. Age above 24 years, male sex, being married and employed, low education level (junior high school, primary school or illiterate), rural residence, and having comorbid psychiatric disorders were all significantly associated with a higher likelihood of alcohol-related disorders. Only 2.4% of the subjects with alcohol dependence were receiving treatment, and a mere 1.4% had sought treatment from mental health professionals.

CONCLUSIONS

Nationwide surveys are urgently needed to further explore the prevalence of alcohol-related disorders in China.

Keep them in school: the importance of education as a protective factor against HIV infection among young South African women

OBJECTIVE

To identify risk factors for HIV infection among young women aged 15-24 years reporting one lifetime partner in South Africa. Design In 2003, we conducted a nationally representative household survey of sexual behaviour and HIV testing among 11 904 young people aged 15-24 years in South Africa. This analysis focuses on the subset of sexually experienced young women with only one reported lifetime sex partner (n = 1708).

METHODS

Using the proximate determinants framework and the published literature we identified factors associated with HIV in young women. The associations between these factors and HIV infection were explored in multivariable logistic regression models.

RESULTS

Of the young women, 15% reporting one lifetime partner were HIV positive. In multivariable analyses, young women who had not completed high school were more likely to be infected with HIV compared with those that had completed high school (AOR 3.75; 95% CI 1.34-10.46).

CONCLUSIONS

Young South African women in this population were at high risk of HIV infection despite reporting only having one lifetime partner. Few individual level factors were associated with HIV infection, emphasizing the importance of developing HIV prevention interventions that address structural and partner level risk factors.

Designing an audio computer-assisted self-interview (ACASI) system in a multisite trial: a brief report

OBJECTIVE

To describe the advantages and limitations of an audio computer-assisted self-interview (ACASI) system in a multisite trial with African American couples and to present the steps in designing, testing, and implementing a system.

METHODS

The ACASI system evolved from a paper and pencil interview that was pilot tested. Based on this initial work, the paper and pencil interview was translated into storyboards that were the basis of the development of ACASI system. Storyboards consisted of 1 page per question and provided the programmers with the test of the question, valid responses, and any instructions that were to be read to the participants. Storyboards were further translated into flow diagrams representing each module of the survey and illustrating the skip patterns used to navigate a participant through the survey. Provisions were also made to insert a face-to-face interview, into the ACASI assessment process, to elicit sexual abuse history data, which typically requires specially trained data collectors with active listening skills to help participants reframe and coordinate times, places and, emotionally difficult memories.

RESULTS

The ACASI was successfully developed and implemented in the main trial. During an exit interview, respondents indicated that they liked using the ACASI and indicating that they favored it as the method to answer questions.

CONCLUSIONS

It is feasible to implement an ACASI system in a multisite study in a timely and efficient way.

Assessment of self-reported sexual behavior and condom use among female sex workers in India using a polling box approach: a preliminary report

BACKGROUND

The accuracy of behavioral data related to risk for HIV and other sexually transmitted infections is prone to misreporting because of social desirability effects. Because computer-assisted approaches are not always feasible, a noncomputerized interview method for reducing social desirability effects is needed. The previous performance of alternative methods has been limited to aggregate data or constrained by the simplicity of dichotomous-only responses. We designed and tested a "polling box" method for case-attributable, multiple-response survey items in a low literacy population.

METHODS

A cross-sectional survey was conducted with 812 female sex workers in Andhra Pradesh, India. For a subset of questions embedded in a face-to-face survey questionnaire, every third participant was provided graphical response cards upon which to mark their answer and place in a polling box outside the view of the interviewer. Multiple logistic regression analysis was used to test for response differences to questions about socially undesirable, socially desirable, or sensitivity-neutral behaviors in the 2 interview methods.

RESULTS

Polling box participants demonstrated higher reporting of risky sexual behaviors and lower reporting of condom use, with no conclusive response patterns among sensitivity-neutral items.

CONCLUSION

Our findings suggest that the polling box approach provides a promising technique for improving the accurate reporting of sensitive behaviors among a low-literacy population in a resource poor setting. Additional research is needed to test logistical adaptations of the polling box approach.

Measuring the public-health impact of candidate HIV vaccines as part of the licensing process

The full impact of vaccines against infectious diseases is manifest at both the individual and the community levels. We argue that evaluating the community-level impact of HIV vaccine candidates should be an integral part of the licensing process. We describe a framework for the public-health evaluation of an HIV vaccine, which is based on the interactive use of mathematical models and community randomised clinical trials (C-RCTs) following completion of individual-based clinical trials (I-RCTs). Mathematical models of HIV vaccine can be used to take public-health considerations into account during the licensing process and can also help to select promising vaccine candidates for testing in C-RCTs. We also describe community and individual-based measures useful for defining public-health criteria necessary to guide the licensing process. To move forward, it is crucial to reach a consensus on what should constitute adequate public-health criteria. At the very least, a suitable vaccine would provide some individual benefit to vaccinees and not be detrimental to the population at large. In future I-RCTs and C-RCTs, quantifying each protective vaccine characteristic (eg, reductions in susceptibility or viral load) is important if regulators are to evaluate adequately the potential community-level impact of the vaccine across different settings, populations, and conditions of use.

Design and integration of ethnography within an international behavior change HIV/sexually transmitted disease prevention trial

OBJECTIVE

To use a common ethnographic study protocol across five countries to provide data to confirm social and risk settings and risk behaviors, develop the assessment instruments, tailor the intervention, design a process evaluation of the intervention, and design an understandable informed consent process.

DESIGN

Methods determined best for capturing the core data elements were selected. Standards for data collection methods were established to enable comparable implementation of the ethnographic study across the five countries.

METHODS

The methods selected were participant observation, focus groups, open-ended interviews, and social mapping. Standards included adhering to core data elements, number of participants, mode of data collection, type of data collection instrument, number of data collectors at each type of activity, duration of each type of activity, and type of informed consent administered. Sites had discretion in selecting which methods to use to obtain specific data.

RESULTS

The ethnographic studies provided input to the Trial's methods for data collection, described social groups in the target communities, depicted sexual practices, and determined core opinion leader characteristics; thus providing information that drove the adaptation of the intervention and facilitated the selection of venues, behavioral outcomes, and community popular opinion leaders (C-POLs).

CONCLUSION

The described rapid ethnographic approach worked well across the five countries, where findings allowed local adaptation of the intervention. When introducing the C-POL intervention in new areas, local non-governmental and governmental community and health workers can use this rapid ethnographic approach to identify the communities, social groups, messages, and C-POLs best suited for local implementation.