Self-reports of HIV risk factors by patients at a sexually transmitted disease clinic: audio vs written questionnaires

Discordant and Concordant Substance Use and Daily Partner Violence in Adolescent and Young Adult Relationships With Baseline Dating Violence

PURPOSE

Intimate partner violence (IPV) and substance use in adolescents and young adults (AYAs) are significant public health issues in the United States. Together, they can harm emotional regulation and romantic relationship functioning. This study examines the role of concordant and discordant substance use on IPV within AYA relationships.

METHODS

A prospective cohort of community-recruited AYA women in a heterosexual dating relationship with past-month IPV completed four months of daily surveys via a cell phone. Each day, participants reported any IPV perpetration and/or victimization, their alcohol and drug use, and observed partner substance use. Concordant substance use was coded when the participant and partner used drugs or alcohol on the same day. Discordant use was coded when only the participant or partner used drugs or alcohol on a given day. Alcohol and drug use were modeled separately. Generalized estimating equations accounted for the correlation of repeated measures.

RESULTS

Participants (N = 143) were 18.2 (1.1) years old, 93% African American race. Discordant alcohol and drug use was associated with same-day victimization, perpetration, and co-occurring violence compared to concordant nonuse. Similarly, concordant alcohol use, drug use, and alcohol/drug use were associated with increased odds of victimization, perpetration, and co-occurring violence compared to concordant nonuse.

DISCUSSION

Daily data illustrated that dyadic patterns of substance use are associated with IPV. These findings may facilitate the development of effective and developmentally appropriate IPV intervention programs for AYA that also integrate strategies to reduce substance use.

Inequitable Experiences Between Black and White Women Discussing Sexual Health With Healthcare Providers: Findings From a U.S. Probability Sample

BACKGROUND

In the United States, efforts to achieve health equity and reduce sexual health disparities remain a national priority; however, limited research has focused on understanding racial differences in patient/provider discussions about sexual health.

AIM

To quantify racial differences between black and white women (aged 18-49 years) in the United States discussing sexual health with a healthcare provider in the past year.

METHODS

Data were analyzed from a subset of 1,654 women aged 18-49 years who participated in the 2018 National Survey of Sexual Health and Behavior. Measures of interest included visiting a healthcare provider and discussing sexual health with the provider in the past year. Log binomial models were developed to estimate risk ratios for the likelihood of sexual health topics encountered by black women; models were adjusted for age, marital status, education level, and annual income.

MAIN OUTCOME

Black women were significantly more likely to report having a healthcare visit in the past year compared to white women and were more likely to have discussed their sexual health activities.

RESULTS

The adjusted risk ratio (ARR) for black women who reported discussing sex or sexual health with a healthcare provider was 1.16 (95% CI: 1.06-1.26). The ARR for black women who were asked if they were sexually active was 1.16 (95% CI: 1.06-1.26) and about their condom use was 1.49 (95% CI: 1.27-1.74). Black women were nearly 2 times more likely to be offered sexually transmitted disease testing (ARR: 1.72, 95% CI: 1.46-2.02) and to report that they were provided condoms for future use (ARR: 1.94, 95% CI: 1.12-3.36).

CLINICAL TRANSLATION

Healthcare providers are encouraged to have routine sexual health discussions with all patients; however, we found that there are differences among black and white women in discussing their sexual health activities.

STRENGTHS & LIMITATIONS

The present study utilized a nationally representative probability survey, including an oversample of black women. The study focused on sexual health discussions of black and white women with a healthcare provider, and therefore, women who did not have a healthcare visit in the past year were excluded from the analysis.

CONCLUSION

Black women reported having conversations about their sexual activities (eg, condom use) and were offered sexually transmitted disease testing more often than white women. These data provide insights that will impact patient/provider communication and aid in improving the delivery of sexual healthcare for all women. Townes A, Rosenberg M, Guerra-Reyes L, et al. Inequitable Experiences Between Black and White Women Discussing Sexual Health With Healthcare Providers: Findings From a U.S. Probability Sample. J Sex Med 2020;17:1520-1528.

Associations between impulsivity, risk behavior and HIV, HBV, HCV and syphilis seroprevalence among female prisoners in Indonesia: A cross-sectional study

HIV, hepatitis B and C, and syphilis share common transmission routes of which primarily unsafe sexual contact and injecting drug use are important. Impulsivity is a major factor contributing to this transmission risk behavior; however comprehensive studies within female, prison, and Asian populations are scarce. This cross-sectional study aims to delineate the contributions of different aspects of impulsivity to risk behavior, among female inmates living in a prison in Jakarta (N = 214). The relationships between various aspects of impulsivity, risk behaviors and seropositivity were tested using analyses of variance and logistic regression analyses. Motor impulsivity was related to alcohol use, reward-related impulsivity to drug use, and cognitive/goal-directed impulsivity to sexual risk behavior. Finally, goal-directed impulsivity was also directly associated with seropositivity. Specific aspects of impulsivity are associated with different types of risk behavior in Indonesian female prisoners, which can be relevant for future studies on infection prevention strategies for such a population.

How and Where Do We Ask Sensitive Questions: Self-reporting of STI-associated Symptoms Among the Iranian General Population

Background: Reliable population-based data on sexually transmitted infections (STI) are limited in Iran and self-reporting remains the main source of indirect estimation of STI-associated symptoms in the country. However, where and how the questions are asked could influence the rate of self-reporting. In the present study, we aimed to assess what questionnaire delivery method (ie, face-to-face interview [FTFI], self-administered questionnaire [SAQ], or audio self-administered questionnaire [Audio-SAQ]) and setting (ie, street, household or hair salon) leads to more reliable estimates for the prevalence of self-reported STI-associated symptoms.

Methods: This cross-sectional study was conducted in winter 2014 on a gender-balanced (50.0% men) sample of 288 individuals aged 18–59 years old in Kerman, Iran. Respondents were recruited in (a) crowded public places and streets, (b) their households, and (c) hair salons. Data was collected on history of current and 6-month (ie, past 6 months) STI-associated symptoms. Three different methods including FTFI, SAQ and or Audio-SAQ were applied randomly in households and non-randomly in streets and hair salons to collect data among the respondents. Generalized estimating equation (GEE) was used to compare the settings and methods separately.

Results: A total of 2.8% of men and 9.4% of women self-reported at least one STI-associated symptom. Respondents were significantly more likely to report STI-associated symptoms when completing questionnaires on the street compared to their household (P = .0001). While women were less likely to report symptoms in FTFI compared to SAQ (P = .036), no significant differences were found between men’s responses across different methods (P = .064).

Conclusion: Further research is needed to evaluate the effect of different combinations of methods and settings to find the optimal way to collect data on STI-associated symptoms.

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.

The Utility of Debriefing Questions in a Household Survey on Drug Abuse

Since subjects are often uncomfortable disclosing sensitive information, questions gauging respondent reaction to survey questions about drug abuse may aid in the interpretation of responses. Such debriefing questions can be worded subjectively, i.e., asking subjects about their own reactions to questions, or projectively, i.e., asking subjects about their perceptions of the reactions of others to questions. Using data from a study employing both types of debriefing questions, we examined whether question wording made any difference. We evaluated the extent to which drug reporting was associated with respondent reaction to the survey and whether reactions varied by type of debriefing question. A factor analysis of debriefing questions appended to an experimental household survey on drug abuse yielded factors reflecting distinct subjective and projective dimensions. Analyses suggested that debriefing question wording does make a difference with respect to respondent reaction. Contrary to expectations, analyses suggested that those reporting drug use expressed less comfort on subjectively worded items and more comfort on projectively worded items. Subjects who self-administered their survey also reported lower levels of subjective comfort. The projective measures derived from analyses were associated with three demographic variables: Younger subjects reported higher levels of projective ease than older subjects. Those with some college reported higher levels of projective ease than those with the least amount of formal education. African-Americans reported lower levels of projective ease than White/Other subjects. Implications for the design, interpretation, and analysis of drug use surveys are considered.

Men's Benefit-Provisioning Mate Retention Behavior Mediates the Relationship Between Their Agreeableness and Their Oral Sex Behaviors

Men perform oral sex on their romantic partner as part of a broader benefit-provisioning mate retention strategy and men higher in Agreeableness are especially likely to provision their partner with benefits. The current research explored whether men's benefit-provisioning mate retention behavior mediated the relationship between their Agreeableness and their oral sex behaviors in their long-term romantic relationship. Men (n = 346) in a committed, sexual, heterosexual relationship completed the Mate Retention Inventory-a 104-item instrument that assesses the frequency with which they performed various mate retention behaviors during the past month, a 40-item personality inventory, and reported on a questionnaire their interest in and the time they spent performing oral sex on their romantic partner during their most recent sexual encounter with her. The results indicated that men higher in Agreeableness reported greater interest in and spent more time performing oral sex on their partner, and that their benefit-provisioning mate retention behaviors partially mediated these relationships. The current research is the first to investigate the relationship between personality dimensions and oral sex behaviors and adds to a growing body of research documenting that mate retention strategies influence sexual behavior.

Associations of sexually transmitted infections with condom problems among young men who have sex with men

BACKGROUND

Young men who have sex with men (YMSM) are disproportionately infected with sexually transmitted infections (STIs). Condom use is the most widely available means of preventing the transmission of STIs, but effectiveness depends on correct use. Condom errors such as using an oil-based lubricant have been associated with condom failures such as breakage. Little research has been done on the impact of condom problems on the likelihood of contracting an STI.

METHODS

Data came from Crew 450, a longitudinal study of HIV risk among YMSM (N = 450). All self-report data were collected using computer-assisted self-interview technology, and clinical testing was done for gonorrhea, chlamydia, and HIV.

RESULTS

Nearly all participants made at least 1 error, with high rates of using oil-based lubricant and incomplete use. No differences were found in rates of condom problems during anal sex with a man versus vaginal sex with a woman. Black YMSM reported significantly higher use of oil-based lubricants than white and Hispanic YMSM, an error significantly associated with HIV status (adjusted odds ratio, 2.60; 95% confidence interval, 1.04-6.51). Participants who reported a condom failure were significantly more likely to have an STI (adjusted odds ratio, 3.27; 95% confidence interval, 1.31-8.12).

CONCLUSIONS

Young men who have sex with men report high rates of condom problems, and condom failures were significantly associated with STIs after controlling for unprotected sex. Educational programs are needed to enhance correct condom use among YMSM. Further research is needed on the role of oil-based lubricants in explaining racial disparities in STIs and HIV.

Comparisons of reported sexual behaviors from a retrospective survey versus a prospective diary in the Botswana Defence Force

This study compares self-reported sexual behaviors from a retrospective survey and a prospective diary among Botswana Defence Force (BDF) personnel. One hundred sixty-one male participants, aged 18-30, completed two weekly prospective diaries and a retrospective survey querying them about behaviors reported during the same time frame as the diaries. Most reported behaviors were similar between the two data collection methods. However, there was low agreement for reporting sex with a spouse and exchanging material goods for sex with a casual partner; frequency of sex and condom use rates (CURs) among married participants also differed. When comparing survey condom use frequencies to diary CURs, the level of agreement diminished from the always to occasionally condom use categories. Inconsistencies in reporting may be due to the frequency of the sexual behavior, question sensitivity, the data collection setting, and the interpretation of response categories. Further research is needed to improve accurate reporting of sexual behaviors.

Behavioral risk assessment in HIV Vaccine Trials Network (HVTN) clinical trials: a qualitative study exploring HVTN staff perspectives

In HIV vaccine trials, the collection and analysis of participant behavior data associated with risk of acquiring HIV-infection is important for a number of reasons. Although the rationale for behavioral risk assessment in HIV vaccine clinical trials is clear, consistent collection of behavioral data over time and across protocols has been challenging for the HIV Vaccine Trials Network (HVTN). Integrating biomedical and behavioral research within the same preventive vaccine clinical trial has proven difficult. The HVTN conducted an internal landscape analysis to: (1) evaluate the challenges of behavioral risk assessment in HIV vaccine trials and observational studies; (2) explore the impact of the Step Study on behavioral risk assessment measures; and (3) identify strategies to overcome existing challenges and improve the quality of data resulting from behavioral risk analysis. These analyses of behavioral risk within the HVTN revealed several challenges and recommendations for improved behavioral risk data collection in future protocols. The recommendations for improvement include: (1) establishment of protocol-specific behavioral risk working groups that include social and behavioral experts; (2) provision of behavioral rationale and objectives to the development team; (3) creation of a template for geographic- and population-specific assessment of low and high risk behaviors; and (4) pilot testing of behavioral risk assessments. Results also underscored the need for routinely conducted analyses of behavioral data.

Retaliatory attitudes and violent behaviors among assault-injured youth

OBJECTIVES

To examine the effect of retaliatory attitudes on subsequent violent behavior and fight-related injuries among youth who presented to the emergency department with assault injuries.

DESIGN

Assault-injured youth were interviewed at baseline, 6 months, and 18 months to assess fighting behavior, retaliatory attitudes, weapon carrying, and injury history as part of a larger randomized control trial.

SETTING

Two emergency departments in urban areas were selected for the study.

PARTICIPANTS

A total of 129 adolescents aged 10-15 years were included in the study.

OUTCOME MEASURES

Fighting behavior, assault injury, weapon carrying, and aggressive behavior.

RESULTS

Higher retaliatory attitudes at baseline were associated with more aggression and a higher frequency of fighting over time.

CONCLUSIONS

Retaliatory attitudes may fuel cycles of violence among youth. Medical professionals in acute care settings have an opportunity to identify youths at risk of future assault injury by assessing retaliation, providing anticipatory guidance, and referring to intervention programs.

Assessment of non-marital sexual behaviours of men in Bangladesh: a methodological experiment using a modified confidential ballot-box method

This study assessed the effectiveness of a modified ballot-box method (MBBM) in eliciting non-marital sexual behaviours compared with face-to-face interview (FTFI). A cross-sectional survey collected data from men aged 18–49 years in Bangladesh using a multistage cluster sampling method. In total, 3499 and 3623 respondents were interviewed by MBBM and FTFI, respectively. In the MBBM, pre-recorded questions were administered using a portable audio-cassette player with two pairs of headphones used concurrently by the respondent and the interviewer. Overall, 18% of the respondents had non-marital sexual exposure in the past year. The MBBM elicited higher responses of non-marital sex (adjusted odds ratio (aOR) 1.3, 95% confidence interval [CI]: 1.1, 1.5) compared with FTFI. The interview methods did not, however, revealed significant differences in response to condom-use rates and the number of non-marital sexual partners. The MBBM is more effective than the FTFI method in eliciting higher responses rates of non-marital sexual contacts and may be recommended for reliable estimates of sexual behaviours.

Test-retest reliability and predictors of unreliable reporting for a sexual behavior questionnaire for U.S. men

Accurate knowledge about human sexual behaviors is important for increasing our understanding of human sexuality; however, there have been few studies assessing the reliability of sexual behavior questionnaires designed for community samples of adult men. A test-retest reliability study was conducted on a questionnaire completed by 334 men who had been recruited in Tucson, Arizona. Reliability coefficients and refusal rates were calculated for 39 non-sexual and sexual behavior questionnaire items. Predictors of unreliable reporting for lifetime number of female sexual partners were also assessed. Refusal rates were generally low, with slightly higher refusal rates for questions related to immigration, income, the frequency of sexual intercourse with women, lifetime number of female sexual partners, and the lifetime number of male anal sex partners. Kappa and intraclass correlation coefficients were substantial or almost perfect for all non-sexual and sexual behavior items. Reliability dropped somewhat, but was still substantial, for items that asked about household income and the men's knowledge of their sexual partners' health, including abnormal Pap tests and prior sexually transmitted diseases (STD). Age and lifetime number of female sexual partners were independent predictors of unreliable reporting while years of education was inversely associated with unreliable reporting. These findings among a community sample of adult men are consistent with other test-retest reliability studies with populations of women and adolescents.

Consistency of self-reported sexual behavior in surveys

Accurate data on sexual behavior have become increasingly important for demographers and epidemiologists, but self-reported data are widely regarded as unreliable. We examined the consistency in the number of sexual partners reported by participants in seven population-based surveys of adults in the U.S. Differences between studies were quite modest and much smaller than those associated with demographic attributes. Surprisingly, the mode of survey administration did not appear to influence disclosure when the questions were similar. We conclude that there is more consistency in sexual partnership reporting than is commonly believed.

Measurement of sexual risk taking among college students

Current measures of sexual risk taking are either too narrowly focused to be used with college students or do not have adequate psychometric properties. The goal of the current study was to develop a broad and psychometrically sound measure of sexual risk taking. A total of 613 undergraduate students (302 men, 311 women) at a mid-sized Midwestern university in the U.S. were surveyed to develop and gather reliability and validity information on a new measure of sexual risk, the Sexual Risk Survey (SRS). The measure was found to be multifactorial with five factors. The measure was found to have good internal consistency and test-retest reliability. The SRS also demonstrated evidence of convergent and concurrent validity by its relationships with reported number of sexual partners and history of infidelity as well as measures of sensation seeking, sexual desire, substance use, sexual excitation and inhibition, and sexual health consequences. Social desirability was not found to be related to sexual risk taking scores and threat of sexual disclosure was only weakly related. An investigation of sex differences revealed that men reported greater intentions to engage in sexual risk behaviors and greater overall sexual risk taking behavior compared to women. The SRS provides researchers with a valid and comprehensive measure of sexual risk taking that can be used to clarify inconsistent findings in the literature and to assess outcome in programs designed to prevent and reduce sexual risk behaviors among college students.

Pregnancy as a window of opportunity for HIV prevention: effects of an HIV intervention delivered within prenatal care

OBJECTIVES

We sought to determine whether an HIV prevention program bundled with group prenatal care reduced sexually transmitted infection (STI) incidence, repeat pregnancy, sexual risk behavior, and psychosocial risks.

METHODS

We conducted a randomized controlled trial at 2 prenatal clinics. We assigned pregnant women aged 14 to 25 years (N = 1047) to individual care, attention-matched group care, and group care with an integrated HIV component. We conducted structured interviews at baseline (second trimester), third trimester, and 6 and 12 months postpartum.

RESULTS

Mean age of participants was 20.4 years; 80% were African American. According to intent-to-treat analyses, women assigned to the HIV-prevention group intervention were significantly less likely to have repeat pregnancy at 6 months postpartum than individual-care and attention-matched controls; they demonstrated increased condom use and decreased unprotected sexual intercourse compared with individual-care and attention-matched controls. Subanalyses showed that being in the HIV-prevention group reduced STI incidence among the subgroup of adolescents.

CONCLUSION

HIV prevention integrated with prenatal care resulted in reduced biological, behavioral, and psychosocial risks for HIV.

Randomized trial of a case management program for assault-injured youth: impact on service utilization and risk for reinjury

OBJECTIVES

The purposes of this study were to (1) assess receptiveness of families to violence prevention interventions initiated after an assault injury and (2) assess the effectiveness of a case management program on increasing service utilization and reducing risk factors for reinjury among assault-injured youth presenting to the emergency department.

DESIGN/METHODS

A randomized controlled trial of youth, aged 12 to 17 years, presenting to a large urban hospital with peer assault injury was conducted. Youth and parents were interviewed at baseline and 6 months to measure service utilization, risk behavior, attitudes about violence, mental health, and injury history.

INTERVENTION

Intervention families received case management services by telephone or in person during 4 months by a counselor who discussed sequelae of assault injury and assessed family needs and facilitated service use. Controls received a list of community resources.

RESULTS

Eighty-eight families were enrolled; 50 (57%) completed both youth and parent follow-up interviews. Intervention and control groups were not significantly different at baseline on demographics, service utilization, and risk factors. Fighting was common in both groups. Most parents and youth identified service needs at baseline, with recreational programs, educational services, mentoring, and counseling as most frequently desired. There was no significant program effect on service utilization or risk factors for injury. Although intervention families were satisfied with case management services, there was no significant increase in service utilization compared with controls.

CONCLUSIONS

Youth and parents were receptive to this violence prevention intervention initiated after an emergency department visit. This pilot case management program, however, did not increase service utilization or significantly reduce risk factors for injury. More intensive violence prevention strategies are needed to address the needs of assault-injured youths and their families.

Access to housing as a structural intervention for homeless and unstably housed people living with HIV: rationale, methods, and implementation of the housing and health study

Homelessness and unstable housing have been associated with HIV risk behavior and poorer health among persons living with HIV/AIDS (PLWHA), yet prior research has not tested causal associations. This paper describes the challenges, methods, and baseline sample of the Housing and Health Study, a longitudinal, multi-site, randomized controlled trial investigating the effects of providing immediate rental housing assistance to PLWHA who were homeless or at severe risk of homelessness. Primary outcomes included HIV disease progression, medical care access and utilization, treatment adherence, mental and physical health, and risks of transmitting HIV. Across three study sites, 630 participants completed baseline sessions and were randomized to receive either immediate rental housing assistance (treatment group) or assistance finding housing according to local standard practice (comparison group). Baseline sessions included a questionnaire, a two-session HIV risk-reduction counseling intervention, and blood sample collection to measure CD4 counts and viral load levels. Three follow-up visits occurred at 6, 12, and 18 months after baseline. Participants were mostly male, Black, unmarried, low-income, and nearly half were between 40 and 49 years old. At 18 months, 84% of the baseline sample was retained. The retention rates demonstrate the feasibility of conducting scientifically rigorous housing research, and the baseline results provide important information regarding characteristics of this understudied population that can inform future HIV prevention and treatment efforts.

Predictors of discordant reports of sexual and HIV/sexually transmitted infection risk behaviors among heterosexual couples

OBJECTIVES

Assessments undertaken as part of couple-based HIV/sexually transmitted infection (STI) prevention intervention studies offer opportunities to expand our understanding of couple reporting of sexual and HIV/STI risk behavior. Increases in heterosexual transmission of HIV worldwide support more attention on the quality and use of couple-level sexual risk assessment.

STUDY DESIGN

This study examined interpartner concordance of self-reported sexual behaviors and HIV/STI risk behaviors among 217 women and their main male sexual partners at high risk for HIV/STI transmission and further explored specific individual and relationship characteristics by partner gender associated with discordant reporting of sexual and HIV/STI risk behaviors.

RESULTS

Consistent with prior studies, findings suggest fair to substantial agreement between partners on reports of most sexual and HIV/STI risk behavior, but only poor to fair agreement on reports of concurrent sexual behaviors and drug or alcohol use. Factors significantly associated with discordant reporting of sexual behaviors included length of couple relationship, level of relationship satisfaction, female partner's marital status, and male partner's HIV status, ethnicity, and age.

CONCLUSIONS

Individual- and relationship-level factors predicting discordant partner reports of sexual and sexual risk behaviors highlight an opportunity to improve couple assessment by anticipating such discrepancies and developing effective mechanisms of quality assurance to avoid, address, or better explain such discordance in couple data sets.

Development and use of touch-screen audio computer-assisted self-interviewing in a study of American Indians

This article describes the development and usability of an audio computer-assisted self-interviewing (ACASI) questionnaire created to collect dietary, physical activity, medical history, and other lifestyle data in a population of American Indians. Study participants were part of a cohort of American Indians living in the southwestern United States. Data were collected between March 2004 and July 2005. Information for evaluating questionnaire usability and acceptability was collected from three different sources: baseline study data, auxiliary background data, and a short questionnaire administered to a subset of study participants. For the subset of participants, 39.6% reported not having used a computer in the past year. The ACASI questionnaires were well accepted: 96.0% of the subset of participants reported finding them enjoyable to use, 97.2% reported that they were easy to use, and 82.6% preferred them for future questionnaires. A lower educational level and infrequent computer use in the past year were predictors of having usability trouble. These results indicate that the ACASI questionnaire is both an acceptable and a preferable mode of data collection in this population.

The feasibility of audio computer-assisted self-interviewing in international settings

OBJECTIVE

To determine the feasibility of using audio computer-assisted self-interviewing (ACASI) for data collection in developing countries, and to compare responses to questions eliciting sensitive information about sexual behavior using ACASI versus computer-assisted personal interviewing (CAPI) in five developing countries.

DESIGN

A feasibility study determined whether ACASI could be used in populations in developing countries. A follow-up, randomized crossover study compared responses to questions eliciting sensitive information about sexual behavior using ACASI versus CAPI.

METHODS

The NIMH Collaborative HIV/STD Prevention Trial conducted a feasibility study of ACASI in convenience samples in China, India, Peru, and Russia, then a randomized crossover ACASI versus CAPI study among volunteers in these countries plus Zimbabwe.

RESULTS

Approximately equal numbers of men and women completed the feasibility study; the results suggested a high comfort level among participants. Married respondents in China and India appeared to give unreliable responses on sexual activity. In the crossover study, the pattern of responses to sensitive questions showed few differences. In China, higher rates of sexual risk were reported on CAPI. In Peru and Russia, differences by mode were found in the number of partners in the past year.

CONCLUSION

Despite variable computer experience and literacy, feasibility study participants reported ease in completing ACASI, and preferred a computer to an interviewer for answering sensitive questions, or had no preference. In the crossover study, most participants gave similar responses on both modes of survey administration. ACASI appears to be feasible in these settings, although low literacy may pose problems if participants cannot clarify questions.

Fear, hope and social desirability bias among women at high risk for HIV in West Africa

BACKGROUND

Self-reports are widely used for measuring behaviour in HIV research and prevention, yet the accuracy of these measures has been shown to be questionable in many cases. Social desirability bias (SDB) is one of the key factors identified as affecting self-report accuracy.

METHODS

Using in-depth interviews, we examined SDB from the perspective of 60 women at high risk for HIV in two West African countries: Ghana and Nigeria. We solicited suggestions for reducing SDB in the context of HIV research and prevention, and asked for feedback regarding methods currently being employed to reduce SDB.

RESULTS

Themes pertaining to fear and a desire to have a better life were pervasive throughout the data. Thematic structure was similar between sites and age groups, although younger women tended to be more concerned about the interview context.

CONCLUSIONS

Vulnerability of a population should be considered when asking sensitive questions. Audio-computer-assisted self-interviews may not be appropriate for vulnerable populations in developing countries, particularly for older respondents.

Efficacy of a booster counseling session 6 months after HIV testing and counseling: a randomized, controlled trial (RESPECT-2)

BACKGROUND

HIV counseling prevents sexually transmitted diseases (STDs), with most of the benefit accumulating in the first 6 months.

STUDY

The authors conducted a multicenter, randomized, controlled trial of a 20-minute additional (booster) counseling session 6 months after HIV counseling compared with no additional counseling for prevention of STDs (gonorrhea, chlamydia, trichomoniasis). Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark.

RESULTS

Booster counseling was completed by 1120 (67.8%) of 1653 assigned to receive it. An incident STD during the 6 to 12 months after initial counseling (and within the 6 months after scheduled booster counseling) was detected in 141 of 1653 (8.5%) participants in the booster counseling group and 144 of 1644 (8.8%) in the no-booster group (relative risk, 0.97; 95% confidence interval, 0.78-1.22). Three months after booster counseling, sexual risk behaviors were reported less frequently by the booster group than the no-booster group.

CONCLUSIONS

Booster counseling 6 months after HIV testing and counseling reduced reported sexual risk behavior but did not prevent STDs.

Relative Efficacy of Prevention Counseling With Rapid and Standard HIV Testing: A Randomized, Controlled Trial (RESPECT-2)

BACKGROUND

Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low.

STUDY

A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months.

RESULTS

Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96-1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06-1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92-3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99-1.48). Behavior was similar in both groups.

CONCLUSIONS

Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.

A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the sexual history

OBJECTIVE

The objective of this study was to compare reporting between audio computer-assisted self-interview (ACASI) and clinician-administered sexual histories.

GOAL

The goal of this study was to explore the usefulness of ACASI in sexually transmitted disease (STD) clinics.

STUDY

The authors conducted a cross-sectional study of ACASI followed by a clinician history (CH) among 609 patients (52% male, 59% white) in an urban, public STD clinic. We assessed completeness of data, item prevalence, and report concordance for sexual history and patient characteristic variables classified as socially neutral (n=5), sensitive (n=11), or rewarded (n=4).

RESULTS

Women more often reported by ACASI than during CH same-sex behavior (19.6% vs. 11.5%), oral sex (67.3% vs. 50.0%), transactional sex (20.7% vs. 9.8%), and amphetamine use (4.9% vs. 0.7%) but were less likely to report STD symptoms (55.4% vs. 63.7%; all McNemar chi-squared P values <0.003). Men's reporting was similar between interviews, except for ever having had sex with another man (36.9% ACASI vs. 28.7% CH, P <0.001). Reporting agreement as measured by kappas and intraclass correlation coefficients was only moderate for socially sensitive and rewarded variables but was substantial or almost perfect for socially neutral variables. ACASI data tended to be more complete. ACASI was acceptable to 89% of participants.

CONCLUSIONS

ACASI sexual histories may help to identify persons at risk for STDs.

Consistency in the reporting of sexual behaviour by adolescent girls in Kenya: a comparison of interviewing methods

OBJECTIVES

To investigate in a district in Kenya the level and consistency of reporting of sexual behaviour among adolescent girls randomly assigned to two modes of survey interview: face to face interview and audio computer assisted self-interview (ACASI).

METHODS

The analysis is based on a subsample of over 700 never married girls aged 15-21 years in Kisumu, Kenya, drawn from a population based survey of over 2100 respondents. A questionnaire with 69 questions was used, two thirds of which were considered sensitive, including questions about risky sexual behaviour, alcohol and drug use, contraceptive practice, pregnancy, induced abortions, and births.

RESULTS

ACASI produced significantly higher reporting of sex with a relative, stranger, or older man, and higher reporting of coerced sex. However, differences by mode for ever had sex and sex with a boyfriend were not significant. Relative to ACASI, the interviewer administered mode produced highly consistent reporting of sexual activity, both within the main interview and between the main and exit interviews.

CONCLUSIONS

Both the mode of survey administration and the probing for various behaviours significantly affect the observed prevalence of sexual activity. The ACASI results suggest that adolescent girls in Kenya have more complex and perilous sex lives than traditional face to face surveys of sexual activity indicate. The level of consistency in the interviewer mode is argued to be suspect, particularly given the much lower levels of reporting, relative to ACASI, for types of sexual partners and coerced sexual activity.

Do people really know their sex partners? Concurrency, knowledge of partner behavior, and sexually transmitted infections within partnerships

BACKGROUND AND OBJECTIVE

An individual's risk of sexually transmitted infections (STIs) has been associated empirically with the individual having concurrent sexual partners (individual's concurrency) and, theoretically, with the individual's partner having concurrent partners (partner's concurrency).

GOALS

The goals of this study were to assess the relationship of STI to individual's concurrency, the partner's concurrency, and awareness of the partner's concurrency.

STUDY DESIGN

We recruited 192 individuals aged 18 to 30 from sexually transmitted disease and family planning clinics in 96 partner dyads that reported first sexual contact during the previous 3 months. All individuals underwent computer interviews and testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Individuals' self-reports of concurrency and perceptions of partners' concurrency were compared within dyads by kappa statistic; associations of STI with individual's concurrency, partner's concurrency, and knowledge of partner's concurrency were examined using chi-squared analysis, t tests, and multivariate logistic regression.

RESULTS

Only 26% of individuals whose partners had other partners were aware of this (kappa = 0.17 for agreement of perceptions vs. partners' reports of concurrency). In multivariate models, STI in individuals was independently associated with partners' concurrency (odds ratio [OR], 3.6), lack of awareness of partner's concurrency (OR, 4.5), perceiving a partner to have concurrent partners when the partner did not (OR, 4.7), living in south San Diego, and sexual contact within 1 week of acquaintance, but not with individuals' concurrency.

CONCLUSION

This study demonstrates that STI is associated with partner's concurrency and with not knowing one's partner's behavior.

Screening for potentially transmitting sexual risk behaviors, urethral sexually transmitted infection, and sildenafil use among males entering care for HIV infection

The study aims were to evaluate the prevalence and predictors of sexual risk behaviors and urethral sexually transmitted disease (STD) among males entering care for HIV infection and to examine if sildenafil prescriptions are associated with potentially transmitting sexual risk behavior (PTSRB). The research design included (1) self-administered questionnaire of symptoms of sexually transmitted infection (STI), number of recent sex partners, unprotected sexual risk behaviors, use of drugs/alcohol during sex, and HIV disclosure; (2) urine gonorrhea/chlamydia polymerase chain reaction (PCR); and (3) record review for sildenafil prescriptions. A PTSRB was defined as insertive anal, vaginal, or oral sex without a condom. Between March 2001 and March 2002, 413 entrants were surveyed. The prevalence of positive urine PCR among those with and without urethral symptoms was 16.7% and 2.4%, respectively. Fifty-one percent met criteria for PTSRB during the preceding month. Those reporting PTSRB were more likely to report multiple partners. In a multiple logistic regression model, the following were significant (p < 0.05) predictors of PTSRB: drug or alcohol use during sex; white race; only male partners, and sildenafil use. Drug use during sex was associated both with more sex partners and more sexual risk behaviors. Always disclosing HIV status was associated with fewer partners. There was a high prevalence of PTSRB among HIV-infected males entering care. Men who have sex with men (MSM), white race, drug/alcohol use during sex, and sildenafil use were independent risk factors. PTSRB was associated with having multiple partners. Physicians should discuss risk behaviors before prescribing sildenafil.

Prevention myths and HIV risk reduction by active drug users

Drug injectors and crack users (526) in South Florida responded to a survey questionnaire that was designed to examine belief in the effectiveness of various strategies, other than condom use, employed to reduce personal risk of contracting HIV during sexual acts. Each strategy was believed to be effective by at least one quarter of the study participants. Factor analysis was used to group these strategies. Subsequent multivariate analysis indicated that the participants who believed in the effectiveness of HIV prevention strategies other than condom use were also less likely to report using condoms. These findings highlight the need for prevention interventions to elicit prevention myths and the full range of risk reduction strategies practiced.

Methodological challenges in research on sexual risk behavior: II. Accuracy of self-reports

Assessing sexual behavior with self-report is essential to research on a variety of health topics, including pregnancy and infertility, sexually transmitted infections, and sexual health and functioning. Recent methodological research has provided new insights regarding the accuracy of self-reports of sexual behavior. We review these studies, paying particular attention to a promising new development: the use of computer-assisted assessments. The collection of sexual risk behavior data with computers has increased dramatically in recent years, but little is known about the accuracy of such assessments. We summarize the evidence, discuss methodological issues that arise in studies evaluating the accuracy of self-reports, and offer recommendations for future research.

Recommendations for incorporating human immunodeficiency virus (HIV) prevention into the medical care of persons living with HIV

The estimated number of annual new human immunodeficiency virus (HIV) infections in the United States has remained at 40,000 for >10 years. Reducing the rate of transmission will require new strategies, including emphasis on prevention of transmission by HIV-infected persons. Medical care providers can affect HIV transmission by screening HIV-infected patients for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors, reinforcing changes to safer behavior, referring patients for services such as substance abuse treatment, facilitating partner counseling and referral, and identifying and treating other sexually transmitted diseases. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop evidence-based recommendations for incorporating HIV prevention into the medical care of persons living with HIV. This article summarizes key aspects of the recommendations.

Adolescent assault injury: risk and protective factors and locations of contact for intervention

BACKGROUND

Violence is a large contributor to morbidity and mortality among adolescents. Most studies assessing markers for violent injury are cross-sectional. To guide intervention, we conducted a case-control study to explore factors associated with assault injury and locations to reach at-risk adolescents.

OBJECTIVE

1) To assess risk and protective factors for adolescent assault injury compared with 2 control groups of youth with unintentional injuries and noninjury complaints presenting to the emergency department and 2) to assess locations of contact with assault-injured youth for prevention programs.

METHODS

Face-to-face and phone interviews were conducted with systematic samples of youth aged 12 to 19 years presenting to the emergency department with assault injury, unintentional injury, and noninjury complaints. Youth with intentional injuries were matched to youth in the 2 control groups on age +/-1 year, gender, race, and residency.

RESULTS

One hundred forty-seven 147 assault-injured youth completed interviews. One hundred thirty-three assault-injured youth were matched to 133 unintentionally injured and 133 noninjured youth presenting to the emergency department. Compared with the 2 control groups, assault-injured youth were more likely to have had more fights in the past year (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 2.02, 7.58; OR: 4.00; 95% CI: 2.23, 7.18) and fights requiring medical treatment (OR: 35.49; 95% CI: 8.71, 144.68; OR: 80.00; 95% CI: 11.13, 574.80). Eighty percent of assault-injured youth had been in 1 or more fights in the last 12 months compared with 55% and 46% in unintentional and noninjured controls, respectively. Assault-injured youth were more likely to have had previous weapon injuries (OR: 9.50; 95% CI: 3.39, 26.6; OR: 8.50; 95% CI: 3.02, 23.95) and have seen someone shot (OR: 2.00; 95% CI 1.12, 3.58; OR: 2.00; 95% CI: 1.12, 3.58). Eighty-six percent of assault-injured youth had a regular health care provider with 82% reporting a visit within the last year. There were no differences between cases and controls with regard to physician contact, extracurricular activity involvement, school or church attendance, police contact, weapon access or weapon-carrying, or witnessing nonweapon-related violence.

CONCLUSIONS

Fighting was common among all groups. Assault-injured youth were more likely to have had previous weapon injuries and were high-risk for future injury. Past fights, past fight injuries, and seeing someone else shot were markers associated with assault injury. Health providers do have access to at-risk teens for clinical risk assessment and intervention.

Effects of two telephone survey methods on the level of reported risk behaviours

OBJECTIVE

Reporting bias due to social desirability is an important consideration in carrying out surveys on sensitive issues. The study compared the frequency of self reported sensitive behaviours and response rates between the conventional "telephone interviewer method" (TIM) and a combined interviewer and computerised data capturing method (telephone interviewer and computerised questionnaire method, or TICQM).

METHODS

A total of 580 males and 582 females were recruited and randomly assigned to either of the two methods in a cross sectional study. The overall response rate was about 51.6%.

RESULTS

While the two methods both had high completion and low item non-response rates, the TICQM respondents reported higher frequencies of sensitive risk behaviours. Sexually active female respondents interviewed by the TICQM were more likely to report that their sex partners were their steady boyfriend, instead of their husband; and were also more likely to admit that they had had "one night stand" experiences or had undergone an HIV antibody test, when compared with their counterparts in the TIM group. Similar contrasts were observed for sexually active male respondents, that the TICQM group were more likely to report that they had had sexual intercourse with female sex workers or non-regular sex partners. Sex differences in the strength of association were observed between some studied behaviours (for example, HIV testing and substance abuse) and modes of data collection.

CONCLUSION

The choice of data collection method has a significant impact on the results of sensitive studies; special attention should be given to designing the study and interpreting the results.

Test-retest reliability of a complex human immunodeficiency virus research questionnaire administered by an Audio Computer-assisted Self-interviewing system

OBJECTIVES

To evaluate the test-retest reliability of a complex questionnaire administered by Audio Computer-assisted Self-interviewing to recently diagnosed human immunodeficiency virus-positive patients.

METHODS

Thirty-seven English-speaking and 32 Spanish-speaking participants completed both test and retest interviews. Pearson correlation coefficients (r) and kappa (kappa) and weighted kappa (kappa) statistics were obtained for individual questions. From these, overall kappa and Pearson correlation coefficients were calculated across all variables and for groups of questions.

RESULTS

Overall measures of reliability were kappa = 0.767, r = 0.728. Some variation in reliability existed for different response formats, question content groups, and languages of the participants. Differences in overall reliability by Spanish compared with English participants were small and not statistically significant.

CONCLUSIONS

Audio Computer-assisted Self-interviewing provides reliable measures for items assessed in the Antiretroviral Treatment and Access Study baseline questionnaire. Some differences exist as a result of question content, interview language, and response format, requiring assessment in future studies and consideration in designing Audio Computer-assisted Self-interviewing systems and questionnaires.

The emotional experience of intercourse and sexually transmitted diseases: a decision-tree analysis

BACKGROUND

Epidemiologic data document high risks for many sexually transmitted diseases (STDs) among US adolescents and young adults.

GOAL

This case-control study used decision trees to investigate the relationship between STD incidence and emotional reactions to intercourse.

STUDY DESIGN

For this study, 188 adolescents and young adults (mean age, 24.9 years [SD = 8.2]) at a regional public STD clinic completed a behavioral and psychological questionnaire and underwent a workup for STD.

RESULTS

The prevalence of STD in this group was 44.8%. Decision-tree analysis identified emotional reactions to intercourse that were associated with STD diagnosis for some patients: feeling good about oneself after sex half the time or less (OR = 3.21; 95% CI = 1.73-5.95), feeling comfortable during sex half the time or less (OR = 2.17; 95% CI = 1.07-4.40), and feeling angry after sex (OR = 1.90; 95% CI = 0.91-3.99). Findings of a logistic regression model of emotional reactions to intercourse were significant (chi-square = 24.6; df = 8; P < 0.002), but adding behavioral variables did not improve prediction.

CONCLUSIONS

For some of these young adults at the time of life when they are at highest risk of STD, emotional factors have higher odds ratios for STD diagnosis than the traditionally assessed behavioral variables. This underscores the need for interventions targeted to specific subgroups and for readily available mental health services.

The patient-computer interview: a neglected tool that can aid the clinician

In this article, I (1) review the process of interviewing patients by computer, (2) summarize computer-interviewing work done in 1968, (3) address the weaknesses of collecting information with the traditional history-taking methods or paper questionnaires, (4) discuss commercial software designed for computer interviewing, and (5) focus on the strengths and weaknesses of interviewing patients with a computer. The strengths of this process compared with traditional interviewing are that computer interviewing allows the physician to gather more data; gives the patient more time to complete an interview; uncovers more sensitive information; provides more adaptability to non-English-speaking patients, patients with hearing impairment, or patients who are illiterate; and provides structured information for research. The weaknesses of computer interviewing are that it generates false-positive responses, is not accepted by a minority of patients, is unable to detect nonverbal behavior, and requires changes in work flow. With the advent of an electronic medical record and the financial rewards for comprehensive history recording, the gathering of history and documentation from patients is increasingly important and favors adaptation to computer interviewing.

A randomized comparison of A-CASI and phone interviews to assess STD/HIV-related risk behaviors in teens

PURPOSE

To compare response bias associated with a telephone survey of sexually transmitted disease/human immunodeficiency virus (STD/HIV)-related risk behaviors and an in-home self-administered audio computer assisted self interview (A-CASI).

METHODS

We randomly assigned an urban household sample of 223 African-American adolescents to a telephone interview or an A-CASI in their home. The sample was previously recruited by telephone for an earlier study regarding STDs and sexual behavior. We queried participants about their STD/HIV-related risk behaviors. We also assessed their perceived comfort, honesty, and accuracy in answering questions in the different modes through a telephone computer-assisted self-interview (T-CASI).

RESULTS

There were no significant differences by mode in percentages of participants reporting STD/HIV-related risk behaviors, except more A-CASI participants reported having engaged in sexual intercourse in past 3 months (43.8% vs. 33.3%). There were no differences in perceived comfort, honesty, and accuracy in answering questions in the different modes. These results also did not change after we adjusted for age, household structure, and current school enrollment.

CONCLUSIONS

Telephone interviews, a more economical mode, can be employed without much risk of increasing the response bias in the data assessing crude measures of risk.

Computer-assisted audiovisual health history self-interviewing. Results of the pilot study of the Hoxworth Quality Donor System

BACKGROUND

The safety of blood for transfusion depends, in part, on the reliability of the health history given by volunteer blood donors. To improve reliability, a pilot study evaluated the use of an interactive computer-based audiovisual donor interviewing system at a typical midwestern blood center in the United States.

STUDY DESIGN AND METHODS

An interactive video screening system was tested in a community donor center environment on 395 volunteer blood donors. Of the donors using the system, 277 completed surveys regarding their acceptance of and opinions about the system.

RESULTS

The study showed that an interactive computer-based audiovisual donor screening system was an effective means of conducting the donor health history. The majority of donors found the system understandable and favored the system over a face-to-face interview. Further, most donors indicated that they would be more likely to return if they were to be screened by such a system.

CONCLUSION

Interactive computer-based audiovisual blood donor screening is useful and well accepted by donors; it may prevent a majority of errors and accidents that are reportable to the FDA; and it may contribute to increased safety and availability of the blood supply.

The cost-effectiveness of expanded HIV counselling and testing in primary care settings: a first look

OBJECTIVE

To estimate the cost-effectiveness of approaches to expanded HIV counselling and testing.

DESIGN

A cost-effectiveness analysis.

SETTING

Primary care practices in the USA.

PARTICIPANTS

New patient visits.

INTERVENTIONS

Two approaches were examined: (i) requesting all patients to complete an HIV-risk screening instrument, with counselling as well as testing offered only to patients disclosing risk factors ('risk histories' option); and (ii) routine offering of voluntary testing to all patients, with consent obtained but no pre-test counselling ('routine testing').

MAIN OUTCOME MEASURES

The primary outcome was the cost per infection identified. We also examined: (i) the costs and numbers of infections averted if individuals change their risk behaviours; and (ii) the additional years of life and quality-adjusted life years (QALY) gained as a result of earlier HIV testing and treatment for infected individuals.

RESULTS

Routine testing is the most cost-effective approach to identifying infected individuals at an incremental cost of US$4200 per infection identified. Although using risk histories is more costly and less effective than routine testing, it becomes similarly cost-effective using plausible ranges for sensitivity analyses. If at least 10% of HIV-positive individuals change their behavior, both routine testing and using risk histories would save money. If testing identifies infected individuals one year earlier than they otherwise would have been diagnosed, routine testing would cost US$22000 per QALY gained.

CONCLUSION

Routine testing is the most cost-effective approach to identifying new HIV infections. However, using risk histories may be similarly cost-effective under various assumptions. Both routine testing and using risk histories are more cost-effective than current practices.

When asked, patients tell: disclosure of sensitive health-risk behaviors

OBJECTIVES

National health care organizations recommend routinely screening patients for behavioral health risks, the effectiveness of which depends on patients' willingness to disclose risky behaviors. This study aimed to determine if primary care patients' disclosures of potentially stigmatizing behaviors would be affected by (1) their expectation about whether or not their physician would see their disclosures and (2) the assessment method.

METHODS

One thousand nine hundred fifty-two primary care patients completed a questionnaire assessing human immunodeficiency virus (HIV), alcohol, drug, domestic violence, tobacco, oral health, and seat belt risks; half were told their responses would be seen by the researcher and their physician and half were told that their responses would be seen by the researcher only. Patients were randomly assigned to one of five assessment methods: written, face-to-face, audio-based, computer-based, or video-based.

RESULTS

Across all risk areas, patients did not disclose differently whether or not they believed their physician would see their disclosures. Technologically advanced assessment methods (audio, computer, and video) produced greater risk disclosure (4%-8% greater) than traditional methods in three of seven risk areas.

CONCLUSIONS

These findings suggest patients are not less willing to disclose health risks to a research assistant knowing that this information would be shared with their physician and that a number of assessment methods can effectively elicit patient disclosure. Potentially small increases in risk disclosure must be weighed against other factors, such as cost and convenience, in determining which method(s) to use in different health care settings.

Risk assessment to improve targeting of HIV counseling and testing services for STD clinic patients

BACKGROUND AND OBJECTIVE

To determine whether self-administered risk assessment could improve targeting of HIV counseling and testing in an STD clinic.

STUDY DESIGN

Computerized records from the Prince George's County, Maryland, STD clinic from 1993 through 1996 were used to develop and test models for predicting a positive HIV test. In 1996, a self-administered risk assessment was compared with a counselor's risk assessment of the same patient.

RESULTS

Testing the 10% of patients at highest risk would identify 39% of those who were HIV-positive; testing 70% of the patients could identify 92% of those who were HIV-positive. In 1996, 2,288 patients completed the self-administered HIV risk assessment. The same number of HIV-positive persons (7 [28%]) were identified using either self-assessment or face-to-face interview.

CONCLUSIONS

Selectively offering voluntary HIV testing based on risk assessment would not be useful because it would miss many infected persons. If prevention counseling cannot be offered to everyone, it could be targeted to those who report a risk by self-assessment.

Reliability and validity of self-report measures of HIV-related sexual behavior: progress since 1990 and recommendations for research and practice

The trustworthiness of self-reported sexual behavior data has been questioned since Kinsey's pioneering surveys of sexuality in the United States (Kinsey et al., 1948, 1953). In the era of HIV and AIDS, researchers and practitioners have employed a diversity of assessment techniques but they have not escaped the fundamental problem of measurement error. We review the empirical literature produced since Catania et al.'s (1990) review regarding reliability and validity of self-administered and automated questionnaires, face-to-face interviews, telephone interviews, and self-monitoring approaches. We also provide specific recommendations for improving sexual behavior assessment. It is imperative that standardized self-report instruments be developed and used for sexual risk-behavior assessment.

Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women

This research evaluated a motivation-based HIV risk reduction intervention for economically disadvantaged urban women. Participants completed a survey that assessed HIV-related knowledge, risk perceptions, behavioral intentions, sexual communication, substance use, and risk behavior. A total of 102 at-risk women (76% African American) were randomly assigned to either the risk reduction intervention or to a waiting list. Women were reassessed at 3 and 12 weeks. Results indicated that treated women increased their knowledge and risk awareness, strengthened their intentions to adopt safer sexual practices, communicated their intentions with partners, reduced substance use proximal to sexual activities, and engaged in fewer acts of unprotected vaginal intercourse. These effects were observed immediately, and most were maintained at follow-up.

Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women

This research evaluated a motivation-based HIV risk reduction intervention for economically disadvantaged urban women. Participants completed a survey that assessed HIV-related knowledge, risk perceptions, behavioral intentions, sexual communication, substance use, and risk behavior. A total of 102 at-risk women (76% African American) were randomly assigned to either the risk reduction intervention or to a waiting list. Women were reassessed at 3 and 12 weeks. Results indicated that treated women increased their knowledge and risk awareness, strengthened their intentions to adopt safer sexual practices, communicated their intentions with partners, reduced substance use proximal to sexual activities, and engaged in fewer acts of unprotected vaginal intercourse. These effects were observed immediately, and most were maintained at follow-up.