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Official websites use. Share sensitive information only on official, secure websites. Address for correspondence and reprints: Roland C. The primary objective of this study was to determine the effectiveness of audio computer-assisted self-interview ACASI -based feedback. This 1-year, randomized, controlled trial at a U. ED enrolled a random sample of to year-old subcritically ill or injured adult patients who were not known to be HIV infected. Participants were randomly assigned to one of two study groups: an intervention group in which participants received immediate ACASI-based feedback in response to each of their reported risk behaviors or a no-intervention group without feedback. Participants were asked to indicate their level of HIV risk on a five-point scale before and after they answered the questions. Because HIV risk behaviors differ by sex, scores were calculated separately for each sex. Linear regression models that adjusted for study group and same subject covariance were employed to determine if higher HIV risk behavior scores were associated with an increase in self-perceived HIV risk. After answering the reported HIV risk behavior questions, Of the Keywords: HIV, emergency medicine, risk-taking, sexual behavior, attitude to health, substance abuse, intravenous. Prior research has demonstrated that uptake of opt-in human immunodeficiency virus HIV screening by emergency department ED patients is partially dependent on their self-perceived risk for having an HIV infection. Those who do not believe themselves to be at risk are less likely to agree to be screened for HIV in the ED. However, they might be unaware of or not concede this risk. Self-perceived risk could then be the target of an intervention to increase uptake of HIV screening. One potential way to increase self-perceived risk for being infected with HIV is by helping patients acknowledge their prior HIV risk behaviors through the use of an HIV risk assessment. If ED patients are also given immediate tailored feedback about their prior HIV risk behaviors, they might increase their self-perceived HIV risk even more. Self-administered HIV risk assessments and interventions that require minimal staff involvement would be ideal in the ED setting. ACASI-based techniques also have the advantages of enhanced privacy of responses, easy delivery, standardized content, and better participant comprehension because the questionnaire components are displayed on a screen and read aloud to participants. ACASI improves the veracity of participant responses to questions about sexual risk behaviors and drug use compared to in-person—based interviewing techniques. In a study that did not involve feedback about reported HIV risk behaviors or an ACASI, participants were more likely to change their self-perceived risk for a future HIV infection when asked about their HIV risk behaviors using an intensive timeline follow-back rather than a standard interview. Participants were randomly assigned to receive tailored, immediate, ACASI-based feedback about these risk behaviors or no feedback. The second objective was to determine if an increase in self-perceived HIV risk is related to the reporting of more HIV risk behaviors. If so, then conducting HIV risk assessments even without feedback might help patients become more aware of their risk for an HIV infection. Knowing which reported HIV risk behaviors influence self-perceived HIV risk could help determine the content and focus of interventions to increase self-perceived HIV risk. This study was a randomized, controlled trial involving the ACASI-based administration of either an intervention with feedback or a no-intervention without feedback version of an anonymous questionnaire about self-perceived HIV risk and reported HIV risk behaviors. The institutional review board of the hospital approved the study and the use of verbal consent for patient participation. The study was conducted at an urban, academic, not-for-profit, adult ED in New England from October 1, , until September 30, During this period, the ED had approximately 54, visits for noncritical illness or injury by English-speaking to year-olds. We do not have a standing HIV screening program. We employed a three-level random selection plan to enroll patients for possible inclusion. The details of this plan are described elsewhere. The shifts for those 16 dates per month were randomly selected using a weighting scheme that was based on patterns in ED patient volume that occur during a typical hour period. A research assistant RA assessed the eligibility of these randomly selected ED patients for possible inclusion in the study by reviewing their ED patient medical records and through an in-person assessment. Patients were eligible for the study if they were 18 to 64 years old; English-speaking; not critically ill or injured; not prison inmates, under arrest, or on home confinement; not presenting for a psychiatric illness; not known to be HIV infected; not participating in an HIV vaccine trial; not intoxicated; and not having a physical disability or mental impairment that prevented providing consent or participating in the study. No incentives were offered to participants. ED staff were not permitted to encourage or refer patients to be in the study. Patients who agreed to have their eligibility confirmed were queried about their demographic characteristics and HIV testing history using instruments developed and employed in prior studies. Patients were informed that as part of the study they would be asked through an anonymous, private, ACA-SI-based questionnaire about their risk for an HIV infection from injection drug use and sex. They were also informed that they would be randomly assigned to either an intervention group that gave feedback to their answers or a no-intervention group. They were not informed about the intent of the intervention or the ultimate purpose of the study. Patients who agreed to participate in the study were randomly assigned to the intervention or no-intervention groups using block randomization to ensure equal size study groups. The questionnaire asked patients twice about their self-perceived risk for currently being HIV infected: once before questions about their reported HIV risk behaviors from injection drug use and sex and again after these questions. The no-intervention group received only the questionnaire, while the intervention group received the questionnaire plus ACASI-based feedback messages to their responses about their reported HIV risk behaviors. The RA followed a strict protocol for reviewing ED paper medical records, approaching patients, confirming their eligibility, and administering the study. The RA underwent over 40 hours of mock study encounters to learn and demonstrate ability to perform the study protocol. The RA was directly observed performing the study each month by the principal investigator. Deviations from protocol were corrected. We calculated the change in level of self-perceived HIV risk by subtracting the post and pre self-perceived HIV risk levels. We also compared the proportion of participants who had an increase in their self-perceived HIV risk levels by sex using two-sample tests of binomial proportions. We devised a score to summarize reported HIV risk behaviors and compare the score to a change in self-perceived HIV risk. Higher scores represented a greater number of reported HIV risk behaviors. Scores were not calculated for respondents who refused to answer any part of the questionnaire. The maximum scores possible were 36 for females and 61 for males. We calculated summary statistics of the reported HIV risk behavior scores by sex and study group assignment. We evaluated an increase in self-perceived HIV risk as a function of reported HIV risk behavior scores using linear regression models that accounted for same-subject covariance. Linear regression models were adjusted for study group assignment. Separate models were formed for males and females. To identify specific topics from the reported HIV risk behavior questions that were associated with an increase in self-perceived HIV risk, we employed polytomous logistic regression models that accounted for same-subject covariance. The base outcome for the models was no change in self-perceived HIV risk level regardless of initial self-perceived HIV risk level. The other outcomes were an increase or a decrease in self-perceived HIV risk level. Only the increase in self-perceived HIV risk level is reported in this article. The independent variables used were the responses to the reported HIV risk behavior questions. We created a point scale similar to the reported HIV risk behavior score described above to indicate the values that comprised the independent variables. The reference groups for the primary questions were participants who indicated that they had not engaged in that particular HIV risk behavior. For the follow-up questions, the reference groups were participants who did not receive that question. Increasing points were assigned for having received that question and providing a response that represented a greater risk. All models were adjusted for study group assignment. During the month study period, 2, English-speaking subjects were enrolled. A total of patients completed the trial. Figure 1 depicts the results of eligibility assessments through study group assignment and the major reasons for study ineligibility, refusing eligibility assessment, and accepting or declining study enrollment. Eligibility assessment and enrollment flow diagram. Table 1 provides a comparison of ED patients eligible for the study who accepted or declined study enrollment and a comparison of participants by study group assignment. Patients who enrolled were on average younger, and more were Hispanic, or never married, had more years of formal education, had previously been tested for HIV, or had ever donated blood. There were no differences in demographic characteristics or history of HIV testing between those randomized to the intervention versus no-intervention groups. Of note, from the eligibility screening of ED patients for this study, we found that 1. Table 2 provides the proportions of participant responses to the pre and post questions about self-perceived HIV risk. Nearly half of the participants, pre and post, did not view themselves at risk for being HIV infected. The proportions of participants who did not perceive themselves to be at risk was the same post vs. Participants received follow-up questions if the answer to the primary questions were yes. For example, for questions 2b1 through 2b4, participants received these questions if they reported having one or more different sexual partners for question 2a. The findings were the same when all participants were included in the comparisons. Questions were asked of those who indicated they had one or more unprotected sexual partners. Table 3 shows the proportion of participants who increased, decreased, or did not change post vs. The proportions of females Of the participants who initially indicated pre that they were not at risk, 9. Table 2 also shows the responses to the HIV risk behavior questions for all participants and by study group assignment. Of the participants, 8. Few of the males 4. The distribution of reported HIV risk behaviors was similar by study group assignment, except for a slightly greater proportion of participants in the no-intervention group who reported having had unprotected heterosexual anal or vaginal sex with an injection drug user. The reported HIV risk behavior scores for female participants ranged from 0 to 0. The reported HIV risk behavior scores of male participants ranged from 0 to 0. Tables 4 females and 5 males present the results of the polytomous logistic regression analyses that aimed to identify specific HIV risk behavior topics associated with an increase in self-perceived HIV risk, compared to no change in self-perceived HIV risk. Injection drug—related behaviors demonstrated the strongest association with a change in self-perceived HIV risk for females. For males, seven topics were related to an increase in self-perceived HIV risk. ORs for decrease in self-perceived HIV risk are not shown. Base outcome in these polytomous models is no change in self-perceived HIV risk. Reference group for the primary question topics 1—3 are those who responded no to those questions. For all others, the reference group are participants who did not receive that question. All models were adjusted for study arm assignment. In this randomized, controlled trial, an ACASI-based immediate feedback message system pertaining to reported HIV risk behaviors from injection drug use and sex had no impact on increasing self-perceived risk for being HIV infected. More importantly, These results suggest that some ED patients can be moved, although modestly, to recognize their risk for being HIV infected by asking about the HIV risk behaviors they have engaged in within the previous 10 years. Emergency department patients appear to consider particular HIV risk behavior topics more strongly than others when considering their self-perceived HIV risk, such as sharing of injection drug use equipment with HIV-infected persons. This consideration is reasonable given that certain HIV risk behaviors are likely more risky than others. The findings also suggest that there are particular topics in a limited intervention that might encourage ED patients to agree to be tested for HIV. Even though the proportions of females and males who increased their self-perceived HIV risk level were similar, females and males appear to respond differently to these HIV risk behavior questions when considering their self-perceived HIV risk. Nearly every topic addressed in the reported HIV risk behavior questions appears to have an influence on increasing self-perceived HIV risk for females. Fewer of the topics have this influence for males. The reasons for these differences are not known and could be the subject of future interventional studies. The lack of an effect of the intervention was not due to an absence of HIV risk behaviors in this population, given that a number of patients reported significant HIV risk behaviors. The association of certain HIV risk behavior items and self-perceived HIV risk does indicate that a relationship exists, at least for the items in this questionnaire. However, as shown in prior studies, 18 — 25 the relationship between self-perceived current or future HIV risk for an HIV infection and reported HIV risk behaviors might not be strong or may even be discrepant. As a consequence, dramatic increases in self-perceived HIV risk might not even be possible through interventions. Denial, misperceptions, or lack of knowledge about HIV and risk; residual beliefs about the exclusivity of HIV among particular demographic groups; beliefs about the HIV status and risk behaviors of sexual partners; unrealistic optimism; perceived invulnerability; and perceptions about the potential protective aspect of monogamous sexual relationships in regard to HIV risk are proposed reasons for a weak or discrepant relationship between actual and self-perceived HIV risk. This might have overridden our ability to detect differences between study groups, despite there being similar HIV testing histories in the intervention and no-intervention groups. Other possible reasons why the intervention failed include that the feedback message content or tone might not have provoked self-reflection about HIV risk; participants might have had trouble in expressing their self-perceived HIV risk using the framework of the questions asked; the 10 year time frame might have been too long a reference period, and asking patients to remember more recent behaviors might instead induce a stronger response about self-perceived HIV risk; the focus of the questions on higher HIV risk behaviors might have led some patients to discount their self-perceived HIV risk; the ACASI feedback might have been too impersonal, and instead an in-person intervention is necessary; or the feedback messages might have been too limited in scope and depth, and further exploration to include thoughts, perceptions, feelings, and the nature of the behaviors and events in relation to risk are needed to create a change in self-perceived HIV risk. These and other possibilities could be explored in future studies to determine if improvements to an ACASI-based message feedback intervention can impact self-perceived HIV risk or if other approaches are needed. It is important to acknowledge that although the intervention did not have an impact on self-perceived HIV risk, it is not known if the intervention might increase uptake of HIV screening. Likewise, it cannot be known from this investigation if completing the questionnaire improves uptake of screening, apart from any effects of the intervention. Further, although this intervention did not affect self-perceived HIV risk, it does not negate the possibility that some other intervention might be effective in changing risk perception. Although we employed a three-stage random selection plan to enroll participants, willingness to participate was related to patient demographic characteristics. Therefore, despite efforts taken to obtain a representative sample, the study findings might not be applicable to other ED settings with different demographics or to patients who do not speak English. Willingness to participate might have been related to HIV risk, although the subject of the study did not appear to deter participation. Although the study instrument was rigorously developed, it might not be reflective of actual HIV risk and has not yet been demonstrated to predict HIV infection. As such, the values of the HIV risk behavior score cannot be interpreted to represent actual risk levels. The lack of observed effects for certain HIV risk behaviors could be due to their relative infrequency. Because we wanted a brief HIV risk assessment tool, we did not inquire about mitigating factors that might influence self-perceived HIV risk, such as engaging in sexual intercourse within and outside of established relationships and use of HIV risk reduction measures. We did not have adequate power to determine if the feedback messages influenced reporting of HIV risk behaviors; however, this effect is likely to be small because there were no differences in reporting of HIV risk behaviors by each question asked. Lack of blinding of the RA and patient to study group assignment potentially could have affected the results, but we would have expected that this would have resulted in a difference instead of lack of difference between study groups. Audio computer self-interview—based immediate feedback about HIV risk behaviors does not increase ED patient self-perceived risk of being HIV infected. The authors acknowledge the assistance of Eric Feuchtbaum who helped with the development and cognitive-based assessments of the questionnaire used in this study, as well as the staff and patients of the Rhode Island Hospital Emergency Department who made this study possible. Merchant and this study were supported by a career development grant from the National Institute for Allergy and Infectious Diseases K23 A This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Acad Emerg Med. Published in final edited form as: Acad Emerg Med. Find articles by Roland C Merchant. Find articles by Melissa A Clark. Find articles by Kenneth H Mayer. Find articles by Victor G DeGruttola. The publisher's version of this article is available at Acad Emerg Med. Open in a new tab. Yes 8. Yes 3. Were there times when the needle or syringe was NOT cleaned with bleach and water before you used it? Yes 0. Yes 1. Yes Yes 3 2. Yes 4. Count each man once. Yes 2. Did any of these men have a sexually transmitted disease such as chlamydia, gonorrhea, genital herpes, or syphilis? Have any of these men ever had sex with another man? Yes 5. Yes 12 Data Supplement S1. Content, development, and script of the HIV risk questionnaire. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Ever tested for HIV not part of a blood donation. In your opinion, what is your risk of being infected with HIV? Section 1: Injection Drug Use. Please think only about the times in the past 10 years you used a needle or syringe that was not cleaned before you used it. Section 2: Heterosexual Sexual Behaviors. In the past 10 years, have you had anal sex with a man? Please think only about the men you had vaginal or anal sex with in the past 10 years when they did not use a condom. In the past 10 years, have you had vaginal or anal sex with someone so they would give you money, drugs, or other things? In the past 10 years, have you used money, drugs or other things to pay for vaginal or anal sex? In the past 10 years, have you had vaginal or anal sex when you were drunk, high, or stoned? In the past 10 years, have you had a sexually transmitted disease such as chlamydia, gonorrhea, genital herpes, or syphilis? Sharing unclean injection drug equipment with known HIV-infected person. Sharing unclean injection drug equipment with unknown HIV-status person. Unprotected sexual intercourse with males with sexually transmitted diseases. Sharing unclean injection drug equipment with unknown HIV status person. Unprotected sexual intercourse with females with sexually transmitted diseases. Number of unprotected anal insertive sexual intercourse male partners. Unprotected anal insertive sexual intercourse with known HIV-infected males. Unprotected anal insertive sexual intercourse with unknown HIV status males. Unprotected anal insertive sexual intercourse with male injection drug users. Unprotected anal insertive sexual intercourse with males with sexually transmitted diseases. Number of unprotected anal receptive sexual intercourse male partners. Unprotected anal receptive sexual intercourse with known HIV-infected males. Unprotected anal receptive sexual intercourse with males of unknown HIV status. Unprotected anal receptive sexual intercourse with male injection drug users. Unprotected anal receptive sexual intercourse with males with sexually transmitted diseases.

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