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We will conduct formative research to inform the design of a discrete choice experiment (DCE) that will quantitatively assess the relative importance of gender, ethnicity and sexual orientation in providers’ decisions to provide Prevention with Positives (PWP) counseling. In the DCE, providers will be presented a variety of scenarios in which factors that impact provision of PWP counseling are varied. Information from their responses will be used to quantitatively assess the relative impact of each of the factors included in the scenarios on providers’ decisions to provide PWP counseling. This study involves three critical steps:

1. To develop preliminary versions of the questions to be used in clinical scenarios that involve decisions to offer HIV prevention counseling to an HIV+ patient.
2. To pilot test the preliminary questions and scenarios with a sample of 20 providers of HIV care in order to finalize the language used in the scenarios.
3. To obtain preliminary information from the 20 provider interviews on responses to DCE scenarios in order to estimate the number of scenarios and participants required.

The first aim will be accomplished by convening three focus groups of key informants with expertise of relevance to PWP counseling. Investigators will present broad outlines of potential scenarios and will ask informants to critique and help refine language that will become part of the information presented in the scenarios, of the questions to be asked during the scenarios, and of the potential response options. For the second and third aims, we will conduct 20 formative interviews with HIV providers in the greater San Francisco Bay Area. Specifically, we will employ cognitive interviewing techniques, in which we present the scenarios, questions, and potential answer options to participants, and ask them to explain their understanding of the items and the thinking that goes into their selection of a response. Providers will also complete a short assessment of their beliefs about clinical care and about their personal characteristics (e.g., race/ethnicity, gender, sexual orientation, professional training). Information from the cognitive interviews will be used to finalize response options, scenarios and sample size to be used in a full DCE study.

In collaboration with investigators at the Francois-Xavier Bagnoud Center at the University of Medicine and Dentistry of New Jersey, we are developing and pilot testing a set of evaluation tools for use by clinical sites implementing routine HIV screening in primary care settings in accord with updated guidelines released by the CDC in 2006. The tools will help staff in these settings to assess:

• Patient and provider preferences
• Satisfaction and attitudes with respect to CDC recommended practice, including opt-out screening
• Patients’ perceptions of their ability to decline testing
• Sufficiency and effectiveness of methods used to impart information prior to testing
• Acceptability of different methods for providing test results Development of the patient assessment tool has been accomplished in two steps.

In the first, we conducted interviews with patients who were routinely tested for HIV in the Kansas City Free Clinic. Results from the first phase were used to develop a quantitative assessment of patient attitudes, reactions and acceptance of new models for HIV screening and prevention and their outcomes in terms of patient care. In the second step, this assessment will be validated through administration to as many as 450 patients seen in three sites nationally, one emergency room and two primary care settings (one seeing primarily privately insured patients, the other publicly-insured ones). The provider tool was developed and tested at San Francisco General Hospital. Findings from this project will be collected in a toolkit of clinical evaluation instruments and protocols for assessing patient experiences and outcomes associated with the enhanced screening projects. The toolkit will be disseminated through tailored technical assistance provided through the Health Resources and Services Administration’s (HRSA) AIDS Education and Training Centers program.

Routine HIV screening in all health facilities has been recommended by the CDC as a critical strategy to reach undiagnosed HIV patients in order to facilitate linkage to care and enhance HIV prevention efforts. Offering HIV testing in hospital emergency departments is viewed as a particularly important mechanism to reach patients who may not have health insurance or access to regular medical care. To address this issue, the California State Office of AIDS will be launching a program to expand HIV screening in three San Francisco Bay Area hospital emergency departments including: Alameda County Medical Center-Highland Hospital, Alta Bates Summit Medical Center and San Francisco General Hospital. This project will evaluate the implementation process of Routine Testing for HIV in each Emergency Department.

HITEC is the evaluation center for the HRSA Special Projects of National Significance (SPNS) Information Technology Networks of Care Initiative. Six demonstration sites are implementing electronic network systems to interconnect providers at different care locations. The goal of these systems is to promote health information exchange to improve the delivery, continuity, and quality of care to people living with HIV/AIDS who receive services in publicly-funded settings. Using a mixed methods design, HITEC seeks to answer the following questions:

• What are the barriers and facilitators to the implementation of health information electronic network systems among sites serving people living with or affected by HIV/AIDS?
• What characteristics of electronic network systems are associated with improved care?
• Are there patients for whom this works better?
• How do electronic network systems improve continuity across sites?

In this study we will conduct an experiment to test the effectiveness of an innovative method of administering a survey interview--conversational interviewing--in reducing respondents’ reporting errors in their responses to sexual behavior questions common in HIV/AIDS research. In studies comparing conversational interviewing to standardized interviewing, conversational interviewing resulted in remarkable improvements in respondents’ understanding of the intended meaning of survey questions and in the accuracy of respondents’ answers. The standardized method of administering survey questions states that if respondents request clarification regarding the meaning of a survey item, interviewers are instructed to read the question again, and if confusion persists, say, “Whatever it means to you.” In contrast, the conversational interviewing method maintains the basic structure of the survey interview but adds procedures to allow interviewers to assist respondents to understand survey questions that are posing difficulties. We will use a mixed method design (n=200) to (1) conduct an experiment comparing conversational interviewing to standard interviewing in a sexual behavior survey; and (2) conduct an in-depth debriefing interview immediately after the survey interview is completed to identify the types of comprehension issues that occurred in the interview.