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This study will use simulation to develop, test and apply new analytic methods (weighted time-series) for evaluation of community-level interventions. It will then compare results using weighted time-series and conventional methods within the context of a clinic-level intervention to provide family-centered HIV care, voluntary counseling and testing (VCT) and prevention services at Family AIDS Care and Education Services (FACES), a community-based organization in Kenya. Because FACES includes observational data on virtually all patients in care at participating clinics, it provides an excellent platform to evaluate the effectiveness of this intervention using both cohort and time-series methods. The results of this study will be used to seek funding to test the broader application of these methods in both community- and clinic-level interventions. The specific aims of the proposed project are:

• To provide the rationale and framework for applying weighted time-series to serial cross-sectional data.
• To use simulation (created data) to apply and test the use of weighted time-series in a setting where the distribution of demographic characteristics and the health status of the population changes over time.
• To use existing clinical data to compare the effect of introducing family-centered HIV care, VCT and prevention services on the transmission of HIV among the families served by participating clinics using cohort analysis, time-series analysis and weighted time-series.

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.

UCSF, the San Francisco AIDS Foundation (SFAF), and Project Inform have created an AIDS Policy Research Center (APRC) to conduct timely research to help policymakers, planning councils and community organizations address the HIV epidemic in the State of California. The center is supported with funds from the California HIV/AIDS Research Program (CHRP). The work of the APRC includes both a Rapid Response Core and a set of planned research projects. The purpose of the Rapid Response Core is to:

• Identify HIV-related policy issues affecting California
• Develop specific research questions and to design studies that answer critical questions of relevance to pressing policy issues
• Collect and analyze research data
• Relay findings back to policymakers and other individuals involved in the formulation of policies

The planned research projects focus on:

• Modeling costs to the State under healthcare reform
• An evaluation of medical homes
• A model of care recently endorsed by the California Visioning Change Initiative
• Estimating funding to the state and its cities under a reauthorization of the Ryan White Program anticipated in the next several years

Research conducted at the APRC is guided by an external Policy Research Advisory Committee (PRAC) that guarantees regular and ongoing communication between the scientific investigators and community partners. The PRAC consists of approximately 10 individuals from non-governmental and community-based HIV/AIDS organizations, public health offices, and clinical care and prevention services programs throughout the State of California.

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.

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.