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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.

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?

The Ryan White HIV/AIDS Treatment Modernization Act (a reauthorization of the original Ryan White CARE Act) changed the formulas used to distribute funding to states and cities in the US. The case counts used to allocate the awards shifted from using only AIDS cases to using both HIV (non-AIDS) and AIDS cases. In addition, federal agencies have been charged with developing a Severity of Need Index, which eventually may be used in formula award allocations to weight HIV/AIDS case data by factors thought to impact the variable cost of treatment around the nation. In this project, we have responsibility for developing models that simulate the distribution of formula awards in order to understand how changes to the Ryan White Program formulas impact funding nationwide—and, in particular, California and its cities.

This pilot study will determine the acceptability and translatability of PalmPal, an innovative structural intervention we designed to improve the process of HIV test counseling. PalmPal is a ten minute risk assessment questionnaire that is self administered by the client using a handheld computer just prior to the test session. The proposed study will recruit a representative sample of 40 test clients from three test clinics to conduct six focus groups. The study will address two main research questions:

1. Is PalmPal usable and acceptable across a variety of test client populations?
2. What are clients’ perceptions about the potential of PalmPal to enhance the testing process?

To address the first question, participants will complete the PalmPal questionnaire at the start of the focus group. To address the second question, the focus group discussions will explore client experiences with a range of counseling strategies and the ways that PalmPal might enhance the session. The demographic, risk, and testing characteristics of participants collected on the PalmPal device will provide valuable context for interpreting participant comments about testing preferences and experiences from the focus group discussion. The proposed study will lay the groundwork for two future research proposals:

1. To expand the scope of the PalmPal intervention to include targeted prevention education for test clients
2. To test the effectiveness of PalmPal as a structural intervention both by itself and combined with face-to-face test counseling

Six Pacific AIDS Education and Training Center (PAETC) local performance sites (LPSs) will target medical settings for activities to promote and support expanded HIV testing, per the 2006 Centers for Disease Control and Prevention Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. This decentralized model provides services based on an understanding of the local epidemic and local health care delivery services. The Hawai’i, Nevada and Arizona AETCs will each work with one hospital-based labor and delivery department to implement rapid HIV testing with women presenting in labor with no prenatal care or documented HIV test result. The East Bay and San Francisco AETCs will each work with one community health center (CHC) or public health clinic to implement opt-out HIV testing when feasible, given state laws and regulations, for primary care clients between the ages of 13 and 64. The University of California Los Angeles AETC will identify and target four CHCs in Los Angeles to expand HIV testing with primary care patients. All targeted health care settings will serve a majority of minorities, primarily Latinos and African Americans in California, Arizona and Nevada, and Pacific Islanders in Hawai’i. The LPSs will use a technical assistance model that includes identification of key decision-makers, support to implement clinic policies and procedures, and accompanying staff training. The San Francisco AETC will develop a binder of resource materials to support implementation in CHC settings. Materials will consist of:

• Federal guidelines and recommendations for testing and initial diagnosis
• Sample protocols, policies and procedures
• Fact sheets
• Staff training materials
• Patient education materials
• State regulations on testing and reporting
• References and resources

The LPSs that work with labor and delivery settings will use PAETC’s resources and reference manual developed for our current California Office of AIDS-supported Rapid Testing in Labor and Delivery program. Level I and II training will be provided to physicians, nurses, nurse practitioners, physician assistants, and pharmacists.