Computerized counseling reduces HIV-1 viral load and sexual transmission risk: findings from a randomized controlled trial.

OBJECTIVE: Evaluate a computerized intervention supporting antiretroviral therapy (ART) adherence and HIV transmission prevention. DESIGN: Longitudinal randomized controlled trial. SETTINGS: An academic HIV clinic and a community-based organization in Seattle. SUBJECTS: In a total of 240 HIV-positive adults on ART, 209 completed 9-month follow-up (87% retention). INTERVENTION: Randomization to computerized counseling or assessment only, 4 sessions over 9 months. MAIN OUTCOME MEASURES: HIV-1 viral suppression, and self-reported ART adherence and transmission risks, compared using generalized estimating equations. RESULTS: Overall, intervention participants had reduced viral load: mean 0.17 log10 decline, versus 0.13 increase in controls, P = 0.053, and significant difference in ART adherence baseline to 9 months (P = 0.046). Their sexual transmission risk behaviors decreased (odds ratio = 0.55, P = 0.020), a reduction not seen among controls (odds ratio = 1.1, P = 0.664), and a significant difference in change (P = 0.040). Intervention effect was driven by those most in need; among those with detectable virus at baseline (>30 copies/mL, n = 89), intervention effect was mean 0.60 log10 viral load decline versus 0.15 increase in controls, P = 0.034. ART adherence at the final follow-up was 13 points higher among intervention participants versus controls, P = 0.038. CONCLUSIONS: Computerized counseling is promising for integrated ART adherence and safer sex, especially for individuals with problems in these areas. This is the first intervention to report improved ART adherence, viral suppression, and reduced secondary sexual transmission risk behavior.

Addressing unmet need for HIV testing in emergency care settings: a role for computer-facilitated rapid HIV testing?

HIV testing in emergency departments (EDs) remains underutilized. The authors evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned nonacute adult ED patients were randomly assigned to a computer tool (CARE) and rapid HIV testing before a standard visit (n = 258) or to a standard visit (n = 259) with chart access. The authors assessed intervention acceptability and compared noted HIV risks. Participants were 56% nonWhite and 58% male; median age was 37 years. In the CARE arm, nearly all (251/258) of the patients completed the session and received HIV results; four declined to consent to the test. HIV risks were reported by 54% of users; one participant was confirmed HIV-positive, and two were confirmed false-positive (seroprevalence 0.4%, 95% CI [0.01, 2.2]). Half (55%) of the patients preferred computerized rather than face-to-face counseling for future HIV testing. In the standard arm, one HIV test and two referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches.

Offering an American graduate medical HIV course to health care workers in resource-limited settings via the Internet.

BACKGROUND: Western accredited medical universities can offer graduate-level academic courses to health care workers (HCWs) in resource-limited settings through the Internet. It is not known whether HCWs are interested in these online courses, whether they can perform as well as matriculated students, or whether such courses are educationally or practically relevant. METHODS AND FINDINGS: In 2011, the University of Washington (UW) Schools of Medicine and Nursing offered the graduate course, "Clinical Management of HIV", to HCWs that included a demographic survey, knowledge assessment, and course evaluation. UW faculty delivered HIV clinical topics through ten 2-hour weekly sessions from the perspectives of practicing HIV medicine in developed and developing settings. HCWs viewed lectures through Adobe Acrobat Connect Pro (Adobe Systems, San Jose, CA), and completed online homework on HIV Web Study (http://depts.washington.edu/hivaids/) and online quizzes. HCWs, who met the same passing requirements as UW students by attending 80% lectures, completing ≥90% homework, and achieving a cumulative ≥70% grade on quizzes, were awarded a certificate. 369 HCWs at 33 sites in 21 countries joined the course in 2011, a >15-fold increase since the course was first offered in 2007. The majority of HCWs came from Africa (72%), and most were physicians (41%), nurses (22%), or midlevel practitioners (20%). 298 HCWs (81%) passed all requirements and earned a certificate. In a paired analysis of pre- and post-course HIV knowledge assessments, 56% of HCWs improved their post-course score (p<0.0001) with 27% improving by at least 30%. In the course evaluation, most HCWs rated the course as excellent (53%) or very good (39%). CONCLUSIONS: This online HIV course demonstrated that opening a Western graduate medical and nursing curriculum to HCWs in resource-limited settings is feasible, popular, and valuable, and may address logistic and economic barriers to the provision of high quality education in these settings.

Computer-facilitated rapid HIV testing in emergency care settings: provider and patient usability and acceptability.

Providers in emergency care settings (ECSs) often face barriers to expanded HIV testing. We undertook formative research to understand the potential utility of a computer tool, "CARE," to facilitate rapid HIV testing in ECSs. Computer tool usability and acceptability were assessed among 35 adult patients, and provider focus groups were held, in two ECSs in Washington State and Maryland. The computer tool was usable by patients of varying computer literacy. Patients appreciated the tool's privacy and lack of judgment and their ability to reflect on HIV risks and create risk reduction plans. Staff voiced concerns regarding ECS-based HIV testing generally, including resources for follow-up of newly diagnosed people. Computer-delivered HIV testing support was acceptable and usable among low-literacy populations in two ECSs. Such tools may help circumvent some practical barriers associated with routine HIV testing in busy settings though linkages to care will still be needed.

Patient and staff perspectives on the use of a computer counseling tool for HIV and sexually transmitted infection risk reduction.

PURPOSE: To explore use of an interactive health communication tool--"Computer Assessment and Risk Reduction Education (CARE) for STIs/HIV." METHODS: This was a mixed method study utilizing participant observation and in-depth interviews with patients (n = 43), and focus groups with staff (5 focus groups, n = 41) from 5 clinics in 3 states (1 Planned Parenthood, 1 Teen, 2 STD, and 1 mobile van clinic). Data were managed using Atlas.ti. Inter-rater reliability of qualitative coding was .90. RESULTS: Users were 58% nonwhite with mean age 24.7 years (74% < 25). Patients could use CARE with minimal to no assistance. Time for session completion averaged 29.6 minutes. CARE usefulness was rated an average of 8.2 on an ascending utility scale of 0 to 10. Patient themes raised as strengths were novelty, simplicity, confidentiality, personalization, and plan development, increased willingness to be honest, lack of judgment, and a unique opportunity for self-evaluation. Staff themes raised as strengths were enhanced data collection, handout customization, education standardization, behavioral priming, and expansion of services. Patient limitation themes included limited responses and lack of personal touch. Staff limitation themes were selecting users, cost, patient-provider role, privacy, and time for use. CONCLUSIONS: CARE was well-received and easily usable by most (especially 18-25-year-olds). Patient and staff perceptions support the use of CARE as an adjunct to usual practice and as a method to expand services. Honesty, reduced time constraints, and lack of judgment associated with CARE appeared to enhance self-evaluation, which may prove an important component in moving patients forward in the behavior change process.

CARE+ user study: usability and attitudes towards a tablet pc computer counseling tool for HIV+ men and women.

CARE+ is a tablet PC-based computer counseling tool designed to support medication adherence and secondary HIV prevention for people living with HIV. Thirty HIV+ men and women participated in our user study to assess usability and attitudes towards CARE+. We observed them using CARE+ for the first time and conducted a semi-structured interview afterwards. Our findings suggest computer counseling may reduce social bias and encourage participants to answer questions honestly. Participants felt that discussing sensitive subjects with a computer instead of a person reduced feelings of embarrassment and being judged, and promoted privacy. Results also confirm that potential users think computers can provide helpful counseling, and that many also want human counseling interaction. Our study also revealed that tablet PC-based applications are usable by our population of mixed experience computer users. Computer counseling holds great potential for providing assessment and health promotion to individuals with chronic conditions such as HIV.