The Positive Choice program identified a high prevalence of ongoing risky behaviors among HIV-positive adults in medical care and achieved significant cessation of illicit drug use and unprotected sex at the group-level, and modest individual-level reductions in days of ongoing drug use and number of casual sex partners compared to the control group. The large trial sample included several important US sub-groups—African-Americans (50% of sample), men who have sex with men (51%), and women (21%)—that are representative of urban, HIV-positive adults in care in the US. Losses to follow-up were low and balanced by randomization group.
may be an important adjunct to risk-reduction efforts in routine clinical practice. It incorporates or exceeds all criteria for a best-evidence HIV behavioral intervention as determined by the CDC's HIV/AIDS Prevention Research Synthesis Team, such as prospective design, random assignment to study arms, at least 3 months of follow-up, and at least 70% retention for follow-up 
. Positive Choice
extends previous efforts since behavioral interventions for HIV prevention have traditionally focused on sexual behaviors. A review of the recent literature (2000–2004) found only 3 out of 18 (17%) best-evidence behavioral interventions attempted to reduce drug use, either alone or combined with sexual risks 
. Drug and alcohol use are associated with increased risky sexual behaviors and present additional barriers to optimal medical care, reinforcing the need for integrated risk-reduction strategies. Positive Choice
addresses multiple risky behaviors and frames these behaviors as a hazard to the patient's own health, in addition to HIV transmission. Positive Choice
also illustrates a key public health principle—that modest changes at the individual level may actually achieve significant effects at the group level. An additional advantage of Positive Choice
is its brevity, requiring less than an hour of patients' time for each session before the medical appointment and no continuing medical education for providers given the ease of use of the Cueing Sheets.
HIV care providers' usual screening for and counseling about risky behaviors may be impeded by concerns about stigmatizing the patient, jeopardizing trust between patient and provider, or ethical issues, such as the “duty to warn” HIV-negative sex partners 
. It is not surprising that a recent survey found overall low rates of transmission prevention counseling to both newly diagnosed and established HIV-positive patients 
. The Positive Choice
program successfully overcame providers' traditional barriers to consistent risk screening and counseling by conducting the risk assessment and delivering tailored risk-reduction counseling prior to the medical appointment. Because health risk information was shared with the provider in real time via the Cueing Sheet, the program supported the patient-provider relationship for improved disease management and risk-reduction counseling. An intervention that focused solely on the threat of HIV transmission would have likely brought up patient and provider resistance. By framing risky behaviors as a concern for the patient's own health as well as transmission to others, Positive Choice
reduced potential stigma and avoided conceptualizing the individual simply as a vector of disease.
We believe that these findings are generalizable to other urban, diverse, English-speaking populations in the US. We make no claims, however, about other settings. Given the worldwide HIV epidemic, future research should explore the efficacy of Positive Choice in other languages, sociocultural contexts, or populations. While our findings are limited to risk reduction in HIV-positive individuals, similar strategies may be effective at promoting behavior change in populations at risk for HIV, as well as assessing and counseling persons suffering from other chronic conditions such as diabetes or hypertension, and their underlying risk factors, such as nutrition, physical activity, and smoking.
We recognize several possible limitations. First, there may have been differential disclosure of sensitive behaviors. This bias may have been further enhanced by the possible reporting of risky behaviors to providers through Cueing Sheets. We are unable to validate participants' self-reports, but remain convinced that computerized questionnaires yield more disclosure of sensitive topics than do other, traditional methods, such as face-to-face interviews or paper questionnaires 
. Although our previous research found that sharing risk information with providers did not inhibit patients' disclosure of sensitive behaviors 
, we have no evidence to deny this occurring in the present study. Second, our risk assessment questions did not assess contextual sexual risk-reduction strategies, such as serosorting (seeking sex only with other HIV-positive people) or strategic positioning (adopting a receptive role with HIV-negative or unknown status partners) 
. Our trial emphasized outcomes that are reframed as potential acquisition risks to the participant (e.g. new sexually transmitted infections) rather than HIV transmission risks to partners. Future studies may explore these contextual aspects of partner selection and related sexual risk-reduction strategies. Third, we failed to find a significant intervention effect for alcohol risk and speculate that risky drinking might differ from other risky behaviors. Given equivalent reductions by the control group, risky drinking may be particularly responsive to repeated self-assessments. Alternatively, our intervention might have been too brief or the Positive Choice
Video Doctor model might not be well suited to address risky drinking. Further complicating the topic, alcohol use is legal, socially sanctioned, and may be consumed appropriately. Perhaps risky drinking is more difficult to define than other risks. We recommend that future studies explore differential intervention effects by type of risk. Fourth, absolute risk behavior declined over time among all participants. For example, the proportion of each control group reporting cessation of risk ranged from 14% for any drug use at 6 months (1-[82/95]
0.137) to 41% for any risky drinking at 6 months (1-[53/90]
0.411). These declines are consistent with results from other randomized controlled trials of behavioral interventions with HIV-positive individuals 
and may be explained by the Hawthorne effect, i.e., participants reported declines because they knew they were being studied. Alternatively, declines may have resulted from regression toward the mean, i.e., participants exceeding risk thresholds at enrollment were above their individual averages and fell back to or below their averages at follow-up. The Hawthorne effect in particular is well known in HIV prevention research 
. This phenomenon, considered a by-product of repeated self-assessments of behavior, is disparately regarded as a major challenge to internal validity 
or as a potential intervention in itself 
. Our findings illustrate the complexities inherent in understanding and changing human behaviors. Finally, the discrete contribution of each of the 3 intervention components—Video Doctor counseling, patient Educational Worksheet, or provider Cueing Sheet—remains unknown and worthy of future study.
Responding to calls for “prevention with positives” interventions, the Positive Choice program was designed to support medical providers' risk-reduction efforts with minimal additional burden. Positive Choice's Video Doctor counseling, patient Educational Worksheet, and provider Cueing Sheet achieved important reductions in risky behaviors among HIV-positive persons. Given the challenges of changing human behavior, our results are notable. Positive Choice is an efficacious adjunct to routine medical care for HIV-positive patients with the capacity to have important clinical and public health impact.