In this randomized controlled trial, an audiocomputer-assisted interview system–based feedback intervention about HIV infection risk from injection drug use and risky sexual behaviors did not improve uptake of opt-in, nontargeted (universal) HIV screening among this random sample of English-speaking, 18- to 64-year-old ED patients. The study findings indicate that the intervention used in this study is not a useful means of improving HIV screening among these patients. The failure of the intervention might be because the feedback messages concerned only the risk for HIV infection from the behaviors themselves and did not advocate for HIV screening more generally. Participants had to infer the need for HIV screening according to the feedback. Self-perception of risk for HIV infection, beliefs about the need for and value of testing, self-awareness about HIV risk, fears of testing, and other factors might have influenced that inference. It is possible that directly advising for HIV screening in the feedback overrode self-reflection and inference about need for HIV screening. Other reasons why the intervention failed include that the focus of the questions and responses on higher HIV risk behaviors might have led some patients to discount the need for HIV screening; the audiocomputer-assisted interview system feedback might have been too impersonal, and instead an in-person intervention is necessary; or the feedback messages might have been too limited in scope and depth, and further exploration to include thoughts, perceptions, feelings, and the nature of the behaviors and events in relation to a need for HIV screening is needed for this type of intervention. Future studies should investigate these possibilities.
Although greater reported HIV risk has been linked to ever having been tested for HIV (which includes being tested as part of a medical examination, being required to be tested, and having requested to be tested),17,18
the association between reported HIV risk and uptake of screening when it is offered has not been fully explored. Previous research in the ED has found that declining HIV screening partially depends on the perception of being at risk for HIV.1–7
We presumed, by extension of this logic, that patients who report more HIV risk behaviors would be more aware of their risk, would see the value of HIV screening for them, and therefore would be more likely to accept HIV screening. Much to our surprise, there was no relationship between reported HIV risk and uptake of screening. We also anticipated that because, as shown in our previous investigation, undergoing a risk assessment through our questionnaire is modestly associated with an increase in self-perceived HIV risk, higher self-perceived HIV risk would mediate greater uptake in HIV screening.8
However, uptake of screening was related to an increase in self-perceived HIV risk only for female participants, regardless of whether feedback was provided. Our previous study did show that self-perceived HIV risk was associated with reported HIV risk among women but not men.8
We do not know the reason for this difference response by sex, given that the proportion of female (14.7%) and male (12.6%) participants with an increase in self-perceived HIV risk was similar (Δ =2.1%; 95% CI −7.9% to 3.7%). As shown in previous studies, the relationship between self-perceived current or future risk for an HIV infection and reported HIV risk might not be strong or may even be discrepant.19–26
The interrelationship of having engaged in HIV risk behaviors, self-perception of the risk for having an HIV infection, and willingness to be screened for HIV also appears to be quite complex and should be the subject of future research.
Uptake of HIV screening was approximately 55% among study participants compared with 40% in our previous study, in which participants did not complete a risk assessment before being asked to undergo HIV screening.1
This finding suggests that asking patients about their HIV risk behaviors through an audiocomputer-assisted, interview system–based, HIV risk assessment questionnaire may improve uptake of screening by 15%, regardless of a feedback intervention about HIV risk. However, because participants were not randomized to a risk assessment or no risk assessment, we cannot definitely conclude that this type of HIV risk assessment alone will increase uptake of HIV screening. Future studies might investigate using a risk assessment alone as an intervention itself to increase uptake of HIV screening in EDs, whether an opt-out or an opt-in approach is used.