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1.  A Qualitative Assessment of Emergency Department Patients’ Knowledge, Beliefs, Attitudes, and Acceptance towards Revised HIV Testing Strategies 
Objectives
The objective of this study was to explore emergency department (EDs) patient’s knowledge, beliefs, attitudes, and acceptability towards revised human immunodeficiency virus (HIV) testing recommendations.
Methods
Participants were recruited in proportion to the racial, sex, and ethnic makeup of the study ED. Interviewers presented participants with a stimulus followed by questions about opt-out consent, elimination of separate written consent, and curtailed counseling. Three investigators coded all transcripts using an iterative coding strategy until thematic saturation was achieved.
Results
Thirty-four semi-structured, in-depth, individual interviews were conducted, including five with patients ages 13 to 17 years, and five with Spanish-speaking patients. Nineteen (56%) participants were women. The mean age was 31 years (SD ±12 years). Most were Hispanic (38%), or African American/black (44%). Only one (2.9%) participant knew about the revised testing recommendations. Participants believed opt-out consent would result in increased testing, but this was confounded by misunderstanding of the consent process: “so the opt-out is, you basically don’t have a choice.” Participants thought eliminating separate written consent was a positive change but that it could result in people being tested without their knowledge. Attitudes diverged over curtailed counseling, but participants felt patients “should have options” for counseling because “everybody isn’t the same.”
Conclusions
Emergency department patients were unaware of revised HIV testing recommendations. Most felt opt-out consent and elimination of separate written consent were positive changes but could result in a patient being tested without his or her knowledge. The response to curtailed counseling was polarized but participants agreed on the need to accommodate personal preferences. This information may be useful to when designing ED-based HIV testing programs.
doi:10.1111/acem.12090
PMCID: PMC3607454  PMID: 23517261
2.  Unconsented HIV Testing in Cases of Occupational Exposure: Ethics, Law, and Policy 
Post-exposure prophylaxis (PEP) has substantially reduced the risk of acquiring human immunodeficiency virus (HIV) after an occupational exposure; nevertheless, exposure to HIV remains a concern for emergency department providers. According to published guidelines, PEP should be taken only when source patients are HIV positive or have risk factors for HIV. Initiating PEP when source patients are uninfected puts exposed persons at risk from taking toxic drugs with no compensating benefit. Forgoing PEP if the source is infected results in increased risk of acquiring HIV. What should be done if source patients refuse HIV testing? Is it justifiable to test the blood of these patients over their autonomous objection? The authors review current law and policy and perform an ethical analysis to determine if laws permitting unconsented testing in cases of occupational exposure can be ethically justified.
doi:10.1111/j.1553-2712.2012.01453.x
PMCID: PMC3473147  PMID: 22994417
3.  Given Resource Constraints, It Would Be Unethical To Divert Antiretroviral Drugs From Treatment To Prevention 
Health affairs (Project Hope)  2012;31(7):1537-1544.
Striking advances in HIV prevention have set the stage for renewed debate on setting priorities in the fight against HIV/AIDS. Two new prevention strategies preexposure prophylaxis and treatment as prevention—use antiretroviral drugs for prevention of HIV/AIDS in addition to treating patients. The potential for success of these new prevention strategies sets up an ethical dilemma: where resources are limited and supplies of lifesaving antiretroviral medications are insufficient to treat those currently living with HIV, how should these resources be divided between treatment and prevention? This article explores several ethical principles used in formulating public health policy. Assuming that limited resources are available for spending on drugs, we conclude that it would be unethical to watch patients with treatable AIDS worsen and die, even with supportive care, so that medications for treatment can be diverted for prevention.
doi:10.1377/hlthaff.2012.0071
PMCID: PMC3572856  PMID: 22778343
6.  Educational Effectiveness of an HIV Pretest Video for Adolescents: A Randomized Controlled Trial 
Pediatrics  2011;127(5):911-916.
OBJECTIVE:
The goal of this study was to compare the effectiveness of a youth-friendly HIV video with in-person counseling in conveying HIV knowledge and obtaining consent for HIV testing among adolescent patients of an urban emergency department.
METHODS:
A 2-armed, randomized controlled trial was conducted on a convenience sample of 200 stable, sexually active people aged 15 to 21 years in an urban emergency department. Participants in both the in-person counseling group and the video intervention group completed preintervention and postintervention HIV knowledge measures. HIV knowledge was the primary outcome measure, and consent for HIV testing was the secondary outcome. Characteristics associated with voluntary HIV testing were identified.
RESULTS:
Of 333 eligible people, 200 agreed to participate. There was no difference in preintervention HIV knowledge scores between groups. Mean postintervention knowledge scores differed significantly between the video (78.5% correct) and the counselor (66.3% correct) (P < 0.01) groups. Overall, 51% of the video group accepted HIV testing compared with 22% in the control group (P < .01). Watching the video (OR: 3.6 [95% CI: 1.8–7.2]), being female (OR: 2.1 [95% CI: 1.0–4.2]), engaging in oral sex (OR: 2.8 [95% CI: 1.4–5.9]), and being older than 18 years (OR: 3.8 [95% CI: 1.8–7.8]) were all positively associated with testing.
CONCLUSIONS:
A youth-friendly HIV educational video improved adolescents' HIV knowledge and increased their participation in HIV testing more than in-person counseling. video-based HIV counseling can perform as well or better than in-person counseling for adolescents in the ED.
doi:10.1542/peds.2010-1443
PMCID: PMC3081187  PMID: 21482613
HIV; education; video; emergency department; adolescent sexual behavior
7.  Orbital Fracture Clinical Decision Rule Development: Burden of Disease and Use of a Mandatory Electronic Survey Instrument 
Academic Emergency Medicine  2011;18(3):313-316.
Objectives
In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs), and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection.
Methods
National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form in order to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI.
Results
Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9%, and took less than five minutes to complete.
Conclusions
National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory electronic data collection instrument linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs.
doi:10.1111/j.1553-2712.2011.01017.x
PMCID: PMC3311987  PMID: 21352401
8.  Adherence to Highly Active Antiretroviral Treatment in HIV-Infected Rwandan Women 
PLoS ONE  2011;6(11):e27832.
Background
Scale-up of highly active antiretroviral treatment therapy (HAART) programs in Rwanda has been highly successful but data on adherence is limited. We examined HAART adherence in a large cohort of HIV+ Rwandan women.
Methods
The Rwanda Women's Interassociation Study Assessment (RWISA) was a prospective cohort study that assessed effectiveness and toxicity of ART. We analyzed patient data 12±3 months after HAART initiation to determine adherence rates in HIV+ women who had initiated HAART.
Results
Of the 710 HIV+ women at baseline, 490 (87.2%) initiated HAART. Of these, 6 (1.2%) died within 12 months, 15 others (3.0%) discontinued the study and 80 others (19.0%) remained in RWISA but did not have a post-HAART initiation visit that fell within the 12±3 month time points leaving 389 subjects for analysis. Of these 389, 15 women stopped their medications without being advised to do so by their doctors. Of the remaining 374 persons who reported current HAART use 354 completed the adherence assessment. All women, 354/354, reported 100% adherence to HAART at the post-HAART visit. The high self-reported level of adherence is supported by changes in laboratory measures that are influenced by HAART. The median (interquartile range) CD4 cell count measured within 6 months prior to HAART initiation was 185 (128, 253) compared to 264 (182, 380) cells/mm3 at the post-HAART visit. Similarly, the median (interquartile range) MCV within 6 months prior to HAART initiation was 88 (83, 93) fL compared to 104 (98, 110) fL at the 12±3 month visit.
Conclusion
Self-reported adherence to antiretroviral treatment 12±3 months after initiating therapy was 100% in this cohort of HIV-infected Rwandan women. Future studies should explore country-specific factors that may be contributing to high levels of adherence to HAART in this population.
doi:10.1371/journal.pone.0027832
PMCID: PMC3219684  PMID: 22114706
10.  Conducting Research in Disease Outbreaks 
doi:10.1371/journal.pntd.0000335
PMCID: PMC2669128  PMID: 19399167

Results 1-10 (10)