MOBILE SCREENING TO IDENTIFY AND FOLLOW-UP WITH HIGH RISK, HIV NEGATIVE YOUTH.

While rates of new cases of HIV have been decreasing or stabilizing among many population groups, HIV risk remains exceptionally high for young men who have sex with men (MSM),1,2 youth with substance use disorders,3 and recently incarcerated youth.4 Young MSM, and in particular young Black MSM, not only face increased risk due to unprotected sexual behaviors, but also because many have older sexual partners who are more likely to be HIV positive.1,2 Youth with substance use disorders face increased risk if they inject drugs, and also because heavy drinking, marijuana use, and illicit drug use may be associated with a greater number of sexual partners, and with less frequent condom use.5 Young men who have recently been incarcerated report more frequent unprotected sex, and are more likely to report having sex while under the influence of drugs and alcohol than those not recently incarcerated.4 Many young people at greatest risk of HIV-infection have limited or inconsistent access to primary care,6–8 and thus may have limited access to preventive care, HIV testing, and related health education. In fact, approximately 60 percent of HIV infected young people remain undiagnosed.3 In recent years, programs to increase HIV testing in non-traditional settings,9,10 including routine testing programs in hospital emergency departments (ED), have reached many patients with undiagnosed HIV, and have facilitated linkage to care for members of high need populations. Still, young ED patients frequently decline testing and are less likely to accept a test offered by hospital staff compared to older patients in the same setting.11 Furthermore, routine testing programs are not designed to identify and provide prevention services to youth who test HIV negative but continue to engage in behaviors that greatly increase their HIV risk. Due to a lack of time and high existing workloads, clinical staff in EDs and other high volume settings may not routinely screen youth for substance use or sexual risks that increase HIV risk, especially if the patient's presenting medical condition does not appear directly related to these risk behaviors. Opportunities to engage high-risk youth may also be missed because many young patients do not disclose substance use or sexual risk when asked by medical staff because they fear legal consequences and/or stigma.7 Moreover, young people who test negative in a high volume clinical setting, but do not receive adequate health education, may not understand the need to re-test for HIV if they receive a negative test result and have been recently exposed to HIV,12 or if they test negative and continue to engage in risky behaviors. Previous research has shown that young patients are more comfortable reporting substance use and sexual risk behaviors via computer compared to an in-person screening, because they do not expect a computer will judge them negatively, but expect that a person will.13,14 Studies have also shown computer-based interventions can increase HIV test rates among patients in high volume clinical settings, including testing by patients who declined tests offered by hospital staff.11 Research with a sample of ED patients who declined HIV testing offered by a triage nurse also indicates an apparent association between reporting problematic substance use via a computer-based intervention and then accepting an HIV test offered by computer.15 Study Objectives The primary objectives of the current research were to: develop a tablet-based intervention to increase HIV testing and facilitate more complete behavioral risk reporting among youth; to examine the feasibility and preliminary efficacy of the tablet-based intervention in a high volume clinical setting; and to examine the feasibility and preliminary efficacy of a text message-based follow up protocol for participants who tested HIV negative and reported increased risk. To increase HIV testing among youth, including youth who decline tests when offered, and to facilitate more thorough behavioral risk reporting, the current research developed a computer-based intervention which incorporated an automated screening tool to facilitate self-reporting of substance use and sexual risk. Because, as mentioned earlier, patients may not understand the need for repeat testing,12 the current research also developed a text message based follow-up protocol to encourage participants who tested HIV negative but reported current substance use, sexual risk factors, or recent incarceration to re-test in 90 days. Once the automated screening tool had been developed, the research team piloted the intervention in a high volume, urban ED to examine preliminary feasibility and acceptability among a sample of young people who initially declined HIV tests offered by a nurse at triage. The main objectives of the current study were to examine the following questions that emerged during the development of the technology and the pilot study protocol: ED-based Screening Would participants aged 18-24, who initially declined HIV tests, participate in the study? Would participants complete the substance use and sexual risk screenings? Would participants report risk that could potentially warrant re-testing, and related follow-up via text message? Text Message Protocol Would participants provide their mobile phone numbers and agree to receive text messages? Would participants respond to text messages sent over several months? Would participants return for HIV re-testing after the 12 week window period?