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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Acad Emerg Med. Author manuscript; available in PMC Sep 15, 2011.
Published in final edited form as:
PMCID: PMC3173950
NIHMSID: NIHMS322149

Effectiveness of Increasing Emergency Department Patients’ Self-perceived Risk for Being Human Immunodeficiency Virus (HIV) Infected Through Audio Computer Self-interview–based Feedback About Reported HIV Risk Behaviors

Abstract

Objectives

Prior research has demonstrated that emergency department (ED) patient acceptance of human immunodeficiency virus (HIV) screening is partially dependent on patients’ self-perceived risk of infection. The primary objective of this study was to determine the effectiveness of audio computer-assisted self-interview (ACASI)-based feedback. The intervention aimed to increase patient’s self-perceived risk of being HIV infected by providing immediate feedback on their risk behaviors.

Methods

This 1-year, randomized, controlled trial at a U.S. ED enrolled a random sample of 18- to 64-year-old subcritically ill or injured adult patients who were not known to be HIV infected. All participants completed an anonymous, ACASI-based questionnaire about their HIV risk behaviors related to injection drug use and sex, as well as their self-perceived risk for being HIV infected. Participants were randomly assigned to one of two study groups: an intervention group in which participants received immediate ACASI-based feedback in response to each of their reported risk behaviors or a no-intervention group without feedback. Participants were asked to indicate their level of HIV risk on a five-point scale before and after they answered the questions. Change in level of self-perceived HIV risk was calculated and compared by study group using Pearson’s chi-square test. An HIV risk behavior score that summarized reported HIV risk behavior was devised. Because HIV risk behaviors differ by sex, scores were calculated separately for each sex. Linear regression models that adjusted for study group and same subject covariance were employed to determine if higher HIV risk behavior scores were associated with an increase in self-perceived HIV risk.

Results

Of the 566 trial participants, the median age was 29 years (interquartile range [IQR] = 22–43 years), 62.2% were females, and 66.9% had been tested previously for HIV. After answering the reported HIV risk behavior questions, 12.6% of participants had an increase, 79.9% had no change, and 7.5% had a decrease in self-perceived HIV risk. Of the 46.6% of participants who initially indicated that they were not at risk for HIV, 11.4% had an increase in self-perceived HIV risk after answering the reported HIV risk behavior questions. Change in self-perceived HIV risk did not differ by study group (p = 0.77). There were no differences in reported HIV risk scores between the intervention and no-intervention groups for females (p = 0.78) or males (p = 0.86). In the linear regression models, a greater increase in self-perceived HIV risk was associated with higher reported HIV risk behavior scores for females (β = 0.59, 95% confidence interval [CI] = 0.15, 1.04) but not for males (β = 1.00, 95% CI = −0.13 to 2.14).

Conclusions

Some ED patients can be moved, although modestly, to recognize their risk for being HIV infected by asking about their HIV risk behaviors. However, ACASI-based feedback messages about HIV risk behaviors do not increase subjects’ self-perceived HIV risk. Female ED patients appear to increase their self-perceived HIV risk more than males when queried about their HIV risk behaviors.

Keywords: HIV, emergency medicine, risk-taking, sexual behavior, attitude to health, substance abuse, intravenous

Prior research has demonstrated that uptake of opt-in human immunodeficiency virus (HIV) screening by emergency department (ED) patients is partially dependent on their self-perceived risk for having an HIV infection. Those who do not believe themselves to be at risk are less likely to agree to be screened for HIV in the ED.15 Many of these patients actually are at risk for being HIV infected, because of their prior or current HIV risk behaviors. However, they might be unaware of or not concede this risk. Self-perceived risk could then be the target of an intervention to increase uptake of HIV screening.

One potential way to increase self-perceived risk for being infected with HIV is by helping patients acknowledge their prior HIV risk behaviors through the use of an HIV risk assessment. If ED patients are also given immediate tailored feedback about their prior HIV risk behaviors, they might increase their self-perceived HIV risk even more. Self-administered HIV risk assessments and interventions that require minimal staff involvement would be ideal in the ED setting. An audio computer-assisted self-interview (ACASI)-based approach could satisfy these needs. ACASI-based techniques also have the advantages of enhanced privacy of responses, easy delivery, standardized content, and better participant comprehension because the questionnaire components are displayed on a screen and read aloud to participants. ACASI improves the veracity of participant responses to questions about sexual risk behaviors and drug use compared to in-person–based interviewing techniques.611

We know of no published studies evaluating the effectiveness of ACASI techniques to increase self-perceived risk of being HIV infected. In a study that did not involve feedback about reported HIV risk behaviors or an ACASI, participants were more likely to change their self-perceived risk for a future HIV infection when asked about their HIV risk behaviors using an intensive timeline follow-back rather than a standard interview.12 Computer-delivered tailored feedback techniques have been successful in interventions that address HIV risk reduction behaviors in adolescents,13 and a multimedia, audio-narrated, interactive computer-based tool for conducting sexual risk assessments and providing risk reduction counseling is under study in outpatient clinic and community outreach settings.14 Calderon et al.15 are also studying a multimedia computer-based approach to assessing HIV risk in the context of HIV testing in the ED.

In our randomized, controlled trial we used an ACA-SI-based system to query ED patients about their self-perceived risk for being infected with HIV and about their HIV risk behaviors. Participants were randomly assigned to receive tailored, immediate, ACASI-based feedback about these risk behaviors or no feedback. The first objective of this trial was to determine if providing ACASI-based feedback increased self-perceived risk for being infected with HIV. The second objective was to determine if an increase in self-perceived HIV risk is related to the reporting of more HIV risk behaviors. If so, then conducting HIV risk assessments even without feedback might help patients become more aware of their risk for an HIV infection. The third objective was to identify particular topics from the HIV risk behavior assessment that had a greater influence on increasing patients’ self-perceived HIV risk. Knowing which reported HIV risk behaviors influence self-perceived HIV risk could help determine the content and focus of interventions to increase self-perceived HIV risk.

METHODS

Study Design

This study was a randomized, controlled trial involving the ACASI-based administration of either an intervention (with feedback) or a no-intervention (without feedback) version of an anonymous questionnaire about self-perceived HIV risk and reported HIV risk behaviors. The self-perceived HIV risk refers to patients’ perception that they currently could be HIV infected, as opposed to their future risk for an HIV infection. The institutional review board of the hospital approved the study and the use of verbal consent for patient participation.

Study Setting and Population

The study was conducted at an urban, academic, not-for-profit, adult ED in New England from October 1, 2007, until September 30, 2008. During this period, the ED had approximately 54,000 visits for noncritical illness or injury by English-speaking 18- to 64-year-olds. We do not have a standing HIV screening program.

We employed a three-level random selection plan to enroll patients for possible inclusion. The details of this plan are described elsewhere.5 We randomly selected 16 dates per month for each of the 12 months we conducted the study. The shifts for those 16 dates per month were randomly selected using a weighting scheme that was based on patterns in ED patient volume that occur during a typical 24-hour period. During each shift we randomly selected 80% of the patients present in the ambulatory care and the urgent care areas of the ED based on their terminal medical record number digit.

A research assistant (RA) assessed the eligibility of these randomly selected ED patients for possible inclusion in the study by reviewing their ED patient medical records and through an in-person assessment. Patients were eligible for the study if they were 18 to 64 years old; English-speaking; not critically ill or injured; not prison inmates, under arrest, or on home confinement; not presenting for a psychiatric illness; not known to be HIV infected; not participating in an HIV vaccine trial; not intoxicated; and not having a physical disability or mental impairment that prevented providing consent or participating in the study. No incentives were offered to participants. ED staff were not permitted to encourage or refer patients to be in the study.

Study Protocol

Patients who agreed to have their eligibility confirmed were queried about their demographic characteristics and HIV testing history using instruments developed and employed in prior studies.5,16 All patients who agreed to have their eligibility confirmed by the RA and were eligible for the study were invited to enroll. Patients were informed that as part of the study they would be asked through an anonymous, private, ACA-SI-based questionnaire about their risk for an HIV infection from injection drug use and sex. They were also informed that they would be randomly assigned to either an intervention group that gave feedback to their answers or a no-intervention group. They were not informed about the intent of the intervention or the ultimate purpose of the study. Patients who agreed to participate in the study were randomly assigned to the intervention or no-intervention groups using block randomization to ensure equal size study groups. Participants completed the ACASI-based “HIV risk questionnaire” (described in the Data Supplement S1, available as supporting information in the online version of this paper) using a tablet personal computer with headphones for the audio components. The questionnaire asked patients twice about their self-perceived risk for currently being HIV infected: once before questions about their reported HIV risk behaviors from injection drug use and sex and again after these questions. The no-intervention group received only the questionnaire, while the intervention group received the questionnaire plus ACASI-based feedback messages to their responses about their reported HIV risk behaviors.

The RA followed a strict protocol for reviewing ED paper medical records, approaching patients, confirming their eligibility, and administering the study. The RA underwent over 40 hours of mock study encounters to learn and demonstrate ability to perform the study protocol. The RA was directly observed performing the study each month by the principal investigator. Deviations from protocol were corrected.

Data Analysis

All analyses were conducted using STATA 9.2 (StataCorp, College Station, TX). The demographic characteristics and HIV testing history elements were summarized and compared between those who did and did not participate in the study and those randomized to the intervention and no-intervention study groups using the Wilcoxon rank-sum tests for age and Pearson’s chi-square tests for categorical variables. In all analyses, an α = 0.05 level of significance was used.

We summarized the proportion of responses to each item in the HIV risk questionnaire and compared responses by study intervention group using Pearson’s chi-square or Fisher’s exact tests. For self-perceived HIV risk, we used McNemar’s test to compare the proportions of participants who indicated that they did not believe themselves to be at risk in the post versus pre self-perceived HIV risk questions. We calculated the change in level of self-perceived HIV risk by subtracting the post and pre self-perceived HIV risk levels. Using Pearson’s chi-square test, we compared the distribution of changes in self-perceived HIV risk levels by intervention group, by sex across intervention groups, and by intervention group for those who indicated that they did not believe themselves to be at risk in the pre self-perceived HIV risk questions. We also compared the proportion of participants who had an increase in their self-perceived HIV risk levels by sex using two-sample tests of binomial proportions.

We devised a score to summarize reported HIV risk behaviors and compare the score to a change in self-perceived HIV risk. Higher scores represented a greater number of reported HIV risk behaviors. Participants received two points for “yes” responses to each question about HIV risk behaviors, one point for “I don’t know,” and zero points for “no” responses. For questions about the number of sexual partners, participants received six points for “21 or more,” five for “11 to 20,” four for “6–10,” three for “2–5,” two for “1,” one for “I don’t know,” and none for “no” responses. Scores were not calculated for respondents who refused to answer any part of the questionnaire. The reported HIV risk behavior score was the sum of each participant’s responses divided by the total possible points for all questions. The maximum scores possible were 36 for females and 61 for males. We calculated summary statistics of the reported HIV risk behavior scores by sex and study group assignment. We compared reported HIV risk behavior scores by study group for each sex using Student’s t-tests.

We evaluated an increase in self-perceived HIV risk as a function of reported HIV risk behavior scores using linear regression models that accounted for same-subject covariance. Linear regression models were adjusted for study group assignment. Separate models were formed for males and females. Beta coefficients with corresponding 95% confidence intervals (CIs) and adjusted R2 values were estimated for these models.

To identify specific topics from the reported HIV risk behavior questions that were associated with an increase in self-perceived HIV risk, we employed polytomous logistic regression models that accounted for same-subject covariance. The base outcome for the models was no change in self-perceived HIV risk level regardless of initial self-perceived HIV risk level. The other outcomes were an increase or a decrease in self-perceived HIV risk level. Only the increase in self-perceived HIV risk level is reported in this article. The independent variables used were the responses to the reported HIV risk behavior questions. We created a point scale similar to the reported HIV risk behavior score described above to indicate the values that comprised the independent variables. The reference groups for the primary questions were participants who indicated that they had not engaged in that particular HIV risk behavior. For the follow-up questions, the reference groups were participants who did not receive that question. Increasing points were assigned for having received that question and providing a response that represented a greater risk. All models were adjusted for study group assignment. Separate models were formed for males and females. Odds ratios (ORs) with corresponding 95% CIs were estimated.

RESULTS

Description of Study Participants

During the 12-month study period, 2,775 English-speaking subjects were enrolled. A total of 566 patients completed the trial. Figure 1 depicts the results of eligibility assessments through study group assignment and the major reasons for study ineligibility, refusing eligibility assessment, and accepting or declining study enrollment.

Figure 1
Eligibility assessment and enrollment flow diagram. 1 Percentages do not total 100% because multiple reasons for ineligibility were possible.

Table 1 provides a comparison of ED patients eligible for the study who accepted or declined study enrollment and a comparison of participants by study group assignment. Patients who enrolled were on average younger, and more were Hispanic, or never married, had more years of formal education, had previously been tested for HIV, or had ever donated blood. There were no differences in demographic characteristics or history of HIV testing between those randomized to the intervention versus no-intervention groups. Of note, from the eligibility screening of ED patients for this study, we found that 1.2% of the random sample of 18- to 64-year-olds knew that they are HIV infected.

Table 1
Demographic Characteristics and HIV Testing History by Enrollment Status and Study Arm Assignment

Self-perceived HIV Risk

Table 2 provides the proportions of participant responses to the pre and post questions about self-perceived HIV risk. Nearly half of the participants, pre and post, did not view themselves at risk for being HIV infected. The proportions of participants who did not perceive themselves to be at risk was the same post vs. pre for all participants (45.9% vs. 46.6%; p = 0.59) and for those in the intervention (43.5% vs. 45.6%; p = 0.47) and no-intervention groups (48.4% vs. 47.7%; p = 1.00).

Table 2
Responses to the HIV Risk Questionnaire by Study Arm Assignment

Table 3 shows the proportion of participants who increased, decreased, or did not change (post vs. pre) their self-perceived HIV risk by intervention group and sex. There were no differences in the distribution of change in level of self-reported HIV risk between the intervention and no-intervention groups for all participants (p = 0.77) and for females (p = 0.62) and males (p = 0.74), by study group assignment.

Table 3
Change in Self-perceived HIV Risk by Study Arm Assignment and Sex

Excluding the nine participants who replied “don’t know” about their self-perceived HIV risk, 12.6% of participants increased, 79.9% had no change, and 7.5% decreased their level of self-perceived HIV risk. The proportions of females (13.0%) and males (11.9%) who increased their level of self-perceived risk were similar (p = 0.68). Of the 263 participants who initially indicated (pre) that they were not at risk, 9.5% increased their (post) self-perceived HIV risk by one level, 1.9% increased it by two or more levels, and 88.6% did not change their self-perceived HIV risk. There were no differences in the distribution of change in level of self-perceived HIV risk by intervention group for those who initially indicated (pre) that they were not at risk for HIV (p = 0.64).

Reported HIV Risk Behaviors

Table 2 also shows the responses to the HIV risk behavior questions for all participants and by study group assignment. Of the 566 participants, 8.3% had injected drugs within the prior 10 years; 82.3% had one or more unprotected anal or vaginal heterosexual sex partners; 8.1% had exchanged (received and / or provided) anal or vaginal sex for money, drugs, or other things; 10.3% knew they had unprotected anal (including men who have sex with men [MSMs]) or vaginal sex with an injection drug user; 3% knew they had unprotected anal (including MSMs) or vaginal sex with someone known to be HIV infected; and 10.1% knew they had unprotected anal (including MSMs) or vaginal sex with someone who had a sexually transmitted disease / infection. Few of the males (4.7%) reported having anal receptive or insertive sex, and of these, 8 of the 10 had unprotected sex with one or more male partners. The distribution of reported HIV risk behaviors was similar by study group assignment, except for a slightly greater proportion of participants in the no-intervention group who reported having had unprotected heterosexual anal or vaginal sex with an injection drug user.

Increase in Self-perceived HIV Risk in Relation to Reported HIV Risk Behavior Scores

The reported HIV risk behavior scores for female participants ranged from 0 to 0.75, the median was 0.19 (interquartile range [IQR] = 0.11–0.28), and the mean (±standard deviation [SD]) was 0.21 (±0.14). The reported HIV risk behavior scores of male participants ranged from 0 to 0.48, the median was 0.12 (IQR = 0.07–0.16), and the mean (±SD) was 0.13 (±0.09). There were no differences in reported HIV risk scores between the intervention and no-intervention groups for females (p = 0.78) and males (p = 0.86).

In the linear regression models, increased self-perceived HIV risk was associated with higher reported HIV risk behavior scores for females (β = 0.59, 95% CI = 0.15 to 1.04; R2 = 0.03), but not for males (β = 1.00, 95% CI = −0.13 to 2.14; R2 = 0.02). For females but not for males, there was an increase in self-perceived HIV risk among females in the highest quartile of reported HIV risk behavior scores (β = 0.30, 95% CI = 0.08 to 0.51), but not for those in the second (β = 0.03, 95% CI = −0.17 to 0.23) or third (β = 0.14, 95% CI = −0.07 to 0.34) quartiles, compared to the lowest quartile.

Increase in Self-perceived HIV Risk and Specific HIV Risk Behavior Topics

Tables 4 (females) and 5 (males) present the results of the polytomous logistic regression analyses that aimed to identify specific HIV risk behavior topics associated with an increase in self-perceived HIV risk, compared to no change in self-perceived HIV risk. For females, all but one topic (vaginal / anal sexual intercourse with males) were related to an increase in self-perceived HIV risk. Injection drug–related behaviors demonstrated the strongest association with a change in self-perceived HIV risk for females. For males, seven topics were related to an increase in self-perceived HIV risk. Unprotected vaginal / anal intercourse with female injection drug users was the topic most strongly associated with an increase in self-perceived HIV risk among males. Results for the MSM topics were either unreliable or inestimable because of the small number of MSM in this sample.

Table 4
Relationship of Each Reported HIV Risk Behavior Topic to Change in Self-perceived HIV Risk (Females)

DISCUSSION

In this randomized, controlled trial, an ACASI-based immediate feedback message system pertaining to reported HIV risk behaviors from injection drug use and sex had no impact on increasing self-perceived risk for being HIV infected. However, approximately 13% of ED patients increased their self-perceived HIV risk when completing a questionnaire about their HIV risk behaviors, regardless of the presence or absence of ACASI-based feedback messages. More importantly, 11.4% of ED patients who initially did not perceive themselves to be at risk increased their self-perceived HIV risk when queried about their HIV risk behaviors. These results suggest that some ED patients can be moved, although modestly, to recognize their risk for being HIV infected by asking about the HIV risk behaviors they have engaged in within the previous 10 years. If, as has been shown in prior studies,15 uptake of opt-in HIV screening in the ED is related to patients’ self-perceived risk, then asking about HIV risk behaviors might lead to greater patient uptake of HIV screening. Although the Centers for Disease Control and Prevention (CDC) recently recommended that initial HIV screening of patients in EDs and other health care facilities be independent of HIV risk, the CDC also recommends that subsequent HIV screening be based on HIV risk.17 Our study findings about the relationship of self-perceived HIV risk and uptake of screening are particularly relevant to future ED-based HIV screening efforts for patients who have previously been screened for HIV.

Emergency department patients appear to consider particular HIV risk behavior topics more strongly than others when considering their self-perceived HIV risk, such as sharing of injection drug use equipment with HIV-infected persons. This consideration is reasonable given that certain HIV risk behaviors are likely more risky than others. The findings also suggest that there are particular topics in a limited intervention that might encourage ED patients to agree to be tested for HIV.

Even though the proportions of females and males who increased their self-perceived HIV risk level were similar, females and males appear to respond differently to these HIV risk behavior questions when considering their self-perceived HIV risk. Nearly every topic addressed in the reported HIV risk behavior questions appears to have an influence on increasing self-perceived HIV risk for females. Fewer of the topics have this influence for males. At least for females, ED patients who report the most HIV risk behaviors are more apt to increase their self-perceived HIV risk. The reasons for these differences are not known and could be the subject of future interventional studies.

There are several potential explanations for why the ACASI-based feedback message intervention failed to increase ED patient self-perceived HIV risk. The lack of an effect of the intervention was not due to an absence of HIV risk behaviors in this population, given that a number of patients reported significant HIV risk behaviors. The association of certain HIV risk behavior items and self-perceived HIV risk does indicate that a relationship exists, at least for the items in this questionnaire. However, as shown in prior studies,1825 the relationship between self-perceived current or future HIV risk for an HIV infection and reported HIV risk behaviors might not be strong or may even be discrepant. As a consequence, dramatic increases in self-perceived HIV risk might not even be possible through interventions. Denial, misperceptions, or lack of knowledge about HIV and risk; residual beliefs about the exclusivity of HIV among particular demographic groups; beliefs about the HIV status and risk behaviors of sexual partners; unrealistic optimism; perceived invulnerability; and perceptions about the potential protective aspect of monogamous sexual relationships in regard to HIV risk are proposed reasons for a weak or discrepant relationship between actual and self-perceived HIV risk.19,23,24,26 Study design, variations in how self-perceived HIV risk and reported HIV risk behaviors were assessed, the populations were included, and prevalence of HIV in the surrounding community also could influence these observed relationships.

The relatively high proportion of prior HIV testing in this sample might also have influenced participants’ self-perceptions that they are not infected with HIV. This might have overridden our ability to detect differences between study groups, despite there being similar HIV testing histories in the intervention and no-intervention groups. Other possible reasons why the intervention failed include that the feedback message content or tone might not have provoked self-reflection about HIV risk; participants might have had trouble in expressing their self-perceived HIV risk using the framework of the questions asked; the 10 year time frame might have been too long a reference period, and asking patients to remember more recent behaviors might instead induce a stronger response about self-perceived HIV risk; the focus of the questions on higher HIV risk behaviors might have led some patients to discount their self-perceived HIV risk; the ACASI 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 risk are needed to create a change in self-perceived HIV risk. These and other possibilities could be explored in future studies to determine if improvements to an ACASI-based message feedback intervention can impact self-perceived HIV risk or if other approaches are needed.

It is important to acknowledge that although the intervention did not have an impact on self-perceived HIV risk, it is not known if the intervention might increase uptake of HIV screening. Likewise, it cannot be known from this investigation if completing the questionnaire improves uptake of screening, apart from any effects of the intervention. Further, although this intervention did not affect self-perceived HIV risk, it does not negate the possibility that some other intervention might be effective in changing risk perception.

LIMITATIONS

Although we employed a three-stage random selection plan to enroll participants, willingness to participate was related to patient demographic characteristics. Therefore, despite efforts taken to obtain a representative sample, the study findings might not be applicable to other ED settings with different demographics or to patients who do not speak English. Willingness to participate might have been related to HIV risk, although the subject of the study did not appear to deter participation. Although the study instrument was rigorously developed, it might not be reflective of actual HIV risk and has not yet been demonstrated to predict HIV infection. As such, the values of the HIV risk behavior score cannot be interpreted to represent actual risk levels. The lack of observed effects for certain HIV risk behaviors could be due to their relative infrequency. Because we wanted a brief HIV risk assessment tool, we did not inquire about mitigating factors that might influence self-perceived HIV risk, such as engaging in sexual intercourse within and outside of established relationships and use of HIV risk reduction measures. A more comprehensive assessment of HIV risk might have provoked greater self-perceived HIV risk, but might not have influenced the effectiveness of the ACA-SI-based intervention. We did not have adequate power to determine if the feedback messages influenced reporting of HIV risk behaviors; however, this effect is likely to be small because there were no differences in reporting of HIV risk behaviors by each question asked. Lack of blinding of the RA and patient to study group assignment potentially could have affected the results, but we would have expected that this would have resulted in a difference instead of lack of difference between study groups.

CONCLUSIONS

Audio computer self-interview–based immediate feedback about HIV risk behaviors does not increase ED patient self-perceived risk of being HIV infected. However, querying ED patients about their HIV risk behaviors related to injection drug use and sex modestly increases self-perceived HIV risk for some ED patients. Certain HIV risk behavior topics appear to be more influential in increasing self-perceived HIV risk and might help motivate ED patients to be tested for HIV.

Table 5
Relationship of Each Reported HIV Risk Behavior Topic to Change in Self-perceived HIV Risk (Males)

Supplementary Material

1

Data Supplement S1:

Content, development, and script of the HIV risk questionnaire.

Acknowledgments

The authors acknowledge the assistance of Eric Feuchtbaum who helped with the development and cognitive-based assessments of the questionnaire used in this study, as well as the staff and patients of the Rhode Island Hospital Emergency Department who made this study possible.

Dr. Merchant and this study were supported by a career development grant from the National Institute for Allergy and Infectious Diseases (K23 A1060363). Dr. Mayer was supported by the Center for AIDS Research at Lifespan / Tufts / Brown (P30 AI42853).

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