Routine HIV Testing Among Adolescents and the Shifting Culture of AIDS

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DESCRIPTION (provided by applicant): There have been important shifts in the clinical understanding and treatment of HIV/AIDS and in public culture as it relates to HIV/AIDS since the epidemic began in the US in the early 1980s. Some of these shifts are reflected in the latest HIV testing recommendations from the CDC. The recommendations suggest that all patients between 13 and 64 be tested; that consent for testing be incorporated into patients' general consent for medical care; and that HIV testing be routinely conducted unless patients 'opt-out.' Though conceived as a supplement to existing prevention programs, the recommendations represent an important shift in the focus of HIV prevention activities. They set the stage for what could be the largest-scale HIV prevention intervention among adolescents in the US to date. The objective of the proposed study is to examine how the new recommendations might be received by adolescents and might be implemented by their health care providers. Interim measures to offer routine testing (though with a separate consent form as mandated by the state) in health care facilities in Baltimore provide an opportunity to assess this. The new recommendations reflect cultural shifts toward a view of HIV as a chronic but manageable disease that is no longer `special.' It is important to understand how adolescents and their care providers respond to the new ideas about HIV that these recommendations embody. This is particularly the case since the effectiveness of the recommendations is premised not only on their ability to promote testing, but on their ability to engender a chain of responses to a test result including adolescents' identification of sexual partners, engagement in care, and change in behaviors to reduce HIV risk. Adolescent medicine providers are cultural brokers. The idea introduced in the clinic that HIV is no longer `special' competes with other cultural views of the disease prevalent in adolescents' social worlds, such as notions about HIV as a death sentence; HIV as a disease that only certain kinds of people get; or HIV as a government plot against people of a particular race or ethnicity. We propose to examine how two adolescent patient populations - one African-American and one Hispanic - negotiate the shifting culture of HIV both inside the clinic and outside of it. We propose to use three distinct, but interrelated, methodological approaches to do this: a patient survey; critical incident interviews with adolescent health care providers; and ethnographic interviews with a sub-sample of adolescent patients. Ethnographic interviews will be conducted with three groups of adolescents: those who come to the clinic seeking an HIV test; those who do not seek a test but who accept one when it is offered as a routine part of care; and those who refuse the offer of an HIV test. These layers of understanding will inform the implementation of the new testing recommendations and highlight culturally inflected barriers to implementation that need to be addressed in order for the recommendations to attain their stated objectives.