Adaptation of Chagas Disease Screening Recommendations for a Community of At-risk HIV in the United States.

Chagas disease (CD), caused by Trypanosoma cruzi, is underdiagnosed in the United States. Improved screening strategies are needed, particularly for people at risk for life-threatening sequelae of CD, including people with human immunodeficiency virus (HIV, PWH). Here we report results of a CD screening strategy applied at a large HIV clinic serving an at-risk population.

The New Era of Long-Acting Antiretroviral Therapy: When and Why to Make the Switch.

PURPOSE OF REVIEW: Despite the availability of safe and effective oral combination antiretroviral therapy, barriers to maintaining viral suppression remain a challenge to ending the HIV epidemic. Long-acting injectable antiretroviral therapy was developed as an alternative to daily oral therapy. This review summarizes the current literature on the efficacy of long-acting cabotegravir plus rilpivirine for the treatment of HIV-1, reasons to switch to injectable therapy, and barriers to switching. RECENT FINDINGS: Long-acting cabotegravir plus rilpivirine is safe and effective in maintaining HIV-1 virologic suppression. Ideal candidates for switching to long-acting cabotegravir plus rilpivirine are virologically suppressed on oral regimens with good adherence and no history of virologic failure or baseline resistance. Indications to switch to injectable therapy include patient preference, the potential for improved adherence, and avoidance of adverse effects. Implementation research is needed to assess and overcome system barriers. Long-acting cabotegravir plus rilpivirine is a novel alternative to oral antiretrovirals, with the potential to improve adherence and quality of life in people with HIV.

Assessing incident depression among older people with and without HIV in U.S.

PURPOSE: Despite substantially higher prevalence of depression among people living with HIV/AIDS (PLWHA), few data exist on the incidence and correlates of depression in this population. This study assessed the effect of HIV infection, age, and cohort period on the risk of developing depression by sex among older U.S. Medicare beneficiaries. METHODS: We constructed a retrospective matched cohort using a 5% nationally representative sample of Medicare beneficiaries (1996-2015). People with newly diagnosed (n = 1309) and previously diagnosed (n = 1057) HIV were individually matched with up to three beneficiaries without HIV (n = 6805). Fine-Gray models adjusted for baseline covariates were used to assess the effect of HIV status on developing depression by sex strata. RESULTS: PLWHA, especially females, had higher risk of developing depression within five years. The relative subdistribution hazards (sHR) for depression among three HIV exposure groups differed between males and females and indicated a marginally significant interaction (p = 0.08). The sHR (95% CI) for newly and previously diagnosed HIV (vs. people without HIV) were 1.6 (1.3, 1.9) and 1.9 (1.5, 2.4) for males, and 1.5 (1.2, 1.8) and 1.2 (0.9, 1.7) for females. The risk of depression increased with age [sHR 1.3 (1.1, 1.5), 80 + vs. 65-69] and cohort period [sHR 1.3 (1.1, 1.5), 2011-2015 vs. 1995-2000]. CONCLUSIONS: HIV infection increased the risk of developing depression within 5 years, especially among people with newly diagnosed HIV and females. This risk increased with older age and in recent HIV epidemic periods, suggesting a need for robust mental health treatment in HIV primary care.

Impact of the COVID-19 Pandemic on Medical Education during Inpatient Internal Medicine Rounds.

OBJECTIVES: Inpatient rounding is a foundational component of medical education in academic hospitals. The coronavirus 2019 (COVID-19) pandemic disrupted traditional inpatient rounding practices. The objectives of this study were to describe how Internal Medicine inpatient team rounding changed because of COVID-19-related precautions and the effect of these changes on education during rounds. METHODS: During February to March 2021, we conducted four virtual focus groups with medical and physician assistant students, interns, upper-level residents, and attending physicians at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, and designed a codebook to categorize focus group commentary. RESULTS: Focus groups revealed that students believed that certain physical-distancing measures in place early on during the pandemic were ineffective and significantly limited their ability to evaluate patients in person. Residents described increased stress levels related to potential severe acute respiratory-coronavirus 2 exposure and limited time at the bedside, which affected their confidence with clinical assessments. Rounding-team fragmentation precluded the entire team learning from all of the patients on the team's census. Loss of intrateam camaraderie impaired the development of comfortable learning environments. CONCLUSIONS: This study evaluated Internal Medicine team member focus groups to describe how the COVID-19 pandemic affected medical education during rounds. Academic teaching programs can adapt the findings from this study to address and prevent pandemic-related gaps in medical education during rounds now and during future potential disruptions to medical education.

A pilot study of cognition and creativity among persons with HIV disease referred for neuropsychological evaluation.

Creativity can help people to innovate, overcome obstacles, and successfully navigate challenges in daily life. Some aspects of creativity rely on the prefrontostriatal loops and executive functions, which can be compromised in persons with HIV (PWH). This pilot study examined whether neuropsychological functioning plays a role in creativity in PWH. A consecutive series of 41 PWH who were referred to an urban neuropsychology clinic in southeastern Texas were enrolled. Participants completed the Abbreviated Torrance Test for Adults (ATTA) to measure creativity, from which standardized creativity scores of fluency, originality, elaboration, and flexibility were derived. Participants also completed several measures of everyday functioning and a brief clinical neuropsychological battery measuring executive functions, motor skills, memory, and visuoconstruction. Global neuropsychological functioning showed a large, positive association with ATTA creativity performance that did not vary meaningfully by creativity domain and was independent of premorbid IQ. ATTA creativity scores were not associated with any measure of everyday functioning. Findings from this pilot study suggest that higher levels of neuropsychological functioning may support multiple dimensions of creativity in adults with HIV disease. Future studies might examine whether creativity moderates the association between HIV-associated neurocognitive impairment and various health behaviors (e.g., adherence, appointment attendance).

The Effect of Initial Patient Experiences and Life Stressors on Predicting Lost to Follow-Up in Patients New to an HIV Clinic.

We conducted a prospective cohort study of 450 patients new to an HIV clinic in Houston, TX, to examine the roles of life stressors and initial care experiences in predicting being lost to follow-up in the first year of care. Patients completed a self-administered survey following their initial provider visit. In logistic regression models, patients who reported better experiences with the HIV provider at the first visit were less likely to be lost to follow-up at 6 months (aOR = 0.866, p = 0.038) and 12 months (aOR = 0.825, p = 0.008). Patients with a higher burden of stressful life events were more likely to be lost to follow-up at 6 months (aOR = 1.232, p = 0.037) and 12 months (aOR = 1.263, p = 0.029). Assessments of patient experience and life stressors at the initial visit have potential to predict patients at risk of dropping out of care.

Acceptability and feasibility of video-based coaching to enhance clinicians' communication skills with patients.

BACKGROUND: Despite a growing call to train clinicians in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of clinician time pressures. We propose a program that includes real-time observation and video-based coaching to teach clinician communication skills. In this study, we assess acceptability and feasibility of the program using clinician interviews and surveys. METHODS: The video-based coaching intervention targets five patient-centered communication behaviors. It uses trained communication coaches and live feed technology to provide coaching that is brief (less than 15 min), timely (same day) and theory-informed. Two coaches were trained to set up webcams and observe live video feeds of clinician visits in rooms nearby. As coaches watched and recorded the visit, they time stamped illustrative clips in real time. Video clips were a critical element of the program. During feedback sessions, coaches used video clips to promote discussion and self-reflection. They also used role play and guided practice techniques to enforce new tips. Clinicians included residents (n = 15), fellows (n = 4), attending physicians (n = 3), and a nurse practitioner (n = 1) at two primary care clinics in Houston, Texas. We administered surveys to clinicians participating in the program. The survey included questions on quality and delivery of feedback, and credibility of the coaches. We also interviewed clinicians following the intervention. We used rapid analysis to identify themes within the interviews. RESULTS: Survey measures showed high feasibility and acceptability ratings from clinicians, with mean item scores ranging from 6.4 to 6.8 out of 7 points. Qualitative analysis revealed that clinicians found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients. CONCLUSIONS: Video-based coaching can help clinicians learn new communication skills in a way that is clinician-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

Reliability and Validity of a Brief Self-Report Adherence Measure among People with HIV Experiencing Homelessness and Mental Health or Substance Use Disorders.

The study examines the reliability and validity of a 3-item self-report adherence measure among people with HIV (PWH) experiencing homelessness, substance use, and mental health disorders. 336 participants were included from nine sites across the US between September 2013 and February 2017. We assessed the validity of a self-report scale for adherence to antiretroviral therapy by comparing it with viral load (VL) abstracted from medical records at baseline, 6, 12, and 18 months. The items had high internal consistency (Cronbach's alpha coefficients at each time point were > 0.8). The adherence scale scores were higher in the group that achieved VL suppression compared to the group that did not. The c-statistic for the receiver-operating characteristic curves pooled across time points was 0.77 for each adherence sub-item and 0.78 for the overall score. The self-report adherence measure shows good internal consistency and validity that correlated with VL suppression in homeless populations.

Acceptability and preferences for long-acting antiretroviral formulations among people with HIV infection.

The study evaluates the acceptability and preferences for long-acting antiretroviral therapy (LA-ART) among a diverse cohort of people with HIV infection (PWH). It consists of a self-administered survey and chart review of PWH presenting to an HIV clinic in Houston, Texas, between February and June 2018; 374 participants were included; 61% indicated that they were likely or very likely to use LA-ART formulations. When asked about preference, 41% preferred pills, 40% preferred injections, and 18% preferred an implant. The most common benefit reported was eliminating the need to remember taking daily HIV pills (74%); 43% were worried that LA-ART will not be as effective as pills. Participants with a college degree, men who have sex with men, and ART-experienced were more willing to use LA-ART. Participants who reported poor or fair health, or who screened positive for depression or anxiety were significantly less willing to use LA-ART. The likelihood of using LA-ART did not correlate with self-reported adherence and HIV suppression. Patients with difficulty scheduling and attending clinic visits preferred injections and implant over pills. Most participants indicated a willingness to use new LA ART formulations. However, 41% still prefers pills, and those more interested in LA-ART were not less adherent.

The relationship between sex-related alcohol expectancies and hazardous drinking among persons with HIV disease.

Hazardous drinking is a clinically significant problem among persons with HIV (PWH) disease, and is associated with a number of poor outcomes. Hazardous drinking among PWH is associated with risky substance use and sexual behavior, but little work has examined factors that may be associated with greater hazardous drinking and subsequent risky sexual behaviors among PWH. Research among the general population suggests that sex-related alcohol expectancies, defined as drinking to enhance sexual experience, increase sexual risk-taking, and disinhibition of sexual behavior, are associated with greater hazardous alcohol use and risky sexual behavior, but these relations have not been explored among PWH. Therefore, the current study examined the associations of sex-related alcohol expectancies with hazardous alcohol consumption, dependence, and problems among 146 PWH (Mage = 50.99, SD = 9.41) \ enrolled in a clinical trial examining a personalized feedback intervention to reduce hazardous drinking in primary HIV care. Results showed that only sexual disinhibition-related alcohol expectancies were significantly associated with the criterion variables, such that greater drinking alcohol for sexual disinhibition was associated with greater hazardous drinking behaviors. These results sit on the backdrop of a larger literature documenting the links between disinhibition and hazardous alcohol use and provide explanatory specificity to PWH who are hazardous drinkers.

Skin and Soft Tissue Infection in People Living With Human Immunodeficiency Virus in a Large, Urban, Public Healthcare System in Houston, Texas, 2009-2014.

BACKGROUND: Skin and soft tissue infections (SSTIs) disproportionately impact patients with human immunodeficiency virus (HIV). Recent declines in the incidence of SSTIs have been noted in the non-HIV population. We sought to study the epidemiology and microbiology of SSTIs in a population of 8597 patients followed for HIV primary care in a large, urban county system from January 2009 to December 2014. METHODS: SSTIs were identified from the electronic medical record by use of International Classification of Diseases-9 billing codes. Charts were reviewed to confirm each patient's diagnosis of acute SSTI and abstract culture and susceptibility data. We calculated the yearly SSTI incidences using Poisson regression with clustering by patient. RESULTS: There were 2202 SSTIs identified. Of 503 (22.8%) cultured SSTIs, 332 (66.0%) recovered Staphylococcus aureus as a pathogen, of which 287/332 (86.4%) featured S. aureus as the sole isolated organism. Among the S. aureus isolates that exhibited antibiotic susceptibilities, 231/331 (69.8%) were methicillin resistant, and the proportion did not change by year. The observed incidence of SSTI was 78.0 per 1000 person-years (95% confidence interval 72.9-83.4) and declined from 96.0 infections per 1000 person-years in 2009 to 56.5 infections per 1000 person-years in 2014 (P < .001). Other significant predictors of SSTI incidences in both univariate as well as multivariate analyses included a low CD4 count, high viral load, and not being a Spanish-speaking Hispanic. CONCLUSIONS: SSTIs remain a significant problem in the outpatients living with HIV, although rates of SSTIs appear to have declined by approximately 40% between 2009 and 2014.

HIV in Lebanon: Reasons for Testing, Engagement in Care, and Outcomes in Patients with Newly Diagnosed HIV Infections.

Little is known about clinical presentation and cascade of care among patients living with HIV (PLWH) in Beirut, Lebanon. The study aims to examine the reasons for HIV testing and to evaluate the clinical characteristics of, predictors of advanced HIV stage at presentation in, and rates of ART initiation, retention in care, and viral load suppression among PLWH in Lebanon. We conducted a retrospective study of PLWH presenting to a tertiary-care centre-affiliated outpatient clinic from 2008 to 2016 with new HIV infection diagnoses. We identified a total of 423 patients: 89% were men, 55% were 30-50 years old, and 58% self-identified as men who have sex with men. About 35% of the patients had concurrent sexually transmitted diseases at the time of HIV diagnosis. Thirty percent of infection cases were identified by provider-initiated HIV testing, 36% of cases were identified by patient-initiated testing, and 34% of patients underwent testing for screening purposes. The proportion of individuals presenting with advanced HIV disease decreased from 40% in 2008-2009 to 24% in 2014-2015. Age older than 50 years and identification of HIV by a medical provider were independent predictors of advanced HIV infection at presentation. Among patients having indications for treatment (n = 253), 239 (94%) were prescribed antiretroviral therapy, and 147 (58%) had evidence of viral suppression at 1 year. Furthermore, 266 patients (63%) were retained in care. The care continuum for PLWH in Lebanon is comparable with those in high-income countries yet still far behind the Joint United Nations Programme on HIV/AIDS 90-90-90 set target.

Primary central nervous system lymphoma in patients with and without HIV infection: a multicenter study and comparison with U.S national data.

PURPOSE: Primary central nervous system lymphoma (PCNSL) in patients living with HIV (PLWH) is a distinct entity; however, the management is adopted from patients without HIV. The study aims to examine the differences in presentation, treatment, and outcomes of PCNSL patients with or without HIV. METHODS: We retrospectively compared the characteristics of 144 patients with PCNSL with and without HIV, and analyzed factors associated with overall and progression-free survival. Results were compared to the Central Brain Tumor Registry of the United States (CBTRUS) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) system. RESULTS: Among all patients with PCNSL, 19% had HIV. PLWH were younger (38 vs. 63 years; p < 0.01) and more likely to be African American (59% vs. 7%; p < 0.01) and male (74% vs. 49%; p = 0.02) than patients without HIV. PLWH were more likely to have multiple lesions (67% vs. 43%; p = 0.02), hemorrhage (59 vs. 37%; p = 0.03), and peripheral rim enhancement (57% vs. 7%; p < 0.01) on imaging; to receive palliative care (15% vs. 2%) or whole brain radiation (63% vs. 3%); and less likely to receive chemotherapy (22% vs. 95%) (p < 0.01). Twenty-four patients, none PLWH, underwent stem cell transplant. Not receiving transplant was an independent factor in mortality and disease progression. Our cohort of patients, compared to the national database, were younger (60 vs. 65 years), 58% were white vs. 75%, and had longer median overall survival 43 vs. 25 months. CONCLUSION: Epidemiology, imaging, and treatment options for patients with PCNSL with and without HIV differ, but HIV was not an independent factor of mortality or disease progression. More efforts are needed to improve access to research and treatment options for PLWH with PCNSL.

Understanding why HIV-infected persons disengaged from pre-ART care in Freetown, Sierra Leone: a qualitative study.

In countries that have not implemented universal antiretroviral treatment (ART), loss to follow-up (LTFU) during pre-ART care remains a problem. We conducted semi-structured interviews with 41 HIV-infected persons who were LTFU during pre-ART care from a prospective cohort of persons newly diagnosed with HIV infection in Freetown, Sierra Leone, in 2012-2013. Interviews determined whether the participant disengaged or transferred care and explored the reasons for being LTFU. Of the 41 participants, 34 (83%) disengaged from care. For persons who disengaged from care, socioeconomic barriers emerged as a dominant theme in both ART-eligible and -ineligible groups while psychosocial barriers emerged as a dominant theme in the ART-ineligible group. Structural barriers emerged as a dominant theme for participants who transferred care. Interventions designed to address socioeconomic and psychosocial barriers may help reduce disengagement from pre-ART care.

The psychology of the wait time experience - what clinics can do to manage the waiting experience for patients: a longitudinal, qualitative study.

BACKGROUND: Wait time, defined as time spent in the waiting and exam rooms waiting to see a provider, is a key quality metric in a number of national patient experience surveys. However, the literature on wait time does not show a consistent correlation between long waits and worse overall patient care experiences. Herein, we examine contextual factors that can shape the manner in which patients may respond to different wait times. We also identify actions providers and clinics can take to promote positive wait experiences and mitigate negative ones. METHODS: We conducted over 130 h of semi-structured interviews with patients new to two HIV primary care clinics in Houston, Texas. We interviewed patients before the first provider visit, again within two weeks of the first visit, and again at 6-12 months. We analyzed the interviews using directed and conventional content analysis. RESULTS: Our study showed that patients' "willingness to wait" is the product of the actual wait time, individual factors, such as the perceived value of the visit and cost of a long wait, and clinic and provider factors. Analyses revealed key steps providers and clinics can take to improve the wait time experience. These include: 1) proactively informing patients of delays, 2) explicitly apologizing for delays, and 3) providing opportunities for diversion. Patients noted the importance of these steps in curtailing frustrations that may result from a long wait. CONCLUSIONS: Our study highlights key steps cited by patients as having the potential to improve the wait time experience. These steps are practical and of particular interest to clinics, where waits are oftentimes inevitable.

Development and Evaluation of a Physician-Targeted Video to Promote HIV Screening.

Introduction. Despite national recommendations, routine opt-out HIV testing has not been widely adopted by physicians. Guided by previous research on physician barriers to HIV testing, we developed a physician-targeted video to promote routine opt-out HIV screening. The objective of this study was to evaluate this video intervention. Methods. From June to July 2016, physicians in two primary care clinics completed an online survey prior to and after watching the video. Survey items assessed acceptability of the video and HIV testing knowledge, attitudes, and intention to screen. Descriptive statistics were generated to analyze data. Results. Of the 53 participants, 90% liked or strongly liked the video. Pre- to postvideo, significant improvements were seen in the knowledge of national HIV screening recommendations (45.3% to 67.9%; p = .010) and of the proportion of unaware Houstonians living with HIV (22.6% to 75.5%; p < .001). Participant beliefs about the likelihood of patients accepting HIV testing increased from 47.2% to 84.9% pre- to postvideo (p < .001). Intention to screen did not change; participants had high intentions pre- and postvideo. Conclusions. Our study found that a video is an acceptable HIV testing promotion medium for physicians. Our video improved physician HIV testing knowledge and attitudes, overcoming key barriers to HIV testing.

Characterising HIV transmission risk among US patients with HIV in care: a cross-sectional study of sexual risk behaviour among individuals with viral load above 1500 copies/mL.

OBJECTIVES: Viral load and sexual risk behaviour contribute to HIV transmission risk. High HIV viral loads present greater transmission risk than transient viral 'blips' above an undetectable level. This paper therefore characterises sexual risk behaviour among patients with HIV in care with viral loads>1500 copies/mL and associated demographic characteristics. METHODS: This cross-sectional study was conducted at six HIV outpatient clinics in USA. The study sample comprises 1315 patients with HIV with a recent viral load >1500 copies/mL. This study sample was drawn from a larger sample of individuals with a recent viral load >1000 copies/mL who completed a computer-assisted self-interview (CASI) regarding sexual risk practices in the last 2 months. The study sample was 32% heterosexual men, 38% men who have sex with men (MSM) and 30% women. RESULTS: Ninety per cent of the sample had their viral load assay within 60 days of the CASI. Thirty-seven per cent reported being sexually active (vaginal or anal intercourse) in the last 2 months. Most of the sexually active participants reported always using condoms (56.9%) or limiting condomless sex to seroconcordant partners (serosorting; 29.2% overall and 42.9% among MSM). Among sexually active participants who reported condomless anal or vaginal sex with an at-risk partner (14%), most had viral loads>10 000 copies/mL (62%). CONCLUSIONS: A relatively small number of patients with HIV in care with viral loads above 1500 copies/mL reported concurrent sexual transmission risk behaviours. Most of the individuals in this small group had markedly elevated viral loads, increasing the probability of transmission. Directing interventions to patients in care with high viral loads and concurrent risk behaviour could strengthen HIV prevention and reduce HIV infections. TRIAL REGISTRATION NUMBER: NCT02044484, completed.

The Impact of Housing and HIV Treatment on Health-Related Quality of Life Among People With HIV Experiencing Homelessness or Unstable Housing.

Objectives. To determine the impact of improvements in housing and HIV clinical parameters on health-related quality of life (HRQOL) in persons with HIV infection experiencing homelessness.Methods. This prospective cohort study took place in 9 US sites. Local efforts sought to improve HIV and housing status. Longitudinal data analyses determined the impact of changes in housing status, HIV suppression, and CD4 cell counts on HRQOL at 12 months, measured as mental and physical component summary scores.Results. Among 909 participants enrolled from 2013 to 2016, 75.1% were homeless, 51.6% did not have HIV suppression, and 23.6% had a CD4 count less than 200 cells per cubic millimeter. Median mental and physical component summary scores were 35.4 and 38.9, respectively. These 5 parameters all improved by 6 months. In multivariate modeling, maintaining or achieving stable housing predicted higher PCS at 12 months, but CD4 count and HIV suppression improvements did not. Improvements in housing, CD4 count, and HIV suppression did not predict mental component score at 12 months.Conclusions. Housing and HIV treatment are necessary but not sufficient to improve HRQOL in this challenging population. The high prevalence of socioeconomic and mental health needs we found support the call for patient-centered comprehensive care.

Single tablet HIV regimens facilitate virologic suppression and retention in care among treatment naïve patients.

Newer HIV regimens are typically taken once daily but vary in the number of pills required. Whether the number of pills in a once-daily HIV regimen affects clinical outcomes is unknown. We retrospectively compared adherence, retention in care, and virologic outcomes between patients starting a once daily single-tablet regimen (STR) to patients starting a once-daily multi-tablet regimen (MTR) in a publicly funded clinic in the United States. Outcomes were measured in the year after starting ART and included retention in care, virologic suppression, and medication possession ratio of at least 80%. Data from patients initiating therapy from 1 January 2008 to 31 December 2011 were analyzed with both unadjusted and propensity-score adjusted regression. Overall, 622 patients started with an STR (100% efavirenz-based) and 406 with an MTR (65% atazanavir-based and 35% darunavir-based) regimen. Retention in care was achieved in 80.7% of STR patients vs. 72.7% of MTR patients (unadjusted OR 1.57, 95% CI 1.17-2.11; adjusted OR 1.49, 95% CI 1.10-2.02). Virologic suppression occurred among 84.4% of STR patients vs. 77.6% of MTR patients (unadjusted OR 1.56; 95% CI 1.14-2.15; adjusted OR 1.41; 95% CI 1.02-1.96). There was no difference in the proportion of patients achieving at least 80% adherence, as measured by medication possession ratio (33.0% of STR patients and 30.1% of MTR patients; unadjusted OR 1.14; 95% CI 0.87-1.50; adjusted OR 1.04, CI 0.79-1.38). While it is difficult to eliminate confounding in this observational study, retention in care and virologic outcomes were better in patients prescribed STRs.

Evaluation of a computer-based and counseling support intervention to improve HIV patients' viral loads.

We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics.