Freya Spielberg

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• Elf, J., Horn, K., Abroms, L., Stanton, C., Cohn, A., Spielberg, F., Gray, T., Harvey, E., Debnam, C., Kierstead, L., Levy, M., Castel, A., Monroe, A., & Niaura, R. (2023). Prevalence and Correlates of Cardiovascular, Pulmonary, Cancer, and Mental Health Comorbidities Among Adults With HIV Who Smoke. Journal of the Association of Nurses in AIDS Care, 34(4). doi:10.1097/jnc.0000000000000416
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  Using data from the D.C. Cohort Longitudinal HIV Study, we examined (a) diagnosed mental health and (b) cardiovascular, pulmonary, or cancer (CPC) comorbidity among adults with HIV who smoked. Among 8,581 adults, 4,273 (50%) smoked; 49% of smokers had mental health, and 13% of smokers had a CPC comorbidity. Among smokers, non-Hispanic Black participants had a lower risk for mental health (prevalence ratio [PR]: 0.69; 95% confidence interval [CI] [0.62-0.76]) but a higher risk for CPC (PR: 1.17; 95% CI [0.84-1.62]) comorbidity. Male participants had a lower risk for mental health (PR: 0.88; 95% CI [0.81-0.94]) and CPC (PR: 0.68; 95% CI [0.57-0.81]) comorbidity. All metrics of socioeconomic status were associated with a mental health comorbidity, but only housing status was associated with a CPC comorbidity. We did not find any association with substance use. Gender, socioeconomic factors, and race/ethnicity should inform clinical care and the development of smoking cessation strategies for this population.
• Kierstead, E., Harvey, E., Sanchez, D., Horn, K., Abroms, L., Spielberg, F., Stanton, C., Debnam, C., Cohn, A., Gray, T., Magnus, M., Patel, M., Niaura, R., & Elf, J. (2021). A pilot randomized controlled trial of a tailored smoking cessation program for people living with HIV in the Washington, D.C. metropolitan area. BMC Research Notes, 14(1). doi:10.1186/s13104-020-05417-3
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  Objective: Morbidity and mortality from smoking-related diseases among people living with HIV (PLWH) in the U.S. surpasses that due to HIV itself. Conventional smoking cessation treatments have not demonstrated strong efficacy among PLWH. We conducted a pilot randomized controlled trial (RCT) to evaluate a tailored smoking cessation intervention based on the minority stress model. We compared standard of care counseling (SOC) to a tailored intervention (TI) including one face-to-face counseling session incorporating cognitive behavioral therapy to build resilience, and 30 days of 2-way text messaging. Results: The primary outcome was smoking cessation. Secondary outcomes included cigarettes per day (CPD), exhaled carbon monoxide (CO), and cessation self-efficacy. A total of 25 participants were enrolled (TI:11, SOC:14), and 2 were lost to follow-up. There were no significant differences in quit rates between study groups. However, there was a significantly greater decrease in CPD in the TI versus SOC (13.5 vs. 0.0, p-value:0.036). Additionally, self-efficacy increased in both groups (TI p-value:0.012, SOC p-value:0.049) and CO decreased in both groups (TI p-value: < 0.001, SOC p-value:0.049). This intervention shows promise to support smoking cessation among PLWH. A larger study is needed to fully evaluate the efficacy of this approach. Clinical trial: Trial Registration: Retrospectively registered (10/20/2020) NCT04594109.
• Hansen, K., Ward, M., Avashia, S., Duc, J., & Spielberg, F. (2020). What impacts HPV vaccination recommendations? An exploration of medical residents’ knowledge, training, barriers, and practices. Family Medicine, 52(10). doi:10.22454/fammed.2020.132480
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  BACKGROUND AND OBJECTIVES: Increasing human papillomavirus vaccination (HPVV) uptake is critical to the prevention of cervical cancer. Effective physician communication and clinical workflow policies have a significant impact on vaccination rates. However, resident training programs vary in the inclusion of training in effective HPVV practices. At Dell Medical School in Aus-tin, Texas, HPVV rates at primary care residents’ clinic sites vary. We examined HPVV-related knowledge, training, barriers, and practices among residents in pediatrics (Peds), family medicine (FM), obstetrics and gynecology (Ob/Gyn), and internal medicine (IM) with the aim of identifying interventional targets to improve vaccination rates. METHODS: This was a mixed-method study including qualitative interviews and a survey. We interviewed a sample of residents from each specialty to assess their training experiences and how they discuss HPVV. We recorded, transcribed, and coded interviews for thematic analysis. All residents were offered the opportunity to complete an electronic survey to quantitatively evaluate knowledge and vaccine practices. We performed χ2 and Fisher ex-act analysis to compare results between disciplines. RESULTS: HPVV-related knowledge was similar across all four specialties and between resident year. Peds residents reported always recommending the HPVV significantly more than FM and Ob/Gyn residents for 11-17-year-old females. Only Peds residents reported receiving evidence-based vaccine communication training. Among all residents, the primary HPVV barriers in-cluded forgetting to offer the vaccine and time constraints. When discussing the vaccine, many interviewed residents were not offering a confident recommendation to all eligible patients, and instead were using a risk-based ap-proach to vaccination. CONCLUSIONS: There were inconsistencies across programs related to how and where residents receive HPVV training. This may impact the frequency and strength of resident vaccine recommendations. To increase HPVV rates, residency programs should prioritize implementation of multimodal interven-tions, including opt-out workflows and education on how to give confident vaccine recommendations.
• Larbi, A., Spielberg, F., Kamanu Elias, N., Athey, E., Ogbuawa, N., & Murphy, N. (2018). Using a retention in care protocol to promote positive health and systems related outcomes*. AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV, 30(Issue). doi:10.1080/09540121.2018.1465173
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  People living with HIV can experience the full benefits of retention when they are continuously engaged in care. Continuous engagement in care promotes improved adherence to ART and positive health outcomes. An infectious disease clinic has implemented a protocol to primarily improve patient retention. The retrospective, facility-based, costing study took place in an infectious disease clinic in Washington DC. Retention was defined in two ways and over a 12-month period. Micro-costing direct measurement methods were used to collect unit costs in time series. Return on investment accounted for the cost of treatment based on CD4 strata. ROI was expressed in 2016USD. The difference in CD4 and viral load levels between the two periods of analysis were determined for active patients, infected with HIV. The year before the intervention was compared to the year of the intervention. Total treatment expenditure decreased from $2,435,653.00 to $2,283,296.23, resulting in a $152,356.77 gain from investment for the healthcare system over a 12-month investment period. The viral load suppression rate increased from 81 to 95 (p = 0.04) over the investment period. The number of patients in need of HIV related opportunistic infection prophylaxis decreased from 21 to 13 (p = 0.06). Improved immunologic, virologic and healthcare expenditure outcomes can be linked to the quality of retention practice.
• Blake, D., Spielberg, F., Levy, V., Lensing, S., Wolff, P., Venkatasubramanian, L., Acevedo, N., Padian, N., Chattopadhyay, I., & Gaydos, C. (2015). Could home sexually transmitted infection specimen collection with e-prescription be a cost-effective strategy for clinical trials and clinical care?. Sexually Transmitted Diseases, 42(1). doi:10.1097/olq.0000000000000221
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  Background: Results of a recent demonstration project evaluating feasibility, acceptability, and cost of a Web-based sexually transmitted infection (STI) testing and e-prescription treatment program (eSTI) suggest that this approach could be a feasible alternative to clinic-based testing and treatment, but the results need to be confirmed by a randomized comparative effectiveness trial. Methods: We modeled a decision tree comparing (1) cost of eSTI screening using a home collection kit and an e-prescription for uncomplicated treatment versus (2) hypothetical costs derived from the literature for referral to standard clinic-based STI screening and treatment. Primary outcome was number of STIs detected. Analyses were conducted from the clinical trial perspective and the health care system perspective. Results: The eSTI strategy detected 75 infections, and the clinic referral strategy detected 45 infections. Total cost of eSTI was $94,938 ($1266/ STI detected) from the clinical trial perspective and $96,088 ($1281/STI detected) from the health care system perspective. Total cost of clinic referralwas $87,367 ($1941/STI detected) fromthe clinical trial perspective and $71,668 ($1593/STI detected) from the health care system perspective. Conclusions: Results indicate that eSTI will likely be more cost-effective (lower cost/STI detected) than clinic-based STI screening, both in the context of clinical trials and in routine clinical care. Although our results are promising, they are based on a demonstration project and estimates from other small studies. A comparative effectiveness research trial is needed to determine actual cost and impact of the eSTI system on identification and treatment of new infections and prevention of their sequelae.
• Kurth, A. E., Spielberg, F., Cleland, C. M., Lambdin, B., Bangsberg, D. R., Frick, P. A., Severynen, A. O., Clausen, M., Norman, R. G., Lockhart, D., Simoni, J. M., & Holmes, K. K. (2014). Computerized counseling reduces HIV-1 Viral load and sexual transmission risk: Findings from a randomized controlled trial. Journal of Acquired Immune Deficiency Syndromes, 65(Issue 5). doi:10.1097/qai.0000000000000100
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  Objective: Evaluate a computerized intervention supporting antiretroviral therapy (ART) adherence and HIV transmission prevention. Design: Longitudinal randomized controlled trial. Settings: An academic HIV clinic and a community-based organization in Seattle. Subjects: In a total of 240 HIV-positive adults on ART, 209 completed 9-month follow-up (87% retention). Intervention: Randomization to computerized counseling or assessment only, 4 sessions over 9 months. Main Outcome Measures: HIV-1 viral suppression, and selfreported ART adherence and transmission risks, compared using generalized estimating equations. Results: Overall, intervention participants had reduced viral load: mean 0.17 log10 decline, versus 0.13 increase in controls, P = 0.053, and significant difference in ART adherence baseline to 9 months (P = 0.046). Their sexual transmission risk behaviors decreased (odds ratio = 0.55, P = 0.020), a reduction not seen among controls (odds ratio = 1.1, P = 0.664), and a significant difference in change (P = 0.040). Intervention effect was driven by those most in need; among those with detectable virus at baseline (
• Catalani, C., Castaneda, D., & Spielberg, F. (2013). Development and assessment of traditional and innovative media to reduce individual HIV/AIDS-related stigma attitudes and beliefs in India. Frontiers in Public Health, 1(Issue). doi:10.3389/fpubh.2013.00021
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  Although stigma is considered a major barrier to effective response to the HIV/AIDS epidemic, there is a lack of evidence on effective interventions. This media intervention took place among key HIV-vulnerable communities in Southern India. Two HIV stigma videos were created using techniques from traditional film production and new media digital storytelling. A series of 16 focus group discussions were held in 4 rural and 4 urban sites in South India, with specific groups for sex workers, men who have sex with men, young married women, and others. Focus groups with viewers of the traditional film (8 focus groups, 80 participants) and viewers of the new media production (8 focus groups, 69 participants) revealed the mechanisms through which storyline, characters, and esthetics influence viewers' attitudes and beliefs about stigma. A comparative pre-/post-survey showed that audiences of both videos significantly improved their stigma scores.We found that a simple illustrated video, produced on a limited budget by amateurs, and a feature film, produced with an ample budget by professionals, elicited similar responses from audiences and similar positive short-term outcomes on stigma.
• Kurth, A., Severynen, A., & Spielberg, F. (2013). Addressing unmet need for HIV testing in emergency care settings: A role for computer-facilitated rapid HIV testing?. AIDS Education and Prevention, 25(4). doi:10.1521/aeap.2013.25.4.287
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  HIV testing in emergency departments (EDs) remains underutilized. The authors evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned nonacute adult ED patients were randomly assigned to a computer tool (CARE) and rapid HIV testing before a standard visit (n = 258) or to a standard visit (n = 259) with chart access. The authors assessed intervention acceptability and compared noted HIV risks. Participants were 56% nonWhite and 58% male; median age was 37 years. In the CARE arm, nearly all (251/258) of the patients completed the session and received HIV results; four declined to consent to the test. HIV risks were reported by 54% of users; one participant was confirmed HIV-positive, and two were confirmed false-positive (seroprevalence 0.4%, 95% CI [0.01, 2.2]). Half (55%) of the patients preferred computerized rather than face-to-face counseling for future HIV testing. In the standard arm, one HIV test and two referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches. © 2013 The Guilford Press.
• Spielberg, F., Crookston, B., Chanani, S., Kim, J., Kline, S., & Gray, B. (2013). Leveraging microfinance to impact HIV and financial behaviors among adolescents and their mothers in West Bengal: A cluster randomized trial. International Journal of Adolescent Medicine and Health, 25(2). doi:10.1515/ijamh-2013-0024
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  Microfinance can be used to reach women and adolescent girls with HIV prevention education. We report findings from a cluster-randomized control trial among 55 villages in West Bengal to determine the impact of nonformal education on knowledge, attitudes and behaviors for HIV prevention and savings. Multilevel regression models were used to evaluate differences between groups for key outcomes while adjusting for cluster correlation and differences in baseline characteristics. Women and girls who received HIV education showed significant gains in HIV knowledge, awareness that condoms can prevent HIV, self-efficacy for HIV prevention, and confirmed use of clean needles, as compared to the control group. Condom use was rare and did not improve for women. While HIV testing was uncommon, knowledge of HIVtesting resources significantly increased among girls, and trended in the positive direction among women in intervention groups. Conversely, the savings education showed no impact on financial knowledge or behavior change. © 2013 Walter de Gruyter GmbH.
• Rees, C., Long, K., Gray, B., West, J., Chanani, S., Spielberg, F., & Crookston, B. (2012). Educating for the future: adolescent girls' health and education in West Bengal, India.. International journal of adolescent medicine and health, 24(4). doi:10.1515/ijamh-2012-0046
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  Adolescent girls in India carry a disproportionate burden of health and social risks; girls that do not finish secondary education are more likely to have an earlier age of sexual initiation, engage in risky sexual behavior, and consequentially be at greater risk of dying from pregnancy-related causes. This paper presents a comparison of girls in school and girls not in school from 665 participants in rural West Bengal, India. The social cognitive theory (SCT), a comprehensive theoretical model, was used as a framework to describe the personal, behavioral, and environmental factors affecting the lives of these adolescent girls. There were significant differences between girls in and out of school in all three categories of the SCT; girls in school were more likely to have heard of sexually transmitted diseases or infections than girls not in school (p
• Spielberg, F., Kurth, A., Reidy, W., McKnight, T., Dikobe, W., & Wilson, C. (2011). Iterative evaluation in a mobile counseling and testing program to reach people of color at risk for HIV-new strategies improve program acceptability, effectiveness, and evaluation capabilities. AIDS Education and Prevention, 23(3). doi:10.1521/aeap.2011.23.3_supp.110
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  This article highlights findings from an evaluation that explored the impact of mobile versus clinic-based testing, rapid versus central-lab based testing, incentives for testing, and the use of a computer counseling program to guide counseling and automate evaluation in a mobile program reaching people of color at risk for HIV. The program's results show that an increased focus on mobile outreach using rapid testing, incentives and health information technology tools may improve program acceptability, quality, productivity and timeliness of reports. This article describes program design decisions based on continuous quality assessment efforts. It also examines the impact of the Computer Assessment and Risk Reduction Education computer tool on HIV testing rates, staff perception of counseling quality, program productivity, and on the timeliness of evaluation reports. The article concludes with a discussion of implications for programmatic responses to the Centers for Disease Control and Prevention's HIV testing recommendations. © 2011 The Guilford Press.
• Spielberg, F., Kurth, A., Severynen, A., Hsieh, Y., Moring-Parris, D., Mackenzie, S., & Rothman, R. (2011). Computer-facilitated rapid HIV testing in emergency care settings: Provider and patient usability and acceptability. AIDS Education and Prevention, 23(3). doi:10.1521/aeap.2011.23.3.206
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  Providers in emergency care settings (ECSs) often face barriers to expanded HIV testing. We undertook formative research to understand the potential utility of a computer tool, CARE, to facilitate rapid HIV testing in ECSs. Computer tool usability and acceptability were assessed among 35 adult patients, and provider focus groups were held, in two ECSs in Washington State and Maryland. The computer tool was usable by patients of varying computer literacy. Patients appreciated the tool's privacy and lack of judgment and their ability to reflect on HIV risks and create risk reduction plans. Staff voiced concerns regarding ECS-based HIV testing generally, including resources for follow-up of newly diagnosed people. Computer-delivered HIV testing support was acceptable and usable among low-literacy populations in two ECSs. Such tools may help circumvent some practical barriers associated with routine HIV testing in busy settings though linkages to care will still be needed. © 2011 The Guilford Press.
• Stein, R., Grimes, T., Malow, R., Stratford, D., Spielberg, F., & Holtgrave, D. (2011). Introduction to special supplement. Monitoring and evaluation of HIV counseling, testing and referral (CTR) and HIV testing services.. AIDS education and prevention : official publication of the International Society for AIDS Education, 23(3).
• Stein, R., Grimes, T., Malow, R., Stratford, D., Spielberg, F., & Holtgrave, D. (2011). Monitoring and evaluation of HIV counseling, testing and referral (CTR) and HIV testing services. AIDS Education and Prevention, 23(3). doi:10.1521/aeap.2011.23.3_supp.1
• Montgomery, E., Woodsong, C., Musara, P., Cheng, H., Chipato, T., Moench, T., Spielberg, F., & Van Der Straten, A. (2010). An acceptability and safety study of the Duet® cervical barrier and gel delivery system in Zimbabwe. Journal of the International AIDS Society, 13(1). doi:10.1186/1758-2652-13-30
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  Background: Adherence problems with coitally dependent, female-initiated HIV prevention methods have contributed to several trials' failure to establish efficacy. Continuous use of a cervical barrier with once-daily cleaning and immediate reinsertion may simplify use for women and improve adherence. We assessed the acceptability and safety of precoital and continuous use of the Duet®, a cervical barrier and gel delivery system, in Zimbabwean women. Methods: Using a two-arm crossover design with a parallel observation group, we randomized 103 women in a 2:2:1 ratio: (1) to use the Duet continuously for 14 days, followed by a minimum of seven days of washout and then 14 days of precoital use; (2) to use the same Duet regimens in reverse order; or (3) for observation only. Women were aged 18 to 40 years; half were recruited from a pool of previous diaphragm study participants and the other half from the general community. Acceptability and adherence were assessed through an interviewer-administered questionnaire at each of two follow-up visits. Safety was monitored through pelvic speculum exams and report of adverse events. Results: The proportion of women who reported consistent Duet use during sex was virtually identical during continuous and precoital regimens (88.6% vs. 88.9%). Partner refusal was the most common reason cited for non-use during sex in both use regimens. Not having the device handy was the most common reason cited for non-daily use (in the continuous regimen). Most women were "very comfortable" using it continuously (86.3%) and inserting it precoitally (92.8%). The most favoured Duet attribute was that it did not interfere with "natural" sex (55%). The least favoured Duet attribute was the concern that it might come out during sex (71.3%). No serious adverse events were reported during the study; 57 participants reported 90 adverse events classified as mild or moderate. There were no statistically significant differences in: (1) the proportion of women reporting adverse events; (2) the severity of events among those using the Duet and observational controls; or (3) event severity reported during each regimen use period. Conclusions: In this study, the Duet was found to be acceptable and safe when inserted precoitally or used continuously for 14 days. Assignment to use of the Duet continuously did not increase adherence to the Duet during sex. Future HIV prevention trials should evaluate use of the Duet (precoitally and continuously) with promising microbicide candidates. © 2010 Montgomery et al; licensee BioMed Central Ltd.
• Reidy, W., Spielberg, F., Wood, R., Binson, D., Woods, W., & Goldbaum, G. (2010). Erratum: HIV risk associated with gay bathhouses and sex clubs: Findings from 2 Seattle surveys of factors related to HIV and sexually transmitted infections (American Journal of Public Health (2009) 99:S1 (S165-S172) DOI 10.2105/AJPH.2007.130773). American Journal of Public Health, 100(8). doi:10.2105/ajph.2007.130773e
• Kim, S., Spielberg, F., Mauksch, L., Farber, S., Duong, C., Fitch, W., & Greer, T. (2009). Comparing narrative and multiple-choice formats in online communication skill assessment. Medical Education, 43(6). doi:10.1111/j.1365-2923.2009.03368.x
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  Objectives We compared multiple-choice and open-ended responses collected from a web-based tool designated 'Case for Change', which had been developed for assessing and teaching medical students in the skills involved in integrating sexual risk assessment and behaviour change discussions into patient-centred primary care visits. Methods A total of 111 Year 3 students completed the web-based tool. A series of videos from one patient encounter illustrated how a clinician uses patient-centred communication and health behaviour change skills while caring for a patient presenting with a urinary tract infection. Each video clip was followed by a request for students to respond in two ways to the question: 'What would you do next?' Firstly, students typed their statements of what they would say to the patient. Secondly, students selected from a multiple-choice list the statements that most closely resembled their free text entries. These two modes of students' answers were analysed and compared. Results When articulating what they would say to the patient in a narrative format, students frequently used doctor-centred approaches that focused on premature diagnostic questioning or neglected to elicit patient perspectives. Despite the instruction to select a matching statement from the multiple-choice list, students tended to choose the most exemplary patient-centred statement, which was contrary to the doctor-centred approaches reflected in their narrative responses. Conclusions Open-ended questions facilitate in-depth understanding of students' educational needs, although the scoring of narrative responses is time-consuming. Multiple-choice questions allow efficient scoring and individualised feedback associated with question items but do not fully elicit students' thought processes. © Blackwell Publishing Ltd 2009.
• Reidy, W., Spielberg, F., Wood, R., Binson, D., Woods, W., & Goldbaum, G. (2009). HIV risk associated with gay bathhouses and sex clubs: findings from 2 seattle surveys of factors related to HIV and sexually transmitted infections.. American journal of public health, 99(Issue). doi:10.2105/ajph.2007.130773
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  OBJECTIVES: We studied the HIV risk behaviors of patrons of the 3 commercial sex venues for men in Seattle, Washington. METHODS: We conducted cross-sectional, observational surveys in 2004 and 2006 by use of time-venue cluster sampling with probability proportional to size. Surveys were anonymous and self-reported. We analyzed the 2004 data to identify patron characteristics and predictors of risk behaviors and compared the 2 survey populations. RESULTS: Fourteen percent of respondents reported a previous HIV-positive test, 14% reported unprotected anal intercourse, and 9% reported unprotected anal intercourse with a partner of unknown or discordant HIV status during the current commercial sex venue visit. By logistic regression, recent unprotected anal intercourse outside of a commercial sex venue was independently associated with unprotected anal intercourse. Sex venue site and patron drug use were strongly associated with unprotected anal intercourse at the crude level. The 2004 and 2006 survey populations did not differ significantly in demographics or behaviors. CONCLUSIONS: Patron and venue-specific characteristics factors may each influence the frequency of HIV risk behaviors in commercial sex venues. Future research should evaluate the effect of structural and individual-level interventions on HIV transmission.
• Mackenzie, S., Kurth, A., Spielberg, F., Severynen, A., Malotte, C., St. Lawrence, J., & Fortenberry, J. (2007). Patient and Staff Perspectives on the Use of a Computer Counseling Tool for HIV and Sexually Transmitted Infection Risk Reduction. Journal of Adolescent Health, 40(6). doi:10.1016/j.jadohealth.2007.01.013
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  Purpose: To explore use of an interactive health communication tool- "Computer Assessment and Risk Reduction Education (CARE) for STIs/HIV.". Methods: This was a mixed method study utilizing participant observation and in-depth interviews with patients (n = 43), and focus groups with staff (5 focus groups, n = 41) from 5 clinics in 3 states (1 Planned Parenthood, 1 Teen, 2 STD, and 1 mobile van clinic). Data were managed using Atlas.ti. Inter-rater reliability of qualitative coding was .90. Results: Users were 58% nonwhite with mean age 24.7 years (74% < 25). Patients could use CARE with minimal to no assistance. Time for session completion averaged 29.6 minutes. CARE usefulness was rated an average of 8.2 on an ascending utility scale of 0 to 10. Patient themes raised as strengths were novelty, simplicity, confidentiality, personalization, and plan development, increased willingness to be honest, lack of judgment, and a unique opportunity for self-evaluation. Staff themes raised as strengths were enhanced data collection, handout customization, education standardization, behavioral priming, and expansion of services. Patient limitation themes included limited responses and lack of personal touch. Staff limitation themes were selecting users, cost, patient-provider role, privacy, and time for use. Conclusions: CARE was well-received and easily usable by most (especially 18-25-year-olds). Patient and staff perceptions support the use of CARE as an adjunct to usual practice and as a method to expand services. Honesty, reduced time constraints, and lack of judgment associated with CARE appeared to enhance self-evaluation, which may prove an important component in moving patients forward in the behavior change process. © 2007 Society for Adolescent Medicine.
• Woods, W., Binson, D., Blair, J., Han, L., Spielberg, F., & Pollack, L. (2007). Probability sample estimates of bathhouse sexual risk behavior. Journal of Acquired Immune Deficiency Syndromes, 45(2). doi:10.1097/qai.0b013e318055601e
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  OBJECTIVE: Previous research links high rates of unprotected anal intercourse (UAI) with men who go to bathhouses; however, the literature provides no prevalence estimates. An exit survey of a probability sample was conducted to describe the prevalence of risk activity at the bathhouse. METHODS: Data are from a 2-stage probability sample of men exiting a gay bathhouse (n = 400). RESULTS: During their visit, 91.5% of men had oral sex and 44.2% had anal sex (11.1% reported UAI and 5.5% reported unprotected receptive anal intercourse). In the prior 3 months, 85% reported having anal sex, which was more likely to be unprotected when it occurred in a private home or hotel as opposed to a public setting (P < 0.001). Moreover, having UAI at home was a significant correlate of risk during the bathhouse visit (P < 0.001). CONCLUSIONS: Most men at the bathhouse engaged in oral sex rather than anal sex, and most anal sex included use of condoms. Furthermore, men were more likely to have UAI in a private home than in any public setting. The bathhouse seems to have facilitated condom use when anal sex occurred on-site. © 2007 Lippincott Williams & Wilkins, Inc.
• Spielberg, F., Branson, B., Goldbaum, G., Lockhart, D., Kurth, A., Rossini, A., & Wood, R. (2005). Choosing HIV counseling and testing strategies for outreach settings: A randomized trial. Journal of Acquired Immune Deficiency Syndromes, 38(3).
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  Background: In surveys, clients have expressed preferences for alternatives to traditional HIV counseling and testing. Few data exist to document how offering such alternatives affects acceptance of HIV testing and receipt of test results. Objectives: This randomized controlled trial compared types of HIV tests and counseling at a needle exchange and 2 bathhouses to determine which types most effectively ensured that clients received test results. Methods: Four alternatives were offered on randomly determined days: (1) traditional test with standard counseling, (2) rapid test with standard counseling, (3) oral fluid test with standard counseling, and (4) traditional test with choice of written pretest materials or standard counseling. Results: Of 17,010 clients offered testing, 7014 (41%) were eligible; of those eligible, 761 (11%) were tested: 324 at the needle exchange and 437 at the bathhouses. At the needle exchange, more clients accepted testing (odds ratio [OR] = 2.3; P < 0.001) and received results (OR = 2.6; P < 0.001) on days when the oral fluid test was offered compared with the traditional test. At the bathhouses, more clients accepted oral fluid testing (OR = 1.6; P < 0.001), but more clients overall received results on days when the rapid test was offered (OR = 1.9; P = 0.01). Conclusions: Oral fluid testing and rapid blood testing at both outreach venues resulted in significantly more people receiving test results compared with traditional HIV testing. Making counseling optional increased testing at the needle exchange but not at the bathhouses. Copyright © 2005 by Lippincott Williams & Wilkins.
• Kurth, A. E., Martin, D. P., Golden, M. R., Weiss, N. S., Heagerty, P. J., Spielberg, F., Handsfield, H. H., & Holmes, K. K. (2004). A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the sexual history. Sexually Transmitted Diseases, 31(Issue 12). doi:10.1097/01.olq.0000145855.36181.13
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  Objective: The objective of this study was to compare reporting between audio computer-assisted self-interview (ACASI) and clinician-administered sexual histories. Goal: The goal of this study was to explore the usefulness of ACASI in sexually transmitted disease (STD) clinics. Study: The authors conducted a cross-sectional study of ACASI followed by a clinician history (CH) among 609 patients (52% male, 59% white) in an urban, public STD clinic. We assessed completeness of data, item prevalence, and report concordance for sexual history and patient characteristic variables classified as socially neutral (n = 5), sensitive (n = 11), or rewarded (n = 4). Results: Women more often reported by ACASI than during CH same-sex behavior (19.6% vs. 11.5%), oral sex (67.3% vs. 50.0%), transactional sex (20.7% vs. 9.8%), and amphetamine use (4.9% vs. 0.7%) but were less likely to report STD symptoms (55.4% vs. 63.7%; all McNemar chi-squared P values
• Spielberg, F., Levine, R. O., & Weaver, M. (2004). Self-testing for HIV: A new option for HIV prevention?. Lancet Infectious Diseases, 4(Issue 10). doi:10.1016/s1473-3099(04)01150-8
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  Self-testing has the potential to be an innovative component to community-wide HIV-prevention strategies. This testing method could serve populations who do not have access to standard voluntary counselling and testing services or because of privacy concerns, stigma, transport costs, or other barriers do not use facility-based, standard HIV testing. This paper reviews recent research on the acceptability, feasibility, and cost of rapid testing and home-specimen collection for HIV, and suggests that self-testing may be another important strategy for diagnosing HIV infection. Several research questions are posed that should be answered before self-testing is realised.
• Spielberg, F., Branson, B. M., Goldbaum, G. M., Lockhart, D., Kurth, A., Celum, C. L., Rossini, A., Critchlow, C. W., & Wood, R. W. (2003). Overcoming barriers to HIV testing: Preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 32(Issue 3). doi:10.1097/00126334-200303010-00012
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  Objective: To determine strategies to overcome barriers to HIV testing among persons at risk. Methods: We developed a survey that elicited testing motivators, barriers, and preferences for new strategies among 460 participants at a needle exchange, three sex venues for men who have sex with men, and a sexually transmitted disease clinic. Results: Barriers to testing included factors influenced by individual concern (fear and discrimination); by programs, policies, and laws (named reporting and inability to afford treatment); and by counseling and testing strategies (dislike of counseling, anxiety waiting for results, and venipuncture). The largest proportions of participants preferred rapid testing strategies, including clinic-based testing (27%) and home selftesting (20%); roughly equal proportions preferred oral fluid testing (18%), urine testing (17%), and standard blood testing (17%). One percent preferred home specimen collection. Participants who had never tested before were significantly more likely to prefer home self-testing compared with other strategies. Blacks were significantly more likely to prefer urine testing. Conclusions: Strategies for improving acceptance of HIV counseling and testing include information about access to anonymous testing and early treatment. Expanding options for rapid testing, urine testing, and home self-testing; providing alternatives to venipuncture; making pretest counseling optional; and allowing telephone results disclosure may encourage more persons to learn their HIV status.
• Spielberg, F., Critchlow, C., Vittinghoff, E., Gross, M., Doherty-Iddings, P., Scotti, R., Judson, F., Marmor, M., & Buchbinder, S. (2001). Slow diffusion of home HIV-specimen collection: Provider concerns at odds with client preferences. Sexually Transmitted Diseases, 28(1). doi:10.1097/00007435-200101000-00012
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  Background: Home specimen collection and telephone counseling (HSCTC) may be a convenient new method for detection of HIV infection among cohorts at high-risk for HIV. Goal: To evaluate attitudes about HSCTC among participants, HIV counselors, and community advisory board members associated with a national multisite study of persons at high risk for HIV. Study Design: Twelve focus groups and surveys were conducted at six sites among 126 counselors, community advisory board members, and cohort participants. Results: Staff and community advisory board members raised concerns about the acceptability, feasibility, safety, and effectiveness of HSCTC. In contrast, participants (92%) reported a willingness to collect blood and oral samples on a frequent basis, and preferred telephone (73%) to office-based counseling. Conclusion: Home specimen collection and telephone counseling appear to be preferred by study participants at high risk of HIV infection. Staff and community advisory board members had stronger reservations than prospective users.
• Spielberg, F., Kurth, A., Gorbach, P., & Goldbaum, G. (2001). Moving from apprehension to action: HIV counseling and testing preferences in three at-risk populations. AIDS Education and Prevention, 13(6). doi:10.1521/aeap.13.6.524.21436
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  This study sought to identify factors influencing HIV testing decisions among clients at a sexually transmitted disease clinic, gay men, and injection drug users. Focus group and intensive interview data were collected from 100 individuals. The AIDS Risk Reduction Model was adapted to describe factors that affect test decisions. Testing barriers and facilitators were grouped as factors affected by "Individual" beliefs, "System" policies and programs, "Testing" technology, and "Counseling" options. Individual factors (fear of death and change), system factors (anonymous test availability, convenience), and counseling and testing factors (rapid results, counseling alternatives) interact to determine whether an individual does not test ("apprehension") or does test ("action"), and ultimately, tests routinely ("integration"). In conclusion, traditional HIV testing presents barriers to some populations at risk for HIV. These findings suggest several strategies to improve HIV test acceptance: acknowledge fears, address system barriers, utilize available test technologies, and expand counseling options.
• Spielberg, F., Critchlow, C., Vittinghoff, E., Coletti, A., Sheppard, H., Mayer, K., Metzger, D., Judson, F., Buchbinder, S., Chesney, M., & Gross, M. (2000). Home collection for frequent HIV testing: Acceptability of oral fluids, dried blood sports and telephone results. AIDS, 14(12). doi:10.1097/00002030-200008180-00018
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  Objective: To assess the feasibility and acceptability of bimonthly home oral fluid (OF) and dried blood spot (DBS) collection for HIV testing among high-risk individuals. Design: A total of 241 participants [including men who have sex with men (MSM), injecting drug users (IDU), and women at heterosexual risk] were recruited from a randomly selected subset of study participants enrolled at four sites in the HIV Network for Prevention Trials (HIVNET) cohort, and assigned at random to bimonthly home collection of OF or DBS specimens over a 6 month interval. Participants could select telephone calls or clinic visits to receive HIV test results. Methods: Bimonthly specimens were tracked for adherence to the schedule, were evaluated for adequacy for testing, and tested using antibody assays and polymerase chain reaction (PCR) for DBS. The acceptability of bimonthly home OF and DBS collection and telephone counseling was assessed in an end-of-study questionnaire. Results: The laboratory received 96 and 90% of expected OF and DBS specimens, respectively; 99% of each specimen type was adequate for testing. Almost all (95%) participants chose results disclosure by telephone. The majority of participants (85%) reported that bimonthly testing did not make them worry more about HIV, and almost all (98%) judged that with bimonthly testing their risk behavior remained the same (77%) or became less risky (21%). Conclusion: Bimonthly home specimen collection of both OF and DBS with telephone counseling is acceptable and feasible among study participants at high risk. These methods will be useful for the early detection of HIV infection and remote follow-up of research cohort participants in HIV vaccine and prevention trials. (C) 2000 Lippincott Williams and Wilkins.
• Spielberg, F., & Kassler, W. (1996). Rapid testing for HIV antibody: a technology whose time has come.. Annals of internal medicine, 125(6). doi:10.7326/0003-4819-125-6-199609150-00014
• Spielberg, F., Kabeya, C., Quinn, T., Ryder, R., Kifuani, N., Harris, J., Bender, T., Heyward, W., Tam, M., & Auditore-Hargreaves, K. (1990). Performance and cost-effectiveness of a dual rapid assay system for screening and confirmation of human immunodeficiency virus type 1 seropositivity. Journal of Clinical Microbiology, 28(2). doi:10.1128/jcm.28.2.303-306.1990
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  Recent studies have shown that rapid, instrument-free assays for the detection of antibody to human immunodeficiency virus (HIV) can be as sensitive and specific as enzyme-linked immunosorbent assay (ELISA) for screening of donated blood in developing countries. Currently, however, specimens which test positive on a screening assay must still be confirmed by Western blot (immunoblot), a method which is not feasible in most developing-country laboratoies. We examined whether a testing hierarchy which utilizes neither conventional ELISA nor Western blot can be reliably used for screening and confirmation of HIV infection in a high-risk population. In a retrospective analysis of 3,878 specimens which were for antibody to HIV in Kinshasa, Zaire, we observed that a testing hierarchy consisting of duplicate HIVCHEK screening assays followed by duplicate Serodia-HIV confirmatory assays resulted in correct confirmation of all ELISA- and Western blot-positive specimens. We conclude that such a testing hiearchy can produce highly accurate results for identification of positive specimens in routine HIV testing and provides a practical alternative to conventional methods of HIV screening and confirmation.
• Spielberg, F., Ryder, R., Harris, J., Heyward, W., Kabeya, C., Kifuani, N., Bender, T., & Quinn, T. (1989). FIELD TESTING AND COMPARATIVE EVALUATION OF RAPID, VISUALLY READ SCREENING ASSAYS FOR ANTIBODY TO HUMAN IMMUNODEFICIENCY VIRUS. The Lancet, 333(8638). doi:10.1016/s0140-6736(89)91610-3
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  Five rapid, visually read assays for detection of antibody against human immunodeficiency virus (HIV) were evaluated on fresh serum samples from 4000 prospective blood donors at Mama Yemo Hospital, Kinshasa, Zaïre. The sensitivity of the assays, based on 214 specimens positive by western blot, ranged from 84·6% to 99·1%. The specificity, based on 3664 samples negative by enzyme-linked immunosorbent assay (ELISA) or western blot, ranged from 92·7% to 98·8%. Three readers scored each test result independently; disagreement about test interpretation occurred in 1·2-8·3% of the specimens. There was no correlation between assay performance and assay principle (agglutination or dot immunobinding) or antigen source (viral lysate or recombinant). Assays such as these can be readily implemented in a developing country transfusion centre, where blood screening by ELISA is not practicable. © 1989.
• Carty, D., Spielberg, F., & Gear, A. (1986). Thrombin causes subsecond changes in protein phosphorylation of platelets. Blood, 67(6). doi:10.1182/blood.v67.6.1738.bloodjournal6761738
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  We have developed a general quenched-flow approach to study platelet function as early as 0.3 seconds after stimulation. Phosphorylation of 20- and 40-kd proteins has been analyzed during the first five seconds of platelet response to thrombin from 0.1 to 5.0 U/mL and compared with the progress of aggregation and serotonin secretion. The onset time for aggregation and phosphorylation of both proteins was less than one second, although with lowest (
• Carty, D., Spielberg, F., & Gear, A. (1984). Thrombin causes sub-second changes in protein phosphorylation of platelets. Federation Proceedings, 43(4).

Proceedings Publications

• Kelly, J., Spielberg, F., & McAuliffe, T. (2008, Summer). Defining, designing, implementing, and evaluating phase 4 HIV prevention effectiveness trials for vulnerable populations. In Journal of AIDS, 47, S28–S33.
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  The efficacy of behavioral HIV prevention interventions has been convincingly demonstrated in a large number of randomized controlled phase 3 research outcome trials. Little research attention has been directed toward studying the effectiveness of the same interventions when delivered by providers to their own clients or community members, however. This article argues for the need to conduct phase 4 effectiveness trials of HIV prevention interventions that have been found efficacious in the research arena. Such trials can provide important information concerning the impact of interventions when applied in heterogeneous "real-world" circumstances. This article raises design issues and methodologic questions that need to be addressed in the conduct of phase 4 trials of behavioral interventions. These issues include the selection and training of service providers engaged in such trials, maintenance of fidelity to intervention protocol in provider-delivered interventions, determination of intervention core elements versus aspects that require tailoring, selection of relevant phase 4 study outcomes, interpretation of findings indicative of field effectiveness, sustainability, and other aspects of phase 4 trial design. © 2008 Lippincott Williams & Wilkins, Inc.
• Hendry, D., MacKenzie, S., Kurth, A., Spielberg, F., & Larkin, J. (2005). Evaluating paper prototypes on the street. In Conference on Human Factors in Computing Systems, CHI EA 2005.
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  The evaluation of paper prototypes is normally conducted in controlled settings such as a usability lab. This paper, in contrast, reports on a study where evaluations of a paper prototype were performed on the street with young adults. We discuss the merits of this approach and how it impacted the design process. A key finding is that the street location can enfranchise people who may otherwise be underrepresented in design. We conclude that evaluating paper prototypes in public, street settings is feasible and informative.

Presentations

• Spielberg, F. (2025, September).

  Collaborative Research for Primary Care. 

  . In: Proceedings of the WONCA World Conference 2025; Sep 17–21; Lisbon, Portugal. World Organization of Family Doctors (WONCA); 2025. . Lisbon, Portugal: WONCA.
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  Invited panel member for a presentation on Multimorbidity innovation in primary care