title: Assessing Problematic Substance Use in HIV Care: Which Questions Elicit Accurate Patient Disclosures?
abstract: Substance use is associated with higher rates of antiretroviral non-adherence and poor HIV outcomes. This study examined how HIV care providers assess substance use, and which questions elicit accurate patient disclosures.
  
  
  
  We conducted a conversation analysis of audio-recorded encounters between 56 providers and 162 patients living with HIV (PLWH) reporting active substance use in post-encounter interviews (cocaine or heroin use in the past 30 days, > 4 days intoxicated in past 30 days, or AUDIT score ≥ 8). We assessed the frequency of substance use discussion, characterized the types of questions used by providers, and determined the frequency of accurate patient disclosure by question type.
  
  
  
  In 55 reports of active substance use, providers already knew about the use (n = 16) or patients disclosed unpromptednn = 39). Among the remaining 155 instances of substance use in which providers had the opportunity to elicit disclosure, 78 reports (50 %) of substance use were not discussed. Of the remaining 77 reports in which the provider asked about substance use, 55 (71 %) patients disclosed and 22 (29 %) did not disclose. Questions were classified as: open-ended (n = 18, "How's the drinking going?"); normalizing (n = 14, "When was the last time you used?"); closed-ended (n = 36, "Have you used any cocaine?"); leading towards non-use (n = 9, "Have you been clean?"). Accurate disclosure followed 100 % of open-ended and normalizing questions, 58 % of closed-ended questions, and 22 % of leading questions. After adjusting for drug type, closed-ended questions were 41 % less likely (p < 0.001), and 'leading' questions 78 % less likely (p = 0.016) than broad and normalizing questions to elicit disclosures.
  
  
  
  Providers in this sample missed almost half of the opportunities to identify and discuss substance use with PLWH. Providers can increase the probability of patient disclosure by using open-ended or normalizing questions that ask about the "last time" that the patient used drugs or alcohol.
authors.affiliation: Johns Hopkins University School of Medicine, 2024 East Monument Street, Baltimore, MD, 21205, USA. wcallon1@jhmi.edu.
authors.forename: Wynne
authors.initials: W
authors.lastname: Callon
authors.affiliation: Johns Hopkins University School of Medicine, 2024 East Monument Street, Baltimore, MD, 21205, USA.
authors.forename: Mary Catherine
authors.initials: MC
authors.lastname: Beach
authors.affiliation: Portland VA Medical Center, Portland, OR, USA.|Department of Medicine, Oregon Health Sciences University, Portland, OR, USA.
authors.forename: Somnath
authors.initials: S
authors.lastname: Saha
authors.affiliation: Johns Hopkins University School of Medicine, 2024 East Monument Street, Baltimore, MD, 21205, USA.
authors.forename: Geetanjali
authors.initials: G
authors.lastname: Chander
authors.affiliation: Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
authors.forename: Ira B
authors.initials: IB
authors.lastname: Wilson
authors.affiliation: Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
authors.forename: Michael Barton
authors.initials: MB
authors.lastname: Laws
authors.affiliation: Saint-Lukes Roosevelt, New York, NY, USA.
authors.forename: Victoria
authors.initials: V
authors.lastname: Sharp
authors.affiliation: Department of Medicine, Wayne State University, Detroit, MI, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Cohn
authors.affiliation: Johns Hopkins University School of Medicine, 2024 East Monument Street, Baltimore, MD, 21205, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Moore
authors.affiliation: Department of Medicine, Oregon Health Sciences University, Portland, OR, USA.
authors.forename: P Todd
authors.initials: PT
authors.lastname: Korthuis
mesh_terms: D000328:Adult; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000523:psychology; D006801:Humans; D007406:Interview, Psychological; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D012650:Self Disclosure; D019966:Substance-Related Disorders / Q000150:complications / Q000175:diagnosis* / Q000523:psychology; D014342:Truth Disclosure
keywords: HIV/AIDS; patient–provider communication; substance use