Audio Computer-assisted Self-interviewing Technology Research Articles

Factors associated with perceived ease of access to syringes in Appalachian North Carolina.

To examine associations between perceived ease of syringe access, syringe sources, injection behaviors, and law enforcement (LE) interactions among people who inject drugs (PWID) in rural Appalachian North Carolina (NC). Using respondent-driven sampling, a diverse sample of 309 self-reported PWID were recruited from rural Appalachian NC. Data were collected via audio computer-assisted self-interview technology from February 2019 through March 2020. Respondents reported demographics, sources of syringes, LE interactions, and injection behaviors. Univariate, bivariate, and linear regression analyses were performed. Respondents most often obtained syringes from pharmacies and syringe service programs (SSPs). Twenty-one percent disagreed that it was easy to obtain sterile syringes, with 28% reporting low or no access to an SSP. PWID who reported longer physical distances to an SSP had greater difficulty accessing syringes (P<.001). PWID who reported greater ease of access to syringes reported engaging in receptive syringe sharing less often (P<.01). PWID who were stopped and searched by LE more often reported injecting drugs somebody else prepared with nonsterile supplies more often (P<.01). Participants shared used injection supplies more than twice as often than they shared used syringes. These results underscore the importance of SSPs to mitigate the spread of human immunodeficiency virus and viral hepatitis in rural areas. Supporting mobile SSP services in rural areas could increase access to sterile syringes and injection supplies. SSPs should educate PWID about the importance of not sharing injection supplies. Pharmacies could increase syringe access in areas where SSPs do not operate.

An Alternative Technique for Youth Risk Surveillance Outside of the School System

PurposeWhen school districts choose not to participate in adolescent health behavior surveys, tracking adolescent health indicators can be challenging. We conducted a countywide youth behavior survey outside of the school system. Our purpose is to describe alternative methods used for gathering these data reliably and ethically. MethodsWe implemented two parallel surveys with youth ages 14–19 residing in a mid-sized county with urban, suburban, and rural neighborhoods. An anonymous phone-based survey used computer-assisted telephone interviewing with a live interviewer in conjunction with an interactive voice response system to survey youth via random digit dialing of landlines and cell phones. A concurrent in-person anonymous survey was conducted with marginalized youth (from juvenile detention centers, shelters, and residential facilities), using audio computer-assisted self-interviewing technology. The survey measures included the Centers for Disease Control Youth Risk Behavior Surveillance System and additional questions about social supports, neighborhood, and adverse childhood experiences. ResultsData were collected between February and December 2014. The phone-based sample recruited 1813 participants; the marginalized sample included 262 youth. Several strategies ensured anonymity and reduced coercion. The final phone-based sample was similar to demographics of the county population. The marginalized youth sample captured out-of-home youth who may have been missed with phone-based sampling alone. ConclusionsWe review alternative strategies for obtaining population-based adolescent health data without the cooperation of schools. These techniques can provide a basis to collect data that may help direct resources and policies relevant to needs of local youth.

Emerging Substance Use of Teenagers With ADHD

use, especially among youth at high risk for substance use, has not been assessed??. Using data from a cross sectional survey of marginalized youth, this study sought to assess the relationship between levels of hope and substance use. Methods: The Division of Adolescent and Young Adult Medicine at Children’s Hospital of Pittsburgh of UPMC, the Institute for Evaluation Science in Community Health at the University of Pittsburgh Graduate School of Public Health, and the Allegheny County Health Department collaborated to conduct this countywide, youth health behavior survey. An anonymous survey technique was implemented with youth ages 14-19. Youth were recruited, using convenience sampling, from juvenile detention centers, shelters, and residential facilities. The survey was administered using audiocomputer-assisted self-interviewing technology (ACASI). Hopewas measured using three previously validated survey questions, (ie. “I believe things will work out for me” with likert scale responses) and risk behaviors were assessed using established Youth Risk Behavior Surveillance Survey questions about substance use. Results: 254 youth had complete data for the variables of interest. Bivariate assessments show higher cumulative hope scores in youth not using hard drugs or binge drinking (p1⁄40.02). Higher hope scores are also found in youth who have not had sex after drug or alcohol use (p1⁄40.01). Youth who do not smoke marijuana or daily tobacco also had higher hope scores than their counterparts who reported daily smoking. After adjusting for relevant demographic variables (age, race/ethnicity, parental education), we found a trend towards decreased odds for binge drinking (0.72) for every 3 point increase in the hope score (range 3 15, p1⁄40.052). Odds ratios are presented at three point increase to assess a meaningful increase in hope score. Increased hopefulness was not associated with a lower likelihood of other substance using behaviors explored in other adjusted models. Conclusions: In a sample of at risk youth, higher levels of hope were associated with a decreased likelihood of risky substance use behaviors in bivariate models. These associations did not persist in adjustedmodels, suggesting that demographic characteristics such as age may be moderating these associations. There may also be unmeasured confounders in this sample of at risk youth. Hope (as a measure of future orientation) may be a potential protective factor in promoting healthier behaviors and reducing risk among adolescents. Studies with larger samples should examine whether hope may be more salient at particular ages or for specific populations. Sources of Support: Funders included the Heinz Foundation, the Hillman Foundation, the Grable Foundation, and The Fisa Foundation.

Health perceptions and symptom burden in primary care: measuring health using audio computer-assisted self-interviews.

To assess the relationships among somatic symptoms and health perception measures in data collected from the implementation of audio computer-assisted self-interview (ACASI) technology in a primary care clinic of a safety-net healthcare system. We approached 2,848 English- or Spanish-speaking patients to complete an ACASI-administered survey before their clinic appointment between April 2011 and July 2012. We administered the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health-10 assessing General Self-Rated Health (GSRH), Global Physical and Mental Health; Memorial Symptom Assessment Scale (MSAS) assessing symptom burden; and the Patient Health Questionnaire-2 (PHQ-2). We calculated population attributable fractions (PAF) of symptoms on poorly perceived health. Participation rate was 90 %, but 51 % of observations were analyzable. Mean age was 57 years; 53 % were non-Hispanic black; and 20 % completed the survey in Spanish. All but 2 % reported at least one symptom most commonly lack of energy (87 %) and pain (83 %). The MSAS was well correlated with PHQ-2 (r = 0.65) and Global Physical Health (r = -0.65), but less with GSRH (r = -0.49). All negative health perception measures were largely attributable to lack of energy and pain, while depression-range PHQ-2 was attributable also to less prevalent symptoms including decreased appetite and sexual disinterest. Symptom burden was less correlated with GSRH than with other measures of poor health perception. Fatigue and pain contributed the highest PAF to all measures of perceived poor health. Success with collecting PROMs in a resource-limited clinical setting demonstrates that the implementation of ACASI technology is feasible.

A Global Study on the Influence of Neighborhood Contextual Factors on Adolescent Health

PurposeThis study uses data collected as part of the Well-Being of Adolescents in Vulnerable Environments study to (1) compare the perceptions of neighborhood-level factors among adolescents across five different urban sites; (2) examine the associations between factors within the physical and social environments; and (3) examine the influence of neighborhood-level factors on two different health outcomes—violence victimization in the past 12 months and ever smoked. MethodsAcross five urban sites (Baltimore, New Delhi, Johannesburg, Ibadan, and Shanghai), 2,320 adolescents aged 15–19 years completed a survey using audio computer-assisted self-interview technology. To recruit adolescents, each site used a respondent-driven sampling method, which consisted of selecting adolescents as “seeds” to serve as the initial contacts for recruiting the entire adolescent sample. All analyses were conducted with Stata 13.1 statistical software, using complex survey design procedures. To examine associations between neighborhood-level factors and among our two outcomes, violence victimization and ever smoked, bivariate and multivariate analyses were conducted. ResultsAcross sites, there was great variability in how adolescents perceived their neighborhoods. Overall, adolescents from Ibadan and Shanghai held the most positive perceptions about their neighborhoods, whereas adolescents from Baltimore and Johannesburg held the poorest. In New Delhi, despite females having positive perceptions about their safety and sense of social cohesion, they had the highest sense of fear and the poorest perceptions about their physical environment. The study also found that one of the most consistent neighborhood-level factors across sites and outcomes was witnessing community violence, which was significantly associated with smoking among adolescents in New Delhi and Johannesburg and with violence victimization across nearly every site except Baltimore. No other neighborhood-level factor exerted greater influence. ConclusionsThis study confirms the important associations between perceptions of a neighborhood and adolescent health. At the same time, it demonstrates that not all neighborhood-level factors are associated with adolescent health outcomes in the same way across different urban contexts. Further longitudinal research is needed to examine the direction of causation between adolescent health neighborhood contexts and health outcomes and the reasons for why different urban contexts may exert varying levels of influence on the health of adolescents.

Feasibility of Conducting Child Abuse Research with Girls in Juvenile Detention Using Audio-Computer Assisted Self-Interview (ACASI) Technology

This paper presents a feasibility study of audio computer-assisted self-interview (ACASI) technology used to elicit self-reported histories of child maltreatment among detained adolescent girls (N = 35). We focus on methodological, legal, ethical, and administrative challenges to the collection of sensitive information from minors who are wards of the state. We conclude that extensive collaboration with detention center staff was required to address and overcome these challenges. Pending the availability of additional evidence from demographically diverse samples, the extent to which the ACASI method improves the completeness and accuracy of child maltreatment histories reported by adolescent girls in juvenile detention remains unclear. Further research is needed to determine whether the advantages of the ACASI technology contribute to more valid and reliable reporting of maltreatment by detained girls in a setting where an empathetic interviewer, who may facilitate the disclosure process, is absent.

Gang Norms and Risky Sex Among Adolescents With a History of Detention

ABSTRACT Prior studies have examined whether or not belonging to a gang was associated with risky sexual behaviors. However, the literature has yet to explore whether it is not just gang membership but gang norms that are associated with risky sex, which was the primary aim of this study. Audio computer-assisted self-interviewing technology was used to collect data from a convenience sample of 136 adolescent detainees who reported gang involvement. Demographics, gang norms, and risky sexual behaviors occurring in the 2 months prior to being detained were assessed. Multiple logistic regression models controlling for demographics documented that adolescents who reported high-risk gang norms were significantly more likely to: have sex while high on drugs, have sex with a partner who was high on drugs, have group sex, and report condom breakage or leakage during a sexual encounter, compared with those with low-risk gang norms. Results suggest that the norms present within gangs infer added sexual risks. Future research should assess how risk norms differ across various gangs. Sexually transmitted infection prevention approaches should target youth who belong to gangs that promote risky norms given that conventions exist on a continuum.

A longitudinal examination of sexually transmitted infection/HIV prevention knowledge and sexually transmitted infections among African-American adolescent females

This study examines whether sexually transmitted infection prevention knowledge predicts the acquisition of biologically confirmed sexually transmitted infections among African-American adolescent females. A total of 715 females were recruited from public health clinics in Atlanta, Georgia, and using audio computer-assisted self-interview technology, we assessed for demographics, sexually transmitted infection prevention knowledge, risky sexual behaviors, and sexually transmitted infections. After controlling for demographics and prior risky sexual behaviors, participants with high prevention knowledge were 0.09 times less likely to report sexually transmitted infections, and those with multiple sexual partners were 1.3 times more likely to report sexually transmitted infections. Our findings suggest that the promotion of accurate sexually transmitted prevention knowledge is critical especially among females with multiple sex partners.

The relationship between ethnic identity and Chlamydia and Gonorrhea infections among low-income detained African American adolescent females

This study explored the relationship between ethnic identity and Chlamydia and Gonorrhea infections among detained African American female adolescents. A cross-sectional survey was conducted among 123 African American female adolescents within eight detention facilities in Georgia. Using audio-computer assisted self-interviewing technology, data were collected on demographics, ethnic identity, laboratory-confirmed Chlamydia and Gonorrhea, and other known correlates for sexually transmitted infections (STIs), such as socioeconomic status, parental monitoring, and risky sexual behaviors. Rates of Chlamydia and Gonorrhea testing yielded incidence rates of 22.6% and 4.3%, respectively. Findings indicated that, controlling for STI correlates, participants who indicated high ethnic identity were 4.3 times more likely to test positive for an STI compared to those scoring low on the measure of ethnic identity.

Examining Parental Monitoring as a Pathway From Community Violence Exposure to Drug Use, Risky Sex, and Recidivism Among Detained Youth

ABSTRACT This study examined whether parental monitoring mediated the relationship between community violence exposure and a spectrum of behaviors such as recidivism, risky sex, and drug use among youth with a history of being detained. It also explored whether risk pathways differed by gender. Adolescents (n = 550) who were detained or previously detained were recruited from eight regional detention facilities in Georgia. Audio computer-assisted self-interviewing technology was used to assess demographic factors (i.e., age, race, and socioeconomic status), risky sex, drug use, and recidivism prior to being detained. Major findings indicated direct relationships between community violence exposures and risky sex and drug use in the 2 months prior to being detained. Findings also indicated that parental monitoring mediated these relationships for both adolescent males and females. These findings document that parental monitoring is an important element even for troubled youth across a broad spectrum of risk factors. Consequently, it is recommended that intervention programs examine the differential effects of monitoring behaviors by a variety of groups such as parental figures, teachers, and peer mentors.

Sexual Risk Behaviors by Relationship Type and Trauma History Among HIV-Positive Men Who Have Sex with Men

The association of trauma exposure and coping style to sexual risk behavior has yet to be fully examined in the context of primary and casual sexual partnerships. The current study assessed a high risk sexual behavior-unprotected anal intercourse (UAI)-in a high risk population of HIV-positive men who have sex with men (MSM) with a history of trauma. Using audio computer-assisted self-interview technology, 132 HIV-positive MSM completed measures of trauma exposure, trauma symptoms, coping strategies, and sexual risk behavior. Hierarchical logistic regression analyses indicated that completing more years of education and having experienced sexual abuse were positively associated with UAI with casual partners. Additionally, use of active coping was negatively associated with UAI with casual partners and the final model significantly predicted variance in UAI with casual partners. However, no variables were significantly associated with UAI with primary partners, suggesting that sexual risk behavior with primary partners may be associated with factors not commonly assessed in risk prediction or prevention research. We discuss the results in the context of developing new or modifying existing interventions to address rates of sexual risk in the relationships of HIV-positive MSM.

Abortion practice in Mexico: a survey of health care providers

BackgroundLittle is known about abortion practice in Mexico postlegalization of abortion in Mexico City in 2007. Study DesignIn 2009, we anonymously surveyed 418 Mexican health care providers at the Colegio Mexicano de Especialistas en Ginecologia y Obstetricia meeting using audio computer-assisted self-interview technology. ResultsThe majority of respondents were obstetrician gynecologists (376, 90%), Catholic (341, 82%), 35–60 years old (332, 79%) and male (222, 53%) and worked with trainees (307, 74%). Prior to 2007, 11% (46) and 17% (71) provided medical and surgical abortions; now, 15% (62) and 21% (86) provide these services, respectively. Practitioners from Mexico City were more likely to provide services than those from other areas. Most medical abortion providers (50, 81%) used ineffective protocols. Surgical abortion providers mainly used either manual vacuum aspiration (39, 45%) or sharp curettage (27, 32%). Most abortion providers were trained in residency and wanted more training in medical (54, 87%) and surgical (59, 69%) abortion. Among nonproviders, 49% (175) and 27% (89) expressed interest in learning to perform medical and surgical abortion, respectively. ConclusionGiven the interest in learning to provide safe abortion services and the prevalent use of ineffective medical abortion regimens and sharp curettage, abortion training in Mexico should be strengthened.

Aberrant Behaviors With Prescription Opioids and Problem Drug Use History in a Community-Based Cohort of HIV-Infected Individuals

Context The treatment of pain in patients with substance use disorders creates tensions for clinicians between undertreating pain and enabling opioid analgesic misuse. Objectives To characterize prevalence and factors associated with aberrant opioid analgesic behaviors in a cohort of HIV-infected individuals who are at high risk for opioid analgesic misuse. Methods We assessed pain and substance use disorders in a cross-sectional study that enrolled 296 participants from the Research on Access to Care in the Homeless cohort, a community-based sample of indigent HIV-infected adults. We measured aberrant opioid behaviors, defined as major or minor depending on level of risk of harm to patients, using Audio Computer-Assisted Self-Interview technology. Results Most participants (91.2%) reported pain in the week before interview, with the majority of these experiencing severe pain (53.7%). More than two-thirds (69.2%) of the participants met criteria for a lifetime history of cocaine, amphetamine, or heroin/opioid use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). More than one-third of the sample (37.4%) had a history of aberrant opioid behavior within 90 days of interview. One-fifth (18.5%) had a history of “major” aberrant behaviors. Conclusion In this high-risk population, severe pain is common and aberrant opioid behaviors are prevalent but not universal. As recommended by American Pain Society and American Academy of Pain Medicine guidelines, when prescribing opioid analgesics, clinicians must consider variation in the severity of aberrant behaviors, particularly aberrant behaviors that may represent undertreatment of pain.

O1-S05.04 Increased risk for Trichomonas vaginalis in an urban population of young adults

BackgroundThe epidemiology of T vaginalis (TV) in the general population is not well understood, although it is reported to be the most common curable sexually transmitted infection worldwide. Surveillance data...

Development and initial validation of a brief screener for focused HIV prevention efforts

The public health response to the spread of HIV relies on behavioural changes, especially reductions in sexual and drug-use-related transmission risk behaviours (TRBs). While understanding the factors that dispose people towards risky behaviours is important scientifically, it can be difficult to distil the many predictors of sexual risk behaviours into a useful clinical tool for focused prevention efforts. Our goal was to evaluate the extent to which known predictors of sexual TRBs (self-efficacy, treatment optimism, engagement with medical care, awareness of risky behaviours, substance use, and relevant behavioural and socio-demographic characteristics) combined with additional attitude-related assessments to identify those who had engaged in recent sexual TRBs and may therefore be at risk of additional TRBs. In this study, we analysed data on beliefs and behaviours related to sex, substance use, HIV prevention and other relevant factors for 280 patients at a publicly funded HIV/AIDS clinic in Seattle. All participants completed a baseline audio computer-assisted self interview (ACASI) as part of a larger trial focused on reducing TRBs. Our multivariate model yielded three screening questions that could prove effective in identifying HIV-positive patients in need of focused prevention resources. The resulting screener holds promise as a brief and easily deployed tool that can be used by providers regardless of access to ACASI technology. Additional validation is needed and longitudinal evaluation is currently in progress.

Sexual Risk and Substance Use Behaviors Among African American Men Who Have Sex with Men and Women

African American men who have sex with men and women (MSMW), but who do not form a sexual identity around same-sex behavior, may experience risk for HIV infection and transmission. This paper reports cross-sectional survey findings on sexual behaviors and substance use of urban non-gay- or non-bisexual-identified African American MSMW (n = 68), who completed behavior assessment surveys using audio-computer assisted self-interviewing technology. Overall, 17.6% reported being HIV-positive. In the past 3 months, 70.6% had unprotected insertive sex with a female, 51.5% had unprotected insertive anal sex (UIAS) with a male, 33.8% had unprotected receptive anal sex (URAS) with a male, 25% had UIAS with a transgender female, and 10.3% had URAS with a transgender female. Findings indicated a bridging potential for HIV and sexually transmitted infections across groups, such that 38.2% reported concurrent unprotected sex with female and male partners and 17.6% reported concurrent unprotected sex with female and transgender female partners. In the past 3 months, 70.6% used alcohol before sex and 85% used drugs before sex. Men who used drugs before sex had a tenfold increased likelihood for unprotected sex with male partners, and men who injected drugs had a nearly fivefold increased likelihood for unprotected sex with a transgender female. Interventions to address sexual risk behaviors, especially partner concurrency, and substance use behavior for these men are warranted.

Distinct Risk Factor Profiles for Human Papillomavirus Type 16–Positive and Human Papillomavirus Type 16–Negative Head and Neck Cancers

High-risk types of human papillomavirus (HPV), including HPV-16, cause a subgroup of head and neck squamous cell carcinomas (HNSCCs). We examined whether the risk factors for HPV-16-positive HNSCCs are similar to those for HPV-16-negative HNSCCs in a hospital-based case-control study. Case subjects (n = 240) diagnosed with HNSCC at the Johns Hopkins Hospital from 2000 through 2006 were stratified by tumor HPV-16 status as determined by in situ hybridization. Two control subjects (n = 322) without cancer were individually matched by age and sex to each HPV-16-positive and HPV-16-negative case subject. Data on risk behaviors were obtained by use of audio computer-assisted self-interview technology. Multivariable conditional logistic regression models were used to estimate the odds ratios (ORs) for HPV-16-positive HNSCC and HPV-16-negative HNSCC associated with risk factors. All statistical tests were two-sided. HPV-16 was detected in 92 of 240 case subjects. HPV-16-positive HNSCC was independently associated with several measures of sexual behavior and exposure to marijuana but not with cumulative measures of tobacco smoking, alcohol drinking, or poor oral hygiene. Associations increased in strength with increasing number of oral sex partners (P(trend) = .01) and with increasing intensity (joints per month, P(trend) = .007), duration (in years, P(trend) = .01), and cumulative joint-years (P(trend) = .003) of marijuana use. By contrast, HPV-16-negative HNSCC was associated with measures of tobacco smoking, alcohol drinking, and poor oral hygiene but not with any measure of sexual behavior or marijuana use. Associations increased in strength with increasing intensity (cigarettes per day), duration, and cumulative pack-years of tobacco smoking (for all, P(trend) < .001), increasing years of heavy alcohol drinking (> or = 15 years of 14 drinks per week; P(trend) = .03), and increasing number of lost teeth (P(trend) = .001). Compared with subjects who neither smoked tobacco nor drank alcohol, those with heavy use of tobacco (> or = 20 pack-years) and alcohol had an increased risk of HPV-16-negative HNSCC (OR = 4.8, 95% confidence interval [CI] = 1.8 to 12) but not of HPV-16-positive HNSCC (OR = 0.67, 95% CI = 0.29 to 1.9). HPV-16-positive HNSCCs and HPV-16-negative HNSCCs have different risk factor profiles, indicating that they should be considered to be distinct cancers.

Are Feelings of Responsibility to Limit the Sexual Transmission of HIV Associated With Safer Sex Among HIV-Positive Injection Drug Users?

We developed a scale among HIV-positive injection drug users (IDUs) to measure self-perceived responsibility to limit HIV transmission during sex. We describe the characteristics of HIV-positive IDUs (n=1114, 62% male, HIV-positive for 9 years on average) who felt responsible for protecting their sexual partners from HIV and evaluated whether such feelings were associated with safer sexual practices. Using this scale (Cronbach alpha=0.83) and audio computer-assisted self-interviewing technology, 75% of this sample felt responsible for protecting their sexual partners from HIV. In cross-sectional multivariate analysis, HIV-positive IDUs who felt responsible were those with greater HIV knowledge (adjusted odds ratio [95% confidence interval]: 1.74 [1.26 to 2.40]), perceived social support (1.77 [1.28 to 2.44]), self-efficacy for safely injecting (1.41 [1.02 to 1.94]), and self-efficacy for using condoms (1.92 [1.38 to 2.68]). Feeling responsible was associated with having relatively fewer sex partners (<10 vs. >or=10, 0.57 [0.34 to 0.96]) and a lower odds of unprotected sex (0.63 [0.45 to 0.89]) but was not associated with safer injection practices. Feelings of responsibility did not vary by demographic characteristics, suggesting that prevention messages that encourage HIV-positive people to play a role in curbing HIV transmission may be acceptable to many HIV-positive IDUs. Working with HIV-positive IDUs to increase or reinforce feelings of responsibility may reduce the sexual transmission of HIV.

Implementation of Audio Computer-Assisted Interviewing Software in HIV/AIDS Research

Computer-assisted interviewing (CAI) has begun to play a more prominent role in HIV/AIDS prevention research. Despite the increased popularity of CAI, particularly audio computer-assisted self-interviewing (ACASI), some research teams are still reluctant to implement ACASI technology because of lack of familiarity with the practical issues related to using these software packages. The purpose of this report is to describe the implementation of one particular ACASI software package, the Questionnaire Development System (QDS; Nova Research Company, Bethesda, MD), in several nursing and HIV/AIDS prevention research settings. The authors present acceptability and satisfaction data from two large-scale public health studies in which they have used QDS with diverse populations. They also address issues related to developing and programming a questionnaire; discuss practical strategies related to planning for and implementing ACASI in the field, including selecting equipment, training staff, and collecting and transferring data; and summarize advantages and disadvantages of computer-assisted research methods.

Perceived Discrimination among Severely Disadvantaged People with HIV Infection

Studies continue to document that people with human immunodeficiency virus (HIV) experience discrimination in their interactions with the health-care system, which can have negative implications for maintaining continuity in care and outcomes. We explored the patient characteristics associated with perceived discrimination and whether these experiences are associated with health-care system quality ratings in a survey of severely disadvantaged people with HIV who are at great risk of inconsistent access to appropriate health care. Five hundred and twenty-three participants were recruited from temporary housing facilities for people with HIV in the New York City area and administered a survey using audio computer-assisted self-interviewing technology. Of the 207 participants (39.6%) who reported experiencing discrimination in the health-care system, the most common attributions were HIV infection (n = 122, 59.8%), drug use (n = 100, 49.8%), homelessness (n = 71, 34.6%), and race/ethnicity (n = 69, 35.2%). Length of time HIV infected, use of non-prescription opioids, white race, higher education, female gender, younger age, and poorer self-reported health status were all significantly associated with greater odds of perceived discrimination. After adjusting for participant characteristics, perceived discrimination was significantly associated with poorer participant ratings of quality of health care. Members of this vulnerable population commonly report experiences of discrimination from within the health-care system and these experiences are associated with poor health-care ratings. These findings support the need for closer examination of the adequacy of cultural competency training within the HIV health-care delivery system to improve access to appropriate care for disadvantaged people.