HIV-Adapted Decision Aid Improves Lung Cancer Screening Understanding
People with HIV face a higher baseline risk for lung cancer, yet the decision to screen is not straightforward. Smoking history, competing illnesses, and the burden of multimorbidity can blur the boundary between a test that may help and a test that may add noise, anxiety, or downstream procedures. A pilot trial published in Chest tested whether a tailored decision aid could make that conversation more precise for patients who were eligible for screening.
The intervention was built on Decision Precision, an approach adapted specifically for people with HIV. It did not simply offer generic information about lung cancer screening. Instead, it delivered personalized screening recommendations along with HIV-specific 5-year risk estimates for both lung cancer and all-cause mortality, giving patients a more individualized frame for weighing benefit against harm.
Personalized Risk Estimates Shifted the Conversation
Forty participants with HIV entered the single-arm pilot trial. The median age was 62 years, 60% currently smoked, and the median 5-year risk estimates were 2.0% for lung cancer and 4.1% for all-cause mortality. Those numbers matter because screening decisions in this population are shaped by more than age and pack-years alone. Competing mortality risk can blunt the absolute benefit of screening, while a higher likelihood of pulmonary disease, prior infections, and other comorbid conditions can complicate interpretation of imaging findings and follow-up care.
The decision aid translated those risks into two recommendation categories. Just over half of participants received an “Encourage Screening” recommendation, while the remainder received a “Preference Sensitive” recommendation. In practice, this meant the tool did not push every eligible patient toward the same answer. It distinguished between patients with a stronger expected net benefit and those for whom screening was more value-dependent and required a more deliberate conversation.
Screening choices in this setting are rarely binary in the clinic room.
Knowledge Rose on the Questions That Matter Most
The most striking change came in patient understanding. After review of the decision aid and shared decision-making visit, participants showed improvement in two validated knowledge measures. Scores on the 12-question lung cancer screening knowledge test improved by 60% relative to baseline, with P < 0.001. Scores on the seven-question lung cancer screening knowledge scale improved by 27%, also with P < .001.
The gains were not limited to abstract familiarity with screening. Participants improved on questions dealing with false-positive and false-negative results, incidental findings, lung cancer-specific mortality benefit, and the potential harms of screening. Those domains are clinically important because they define whether a patient understands the tradeoffs. A chest CT can detect an early malignancy, but it can also uncover nodules and incidental findings that trigger repeat imaging, procedures, and stress without delivering a survival benefit. In people with HIV, who may already navigate frequent medical care, the ability to grasp those tradeoffs is central to a credible shared decision-making process.
Low Decisional Conflict and High Acceptability
Participants did not appear to leave the encounter torn or unsettled. The decisional conflict scale was low, with a median score of 0 and an interquartile range of 0 to 5. Acceptability was high as well, suggesting the tool fit well into the clinical discussion rather than competing with it.
Those findings are especially relevant in HIV care, where screening recommendations often sit beside conversations about antiretroviral therapy, cardiovascular prevention, substance use, and other chronic disease management. A decision aid that improves comprehension without adding friction can make a difficult prevention discussion more usable at the bedside. It also gives clinicians a structured way to explain why one patient should be encouraged toward screening while another may reasonably weigh the choice differently.
Screening Uptake Followed Quickly After the Visit
Ninety percent of patients ultimately underwent screening within 1 month of the visit. In a prevention study, that high uptake is not a minor operational detail; it suggests the decision aid did more than improve test scores. It appears to have supported action.
The result does not prove causation, because the study used a single-arm pilot design and did not include a control group. Even so, the uptake rate is consistent with a tool that clarifies rather than confuses. When people understand why they are being offered screening, what the likely benefits are, and where the harms may lie, they may be more prepared to move forward with the plan they choose.
For clinicians, the design also offers a practical model. HIV-adapted risk estimation may be particularly useful because standard screening conversations often rely on population averages that may not reflect the layered risk profile of people living with HIV. Personalized estimates of lung cancer and all-cause mortality may help anchor the discussion in a patient’s own expected benefit horizon, which is exactly where shared decision-making becomes most meaningful.
What This Pilot Can and Cannot Claim
The trial supports feasibility, acceptability, and improved understanding, but it remains a pilot study of 40 participants. The single-arm design cannot determine whether the decision aid outperformed usual counseling, and it does not establish effects on long-term screening adherence, cancer detection, stage shift, overdiagnosis, or mortality. Those outcomes would require a larger comparative study.
Still, the signal is clinically coherent. Lung cancer screening in people with HIV sits at the intersection of elevated cancer risk and substantial medical complexity. A tailored decision aid that improves knowledge about false positives, false negatives, incidental findings, and expected benefit may make the screening conversation more honest and more patient-centered. For now, the evidence shows that participants were able to understand the tradeoffs better, felt little conflict about the decision, and largely proceeded with screening after the visit.