AIDS Community-Based AIDS Prevention Studies of Intravenous Drug Users and Their Sexual Partners Proceedings of the First Annual NADR National Meeting U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse Division of Applied Research Community Research Branch 5600 Fishers Lane Rockville, MD 20857 Wel The Community Research Branch publishes reports and monographs that are designed to share findings from Branch-sponsored studies having relevance for service delivery and program development. These will include state-of-the-art papers, innovative service delivery models found effective with different client populations, and research studies with significance for clinical programming. ACKNOWLEDGMENT This monograph is based on papers presented at a meeting of the National AIDS Research Consortium (NARC) held October 15-18, 1989 in Rockville, Maryland—the first annual meeting of Principal Investigators and other staff of grant and contract programs involved in the National AIDS Demonstration Research (NADR) Project. The meeting was sponsored by the Community Research Branch, Division of Applied Research, National Institute on Drug Abuse. This publication was developed for the Community Research Branch, National Institute on Drug Abuse, under Contract No. 271-88-8231 with NOVA Research Company, Bethesda, Maryland. COPYRIGHT STATUS All material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. Opinions expressed in this volume are those of the authors and do not necessarily reflect the opinions or official policy of the National Institute on Drug Abuse or any other part of the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. DHHS Publication No. (ADM)91-1752 Printed 1991 CONTENTS N oo | | “Ul Page FOREWORD ........coconiiiiiiiiiiiictiitniiict iiss esses esses sass ssssas se ssassessasassans ix INTRODUCTION A Report on the National AIDS Demonstration Research Project BArry S. BIrOWR .........uoueeueneieininieenrinesisssesssssessessssssesssssssssesssssssssessassssssonses 1 OUTREACH ACTIVITIES .........ooiiniiiiniiinncntiriinnesesisessssssssessessssesssssssass 9 Selection Criteria Used To Define Target Neighborhoods for Reaching IVDUs and Sexual Partners Indu B. ARIUWGLIQ ........coueeeeeeeienniininiennieiiieisienniessiessnesssessse sss sasesasesssesssens 11 Horizontes Laredo—Indigenous Outreach Project Pedro AIfQro ......ueeoeeeeiieiiineenieeiesriesstessisssissscssseessss sass sass ssssssss sass ssssssenns 15 AIDS and Female Partners of IV Drug Users: Selected Outreach Strategies, Accomplishments, and Preliminary Data from One Project SQITA MOIR .....ccneoneenennieiiieeeieniietiiesiins sistent sas sssess esas sase sass ss eases esas ss 18 A Mobile Outreach Program to Intravenous Drug Users and Female Sexual Partners in Long Beach, California Donna Yankovich, Eduardo Archuleta, and Silvia Simental ..................cccuu.... 26 Outreach to IVDUs in the Hospital Setting Karen R. Charron and Mary Jane Reynolds ..................ccovevininunnsinennnanes 30 Effective Techniques for Outreach to Intravenous Drug Users and Sexual Partners to Combat AIDS Roy Griffin, Betty Ryder, and Carolyn TUIRET ...............ccuuiniininiiniiniennennens 34 Effectiveness of Street Outreach as an AIDS-prevention Strategy for IV Drug Users, Their Sexual Partners, and Prostitutes in Philadelphia Jon Liebman and Brunilda Sepulveda—Irene .................ccccocvveevecunsuinscnunsenns 40 Indigenous Outreach in San Juan: Results of a One-year AIDS-education Effort among Intravenous Drug Users ALICE KTOLICZAK ..nveeeeeneeneereeieeiecieeiesiiesstessie sss sass sass ssssssssssssssssssasssassssessnns 47 Evaluating Outreach in San Francisco EFIC MATQOIIS «ennai cries esse ste ae ss esse sa sna se snsssons 59 iii IIL on 151 Page Y METHODOLOGICAL ISSUES ...........coouonnnninieereresneeesssssesesesesssss se ssaens 109 Ethnographic Evaluation of AIDS-prevention Programs Jean J. Schensul and Margaret Weeks ..............ueeeeeeeeeeeeueneeeeeeeereeeeeeeesennnns 110 Finding, Interviewing, and Retrieving Blood Samples from Tecatos: AIDS Prevention and Research in San Diego AITO VElASCO ......uceouennerereeerererecrererenseresaesessesssessessssessssessesssssnsessessnsens 121 Interviewing Techniques: Building Rapport and Getting Quality Data Stephanie Tortu, Westley Jones, Marsha McGriff, and Janet Prosper ......... 126 Development of Instruments To Index Variables in a Model of AIDS Risk Reduction among Intravenous Drug Users Julie R. Erickson, Antonio L. Estrada, Peggy Glider, and Sally Stevens ...... 130 Pretest Effects of the AIA among Treatment and Nontreatment Populations Scott Ray, Adelbert Jones, Vernon J. Shorty, Joseph Bouie, Gail Wise, ANA SRETYL RALCHLT .....oveevereererenreiereereereeressenresessesses esses essessossessessessesseneene 138 Reliability of the Southwest Research Group AIA Trailer Form Adelbert Jones, Scott Ray, and Vernon J. SROTty ...........oeeeeeeueeveveenseveeennnne 164 Report on Reliability of the AIDS Initial Assessment Questionnaire Max H. Myers, Frederick R. Snyder, E. Earl Bryant, ANA PAUL A. YOUNG ......uouoneovireeeieenreirenssreneessesesssesssssesssssesesssssssssssssssssssens 167 HIV-TESTING ISSUES ........ccoooieiiereneienenneseresesesesssssese esos ss esesesesesesesens 183 HIV Counseling and Testing: Issues in a Research Context JIEM. SITGWR ........couoniiiieiniinerirircienirenissssssss esses senses ssssssassssssasese sess ssssnnns 184 The Relation between HIV-antibody Testing and HIV Risk Behaviors among Intravenous Drug Users Linda Roggenburg, Beverly Sibthorpe, Helen Tesselaar, Jeanne Gould, ANA DAVIA FIEIMING .......cuuvererrineeeeeeseisee sie ssssesssssssassssssssesssesssesesesesesns 192 AIDS, A Guide to Legal and Policy Issues RO NEmeth—COSIett ...........ouocuveeeenreienenenriniesenseinenssssssessesasesssssssessssessesenns 197 INTERVENTION THEORY AND PEDAGOGY .......ccoovvnniinrrerenrerennieennnns 201 Grounding Interventions Aimed at AIDS Risk Reduction in Models of Prevention Julie R. Erickson, Sally Stevens, Antonio L. Estrada, and Peggy Glider ...... 202 The Structure and Functions of the IV Drug User’s Social Network: Testing a Theoretical Model Rafaela Robles, Héctor Colon, Lourdes Aponte, and Tomds Mdtos ............. 211 iv VL Social Network Analysis: An Approach for Understanding IV Drug Users Susan Alperin and Richard Needle ........................ucuenuirinenunnrennnruenrnnnens 217 Ethnography and AIDS Intervention in New York City: The Use of Life History as a Research Strategy MiCRAEL C. CLAS ...coueoeeeinniainrenriniiiintinstiiessinssiesssssssssssssessse ss snsessssssassens 225 Culturally Appropriate AIDS Prevention for IV Drug Users and Their Sexual Partners Merrill Singer, Peggy Owens, and Lydia ReYes ..............c.cuevvevuneninienrannenn. 234 Health-care Safety Networks among Adolescent Intravenous Drug Users: Implications for AIDS Intervention Joseph A. Kotarba, Jay Johnson, and Mark Williams ................ccueerevuenennes 241 Drugs and Sex in Cross-cultural and Historical Perspective with Special Reference to Pacific Island Societies Jo Scheder and Tom KEENE ..........uoceeuueeeeeeiineeeeececneneeecscsssnsssssssssansssssssns 249 Curriculum-development Issues for AIDS Education Directed to Arrestees Linda Van Den Bossche and Bobbi KIiSRIS .........ccueeeeveeeieineeenireeecssnnesesssenns 253 PROGRAM/INTERVENTION DESCRIPTIONS ......oreereereecrre ene 257 VI-A. General Program Overviews The Harlem AIDS Project: Description and Preliminary Findings SREITY DEEN .......cueeeenerieeiieeiieerieteiecienecsessssst esses ss esas sabes sss as eases anne 259 Intervention Strategies for Sexual Partners at Proyecto Comparieros Lynne N. Harrold... iiss 273 The History and Development of a Consortium for Research and Prevention of AIDS in Southern Arizona Sally J. Stevens, Peggy Glider, Antonio Estrada, and Julie Erickson ........... 279 An Innovative Approach for AIDS Research, Prevention, and Education in the Criminal-justice System Sally J. Stevens, Peggy Glider, Julie Erickson, and Antonio Estrada............ 285 AIDS Education in the Jail Setting: Achievements and Frustrations Edward Hernandez and Steve Radvick .................cooueoniiniinnvinnnnininninennnenns 291 Belle Glade, Florida: The National AIDS Demonstration Research (NADR) Project’s Only Rural AIDS-intervention Program Clyde B. McCoy, Edward J. Trapido, Nancy Lewis, and Elizabeth L. KROULY ........c.couovuviveniiniiniiiiiiiiniisinessseessssssssessessessessanees 295 VIL Page VI-B. Focused Interventions Enhanced AIDS Prevention Counseling for Injection Drug Users Incorporating High-threat Appeals and Personal Contracting Nancy H. Corby, Fen Rhodes, and Jesse HON .............ueeoveeeeeereevevevereenns 309 Interpersonal Cognitive Problem-solving Interventions with Addicts Jerome J. Platt and Stephen D. HUSDANA .................ooeeeeeeesreereeerererseererenns 316 A Case Study of an AIDS-enhanced Psychoeducational Group: Resistance of IVDUs and Their Sexual Partners to Behavior Changes for AIDS Prevention Emma Plaga, Carol Tobkes, and Edith Springer ...............uueeeeeeeeerererennnn 324 Codependents: AIDS Intervention and Drug Abuse Treatment Deena D. WALSON ...........cccuvuvinininininrnrnrererererereresesesssssssssssssse sess ss sss ss sess sssnas 327 A Community-organization Approach to HIV Research, Education, and Prevention Joseph Bouie, Vernon J. Shorty, Adelbert Jones, and Scott Ray ................... 329 Community Organizing as a Primary Intervention to Reach IV Drug Users and the Sexual Partners of IV Drug Users George Freeman, Jr., and P. Catlin Fullwood. ...................ccueeeeeesvereeeernn 333 Sponsoring Addict Self-organization (Addicts against AIDS): A Case Study Gregory Carlson and Richard Needle .....................uuueeeeeeeeeiseeseeseseerensns 342 RESEARCH FINDINGS ......ccocooiiiiiiineerereteeeeeee ees ssssssssesesesesesesesssesssssssnns 351 Use of Crack and Cocaine, Sexually Transmitted Diseases, and HIV Infection Richard Needle, S. Susan Su, and Linda GUSE .............ceeeeeeeeeeeveeerereesererannn. 353 Needle-use Behavior among Puerto Rican IV Drug Users Hector Colon, Rafaela Robles, and Tomds MaIOS .............uueeeeeeeeueereereecnanns 367 Drug Use and Sexual Behavior Differences among “Young” and “Old” Intravenous Drug Users in Houston, Texas Mark L. WIllIQINS o.oo iesessenessesesesesesesesesesessssssnsnsssssens 375 Psychological Reactions and Retention by Cocaine Addicts during Treatment according to HIV Serostatus: A Matched-control Study William W. Weddington, Charles A. Haertzen, Judith M. Hess, ANA BAITY S. BIOWN ......uouueverererrereerereseeseesesssssessesisssssessessossesssssesssssessssensen 380 Everyday Health-care Activities among Women at Risk for AIDS Joseph A. Kotarba and Mark L. WilliQms .............c.eceeeeeevreveerieeereereeseeeenens 383 vi Preliminary Findings Regarding AIDS Intervention among Hispanics in the Southwest United States ALICE KTOLICZAK c...oooeonnereneneeeieieeeiiiisiisssesssssssssssssssassssessassssssssssssssssses Frequency Modulation as an Explanation of Common Patterns of Intravenous Cocaine-Amphetamine Use Jay Johnson and Mark Williams ..............c..ocuevveeninnneinsecnsunnsnnsnsssaessseenne Reaching Everyone! AIDS and Cincinnati’s Health (REACH) Year-One Data E. Don Nelson, Ronn D. Rucker, Bill Epps, Leonard T. Sigell, and Stanley E. BroQAnax .............eeccueveeeeeenenesuinsisenseessssssssssssssssssssssssssssses Preliminary Findings for the AIDS Targeted Outreach Model to Intravenous Drug Users in Three Northeastern Methadone Programs Ann M. Downey, Willie H. Davis, Hillard Davis, Tina Stackhouse, ANA FTA ROYSIEY .....ooeveeeieieieineeeeeneseeeesessseessssssesssssssasssssssassnsessssens Preliminary Findings: Changes in Drug Use, Needle Use, and Sexual Behavior among Intravenous Drug Users George R. Reinhart and Arlen M. Rosenthal ...................coovuininuenronnnnnens Behavior Change in Sexual Partners of Intravenous Drug Users (IVDUs) H. Virginia MCCOY ......couovueveninciirininciininiensinstisessssssssssssesssessessssssesssens Behavior Changes of Intravenous Drug Users after an Intervention Program Dale D. Chitwood, Mary Comerford, Elizabeth L. Khoury, And JUdith A. VOGEL ..........uuueeeuveririininnienuenicinsesnsscssssssscssssssssssssssssesssens vii FOREWORD The National AIDS Research Consortium (NARC)* is composed of Principal Investigators of the National AIDS Demonstration Research (NADR) Project grants, AIDS Targeted Outreach Model (ATOM) contracts, and National Data Coordination and Evaluation Center funded by the National Institute on Drug Abuse (NIDA) Community Research Branch. These programs have been designed to develop and test innovative and effective ways of reaching and intervening with two populations that are being severely affected by the AIDS epidemic, but have been seen as beyond the reach of traditional drug abuse service and research efforts—intravenous drug users not in treatment and their sexual partners. The participants in this initiative have had to respond to a variety of challenges: finding a balance between service delivery and research that would meet both study needs and the needs of clients; working with persons never before targeted for behavior change; developing or adapting strategies to meet the needs of those new clients; and always working toward the goal of preventing the contracting and spread of a lethal disease to which drug abusers and their sexual partners are particularly at risk. Patience, ingenuity, and commitment have all been required in large measure, and if frustrations have been great, rewards have been still greater. As these papers from the Consortium's first national conference attest, much has been accomplished. We can now better characterize people we could not even identify a short time ago—describing individuals’ demographic characteristics, risk factors for HIV infection, and medical and drug treatment histories. This monograph reports preliminary findings on the efficacy of outreach and intervention strategies with differing populations. Already, the programs of the NARC affirm the premise upon which the NADR Project was founded—that it is possible to reach large numbers of hitherto unidentified at-risk individuals and help them to reduce their risk for AIDS. This monograph should convey the findings and enthusiasm of program staff and encourage additional researchers and service providers to join in efforts to respond aggressively and sensitively to communities and individuals that have for too long been dismissed as “hard to reach,” even as they are acknowledged to be in grave danger. To these communities and individuals, from whom we have learned so much, and to George Beschner, former Chief of NIDA’s Community Research Branch, whose creativity, vision, and prodigious energy helped shape the NADR Project, this volume is gratefully dedicated. The Community Research Branch 1991 * Marcia Andersen, Ph.D., Robert Baxter, M.Ed., Sandra Baxter, Ph.D., Pat Biernacki, Ph.D., Stanley E. Broadnax, M.D., Vivian B. Brown, Ph.D., Willie Davis, MBA, Larry DeNeal, Ph.D., Sherry Deren, Ph.D, Patricia Evans, M.D., Harvey Feldman, Ph.D., David Fleming, M.D., John French, Ph.D., Samuel Friedman, Ph.D., Sena Gates, B.A., Peggy Glider, Ph.D., Annette Green, M.S.W., James Halikas, M.D., Ted Hammett, Ph.D., Dana Hunt, Ph.D., Jennifer Keyser-Smith, M.S.W., Lynne Kotranski, Ph.D., William McAuliffe, Ph.D., Clyde McCoy, Ph.D., Stephen Margolis, Ph.D., Josette Mondanaro, M.D., Harvey Musikoff, Ph.D., Richard Needle, Ph.D., J. Valley Rachal, Ph.D., Fen Rhodes, Ph.D., Rafaela Robles, Ph.D., Roy Ross, M.A., Bruce J. Rounsaville, M.D., Jean Schensul, Ph.D., Vernon Shorty, Ph.D., Harvey A. Siegal, Ph.D., Merrill Singer, Ph.D., Sally Stevens, Ph.D., Kenneth N. Vogtsberger, M.D., Deena D. Watson, M.A., Wayne Wiebel, Ph.D., Mark L. Williams, Ph.D., Robert W. Wood, Ph.D., and Paul A. Young, MBA. ix CHAPTER I INTRODUCTION A Report on the National AIDS Demonstration Research Project Barry S. Brown Intravenous drug users (IVDUs) are the most rapidly growing portion of the AIDS population. As of 1989, 30% of new AIDS cases could be attributed to IV drug use, either by virtue of persons with AIDS themselves or persons who contracted the disease as a result of sexual activity with IVDUs. Findings by gender and ethnicity are even more dramatic. Fifty percent of all AIDS cases in the Black community and 50% of all cases in the Hispanic community can be attributed to IV drug use; 71% of AIDS cases among women can be attributed to contacts with IVDUs or use of IV drugs by women themselves (CDC 1990). With the threat posed by IVDUs both to themselves and to the communities in which they live, two courses of action have appeared obvious. On the one hand, there is an immediate and continuing need to develop and maintain treatment slots to allow IVDUs access to drug-abuse treatment. Treatment remains our surest strategy for effecting long-term behavior change. Second, there is a need for outreach strategies to provide education/behavior-change programs where treatment slots either are unavailable or are seen by IVDUs as inappropriate to their needs. Consequently, the Federal Government appropriated funds to increase the availability of treatment slots and, through its National Institute on Drug Abuse (NIDA), initiated a program of outreach/intervention designed to encourage entry into treatment where possible and to work with IVDUs in the community in reducing risk-taking behaviors where treatment entry was not possible. Populations of Concern In all, four populations were identified for NIDA’s outreach/intervention project: IVDUs who were not currently in drug-abuse treatment; the sexual partners of IVDUs; prostitutes; and runaway youth. A particular emphasis was placed on both the out-of-treatment IVDU population and the sexual partners of IVDUs. Prostitutes were specifically targeted in some programs, but were more frequently accessed as a part of program efforts to work with IVDUs and/or sexual partners, populations with which they obviously overlapped. Young people who were runaways were targeted in a few programs, and were soon found to be a particularly difficult population to reach and to influence with behavior-change strategies. These youth came to be seen as a population requiring programs specific to their needs, which the Institute is now in the process of developing for implementation and study. At the same time, it would be difficult to underestimate the risk that runaway youth pose to themselves and to their communities for contracting and spreading the human immunodeficiency virus (HIV). These youth, living on the streets, often have no commodity to exchange for survival beyond their own bodies and frequently are engaged in sexual activity with little or no thought to the use of protective devices. Moreover, while not engaged in the use of IV drugs, the vast majority are involved in the use of disinhibiting drugs, ranging from alcohol to crack cocaine. 1 Project Structure During 1987 and 1988, through a grants and contracts program, NIDA developed 41 outreach/ intervention programs in nearly 50 cities and at more than 60 sites. The programs are concentrated in the northeastern part of the United States by virtue of that region’s higher rates of IV drug use and seroprevalence. Nonetheless, they are truly nationwide, stretching from San Juan, Puerto Rico, in the East, to Honolulu, Hawaii, in the West (F. igure 1). The 41 programs are of two types. Twenty-nine of the 41 are comprehensive community programs targeting both out-of-treatment IVDUs and sexual partners of IVDUs located in a variety of community settings. Twelve of the 41 programs are targeted either to IVDUs or sexual partners and focus on a particular community setting where that population can be found, e.g., the criminal-justice system for IVDUs and housing-authority programs for sexual partners. All of the programs offer a mix of both services and research. The services are designed to provide impetus to behavior change either through encouragement to enter drug-abuse treatment or through innovative behavior-change strategies developed by program staff and designed to meet the particular needs and concerns of the target population. The studies conducted in this demonstration research project have two objectives. The first is to clarify the characteristics and functioning of out-of-treatment IVDUs and their sexual partners. Virtually no studies are available that examine the characteristics and functioning of these populations. A second study objective is to assess the efficacy of behavior-change strategies mounted to modify and reduce risk-taking behaviors. Findings from both types of studies will be employed to guide the initiation of outreach/intervention programs in additional communities. NIDA will share effective strategies as well as findings important to the delivery of outreach/intervention services through a program of technology transfer. Outreach Strategies As could be expected, outreach initiatives differ in accord with the population for which services are planned (see Section II, Outreach Activities). Where the target population is out-of-treatment IVDUs, outreach programs have emphasized case findings in three community settings. First, and most commonly, emphasis has been placed on providing outreach to “copping areas,” i.e., open-air markets within the community where illicit drugs are bought and sold. Copping areas are those parts of the community in which IVDUs will need to gather at regular and reasonably predictable times and so represent locations appropriate to outreach efforts. To access drug users it is necessary that the program and its personnel be viewed with trust by both drug users and the public officials responsible for law enforcement. Negotiation with the latter is the task of the program leadership. As will be described below, negotiation in the street is largely the responsibility of recovering addict outreach workers known and respected by their addict peers. In addition, many programs conduct outreach in the criminal-justice system. Significant percentages of IVDUs become known to the criminal-justice system. Surveys of State and Federal penitentiaries have indicated that 15% to 25% of prisoners have histories of heroin use (Eckerman et al. 1971); more recent data gathered from arrestees sampled through the Drug Use Forecasting (DUF) system of the National Institute of Justice (NIJ) reveal still higher rates of cocaine and other drug use among those charged with felonies (NIJ 1989). At any time, from 2 Figure 1. National Institute on Drug Abuse NADR' and ATOM! PROGRAM SITES Seattle Portland ® Boston (6) ® New Haven St. Paul/Minneapolis (1) Bridgeport b> (4 )Nasssu County Detroit Buffalo 4 o 2 8 Bry (5) hol Manhattan City @7Q) New York (2 Chicago © Cleveland @ philadelphia (4 )Camden, NJ Pittsburgh oa San Francisco ® 7 ) Prince Georges County © SF oath Do ; SF-2 _ §J Washington (3) Jersey City pt; SF- (® Denver Cincinnati Columbus Washington Deaimore (4 Atantic City 3) Baltimore Los Angeles 1 8 Long Beach Phoenix San Diego 3 3 Maricopa County Tijuana @ Tucson a)Tucson 3)E! Paso © Dallas 1 )\Juarez © Hawaii Houston 4) New Orleans 00 San Antonio 0, ew Orleans Honolulu oS Hilo D San Juan 3 Laredo Puerto Rico @ Puerto Rico LEGEND Migrants/U. of Miami Model: Belle Glade @ =NADRSites Sexual Partners Outreach - Model 1: Boston, Los Angeles, Phoenix, San Juan, Bridgeport, El Paso/Juarez (Phase Number) Emergency Rooms/Health - Model 2: Detroit, Baltimore, Brooklyn, NY ® — ATOM Sites Indigenous Workers Outreach - Model 3: El Paso, Denver, Baltimore, Laredo, San Diego/Tijuana, San Juan (Model Number) Methadone Maintenance - Model 4: Nassau County, NY, Jersey City, Atlantic City, New Orleans, Camden,NJ, Tucson, AZ - Buffalo, NY, Pittsburgh, PA Therapeutic Community - Model 5: Providence, West Manhattan, NY, Washington, DC — ) Pregnant Women & Children - Model 6: Boston, Los Angeles, Philadelphia, Bronx, NY National AIDS Demonstration Research Programs Criminal Justice Arrestees - Model 7: Maricopa County, AZ, Prince Georges County, MD t AIDS Targeted Outreach Model Programs Public Housing Projects - Model 8: Buffalo, NY; Tampa, FL lock-up to probation or parole, programs can be structured to reach and to educate criminal- justice clients regarding risk-reduction strategies. Hospital emergency rooms are another institutional setting in which IVDUs are recruited. Overdose, or other toxic reaction frequently accompanies the use of IV heroin or cocaine. It can be reasoned that individuals in hospital emergency rooms may have been made more accessible to behavior-change interventions by virtue of a heightened sense of their own vulnerability. Prior studies suggest that IVDUs in hospital emergency rooms can indeed be induced to enter drug abuse treatment directly from that setting or—where individuals do not enter formal treatment—can be accessed for a continuing program of supportive counseling designed to reduce drug-taking behavior through contacts in the client’s home or other community setting. Moreover, in the hospital emergency room, as in the criminal-justice system, the IVDU will be reliably available to efforts to provide support and to induce behavior change to an extent impossible in other settings. Sexual partners of IVDUs are typically recruited in a variety of community settings. They are recruited, for example, in street settings through the use of mobile health screening vans, through onsite outreach in public-authority housing programs, through outreach in community settings frequented by women such as in launderettes and beauty parlors located in high drug- use neighborhoods. Institutional settings include obstetrical/gynecological clinics, well-baby clinics and other health-care facilities such as sexually transmitted disease (STD) clinics and public-health facilities. Social-service programs are also an important institutional source of sexual partners as clients. Because poverty and long-term drug use are frequently closely tied, sexual partners may be recruited through financial-support programs for low-income women. Sexual partners may also be located in homeless and/or battered women’s shelters, since women at risk for AIDS are likely to suffer a variety of social and physical insults associated with a frequent dependence on unreliable male supports for themselves and for dependent children. Prostitutes, as a specific client population, are recruited through outreach into “stroll” areas, i.e., the areas of a community in which women are engaged in the sex trade. Prostitutes may also be recruited through the criminal-justice system, since the need for these women to make themselves readily available to customers also makes them readily identifiable by the police and subject to frequent arrest. Runaways may also be recruited directly from the streets, often near or within stroll areas. Institutional sources of runaway youth are chiefly youth shelters or those outreach initiatives already existing in the community and specifically tied to youthful runaways. The individuals hired to conduct outreach are typically individuals who share a background and set of experiences with the populations they are attempting to recruit. In particular, this has meant an effort to recruit IVDUs through the use of a recovering drug-addict population. In the parlance of drug-abuse treatment, “to talk the talk, you first have to walk the walk.” The individual who has lived the life of addiction, weathered its vicissitudes, and made the lifestyle changes he or she is suggesting is thereby a credible agent for change. Similarly, women who have shared the lifestyles of the female clients they will be recruiting are typically employed to conduct outreach. Persons conducting outreach with runaway youth, on the other hand, are not typically themselves youth, although they commonly constitute a younger population than might otherwise be used to conduct outreach and are, of course, expected to be conversant with the lifestyles and functioning of the population with which they will be working. Research Design The evaluative research design (see Section III, Methodological Issues, and Section VII, Research) involves four key elements. 1. As part of intake, all clients are given a structured, primarily closed-ended interview schedule requesting demographic and background information, drug-use history, needle-using behaviors, sexual activity and behavior, medical history (including HIV testing), and AIDS knowledge and information sources. All interviewers have received training in administering the AIDS Initial Assessment (AIA), the intake interview schedule. The AIA takes about 45-60 minutes to administer and is delivered face-to-face in a setting ensuring privacy and under a Federally assured certificate of confidentiality. At intake, opportunity is also taken to get locator data to be used for follow-up. Locator data include names, addresses, and telephone numbers of all persons likely to remain knowledgeable about the client’s whereabouts. Information obtained from the AIA provides both baseline data regarding risk-taking behaviors prior to receiving a preventive intervention and descriptive information regarding the characteristics of out-of-treatment IVDUs and sexual partners of IVDUs. Immediately after the AIA, all clients are offered HIV testing and pretest counseling (see Section IV, HIV-Testing Issues). While not required to receive testing in order to receive the preventive intervention, clients are encouraged to learn their serostatus. 2. After the interview and (for most) after HIV testing, clients are randomly assigned either to the standard intervention (typically one session of didactics and supportive counseling) or the enhanced intervention of a type described above. Control over assignment is the responsibility of the research staff. 3. Six months after initial contact, using information from the locator form, clients exposed to both standard and enhanced interventions are recontacted and administered the AIDS Follow-up Assessment (AFA) interview schedule. That interview schedule is designed to obtain information about risk-taking behaviors regarding drug use and sexual activity that will reflect change from baseline (i.e., from the AIA). Change in knowledge is also obtained. As with the AIA, all interviewers receive identical training. The interview consumes about 45-60 minutes. At the end of the interview, clients again are offered an opportunity for HIV testing. 4. All AIA and AFA data are forwarded to a central database-management program that has the capacity to report data nationally while also making reports to individual sites. In this way, exploration can be made across sites of the characteristics of subjects by total sample, region, or selected variables (e.g., treatment history). Intervention As noted above, a key issue in terms of the conduct of these programs is the achievement of an understanding of the efficacy of interventions to reduce individuals’ risk of contracting AIDS (see Section V, Intervention Theory and Pedagogy, and Section VI, Program/Intervention Descriptions). To this end, studies typically involve a comparison of a standard intervention 5 (i.e., an intervention involving a single session combining instruction, educational materials, and supportive counseling) with an enhanced intervention (i.e., a behavior-change strategy that differs in both type of effort and quantity of effort from the standard). In general, the interventions employed by programs may be divided into three major types, although interventions often exist in combination with each other. First, and perhaps most frequently, is the use of counseling initiatives. These may be directed to an individual, a group, or couples, where the IVDU and his or her sexual partner are seen in the same counseling sessions. Counseling sessions for AIDS prevention are not unlike counseling sessions designed to achieve other types of behavior change. An effort is made to understand resistances to behavior change, to provide support and encouragement to induce behavior change, and to explore strategies for maintaining change over time. Group counseling makes use of an additional capacity to use the group as an element of support. Initial reports by our investigators indicate that the use of groups to provide support and encouragement for behavior change is particularly helpful for female IVDUs and sexual partners of IVDUs. Presumably, this is because female IVDUs are more subject to criticism and disparagement as a minority group within the larger body of IVDUs and because they often depend for financial and emotional support on those who at the same time threaten them with contracting AIDS. Behavioral-skills-training strategies may employ any of several initiatives, either alone or in combination. Thus, a cognitive-skills-training strategy will emphasize the exploration of alternative courses of behavior in situations that threaten the risk of HIV infection. Specifically, individuals can be asked to script responses with which they will be comfortable when faced with risk situations (e.g., being offered used needles by a running partner). The client can then practice his or her response to that situation under simulated conditions and with comments and suggestions offered by the counselor and/or other group members where skills training is delivered in a group setting. In this way, the client can develop a body of behaviors to employ in relation to both external and internal cues for risk-taking behaviors. Individuals can also develop skills in negotiating behaviors around sexual activity. This is of obvious significance for the sexual partners of IVDUs. The development of skills to negotiate with a partner to use protective devices without giving offense to the partner may be crucial to both maintaining the relationship and reducing the threat of infection. More fundamental skills training in terms of the proper use of condoms and the cleaning and sterilization of needles, where individuals are committed to continuing their needle use, are made available to all clients as appropriate. Strategies involving individual or group counseling and strategies involving behavioral-skills training may also be combined. Thus, training in negotiating skills may be combined with supportive group counseling in an effort to better establish risk-reducing behaviors. In the use of both behavioral-skills training and counseling strategies, clients are typically referred by outreach workers to individuals whose backgrounds and training allow them to employ those interventions. The outreach worker functions as a specialist in locating individuals at risk, gaining their confidence, and securing their involvement in the interventions designed to reduce the threat of AIDS. In addition, the use of behavioral-skills training and counseling may also employ efforts to heighten the individual's sense of personal vulnerability. Thus, it is reasonable to posit that individuals who daily risk disease, and indeed death, through injecting substances of unknown purity and origin, have developed an abnormally high tolerance for danger. Various strategies, but most particularly the use of specially designed media products such as educational videotapes, may be used to heighten a client’s sense of his or her own risk for contracting AIDS. Afterward, counseling and/or behavioral-skills training is used to reduce the anxiety created and to provide strategies for dealing with dangers to which they have become newly sensitive or to which their sensitivity has been increased. A third intervention strategy relies on the outreach worker both to locate individuals at risk for AIDS and to guide the initiative to reduce that risk. In what has been described as a clinical application of ethnography, the outreach worker inserts himself or herself in the drug-using network with the avowed intention of inducing change on behalf of individuals within that network. Typically, the outreach worker will be nonjudgmental about behaviors that the larger society deems inappropriate (e.g., drug use), but will act with and for the client in encouraging the adoption of behaviors that limit the risk of HIV infection. Thus, the outreach worker, working with a street-corner group, will support individuals’ efforts to reduce drug use and/or to enter drug-abuse treatment; however, where the individual is intent on continuing his or her use of IV drugs, the outreach worker will encourage the use of sterilization techniques to limit the risk of infection to the individual and to others. The outreach worker’s ultimate goal is to change the group ethos regarding risky behavior so that the group will act as a brake on the behavior of its individual members, promoting a greater degree of caution about those behaviors associated with contracting and spreading HIV. All interventions, whether any of the three innovative types described or the standard intervention, also involve the dissemination of educational material in the form of pamphlets and brochures designed for the individual and for sharing with partners and others. In addition, interventions will typically involve a distribution of condoms as well as bleach kits, unless forbidden by State law or local policy. The First Annual NADR Meeting (October 1989) Nearly 300 principal investigators, research analysts, ethnographers, interventionists, outreach workers, and others attended the three-day meeting that produced these papers. The format included platform presentations, panels, and poster sessions and was characterized by a productive and healthy exchange of information on a problem of common concern: effective intervention to change behaviors that put IVDUs and their sexual partners at risk for HIV infection. These papers are presented in a format that reflects the activity of the NADR programs themselves: they begin with outreach, move through data collection and intervention, and conclude with research. While each paper or section may be read separately, the entire monograph has a logical internal structure that will be apparent to those familiar with the Project. Readers who are not acquainted with the purposes and structure of the NADR Project may find this introduction a helpful orientation to the program and to these collected papers. These papers capture the spirit and accomplishments of the NADR Project at an early and critical point of its existence. We look forward to the Second Annual NADR National Meeting (November, 1990) and to further indications of progress from the dedicated staff members whose work is reflected in these pages. References Centers for Disease Control. HIV/AIDS Surveillance Report, December 1989. Eckerman, W.C.; Bates, J.D.; Rachal, J.V.; and Poole, W.I. Drug Usage and Arrest Charges. Drug Enforcement Administration: Washington, D.C., 1971. National Institute of Justice. Drug Use Forecasting: April to June 1989. National Institute of Justice, Washington, D.C., 1989. Iguchi, M.Y.; Wiebel, W.; McCoy, C.B.; Chitwood, D.D.; Watters, J.; Biernacki, P.; Kotranski, L.; Liebman, J.; Williams, M.; and Brown, B.S. Early indices of efficacy in the NIDA AIDS outreach demonstration project: A preliminary report from Chicago, Houston, Miami, Philadelphia, and San Francisco. MMWR 39(31), August 10, 1990. Author Barry S. Brown, Ph.D. Chairperson, First Annual NADR National Meeting Chief, Community Research Branch National Institute on Drug Abuse Rockville, MD 20857 CHAPTER II OUTREACH ACTIVITIES This monograph begins where the NADR Project begins, by focusing on outreach efforts. It is outreach that sets each NADR Project in motion. Street outreach, often performed by individuals who are indigenous to the target neighborhoods, is a common denominator of the NADR grantees as well as some of the contractors. For other programs, outreach is based at a certain site, such as hospital emergency rooms, government-assisted housing projects, or jails and prisons. For still others, outreach is targeted toward a specific population; these include pregnant women, prostitutes, and therapeutic-community clients. The subject of outreach is approached from two perspectives. The first papers in the section are descriptive, while the final pieces are evaluative. Ahluwalia and Alfaro, authors of the first two papers in this group, begin by discussing considerations involved in successfully targeting outreach efforts in two very different communities, New Haven, Connecticut, and Laredo, Texas. Moini then shares the experience gained in conducting outreach to a specific target group, the nondrug-using female sexual partners of intravenous drug users (IVDUs), in three geographically diverse areas. She reports on the demographics and behaviors of these women and describes successful outreach strategies using fotonovelas, clothing boutiques, and other innovative adjuncts. Yankovich and coauthors next describe an outreach program that is tailored to the geographically dispersed drug-using population of Long Beach, California, and neighboring cities. The program not only operates two drop-in centers but also deploys a mobile van into the community to reach IVDUs who cannot be easily reached from a stationary site. By increasing the program’s visibility and access, the van has considerably strengthened the effectiveness of the Long Beach effort. Charron and Reynolds describe the advantages and disadvantages of outreach in hospital emergency rooms (ERs) in metropolitan areas. Among the challenges of institution-based outreach is interacting with hospital staff and administrators; issues of confidentiality also arise. A major advantage of ER outreach is that it permits immediate access to clients who are often in need of immediate assistance and therefore amenable to intervention. Griffin and colleagues, members of the outreach team in Dallas, share their outreach “doctrine” and outline the characteristics needed by outreach workers as well as successful outreach strategies, which include canvassing homes and businesses, daily visits to the “stroll” and to copping areas, and an “each one reach one” philosophy through which the outreach workers secure clients’ help in promoting program services. In the first of the papers in this section dealing with evaluation, Liebman and Sepulveda-Irene describe the effectiveness of street outreach in Philadelphia. The program has received a positive response from the community. Among elements contributing to program success are the way in which the community health outreach workers are trained and deployed as well as the fact that program staff took time to build good relations with area business owners, clergy, police, and others in the community before launching the outreach program. The section concludes with papers summarizing outreach effectiveness at NADR Project sites in Puerto Rico and California. Kroliczak describes the impact outreach efforts of the Horizontes project in the IVDU community in San Juan; data from nearly 400 predominantly male, Hispanic IVDUs indicate a movement toward safer sex and needle cleaning behaviors among users participating in the project. Margolis presents results of formative evaluation research among IVDUs and sexual partners in six diverse neighborhoods in San Francisco; also included in his paper is a summary of outreach to sexual partners, an activity that is staffed by the Sexual Partners Integrity and Resource Intervention Team (SPIRITS), a team of women from ethnically diverse backgrounds. 10 SELECTION CRITERIA USED TO DEFINE TARGET NEIGHBORHOODS FOR REACHING IVDUs AND SEXUAL PARTNERS Indu B. Ahluwalia Introduction Acquired immune deficiency syndrome (AIDS) is one of the most devastating public-health problems of the twentieth century. By November 1989, 113,211 cases of AIDS had been diagnosed among adults, and there were 1,947 reported cases among children under 13 years of age (Centers for Disease Control [CDC] 1989). The epidemiology of AIDS indicates an increasing number of AIDS cases among intravenous drug users (IVDUs) and sexual partners of IVDUs. CDC surveillance statistics indicate that 21% of all AIDS cases have now occurred in IVDUs (CDC 1989). Current seroprevalence among IVDUs varies from 50-60% in New York City to less than 5% in the midwestern States (CDC 1987). The Centers for Disease Control (CDC) estimates that there are 1.1 million IVDUs in the United States. The National Institute on Drug Abuse (NIDA) estimates that out of the 1.1 million IVDUs, 900,000 are heavy users and 200,000 are occasional or intermittent users (CDC 1987). In an effort to limit transmission of HIV infection among IVDUs and their needle-use and sexual partners, NIDA has mobilized a national effort. Its goal is to combine the drug knowledge and expertise to reach the IVDUs and their partners. Demonstration projects have been funded by NIDA to devise outreach strategies to reach IVDUs and their sexual and needle-sharing partners and to educate them about AIDS prevention. New Haven is one of the programs funded by this national research and demonstration program. New Haven New Haven is a medium-sized city with a population of slightly more than 126,000 (New Haven City Planning Department 1981). It is located midway between New York City and Boston. The incidence of AIDS cases with respect to the population size has increased sharply over the past decade, from 0.79/100,000 in 1981 to 48.4/100,000 in 1988. According to the Connecticut surveillance reports, 54% of the AIDS cases reported in New Haven have been among IVDUs. Ethnic minorities are disproportionally affected by the AIDS epidemic. Sixty- seven percent of New Haven’s AIDS cases were reported among African Americans, 14% among Latinos, and 19% among Whites. The incidence of AIDS cases per 10,000 population indicates a rate of 5.2 cases among the White population, 32.1 cases among the African American population, and 28.9 cases among the Latino population. The drug-treatment facilities in New Haven estimate that there are between 5,000-6,000 IVDUs in New Haven (APT Foundation 1989). 11 Several AIDS-prevention programs in New Haven focus on reaching IVDUs and their partners. The aim of our project is to reach IVDUs and partners who may not be reached by traditional strategies. The Community Health Eduction Project (CHEP) is a multifaceted project, one component of which is community outreach via a door-to-door household survey and stationing of a health van in the target areas in New Haven. In order to define areas of outreach for our program, we examined various selection criteria, including: police statistics, 1980 census information, methadone maintenance information, availability of health-care facilities in the New Haven neighborhoods, infant health statistics, and informal information from the leaders in the community. We examined each of the variables and considered the potential advantages and disadvantages according to the population demographics of New Haven. One of the first factors considered was census information. The census information was readily accessible through the City Planning Commission. The census data provided extensive information on demographic and socioeconomic characteristics of New Haven neighborhoods. We were able to link recent socioeconomic estimates with the census information. Detailed information about the city’s public-housing units and maps was also available. There were many advantages in using the census information; however, it was nearly a decade old and had to be used with caution. Infant Mortality Rates (IMR) were a second factor considered for selecting target areas. IMR is an indicator of the health-care needs of infants and mothers, their exposure to adverse environmental and socioeconomic conditions, and their lack of medical and educational resources. New Haven has an active Commission on Infant Health, whose office provided statistics on IMR and low birthweight infants born to women in specific neighborhoods of the city. Some neighborhoods have infant mortality rates in excess of 30 deaths per 1,000 live births (New Haven Commission on Infant Health 1983-1985). There are many advantages to using IMR information due to its applications in conducting health-care needs assessments. This information focuses on women of childbearing age only and thus may not be considered representative of the entire population. A third factor considered prior to selecting areas for target outreach were the New Haven police statistics on drug-related crimes. The Police Department cooperated in providing the appropriate demographic statistics on arrestees and locations of the “drug busts” or “sting” operations that it had performed. The police information was extremely useful in pinpointing geographic areas of heavy drug transactions. The statistics on drug-related arrests were not reliable due to the crime- classification scheme used by the New Haven Police Department. AIDS surveillance information for New Haven provided information on the scope of the problem among IVDUs. This information was used for general needs-assessment purposes, but it did not supply data needed to target specific areas or neighborhoods. The number of AIDS cases may not be representative of the true prevalence of HIV infection among IVDUs and their sexual partners. This information is also biased towards the treatment-seeking population. The drug-treatment programs in New Haven provided information regarding the population served by the city’s two Methadone Maintenance Programs (MMP). The two programs served 12 approximately 460 people, of whom 77% were White, 19% were African American, and 4% were Latino. The majority (60%) of the people in the MMPs, however, were not from the city of New Haven. Discussion After examining these variables, we used infant mortality rates, family poverty levels, geographic breakdown of neighborhoods according to the 1980 census, and police information to select target areas for outreach. Since IMR and family poverty levels are good indicators of the socioeconomic status, these were used to select specific neighborhoods within New Haven. Neighborhoods were matched on the rates of IMR. The neighborhood statistical program (NSP) information was used to refine the selection process within each neighborhood. Ethnographic and police information was further used to select blocks within neighborhoods for stationing of our health van and for conducting door-to-door outreach. In order to limit the selection bias, the health van was randomly assigned to half of the neighborhoods. The outreach efforts have been monitored for the past six months. The health van reaches many people and is a nonthreatening approach to reaching people in the epicenters of IV-drug-use activity in the neighborhoods. The door-to-door approach has been able to reach some IVDUs and sexual partners, but has not been effective in attracting individuals at risk for HIV infection. Some neighborhoods selected for our outreach efforts have large-scale drug-related activities, but few IVDUs. The information gathered by the outreach staff has been useful in evaluating our strategies and in redesigning our efforts to reach a maximum number of IVDUs and sexual partners at risk for HIV infection. Conclusions Outreach strategies for conducting community-based AIDS-prevention programs must be based on the characteristics of the community. Population dynamics of the target community should be studied in detail, and ethnographic information pertaining to the patterns of drug use and political aspects of the neighborhoods must be explored before field work begins. Continued evaluation of the outreach strategies and field work will reveal potential problems and solutions to these problems, enabling outreach programs to mount effective programs. References APT Foundation; Drug treatment information, personal communication. 1989. Centers for Disease Control. HIV/AIDS Surveillance Report, December 1989. Centers for Disease Control. Human immunodeficiency virus infection in the United States: A review of current knowledge. MMWR, Supplement 36(S-6), December 1987. New Haven City Planning Department, 1980 Census Information. 1981. New Haven Commission on Infant Health. 1983-1985. 13 Acknowledgment Supported by the National Institute on Drug Abuse Grant #R18DA05758-02. Author Indu B. Ahluwalia, M.P.H. Project Coordinator APT Foundation, Inc. 904 Howard Avenue New Haven, CT 06519 14 HORIZONTES LAREDO—INDIGENOUS OUTREACH PROJECT Pedro Alfaro Social, geopolitical, and ethnographic factors have dictated the necessity of a cohesive, readily identified, community-based program to relay AIDS information on a street level to the “frowned upon” intravenous drug user (IVDU). The IVDU is involved in drugs, trafficking of drugs and undocumented immigration, theft, prostitution, and shoplifting, yet maintains the idealistic concept of “family, religion, honor,” and the integration of machismo through rationalization of the same. Horizontes—Laredo, one of KOBA Institute’s three outreach projects funded under the National Institute on Drug Abuse (NIDA) contracts, is based on an AIDS-intervention model developed by Wayne Wiebel. The basic tenet of this model is to focus intervention strategies on IVDU social networks. The outreach workers, known as community health outreach workers (CHOWsS), use existing social networks and build their own networks contingent on referrals from IVDUs. Our Horizontes staff were selected for their street knowledge and survival skills involving substance abuse. The street is their corporate office and, as is true of any business, communication and social networking are of tantamount importance. In this instance, CHOWs provide program footholds in IVDU communities. This approach allows us to enumerate and identify the size of IVDU communities and to identify social mores of the IVDU population by neighborhood, locality, and/or metropolitan area. This IVDU population of Laredo is estimated to number between 2,000 and 10,000. At least nine factors complicate IV drug use in Laredo: (1) an unidentified IVDU population; (2) proximity to the Mexican border—a source for cheap drugs; (3) a major port of entry for undocumented workers and for drug trafficking; (4) a troubled economy resulting from the devaluation of the Mexican peso, a depressed cattle industry, drought, and a declining tourist trade; (5) a skyrocketing unemployment rate (Laredo has the lowest per capita household income in the United States); (6) a methadone treatment center for only 60 outpatients, a 22-bed detoxification unit that serves three counties, and only two general hospitals, one of which receives no Government funds; (7) a health department whose HIV-antibody testing center is understaffed and inconveniently located; (8) a large import-export trucking/railway/air-freight business; and (9) legalized prostitution in Nuevo Laredo, Tamaulipas, Mexico. Our nine-month research in Laredo has led us to conclude that there is: ® A significant IVDU population and drug trade on both sides of the Mexican/United States border. e Significant trafficking in drugs and smuggling. An ounce of heroin sells for $10,000 in the United States. Resale street value after being diluted to 15 street-level injection form is $120,000. The price often inflates as it travels further into the United States, making it a very lucrative business for an illiterate Mexican farm worker, producer, dealer, pusher, or smuggler. A poor, itinerant farm worker in Mexico can make 10 to 20 times more money for growing marijuana or opium than he can make for growing corn, tomatoes, or other staple crops. His family needs to be fed, clothed, and educated. At the current exchange rate of 2,400 pesos to one U.S. dollar, drug dollars offer a tempting means of survival. ® A moderate-sized United States port of entry facilitating much import-export traffic. False compartments in luggage and in vessels, as well as multiple bridge crossings, allow heroin to be brought into the United States where it is distributed locally and nationally. ® A high crime rate. A drug habit leads the addict to shoplifting, drug smuggling, car theft, burglary, assaults, muggings, break-ins, and undocumented worker smuggling and/or trafficking. ® Prostitution. Early in the month, most of this activity is concentrated in the plaza across from the senior citizens’ home. This activity apparently coincides with the receipt of social security payments. Throughout the rest of the month, prostitution is relegated to the red-light district of Nuevo Laredo, Tamaulipas, Mexico, where there are many bars. Particularly interesting is the proximity of these bars to cheap hotels that cater to prostitutes and their clients, whose frequent business increases hotel revenues. Proprietors of these hotels also cater to Mexican and American clients who purchase stolen merchandise, paying 25 cents on the U.S. dollar for specific items that they will resell to tourists. Paradoxically, Mexico’s biggest substance-abuse problems are alcoholism and inhalant abuse, not heroin or cocaine use. These last two are exported to the United States, where they are exchanged for the more stable United States dollar. A second paradox is the differential treatment received by addicts on either side of the border. Drug addicts are poorly tolerated by Mexican law-enforcement officers and are often beaten when caught. They are usually jailed for years when they are caught with any drug paraphernalia. The few addicts who are Nuevo Laredoans shoot up on the U.S. side because they are treated better by U.S. law enforcement and because the jail sentences are not as severe as they are in Mexico. Does the drug problem reside in Mexico? Are we correct in blaming drugs and our drug problems on Mexico? Do we also get AIDS from Mexico? I do not believe that to be the case. The drug problem is a social one, based on poverty, illiteracy, ignorance, injustice, and homelessness. Drug use is a problem, poverty is a problem, social injustice is a problem, but now we contend with AIDS. AIDS is a problem because it is spread by IV drug sharing, high- risk sexual activities, and ignorance. It is a problem with global implications. Horizontes Laredo has taken the first step in combatting AIDS by providing substance-abuse education. Horizontes teaches prevention through behavior modification in IV drug use and sexual practices. We have established an excellent rapport with the IVDU community; we now have working relationships with existing community referral sources and have been widely accepted by the community and law-enforcement agencies. This rapport has enabled us to document the lifestyle of the IVDUs, not by arresting them but by dealing with a common threat known as AIDS, which knows no barriers. Research is vitally important, if not tantamount, to 16 the survival of American society, as we deal with problems we cannot yet comprehend as a society, much less accept as individual citizens. Study, patience, and adaptation by our society are needed if we are to have a future. Bibliography Laredo Police Department. Laredo Police Department Annual Report. Laredo, TX, 1988. Miller, Michael V. Perspectives on the social and psychological consequences of the 1982 peso devaluation in Laredo, Texas. Border Health/Salud Fronteriza II(1), 1986. National Institute on Drug Abuse. A Strategy for Local Drug Abuse Assessment. DHHS Pub. No. (ADM)80-966. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1980. National Narcotics Intelligence Consumer Committee. NICC Report 1988: The Supply of Illicit Drugs to the United States. Washington, D.C., April 1989. Texas Department of Health, Bureau of Vital Statistics. Texas Vital Statistics. Austin, TX, 1987. Texas Employment Commission. Texas Labor Market Review. Austin, TX, May 1989. United States Border Patrol, Laredo Sector. Fiscal Year Report. Laredo, TX, 1987. United States Border Patrol, Laredo Sector. Fiscal Year Report. Laredo, TX, 1988. United States Border Patrol. End-of-the-month news release. Laredo, TX, June 1989. Webb County Sheriff’s Department. Uniform Crime Reports. Laredo, TX, 1988. Acknowledgment Supported by the National Institute on Drug Abuse Contract #271-88-8232. Author Pedro Alfaro, M.D. Project Coordinator Horizontes Laredo 1502 Laredo Street, Suite 5 Laredo, TX 78040 17 AIDS AND FEMALE PARTNERS OF IV DRUG USERS: SELECTED OUTREACH STRATEGIES, ACCOMPLISHMENTS, AND PRELIMINARY DATA FROM ONE PROJECT Saira Moini HIV Infection/AIDS and Female Partners of Intravenous Drug Users While women represent only a fraction of the 112,241 total AIDS cases reported so far, the number is increasing steadily from year to year. As of October 1989, 10,008 women in the United States have been diagnosed with AIDS. A disproportionate number of these cases have occurred among Black and Latina women. Of the women infected, at least 1,890 cases are clearly attributable to exposure through sex with an intravenous drug user (IVDU) (Fineberg 1988). HIV transmission through heterosexual contact (mostly from men to women) is expected to continue to increase over time (Centers for Disease Control [CDC] 1989). Public health experts believe that people are unlikely to change the behaviors that place them at risk for HIV infection until they perceive themselves as “personally” vulnerable to infection (Newmeyer April-June, 1988). The exigencies of health and survival now demand that women, particularly the partners of IVDUs, view themselves as “personally” vulnerable to HIV/AIDS and begin to reduce their risk of exposure. Some women are not aware of their partner’s present or past IV drug use and do not know that it poses a risk to their own health or that of their children. Of those women who are aware of these facts, many, especially those struggling with poverty and its accompanying problems, are likely to relegate AIDS risk reduction to the lowest of their concerns (Mays and Cochran 1988). Complicating the situation for these women is the fact that risk reduction usually involves cooperation from their IV-drug-using partners. Although aware of their partner’s IV drug use, many of the women are not in a socioeconomic or sociocultural position to assert themselves with a male partner regarding the cleaning of injection equipment (“works”) or the use of condoms (Worth 1988). Recent studies have shown that male IVDUs enlightened about HIV infection and risk reduction are far more likely to begin cleaning or stop sharing their “works” (primarily to protect themselves) than to start using condoms with their female partners (Newmeyer 1988). For IVDUs, as for most people, self-preservation (protecting themselves) takes priority over altruism (protecting their partners). This finding is important in relation to AIDS because it shows that the brunt of the burden of risk reduction falls on the female partners. These are some of the issues that AIDS-education projects tackle through interventions such as individual counseling, group-empowerment sessions, and videotape screenings. For intervention to occur, however, the women at high risk must first be located and informed of the interventions available to them. Programs must serve both those women who will seek further 18 information and those who will not. Outreach must work simultaneously as an introduction to the subject and as an education in itself (Moini 1989). After initially contacting or attracting the women who are partners of IVDUs, there remain additional challenges for the outreach component of AIDS projects. These include: (1) creating an awareness of the nature of AIDS; (2) personalizing the risk of infection; and (3) presenting risk reduction in terms that make it appear manageable, as well as socially and culturally acceptable, within the target population’s frame of reference (Morin 1988). This paper discusses several strategies used by Abt Associates’ project site staff in conducting outreach to women who are sexual partners of IVDUs. Outreach to Female Partners: Adaptation and Flexibility Abt Associates is coordinating an outreach and education project for female sexual partners of male IVDUs as one of the AIDS Targeted Outreach Model (ATOM) Projects sponsored by the National Institute on Drug Abuse (NIDA). This project is also targeting female prostitutes. The project comprises three semiautonomous programs in three very different sites: Bridgeport, Connecticut; San Juan, Puerto Rico; and Juarez, Mexico. The sites are different not only in terms of culture but also in their experience of AIDS. The first two cities have already seen a substantial number of AIDS cases—as of October 1989, Bridgeport had reported 398 cases and San Juan 1,741—and the infection is presumed to be spreading in these metropolitan areas (CDC 1989). The third city, Juarez, has reported few AIDS cases to date. Juarez is of particular interest to NIDA because of IV drug activity and prostitution in the U.S.-Mexico border areas and because it presents an opportunity to stem the spread of AIDS before many people are infected. Each project site’s outreach strategies reflect its geography, sociocultural milieu, and experience of AIDS. The Bridgeport program has adopted a comprehensive human-services approach. The San Juan program has focused more sharply on HIV counseling, testing, and education. The Juarez program has introduced the concepts of AIDS and AIDS risk reduction gradually, offering this information in the context of friendship and health promotion. At the same time, the programs in all three sites have emphasized flexibility and adaptation in outreach (Abt Associates 1989). Successful Outreach Strategies Posters and Fotonovelas Since many outreach tools can serve also as educational tools, the project has put much effort into developing and field testing posters for the three sites. The poster for Bridgeport reads, “Why take the RISK?” Beneath these words, which appear in bold red letters, is a large color photograph of three smiling children: a Black girl, a White boy, and a Latina girl. Beneath them is the caption, “Don’t you want to be around when they grow up?” and then the words, “Learn how to protect yourself from AIDS, contact the Bridgeport Women’s Project.” Displayed in clinics, housing projects, and human-service agencies, the poster has reportedly been very effective in outreach. The San Juan and Juarez sites are using a Spanish version of this poster, the Juarez one featuring two smiling Mexican girls, one holding a baby boy. These posters attempt to attract attention to the issue and to the programs without intimidating potential clients. 19 The San Juan program, by contrast, has developed a stark, black-and-white Spanish poster featuring a photograph of a man “shooting up” in a run-down apartment, while his pregnant wife sits beside an obviously sick little boy. This sobering poster begins, “An addict can give many things to you and your children.” The San Juan site staff have used this poster at various housing projects to announce upcoming visits and events such as the screening of AIDS videotapes. Underlying the maternal emphasis of these posters is the belief, widely held among public-health educators, that children are a strong motivator for behavioral change among women (Andriote 1988). One of the more compelling printed materials used by this project is the fotonovela, a comic book illustrated with photographs and written in a soap-opera format. For the Juarez site, the project has developed a series of Spanish fotonovelas, photographed in recognizable city locations. Local actors are used in the fotonevelas in order to impress upon women the relevance of AIDS to their community. One fotonovela depicts a conversation between an older woman and her pregnant daughter-in-law, whose husband shoots drugs. The older woman encourages the younger one to seek the advice of an outreach worker she has met from Proyecto Comparieros, the Juarez program. The story continues with the daughter-in-law’s visit to the program office. Clothing Boutique, Staff Uniforms, and Adjusted Hours Several other adaptive outreach strategies have allowed project site staff to gain access to sexual partners of IVDUs and to earn their trust. In Bridgeport, the staff have set up a clothing boutique that offers free shoes, clothing, and linens, all new or in near-perfect condition. These are donated by local and national organizations as well as individuals. The boutique is a star attraction for the program office, with news of it spread by word of mouth. It serves the dual function of improving a woman'’s self-image and drawing her into the program’s activities. For example, a woman may initially stop by the boutique to pick up some new clothes and then stay to watch an AIDS videotape or to talk with a counselor. Program staff believe that even if she merely takes the clothes and leaves, providing such articles for her helps to build her sense of self-worth and may also serve as an impetus for her to return to the program in the future. This boutique symbolizes the comprehensive psychosocial approach to AIDS prevention that the Bridgeport program has taken since its inception. The process of building trust, while a necessary part of all outreach work, must be adapted to the situation and surroundings. In San Juan, the program staff wear a distinctive peach-and-khaki uniform that establishes them as health workers and yet distinguishes them from the health professionals who work in the housing projects’ community centers. The uniform protects staff by reassuring community residents that the staff are not police informants. Since the concept of health workers is familiar to Puerto Ricans, this uniform has eased the staff’s entry into each housing project. Juarez program staff have established afternoon and evening outreach and intervention work hours to fit the schedules of the women they are targeting. This flexibility has allowed staff to reach large numbers of both women and men. Juarez, unlike San Juan, has recruited many women through their male partners. The staff have attained this success by conducting intensive, sometimes weeks-long outreach to the IV-drug-using men, after which the men consent to their female partners’ participation in the project. This is just one example of how the 20 outreach staff in Juarez have tapped into the gender and family relationships of Mexican culture in order to spread the word about health and AIDS. Data Collection and Analysis Initial-Contact Form (Table 1) Project staff at all three sites carry compact pads of Initial-Contact Forms on which they record data from all significant first encounters with women in the community. The forms ask about the location and time of contact, previous sources of AIDS information, previous information regarding this project, the person’s age and ethnicity, number of children, and the types of services delivered at that contact by the outreach worker. These data are coded and entered into a database designed specifically for the part of the project involving analysis of individual participation in the program. One of the purposes of the database is to provide aggregate data in report format. For example, the reports show that for a sample of 488 encounters by Juarez staff (between October 1988 and October 1989), 56% of all contacts took place in the community (i.e., in bars and other public locations). The reports show, furthermore, that approximately half the women contacted at all three sites are between 20 and 29 years of age. Another interesting finding is that while three-quarters or more of the women contacted in San Juan and Juarez mention television as a source of prior AIDS information, only one-third of the women contacted in Bridgeport do so. These data help the site staff to refine their outreach efforts and intervention techniques. Selected AIDS Initial Assessment Data (Table 2) An examination of selected AIDS Initial Assessment (AIA) data reveals some of the AIDS- related attitudes, knowledge, and behaviors of a group of sexual partners of IVDUs at the start of program participation. For example, cocaine use is prevalent among female partners in both Bridgeport and San Juan. Thus, apart from the IV drug use of their male partners, these women have the added risk of HIV infection posed by the cocaine-HIV behavioral connection. In general, it is more difficult to teach risk reduction to drug-using women. Over half of the women in these three sites never use condoms. At the same time, about half to three-quarters in all three sites believe they have “some chance” of developing AIDS. The majority report that they have not been tested for HIV antibodies within the last six months. On the AIA test of AIDS knowledge, most of the women in Bridgeport and San Juan answered most of the questions correctly. These data reflect the relatively high prevalence of AIDS in those cities. In Juarez, however, most of the women answered fewer than three-quarters of the questions correctly, confirming staff observations that much misinformation and lack of information about AIDS exist in that city. The AIA data mentioned here, while representing a small sample of women at the sites, confirm that these sexual partners of IVDUs (those participating in the program) behave, and sometimes think, in ways that increase their risk of HIV infection. 21 Table 1. Selected Characteristics of Target Populations’ Sitet Juarez, San Juan, Bridgeport, Mexico Puerto Rico Connecticut N (%) N (%) N (%) Sexual partners (non-IVDU)# 91 (19) 184 (80) 108 @1) Non-IVDU prostitutes 296 (61) 34 (15 142 27 IVDU prostitutes 8 © 4 © 70 (13) Other* 93 (19) 7 3) 202 (39) Contact Location Community (bars, diners) 272 (56) 2 0.9) 22 4) Criminal justice system 87 (18) 0 ©) 1 0.2) Housing project 0 ©) 167 (73) 4 (1) Project office 8 © 1 (04) 266 (51) Street 31 ©) 46 200 129 (25) Other” 90 (18) 13 © 100 (19) Duration of Contact 0 - 15 minutes 115 24) 151 66) 290 (56) 16 - 30 minutes 207 42) 62 @n 70 (13) 31 - 60 minutes 89 (18) 1 (04) 41 ®) Other” 77 (16) 15 mn 121 (23) Race/Ethnicity Mexican (native) 473 on 0 ©) 0 ©) Puerto Rican 1 (02 22 (96) 49 ©) Hispanic (other) 2 (04) 0 ©) 43 ®) Black 0 ©) 0 © 309 (59) White 0 ©) 6 3) 87 an Other* 12 3) 1 (04) 34 ©) Age 20 - 29 years 215 @4) 115 (50) 251 (48) 30 - 39 years 99 (20) 72 3) 179 (34) Other (<20 and >39)* 174 (36) 42 (18) 92 (18) Source of Prior AIDS Information® Television 356 (72) 206 90) 196 (38) Newspaper, magazine 213 44) 173 (76) 156 30) Pamphlet 74 as 132 (58) 189 (36) Health department 79 (16) 42 (18) 135 (26) Friends 34 ™ 76 (33) 131 (25) Services Provided at Contact” Written information 200 @1) 98 @3) 327 (63) Oral information 457 (94) 210 92) 420 (80) Condom 151 31) 106 @46) 348 (67) Source: Abt Associates, Initial Contact Form. Juarez (N=488); San Juan (N=229); Bridgeport (N=522). Since complete data were unavailable for analysis at the time, these N's represent a percentage of total contacts made during the period October 1988-October 1989— for Juarez (75%); San Juan (83%); Bridgeport (97%). §4Other” includes categories with unspecified or minimal data, missing values, N/As, etc. The nature of an initial contact does not always allow for comprehensive data collection. *Not mutually exclusive. #The data reflect outreach strategies from the initial stages of the project. At the time, in two sites, prostitutes, rather than sexual partners, were more heavily targeted. 22 Table 2. Selected AIDS-Related Behaviors, Attitudes, and Knowledge of Female Sexual Partners of IVDUs site’ Behavior/ Juarez, San Juan, Bridgeport, Attitude Mexico Puerto Rico Connecticut N (%) N (%) N (%) Drug Use! N=42 N=160 N=92 Crack (ever used) 0 ©) 10 ©) 50 (54) Cocaine (used) 6 (14) 57 (36) 66 72) Heroin (used) 1 ? 24 (15) 16 17 Cocaine (injected >6 months ago) 0 © 9 ©) 15 (16) Heroin (injected >6 months ago) 0 © 8 ® 17 (18) Condom Use Single partner N=37 N=140 N=62 Always 0 ©) 4 3) 7 (11) 2 half of the time 2 5) 3 2) 7 (11) < half of the time 3 ® 9 ©) 4 ©) Never 32 (86) 124 (51) 44 7) Multiple partners N=5 N= N=30 Always 0 ©) 0 © 3 (10) 2 half of the time 0 ©) 3 (15) 6 (20) < half of the time 0 ©) 2 (10) 5 17 Never 5 (100) 14 (70) 16 (53) Most Trusted Source of AIDS Information N=41 N=160 N=92 Television 1 2) 56 35) 19 21) Newspapers, magazines 1 © 15 © 6 ©) Brochures, fliers, pamphlets 1 ?) 34 21) 15 (16) This AIDS intervention program 32 (78) 22 (14) 6 6) Outreach worker 4 (10) 6 4 19 (20) Other" 2 ©) 30 (19) 27 (29) Self-Predicted Chance of Developing AIDS N=41 N=160 N=92 No chance 9 (22) 40 (25) 16 a7n Some chance 25 61) 83 (52) 64 (70) High chance 5 (12) 15 ©) 7 ® Sure chance 2 ®) 10 ©) 2 2 Don’t know/unsure 0 © 11 @ 2 2) Refused or N/A (has AIDS) 0 ©) 1 (0.6) 1 1) Tested for HIV Antibodies <6 months ago N=42 N=160 N=92 No 42 (100) 140 (88) 68 (74) Yes 0 ©) 19 (12) 24 (26) Don’t know/unsure 0 ©) 1 1) 0 ©) Got Test Results (if tested) N=0 N=19 N=24 No 0 ©) 3 (16) 2 ® Yes 0 ©) 16 (84) 22 92) General Knowledge of AIDS (number of correct answers on AIA) N=42 N=160 N=92 < 1/2 correct 7 (17) 9 ©) 6 ©) 1/2 to 3/4 correct 32 (76) 93 (58) 36 (39) > 3/4 correct 3 ®) 58 (36) 50 (54) Source: Abt Associates, AIA interviews. "The data reflect outreach strategies from the initial stages of the project. At the time, in two sites, prostitutes, rather than sexual partners, were more heavily targeted. §Not mutually exclusive. *“Other” includes categories with minimal data, missing values, N/As, etc. Conclusion The AIDS project coordinated by Abt Associates continues to test various outreach strategies, many of which have been successful. While certain sites have found it less difficult to conduct outreach to female partners of IVDUs than the others have, adapting the method and manner of outreach, as indicated, have worked well for all three sites. References Abt Associates. “First Annual Report to NIDA: AIDS Outreach to Female Prostitutes and Sexual Partners of Intravenous Drug Users.” Unpublished report, Cambridge, MA, June 8, 1989. Andriote, J. For women at risk, prevention begins with self-esteem. National AIDS Network Monitor, Fall, 1988. pp. 12-14. Centers for Disease Control. HIV/AIDS Surveillance Report, November 1989. Fineberg, H. Education to prevent AIDS: Prospects and obstacles. Science 239: 592-596, February 5, 1988. Mays, V.M,, and Cochran, S.D. Issues in the perception of AIDS risk and risk reduction activity by Black and Hispanic/Latina women. Am Psychol 43: 949-957, 1988. Moini, S. AIDS-related attitudes, behaviors, and community education projects for risk reduction: A review. In: Abt Associates, eds. “First Annual Report to NIDA: AIDS Outreach to Female Prostitutes and Sexual Partners of Intravenous Drug Users.” Cambridge MA, June 8, 1989. Morin, S. AIDS: The challenge to psychology. Am Psychol 43(11): 838-842, November 1988. Newmeyer, J. The intravenous drug user and secondary spread of AIDS. J Psychoactive Drugs 20(2): 169-172, April-June 1988. Newmeyer, J. Why bleach? Development of a strategy to combat HIV contagion among San Francisco’s intravenous drug users. NIDA Research Monograph 80. DHHS Pub. No. (ADM)88-1567. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 151-159. Worth, D. Self-help interventions with women at high-risk of HIV infection. New York: Montefiore Medical Center, April 1988. 24 Acknowledgments Supported by the National Institute on Drug Abuse Contract #271-88-8224. Author Saira Moini Junior Analyst Abt Associates, Inc. 55 Wheeler Street Cambridge, MA 02138 25 A MOBILE OUTREACH PROGRAM TO INTRAVENOUS DRUG USERS AND FEMALE SEXUAL PARTNERS IN LONG BEACH, CALIFORNIA Donna Yankovich, Eduardo Archuleta, and Silvia Simental Abstract The California State University, Long Beach (CSULB) AIDS Research and Education Project Community Health Outreach Program utilizes a street outreach approach to AIDS education with intravenous drug users (IVDUs) and their female sexual partners in the greater Long Beach area. Basic and enhanced education, risk-reduction counseling, and initial and follow-up research interviews are conducted. In addition, human immunodeficiency virus (HIV)-antibody testing and counseling are offered. A customized mobile unit has been designed to facilitate the outreach efforts and offer services to individuals who may not have ready access to the project sites. Typically, the mobile unit operates in neighborhood parks frequented by IVDUs. Interview and counseling sessions are conducted in the vehicle or, when conditions permit, at park benches isolated from pedestrian traffic. Although the mobile unit has significant drawbacks, including space limitations, the increased access permits the education and interviewing of individuals who would otherwise be excluded from the program. Introduction The CSULB AIDS Research and Education Project was funded as a National AIDS Demonstration Research (NADR) program on October 1, 1988, for the purpose of providing research-based HIV risk-reduction interventions to targeted populations in the Long Beach area. These target groups are IVDUs not in treatment, non-IV-drug-using female sexual partners of IVDUs, and street youth. The geographic target area includes Long Beach and bordering cities located in Los Angeles County. This urban area has a population of approximately one-half million and covers roughly 55 square miles. Pockets of drug activity are dispersed throughout this region. During the summer of 1988, a team of ethnographers, using key-informant interviews, mapped out sites in the Long Beach area frequented by IVDUs as part of a pilot study for the Centers for Disease Control (CDC). The National Institute on Drug Abuse (NIDA) program used these data in planning and organizing outreach efforts. Subsequently, outreach workers and research participants provided additional information regarding the appropriateness of the 12 targeted neighborhoods. 26 Outreach Facilities Although the NADR program is operated through CSULB, three community-based facilities are used for all outreach activities. The activities include behavioral interviews, counseling, education, and HIV-antibody testing. The three outreach facilities include two drop-in centers (one located in a residential area, the other in a storefront) and a customized motor home. Drop-In Centers The first drop-in center is designed to serve the youth and female-sexual-partner populations. All outreach staff are housed at this location. Youth participants receive education, support, and social-service referrals at this center; additionally, female sexual partners of IVDUs can participate in support groups and obtain referrals for other services. The storefront drop-in center serves IVDUs. In addition to being a location where condoms, bleach, alcohol wipes, and refreshments are dispersed, this facility is also used for conducting interviews, drawing blood for HIV-antibody testing, and providing standard and enhanced counseling sessions. Mobile Vehicle A mobile vehicle is used as a third facility in the outreach project. This strategy was adopted to address several access issues. Long Beach does not have one or two specific neighborhoods or areas with a high concentration of IVDUs who can be easily accessed from a single site. Instead, identified access sites are spread throughout the geographic region, making it difficult to reach a large number of individuals. The mobile vehicle assists outreach personnel in overcoming these obstacles. The 30-foot customized motor home was put into service in May 1989 and has been to several different sites. The amount of time at any one site is dependent on factors such as: (1) the total number of potential participants that can be recruited from the area; (2) the number of individuals needed for sampling quotas; and (3) the cooperation and consent of the community. The vehicle generally goes into a location biweekly for a two-month period. This allows staff time to offer two weeks of interviewing, two weeks of standard counseling, and four weeks of enhanced interventions. Before the arrival of the mobile vehicle, outreach workers go into each neighborhood to screen and schedule appointments. The motor home consists of three private rooms used for interviewing, counseling, and drawing blood. One room is approximately 5° x 8’; the others are approximately 5° x 5° each. There is also a reception area, a supply area, and a restroom. Each private room is equipped with a table and chairs as well as equipment for counseling and education. Special features include a videocassette recorder for enhanced educational strategies, a cellular phone to coordinate activities with the other locations, and a refrigerator for storage of beverages provided to participants. An awning attached to the exterior provides shade for outdoor discussions. Interviews are conducted either in the vehicle or, weather permitting, outside of the vehicle in areas isolated from pedestrian traffic. At the end of each week, vehicles are maintained and restocked. 27 Procedures After outreach workers have obtained initial demographic and screening information, individual appointments are scheduled for the following week. On arrival, the individual takes partin a final screening for participation, which includes checking for needle marks or tracks. If deemed eligible for the study, the participant is interviewed regarding risk behaviors. Following the interview, the participant meets with a counselor to discuss HIV prevalence, transmission, and testing. At this time, methods for risk reduction are also discussed, and bleach, condoms, lubricant, alcohol wipes, funnels, and referral cards are distributed. If a participant has decided to be tested for HIV antibodies, a blood sample is drawn by a phlebotomist when the counseling session has been completed. After this, he or she receives $10, and a return appointment is scheduled. The vehicle is also used to share HIV test results with the participants and to provide further enhanced educational sessions. Conclusions Although the mobile vehicle provides many advantages in conducting street outreach, it also has several disadvantages. Maintaining this vehicle is expensive; the cost of leasing it is $2,500 per month. In addition, space is limited. Interview rooms are small, and the waiting area will only accommodate two or three individuals. Maintenance, which includes cleaning, restocking, repairs, and upkeep, is time consuming. Logistically, the vehicle’s location is frequently miles from where the outreach workers and other staff are based, complicating outreach coordination efforts. Finally, it has been difficult to find qualified, insurable drivers. Before instituting the outreach program, one concern was that the presence of the vehicle might allow identification of those who visited it as IVDUs. However, in reality, concern among the IVDU population is minimal, and arrangements are made to accommodate any individuals concerned about confidentiality at the storefront facility. In spite of these challenges, the advantages of the vehicle seem to outweigh any disadvantages. It increases the project’s visibility and ability to access a large area, which, in turn, increases our client population. Participation is more convenient for the targeted population, which increases the number of initial contacts and improves the ability to conduct follow-up assessments. These benefits seem to be well worth the effort. 28 Acknowledgment Supported by the National Institute on Drug Abuse Grant #1R18DA0574-02. Authors Donna Yankovich, M.A. Director of Program Operations Eduardo Archuleta Health Adviser Silvia Simental, B.S.W. Referral Specialist/Health Adviser AIDS Research and Education Project California State University, Long Beach Psychology Department, Room 440 1250 Bellflower Boulevard Long Beach, CA 90840-0901 29 OUTREACH TO IVDUs IN THE HOSPITAL SETTING Karen R. Charron and Mary Jane Reynolds Introduction Model 2 of the National Institute on Drug Abuse (NIDA)-sponsored AIDS Targeted Outreach Model (ATOM) involves outreach through hospital emergency rooms and detoxification units. Personalized Nursing Corporation, PC (PNC) has subcontracted with three inner-city hospitals in Detroit, Michigan; Brooklyn, New York; and Baltimore, Maryland, to implement its NIDA contract. Our aim is to provide outreach to intravenous drug users (IVDUs) as they access the health-care system. Our primary referral mechanisms are staff in the emergency rooms, outpatient clinics, and inpatient units in these hospitals. Challenges of Hospital Outreach Outreach in the hospital presents many challenges. Our potential clients are ill and often at a point of crisis. They are often experiencing a loss of control in their lives. Many IVDUs seek medical attention only when they have hit the proverbial “bottom.” For many, the hospital environment is threatening. Despite these potential barriers, PNC feels hospitals can provide a good opportunity to interact with IVDUs who may not approach a street outreach worker. With the use of the Personalized Nursing LIGHT Model (Andersen and Smereck 1989), we reach out to these individuals, begin to advocate for them, and help them deal with this stressful situation. Our biggest challenge, however, is not the clients, but the hospitals themselves. Obtaining legal authorization from hospital administrators that will permit outside research groups to have access to their patients is a long, involved process. Research projects must submit all documents including data collection tools, intervention strategies, and informed-consent forms, for review and approval of the human volunteer committee. Once this long procedure is complete, the process of establishing ourselves within the institution begins. PNC uses nurses, who are indigenous to the hospital setting, and pairs them with outreach workers, who are indigenous to the community being studied. Each are valued for their core of special competence that they bring to the team. The outreach workers, however, are not always valued by the hospital professionals, which makes relationships difficult at times. Each of the hospitals has established a liaison department to help advocate on PNC’s behalf and facilitate as mediator between PNC and referral sources. This can be helpful, but “outside” agencies are still viewed with suspicion and cause many hospital staff to question our right to see their patients, in spite of our contract with their institution. There are also problems with validity testing and territorial disputes from hospital professionals. They want to be assured that PNC has accurate information on HIV and drug users. As a result, 30 we must spend a good deal of time providing inservice education to hospital personnel and reassuring them of our qualifications. Territorial issues are more difficult to circumvent, since many hospital personnel are threatened by newcomers. Some wish to engage in power struggles to control access to potential clients. Conflicting research projects have also made progress tedious. Once the bureaucratic pathways are cleared, it is necessary to weed through the entanglement of fear and anger associated with the treatment of IVDUs and HIV-related issues. We have observed that health-care workers have stereotypical views of IVDUs. We hear many express opinions that IVDUs are “lazy,” “uneducated,” “unreachable,” and “unsalvageable.” IVDUs are thought of as emotional and financial drains on the health-care system (Iglehart 1987). These feelings have been intensified by “HIV phobia.” Hospital personnel do not take the time to obtain adequate education about their actual risk for HIV and precautions necessary to protect themselves (Fahey et al. 1988). This lack of knowledge is then transferred to fear of caring for anyone at risk for HIV infection, and IVDUs are at the top of the list. Another problem is the lack of drug-treatment resources in these cities. Staff are reluctant to identify someone with a drug problem if they are unable to offer any treatment options to that individual. Hence if hospital staff do not identify IV drug use, they cannot refer eligible patients to PNC’s outreach and intervention program. Once a patient is referred to PNC, lack of privacy becomes an important issue. Patients are usually in semiprivate rooms or on emergency-room stretchers, making it difficult to protect them from “unintentional” eavesdropping. Due to the highly personal and sensitive nature of the interview, this problem can hardly be ignored, however, it is impossible to eliminate in a busy hospital. Ambulatory clients also have problems, as the hospitals have provided one closet-sized “office” at each site to run this project. Lack of space makes it difficult for PNC staff to function, let alone offer privacy for client interviewing and education. One of the ways we have overcome this problem has been to establish off-site storefronts for follow-up activities. Advantages of Hospital Outreach Although these negative aspects may seem overwhelming, there are many positive reasons for using hospitals as a place to provide outreach to IVDUs. The clients are somewhat captive and confused, and often are looking for some sign as to where to go next. They are looking for something to put their life back into equilibrium. As PNC staff, we present ourselves as a kind face, a soft voice, and a friend. We become an advocate for them and help them deal with their immediate concerns. HIV is not the first thing on their minds and we must address their needs before we can hope to accomplish our objective. It may be that they are in the emergency room and they haven’t eaten in a long while. PNC provides some basic nourishment to them. If they are cold, we get them a blanket. Simple acts of human kindness begin the long process of building a trusting relationship with that individual through the use of the LIGHT Model. The LIGHT Model requires that we bond with each client using a symbiotic valuing and learning experience. We treat them not as clients, but as co-human beings with the belief that both staff and client can learn from each other. Each client is entered into the PNC family and is introduced to all the staff available. When we value 31 their worth, we in effect teach them how to value themselves. This, in turn, encourages clients to make positive behavior changes in order to begin the process of improving their overall well- being and reducing their risk for HIV infection and transmission. After the initial encounter, each eligible client is interviewed by an outreach worker with the AIDS Initial Assessment (AIA). The client is then seen by a nurse, who assesses his or her talents, strengths, and patterns. We help each client identify the focal concern in his or her life and identify goals he/she would like to achieve. All receive basic education on HIV prevention; a “prevention packet” containing literature, condoms, and bleach; and a “well-being journal.” We schedule two follow-up teaching and counseling sessions during which HIV and well-being issues are discussed in depth. Throughout this process, we encourage the clients to raise the bottom and begin to love themselves. They are encouraged to maintain their “well-being journal” to record their thoughts, concerns, and goals. Many continue to maintain their journal after completing their three-month and six-month AIDS Follow-up Assessment (AFA). Evaluation The AFA has documented behavior changes in quantitative terms, indicating that our clients are decreasing IV drug use and needle sharing while increasing needle cleaning and condom use (Andersen et al. 1989). We have seen over 1,700 clients from March 1987 through September 1989 in the three sites. The follow-up rate at PNC’s Baltimore site is 66%. The overall project follow-up rate is above 50% (Andersen et al. 1989). Client “well-being journals” are often shared with PNC staff and are among the many acknowledgments that are being evaluated as qualitative documentation of our effectiveness. Other types of qualitative documentation include: cards, flowers, letters sent to us from jail, hugs, sharing pictures of their children, bringing their family in to meet PNC staff, referring sexual or shooting partners, and volunteering at the storefront, to name a few. The biggest acknowledgment is when clients return to visit us after they have completed the project. They come back to us for myriad reasons: to show us they are doing well (or maybe not so well) and enlist our support; to introduce us to their family and friends; to get something to eat or drink; or even for just a hug and a smile. It amazes us that we are often the first outside contact a client seeks once he or she is released from jail. Summary Outreach to IVDUs in the hospital setting has many challenges, but it is effective. Through this project, PNC has made a difference in many people’s lives. As the project draws to a close, we are able to smile. We have not only made a positive impact on our clients’ well-being, we have influenced health-care professionals as well. With the use of the LIGHT Model, we have changed the way that many professionals view the IVDU population and the AIDS epidemic. AIDS and drug abuse are not things that affect “them.” AIDS and drug abuse affect us all. We all need to work together to make a change. 32 It is important to note that this project has changed the PNC staff as well. Each client has, in effect, become our extended family and we have become theirs. The specialness of these people has permanently touched us all, both professionally and personally. It is truly amazing what we can learn from each other if we only stop and listen. References Andersen, M.; Smereck, G.; and Braunstein, M. Progress report for AIDS outreach to emergency rooms and detoxification units. Rockville, MD: National Institute on Drug Abuse, September 1989. Andersen, M.D., and Smereck, G.A.D. Personalized Nursing L.I.G.H.T. Model. Nurs Sci Q 2(3): 120-130, 1989. Fahey, B.J.; Meehan, P.E.; and Henderson, D.K. The risk of HIV-1 transmission in health care workers. Infections in Surgery 7: 249-264, April 1988. Iglehart, J.K. Financing the struggle against AIDS (Health Policy Report). N Engl J Med 317: 180-184, 1987. Acknowledgment Supported by the National Institute on Drug Abuse Contract #3871-87-8212. Authors Karen Rossi Charron, R.N., B.S.N. Registered Nurse Mary Jane Reynolds, R.N., B.S.N. Site Coordinator Personalized Nursing Corporation, PC University of Maryland Hospital 22 South Green Street, Box 101 Baltimore, MD 21201 33 EFFECTIVE TECHNIQUES FOR OUTREACH TO INTRAVENOUS DRUG USERS AND SEXUAL PARTNERS TO COMBAT AIDS Roy Griffin, Betty Ryder, and Carolyn Turner Introduction The National Institute on Drug Abuse (NIDA) sponsors outreach and intervention projects in 29 metropolitan areas, including Dallas, Texas, as part of the National AIDS Demonstration Research (NADR) Project. The focus of this nationwide research is on needle and sexual practices that place intravenous drug users (IVDUs) at risk of acquiring the human immunodeficiency virus (HIV) and AIDS. To gauge these risks in conjunction with outreach and other interventions, such as AIDS education, an AIDS Initial Assessment (AIA) interview is given, followed six months later by an AIDS Follow-up Assessment (AFA) interview. In the Dallas NADR program, outreach staff are called upon to do recruitment and the follow-up outreach leading to the AFA. This paper focuses on the outreach leading to the AIA. Within this context, the philosophy and doctrine of the Dallas NADR program are described, as well as the techniques on strategies employed. The report ends with a brief account of the outreach accomplishments. Several approaches have been developed by the Dallas program for contacting potential clients and obtaining their participation. These intervention techniques evolved out of a common bond and commitment by the staff to serve as a positive change agent in their own ethnic and cultural communities. Examples of these positive actions are immediate access to health-care services when needed, user-friendly drug treatment, and referral to social services, employment, and other helping agencies. Early in the program, outreach teams developed techniques for pinpointing the geographic areas that were to be targeted. Each two-person team went into its assigned area daily and conveyed a single, straightforward message for the targeted population: “If you take part in our research, we can do many things for you. For example, help is available to anyone wanting to get off drugs.” Team members were encouraged to develop friendship or kinship relations as a key element in gaining the trust of the drug community and demonstrating their commitment to the well-being of this population by offering opportunities for individuals to make certain things better in their lives. 34 Selecting Target Communities In geographic locations reputed to have high concentrations of IVDUs, the outreach teams focused on becoming recognized and accepted in the strolls (hangouts) and copping areas frequented by users. Initially, the outreach workers (OWs) went to certain parts of Dallas that had been selected on the basis of sociodemographic, drug-enforcement, and related ethnographic data. They spent approximately a month observing street and neighborhood activities with the aid of the staff’s knowledge of copping areas and an unwritten agreement of “noninterference” with the city police department. Based on these observations, the targeted areas were narrowed down to certain portions of South Dallas, West Dallas, Oak Cliff, and East Dallas around Garrett Park. During the first two to three months, outreach workers observed the street scene, with the intent of becoming aware of what to look for and how to carry themselves. They learned about the language, signs, symptoms, and demeanor of IVDUs. They also developed skills and techniques for locating the target group when the area was too “hot” due to police crackdowns or other happenings. For example, key contacts or individuals in the communities would often let outreach workers know where to find new hangouts and scoring areas, or pickup areas for prostitutes. They found, for example, that prostitutes who were strung out on drugs generally remained in close proximity to their dealers. Needless to say, this had to be taken into account in engaging this group. Another population identified was composed of prostitutes who were not necessarily involved in IV drug use, but worked to make money to satisfy their lifestyle or their addiction to crack. These individuals had to be recruited in a different manner. Thus, messages for IVDU and non-IVDU prostitutes were attuned to the needs and circumstances of each group. Outreach Doctrine To gain the respect and trust of prospective clients, it was recognized that the outreach worker must spontaneously and habitually act in certain fundamental ways. These fundamentals were viewed as a doctrine that applies to all the outreach procedures and techniques described later in this report. The doctrine sets forth six fundamental qualities or attributes needed by the outreach worker. Attractiveness Appearance is important because the client’s initial impression of the OW often determines whether the person being approached will give the OW a “brush off” or will be interested in hearing what the outreach worker has to say. Characteristics that may promote attractiveness are: (1) matching gender and ethnicity between client and OW; (2) casual attire and neat appearance; and (3) a lively, but not loud or boisterous, personality. Helpfulness — Be ready to help the client in any appropriate way without strings attached; i.e., never extract a promise to participate in the project if help is provided. 35 Provide pertinent information about services available under the project or from other agencies so the client may decide whether he or she wishes to proceed further. Respect the client’s opinion and avoid giving advice unless the client seeks it. If the client appears to be eligible and agrees to participate in the project, make an appointment for the AIA or other services. In other words, act immediately upon opportunities offered. If asked, make it clear that except for the satisfaction of being helpful, he or she receives no special “payoff.” Empathy Take the perspective of the client, by “tuning in” on his or her wavelength. Show an understanding of the client’s world and the problems it presents from his or her perspective. Recognize that clients feel varying degrees of helplessness with respect to bettering their lives and becoming free of drug addiction. Recognize that clients may deny or rationalize their addiction or other behavior that places them at risk of AIDS. Warmth — Accept the client without any hint of dislike, criticism, or negativism. Show unconditional care and concern for the client; do not be judgmental. Be a good listener. If appropriate, let the client know that you have been through the same sort of thing as he or she is talking about. Openness and self-disclosure encourage the client to also be frank and forthright. Honesty — Avoid promises or assurances that may not be fulfilled or met. 36 — Build trust at every opportunity. Expertness — Maintain accurate, detailed knowledge of the services offered by the NADR program and other helping agencies. If you do not know the answer to a question the client has asked, offer to find it and pass it along to the client. — Understand street slang. — Keep well informed concerning AIDS, the HIV-antibody test, and AIDS prevention. The Message Although we encourage staff members to develop their own styles of delivering the outreach message, each is required to cover the same key elements in a straightforward and concise manner. “We are here to help you reduce the risk of contracting AIDS.” . .. “We are here to offer you an opportunity to get off drugs.” . . . We quickly learned that if the basic message was not conveyed at the outset, our communication would be sidetracked and we would lose the client. Our outreach workers strive to be personal, conversational, nonjudgmental, and accepting. We stress how much we value and care for the people whom we are helping. Outreach Recruitment Strategies The outreach teams tried several different strategies for recruiting clients. Testing the response to these varied approaches in the selected communities, they quickly discovered that a technique that is successful in one area of town may fail in another area. Recruitment strategies used by the outreach teams involved: (1) canvassing of key business and service establishments; (2) daily visits to the stroll and copping areas; (3) door-to-door canvassing; and (4) using ice- breakers such as condoms and peppermint candy to get the attention of prospects and then giving them pamphlets about the project. Other helpful recruitment measures were: (1) providing immediate transportation for clients who were ready to be interviewed; (2) securing help from selected respondents that enabled us to access new social networks among prostitutes and IVDUs; (3) working a “hot spot” in which activity had settled down just once or twice a week, just to let clients know that we were still around, still cared, and were still interested in them; (4) remaining with the respondents briefly after they arrived for the interview in order to establish rapport and help them get through the intake procedure; (5) forming a relationship with drug dealers that focused on obtaining their help in urging their customers to seek testing for AIDS; and (6) buying food or drink for potential clients when they are too hungry or too sick to proceed with the interview. 37 Results Door to Door Knocking on doors enabled us to reach disabled IVDUs or sexual partners who ordinarily do not hang out on the stroll. Fabergé Effect In a widely acclaimed TV commercial for Fabergé hair care products, a pleased customer tells two friends about the product and, in turn, each of them passes the word to two friends, and so on. The motto became “Each One Reach One.” Referred to as the Fabergé effect, this strategy was employed when a prospective client appeared to have responded favorably to information the outreach worker(s) had provided about the project and the kinds of services or help available. Briefly stated, the prospect was asked to pass the word to acquaintances who were thought to be eligible for participation in the project and the benefits it offers. To make it easy for the prospect to do this, extra informational pamphlets about the project, and how to get in touch with an outreach worker, were provided. Caring Outreach teams are called on to make a special effort to create favorable opinions of the project by the target population. Emphasis is placed on giving special attention to each client and to providing services without a lot of hassle. To demonstrate that the welfare of clients is an uppermost consideration, the outreach teams may offer immediate help to a prospective client. Each person is treated as a very important person (VIP). Referrals to social-service or health- care agencies are just one example of the types of services provided. In addition, the outreach team is careful to allow ample time for prospective clients to reach a decision regarding participation in the project. In the event the prospect declines the opportunity, the outreach team remains cordial and invites future contact, should the prospect reconsider. Accomplishments As an indication of the fruits of the OWs’ efforts during the first eight months following the initiation of the street work, 738 clients completed the AIA. Although the vast majority of the 738 inject heroin and cocaine together, those who injected only heroin made up the second- largest group. Approximately 68% were African Americans, compared with 24% Whites and 8% Hispanics (primarily Mexican Americans). Thirty-two percent of the clients were between 31 and 36 years of age. Approximately 63% were males. Three percent of the 738 respondents were found to be HIV-antibody positive. Summary Although our recruitment strategies have worked reasonably well, we are aware that much remains to be learned about outreach recruitment in this population. At the same time, the outreach staff has been rewarded countless times by the positive responses of clients to the opportunities and services made available through the NADR program. Unfortunately, this appreciation cannot be statistically described. 38 Acknowledgment Supported by the National Institute on Drug Abuse Grant #1R18DA05176-01. Authors Roy Griffin Outreach Director Betty Ryder Supervisor, Institutional Outreach Workers Carolyn Turner Supervisor, Neighborhood Outreach Workers Darco Drug Services, Inc. 2722 Inwood Road Dallas, TX 75235 39 EFFECTIVENESS OF STREET OUTREACH AS AN AIDS-PREVENTION STRATEGY FOR IV DRUG USERS, THEIR SEXUAL PARTNERS, AND PROSTITUTES IN PHILADELPHIA Jon Liebman and Brunilda Sepulveda—Irene Introduction An important aspect of public-health practice is the provision of information and services to people who do not participate in the mainstream of society’s cultural, social, and economic life. Services to the homeless, migrant workers, recent immigrants, and others must be tailored to their particular circumstances, precisely because they do not, or cannot, take full advantage of the resources provided to most of the population. With the rapid spread of the AIDS epidemic, attention has focused on intravenous drug users (IVDUs), who are in urgent need of health education and other services, yet do not routinely receive them. Outreach efforts have been attempted, with varying degrees of success, as an approach to providing services to IVDUs and other hard-to-reach populations (Friedman et al. 1989; Neaigus et al. 1989; Williams 1986; Herz et al. 1988). There is little literature, however, evaluating outreach strategies to different populations or describing elements key to the successful implementation of such projects. In light of the difficulties inherent in working with IVDUs and the imperative to target AIDS-prevention dollars to the most promising and productive strategies, this information is critically needed. This paper describes an outreach demonstration project targeted at IVDUs not in treatment, their sexual partners, and prostitutes in Philadelphia. Using both qualitative and quantitative data, we evaluated the effectiveness of our outreach strategy in reaching this population and engaging them in AIDS-education and prevention activities. Project design and implementation are discussed, as are implications for the development of similar outreach efforts in other locations or with other populations. Project Overview The National AIDS Demonstration Research (NADR) Project, funded by the National Institute on Drug Abuse (NIDA) in 1987, currently supports more than 60 AIDS-prevention programs that involve aggressive outreach to IVDUs and others in a variety of noninstitutional settings. The implementation of a large-scale outreach project is a major undertaking. Costs are high due to the labor-intensive nature of the work; outreach workers face real dangers, particularly when working with drug users and others involved in illegal activities; and the prospects for success are unclear. In spite of these difficulties, street outreach is employed because face-to-face 40 interactions are believed to be more effective in communicating and establishing rapport with IVDUs and because this population generally lacks relationships with existing health and social- service providers. As one of the six original demonstration sites of the NADR Project, the Philadelphia Health Management Corporation (PHMC) has received funds from NIDA since October 1987 to conduct an outreach and education project in Philadelphia. PHMC’s IV/AIDS Community Outreach Demonstration Project attempts to reduce the spread of HIV infection and AIDS among IVDUs who are not in treatment, their sexual partners, and prostitutes. This emphasis on IVDUs who are not in treatment is important both because of the strong association of IV drug use with HIV transmission, and because as few as one-third of Philadelphia’s IVDUs are believed to pass through the treatment system during the course of a year (Philadelphia Department of Public Health 1989). While addicts in treatment may receive AIDS education in those settings, it is clear that risk-reduction behavior must be adopted by the much larger population of IVDUs who are not in treatment if the course of the AIDS epidemic is to be changed. Project goals include basic AIDS-prevention education; support services for people attempting to adopt risk-reduction behaviors; HIV-antibody testing services; and research on drug use, risk behavior, and behavioral change. The project employs nine community health outreach workers (CHOWs), who work in the most active drug-using and selling areas of a large, impoverished section of Philadelphia. CHOWs provide basic AIDS-prevention information to all community residents with whom they come in contact, and make special efforts to reach individuals suspected of being either IVDUs, sexual partners of IVDUs, or prostitutes. In addition to providing information, CHOWSs demonstrate specific techniques to reduce the risk of infection with and transmission of HIV. For example, bleach kits for the sterilization of needles and condoms for safer sex are distributed to encourage the adoption of less-risky drug- use and sexual practices. CHOW: refer their contacts to a field office for participation in an interview and for further services such as HIV testing and individual or group counseling. When requested to do so by their contacts, CHOWs also refer individuals to drug treatment and other health and social-service programs. Evaluation Questions Evaluation of PHMC’s outreach efforts has focused on several key questions relevant to public- health officials considering funding or implementing AIDS community outreach programs. These questions include: 1. How successful are the CHOWs in identifying those individuals at highest risk for HIV infection and transmission, given the illicit nature of drug use, the violence often associated with drugs, and the general distrust most addicts and prostitutes have for institutions and agencies? 2. How efficiently are the CHOWs able to identify these high-risk individuals—i.e., do they have to work with many low-risk individuals in order to identify a few high-risk ones? 41 3. How receptive are high-risk individuals to the CHOWS and to receiving condoms and bleach-sterilization kits? 4, How effective is the outreach strategy in recruiting high-risk individuals to participate in the project’s other services, such as individual and group counseling, HIV testing, and an interview? 5. What characteristics of the CHOWs and of the design of the outreach effort are most important in the implementation of such a project? Methodology and Data Collection Both qualitative and quantitative data were used in evaluating the project's outreach activities. Qualitative data were recorded in daily field notes kept by the CHOW: and in weekly summaries given to their supervisor. In addition, CHOW:s are periodically observed during their field work. Quantitative data are collected in the form of contact/screener cards, which the CHOW s use to document all contacts they make. A contact is defined as an interaction with anyone who is suspected to be an IVDU, a sexual partner of an IVDU, or a prostitute, in which there is sufficient interchange for the CHOW to determine whether the person does fall into one of these categories. Each contact represents at least a few minutes of face-to-face conversation with an individual. Data presented here are from a sample of 6,629 contacts made between May 1988 and April 1989. Because CHOWs and the individuals they work with move throughout the community, recorded contacts may include multiple interactions with the same individual. Based on data collected by the CHOWs, we estimate that at least 15% of CHOW contacts during this period are with individuals previously contacted. As the project continues in the same community, this proportion may increase. Evaluation of Outreach Efforts CHOWs have been extremely successful in identifying high-risk individuals on the street, in shooting galleries and crack houses, and in institutional settings such as shelters for the homeless. During their first 17 months in the community, CHOWs documented nearly 20,000 contacts, or an average of about 150 contacts per CHOW per month. Characteristics of the individuals contacted reveal that the CHOWS were able to interact with a wide variety of people, despite high levels of racial tension within the community, the reported reluctance of Hispanics to converse openly about sexuality issues such as AIDS and condom use, and the strained male-female relationships engendered by prostitution and sex-for-drugs exchanges. While CHOWs were more successful in interacting with men than with women, 29% of all contacts were with women. The racial distribution of contacts reflected the diversity of the community in which the CHOWs work: 57% were Black, 28% were Hispanic, and 14% were White. More than one-quarter (27%) of all contacts were with persons under age 25; 60% were with persons between the ages of 25 and 40; and 14% were with persons over age 40. Female contacts tended to be somewhat younger than male contacts, and Blacks tended to be 42 somewhat older than Hispanics or Whites. The overwhelming majority (86%) of all contacts reported being unemployed, a figure that reflects the project’s focus on reaching people on the street during the daytime. CHOWSs work normal weekday business hours and have conducted only limited outreach in factories or other places of employment. In addition, employed individuals may be reluctant to admit to drug use for fear of losing their jobs. Individuals who are working illegally may deny being employed. The educational level of contacts was generally low: more than one-third (37%) had not graduated from high school, and only 14% had more than a high school education. This has obvious implications for the design of written educational materials and messages. CHOW:s have been quite efficient in identifying high-risk individuals—overall, two-thirds of their contacts were with IVDUs or their sexual partners. Nine percent of their contacts were with women whom CHOW: identified as prostitutes, the majority of whom (61%) were drug users. A very high proportion of all CHOW contacts (80%) were drug users—54% had used IV drugs in the previous six months. Over half (58%) of those currently using drugs reported cocaine use and 36% reported heroin use. Drug users contacted by the CHOWs are not likely to receive education about AIDS and IV drug use in other settings; 89% of the drug users contacted reported that they had not been in treatment in the previous month. While many high-risk individuals choose not to interact with the CHOWs, those who do are usually quite receptive to the CHOWSs’ outreach efforts. All contacts over the age of 18 are offered condoms, and contacts identified as IVDUs are offered bleach kits for needle sterilization. Eighty-two percent of all contacts accepted condoms and 59% accepted bleach kits. With the exception of prostitutes, 90% of whom accepted condoms, women were slightly less likely to accept condoms than were men (74% vs. 84%). In the project’s group AIDS-education sessions, women frequently report being hesitant to suggest the use of condoms to their partners, for fear of being subjected to physical or psychological abuse. The project’s outreach model has worked well in recruiting high-risk individuals to participate in the project’s other AIDS-prevention activities. During the first 18 months of the project's operation, over 1,500 individuals referred by the CHOWs were interviewed in the project’s field office (about 50% of those referred actually present themselves for the interview) and, of these, close to 600 participated in a pre-test counseling session for HIV-antibody testing. In addition, over 125 individuals participated in group counseling and education sessions that emphasize behavioral change as a means to reduce the risks of HIV infection and transmission. Conclusions As the above data demonstrate, PHMC’s outreach efforts have been successful in reaching high- risk individuals and providing them with basic AIDS education. In addition to the quantifiable measures discussed here, an equally important measure of the project’s success has been the strong positive response from community residents and institutions. Over time, community residents have increasingly initiated contact with the CHOW: in order to obtain information on AIDS, referrals to service agencies, and other types of assistance. Residents have also provided CHOW:s with information and assistance in identifying and locating high-risk individuals. This community involvement is considered essential to the project’s long-term success. Further research is required, however, to determine the effect of these accomplishments on the course of 43 the AIDS epidemic in this population, as the relationship between education and behavioral change is by no means clear. Our experience demonstrates that a single outreach strategy will not work equally well with all groups. For example, PHMC’s CHOWs have had a much easier time identifying IVDUs and prostitutes on the street than they have had with the project’s third target group, the sexual partners of IVDUs. This is due to a variety of reasons, including psychological denial of risk behavior on the part of sexual partners and the fact that sexual partners may spend less time in public places such as street corners. While it has been easy for CHOWs to identify and approach prostitutes and to provide them with condoms, it has been far more difficult to involve this group in other activities such as counseling and HIV-antibody testing. Apparently, the financial and other incentives offered by the project cannot compete with the financial rewards of prostitution. In addition, the pimps of some prostitutes have been resistant to their participation in AIDS education. Although there is substantial evidence that many employed people use drugs, the project has tended to exclude them because of the hours of operation and consideration of safety and confidentiality issues. In spite of the project’s strict confidentiality protections, employed persons may shun involvement with the project because they fear public exposure of their drug use. Project staff are continuing to modify their outreach approach to accommodate the needs of each of these groups. Several important elements of our outreach efforts have contributed to their success. These include the following: Recruitment and Training of CHOWs CHOWs were largely recruited from the same community in which they work and were selected to form a team reflective of the racial and ethnic composition of that community. The project employs Black, White, and Hispanic CHOW: of both genders. Several are bilingual. CHOWSs work in male-female pairs, to allow their contacts to discuss sensitive sexuality issues with a CHOW of either gender. Initial Relationship Building with the Community The first few months of the project were devoted to establishing relationships with business owners, clergy, police, and others in the community, so as to explain the project’s goals and defuse potential hostility. The importance of this initial work should not be underestimated, given the current antidrug political climate and the potential for PHMC’s outreach to addicts to be mistaken for support of their lifestyles. Public-Health Orientation The project makes a clear distinction between public-health and social-work orientations towards working with drug users. CHOWs stress risk reduction rather than abstinence from drug use and only become involved in counseling or referring contacts to drug treatment and other services at the initiation of the individual. This approach has facilitated the CHOWS’ acceptance by both IVDUs and drug dealers, whose opposition to the project would certainly create enormous and dangerous obstacles for the CHOWSs, and has allowed the CHOWS to enter shooting galleries and other settings normally closed to social workers. 44 Distribution of Bleach and Condoms Distributing condoms and bleach kits for needle sterilization has been an important outreach tool. Many IVDUs are not familiar or comfortable with the use of condoms and do not know how to properly sterilize their needles. Dispensing these materials allows the CHOWs to enter into discussion of their proper use and the necessity for doing so. The distribution of free materials has also aided the CHOWs in gaining the acceptance and trust of this community. Lastly, because addicts’ lives become focused on the procurement and use of drugs, many addicts are reluctant to spend money on items such as bleach and condoms when their resources are scarce. Outreach workers play a critical role as distributors of these materials to individuals who may not purchase them but will use them if they are available. We believe that outreach efforts such as the Philadelphia IV/AIDS Community Outreach Demonstration Project represent an important strategy in the fight against AIDS. The models being developed by PHMC and other NIDA-funded projects could, moreover, be adapted to address other public-health problems affecting hard-to-reach populations. For example, PHMC is engaged in similar outreach efforts directed at involving pregnant IVDUs in prenatal care and at the prevention of sexually transmitted diseases (STDs) among teens. Replicating the successes of PHMC’s outreach project in other communities will require a full understanding of the strengths and limitations of an outreach strategy and an appreciation for specific local conditions. For example, in Philadelphia, security concerns have kept PHMC staff from working at night or in gang-controlled neighborhoods. Special efforts will be required to reach ethnic and cultural minorities, teenagers, and others, and to develop effective communication strategies. References Friedman, S.R.; Des Jarlais, D.C.; and Goldsmith, D.S. An overview of current AIDS prevention efforts aimed at intravenous drug users. J Drug Issues 19(1): 93-112, Winter 1989. Herz, E.J.; Olsen, L.M.; and Reis, J.S. Family planning for teens: Strategies for improving outreach and service delivery in public health settings. Public Health Rep 103(4): 422-430, July-August 1988. Neaigus, A.; Sufian, M.; Friedman, S.R.; Goldsmith, D.; and Stepherson, B. “Effects of outreach intervention on risk reduction among intravenous drug users.” Paper presented at the Annual Conference of the American Public Health Association, Chicago, Illinois, October 1989. Philadelphia Department of Public Health, Coordinating Office of Drug and Alcohol Abuse Programs. December 1989, personal communication. Williams, L.S. AIDS risk reduction: A community health education intervention for minority high risk group members. Health Educ Q 13(4): 407-421, Winter 1986. 45 Acknowledgments Supported by the National Institute on Drug Abuse Grant #DA04841. Authors Jon Liebman Brunilda Sepulveda—Irene Philadelphia Health Management Corporation 260 South Broad Street 20th Floor Philadelphia, PA 19102-3890 46 INDIGENOUS OUTREACH IN SAN JUAN: RESULTS OF A ONE-YEAR AIDS-EDUCATION EFFORT AMONG INTRAVENOUS DRUG USERS Alice Kroliczak Background and Significance According to the AIDS Surveillance Report produced by the Centers for Disease Control (CDC), Puerto Rico has one of the highest incidence of AIDS cases in all of the United States and its possessions. In fact, it is second only to that of Washington, D.C. To combat the spread of this disease, the Horizontes project began in March 1988, as an AIDS research and indigenous outreach intervention project in four target areas of San Juan, Puerto Rico. The project was funded by the National Institute on Drug Abuse (NIDA) and directed by KOBA Institute of Washington, D.C. Its goals were to provide AIDS education and outreach to intravenous drug users (IVDUs) not in treatment and at risk of contracting human immunodeficiency virus (HIV) infection, to gather information about HIV seroprevalence among the San Juan IVDU population not in treatment, to encourage this target population to modify their high-risk sexual and drug-use behaviors, and to measure the impact of an AIDS education and outreach effort among such a hard-to-reach population. The project lasted 18 months, ending its first year of outreach and research activities in San Juan in September 1989. Initial results of this effort are now available and are presented in this paper. Methods Horizontes is based on an ethnographic model developed in Chicago in the 1970s to stop the injected use of heroin. Four research sites (i.e., Northern, Northeast, Southeast, and Central Northern San Juan) (Figure 1) were selected based on the high volume of IVDU activity there. The target population was IVDUs not in treatment, most of whom had engaged in behaviors such as unsafe sex and the sharing of needles and works, behaviors that placed them at risk for HIV infection. Outreach workers, some of them ex-IVDUs, were hired to make inroads into the IVDU networks based on their own contacts there. Outreach workers made initial contacts on the street within the four research areas, using a snowball sampling technique. A network model was used whereby outreach workers used their own contacts among the target population to lead to additional contacts within the same population. They screened the contacts for participation in the study, using IV drug use within the last six months as the major criterion for admission. 47 Figure 1. Research Areas in San Juan Northern San Juan Southeast San Juan Old San Juan San Jose Project Puerta de Tierra Quintana Complex La Perla Barrio Relincho Enbalse I and II Manuel A. Berez Project Northeast San Juan Barrio Bitumul Llorens Torres Project (Residential) Central Northern San Juan La Playita Barrio Trastalleres Shanghi Barrio Santurce Villa Palneras II Condado Area Outreach workers gathered basic demographic information from the users at point of initial contact and gave them an overview of the project. Contacts were then offered the opportunity to participate in the study. Participation consisted of taking a one-hour AIDS Initial Assessment (AIA) interview, receiving condoms, bleach, and AIDS-education brochures, and attending AIDS-education sessions on how to change unsafe sexual and needle-sharing behaviors. The one-hour AIDS Follow-up Assessment (AFA) interview was scheduled for six months after the initial interview. Participants were also asked to submit to HIV testing at initial and follow-up interview time. Data collection started in early October 1988 and was completed at the end of August 1989. During this time, trained interviewers administered the AIA and AFA questionnaires to 371 Hispanic IVDUs who gave voluntary and informed consent for participation. Interviews were conducted at the site office in Puerta de Tierra, in parks or local settings within the research areas, and, particularly, at a garbage dump at Parada 19. Incentives of $15 were given to clients after both interviews. San Juan prison officials supported efforts to follow up on incarcerated clients, and nurses conducted HIV testing and pre- and post-test counseling at the CDT or health clinic in each of the four research areas. Outreach workers also collected ethnographic information in a daily log. In addition, an ethnographer observed the four outreach areas for two weeks and gathered information about the client population and drug activity in each of these areas. 48 Results Although only descriptive information is available from the data, it is obvious that the Horizontes project has made an impact on the IVDU community in San Juan. Outreach workers have distributed condoms, bleach, and AIDS-education brochures to 1,245 IVDU contacts during the duration of the project. The majority of contacts were Hispanic (99%), male (79%), and between 31 and 50 years of age (48%). Of these contacts, 371 IVDUs agreed to participate in the study. Outreach workers then met with them an average (mean) of two times for AIDS education and outreach. Outreach workers met with 20% of these clients at least once prior to their first interview appointment. For the remaining 80%, it was necessary to meet between two and five times before clients would appear for their initial interview (AIA). Pre-AIA appointments lasted an average of 38 minutes, while post-AIA AIDS education sessions on the street lasted an average of 33 minutes. Outreach workers met with their clients on the street an average of two times and had almost no phone contact with these same clients. Outreach workers did not meet with clients for pre- or post-HIV-test counseling sessions. The latter were conducted by nurses on staff at the city health clinics as part of Horizontes’s subcontracted services from the City of San Juan Health Department. Outreach workers generally met with clients in the Horizontes project office or in another location in the outreach neighborhoods, but rarely in a referral agency or in the client’s home. When outreach workers met with clients, clients were most often alone, but sometimes with friends. Demographic Characteristics of IV Drug Users Data on the the 371 IVDUs in the study are illustrated in Tables 1 and 2. The largest proportion were male (82%), Catholic (57%), and had not completed high school (73%). Figures 2 and 3 illustrate that the largest proportion of respondents was Hispanic (95%) and between 25 and 44 years of age (80%). HIV Test Background As illustrated in Table 3, only 36% of the study participants had an HIV test prior to their participation in the Horizontes project; all had been tested within the two years preceding the project. More than half of those who had been tested did not return to the test site for their test results. At the time of their initial interview (AIA), the majority of respondents (72%) thought they had some chance of developing AIDS. Results of HIV tests administered to 273 clients during the Horizontes project indicated that 56% tested positive for HIV. Only one client seroconverted during the course of the project. Intravenous Drug Use The mean age for first usage of drugs in this sample was 16.9 years, with half having used before the age of 16. Shooting drugs seemed to start at a later age, with the average age for first injection being 18.9 years. Fifty percent of the sample started shooting before they reached 18 years of age. While 98% had injected heroin by itself, and 96% cocaine by itself, 98% had been injecting “speedball,” a mixture of heroin and cocaine. 49 Table 1. Gender and Religion of IVDUs IN =1371) Characteristics N % Gender Male 305 82.0 Female 66 18.0 100.0 Religion Catholic 212 57.0 Protestant 69 19.0 None 90 24.0 100.0 Table 2. Education of IVDUs Level of Education N % Less than high school 270 73.0 Graduated or attended higher education institution 94 25.0 Graduated from college 7 2.0 Total 371 100.0 Table 3. HIV Testing and History of 371 IVDUs Testing/Serostatus N % Had an HIV test prior to this program 134 36.0 Tested within two years prior to Horizontes 134 36.0 Received HIV test results prior to Horizontes 63 17.0 Thought they had some chance of developing AIDS 267 72.0 50 Figure 2. Distribution of IVDUs by Race (N=371) P E R C E N T 3 1 1 SEER } ; i RACE Black White Other Figure 3. Age of IVDUs (N=371) 255 45-54 A G 35.44 E 25-34 a . Under 25 PERCENT 0 5 10 15 20 25 30 35 40 45 Figure 4 illustrates that the average frequency of injection seems to have dropped slightly between the time that the AIA was administered and the time of the AFA. No significant tests for differences were conducted. Among those who reported daily IV drug use, smaller proportions reported heroin, cocaine, speedballing, or polydrug use at the time of their follow-up interview (Figure 5). Risk-Taking Behaviors Sexual Activity Due to the frequency and intensity of IV drug use among the San Juan respondents at the time of their initial interview, almost half of the study’s respondents (46%) reported not having sex in the last six months. An even larger proportion (62%) reported no sexual activity at their follow- up interview (Table 4). Regardless of the number of sexual partners they had at the time of their initial interview, the majority of users reported not using condoms in the past six months (73% with single partners, and 45% with multiple partners) as found in Table 5. In addition, larger proportions of clients reported using condoms since becoming involved with Horizontes, compared with proportions reporting condom use prior to their participation in the project. Needle Cleaning and Sharing At the time of their initial interview, more than half (66%) of those injecting reported having shared needles within the last six months. A similar proportion (65%) reported such sharing at the time of their follow-up interview (Table 6). However, of those sharing needles, the proportion who reported always cleaning properly more than doubled at the time of the follow- up interview; there was a similar decline in the proportion of those reporting that they never cleaned needles properly (Table 6). Health Status If we examine the health status of the San Juan respondents, we find small proportions reporting previous diseases or health conditions related to unsafe sexual activity or IV drug use (Figure 6). The largest proportion (36%) reported having had gonorrhea and/or syphilis (15%) while similar proportions (29%) reported having had hepatitis and/or pneumonia (15%). Finally, the impact of the Horizontes outreach program can be seen upon examining the sources of AIDS information reported by the San Juan IVDUs. Respondents identified outreach workers and the Horizontes program as the most frequent sources of AIDS information, while they reported that drug-treatment programs, jail or prison, and their church were the least likely sources of such information (Table 7). 52 Table 4. IVDUs Having Sex in Last Six Months as Reported in AIA and AFA Interviews Interview N % AIA Yes 202 54.0 No 169 46.0 Total 371 100.0 AFA Yes 128 38.0 No 206 62.0 Total 334 100.0 Table 5. Condom Use by Number of Partners at AIA and AFA Single Partner Multiple Partners Frequency of AIA AFA AIA AFA Condom Use % (N) % (N) % (N) % (N) Never 73 (78) 62 (49) 45 (43) 29 (14) Half the time or less 7 9 17 (16) 18 (9) More than half the time 2 (2 4 (3) 16 (15) 27 (13) Always 18 (19) 25 (20) 23 (22) 27 (13) Total 100 (106) 100 (79) 100f (96) 1007 (49) Percents do not add to 100 due to rounding. 53 Table 6. Changes in Needle-Use Behaviors of IVDUs between AIA and AFA Interviews Needle-Use AIAf AFA¢ % Change Behaviors % N) % N) Do Not Share Needles 34 (125) 35 (118) 1* Share Needles 66 (246) 65 (216) -1* Never clean properly 42 (103) 12 (26) 30 * Sometimes clean properly 36 (88) 22 (48) -14 . Always clean properly 8 21) 20 (43) 12 Other 14 (34) 46 (99) 32 Total number of AIA respondents = 371. §Total number of AFA respondents = 334. *Percent change in desired direction. Table 7. Sources of AIDS Information Reported by IVDUs (expressed in percent) Source of AIA AFA Information % % Outreach Workers 97 100 Intervention Programs 96 100 Brochures, Fliers, etc. 86 97 On the Street/Word of Mouth 88 93 Billboards 77 93 Newspapers/magazines, etc. 77 92 Television 72 85 Radio 66 81 Relatives and Friends 79 79 Other Health Care Facilities 57 65 Places that Provide AIDS Counseling and Testing 70 54 Drug Treatment Programs 38 38 Church/Temple 13 19 Jail or Prison 30 15 54 Figure 4. Average (Mean) Frequency of Injection among San Juan IVDUs 4 times a day, AFA almost daily 2-3 times a day, almost daily (N=190) Once a day 2-6 times a week Once a month Less than 4 times a month None Heroin Cocaine Heroin & Cocaine 55 Figure 5. Intravenous Drugs Used Daily During the Pa Six Months as Reported by Daily Injectors on AIA (N=348) and AFA (N=236) Polydrug use (heroin and cocaine mixed; cocaine and/or heroin) Heroin alone Cocaine alone Heroin and cocaine mixed Amphetamines 1 1 1 - ye -y : a 1 I I I I 0 10 20 30 40 50 60 70 80 90 100 Percent 56 Figure 6. Previous Diseases Reported by IVDUs (AIA Interview Data Only) Gonorrhea Pneumonia Hepatitis Syphilis Tuberculosis Endocarditis Genital Herpes ARC AIDS 1 1 1 L L 1 I I I I 1 I I I 0 5 10 15 20 25 30 35 40 45 50 Percent 57 Discussion These preliminary results demonstrate the successful impact of using an outreach approach to IVDUs not in treatment in San Juan. After some initial skepticism regarding the role of Horizontes in the community, IVDUs were quite receptive to the project’s outreach staff and the AIDS-prevention education being offered. Although a substantial proportion of study participants tested positive for HIV, figures show a movement toward safer sex and needle- cleaning behaviors among users while participating in the project. Further analyses of potential behavior differences between seropositive and seronegative respondents and other subgroups of study participants will be forthcoming. Acknowledgment Supported by the National Institute on Drug Abuse Contract #271-88-8232. Author Alice Kroliczak, Ph.D. Principal Investigator KOBA Institute, Inc. 1156 15th Street, NW Suite 200 Washington, D.C. 20005 58 EVALUATING OUTREACH IN SAN FRANCISCO Eric Margolis Introduction San Francisco’s Youth Environment Study (YES)! was originally funded by the National Institute on Drug Abuse (NIDA) in 1981 to “. . . evaluate the utility of ethnographic research and neighborhood-based techniques in designing early intervention services for young drug users.” The objective was to demonstrate the effectiveness of ethnography as a tool for: (1) establishing rapport with and learning about natural communities of young drug users; (2) designing effective intervention strategies for young out-of-school, out-of-treatment drug users; (3) training indigenous outreach workers to provide street-based services to drug users; and (4) monitoring the effectiveness of the outreach effort on an ongoing basis. Thus, before it was known that AIDS posed a major threat to intravenous drug users (IVDUs), YES was developing a model combining street-based ethnography with community outreach workers to reach and change the behavior of “hidden” or “hard-to-reach” populations (Feldman et al. 1985). In 1986, YES received funding as one of NIDA’s National AIDS Demonstration Research (NADR) programs. During an intensive two-week training program, new employees are taught to deliver accurate educational messages about risk factors and prevention methods associated with human immunodeficiency virus (HIV) transmission. They also learn to identify the needs of their clients and to assist them in their encounters with social-service agencies. Community Health Outreach Workers (CHOWSs) work the streets, handing out condoms and one-ounce bottles of bleach; however, YES is not simply a bleach and condom distribution service. It is primarily a street-based health-education project aimed at changing behavior. Providing condoms and bleach is not as an end in itself but a means through which to establish positive relationships of reciprocity and good faith. The goal is to have the prophylaxis technology adopted by the subculture (Watters 1987). CHOW: are also trained and supervised in the collection of ethnographic information about the IVDU subcultures. Their position as participant-observers puts them in the ideal situation to gather information about drugs and use patterns, the location of needle scenes, the shifting locales of the sex trade, rapid influxes of homeless youth, and the other myriad bits of “news” that enable YES to ensure that no significant groups are omitted from outreach and research (Figure 1). 59 Figure 1. Formative Evaluation Service Delivery System = Staff Meetings Reinforcement ¥ CHOW | Project Director CHOW CHOW Reports Formative Ethnography Evaluation Participant Observation | ati 0 ethnography | Ethnographer Interim oe] (| Two levels of evaluation have been specified for the NADR programs: (1) ongoing ethnographic process evaluation; and (2) quantitative outcome studies. YES’s evaluation strategy is to apply the formative-summative approach developed in educational assessment research.2 The goal is to collect data allowing revisions to be made to the program as it develops. This is a particularly appropriate strategy because the outreach being undertaken to stem the AIDS epidemic is in fact an education system, a “classroom without walls,” with a curriculum, teachers and learners, and desired outcomes specified as behavioral changes. The formative-summative model utilizes continuous qualitative and quantitative data probes, with periodic feedback. The project approach to designing the formative evaluation research is primarily decision-utility based. The concern here is fourfold: 1. To develop evidence and benchmarks to observe the process and to collect data that will be maximally useful to program improvement. To inform the decision process at the sponsor and funding levels. To better understand issues relating to behavior change among individuals at high risk for HIV infection. 4. To discover the most useful methods to present evaluation findings to facilitate change of the project so as to improve learning and behavior change among those at risk for HIV infection. The general objectives of the evaluation research are: 1. To evaluate implementation and to determine if an intervention has in fact been delivered. 2. To describe the specific nature of the intervention. To evaluate the impact of the intervention on the targeted populations and, in some cases, on nontargeted populations. 4. To analyze the comparative effectiveness of two or more intervention strategies, or on populations with different characteristics. 5. To generate explanatory conceptual models that facilitate understanding of why a particular intervention works or does not work. Behind the YES model stands the concept that the way to stem the AIDS epidemic is to carefully track the disease’s spread, to identify groups at risk, and to thwart HIV transmission with targeted education efforts. Data provided by the CHOWs are used to “map” the epidemic and the outreach effort. As used here, the word map has three meanings: (1) quantitative and ethnographic investigations of the social worlds of San Francisco; (2) models and representations constructed to visualize both the epidemic and the outreach effort; and (3) the project’s concrete but fluid plan of attack. The first set of charts and maps uses data from the Centers for Disease Control and the San Francisco Department of Public Health to describe the epidemic in the United States and in San Francisco. 61 Figure 2 depicts San Francisco AIDS cases through August 31, 1989. Of the 7,102 AIDS cases in the city as of that date, 6,014 were gay men, 766 were gay male IVDUs, and 151 were heterosexual IVDUs.3 By October 31, 1989, the heterosexual IVDU caseload had risen to 161. It is this specific subpopulation of IVDUs, and their sexual partners, whose behavior YES and the MidCity Consortium to Combat AIDS are concerned with identifying and changing. Figure 3 compares heterosexual IVDUs by race for San Francisco and the United States as a whole. While AIDS has disproportionately invaded San Francisco’s minority communities, the racial and ethnic distribution is quite different from the national data. Among heterosexual IVDUs, San Francisco has a higher percentage of White cases and a much lower proportion of Latino cases than the United States as a whole. Curiously, the three cases reported in Figure 3 as “other ethnicity” in San Francisco are all female Filipinas, who, by some accounts, were prostitutes. Figure 4 is a map depicting IVDU AIDS cases by neighborhood. It indicates the geographic location and the magnitude of infection. The greatest concentration of cases is in the Tenderloin, followed by the Mission, and the Western Addition. YES administers the AIDS Initial Assessment (AIA), an hour-long questionnaire, to IVDUs and their sexual partners. The questionnaire, used by NADR programs nationwide, collects subjects’ addresses in order to perform a six-month follow-up interview. Figure 5 plots locator information given by the AIA subjects to provide another representation of where the target population can be found. Geographical data make it possible to pinpoint circles of users, which allows YES to deploy outreach workers more effectively. The Outreach Neighborhoods Many people mistakenly associate “indigenous” outreach workers with “ex-addicts.” This is not the case at YES/MidCity. The CHOWs represent a wide variety of backgrounds: some are ex- addicts, and some have master’s degrees in social work. There are men and women drawn from each of the ethnic groups being served. Some are gay, some are straight. Some are motivated by political concerns, some by religious convictions, but all share a deep sense of caring. The descriptions of the various neighborhoods and outreach styles that follow will try to convey the “goodness of fit” between successful CHOWs and the neighborhoods in which they operate. Eighteen community-health outreach workers are assigned to six neighborhoods with high incidence of IV drug use. Another team of three women works city-wide with the female sexual partners of IVDUs. Outreach workers provide weekly statistics on their activities and the demographic characteristics of the people they serve. These weekly reports indicate the age, race, and gender composition of the population served by the outreach. The next sections describe the target neighborhoods and subpopulations. The data reported here detail the outreach effort for the three-year period from June 1, 1986, to April 30, 1989. Relative numbers of client contacts in each of the outreach neighborhoods, including sexual partners, are presented in Figure 6. 62 Thousands Figure 2. Adult AIDS Cases in San Francisco 6.014 (Through August 31, 1989) 0.766 0.151 0.157 7.102 i 3 T T Gay/Bisexual Gay/Bisexual Heterosexual Other White Male IVDU IVDU Black © Latino Total Other Source. San Francisco Department of Public Health AIDS Report 8-31-89. Fourteen cases are not identified as to transmission route. 63 Figure 3. AIDS among Heterosexual IVDUs by Ethnicity (United States and San Francisco) United States* San Franciscot (N=17,999) (N=152) : Other 2% White 20% White 35% Latino 30% Latino 17% Black 46% Black 50% As of 3-30-89 As of 8-31-89 *Source. HIV/AIDS Surveillance Report, April 1989. tSource: San Francisco Department of Public Health, AIDS Report August 31, 1989. Figure 4. [VDU AIDS CASES 65 Figure 5. m AJA SUBJECTS 1988 — 1989 66 Figure 6. Total Client Contacts 0, Sexual Partners 9% Western Addition 18% Inner Mission 5% Haight Ashbury 3% South of Market 7% Polk Street 28% Tenderloin 30% 67 The Western Addition The Western Addition (Figure 7) has a reputation as a tough neighborhood, but it is a far cry from the mean streets of some Eastern cities or the gang-ridden ghetto of Watts in Los Angeles. It has retained a socioeconomic mix as a working- to middle-class Black neighborhood, with a healthy infrastructure and active community organizations. Housing ranges from single-family homes to rooming houses and low-income public-housing projects. Some of the projects are “livable,” but one 11-story housing project stands empty and in ruins. Whites have always lived in the Western Addition, but a few years ago “yuppies” began moving in, attracted by reasonable real-estate prices and classic Victorian homes to renovate. High-rise condominiums and shopping centers herald a period of gentrification. There appears to have been a substantial decline in the Black population during the 1980s. Drug use is not uncommon in the Western Addition. During the 1920s, F.V. “Wiggy” Williams, ace reporter for the San Francisco Daily News, lived for a time with White IVDUs in a “coke den” run by Dawson Sue on Gough Street. He reported extensive IV cocaine and morphine use, as well as the mixture of the two called “speedball.” Wiggy estimated that San Francisco had between 15,000 and 20,000 drug addicts, and that the population “embraces all classes and conditions and takes in many men and women who are working and at the same time secretly using morphine” (Aldrich 1988). Williams’s analysis is as true today as it was during the “roaring 20s.” Prior to World War II, the Western Addition had both Jewish and Japanese communities, but when the Japanese were transported to relocation camps, the neighborhood underwent a transition. African American immigrants from the South and elsewhere moved to San Francisco to work in the shipyards and defense industries. During and after the War, the Western Addition became a center of Black culture, famous for jazz clubs and soul-food restaurants. Heroin and cocaine continued to be available, but their use was confined to bohemian artists and entertainers. Drugs were not deemed a major social problem. During the 1960s, the Fillmore Auditorium attracted a “mixed” crowd of hippies and local Blacks. Drugs as well as music facilitated culture contact. Black IVDUs introduced heroin and cocaine to hippies and, in turn, were introduced to speed and psychedelics. Today, IV drug use continues, but as is true for the rest of America, the smokable form of cocaine (“crack”) has dramatically changed the situation. The Western Addition—in fact San Francisco in general—has had only a few incidents of gang warfare. Occasional shootings make headlines, but do not compare to the problems reported in Los Angeles. Nonetheless, individual murders, drive-by shootings, cocaine-addicted babies, “toss-ups,”S and the like have been reported in the Western Addition. YES/MidCity has been working in the Western Addition for two years. As of April 1989, there were two CHOWs on the street: one man and one woman. One outreach position has turned over frequently, but the male CHOW was born and raised in the neighborhood and has been with the program since its inception. Although he is a practicing Muslim who has never used drugs or alcohol, a professional, nonjudgmental demeanor comes easily to this man. He is intimately familiar with the community, and his street reputation is of a hard-working family man. His goal is “to educate IV drug users, their sexual partners and anybody else within the Street scene how not to get HIV infection. My approach has been intensive one-on-one contact 68 and then following up on clients’ specific requests for drug, health, housing, public assistance, jobs, and anything else legal.” The Western Addition CHOWs have the agency’s highest proportion of referrals to drug-detoxification programs. The Western Addition, with only 18% of the project’s total client contacts, accounted for about one-third of all treatment referrals. Western Addition CHOWSs serve what some call “righteous dope fiends,” an older population of Black, male, career addicts (Figure 8). According to the CHOW reports, 89% of Western Addition clients are Black, 75% are male, and 71% are over 29 years old. Polk Gulch Polk Gulch, the area defined by Polk and Larkin Streets, is contiguous with the Tenderloin. Distinguished from the Tenderloin because it is a neighborhood frequented by runaway, castaway, and homeless youth, Polk Gulch is perhaps more a state of mind than a physical location. It is well known as a center for adolescent prostitution and drug scenes. Many of the youth found in this area have a history of physical or sexual abuse by family members. While a few are gay-identified, the population is characterized by sexual experimentation and shifting sexual identities. Stable relationships are uncommon. Some heterosexually-identified men engage in sex for money with older men. Recently, youths from the Polk Gulch area attracted media attention in conjunction with a sex scandal involving city officials. As with other prostitute populations, needle use is common. These factors conspire to create a hospitable environment for the transmission of HIV. The Larkin Street Youth Center and the Diamond Street Youth Shelter provide services specifically to this population. The Larkin Street Center offers counseling services and a day room where youth under 18 can find respite from the streets. In Polk Gulch, 63% of the clients are under 18, and 82% are under 20 (Figure 9). The population is almost evenly divided between men and women. The majority of the youth are White, although Blacks and Latinos constitute sizeable minorities. In May 1988, when the NADR project began, YES had two experienced CHOWs working Polk Street: one White, openly gay man, and one “straight” woman. The female CHOW is White, British, likes punk rock, and sometimes dyes her hair pink. She is “thirty-something” but hip enough to establish rapport with the kids. The male CHOW worked at the Larkin Street Youth Center for more than a year. When he resigned, two new CHOWs were hired: one White female and one Latino male. Polk Gulch CHOWs reported more than one-quarter (28%) of all YES/MidCity client contacts; during these encounters about 45,445 condoms and 32,978 bottles of bleach were distributed. (Unless otherwise noted, all YES/MidCity totals are for the period from June 1986 to April 30, 1989.) The Tenderloin In the nineteenth century, the word “Tenderloin” was coined to describe lower Manhattan west of Broadway, an area known for prostitution, crime, and police graft. The name came to characterize any similar district and, since the 1880s, a section of San Francisco’s downtown has been known as the Tenderloin (TL). Bordered by prestigious Nob Hill and the Financial District to the northeast and the Civic Center to the southwest, three streets—Eddy, Turk, and Ellis—form the central corridor of a district (Figure 10) that has a population of 35,000 to 69 40,000 people, many of them homeless. The TL has one of the highest crime rates in the city. It also has the highest incidence of heterosexual IVDU AIDS cases—24 cases as of March 31, 1989. The cases break down as follows: three White males, eight White females, seven Black males, four Latino males, and two Filipina females. The TL is unique because of its community awareness and organization. In the original (1984- 85) ethnographic studies from which the outreach model was developed, denizens of the Tenderloin provided self-report information on needle-sharing behavior and welcomed participant observers. CHOWSs working for YES and MidCity have worked the Tenderloin streets since 1986, and today the TL consumes the largest proportion of the YES/MidCity outreach effort (30%). There are a number of other community organizations working on issues of drugs, homelessness, and AIDS. YES was one of the founding agencies in the Tenderloin AIDS Network (TAN), a community umbrella group formed to coordinate social services. In a neighborhood needs assessment completed in March 1988, TAN estimated that the Tenderloin population included 200 transsexuals and transvestites, many of whom shared needles to use IV stimulants or black-market hormones. As the center of the city’s sex trade, the TL includes large numbers of male, female, transvestite, and transsexual sex workers. While there is some gay male prostitution, most prostitution is heterosexual. Prostitutes typically work the streets, although there is a substantial sex trade operating out of massage parlors. Drug users gather on street corners and in Boedekker Park. The single room occupancy (SRO) hotels that line Eddy Street are well-known copping areas and the daily resting place for numerous users of IV heroin and cocaine. TAN counted approximately 800 “hard-core” heroin addicts and an unknown number of cocaine and amphetamine users. They observed that the drug subculture also encompassed a number of female sexual partners of IVDUs. TAN noted about 400 female prostitutes, about half of whom used IV drugs (Foster and Frank 1988). The Tenderloin is not just an underworld. A door-to-door survey by the Bay Area Woman’s Resource Center (1987) estimated that the number of children under 19 living in the Tenderloin had doubled between 1980 and 1985. Single parents of all ethnic backgrounds are attracted by reasonable rents. Black, White, Asian, and Latino families with children occupy the single- room flats. Forty percent of the Bay Area population is Asian; many Southeast Asian refugees live in the TL. The Asian communities are family- and small-business oriented. Grocery stores, restaurants, and cleaners are successfully competing for space with bars and pornography shops. Much of this transition has occurred since the 1980 Census. The demographics of the four Tenderloin CHOWSs roughly reflect the population being served. The supervisor is a Black male, an ex-addict who has lived in the TL for years. A White, openly lesbian female is assigned to the residential hotels. In one six-story SRO hotel, most of the tenants are HIV-antibody-positive, and 25% have been diagnosed with AIDS. CHOW visit six or seven other hotels on a regular basis. Another CHOW is a New York-born Puerto Rican male. He makes daily deliveries of bleach, condoms, and information to at least 50 establishments, including hotels, poolrooms, markets, and prostitutes’ hangouts. He has a “straight-up” street reputation and has developed a large “caseload” of IVDU, including Cuban immigrants. Formerly employed by the parole department, he is sometimes able to intercede with the criminal-justice system by getting clients assigned to work-furlough programs. 70 YES recently hired an Asian American woman, a lesbian, to provide services to the Asian/Pacific Islander population. She began working city-wide, visiting places where Asians gather— grocery stores, barber shops, and senior centers—to develop contacts with a varied population that includes Vietnamese, Cambodians, Laotians, Chinese, Filipinos, and Pacific Islanders. Eventually, she began to provide Asian-owned massage parlors with condoms and bleach. The other team member is a Black female who carries on a continuing dialogue with many of the prostitutes, “toss-ups,” transvestites, and transsexuals in the TL. Her job includes making referrals to HIV test sites, conducting support groups for prostitutes who want to leave the business, and obtaining referrals for those seeking respite from the streets. hy of the Tenderloin MidCity clients in the Tenderloin are generally “marginal” people who have lived on the fringe for most of their lives (Figure 11). Included are IVDUs, alcoholics, gay and heterosexual hustlers and prostitutes, drag queens, pre- and post-op transsexuals, transvestites, and many with serious psychological problems who have been “deinstitutionalized” to the streets. They pass in and out of institutions, ranging from prison to detoxification programs. Some are homeless, living on the streets or in the SRO hotels that force people to move every 30 days, lest they establish claims to residency. Most of the TL clients are in their 30s and 40s. Almost 80% of the reported contacts are Black and about 15% are White. CHOW:s reach a tiny but important number of Native Americans, many of whom are homeless, use drugs, or have substantial risk factors related to sex and alcohol. During the three-year period covered in this report, the Tenderloin team recorded nearly 24,000 client contacts and distributed more than 48,000 bleach bottles and almost 100,000 condoms. South of Market Market Street is an imaginary line separating the Tenderloin from the area called South of Market. Both districts are mixed residential and commercial areas, with concentrations of porno movies, sex shops, massage parlors, and bars. Many of the clients drift back and forth across Market Street. The South of Market area is less densely populated, a sprawling area of warehouses, SRO hotels, sex clubs, bars, and discos that attracts large numbers of rootless, transient, and homeless people. The bus terminal is here. Because of the lack of personnel to adequately cover this huge area that stretches down to the waterfront, YES’s outreach in the South of Market district has been limited, with the Tenderloin teams serving the area only occasionally. In the CHOW reports, a much higher percentage of White clients are reported South of Market than in the Tenderloin, but Blacks and a few Latinos are also represented. More than 80% of the targeted population are adults between 21 and 39 years old (Figure 12). 71 Figure 7. WESTERN ADDITION Sse Plaet WM USER CIRCLES NC SEO J 2 J OO PROSTITUTE STROLL Peon eas oa Ae eee c= i —- er Thee =r Sec Hi 2 ma oer ST Vn Sn ST == re EEE eS EE 1 SOE rem 2 == C= FEAL 0 ata AOL == un Sree SI Ea c Eee es = Be (ud! = LL TIE ECP IC ate fae ! "HAYES ST A SE AEE DEE Lear eo ea Loses HAIGHT ST WEEE wa = 7 72 Figure 8. The Western Addition—June 1986—April 1989 Percent RR <18 18-20 21-29 30-39 40-49 Over50 Age 100, 60 Percent 5g] 1 <1 «<1 Black White Latino Asian Other Ethnicity/Race 73 Figure 9. Polk Gulch—June 1986-April 1989 100 , Percent 0 h tT T \z al Under 18 18-20 21-29 30-39 40-49 Over 50 Age 70 - 62 Percent 60 A fs Black White Latino Asian Other Ethnicity/Race 74 th AALAND Sse neat — LEA thst YRS! POSTS eh 0 FARRELL STN L == THEN ST ARUH Ss? Se DORON TURK Sle Lips SE i TT TC ALLISTER ST 0) . % 7 Mx al 0 [oe] = = = - cD “ eR RNY 75 Figure 11. Tenderloin—June 1986-April 1989 100 - Percent 38888388 10 4 <1 2 <18 18-20 21-29 30-39 40-49 Over 50 Age Percent 4 2 1 Black White Latino Aslan Other Ethnicity/Race 76 Figure 12. South of Market—June 1986-April 1989 100 4 90 4 80 - 70 + Percent 60 4 50 - 40 - 30 - 20 - 10 - <1 100, 90 | 80 | 70 | 60 | Percent 50 | 40 | 30 | 20 J 10. <1 <18 18-20 21-29 30-39 40-49 Over50 Black Age 70 White Latino Aslan Other Ethnicity/Race 77 Haight Ashbury Haight Street is the main corridor in the Haight Ashbury district (Figure 13); this district stretches from Golden Gate Park down toward Divisadero Street, where it merges with the Western Addition. On the north, the Haight includes the Panhandle, a narrow tongue of grass thrusting out from the park. It is a colorful neighborhood that began to develop in the early *60s as a community of disaffected White youth. Golden Gate Park has always given the district its personality. In the 60s, the open spaces were perfect for free rock concerts, but the park is less enchanting today. It is the bedroom for many homeless persons; others sleep in cars, vans, and campers parked along the Panhandle. Summer and fall are the busiest seasons, but some residents have lived in the park for years, keeping semipermanent residences hidden within the bushes. Golden Gate Park can be a violent place to live; rape is commonly reported, and three murders occurred during an eight-month period in 1989. In the evenings, people pool their resources to buy dinner and cook over an open fire. They chip in to buy liquor, sit in circles passing the bottle, and tell stories, sing songs, fight, and bicker. Alcohol is the primary drug, but most are willing to use other drugs when they become available, including LSD, crack, cocaine, and marijuana. IV drug use is less common, although heroin and speed are easily available in the area. Two Haight Street clients are heroin addicts, both with severe addictions. One male suffers chronic opiate addiction and spends much of the time in drug-induced psychosis. The other, a female, is a late-stage heroin addict and has been near death for much of the year. Sexual activity between Haight clients is the main risk factor for HIV transmission. Alcohol and drugs are a disinhibition factor, making condom use problematic. One of the community self-help agencies started during the “Summer of Love” still dispenses vital medical services to the neighborhood. The Haight Ashbury Free Medical Clinic is one of the founding agencies of the MidCity Consortium to Combat AIDS, and operates a detoxification clinic as well as providing a variety of other services. During 1986 and 1987, one White male CHOW served the Haight in addition to several other districts. With the advent of the NADR project, YES hired a gay White female working on her master’s degree in social work. She was deployed at the Haight Ashbury Free Clinic to identify and cultivate rapport with the target population. For over a year she contacted clients in the park and on the street. According to her reports, about one-third of clients in the Haight were female. The age distribution of Haight clients was quite even. Roughly one-quarter were under 21, another quarter between 21 and 29, and another quarter between 30 and 39 (Figure 14). The rest were 40 and over. Blacks, Whites, and Latinos were represented, but the average client was a White male, usually a mid-stage alcoholic, in poor health. Many had family elsewhere, but some did not. Some were mentally disordered. There were far more drinkers than needle users in the Haight, and after a year, the CHOW recommended that MidCity terminate services to the Haight. She explained: “In an ideal situation with unlimited resources, I would recommend we continue CHOW services to the Haight Ashbury. However, the concentration of IV drug users is far greater in other areas of the city. In this time of constrained resources and cutbacks, I believe our energy may be better used in other areas.” YES made the decision to drop the Haight as a target area in order to redeploy scarce resources where they could be more effective. 78 Figure 13. | mE INHARNDL = THALIGHT THWALLER ST ATT HAIGHT ASHBURY — =) m BLEACH DEPOTS Co 79 Figure 14. Haight Ashbury—June 1986—April 1989 dh 058858838288 Percent <18 18-20 21-20 30-39 40-49 Over 50 Age 100, Percent 50 20 4 10; Black White Latino Asian Other Ethnicity/Race 80 The Mission The Mission (Figure 15) is the center of the Spanish-speaking community. Since World War II, the community has been primarily Mexicano and Chicano. But recently, the Mission has received a tremendous influx of refugees from Central America, Cuba, the Philippines, and other Pacific Islands. Today, the Mission is a multicultural, multiethnic community with significant populations of Blacks and Whites as well as Latinos. As of August 31, 1989, there were 598 Latino AIDS cases in San Francisco: 500 gay or bisexual males, 53 gay or bisexual male IVDUs, and 25 heterosexual IVDUs; 8 of the Latino AIDS cases were female (San Francisco Department of Public Health 1989). In 1987, a survey of AIDS risk was undertaken in the city’s Latino communities. Four hundred and four persons were randomly selected and interviewed. A great majority, 92%, chose to conduct the interview in Spanish. Five percent of those interviewed reported having had a sex partner in the past year who could be defined as “high risk.” Two percent reported that they had engaged in unsafe IV drug use, while 13% had engaged in either unsafe needle or unsafe sexual behavior (Fairbank, Bregman, & Maullin, Inc. 1987). An experienced CHOW supervises the Mission team, which currently has two other CHOWs, both Chicano males. The supervisor is an ex-addict who completed a Ph.D. program in sociology but never finished his dissertation. He did much of the initial ethnography of needle sharing that resulted in the design of the outreach model (Feldman and Biernacki 1988). Having lived most of his life in the Mission, he knows everyone, is considered an opinion-leader, and spends most of his time strolling the corridor with his bag of bleach and condoms. People stop to visit, exchange street news about who has been busted, where the police surveillance is concentrated, and who is sick. Working the conversation around to safe sex and clean needles, he reminds folks of the need to be careful and makes sure they leave with a bottle of bleach and a condom or two. Sensitive to the needs of “weekend warriors” (casual or intermittent users, many of whom work at regular jobs during the week) and others seeking anonymity, he hands bottles of bleach with the same surreptitious elan that a dealer uses to pass a bag of dope. Demography of the Mission (Figure 16) Almost half (47.79%) of client contacts in the Mission are Latino, but CHOWSs also serve significant numbers of Blacks and Whites. Substance-use patterns range from heavy drinking, marijuana, PCP, amphetamines, psychedelics, and barbiturates, to serious addictions of heroin, powdered cocaine, and crack. Because of the variety and access to different drugs, there are also large numbers of casual users or “weekend warriors,” who manage their drug use and have not fallen into the pattern of career addicts who orient their lives around drugs. About two-thirds of the clients are male. While there are many female IVDUs and sexual partners, they do not take part in what is primarily a male-dominated street scene. As with the Western Addition, the majority of Mission clients are older career addicts, veteranos in Spanish. Ninety percent are over 20, and a surprising number are over 50 years of age. 81 Figure 15. PEER ASK su=ull [] A No 5 po ST I Leet Tein = 1 ELLA ETT BES rani EE et i ’ 7 [3H = = oon J A A TTT TT =p TECHN CJ INNER MISSION Marr pC Ce a Dik m USER CIRCLES Jee J) oe common IA orhes oo a — HARRISON ST Em yr st B 82 Figure 16. The Inner Mission—June 1986-April 1989 Percent 00 90 80 70 60 | Percent 50 40 | 30 20 10 0 Black aa RRR 18-20 21-29 30-39 40-49 Over 50 Age Other White Latino Asian Ethnicity/Race 83 The social groups accessed in the Mission are a succession of discrete circles of users identified by particular geographic locations. Street-comer societies reflect a community of shared norms and values (Whyte 1955). They serve as a place where people establish a semblance of family ties through strong personal connections with friends. One can readily see this in the mutual aid that “homeboys” provide each other: helping one another by looking out for the “narcs,” sharing food, helping pay the rent for others who are not working and, finally, recommending each other for jobs that may come up. The Mission scene includes a variety of user groups that have little contact with one another. For example, there is a group of young illegal Mexican immigrants living in cheap hotels, with as many as five to ten persons in a single room. They use both cocaine and heroin. Another circle includes refugees from Central America. Roughly the same age as the Mexicans, they have also recently arrived in this country, but there is not much contact between the two circles. Still another corner is the center for a mixed circle of Latinos in their 20s or early 30s. The group includes both second-generation “dudes” from Puerto Rico and local Chicanos. An important role is played by the Mission’s Black IVDU population. They have lived in the area a long time, are well known by the Latinos and Whites, and are accepted as “regulars.” The “regular” Blacks in the Mission act as a buffer, facilitating deals for Blacks from other areas. A circle of older White IVDUs in the area are also part of the regular scene, and perform a similar function for outsider Whites. Most of them deal for the Latinos, acting as go-betweens for outsiders. Valencia Gardens, a public-housing project, is one of the main cocaine outlets in the area. Drug traffic is controlled largely by Blacks, ranging in age from 14-year-old “scouts” to 40-year-old dealers. Dealers sell powdered cocaine and “crack rocks,” drawing a constant stream of customers from early morning until late at night. The youngsters operate so openly that Valencia Gardens attracts considerable police activity. Furthermore, increased competition and bad deals have resulted in a couple of murders and drive-by shootings that have been luridly reported in the press. Mission Street between 16th and 20th Streets is one of the major “copping” centers in San Francisco. There are donut shops and cafeterias where drug users hang out; nearby, small shooting galleries accommodate local users. Outsiders who come to buy drugs generally retire from the area to use. The drug of choice is heroin, and traffic is controlled by older Chicanos or Mexican immigrants, most of whom are themselves addicts. The Sexual Partners Unit The Female Sexual Partners Unit was initiated in February 1988—a time when the rate of seroconversion for sexual partners of IVDUs was estimated to exceed that of IVDUs themselves. In April 1989, the unit consisted of a full-time program coordinator with a master’s degree in social work and four outreach workers, referred to as the SPIRITs. The at-risk population of female sexual partners of IVDUs comprises low-income African American women and Latinas. The Sexual Partners Integrity and Resource Intervention Team (SPIRITs) were recruited from the community with which they would be working. Three of the women are African Americans and one is a Latina; one is lesbian. All of the SPIRITs have personal histories working or living in the communities they serve. The unit works closely together, utilizing a team approach in its activities. This team’s approach differs from that of most of the 84 other CHOWSs, who are assigned a particular area and work individually in their outreach efforts. Furthermore, the SPIRITS are the only all-female unit in the agency. The SPIRITS explored specific methods for locating female sexual partners and began to develop the types of educational programs that might reach women who were sexually involved with IVDUs. Possessing professional and personal expertise in street and ethnic-community outreach, the women on the SPIRIT team looked for ways to translate the basic goals of providing AIDS education and the technology of prevention into specific patterns of outreach to women. The SPIRITS generally serve three neighborhoods: the Tenderloin, Western Addition, and the Mission. Areas served also include prostitute “strolls.” Two established programs that had experience working with women sexual partners, the California Prostitute Education Program (CALPEP) and the Association for Women’s AIDS Research and Education (Project AWARE), shared intervention techniques and assisted the SPIRITS in developing an outreach model. Drawing on the strengths of the YES street-based outreach model, the SPIRITs began to ethnographically map the target population. They explored the areas in which IVDUs lived. They talked to people on the streets and in the hotels and public-housing projects, searching for families, particularly for wives and lovers, of IVDUs. They analyzed the various age and ethnic groups and investigated their activities. The goals of the ethnography were to identify and locate women, so as to determine the best way to access the population. Female sexual partners of IVDUs do not congregate on street corners, and female drug users who may hit the street to “cop” generally do not hang out. Female sexual partners are usually either employed or spend much of their time in their homes caring for children. Because of the structure of social norms and government programs like AFDC and welfare, poor women are made responsible for the home and housing. They take responsibility for the family, which involves coping with the daily problems of the underclass—paying the rent, clothing their children, buying food, standing in line for health care—the list goes on. Based on the insight they were developing into the lifestyles of women involved with IVDUs, the SPIRIT team incorporated a strong sense of women’s culture into their outreach (Romero 1990). Outreach was shaped around an understanding of the lifestyle and needs of women, rather than the more narrowly defined target groups of IVDUs or sexual partners. The SPIRITs built bonds of trust with the women by serving as advocates to help them gain public assistance. The SPIRITS listened closely to the needs of their clientele, which included food, housing, clothing, and health care. Then they began to assist the women in contacting agencies; they walked them through the health-care system. The difference between the SPIRITS’ clients and those of other CHOW: is that most of the people served by the SPIRITS are supporting children; hence, their social-service needs are more complicated and time consuming. More intensive interactions take place: for example, two clients had children who died, and this involved the SPIRITS in long-term, emotionally difficult relationships. In order to create an environment to discuss AIDS, the SPIRITs had to help out with the women’s current crises. They also conceived strategies that place AIDS education within a more appropriately female context. SPIRITs obtained a hotel room in the Mission and set it up as a safe haven for women to come and discuss issues related to AIDS, sex, and drugs—issues perhaps discussed by men in their corner societies, but not commonly discussed by women on 85 the streets. Called “A Room of Her Own,” it has become one of the most successful of YES’s programs. The hotel room accomplished more than simply reaching the target population; it created a female-dominated space in which an atmosphere of trust was created. The space could then be used to educate, counsel, and serve female sexual partners. “A Room of Her Own” draws on women’s culture, and in the process assists women in making changes in their relationships with their sexual partners. The concept of women’s culture has recently appeared in studies that explore the coping and resistance strategies used by women in the community. By creating “A Room of Her Own,” the SPIRIT team reproduced women’s culture to create an environment that not only attracts the population they wish to address, but also produces an ideal setting for empowering women to change sexual practices. The SPIRIT team’s approach to reaching the sexual partners of IVDUs is based on “indigenous” knowledge about women’s culture and its use to reach a previously invisible and ignored population. Demography of the SPIRITS (Figure 17) The SPIRIT team has been active since June 1988. During that time, over 80% of the clients were females between 21 and 39. Most of the clients are Black women, but Latinas and Whites also visit “A Room of Her Own.” Client Contact by Area (Figure 18) Client contacts are plotted geographically. The Tenderloin, Polk Gulch, and the Western Addition account for most of the contacts, and this is where the disease is spreading among IVDUs. Differences in frequency reflect the number of CHOWS on the team and, in some cases, differences in style. Some CHOWSs spend most of their time on the streets; thus, they report a higher number of contacts. Others concentrate more on one-to-one case management. Their overall number of contacts is lower. Total Bleach (Figure 19) One way of assessing outreach is to analyze the nature of the services provided. YES outreach workers have distributed more than 150,000 bottles of bleach since June of 1986. Bleach Depots (Figure 20) “Bleach depots” can be bars, liquor stores, hotel lobbies, sex shops, or even abandoned cars and parks where CHOWs leave bleach and condoms. This is one way of ensuring coverage even when CHOWs are not on the street. Total Condoms (Figure 21) In the three year period, more than 285,000 condoms have been distributed by the CHOWs. It is hard to imagine a pile of almost 100,000 condoms, but that is approximately how many have been distributed in the Tenderloin area alone. 86 Figure 17. Demographic Characteristics of Sexual Partners June 1988-April 1989 100 - 90 - Percent 70 4 <18 18-20 21-29 30-39 40-49 Age 62 Percent NEBZE2IBSS RR Black White Latino Asian Other Ethnicity/Race 87 Figure 18. TOTAL CLIENT CONTACTS YES/MIDCITY JUNE 1986 — APRIL 1989 ETT 22300 to 25000 28500 to 22200 13500 to 20400 5100 to 13400 3900 to 5000 2200 to 3800 88 Figure 19. TOTAL BLEACH DISTRIBUTED YES/MIDCITY JUNE 1986 — APRIL 1989 B | 45200 to 54000 312008 to 45100 28900 to 31100 23708 to 28800 18300 to 23600 17100 to 18200 89 Figure 20. m BLEACH DEPOTS Y1S/ MIDCITY be ad TERS Figure 21. YES/MIDCITY TOTAL CONDOMS DISTRIBUTED JUNE 1986 — APRIL 1989 933060 to 395004 48300 to 93204 Ed 41500 to 48804 3 28100 to 41404 22800 to 28000 Oc 13800 to 22700 91 Referrals to Treatment (Figure 22) More than 1,800 referrals to drug-treatment or detoxification programs have been made by CHOW: since the project began. If the “guesstimate” of 16,000 IVDUs in the city is correct, then CHOWs have helped 11% find their way to treatment (Newmeyer 1988). Outcome Measures Comparing the demographics of the client population, as reported by the CHOWs and by the AIDS Initial Assessment (AIA) questionnaire used in the outcome evaluation, suggests that the sample taking the AIA reflects the population accessed by the outreach workers. Responses to the questionnaire provide vital information that can be fed back to the outreach workers and used to modify their educational message. Sexual Behavior (Figure 23) San Francisco’s 1988 AIA sample was 28% female and 72% male. Forty percent of sexually active respondents reported having only a single sexual partner during the previous six months. Based on their self-reported sexual behavior (and not on a self-identification as to sexual orientation), roughly three-quarters of those interviewed were heterosexual; 9% of the males, and 3% of the females reported exclusive homosexual behavior. An additional 12-15% were sexually inactive. Only about 3% of the males reported bisexual behavior; this is important since some studies have postulated the importance of the bisexual transmission route, connecting the gay community with IVDUs (Battjes et al. 1989). Risk Factors (Figure 24) In the initial analysis of the data, we were specifically interested in the extent of compliance with the twin protocols of bleach and latex protection. An examination of risky behavior whereby HIV could be transmitted, revealed that unprotected sex with an IVDU was reported by more than twice as many respondents as was unsafe needle use. Unprotected Sex Acts (Figure 25) Perhaps the most unhappy statistic, given the almost 100,000 condoms distributed each year by MidCity CHOWs, is that 60% of the sexually active AIA respondents reported never using a condom during the preceding six months. This is an improvement over previous studies, but even so, it indicates a transmission route and a critical area for CHOW: to target in their educational efforts. Clearly, the most common unprotected sex act members of our sample engaged in was penile-vaginal or vaginal-penile intercourse. This was followed by penile-oral or oral-penile sex. Among both heterosexuals and those reporting homosexual contacts, about one-fifth (18%) engaged in receptive anal intercourse and about one-quarter (26%) reported being an insertive partner in anal intercourse, acts which are thought to be particularly risky for HIV transmission. 92 Figure 22. DRUG TREATMENT REFERRALS YES/MIDCITY JUNE 1986 — APRIL 1989 N LE 680 to 650 370 to S80 260 to 360 240 to 250 S80 to 230 40 to 88 93 Figure 23. Sexual Behavior of Respondents Reporting a Single Partner Transsexual 1% Bisexual 8% Lesbian 3% Inactive 12% Heterosexual 76% Females 234 (28%) (N=837) Bisexual 3% Gay 9% Inactive 15% Heterosexual 73% 94 Figure 24. Risk Factors of 837 AIA Respondents Number of Respondents 600 100 Sex with Share Dirty Sex for IVDU Needles Money Risk Factor 95 Figure 25. Unprotected Sex in Last Six Months Subject—Partner (% committing act at least once) Penile—Vaginal Vaginal—Penlle Penile—Oral Oral—Penile Penile—Vaginal * vaginal—Penile * Penile—Anal Anal—Oral Anal—Penlle Oral—Anal 100 80 60 40 20 0 20 * During menses 96 100 The implication is quite clear: safe-sex protocols are not being adopted as widely as the bleach protocol. The CHOW intervention must begin to focus the educational messages more clearly on the sexual mode of transmission. However, if the intervention is to be effective, it must be based on a better understanding of the barriers to the use of latex protection. Both ethnographic and quantitative data analysis are needed to adapt the educational message. AIDS Cases by Transmission—U.S. and San Francisco (Figure 20) In certain respects, the epidemic in San Francisco is different from the rest of the United States. Segmenting cases by transmission route reveals that 20% of U.S. cases were heterosexual IVDUs, compared with only 2% of San Francisco’s. Chaisson et al. (1987) predicted of San Francisco “Now that the virus is established among IV drug users, the rate of increase in prevalence may parallel changes seen in other populations of addicts in the eastern U.S. and Europe.” Chaisson’s prediction, that over time the epidemic among IVDUs in San Francisco would reach the same proportions as it had on the East Coast, has so far turned out to be inaccurate. Estimates of seropositivity continue to range from 15-18% among IVDUs in San Francisco. (Watters et al. 1988, Chaisson et al. 1987) Shooting Gallery (Figure 27) Chaisson observed that San Francisco’s incidence of AIDS in IVDUs lagged behind the East Coast’s because the city did not have large numbers of shooting galleries where anonymous needle sharing takes place, nor a large bisexual population connecting heterosexual IVDUs to the gay population. Both of Chaisson’s findings have been borne out in the AIA data. The vast majority of the individuals in the 1988 AIA sample had not visited a shooting gallery within the six months prior to the interview. Increase in Safe Needle Use (Figure 28) We hypothesized an even more important reason why AIDS has spread more slowly in San Francisco—the advent of the YES/MidCity project, which began to disseminate AIDS- prevention information and materials in 1985. Moss and Chaisson’s 1986-87 data indicated that 40% of IVDUs in treatment who reported sharing needles also reported using bleach “frequently” or “regularly.” In that same period, Watters (1987) reported that the percentage of IVDUs claiming that they “always” or “most of the time” used effective means to clean their works increased from 53% in 1986 to 66% in 1987. In the AIA data, nearly 82% of IVDUs who reported sharing needles also reported that they disinfected their works “always” or “more than half the time.” Thus, during the two years since Moss and Chaisson’s study, the percentage of IVDUs who are taking steps to disinfect their injection equipment has apparently doubled from 40% to 80%. 97 Figure 26. Adult AIDS Cases by Route of Transmission (United States and San Francisco) United States* (N=89,501) Heterosexual Contact4% | | Heterosexual IVDU 20% Gay/Bisexual Male IVDU 7% Gay/Bisexual Male (not IVDU) 61% Other 7% (as of 3/31/89) *Source: HIV/AIDS Surveillance Report, April 1989. San Franciscot (N=7,123) Heterosexual IVDU 2% Gay/Bisexual Male 4 IVDU 11% Gay/Bisexual Male (not IVDU) 85% Other 2% (as of 8/31/89) tSource: San Francisco Department of Public Health AIDS Report, August 31, 1989. 98 Figure 27. Shooting Gallery Use in San Francisco Number of Respondents 200 100 Never < Half Half the > Half the Time Time the Time Always Frequency Figure 28. Changes in Needle Cleaning— Percent 100 1986 UHS Study 20 Cleans Always or Most of the Time San Francisco 1986-1988 Comparison of Four Studies 1988 1987 UHS Study 5 a 1986-1987 CAP 5 a Cleans Cleans Always or Cleans Always Frequently or Most of the Time or More Than Regularly Half the Time Needle-Cleaning Activity 100 Clean X Share (Figure 29) YES’s professional position is that the “always” or “usually” cleans criteria reported by earlier researchers is too loose. The analysis reported here is based on answers to four questions about needle sharing and four questions about cleaning on the AIA. The preliminary analysis indicates that 44% of those reporting that they sometimes share works also report that they always disinfect their works, 16% never shared needles while 40% sometimes shared needles without cleaning. We worry about statistics that show 40% of the target population at least occasionally committing risky acts. Needle Practices by Age Why do people take risks that may lead to a deadly disease? Almost all IVDUs in San Francisco know that HIV can be transmitted with unsterile injection equipment. We found no significant association between safe IV-drug use and gender or race/ethnicity. The fact that older people are significantly more likely to engage in “safe” use was due to a much lower propensity to share, not to (statistically significant) differences in cleaning (Figure 30). This finding has implications for the outreach effort. Older clients seem to make more demands on the CHOWs for social service assistance, but because younger people share more, they clearly need more intensive educational efforts about cleaning their injection equipment. Yet, YES’s outreach has been overwhelmingly concentrated on an older population (51% of client contacts over 30). The finding also indicates the need for additional research: Does the youth culture have different norms and values with respect to needle sharing? Is the lower propensity to share among older users evidence of the “maturing-out” thesis? Are youths more likely to utilize shooting galleries? Are our findings with respect to age reproduced in other cities? Both a more intensive analysis of the AIA and additional ethnography among young users may provide answers to some of these questions. In any case, in an era when one can expect declining resources for outreach, hard data is necessary to maximize the outreach effort. Reasons for Not Cleaning (Figure 31) The reasons why people report that they used unclean injection equipment appear to be both situational and behavioral (Huang et al. 1989). The problem is compliance with procedures that the IVDUs know to be correct. For a variety of reasons, members of the target population occasionally find themselves injecting drugs in a situation where they have neither a clean needle nor the means to clean one; they may also lack the motivation because they “need the high,” “have no time,” “have to hide the needles,” or are “not at their own place.” Their behavior is driven by addiction. In such situations, they may make a risk assessment, evaluating the potential partner against their own needs and desires, and some of the people, some of the time, will “take the chance.” Here too, we need more information. On what basis are these risk assessments made? Are the decisions based on “facts” provided by outreach workers and other AIDS educators, or are the criteria simply an outgrowth of street culture e.g., that “you can tell if a person has AIDS.” 101 Figure 29. Needle Sharing and Cleaning Behaviors Share but Always Share Works without Always Clean Cleaning 260 (44%) 237 (40%) 98 (16%) Do not Share Source. AIA San Francisco. Sample drawn May-September 1988. 102 Figure 30. Needle Practices by Age Percent 100T 20 4 18-20 21-29 30-39 40-49 50-59 >60 Ever Share Safe IV Use 1 Always Clean Chi-square AGEGP X SAFEIV 13.58, p<0.035 103 ow S0oTWOOT (PETITE Y gE § 8 8 nN o 10 Figure 31. Reasons for Failure to Clean Needles Lack of Materials 59 No Bleach No Clean No Clean Needle Water Reasons Place-Related Not at Own Not at Place Friends Reasons ovw30TUOOD o0w3I0TOOD € 88 3 == NN oc Oo o Self-Related Need No Needto Too High Time Hide Sick Needles Reasons Partner-Related Partner Doesn't Insult to Clean Partner Reasons 104 The situational lesson is important for outreach projects as well as for national policy makers. The educational messages must constantly be reinforced, but education is only part of the story. Without bleach distribution it is unlikely that IVDUs will procure and use bleach of their own. The YES/MidCity experience demonstrates that outreach can have a dramatic effect by introducing a new cultural norm to IVDUs. But, if we expect users to continue to practice safe needle use, the outreach and bleach distribution must continue. The individual outreach worker is the critical link in the chain—seeing that bleach and condoms are available when they are needed. End Notes 1. The Youth Environment Study is one of the founding agencies in the MidCity Consortium to Combat AIDS (MidCity). MidCity is an umbrella group of six research and social-service agencies which was formed to coordinate outreach in San Francisco. MidCity agencies include the Urban Health Study, the Haight Ashbury Free Medical Clinic, Central City Hospitality House, the Larkin Street Youth Center, and the California Prostitutes Education Project (CALPEP). Many of the outreach workers supported by the NADR grant are deployed with some of these agencies. 2. The notion of “formative” evaluation was first developed as a method of evaluation to be implemented while a new curriculum was being tried out. The goal was clearly to collect data, allowing revisions to be made to the program as it was tested. See Scriven 1967. 3. Source: CDC data. Unless otherwise stated, “gay” and “heterosexual” refer to reported sexual behavior and do not necessarily reflect self-identification. 4. Eighteen workers represents full staffing. Due to the stresses of the work, this has rarely been achieved for more than a few months at a time. 5. The term “toss-up” refers to those who exchange sex for drugs. Male toss-ups are called “raspberries” and females are called “strawberries.” 6. This section was written in large part by Mary Romero, c.f., The use of women’s culture in AIDS outreach. In: Cayleff, S.E., and Bair, B., eds. Minority Women and Health: Gender and the Experience of Illness. Detroit, MI: Wayne State University Press, in press. References Aldrich, M.R. “Speedball History.” Unpublished paper, Youth Environment Study, San Francisco, CA, 1988. Battjes, R.J.; Pickens, R.W.; and Amse, 7. “Introduction of HIV Infection among IV Drug Abusers in Low Prevalence Areas.” Unpublished paper, N.D. Bay Area Woman’s Resource Center. “Children of the Tenderloin.” Unpublished paper, 1987. Chaisson, R.E.; Moss, A.R.; Onishi, R.; Osmond, D.; and Carlson, J.R. Human immunodeficiency virus infection in heterosexual intravenous drug users in San Francisco. Am J Public Health 77(2): 169-172, February 1987. 105 Fairbank, Bregman, and Maullin, Inc. “Report on a Baseline Survey of AIDS Risk Behaviors and Attitudes in San Francisco’s Latino Communities.” Prepared for the Office of AIDS, San Francisco Department of Public Health, July 6, 1987. Feldman, H.W., and Biernacki, P. The ethnography of needle sharing among intravenous drug users and implications for public policies and intervention strategies. In: Battjes, R.J., and Pickens, R.W., eds. Needle Sharing among Intravenous Drug Users: National and International Perspectives. NIDA Research Monograph 80. DHHS Pub. No. (ADM)88- 1567, pp. 28-39. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1988. Feldman, H.W.; Mandel, J.; and Fields, A. In the neighborhood: A strategy for delivering early intervention services to young drug users in their natural environments. In: Friedman, S.A., and Beschner, G.M., eds. Treatment Services for Adolescent Substance Abusers. NIDA Treatment Research Monograph Series. DHHS Pub. No. (ADM)85-1342, pp. 112- 128. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1985. Foster, B.L., and Frank, N.J. “AIDS in the Tenderloin: Needs Assessment.” Unpublished report, Barbara Foster and Associates, Greenbrae, CA, March, 1988. Huang, K.H.C.; Watters, J.K.; and Case, P. “Predicting Compliance with HIV Risk Reduction Behaviors among Heterosexual Intravenous Drug Users: Relative Contributions of Health Beliefs and Situational Factors.” Paper presented at the Fourth International Conference on AIDS, Montreal, Canada, June, 1989. Moss, A.R., and Chaisson, R.E. “AIDS and intravenous drug use in San Francisco.” Unpublished paper, Center for AIDS Prevention Studies, University of California San Francisco, N.D. Newmeyer, J.A. Prevalence of drug use in San Francisco in 1987. J Psychoactive Drugs 20(2): 185-189, 1988. San Francisco Department of Public Health. San Francisco Incidence and Mortality by Month of Diagnosis or Death, 1980-1989. San Francisco, CA: San Francisco Department of Public Health, August 31, 1989. Scriven, M. The methodology of evaluation. AERA Monograph Series on Curriculum Evaluation 1: 39-83, 1967. Watters, J.K. “Preventing Human Immunodeficiency Virus Contagion among Intravenous Drug Users: The Impact of Street-Based Education on Risk Behavior.” Paper presented at the Third International Conference on AIDS, Washington, D.C., June 2, 1987. 106 Watters, J.K., Lewis, D.; Cheng, Y.T.; Jang, M.; and Carlson, J. “Drug-Use Profile, Risk Participation, and HIV Exposure among Intravenous Drug Users in San Francisco.” Paper presented at the Fourth International Conference on AIDS, Stockholm, Sweden, June 1988. Whyte, W.E. Street Corner Society. 2d. ed. Chicago: University of Chicago Press, 1955. Williams, F.V. The Hop-Heads: Personal Experiences among the Users of ‘Dope’ in the San Francisco Underworld. San Francisco: Walter N. Brunt, 1920. Acknowledgments Supported by the National Institute on Drug Abuse Grant #s 5R01DAV4319-03 and 5R18DAO05879-01. Author Eric Margolis, Ph.D. Director of Research Youth Environment Study, Incorporated 1779 Haight Street San Francisco, CA 94117 107 CHAPTER III METHODOLOGICAL ISSUES The methodological issues involved in the administration of NADR programs reflect the diversity and complexity of this project. This section presents perspectives on a number of the methodological issues that confront program staff. It begins with a paper by Schensul and Weeks that discusses ethnography as a complement to quantitative data in the evaluation of AIDS-prevention projects and suggests ways in which the two approaches can interact. Ethnographic evaluations, the authors suggest, can provide information on how interventions work, what factors influence participation in intervention, and intracultural variations in participation and outcome. Next, Velasco describes program methodology used at Horizontes San Diego. He stresses the importance of sensitivity to ethnic and cultural differences in the Chicano and Mexicano communities served at the international border. Interviewing methodology is the major subject of Tortu and colleagues, whose paper provides suggestions for interviewers that have been field tested by staff of the Harlem AIDS Project. By developing rapport and putting clients at ease, interviewers can improve the probability that data will be as reliable, valid, and consistent as possible. Erickson and research staff from the Tucson NADR program next discuss their efforts to index variables in Pender’s Health- Protecting Model, a variation of the Health-Belief Model. This model was believed to be applicable to the study of AIDS risk reduction, and current data support the relevance of its concepts to the target population. The remaining papers in this section focus on the AIDS Initial Assessment (AIA) survey, the questionnaire that is administered to all NADR clients. Ray and his New Orleans colleagues examine the issue of pretest sensitization. They report that the pretest effect appears to affect behavioral domains but does not influence cognitive and attitudinal domains. The existence of a pretest effect, they add, implies the need for partitioning of program and pretest effects. These same researchers next contribute a brief paper describing a trailer survey form designed by the Southwest Region NADR grantees that compensates for selected perceived deficiencies in outcome measure in the AIA and AIDS Follow-up Assessment (AFA) questionnaires. Finally, Myers and colleagues of NOVA Research Company, NIDA’s Data Coordination and Evaluation Center, present the results of a test-retest reliability study of each variable on the AIA. This project was a joint effort of NIDA, NOVA, and nine NADR grantees and is based on 196 test— retest interview pairs. 109 ETHNOGRAPHIC EVALUATION OF AIDS-PREVENTION PROGRAMS Jean J. Schensul and Margaret Weeks Introduction The thesis of this paper is that ethnographic methods complement standard treatment/control group design and Knowledge, Attitudes, and Behavior (KAB) studies by providing contextual and culturally sensitive information to administrators and service providers in AIDS-prevention programs. Experimental design and ethnography are two different, but potentially interactive, research paradigms in the documentation and assessment of AIDS-intervention programs. The network of AIDS-prevention projects and programs funded by the National Institute on Drug Abuse (NIDA) has used both with varying degrees of success. The purposes of this paper are: (1) to outline some of the difficulties inherent in the use of experimental or quasi-experimental design in the evaluation of AIDS-prevention programs for intravenous drug users (IVDUs); (2) todiscuss ethnography as a useful complement to quantitative process and outcome data in the monitoring and evaluation of the AIDS outreach and intervention projects; (3) to suggest ways in which these two approaches to research can interact to produce a more comprehensive picture of client-oriented intervention or service programs; and (4) to suggest ways in which program staff can participate in the ethnographic documentation of AIDS programs. Advantages and Problems of Experimental Design in NIDA-funded Programs The benefits of comparative (experimental or quasi-experimental) design in the evaluation of AIDS-education and -prevention programs are clear: greater validity and generalizability. Standardization of outcome measures produces the potential for cross-site comparisons and the development of a national database for longitudinal as well as cross-population studies. However, a number of methodological issues have been raised by programs in the NIDA network that are faced with the need to implement and evaluate a quasi-experimental design with a predetermined set of quantitative outcome measures in the rapidly changing, relatively unknown sociocultural domain of substance abuse and human immunodeficiency virus (HIV) infection. The following are some of the most critical of these issues, as raised during the First Annual Meeting of the National AIDS Demonstration Research (NADR) Project in October 1989. 110 The Immediacy of the Problem of AIDS and IV Drug Use and the Need for a National Database Quasi-experimental design is based on the design and testing of an intervention. In new situations, where there is insufficient knowledge of the target population, we run the risk of putting interventions into place that may be inappropriate to the population, based on theories that are not context-specific. We then evaluate them using generic or previously validated instruments that may be neither valid nor reliable for the specific population to which the program is targeted. First-year NIDA-funded programs had more opportunity to engage in exploratory research than those that came later. By the second year of funding, however, comparative design with more rigorous outcome measures was encouraged. The AIDS Initial Assessment (AIA) and the AIDS Follow-up Assessment (AFA), mechanisms for developing cross-site baseline data on IV drug use and risk behavior, were already developed. Sites that had not been already funded to carry out exploratory research did not have in-depth knowledge of their target populations. In such situations, a continuous assessment model, rather than an intervention/outcome model would constitute a more effective way of ensuring the development of appropriate interventions. Early Consolidation of the Intervention The continuous assessment model calls for adjustments in the intervention with continuous post- measurements on individuals. In this model, the interviewer varies the intervention until the desired effect is achieved. Experimental design calls for early consolidation of the intervention model in order to describe differences between those who undergo and who do not undergo the intervention, and to measure the effects on a sufficiently large sample to ensure statistical reliability. Early consolidation of the intervention is “good experimental design,” but is best utilized after a variety of intervention methods have been developed, documented, and continuously assessed in the field. Design Rigor/Design Rigidity Experimental design, with its accompanying instrumentation, is relatively inflexible. Design inflexibility makes it difficult, although not impossible, to explore new intervention avenues or to ask outcome questions related to the intervention. Narrowness of the Measurement Tool In cross-site evaluation of outcomes, our measurement tools reflect neither the anticipated effects of the individual interventions nor the characteristics of a diversity of target populations in different geographic areas of the country. To ensure comprehensiveness of questions, language, perspectives, target populations, risk behavior, and beliefs and attitudes about AIDS and HIV infection, cross-site quantitative instruments are best built after extensive fieldwork in a diversity of sites across the country. 111 Emphasis on Individual Outcomes At the October 1989 NADR meeting, Dr. Samuel Friedman articulated what we all know through experience and observation: AIDS is a social disease, contracted through social interaction with others, in social settings that prescribe and proscribe appropriate behavior. The primary unit of intervention in AIDS-prevention programs has been the individual. The individual is generally the focus of attention when: (1) the intervention is seen as “educational”; (2) the evaluation design is “experimental”; (3) the results are measured with “validated instruments”; and (4) the boundaries of the social network that constitute the “locus” of high-risk activity are unclear. One of the most exciting and promising new areas of research and development in AIDS prevention concentrates on efforts to bound and describe “dyads,” or “social networks,” as the social units within which high-risk behavior concentrates and as the loci of intervention. If interventions are to address social units beyond the individual, acceptable new approaches to intervention must be found, since such interventions do not lend themselves to the division of units into mutually exclusive treatment and control/comparison groups, nor to pre- and post-testing. The Need for Ethnographic Research on AIDS Behavior The inability of survey research and experimental and quasi-experimental design to provide fully satisfactory answers to such questions has led some health-science researchers to propose that “ethnography” or “ethnographic evaluation” may be cited as a solution to health-policy, service- delivery, or program-evaluation problems under the following circumstances: (1) The disease is new and its natural history and social definition are relatively unknown or emerging. (2) The target population is new, unknown, unpopular, or difficult to reach by public-health officials, physicians, and traditional health-care providers. (3) The health problem is of considerable concern to the public. (4) Existing research paradigms (i.e., experimental design or epidemiology) do not provide satisfactory answers to questions or problems concerning the environment in which the disease is spread, the vectors or vehicles for its contagion, popular responses to the problem, or unexplained differential, unanticipated effects of the disease or public response to it. (5) Existing interventions have not solved the problem of infection or transmission, as in the case of malaria (Sevilla-Casa 1989), diarrhea, or acute respiratory infection. Ethnography offers methods of identifying, observing, documenting, and analyzing culture (patterned beliefs and behaviors) in communities, institutions, and target populations under difficult field circumstances. In addition, the ethnographic perspective insists on identification and interpretation of the meanings behind observed behaviors (e.g., responses to disease) (Werner and Schoepfle 1987; Weller and Romney 1988). Ethnographers assume that patterns of behavior and interpretation vary with ethnicity or cultural identity and, further, that ethnic groups are characterized by intraethnic diversity that must always be taken into consideration. The methods of ethnography are generally utilized to understand how and why systems function, in what ways people interact with them, and how they interpret and explain both the systems and their own interactions with them. The behaviors and ways of thinking of newly affected target 112 populations are relatively unknown to health policy makers. When these populations do not respond to interventions or services in expected ways, ethnography can offer new interpretations to health decision makers and members of the target population themselves. What is Ethnographic Evaluation? The term “ethnographic evaluation” poses a contradiction for the following reason. Evaluation refers to judgment against an already defined standard; ethnography constructs a theoretical framework to account for or predict the ways in which cultural systems function. Evaluation is prescriptive; ethnography is descriptive (Wolcott 1984). Evaluation tests outcomes against a theory of action. Explicitly stated as a consequence of the theoretical framework are a set of clearly articulated goals and objectives and an action plan (Rossi and Freeman 1985; Suchman 1967). Ethnography, in contrast, is a set of “discovery procedures” through which theory of action—or program theory—is generated, and goals, objectives, and action can be defined as they are being implemented. Ethnography works best in evaluation when the model is emerging or developing (i.e., in the early stages of program development) or when the program is viewed as constantly having to adapt to changing circumstances. Ethnography is most useful when theory, standards, goals, and objectives are viewed as “fuzzy,” flexible, “discoverable,” and changeable; in other words, when it can assist in generating or discovering the theory and methods underlying a program approach. Evaluations based on experimental or quasi-experimental designs and quantitative outcome measures assume clear-cut positive or negative outcomes as evidenced by a selected set of outcome measures. Ethnography, on the other hand, works best when there is a stated desire or willingness to: (1) seek expanded and unanticipated outcomes; (2) accept and explore negative outcomes; and (3) recognize that the target population is diverse and unknown and that the program is likely to affect that population in different and not fully predictable ways. Quantitative evaluation of individual outcomes generally compares “classes” of individuals; ethnography is most useful in examining and explaining differential outcomes and variation in outcomes among individuals or across subgroups within the target population. In short, ethnography can play a critical role in AIDS program evaluation under the following circumstances: (1) There is a recognized need to understand cultural variations in target populations in order to increase efficacy of outreach and prevention/ education efforts. (2) AIDS-prevention programs are in the formative stages and information about the process of the program, the organizational base, the community context of the program, and the target population is critical to shaping the program itself. (3) The program is ongoing, but theory, goals, objectives, methods, and even desired results are not clearly stated or understood. (4) There is a clear discrepancy between the program standard and program operation and the reasons for this discrepancy, as well as its consequences, are not understood. 113 (5) Aspects of a program are not working as anticipated and an explanation is required. (6) Outcomes are uneven or not as anticipated and the explanation is believed to lie with as yet unidentified patterns of difference among program participants. (7) There is an interest in describing or demonstrating operational aspects of a program for adaptation by others. AIDS Programs Almost all AIDS programs are prevention oriented. AIDS-prevention programs fall into three classes (Fischl 1988; Hopkins 1987; Mason et al. 1988): (1) AIDS-prevention education intended to change high-risk behavior in order to reduce exposure to HIV; (2) AIDS post-test counseling for those whose HIV-test results are positive and who may be at risk for continuing exposure to HIV or are at risk for transmitting the virus to others; and (3) prevention education and support programs for persons who are HIV-antibody positive and people who anticipate or who are already experiencing symptoms and diseases associated with AIDS. These programs may have multiple target groups and staffs, differentiated by ethnicity, gender, HIV status, education, and other factors. They may provide services in multiple sites. They are susceptible to changes in administration and staff, funding, organizational and national policies, competition from other programs in the environment, the results of new research, and many other factors. It is helpful to think of AIDS-prevention programs as including the following components, all of which may influence the ways in which the programs operate: (1) Institutional Base The base from which the program to be evaluated is operating (2) Target Population The population in a community setting from which program participants are drawn and against which they may be evaluated (3) Program Standard Theoretical framework, goals, objectives, and action plan (4) Inputs or Resources Human, technical/material, economic, and informational (5) Process Activities, actions, and interactions that may or may not be related to (2), may or may not be anticipated, intended, expected, or recognized, and that may have unintended as well as intended consequences bearing on outcomes (6) Consequences and Outcomes Short-, intermediate-, and long-term; desired, undesired, and/or unrecognized. 114 A comprehensive evaluation must take all of these program elements and their interactive effects into consideration. Unfortunately, the constraints of program funding generally do not favor comprehensive program documentations. Even programs that include ethnographers on the staff must make choices concerning what the ethnographer will document. One solution is to improve the observation and documentation skills of program staff. This strategy has several benefits. First, program staff become increasingly self-conscious and self-aware in selecting elements of their own interventions, whether in carrying out street outreach or in administration. Second, program staff, through active participation, learn to value evaluation. Third, the distinctions between “researchers” and “activists” on program staff are eliminated. The remainder of this paper describes ways in which ethnographic documentation and assessment of AIDS-intervention programs can be carried out by program staff to complement the quantitative data gathered and analyzed through experimental or quasi-experimental design. Use of AIDS-Prevention Program Staff for Qualitative Data Collection ’ In the absence of a project ethnographer to conduct ethnographic studies or to collect qualitative data to supplement quantitative measures and to do process evaluation, it is possible to rely on a variety of project staff to participate in these activities. Several general factors affect the ability of these staff to act as partial ethnographers and collect these kinds of data. First, all staff are already overextended with the responsibility of collecting and organizing qualitative data. Second, most staff are untrained in the collection of these data. They have not been trained in skills of observation and documentation, in rigor and consistency in data collection, and in developing an analytical framework within which to place the information and questions that develop through the process of ethnographic work. When considering staff to participate in qualitative data collection, it is important to address the issues deemed important by the staff themselves. It is essential to involve these staff in the planning process to decide what is to be collected and through what means. This ensures that their own issues will be addressed by the data-collection process. Second, it increases the likelihood that they will see the value of the tasks they are performing and that they will understand the inherent need to perform them. Contributions of Specific Staff to Qualitative Data Collection Staff in a variety of roles in the NADR programs can contribute to the collection of qualitative data from their own vantage points. Some of the ways people in different roles can participate within the frameworks of their other responsibilities are as follows: Project Administrators While organizing and implementing these demonstration research projects, administrators can participate in a number of activities to pursue questions of interest to the project or can contribute on an ongoing basis to process evaluation. Questions of interest may spring from initial setup needs of the project or they may develop while carrying it out. In Project COPE, the NADR program based in Hartford, Connecticut, administrators conducted preliminary focus groups with IVDUs and prostitutes to gain a sense of the target population’s 115 needs and interests, to provide information useful in locating and recruiting these targeted groups, and in designing interventions that could address their needs appropriately. Additionally, administrative staff played a key role in documenting project setup and revisions in project design and structure. Additional activities in which administrative staff may participate include designing and documenting appropriate methods to address ongoing problems and issues that arise while implementing the project. These methods often require staff to address the issues in a manner that is appropriate within the theoretical framework of the project design. Issues that arise in these NIDA projects may include such problems as why we are not reaching certain groups, and how we can document and analyze differential participation by clients in our interventions in order to operationalize our activities to measure and analyze outcome. Staff at Project COPE face other issues that stem from a research design oriented toward the development of culturally appropriate interventions for specific ethnic groups. We have tried to create a common understanding among all project staff of concepts like “culture” and “culturally appropriate.” We then have had to find ways to use this common language to document the cultural components of our interventions. In summary, project administrators can participate in the analytical tasks of defining issues and then developing appropriate methods to address them; they can revise the research design or project structure to incorporate new knowledge or conditions in the project’s environment; and they can help determine issues that must be studied further if the project is to keep up with changes in the city, among targeted populations, and within their own project. Aside from these contributions, administrative staff are limited as to what they can contribute to the collection, organization, and analysis of ethnographic data. In many NADR projects, administrative personnel are not trained in qualitative data collection. Additionally, they do not have time to do complete and systematic ethnographic work, exhausting a particular question. Even in the documentation of their own project’s activities, because of the difficulty or impossibility of always being present when outreach or intervention is taking place, administrative staff must depend on other project staff to provide documentation of these activities. Outreach Workers In the context of their street, agency, or other outreach and AIDS-education activities, outreach workers can contribute greatly to the program’s awareness of activities in the city and issues affecting its participants. Because they are on the streets, they can pursue specific questions and provide the information necessary to keep the project in touch with changes in the general environment and those that affect specific participant needs. At Project COPE, outreach workers have been asked to pursue several key questions. In the early stages of the project, street outreach workers observe and document activities in specified areas of the city, looking for patterns and new activities. They are also asked to pursue, with male participants, the issue of introducing their partners to the program. Finally, outreach workers attempt to find project participants who drop out before completion of the intervention. They also track those who never attended any intervention and ask them why they left the program. 116 Outreach workers can also play a significant role in collecting qualitative data for the project. Most programs ask that their outreach workers keep records of street contacts, documenting whom the project is reaching. These data are, in many programs, augmented with log records that provide anecdotal information that sometimes provides answers to questions raised during outreach. At Project COPE, agency outreach workers also interview agency staff and service providers on issues pertaining to the sociocultural environment of the target population. It is hoped that this will lead to more services being provided to that group. Their direct, regular contact with people on the streets and in social-service agencies makes outreach workers suitable to pursue questions and issues of interest in these areas. However, because of limitations on time and training, outreach workers cannot provide thorough ethnographic or qualitative documentation while they are recruiting or providing AIDS education and intervention. These limitations make it difficult for outreach workers to be systematic in their collection of data. It is also extremely difficult for them to pursue a question to completion, either through observation or in-depth interviewing. Though anecdotal information in logs, and even partial answers to questions of interest pursued on the streets and in agencies, can be useful and interesting, such information is likely to be incomplete (and therefore possibly misleading) and is generally without a theoretical framework from which to assess and analyze these data. Social Workers and Other Intervention Providers Because they provide intervention and education through direct contact with participants, social workers may naturally assume several tasks in qualitative data collection and documentation. In addition to keeping records of their own activities, they can contribute to the collection of other important qualitative data for the project. In documenting their intervention activities, they are able to provide detailed descriptions of the kinds of intervention they offer, the general outline of their intervention program, and records of how much intervention they have given to each participant. Several NADR programs have found it necessary to develop forms to detail the level of participation and amount of intervention for each participant. These forms often include records of more qualitative kinds of data, such as participant feedback on the impact of the intervention, including group sessions, one-on-one counseling, and other formal or informal intervention provided to them. It is important to note that the original ideas for the content of the forms used by Project COPE came from records the social workers were keeping for their own needs. These forms were then augmented to address research needs of the project with the assistance of staff members who would be using them. Social workers are also in a strategic position to collect the in-depth information that surfaces during the intervention, while upholding the principle of confidentiality. They are key sources of information that is critical for specific groups, for example female IV drug users, female sex partners, and specific ethnic groups. They can also provide key information on the variation within groups of participants, their responses to the intervention, and the issues these participants feel are critical. Because of their responsibility to provide intervention to the participants, social workers, too, are limited in their ability to collect qualitative data. It is not possible for them to observe and document how they run a group session while they are in the process of doing it. Another observer is required to fill this function. They are also not able to do exhaustive documentation 117 of issues that come out of the intervention, either for individuals or special groups, nor can they be expected to record the various responses to the intervention. The duty of the social workers is to provide services, not to pursue research questions. Paperwork is time consuming and, for them, secondary to implementing the intervention. A possible solution to these limitations is to have other project staff discuss with the social workers some of the issues that arise during the intervention within groups or for individuals. One way to work through the limitations on qualitative data collection is to combine the efforts of people in different positions and have them work in conjunction with each other. For example, at Project COPE, interviewers work with social workers to observe and document activities in group sessions at the intervention sites. Sharing the time required to do this kind of documentation and collection of other qualitative data is necessary because all staff are limited by the demands of their other project responsibilities. Training of Project Staff in Ethnographic Data Collection Proper training of project staff is critical in preparation for qualitative data collection. This preparation should serve two purposes: (1) project improvement by improving inquiry, observation, and interpretation skills to strengthen outreach and capacity; and (2) project dissemination by collecting data leading to a more accurate description of interventions for project replication. Project COPE has made a commitment to train interviewers, agency outreach staff, and project social workers in ethnographic data collection and analysis. Interviewers are also assigned to perform agency outreach and to document our culturally targeted interventions. To increase their ability to document agency support systems for IVDUs, their partners, and the entire intervention process, we developed an ethnographic training curriculum. When we reviewed this curriculum with project social workers, they saw the advantage of working on observation skills and asked if they could join the training group. The social workers are the central figures in Project COPE site interventions, and their participation in these sessions offered the potential for developing observer-facilitator documentation teams (cf. Erickson and Shultz 1982; Scheinfeld et al. 1989). This was an exciting option for us. In our experience, observer- facilitator teamwork offers rich possibilities for raising critical questions, offering multiple perspectives on project activities, increasing the ability to understand and interpret participant responses, and expanding explanatory materials for use in manuals and guides to interventions. We have now completed 7 of 15 ethnographic training sessions. These sessions have addressed such topics as the observer as instrument of observation, observer bias, observation, recording and notetaking, interpretation and analysis, the basic elements of a program, components of the Project COPE intervention, and process questions raised by observer-facilitator teams. Future sessions will focus on such topics as social mapping, activity sequences, ways of measuring risk perception, facilitator-participant interaction, intragroup diversity in participation in interventions, and cultural symbolism in curriculum content. A curriculum from each of the sessions, coupled with exercises, notes, and comments produced by these sessions, will be collected as the basis for an ethnographic/process-evaluation training manual for use by staff members of all AIDS-prevention programs. Our next challenge is to 118 monitor, manage, maintain, and present the ethnographic data obtained through observation, interviewing, pile sorts, maps, and other materials, so that its utility is guaranteed. Concluding Comments Ethnographic documentation of AIDS-prevention programs can complement quantitative outcome data by providing information on: ¢ how interventions “work”; e factors influencing the levels of participation in interventions; e intracultural variations in participation and outcomes; and * intersite variations in process and outcome. Effective documentation is invaluable in producing materials and manuals for replication and adaptation by other sites. It is the best means by which the rich detail of intervention activities can be captured as examples for others of what can be expected through time and across ethnic and other cultural groupings. Documentation can be done by various project staff members in conjunction with ethnographers, keeping in mind the burden carried by intervention staff of having to observe and record in writing their own activities. The most effective mode of documentation and interpretation, in our experience, has been the observer-facilitator team model in which the observer (who may or may not be a formally trained ethnographer), works closely with onsite facilitators as a participant- observer. This relationship is especially critical for “project ethnographers,” who frequently find themselves outside the project mainstream, because it gives them a central role in the intervention. However, it is also important for any observer, as it enhances understanding, eliminates the hierarchical and disciplinary distinctions between research and action, and ensures the utility of the research process and research results for facilitators and adaptors. References Erickson, F., and Shultz, J. The Counselor as Gatekeeper, Social Interaction in Interviews. New York: Academic Press, 1982. Fischl, M.A. Prevention of transmission of AIDS during sexual intercourse. In: Pevita, V.T.; Hellman, S.; and Rosenberg, S.A., eds. AIDS: Etiology, Diagnosis, Treatment and Prevention 2d ed. Philadelphia, PA: J.B. Lippincott Company, 1988. pp. 369-374. Hopkins, R. Public health measures for prevention and control of AIDS. Public Health Reports. 102(5): 463-467, September—October 1987, Mason, J.O., Noble, G.R.; Lindsey, B.K.; Kolbe, L.J.; Van Ness, P.; Bowen, G.S.; Drotman, D.P.; and Rosenberg, M.L. Current CDC efforts to prevent and control human immunodeficiency virus infection and AIDS in the United States through information and education. Public Health Reports. 103(3): 255-260, May-June 1988. Rossi, P., and Freeman, H. Evaluation: A Systematic Approach. Beverly Hills, CA: Sage Publications, 1985. 119 Scheinfeld, D.R.; Marshall, P.; and Beer, D. Knowledge utilization structures, processes and alliances in a psychiatric hospital study. In: van Willigen, J.; Rylko-Bauer, B.; and McElroy, A., eds. Making Our Research Useful: Case Studies in the Utilization of Anthropological Knowledge. Boulder, CO: Westview Press, 1989. Sevilla-Casas, E. Malaria and anthropology: Towards a treatment of malaric communities as human ecosystems. Draft for restricted circulation. June 1989. Suchman, E.A. Evaluative Research Principles and Practices in Public Service and Social Action Programs. New York: Russell Sage Foundation, 1967. Weller, S.C., and Romney, A.K., eds. Systematic Data Collection. Vol. 10, Qualitative Research Methods. Beverly Hills, CA: Sage Publications, 1988. Werner, O., and Schoepfle, G.M., eds. Foundations of ethnography and interviewing. In: Systematic Fieldwork. Vol. 1. Beverly Hills, CA: Sage Publications, 1987. Werner, O., and Schoepfle, G.M., eds. Ethonographic analysis and data management. In: Systematic Fieldwork. Vol. 2. Beverly Hills, CA: Sage Publications, 1987. Wolcott, H. Ethnographers sans ethnography: The evaluation compromise. In: Fetterman, D., ed. Ethnography in Educational Evaluation. Beverly Hills, CA: Sage Publications, 1984. pp. 177-210. Acknowledgment Supported by the National Institute on Drug Abuse Grant #1R18DA05705. Authors Jean J. Schensul, Ph.D. Co-Principal Investigator Margaret Weeks, Ph.D. Project Director Institute for Community Research 999 Asylum Avenue Hartford, CT 06105 120 FINDING, INTERVIEWING, AND RETRIEVING BLOOD SAMPLES FROM TECATOS: AIDS PREVENTION AND RESEARCH IN SAN DIEGO Alfredo Velasco Introduction San Diego, California, for all of its tourist attractions, world-famous climate, and international flair, is home to 1,635 persons with AIDS (Centers for Disease Control [CDC] 1990). The preponderance of these individuals are gay Anglo men; only a few are intravenous drug users (IVDUs). However, the County of San Diego Public Health Services estimate that there are approximately 15,000 IVDUs in this county. It is this latter category, the IVDUs, that this report will address. In the midst of the inner city there are a number of predominantly Spanish-speaking barrios, (Clark 1970) where a disproportionate number of IVDUs are to be found. These IVDUs, known on the streets as tecatos, (Polkinhorn et al. 1986) are being sought out and invited to participate in a National Institute on Drug Abuse (NIDA) research project seeking to analyze risk behaviors that may lead to human immunodeficiency virus (HIV) infection. This effort, concentrated in the southern portion of the County of San Diego, is called Horizontes, a project of the KOBA Institute, Inc., Washington, D.C. The Setting The southern portion of the County of San Diego is made up of four incorporated cities: San Diego, National City, Chula Vista, and Imperial Beach. At the southernmost tip of the county is the barrio of San Ysidro, located on the United States/Mexico international border across from the city of Tijuana, Baja California, Mexico. Together, these San Diego County cities have a population of approximately 400,000 persons, many of whom are Spanish speaking. The Latino population has increased during the past decade by as much as 30%. The growth has brought a concomitant increase in urban problems, e.g., crime, gangs, drug use, teenage pregnancy, school dropout, and absentee landlords. The barrios targeted in this study are home to as many as 200,000 Spanish-speaking Chicanos, Mexicanos, and other Latinos. All of the barrios are affected by the social ills noted above. The barrios of the region have been subdivided into four areas: (1) San Ysidro and Imperial Beach; (2) Chula Vista and National City; (3) Sherman Heights, which includes Shelltown, Barrio Logan, Golden Hill, Encanto, and Logan Heights; and (4) Southeast San Diego, which includes Normal Heights, Center City, East San Diego, Kensington, University Heights, and State College. These four geographic regions comprise an area that is 20 miles long and 10 121 miles wide. This vast extension of urban geography is the target area into which Horizontes has put 10 outreach workers. The difficulty of performing outreach work in these areas is related to a number of variables, including geographic distance, Spanish-speaking communities, distrustful tecatos, and the inherent danger of working within the drug culture. All are compounded by the aura and specter of HIV/AIDS. Tecatos are unwilling to approach service agencies outside the barrios for a number of reasons, here couched under the rubric of “paranoia.” Trying to make contact with IVDUs can be dangerous, oftentimes requiring permission from drug dealers. Going into some of the toughest neighborhoods in the barrio is also a problem for staff persons who are not familiar with the environs. For these reasons, the staff persons of Horizontes are selected very carefully. The indigenous leader outreach workers, as the outreach staff members are officially known, are street smart, have a general knowledge of the drug culture, have worked and are experienced with human-care social-service agencies, and are willing and motivated to work with fecatos and HIV/AIDS. The outreach staff work in an environment that is familiar to them. They understand the Chicano and tecato cultural nuances that dictate social behavior and communication. They are not necessarily intimidated by the sometimes threatening atmosphere of the inner barrio. Consequently, Horizontes staff are able to locate tecatos in their homes, shooting galleries, neighborhood parks, hangouts, and so on. Without knowledge of the culture of both the barrio and the tecatos, it would be nearly impossible to work so close to the clients’ homes. Some members of the Horizontes outreach staff are ex-heroin addicts who were sent into the community to make first-hand contact with IVDUs. All have years of experience in doing community work. The principle underlying this dual approach of having both paraprofessionals and community-based agencies is straightforward—to bridge the gap between the “square society” and the addict in such a way as to have the IVDU trust and follow the advice of the outreach workers. Horizontes-San Diego’s Methodology The principal objective of our project is to locate and inform. It is our intent to locate tecatos, inform them about the risk of HIV/AIDS, encourage them to come into one of our offices and be interviewed, and to have a blood test for HIV infection. Cash incentives are awarded to clients for participation. The process is as follows: 1. Initial contact. The outreach worker seeks out the tecatos in their own neighborhoods and acquaints them with the project and its intent. 2. Interview. The tecatos are brought into one of the offices and are administered the AIDS Initial Assessment (AIA) questionnaire. This takes about 40 minutes. The AIA includes questions on needle use, sexual behavior, and AIDS knowledge. 3. HIV-antibody test. The tecatos have blood drawn, which is then sent to a laboratory for analysis. 4. Initial intervention. The outreach workers take the tecatos step by step through an analysis of their behaviors, asking predetermined questions 122 and providing specific information to the clients. Issues having to do with high-risk behaviors, such as the sharing works/rigs/needles and unsafe sexual behavior are discussed in detail. 5. Testing results. Two weeks after the administration of the AIA and the HIV test, the client is brought back to the appropriate Horizontes office and given the results of the HIV blood test. 6. Second intervention. Two months after the initial intervention, the outreach workers follow up by trying to find each client, assessing whether there have been changes in his or her AIDS-related behaviors or knowledge. 7. Third intervention. Four months after the initial intervention, the outreach workers once again follow up with the clients to see how they are doing and to remind them about the pending AIDS Follow-up Assessment (AFA) questionnaire, to be administered six months after AIA. 8. AIDS Follow-up Assessment (AFA) questionnaire. The clients are brought back to the appropriate office, where the AFA is administered. Time and money permitting, the clients are given the option of taking a second blood test for HIV. If they opt to take the blood test, they return two weeks later for the results. After completing this stage, the clients are no longer part of the Horizontes project. The intent of these interventions is to effect changes in high-risk behavior, determine the effectiveness of the outreach model in stemming the spread of HIV/AIDS among tecatos, and garnering important data on high-risk behaviors practiced by this population. The Uniqueness of San Diego The National AIDS Demonstration Research (NADR) programs are concentrated in 63 sites across the nation. San Diego is unique among these cities in several respects. The barrios of San Diego are predominantly Chicano/Mexicano. Members of other Latino groups comprise a smaller portion of the barrio population. These barrios vary in both ethnic composition and language preference, but the ones located closest to the international border reflect a greater degree of Mexicanization and have more Spanish-speaking residents than those that are further from the border. The barrio populations of Barrio Logan, Sherman Heights, and Logan Heights, all located in the urban center of San Diego, are the most mixed with respect to ethnicity/race and language use. Sherman Heights, for example, is 79% Chicano/Mexicano. San Ysidro, the barrio along the international boundary, is 89% Chicano/Mexicano and Spanish speaking. The barrios of San Diego dictate that the outreach workers speak Spanish and have a firm understanding of the cultural nuances pertinent to Chicanos and Mexicanos. The importance of this understanding has never been more obvious than it is with this study. The results from the data, and the procedures for approaching tecatos are quite different in San Ysidro than in San Diego proper. The tecatos in San Ysidro, for example, are much more responsive to the HIV- antibody test results than are their counterparts in Sherman Heights. The reason for this difference is unclear; proximity to the border would appear to be the prevailing factor. 123 Along the international border in San Ysidro, the tecatos appear to be much more “Mexican.” This is an important observation, because finite cultural distinctions can be observed and subsequently addressed. Spanish is frequently the language of communication, etiquette plays a more significant role in social behavior, and male and female roles appear to be more clearly defined. This simple collection of examples may be juxtaposed to those less-Mexicanized traits, which become more predominant in the barrios further from the international border. Sherman Heights, for example, is 18 miles from the international border. The predominant social nuances of this area are of Chicano, not Mexicano. The subtle differences between the Chicano and Mexicano cultures are frequently noticeable only to those individuals in both groups who are most culturally sensitive. The differences include a high number of English-speaking persons, even among Spanish-surnamed clients, and the less formal mannerisms associated with salutations and departures exhibited by Chicanos. It is important to note that San Diego has tecatos who belong to the Chicano culture, others who belong to the Mexicano culture, and still others who fall somewhere in between the two. The comparative results that outline these subtle differences have to do with distance and proximity from the international border. The Mexicano tecatos in San Ysidro are a great deal more concerned with their HIV-antibody test results than those in other areas served by our program. These individuals come back to the office in great numbers, perhaps as many as 80% of those who originally took the AIA. In the Sherman Heights barrio, on the other hand, as few as 40% of the Chicanos return for the results of their HIV-antibody tests. This single discrepancy singularly illustrates the variation between the Chicano/Mexicano populations of the two geographic areas. The variation in numbers of people returning for HIV-antibody test results may be related to the enculturation levels of the two distinct barrios. Many of the clients visiting our offices in San Ysidro are Mexicanos from Tijuana, Baja California. As Mexican tecatos, they have crossed into the United States for a number of reasons, one of which may be to buy and shoot their drug of choice. They believe that the drugs are better and of higher quality in the U.S. than in Mexico. Their fear of HIV/AIDS brings them to Horizontes. The exact number of Mexicano clients in San Ysidro is uncertain. San Diego is a unique test site for an array of cultural variables that differentiate IV-drug-use behavior between Chicanos and Mexicanos. Thus, it is important to ascertain the meaning of this dichotomy, to translate these cultural nuances into plans of action for dealing with both tecatos and the HIV/AIDS epidemic, and to formalize programs that will best address these distinct population groups. We recognize that there are finite differences between these two subgroups. It is now time to further analyze these variations in risk behavior, drug of choice, and reasons for seeking assistance, especially as they pertain to IV drug use and HIV/AIDS. Conclusions San Diego’s AIDS Prevention and Research Project is a unique combination of streetwise staff persons and cultural affinity to the tecatos in their own barrios. The staff members approach the client population with a predeveloped collection of interventions. They seek to educate the clients and to keep them abreast of their pending interview session. The interventions inform the tecatos about high-risk behaviors and the dangers inherent therein. 124 The neighborhoods in which the outreach workers recruit clients are riddled with social problems such as high crime rates, gangs, drugs, school dropouts, and teen pregnancies. Community-based organizations use indigenous workers because these individuals know and understand the barrios. Horizontes, for the same reason, is dependent on indigenous outreach workers. These outreach staff members are a productive, knowledgeable, and sensitive approach to working with tecatos in their own barrios. The tecato population is divided into two subgroups: the Chicanos, living in the urban center of San Diego; and the Mexicanos, living close to the U.S./Mexican international border. Certain social traits distinguish the two groups, with the Mexicanos being much more formal, respectful, and concerned with getting their results from the HIV blood test. The Chicanos, on the other hand, speak less Spanish, are less formal with salutations and departures, and not as interested in knowing their HIV blood test results. These few examples of cultural heterogeneity among IVDUs illustrate that special attention must be paid to the diversity in this population. Staff who work with these populations must be prepared to understand the finite differences in cultural behavior to be found among these Spanish-speaking subgroups. After one full year of work in the barrios in the southern portion of San Diego County, Horizontes staff are convinced that this project has had a major effect on tecatos. With high numbers of clients returning to our offices for their six-month follow-up, we have gotten a sense that many of them are following the advice we have prescribed about risk behaviors. A large number of clients are using bleach, if and when they share their outfits. Our efforts to convince the tecatos not to practice risk behaviors are working. Many individuals coming to the project offices for the first time, mention that they have learned about risk behaviors from our past clients; some are already making behavior changes. Outreach in the barrios by knowledgeable, experienced, street-wise staff has made the difference. References Centers for Disease Control. HIV/AIDS Surveillance Report, January 1990. Clark, M. Health in the Mexican-American Culture. Berkeley, CA: University of California Press, 1970. Polkinhorn, H.; Velasco, A.; and Lambert M., eds. EI Libro de Calé: The Dictionary of Chicano Slang. Encino, CA: Floricanto Press, 1986. Acknowledgment Supported by the National Institute on Drug Abuse Contract #271-88-8232. Author Alfredo Velasco, Ph.D. Project Coordinator Horizontes-San Diego 610 22nd Street San Diego, CA 92102 125 INTERVIEWING TECHNIQUES: BUILDING RAPPORT AND GETTING QUALITY DATA Stephanie Tortu, Westley Jones, Marsha McGriff, and Janet Prosper Introduction To an inexperienced person, it may appear that it is a simple matter to ask a respondent a set of prepared questions and to record his or her replies. But interviewers soon find that obtaining a specific, complete response is an extremely difficult task. Among other things, respondents may qualify their answers, contradict themselves, misinterpret the question, and change the topic. These things may be especially true with an instrument like the AIDS Initial Assessment (AIA) questionnaire, which probes for information concerning illegal activities and intimate sexual behavior. Therefore, it is important that interviewers create an atmosphere in which respondents feel at ease, yet keep attention on the business at hand, that is, getting the accurate information required for research purposes. This paper provides a general set of “tips” for interviewers that have been field tested by the staff of the Harlem AIDS Project. Attention will be paid to two topics: (1) creating an atmosphere that puts the client at ease; and (2) ensuring that data are as reliable, valid, and consistent within the interview as possible. In this paper, the words client and respondent will be used interchangeably. Developing Rapport The first goal of the interviewer is to put the client at ease before the actual interview begins. We have noticed that a simple but effective means of beginning the interview session is to offer the client a cup of coffee and a snack. After several minutes of conversation in the private interview room, we ask the client to read the informed-consent form, suggesting that this be done slowly and carefully. After the statement has been signed, we assure our clients of confidentiality. We tell them: “No one but the research team will see the answers, and you are identified by number only.” We find it helpful to provide the respondent with a pencil and paper so that he or she can copy the name and telephone number of the principal investigator in case they may want to speak with her. Finally, we give the client a few moments to ask the interviewer any questions about the interview or the AIDS project in which he or she is participating. This helps to make sure that any lingering doubts are resolved before the interview actually starts. The attention paid to making the client feel at ease does not stop after the initial minutes of contact. There are moments during the interview when we remind the client about our pledge of confidentiality. We routinely do this, for example, when the client is asked about illegal means of support. Before asking the questions on sexual activity, we advise the respondent that the language used in this segment is not meant to be offensive. We tell them that it is necessary to use those terms to get the information we need. Sometimes, we sense that a client is 126 uncomfortable about revealing certain details related to “life on the streets.” It is helpful at this point for the interviewer to say (when it is appropriate): “I know what it’s like. I've been there.” Finally, gently humorous remarks (“Why, you haven’t smiled once!”), used at the right time, can also help to lighten up the interview experience. As expected on a project that recruits drug users, we know that many clients are high when they come to the interview. We feel that it is critical to deal with this before the interview starts. On those occasions when we see that the client is nodding out or extremely agitated, we tell him or her that we wonder if we’ll be able to complete the interview because we have doubts that we will get quality data. Usually, this upsets a client because he or she does not want to lose the interview fee. We let them know that they can return when they are in better shape, and we urge them to reschedule their appointment. We have found, however, that in most cases, this motivates them to straighten themselves out and get control. We work along with them if we can see that they are trying, and we do give the person a chance to go through the interview if they make a serious attempt to give us information that makes sense. However, if we find that it is impossible to get cooperation during the interview, we politely but firmly terminate the interview and reschedule it. This is done infrequently, and it may cause the client to get angry. We are prepared for this, and we use our security guard to help escort the client off the site if we feel it is necessary. Getting Quality Data During the interview, the goal is to get data that are reliable, valid, and consistent. To accomplish these goals, we emphasize that an interviewer does not function merely as a passive recorder of responses. In a long and complicated interview like the AIA, it is necessary to be alert and attentive to what the client is saying and how he or she is saying it. When inconsistent responses are noticed, we address this during the interview session to find out which response is correct. For example, we often note inconsistencies between a client’s responses on the drug matrix and the response to the question concerning the age at first injection. Moreover, responses that are too consistent (client always answers “C”) may be an indication that the client has trouble understanding the response cards or is not paying sufficient attention to the questions. If the client has trouble understanding the response cards, the interviewer takes a few seconds to review them with the client. When clients are not paying attention to the questions or are merely going through the motions, we ask them to cooperate with us so that we will be able to give them their money. We remind them that if we have to terminate the interview because they are not cooperating, they will not get their money. We have often found that our clients have difficulty understanding the concept of percentage. In these instances, we ask them to estimate “the number out of a hundred.” Likewise, respondents also routinely have difficulty recalling exact numbers, particularly in response to questions about sexual activity. We must also frequently specify to the respondent that on some questions dealing with sexual behavior, the answers to those questions should account for all sexual partners. Because these are complicated things to recall in great detail, we let the respondent think for a few minutes before answering. Another area of difficulty concerns the illegal drug first used by the client. While this was probably marijuana, our clients don’t define marijuana as a drug. Thus, when clients state that cocaine or heroin was their first drug, it is advisable to use a neutral probe. In our experience, 127 the probe sometimes jogs the client’s memory and reminds him or her of the experience with marijuana. As frequently happens with an interview that is focused on personal experience, the AIA sometimes spurs clients to want to talk about their lives in great detail. Indeed, for many respondents, this is a cathartic experience. They may be talking for the first time in years about their drug use or sexual behavior. If this occurs, we let the client talk for a few minutes, but it is necessary to pull the person back to the task at hand after a few minutes. Our respondents often have questions about AIDS or drugs that are far afield of the interview topics. In these instances, the interviewer should make it clear that although he or she is unable to answer those questions, there is someone available on the project who can. In our case, there are health educators/counselors working at the research sites who will address these concerns once the interview is over. Clients Who Cannot Read Several of our clients have not been able to read. This makes the interview more difficult, but not impossible. We usually notice that the client cannot read when we give him or her the informed consent. This situation must be handled delicately. We usually tell clients that we are not here to embarrass them and we can help them get through the interview. We let them know that by cooperating with us, we can both get what we want: they will get their money, and we will get our answers. We ask them to listen carefully as we read the informed consent. We speak slowly during the interview and allow them extra time to think. If we must, we carefully explain the response cards every time we use them. Conclusion We work with clients who have multiple problems. AIDS is one of many other difficulties in their lives. Sometimes this job causes us to feel stressed, depressed, or tense. We see many things that we cannot do anything about. On the Harlem AIDS Project, we have learned that the best way to work out some of our feelings is to share them regularly with another interviewer. This is the way that we can take care of ourselves so that we do not become disillusioned and burned out. There is one final message that we would like to give others who do this work. We feel strongly that being a good interviewer requires a commitment to fighting this disease and a commitment to serving our targeted population. None of the tips that we have provided in this presentation will work unless the interviewer respects the human dignity of the clients and has the humility to recognize that we are all prone to weakness and bad judgments at times. Interviews must be done with love and patience. While we are certainly rewarded by knowing that our data will help to fight AIDS, our best reward comes when a client tells us after an interview, “Thank you. You have made my day. I really enjoyed talking to you.” Acknowledgment Supported by the National Institute on Drug Abuse Grant #R 18DA05746. 128 Authors Stephanie Tortu, Ph.D. Project Director Westley Jones Interviewer Marsha McGriff Interviewer Janet Prosper Interviewer Harlem AIDS Project Narcotic and Drug Research, Inc. 11 Beach Street New York, NY 10013 129 DEVELOPMENT OF INSTRUMENTS TO INDEX VARIABLES IN A MODEL OF AIDS RISK REDUCTION AMONG INTRAVENOUS DRUG USERS Julie R. Erickson, Antonio L. Estrada, Peggy Glider, and Sally Stevens Introduction Theoretical models for health-promoting behaviors, including the Health Belief Model (HBM) (Rosenstock 1974) and Pender’s (1983) Health-Protecting Model (HPM), designate concepts significant to prevention behaviors and hypothesize relationships among those concepts. Theories must be tested empirically to examine their relevance to actual prevention behaviors demonstrated by a group of people. To test a model, concepts must be defined operationally and be measurable. To measure concepts empirically, valid and reliable indices must be used. The purpose of this paper is to discuss how instruments indexing variables in Pender’s (1983) Health-Protecting Model are being developed. Pender’s Health-Protecting Model Pender’s model was selected for use in a study of AIDS risk reduction among intravenous drug users (IVDUs) for four reasons: (1) the Health-Protecting Model is a modification of the Health Belief Model, which lends some support to its credibility; (2) Pender’s model clearly specifies variables relevant to prevention and stages the influence of variables on each other as well as on the outcome variable—variables in the model and their hypothesized relationships are consistent with recent work on AIDS (Emmons et al. 1986; Joseph et al. 1984); (3) its ability to examine health in a narrowly defined sense, in terms of AIDS risk, or widely focused, in terms of general health issues for IVDUs; and (4) the structure and staging of the model provide clear guidelines for the content and timing of interventions directed at AIDS risk reduction among IVDUs (Erickson et al. 1989) (Figure 1). Variables in the Model In Pender’s model, 11 variables are hypothesized to influence, directly or indirectly, the outcome variable of engaging in preventive health behaviors. The model, as presented in this paper, has five stages, with stages one through three comprising the decision-making phase and stages four and five being the action phase. In Stage One, there are three concepts labeled demographic, interpersonal, and situational. These concepts are the modifying factors in the Health Belief Model (Becker et al. 1977). Demographic concepts are those defined as individual characteristics influencing a person’s perceptions about health and risk. Demographics can be quantified empirically by age, sex, ethnicity, income, and education. Intrapersonal concepts stem from those personal experiences 130 that influence perceptions of health and illness and have multiple categories of measurement, including current preventive practices, patterns of health care, expectations of others, level of acculturation, and knowledge of the health threat. Situational concepts are social influences or pressures that directly influence an individual’s health and illness perceptions. The situational concept can be measured using data on reference-group norms for preventive behaviors, cultural acceptance and attitudes toward behaviors, and sources of information. Stage One variables directly influence the individual perception of health, risk, and prevention in Stage Two and, consequently, have an indirect effect on variables in subsequent stages of the model. As defined in the Health Belief Model, “susceptibility” is the individual’s perception of his/her probability of contracting the specific disease; “seriousness” looks at individual perceptions of the disease’s impact on well-being; and “benefits” addresses perceptions of the value or worth of the preventive behaviors to personal well-being (Becker et al. 1977; Rosenstock 1966). “Importance of health” is defined as the individual’s perception of the salience of his/her health, and “control over health” is perceptions of ability to self-regulate health status (Pender 1983). The five Stage Two variables are hypothesized to directly and positively influence the individual’s likelihood of taking preventive action. “Likelihood” is defined as the individual’s subjective estimate of his/her probability of adopting one, some, or all of the prevention behaviors. Likelihood is not action but is a decision for action. Likelihood, seen as a potential for action, is hypothesized to negatively influence barriers to action and to positively relate to the cues to action in Stage Four. Barriers are real or perceived obstacles to engaging in preventive behaviors, with categories of measurement possibly including financial cost, self-efficacy, demands for lifestyle changes, and social pressures. Cues to action are experiences perceived by the person to trigger overt action. Since these experiences may be diverse, measurement of cues might focus on the personal, social, cultural, educational, and environmental experiences. Pender’s model hypothesizes that participation in preventive health behaviors in Stage Five is negatively influenced by barriers and fostered by cues. In a study of AIDS risk reduction among IVDUs, measures of preventive action focus on needle use and sexual practices. To test this model empirically, valid and reliable instruments must be used that index variables as distinct entities as well as account for relationships among variables. These instruments are in an early stage of development by Pender. Review of the Literature In our study, instrument development began with an extensive review of the preventive health, drug, and AIDS literature to discover measures with empirical evidence for validity and reliability that appeared relevant to the HPM. Several instruments were found among the work of Champion (1984) on the HBM; Emmons et al. (1986) on homosexual men and risk for AIDS; Kulbok (1985) on health resources; Laffrey (1986) on health conception; Murdaugh and Hinshaw (1986) on personality variables affecting preventive behaviors; Pender and Pender (1986) on health promotion; Sechrist, Walker and Pender, (1987) on exercise barriers and benefits; Walker, Sechrist and Pender, (1987) on lifestyle profiles; Wallston and Wallston (1978) on health locus of control; and lastly, Weinstein’s (1984) work on risk perceptions. 131 Each instrument found was developed and tested in populations not including IVDUs and looked at health threats other than AIDS, with the one exception of Emmons et al. (1986). Aims of the Study To further develop instruments for testing the AIDS risk-reduction model among IVDUs, a qualitative research study was planned. There were five goals for this investigation, three of which related directly to instrument development. These three aims were: (1) to explore variance within a concept across a sample of the target population, that is, discover if diversity exists and if the concept acts as a random variable in the model; (2) to discover commonly used phrases or words that can be used in items to make instruments more meaningful to IVDUs; and (3) to discover naturally occurring scaling formats for use in instruments to foster validity of the findings. Two additional aims, to explore the relevance of concepts and to discover empirically the nature of relationships among concepts, were indirectly related to instrument development. Examining data collected in terms of these two aims would lend support or suggest changes in the model. The goal of this research is to produce instruments indexing model concepts. Instruments may be modifications of existing measures, if appropriate given the data, or may be newly constructed from the data. Design of the Study Question sets, consisting of four to six open-ended questions, were developed for all variables in stages one through four of the model except for the demographic variable. Each set explored questions of who, what, where, when, and why as appropriate for each variable (Table 1). Interviewers, experienced in administering the AIDS Initial Assessment (AIA), were trained during a one-hour session as to the purpose of this study, how to ask open-ended questions, and how to record responses. Interviewers were instructed to record answers verbatim. Interviewers were allowed to translate questions into Spanish, when necessary, and could then record responses in Spanish or English. A nonrandom sample of IVDUs provided the data. Each interviewer was given six copies of a question set and was instructed to administer that questionnaire to each of the next six respondents to the AIA. The question sets were asked immediately following completion of the AIA and the Southwest Trailer Form. Interviewers would finish a question set and then begin another batch of six-question sets. With this survey design, a respondent answered only one question set. For each respondent, the interviewer recorded sex and ethnicity. Approximately 45-50 surveys were completed for each question set. All data collection is complete. Content analysis (Miles and Huberman 1984; Weber 1985) is being used to examine these data. The focus of analysis reflects the aim of this qualitative study. Analysis of a question set examines data for the total sample of IVDUs responding to the set and also explores differences by sex and ethnicity when sample characteristics permit. Approximately 55% of our respondents were Anglo, with 33% Hispanic, 10% Black, and 2% Native American. Approximately 85% were male. 132 Figure 1. Model for AIDS-Preventive Health Behaviors Among Intravenous Drug Users Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Demographic Perceived Barriers to Action Perceived Control Over Health Preventive Action Likelihood of Taking Preventive Action Perceived Interpersonal Susceptibility Cues to Action Perceived Seriousness ituational Stuationa Perceived Benefits of Prevention TAdapted from Pender, 1983. 133 Table 1. Example of Question Sets Model Variable: Importance of Health 1. What does being healthy mean to you? 2. How important is being healthy to you? 3. Why is health important (or not important) to you? 4. Do you worry about your health? Model Variable: Perceived Seriousness 1. How does being ill affect you and your life? 2. Do you worry about getting sick? 3. What upsets you (or not upsets you) about getting sick? 4. If a person like you were to get AIDS, how would it affect his/her life? Findings Seven question sets have undergone initial analysis. This analysis has focused on the three aims directly related to instrument development. Those three are variance, wording, and response format. Findings presented here are preliminary and may change as analysis continues. Variance does exist within each concept when data from the total sample are considered. This finding suggests that each concept functions as a random variable and not as a constant in the model. The variance in responses within concepts appears to take on three patterns of distribution. For some responses (such as to the question “How important is your health?”), the pattern appears as a chi-square distribution with responses of “a lot” or “very much” occurring most frequently, but with a tail of responses across the continuum to “not much.” For some responses (such as to “Do you feel you are in control of your health?”), the pattern is bimodal (in this case, “yes” or “no”) but with some intermediate responses (in this case, “pretty much so,” “to some degree,” and “not necessarily”). The last pattern of responses (such as to “Do you worry about your health?”) suggests a normal distribution with the majority of responses falling between “very much” and “not at all.” 134 Clear implications for the phrasing or wording of items have not yet emerged from the data, and analysis continues. However, it is evident that the phrasing and wording of questions must be very carefully considered in translating from one language to another. For the few respondents who were Spanish speaking only, on-the-spot translation by experienced bilingual interviewers generated responses that suggested either a misunderstanding or a total lack of understanding of the question. Hispanic respondents who were English speaking, appeared to understand the intent of the same questions. The discrepancy between Spanish-only and English-speaking Hispanic respondents suggests that translation alone, not content of the questions, was problematic. Further instrument development will focus on Spanish-language tools. Approximately 20% of our current project participants are Spanish speaking only. Implications for a response format are emerging from these data. “Yes/no” responses are completely uninterpretable and should not be used in instrumentation. A similar combination of factors, experiences, and feelings may result in a “yes” response for one respondent and a “no” response for another. Sets of totally different circumstances may produce the same response from two respondents. These patterns of response categories appear consistent over question sets examined. For questions relating to behaviors, respondents seem to use “a lot” and “never” as anchors for the response range, but the usual Likert pattern for mid-range responses does not appear applicable. Instead, most respondents not electing the extremes for responses report frequency of behavior (e.g., “I go to the doctor every six months.”) or percent of time (e.g., “Condoms are 50% effective.”) for mid-range responses. Responses to questions on how the individual thinks about concepts or what the individual thinks of the concepts reveal a three-point response range. One example is “not really,” “sometime,” and “strongly.” Another pattern is “not much,” “not very much,” and “a great deal.” Responses to questions on feelings are diverse and appear amenable to the standard Likert format with anchors “none” to “a lot” or “nothing” to “extremely.” In general, data support relevance of the concepts to the target population and will function to further refine definitions of these concepts. Relationships among concepts are being explored, although the study design limits this exploration. No recommendations for the modification of existing instruments or the development of new instruments are possible until data analysis is complete. References Becker, M.; Haefner, D.; Kasl, S.; Kirscht, J.P; Maiman, L.A.; and Rosenstock, I.M. Selected psychosocial models and correlates of individual health-related behaviors. Med Care 15:27, 1977. Champion, V. Instrument development for Health Belief Model constructs. Adv Nurs Sci 4: 73, 1984. Emmons, C.; Joseph, J.; Kessler, R.; Wortman, C.B.; Montgomery, S.B.; and Ostrow, D.G. Psychosocial predictors of reported behavior change in homosexual men at risk for AIDS. Health Educ Q 13: 331, 1986. 135 Erickson, J.R.; Stevens, S.; Estrada, A.L.; and Glider, P. “Grounding interventions aimed at AIDS risk reduction in models of prevention.” Paper presented at the First Annual NADR National Meeting, Rockville, Maryland, October 1989. Joseph, J.; Emmons, C.; Kessler, R.; Wortman, C.B.; O’Brien, K.; Hocker, W.T.: and Schaefer, C. Coping with the threat of AIDS. Am Psychol 39(11): 1297, 1984. Kulbok, P. Social resources, health resources, and preventive health behavior: Patterns and predictors. Public Health Nurs 2: 67, 1985. Laffrey, S. Development of a health conception scale. Res Nurs Health 9: 107, 1986. Miles, M., and Huberman, A. Qualitative Data Analysis. London: Sage Publications, 1984. Murdaugh, C., and Hinshaw, A. Theoretical model testing to identify personality variables effecting preventive behaviors. Nurs Res 35: 19, 1986. Pender, N. Health Promotion in Nursing Practice. Norwalk, Connecticut: Appleton—Century— Crofts, 1983. Pender, N., and Pender, A. Attitudes, subjective norms, and intentions to engage in health behaviors. Nurs Res 35: 15, 1986. Rosenstock, I. Why people use health services. Milbank Q 44: 94, 1966. Rosenstock, I. Historical origins of the Health Belief Model. In: Becker, M., ed. The Health Belief Model and Personal Health Behavior. Thorofare, New Jersey: Charles B. Slack. 1974. pp. 1-8. Sechrist, K.; Walker S.; and Pender, N. Development and psychometric evaluation of the exercise benefits/barriers scale. Res Nurs Health 10: 357, 1987. Walker, S.; Sechrist, K; and Pender, N. The health-promoting lifestyle profile: Development and psychometric characteristics. Nurs Res 36: 76, 1987. Wallston, K., and Wallston, B. Health locus of control. Health Educ Q 6: 580, 1978. Weber, R. Basic Content Analysis. London: Sage Publications, 1985. Weinstein, N. Why it won’t happen to me: Perceptions of risk factors and susceptibility. Health Psychol 3: 431, 1984. 136 Acknowledgment Supported by the National Institute on Drug Abuse Grant #5R18DA0S5748. Authors Julie Reed Erickson, Ph.D., RN. Co-Investigator/Research Director Antonio L. Estrada, Ph.D., M.S.P.H.T Co-Principal Investigator Peggy Glider, Ph.D.§ Co-Investigator Sally Stevens, Ph.D.3 Principal Investigator TUniversity of Arizona College of Medicine Rural Health Office 3131 East 2nd Street Tucson, AZ 85716 $ Amity, Inc./COPASA 316 South 6th Avenue Tucson, AZ 85701 137 PRETEST EFFECTS OF THE AIA AMONG TREATMENT AND NONTREATMENT POPULATIONS Scott Ray, Adelbert Jones, Vernon J. Shorty, Joseph Bouie, Gail Wise, and Sheryl Ratcliff Pretest Sensitization in Quasi-experimental Research Pretest sensitization is a fundamental issue in quasi-experimental research. Membership in groups requiring comparison in research in the field (e.g., intravenous drug users [IVDUs] “in treatment” and IVDUs “not in treatment”) frequently predate the conceptualization of the research. The logistics of identifying and recruiting clients with predesignated attributes in the field can also inhibit random selection and assignment. When clients cannot be randomly assigned in respect to all quasi-experimental factors under consideration, it cannot be assumed that those clients (e.g., those in pre-existing groups) have statistically acceptable homogeneous levels of outcome variables prior to the administration of experimental stimuli, testing, or both (Winer 1971; Campbell and Stanley 1963). Under these circumstances, significant differences in outcome variables on post-tests cannot be inferred to be a result of experimental stimuli unless subjects are pretested to allow statistical comparison of antecedent levels of outcome variables. Thus, quasi-experimental designs typically require pretesting to establish a baseline on clients’ pre-existing levels of post-test measures (Winer 1971; Campbell and Stanley 1963). While the pretest establishes a baseline for comparing groups prior to the administration of experimental stimuli, it can also, in some cases, sensitize subjects to the issues or attributes being assessed. Such “pretest sensitization” can result in cognitive, attitudinal, or behavioral changes in the subjects being tested. Any effects of pretest sensitization are confounded with the effects of experimental stimuli in quasi-experimental designs limited to universal pre- and post- testing of two or more groups (Winer 1971; Campbell and Stanley 1963). Given these design complications, pretests should be evaluated for their potential to sensitize subjects and affect their post-test scores. If a pretest sensitization effect is suspected, the appropriate solution is to incorporate both pretested and nonpretested groups into each factorial group of subjects being tested. The basic model for this design in a classic two-group quasi- experimental analysis is the Solomon Four-Group Design (Winer 1971; Campbell and Stanley 1963). The result of this innovation in design is that post-test differences between pretested and non- pretested clients can be compared to partition pretest sensitization effects from the effects of quasi-experimental stimuli or factors. When the potential for pretest sensitization is evident and these precautionary design features are not implemented, confirmation of hypothesized 138 significant differences in outcome variables does not confirm the hypothesized effect of the experimental stimulus, because the extent to which the hypothesized differences is statistically significant could result from the confounded pretest sensitization effect rather than from that of the experimental stimulus. AIDS Initial Assessment (AIA) Questionnaire The AIA questionnaire was developed by NOVA Research Company for the National Institute on Drug Abuse (NIDA) for use in the National AIDS Demonstration Research (NADR) Project and other related programs. A counterpart, the AIDS Follow-up Assessment (AFA) questionnaire, was developed for follow-up assessment of clients six months after the administration of the AIA and experimental intervention (NOVA Research Company 1989). These pre- and post-test instruments are utilized in NADR programs to evaluate the effects of educational interventions targeted at changing behaviors that increase the risk of contracting and/or transmitting the human immunodeficiency virus (HIV) among high-risk populations (e.g., IVDUs, sexual partners of IVDUs, prostitutes). The use of these instruments has become fairly standard in other related NIDA-sponsored research as well as in related research sponsored by other National Institutes of Health (NIH) agencies such as the Centers for Disease Control (CDQ). The typical NADR program uses the AIA and the AFA to test the difference in effects between a “standard” and an “enhanced” intervention. While a wide variety of intervention strategies are being tested at the NADR sites, standard interventions are typically limited to presentations of less than 10 minutes that may be conducted at remote locations where outreach workers locate clients. These interventions focus on basic facts on HIV and its transmission, methods for cleaning syringes, condom use, etc. The AIA interview schedule requires approximately 45 minutes to administer and produces 700 variables for analysis. The interview covers a wide variety of intimate and sensitive topics, including extraordinary detail on drug-taking and sexual behaviors. Clients are asked to share information on (1) current sexual partners and practices; (2) lifetime history of drug use; and (3) other related topics such as experience with the criminal-justice system. At many sites, the AIA interview is followed immediately by the administration of additional localized questionnaires, HIV pretest counseling, and voluntary HIV-antibody testing. Given the extensive and intimate nature of the AIA, these researchers speculate that the interview itself might lead some respondents to reflect upon their high-risk behavior and that this process might, in some cases, lead to attitudinal and/or behavioral change. Finally, the AIA interview includes a 16-item test of knowledge about transmission of AIDS, and the interview requires the interviewers to review incorrect answers and explain the correct responses to the clients upon completion of the interview. Thus, the interview itself should have an effect on at least some clients’ level of knowledge about AIDS. Given the potential for a pretest effect of the AIA in comparison with the much more limited, shorter, less intimate, and more focused nature of standard interventions being tested, it is reasonable to speculate that pretest effects of the AIA not only exist, but also that these effects could very well exceed those of the standard intervention and some enhanced interventions. 139 Finally, the AIA itself might reinforce certain behavior and thus interact with both standard and enhanced interventions. These possibilities exceed the limit of the current research. The focus here is to test the initial general hypothesis that there is a pretest sensitization effect of the AIA that might be confounded with intervention effects in the two-group pre- and post-test designs presently used in most NADR programs. If there is a strong, significant, pretest effect of the AIA, in addition to complicating the analysis, the interview itself may prove to be an effective element of intervention. HIV Risk and Intravenous Drug Users The HIV currently appears to be spreading faster among IVDUs than among any other group. Preliminary results of HIV tests of IVDUs in New Orleans are currently yielding a 13% rate of HIV seropositivity. IVDUs typically transmit HIV by sharing needles and syringes without cleaning (or proper cleaning) between uses. IVDUs also contract and transmit HIV through sexual contact, and risk of sexual transmission is frequently related to trading sex for drugs or money. As a result, educational interventions designed to address the transmission of AIDS among this high-risk population typically focus on effective methods of cleaning needles and syringes, proper condom use, and other related topics (ROW Sciences, Inc. 1989). Methadone Treatment Methadone is used to treat heroin addiction by relieving the symptoms of withdrawal. Once the physiological necessity of obtaining heroin, and the cash to purchase it have been removed, the addict is relieved of the necessity of resorting to criminal means to satisfy his or her physiological need for heroin (Langrod et al. 1972; Mezritz et al. 1974; Lofchie et al. 1974; Rabin and Stimmel 1974). Pharmacotherapy is typically accompanied by limited counseling and referral to other support services that may help meet the needs of the individual. Most clients enroll in methadone rehabilitation voluntarily; this fact, in and of itself, frequently indicates a recognition and desire for a more “normal” lifestyle. Thus, methadone treatment tends, to some extent, to enable “normalization” of the addict’s life (Langrod et al. 1972; Mezritz et al. 1974; Lofchie et al. 1974; Rabin and Stimmel 1974). Heroin is the only addiction for which methadone is an appropriate treatment, and the use of heroin and other opiates (with the exception of Talwin) has waned during the past two decades as the use of other drugs has grown. Research at several NADR sites has indicated that heroin users tend to represent an “old guard” of IVDUs, while younger IVDUs are much more likely to report injected cocaine as their drug of choice (Langrod et al. 1972; Mezritz et al. 1974; Lofchie et al. 1974; Rabin and Stimmel 1974). As a result of these factors combined, clients in methadone-treatment programs are generally expected to be at lower risk of AIDS transmission than IVDUs who are not in treatment. Methadone is typically administered orally, and most methadone-treatment programs try to ensure that clients ingest the drug at the treatment site. Program staff also usually add substantial amounts of water to the methadone before giving it to the client. Both of these procedures are 140 intended to inhibit the clients’ ability to inject the drug (Langrod et al. 1972; Mezritz et al. 1974; Lofchie et al. 1974; Rabin and Stimmel 1974). Theoretically, clients in methadone treatment should not inject any drug, although some do find a means of injecting the methadone in order to produce a euphoric state. These clients might also inject other drugs (e.g., cocaine). Additionally, some clients inject larger amounts of heroin than would normally be required in order to “override” the methadone and produce a “high,” while relying on the methadone administered orally to prevent the symptoms of heroin withdrawal. Therefore, while a condition of methadone treatment is refraining from injecting drugs, some clients still use needles (Langrod et al. 1972; Mezritz et al. 1974; Lofchie et al. 1974; Rabin and Stimmel 1974). Nonetheless, individuals in treatment, as a group, should be expected to have lower levels of needle use than IVDUs who are not in methadone treatment. Given that IVDUs in methadone treatment are generally older, more “normalized,” and generally more stable than those who are not in treatment, it is also reasonable to suspect the former to have lower levels of high-risk sexual behaviors. IVDUs in treatment are also likely to have received information on AIDS through their participation in methadone treatment and can therefore be expected to have higher levels of knowledge about AIDS than IVDUs who are not in treatment. Finally, since IVDUs in treatment are thought to be likely to be more informed and at relatively lower HIV risk than IVDUs not in treatment, they are likely to have less concern about transmitting HIV. While heroin IVDUs in treatment are considered to be among the high-risk population of IVDUs, they are likely to be the lowest-risk subgroup of that population. Consequently, educational interventions are less likely to produce significant changes in knowledge, attitudes, and behaviors of this group, because they are likely to have relatively high pre-existing levels of knowledge and relatively low pre-existing levels of high-risk behaviors, especially in comparison with IVDUs not in treatment. Hypotheses Given the likelihood that IVDUs in treatment will engage in fewer high-risk behaviors, have higher AIDS awareness, less need for concern about transmitting AIDS, and less need to change their behavior, those in treatment are less likely to experience change in these attributes, and AIA pretest effects are therefore less likely to be manifest in significant differences between AIA- pretested and non-AIA-pretested clients who are in treatment. Moreover, pretest effects are more likely to be manifest among IVDUs not in treatment. Since pretest effects of the AIA are likely to reduce differences between treatment and nontreatment groups, treatment effects are more likely to be manifest between non-AIA-pretested treatment and nontreatment groups. Consequently, interactions are hypothesized regarding six dependent variables in which pretest effects (significant differences between AIA-pretested and non-AIA-pretested groups) are hypothesized to be found only among those IVDUs who are not in treatment, and treatment effects (significant differences between those in treatment and those not in treatment) are hypothesized to be found only among those clients who are non-AlIA pretested. The six dependent variables include: (1) Knowledge about AIDS—The percentage of correct responses that an individual gives on true-false test on AIDS; 141 2) Concern about transmitting HIV infection to others—An individual’s Likert Scale response reflecting the intensity of his or her concern about the possibility of transmitting HIV; (€)) Needle-risk behavior—The needle-use behaviors that place an individual at a higher risk of contracting and/or transmitting HIV; (4) Change in needle risk—Self-reported change in needle-use behaviors that should lower risk of contracting or transmitting HIV; 5) Sex-risk behavior—Sex-related behaviors that place an individual at a higher risk of contracting and/or transmitting HIV; and 6) Change in sexual risk—Self-reported change in sex-related behaviors that should lower risk of contracting or transmitting HIV. The independent variables in this analysis will operationalize the concepts of treatment status and pretest status. “Treatment status” refers to whether an individual is “in treatment” (methadone) or “not in treatment.” “Pretest status” refers to whether an individual was randomly assigned to the groups which were “AIA pretested” or “non-AIA pretested.” It is hypothesized that: 1) There is a significant interaction effect of pretest status (“AIA-pretested” versus “non-AlIA pretested”) and treatment status (“in treatment” versus “not in treatment”) on knowledge about AIDS. Non-AIA-pretested clients who are not in treatment will have significantly lower levels of knowledge than AIA-pretested clients who are not in treatment, and non-AlA-pretested clients in treatment will have significantly higher levels of knowledge than nonpretested clients not in treatment. 2) There is a significant interaction effect of pretest status and treatment status on level of concern about transmitting AIDS. Non-AIA pretested clients not in treatment will have higher levels of concern about transmitting AIDS than non-AIA-pretested clients in treatment. Non- AIA-pretested clients not in treatment will have significantly higher levels of concern about transmitting AIDS than AIA-pretested clients who are not in treatment. 3) There is a significant interaction effect of pretest status and treatment status on needle-risk behavior. AIA-pretested clients not in treatment will have lower levels of needle-risk behavior than non-AIA pretested clients not in treatment, and non-AIA-pretested clients in treatment will have lower levels of needle-risk behavior than non-AIA-pretested clients not in treatment. (4) There is a significant interaction effect of pretest status and treatment status on change in needle-risk behavior. Non-AIA-pretested clients not in treatment will have less change in needle-risk behavior than AIA- pretested clients not in treatment, and non-AIA-pretested clients in treatment will have more change in needle-risk behavior than non-AIA- pretested clients not in treatment. 5) There is a significant interaction effect of pretest status and treatment status on change in sex-risk behavior. Non-AIA-pretested clients not in 142 treatment will have less change in sex-risk behavior than non-AIA- pretested clients not in treatment, and non-AIA-pretested clients in treatment will have less change in sex-risk behavior than non-AIA- pretested clients not in treatment. (6) There is a significant interaction effect of pretest status and treatment status on change in sex-risk behavior. Non-AIA-pretested clients not in treatment will have less change in sex-risk behavior than AIA-pretested clients not in treatment, and non-AIA-pretested clients not in treatment will have less change in sex-risk behavior than non-AIA-pretested clients in treatment. Methods Sample and Procedures Clients enrolled in the Desire Narcotic Rehabilitation Center (DNRC), Inc., Methadone Treatment Program were recruited and randomly assigned to experimental and control groups. Outreach workers in the New Orleans NADR program also identified and recruited IVDUs who were not in treatment in the Desire Housing Project in New Orleans, and these clients were also randomly assigned to experimental and control groups. The AIA was administered as the experimental stimulus to clients in the experimental group. A follow-up interview and a brief questionnaire were administered two to three weeks following the AIA. The data collected in the second interview served as the data for analysis in this research. Control clients received only the follow-up interview during the same time that the experimental clients received their follow-up interviews. Instrumentation The test instrument consisted of: (1) the 16 knowledge items from the AIA, and (2) the Southwest Region Trailer Form (SWRTF). The SWRTF was created by Dwayne Simpson and associates of the Institute of Behavioral Research (IBR) at Texas A&M University, with the input of Southwest Region NADR grantees to accompany and compensate for selected deficiencies in outcome measures in the AIA and AFA questionnaires (Appendix A). The central variables of focus were scales of needle-risk behavior and sex-risk behavior, knowledge about AIDS, and level of concern over transmitting AIDS. Scales of needle-risk behavior and sex-risk behavior were developed by the IBR (Joe et al. 1989). A reprint is attached as Figures 19 and 20. The number of positive responses to SWRTF items 7a, 7b, and 7c, asking clients whether they had changed their needle-risk behaviors (reduced IV drug use, reduced needle sharing, and initiated procedures for cleaning syringes), were summed to produce a measure of “change in needle-risk behavior.” The number of positive responses to SWRTF items 7d, 7e, and 7f, asking clients whether they had changed their sex-risk behaviors (reduced number of sexual partners, initiated condom use, and sought information on AIDS), were summed to produce a measure of “change in sex-risk behavior.” 143 The percentage of correct responses on the 16-item knowledge test from the AIA was computed to represent each respondent’s level of knowledge about AIDS. SWRTF item 9, soliciting a Likert Scale response on concern about the possibility of transmitting AIDS, was used to operationalize concern about HIV transmission. Analysis The six dependent variables described in the previous section were analyzed in a (2x2) factorial multiple analysis of variance (MANOVA) using the factors of pretest status (AIA pretested versus non-AIA pretested) and treatment status (in treatment versus not in treatment). Significant differences between pretested and nonpretested groups indicated pretest effects of the AIA. Significant differences between clients in treatment and not in treatment represented methadone-treatment effects. Cochran’s C, Bartlett’s Box, and the Box M statistics were utilized to test the MANOVA assumptions of multivariate and univariate homogeneity of variance. Bartlett's test of sphericity was used to test the MANOVA assumption of correlation between the dependent variables. Since these assumptions could not be met by all of the variables in the analysis, those dependent variables upon which results showed significant differences on factors close to the criterion alpha level of 0.05, were also analyzed with the nonparametric technique, the Kruskal-Wallis One-Way ANOVA (analysis of variance) Test. Results Descriptive Statistics Figures 1 through 18 present the distributions of gender, the six dependent variables, the five items utilized to compute the scale of needle-risk behavior, and the six items utilized to compute the scale of sex-risk behavior. All clients studied were Black IVDUs. Eighty-one percent were male and 19% were female (Figure 1). A majority of clients (69.5%) scored 75% or better on the test of knowledge about AIDS (Figure 2). The mean knowledge score was 75.4%. Only 4.9% scored 50% or below and only 3.7% scored 90% or above. Figure 3 shows that over 20% claim to have a considerable amount of concern over the possibility of their giving AIDS to someone else; 22.5% claim to have no such concern. Scores on scales of needle- and sex-risk behaviors were recoded into categories for graphic presentation of the descriptive statistics. The needle-risk-behavior scale has a potential range of zero to 126, and the sex-risk behavior scale has a range from zero to 150. Figures 4 and 11 show that scores on needle- and sex-risk behaviors are skewed toward the lower-risk end of the scales. Regarding needle risk, 73.8% of the clients scored zero; 19.5% scored zero on sex-risk behavior, with another 44.1% scoring from one to five. The average scores were 4.07 for needle-risk behavior and 10.31 for sex-risk behavior. These results, in conjunction with the results on individual items utilized in computing these scale scores, reveal higher levels of sex risk than needle risk. Considering the characteristics of IVDUs in treatment, the skewed distributions toward lower levels of risk was expected, especially in regard to needle-risk behavior. However, as multivariate results will show below, these skewed distributions depart from normality 144 sufficiently to prevent the variables from meeting the MANOVA assumption of homogeneity of variance. Figures 5 through 9 present the distributions of those items that were combined and weighted systematically to create the scale of needle-risk behavior. These items all address needle-use behavior over the past six months. Nearly 28% reported “never” having used a new needle during that time, but 63.8% reported “never” having used an old needle after cleaning with bleach. Alternatively, 77.5% reported “never” having used a “dirty” needle previously used by someone else; 84% responded “zero” when asked how many persons they had shared needles with, and only 2.5% reported sharing needles with strangers. Nearly three-quarters of the respondents reported making at least two of three potential types of changes in needle-risk behavior, rendering them at lower behavioral risk of HIV in the past six months (Figure 10). Figures 12 through 17 present the distributions of items that were systematically combined to create the scale of sex-risk behavior. Figure 12 reveals that 30.9% reported having been celibate for the past six months, 45.7% reported having been monogamous, and 23.5% reported having had multiple sex partners. Figure 13 shows that 54.3% reported having had sex while intoxicated, and Figure 14 shows that 25% reported having had sex with another IVDU. Five percent (Figure 15) reported having had sex with someone they had not known well. Only 3.8% (Figure 17) reported having traded sex for money, gifts, or drugs. Fifty percent said they had implemented at least two of three possible types of changes in sex-related behaviors, placing them at lower risk of HIV (Figure 18). Originally, 55 methadone clients were identified and randomly assigned to the AIA-pretested group (30) and the non-AIA-pretested group (25). The AIA-pretested group was larger simply to give interviewers more experience in administering the AIA. Three subjects in the AIA- pretested group and four subjects in the non-AIA-pretested group declined to participate in the study. Twenty subjects were recruited and randomly assigned to each of the two pretest-status groups from the population of IVDUs who were not in treatment, and six of those who were pretested either could not be located or refused to return for the follow-up interview. MANOVA Analysis MANOVA is a technique used for testing group differences on a set of interval-level dependent variables. The advantages of MANOVA over traditional ANOVA are: (1) the availability of multivariate significance testing in addition to univariate significance testing, and (2) the fact that calculation of these multivariate significance probabilities takes into account the effects of correlations between multiple dependent variables. The result of both of these factors is a reduction of Type 1 error—rejection of null hypotheses that are true (Norusis 1988). When multiple tests of group difference are performed utilizing standard techniques developed for testing group differences on a single dependent variable, the researcher essentially “capitalizes on chance.” As null hypotheses are repeatedly rejected at a given level of significance (e.g., 0.05), the probability that a null hypothesis will be falsely rejected steadily increases. The multivariate test of significance resolves this dilemma, to some extent, by producing an estimate of the probability that the groups under analysis are collectively different on the entire set of dependent variables to a statistically significant degree. The testing of 145 differences between particular groups on distributions of multiple dependent variables with MANOVA, however, requires data that meet the assumptions of the statistical technique. Cochran’s C and Bartlett’s Box are two univariate tests of the MANOVA assumption of homogeneity of variance. Box’s M is a multivariate test of this assumption. In each case, a probability of less than 0.05 indicates that the assumption of homogeneity of variance is not met. Bartlett's test of sphericity is a test of the assumption that the dependent variables are correlated. A significance probability of less than 0.05 indicates that this assumption is met by the data (Norusis 1988). These results of these tests are presented in Table 1. Needle-risk behavior, sex-risk behavior, and concern about transmitting AIDS do not meet the assumption of homogeneity of variance on the basis of the univariate tests; consequently, the set of variables does not meet this assumption on the basis of the multivariate test. Recall that the discussion of descriptive results referred to the non-normality of the distributions of needle- and sex-risk behaviors and that these departures from normality result in the failure of these data to meet the assumption of homogeneity of variance. Given the inability of the data to meet these assumptions, judgment on the rejection of the null hypothesis will be reserved on significance probabilities close to the criterion level (0.04 to 0.06), unless statistical significance is confirmed by the nonparametric Kruskal-Wallis One-Way ANOVA Test. The group means corresponding to each dependent variable are presented in Table 2. Significant univariate effects are indicated as appropriate. The multivariate tests reveal that, collectively for the six dependent variables, there are significant interaction effects (p=0.031), significant treatment-status effects (p=0.000) and significant pretest-status effects (0.001). Univariate results will be reviewed in the order in which they are presented. There are no significant interaction, treatment status, or pretest-status effects (p<0.05) on knowledge about AIDS. Therefore, the results do not warrant the rejection of the null form of hypothesis 1 (i.e., there is a significant interaction effect of pretest status and treatment status on knowledge about AIDS in which non-AIA-pretested subjects who are not in treatment will have significantly lower levels of knowledge than AIA-pretested subjects who are not in treatment, and non-AIA-pretested subjects in treatment will have significantly higher levels of knowledge than nonpretested subjects not in treatment). Regarding concern about transmitting AIDS, there is no significant interaction effect and no significant pretest-status effect; however, there is a significant (p=0.005) treatment-status effect. These results do not warrant the rejection of the null form of Hypothesis 2 (i.e., there is a significant interaction effect of pretest status and treatment status on level of concern about transmitting AIDS in which non-AIA-pretested subjects not in treatment will have higher levels of concern about transmitting AIDS than non-AIA-pretested subjects in treatment, and non-AIA- pretested subjects not in treatment will have significantly higher levels of concern about transmitting AIDS than AIA-pretested subjects who are not in treatment). Alternatively, these results indicate that those in treatment are consistently less concerned about the possibility of transmitting AIDS than those not in treatment. 146 The results on the scale of needle-risk behavior reveal significant interaction effects (p=0.037), treatment-status effects (p=0.003), and pretest-status effects (p=0.013). These results warrant the rejection of the null form of Hypothesis 3 (i.e., there is a significant interaction effect of pretest status and treatment status on needle-risk behavior in which AIA-pretested subjects not in treatment will have lower levels of needle-risk behavior (X=2.61+-4.64) than non-AIA-pretested subjects not in treatment (X=13.73+-21.60), and non-AIA-pretested subjects in treatment (X=1.28+-5.44) will have lower levels of needle-risk behavior than non-AIA-pretested subjects not in treatment (X=13.73+-21.60). The results on change in needle-use behavior indicate a significant interaction effect (p=0.022), treatment-status effect (p=0.002), and pretest-status effect (0.039). Thus, these results warrant the rejection of the null form of Hypothesis 4 (i.e., there is a significant interaction effect of pretest status and treatment status on change in needle-risk behavior in which non-AIA-pretested subjects not in treatment (X=1.25+-0.91) will have less change in needle-risk behavior than AIA-pretested subjects not in treatment (2.00+-1.10), and non-AIA-pretested subjects in treatment (X=2.28+-0.71) will have more change in needle-risk behavior than non-AIA- pretested subjects not in treatment (X=1.25+-0.91). The results on the scale of sex-risk behavior indicate no significant interaction but a significant treatment-status effect (p=0.011) and a probability level on the effect of pretest-status (p=0.054) which are inconclusive, given the inability of these data to meet the MANOVA assumption of homogeneity of variance. Given the ambiguity of these results, the Kruskal-Wallis One-Way ANOVA (nonparametric) Test was computed to make each of the four comparisons. The results presented in Table 3 confirm only the significant difference (p=0.033) between treatment and nontreatment subjects among those who were not pretested. This is not surprising, because nonparametric tests are generally less powerful (i.e., less sensitive to significant differences) than parametric tests. The hypothesized significant difference between AIA-pretested and non- AIA-pretested subjects who are not in treatment is the greatest mean difference in Table 2 on the scale of sex-risk behavior; however, those means are accompanied by large standard deviations. Given the ambiguity of these results, judgment should be withheld on the significance of the difference between AIA-pretested and non-AIA-pretested subjects not in treatment pending further research. On the other hand, the results of the MANOVA yielded a sufficiently low F- score probability (0.011) on sex-risk behavior to accept the validity of this result. In other words, there are significant treatment-status effects across both categories of pretest status in which those in treatment have significantly lower levels of sex-risk behavior. Nonetheless, these results do not warrant the rejection of the null form of Hypothesis 5 (i.e., there is a significant interaction effect of pretest status and treatment status on sex-risk behavior in which AJA-pretested subjects not in treatment will have lower levels of sex-risk behavior than non- AIA-pretested subjects not in treatment, and non-AIA-pretested subjects in treatment will have lower levels of sex-risk behavior than non-AIA-pretested subjects not in treatment). Regarding the measure of change in sex-risk behavior, there is no significant interaction effect or treatment-status effect; however, there is a significant (p=0.000) pretest effect. These results do not warrant the rejection of the null form of Hypothesis 6 (i.e., there is a significant interaction effect of pretest status and treatment status on change in sex-risk behavior in which non-AIA- pretested subjects not in treatment will have less change in sex-risk behavior than AIA-pretested subjects not in treatment, and non-AIA-pretested subjects not in treatment will have less change 147 in sex-risk behavior than non-AIA-pretested clients in treatment). These results do indicate a significant pretest effect across the categories of treatment status. Among those in treatment, those who were AIA pretested (X=2.18+-0.73) report significantly more change toward less- risky sexual behavior than those who were not pretested (X=1.76+-0.70). Among those subjects not in treatment, those who were AIA-pretested (X=2.21+-1.05) report significantly more change toward less-risky sexual behavior than those who were not AIA-pretested (X=1.45+-0.88). These results on change in sexual behavior confirm a pretest effect that is not mitigated by treatment-status effects. Given these results, further research should be expected to confirm the pretest on the scale of sex-risk behavior. Table 1. Tests of Assumptions of MANOVA Univariate Homogeneity of Variance Tests P Knowledge about AIDS Cochran’s C (18,4) 0.39519 0.118 Bartlett-Box F (3,7590) 2.03287 0.107 Concern about transmitting AIDS to others Cochran’s C (18,4) 0.50744 0.003 Bartlett-Box F (3,7590) 8.22262 0.000 Needle-Risk Behavior Cochran’s C (18,4) 0.90441 0.000 Bartlett-Box F(3,7590) 58.78070 0.000 Change in Needle-Use Behavior Cochran’s C (18,4) 0.35386 0.327 Bartlett-Box F (3,7590) 6.99865 0.000 Sex-Risk Behavior Cochran’s C (18,4) 0.55036 0.000 Bartlett-Box F (3,7590) 6.99865 0.000 Change in Sex-Risk Behavior Cochran’s C (18,4) 0.32881 0.554 Bartlett-Box F (3,7590) 0.83562 0.474 Multivariate test for homogeneity of dispersion matrices Box’s M = 307.63657 F With (63,6916) DF = 4.04191 0.000 Chi square with 63 degrees of freedom = 257.44244 0.000 Bartlett’s test of sphericity = 37.66980 with 15 degrees of freedom Significance = P 20.001 148 Table 2. Group Means on Six Dependent Variables AIA Pretested Non-AIA Pretested Variable Mean S.D. Mean S.D. Knowledge about AIDS Treatment 71.77 9.70 75.00 14.11 Nontreatment 78.12 9.72 70.93 11.34 Concern about Transmitting HIV Treatment 2.59 0.69 2.28 0.90 Nontreatment 3.08 1.92 3.30 1.62 Needle-Risk Behaviort§* Treatment 0.14 0.45 1.28 5.44 Nontreatment 2.61 4.64 13.73 21.60 Change in Needle Uset$* Treatment 2.25 0.59 2.28 0.71 Nontreatment 2.00 1.10 1.20 0.91 Sex-Risk Behavior? Treatment 5.60 7.57 8.09 13.73 Nontreatment 9.46 11.60 20.05 21.46 Change in Sex-Risk Behavior$ Treatment 2.18 0.73 1.76 0.70 Nontreatment 2.21 1.05 1.45 0.88 tSignificant treatment effect. §Significant pretest effect. *Significant interaction effect. Table 3. Kruskal-Wallis Comparisons of Test and Treatment Status Groupson the Scale of Sex-Risk Behavior AIA Pretested Non-AIA Pretested P Treatment Subjects Mean Rank 23.10 23.98 0.8195 Nontreatment Subjects Mean Rank 12.96 18.19 0.1105 Treatment Nontreatment P AIA Pretested Subjects Mean Rank 19.40 19.69 0.9375 Non-AIA Pretested Subjects Mean Rank 16.45 24.14 0.0336 149 Figure 1. Sex of Respondents Figure 4. Needle-Risk Behavior 100 80+ 738 o 1 70 70 J 60; 60 50 4 50 4 40 o 1 30 20 | 20 | 10 J 10 6.3 2.5 3.8 0. 0) ; : Males Females 0 1-10 11-20 21-30 >3 Figure 2. Knowledge about AIDS Scores Figure 5. Use of New Needle 454 42.7 307 278 26.6 40 ; 35 30+ 25. 20 15 104 54 0 1 2 3.5 610 >I Figure 3. Concern about Transmitting Figure 6. Frequency of Use of Old AIDS to Others Needle After Cleaning with Bleach 45 41.3 70 1 63.8 40 1 : 35 30 + 25 1 20 + 15 | 10 1 5 0 A 5 3 0 : i Notat Alidle Some Alot All the 0 1 2 3-5 610 >I all same 150 Figure 7. Frequency of Dirty Needle Use Figure 10. Level of Change in After Use by Another IVDU Needle-Use Behavior 80 7 761 45 41.5 70 | 60 A 50 - 40 A 30 A 20 A 10 0 - 0 4 0 1 2 3.5 6-10 >10 No 1Change 2 Changes 3 Changes Changes Figure 8. Number of People with Figure 11. Scale of Sex-Risk Whom Respondent Has Shared Needles Behavior 9%; 8 4s, M2 80 4 40 | 70 | 35 60 + 30 A 50 4 25 40 | 20 | 30 4 15 - 20 | 10 - 10 ; 25 82 37 2s gp 59 0 ] 2 35 610 >10 OE T1560 11.20 2130 3140" 41-50 >50 Figure 9. Frequency of Sharing Needles Figure 12. Number of With Strangers Sex Partners 100 - 97.5 0 ; 457 90 A 80 1 70 | 60 A 50 4 40 A 30 4 20 A 10 - 2.5 0 + Sie, - 0 1 0 1 2 35 610 >10 151 Figure 13. Frequency of Sex Figure 16. Frequency of Anal While Intoxicated Intercourse 50. 100+ 962 45 40 35, 30. 25. 20. 15 10. 1 25 0 13 0 0 0 1 2 35 6-10 >10 1 2 35 610 >I Figure 14. Frequency of Sex Figure 17. Frequency of Trading Sq with an IVDU for Money, Drugs, or Gifts 100 ¢ 92.7 8.8 63 s s Never < Half the Half the > Half Usually/ time time the time Always Figure 15. Frequency of Sex with Figure 18. Change in Sex Behavio Someone They Didn't Know Well 50 1007 > 90 1 80 LE 70 60 - 50 1 40 30 1 20 1 10 1 2.5 0 2.5 0 0 0 p RRR RRR + + SEES + + 1 0 5 1 2 3-5 6-10 >10 0 Changes 1 Change 2 Changes 3 Chan 152 Figure 19. AlA-Trailer Sex-Risk-Behavior Components Sex Partners Number (Qx3.a) (Weight=1) range: 0-5 Sex While Intox (Qx 3.b) (Weight=1) range: 0-5 Sex With IVDU Freq. (Qx 3.c.1) (Weight=1) range: 0-5 Sex With Stranger Freq. (Qx 3.c.2) (Weight=1) range: 0-5 Anal Sex Freq. (Qx 3.c.3) (Weight=1) AlA-Trailer Sex-Risk-Behavior Components range: 0-5 Trade Sex Freq. (Weight=1) range: 0-5 153 range: 0-150 Figure 20. AIA-Trailer Needle-Risk-Behavior Components Dirty Needle: Any Use (Qx 1.b, Qx 1.c) (Weight=1) range: 0-1 Dirty Needle Freq. Qx 2) (Weight=1) range: 0-5 Dirty Needle Sharing: Number Persons (Qx 2.b) (Weight=2) range: 0-5 Dirty Needle Sharing: Stranger (Qx 2.2.4) (Weight=2) AJA-Trailer Needle-Risk-Behavior Components range: 0-5 154 range: 0-126 Discussion The general hypothesis of an interaction between pretest and treatment effects was confirmed in regard to needle-risk behavior and change in needle-risk behavior. Regarding these two variables, the pretest effect of the AIA was evident only among the generally higher-risk population of IVDUs not in treatment. In regard to sexual behavior, the pretest effect of the AIA was found to be strongly evident in terms of change in sex-risk behavior, but it was not interpreted by a treatment-status effect. Alternatively, no clear judgment could be made on the significance of the pretest effect as evidenced in the scale of sex-risk behavior, because the data did not meet the assumptions of the MANOVA technique and the statistical results were clearly borderline. There is not sufficient evidence to warrant the rejection of this specific application of the general hypothesis. While the pretest effect of the AIA was confirmed in two behavioral domains, it was confirmed neither in the cognitive domain of knowledge about AIDS nor in the attitudinal domain of concern about transmitting AIDS. No significant differences were found in regard to knowledge, and those in treatment were found to be less concerned about transmitting AIDS to others than those not in treatment. These results indicate statistically and clinically significant pretest effects of the AIA interview. The questions remaining for future research are: (1) the specific cognitive, attitudinal, and behavioral domains in which the AIA pretest effect is clinically significant; and (2) the extent to which this pretest effect might decline or intensify over time. These results have two major implications. First, they raise questions about applicability of a health-belief model in this area, because the pretest effect appears to affect behavioral domains without influencing cognitive and attitudinal domains. Second, confirmation of a pretest effect of the AIA indicates that projects using these instruments for program evaluation will be open to harsh criticism if they do not adopt a Solomon Four-Group or similar design allowing for the partitioning of program and pretest effects. One limitation of this research is that the AIAs administered as the experimental stimulus were among the first actual field interviews administered by the interviewers. It was for this reason that larger numbers of pretested treatment subjects were interviewed. The most important limitation is the inability to determine from the data whether clients actually changed their behaviors as a result of the AIA interview experience or whether they learned from the interview which responses were desired by the interviewers and responded accordingly. While this research cannot tell us why clients exhibit a pretest effect in their responses, it nonetheless confirms that as a result of the AIA, the IVDUs studied here learned some of what they needed to know to reduce their risk of contracting HIV. Despite the methodological complications created by the pretest effect of the AIA, those effects in and of themselves might be used as a forceful element of treatment. 155 References Campbell, D.T., and Stanley, J.C. Experimental and Quasi-Experimental Designs for Research. Chicago: Rand McNally, 1963. Joe, G.; Menon, R.; and Simpson, D. “Outcome Measures for the Southwest Regional Trailer Form for the AIA.” Paper presented at the meeting of the NADR Southwest Regional Research Group, Tucson, AZ. August 3, 1989. Langrod, J.; Brill, L.; Lowinson, J.; and Joseph, H. Methadone Maintenance from Research to Treatment. In: Brill, L., et al, eds. Major Modalities in the Treatment of Drug Abuse. Morningside Heights, New York: Behavioral Publications, 1972. Lofchie, S.; Davenport, D.; Turner, J.; and Rafalsky, T. Early performances as a predictor of treatment outcome in a methadone maintenance program. In: Senay, F.; Shorty, V.; and Alksne, H., eds. Development in the Field of Drug Abuse. Cambridge: Schenkman, 1974. Mezritz, M.; Slobetz, F.; Kleber, H.; and Riordan, C. A follow-up study of successfully detoxified methadone maintenance patients. In: Senay, F.; Shorty, V.; and Alksne, H., eds. Developments in the Field of Drug Abuse. Cambridge: Schenkman, 1974. Norusis, M.J. SPSS-X Advanced Statistics Guide. 2d ed. Chicago: SPSS, Inc., 1988. NOVA Research Company. Program Orientation Book for National Institute on Drug Abuse National AIDS Demonstration Research (NADR) Grantees and AIDS Targeted Outreach Model (ATOM) Contractors. Bethesda, MD, 1989. Rabin, J., and Stimmel, B. A follow-up of patients discharged from methadone maintenance. In: Senay, F.; Shorty, V.; and Alksne, H., eds. Developments in the Field of Drug Abuse. Cambridge: Schenkman, 1974. ROW Sciences, Inc. AIDS Outreach in the Community: Health Education and Prevention for the IV Drug User Participants Manual. Rockville, MD: ROW Sciences, 1989. Winer, B.J. Statistical Principals in Experimental Design. New York: McGraw-Hill, 1971. 156 Appendix A. Southwest AIA/AFA Trailer Form RESID: SITE: __ FORM: 1=AIA 9] [11] (CIRCLE) 2 = AFA [12] I need to review some earlier questions and clear up my records before we finish. Please use this card for some of your answers, and remember that everything you’re telling me is private. [HAND “ANSWER CARD” TO RESPONDENT] 1. Inthe last 6 months, how often did you — [USE “ANSWER CARD] a. shoot up any kind of drugs with needles (Works, rigs)?.....cccccevuninenuennne. —__* b. shoot up with brand new (never used) needles? .............coeeiiiiiiiiinnnnn. _ c. shoot up with used needles, but after cleaning them with bleach or Clorox (not just with Water)? ........coeveiiiriniiiiiiiininiiieniiiiennnnn. _ *IF “NO” IV Drug Use (i.e., Qla RESPONSE CATEGORY = 0), SKIP TO Q3: d. Does your wife/husband or usual sexual partner know you shoot drugs?........eeeviiiiiiiinnnnninnnn. 1.No 2.Yes 3.NA 2. How often in the last 6 months did you ever shoot up with a “dirty needle” —I mean one used earlier by someone else and you had not cleaned with bleach? [USE “ANSWER CARD | a eutiiiiii etter eee e te eaaeneeteaenaeaeesnttatasenenssneenenennenans * [17] *IF “NEVER” (RESPONSE CATEGORY = 0), SKIP TO O3: a. How often in the last 6 months did you share “dirty” needles (without cleaning them in bleach) with—[USE “ANSWER CARD] 1. your regular shooting partner(S)? .........oeeevininiiiiiiniineneieneininenennes . your wife/husband or usual sexual partner?.............cooeeiiiiiiiiiiiinn. . your friends or others you know well?.......cccoooviniiiniiiniiinninnns 2 3 4. strangers or others you don’t know very well? ..............oooiiiiini. 5 . men who have had sex with othermen? ..........cooeiiiiiiiiiiiiiiiinnnn. - 6. prostitutes (either male or female)? .............coooeiiiiiiiiiiiiiii. b. Altogether in those 6 months, how many people did you share “dirty” needles (rigs) with? [RECORD NUMBER].......... c. How many of them were people that you usually or regularly shot up with? [RECORD NUMBER] .............. [27-29] TRAILER-A IBR (8/89) 157 . In the last 6 months, how often did you have any kind of sex (vaginal, anal, or oral) with another person? [USE “ANSWER CARD] .....c.ccciviviiuiiiiiniiiiiiiininiinineninnen. *TF “NEVER” (RESPONSE CATEGORY = 0), SKIP TO Q 4: a. And how many sexual partners did you have in the last six months? [RECORD NUMBER]................... b. How often did you have sex while you or your partner were high (intoxicated) on drugs or alcohol? [USE “ANSWER CARD]............... _ c. How often in the last 6 months did you have unprotected sex (that is, without using a latex condom/rubber) — [USE “ANSWER CARD”’] 2. with someone you didn’t know well?.........cccooiiiiniiiiiiiiiiinniiiiiinnnnnn 3. involving anal sex (penis to anus)?........cccccceviiiiiiiiiiiiiiiiiiiiiinnnninnnn d. How often during the last 6 months did you ever trade sex for money, drugs. or gifts? [USE “ANSWER CARD] ......cccocviviiiiiiiniiiiiiinininininnnn, . Did you spend any time in jail or prison during the last 5 years? .......... 1. No* 2.Yes *IF “NQ”, SKIP TO Q5: [Remind client that this information will be kept confidential. ] a. During the last 5 years, did you ever shoot drugs while you were in jail or prison? ..........cccvviiiiiiiiiiiiiiinn, 1. No 2.Yes b. (IF MALE) Did you ever have anal sex (penis to anus) while you were there?.......ccoviiiiiiiiiiiiiiiiiiiiiiiiininnnnnenn, 1. No 2.Yes c. Just in the last 6 months, how many nights did you spend in jail or prison? [RECORD NUMBER]..........c.ccoviviiiiiniiininnn, IF “0” NIGHTS WERE SPENT IN JAIL/PRISON IN LAST 6 MONTHS, SKIP TO OQ 5!! d. How many different people did you shoot drugs with while in jail or prison during the last 6 months? [RECORD NUMBER]................. e. (IF MALE) And how many people did you have anal sex (penis to anus) with while in jail/prison during the last 6 months? [RECORD NUMBER]........c.cccocviviniiiiiiiiiniiiniiniennn, TRAILER-A, Page 2 IBR (8/89) 158 [43+ 49- . How often do you think about getting AIDS — not at all, a little, some, a lot, or all the time? [CIRCLE ANSWER] 1. Not 2. A 3. Some 4. A 5. Al 6. (Don’t atall little lot the time know) . How concerned or worried are you about getting AIDS — not at all, a little, some, a lot, or all the time? [CIRCLE ANSWER] 1. Not 2. A 3. Some 4. A 5. All 6. (Don’t atall little lot the time know) [53] . Have you done anything in the last 6 months to reduce your chances of getting AIDS? For instance, how often have you — [USE “ANSWER CARD;” ENTER “9” IF NOT APPLICABLE] cut back your IV drug use? .........oiuiiiiiiiiiiii ee — cut back your needle sharing? ..........coovviiiiiiiiiiiiiii -— cleaned your needles with bleach?............oooiiiiiiiiiiiii _ cut back the number of your sexual partners?..........coovviiiiiiiiiiiiiineninnnnn. _ used latex condoms for protection?.........ocoevviiininiiiiiiiiiiiiiiiiieeeans _ looked for more information about AIDS?........ccccoviiiiiiiiiiiiiiiiiiiiiiinnnnn. _ [59] mo a0 op . How many people do you know who have AIDS or have died of AIDS?.. _ __ _* *IF “NONE”, SKIP TO Q9: a. How many of them did you ever share a needle with?.................... —_— b. How many of them did you ever have sex with? ..........ccoooevvniiinn . How concerned or worried are you that you could be giving AIDS to someone else— not al all, a little, some a lot, or all the time? [CIRCLE ANSWER] 1. Not 2. A 3. Some 4. A 5. Al 6. (Don’t atall little lot the time know) [69] That’s all I have to ask you. Thanks for your help. AJA/AFA Batch Number Interviewer Name TRAILER-A, Page 3 IBR (8/89) 159 TRAILER-A, Page 4 IBR (8/89) [0]. [1]. [2]. [3]. [4]. [5]. [6]. ANSWER CARD 0 TIMES (NEVER/NONE) LESS THAN 4 TIMES PER MONTH ABOUT 1 TIME A WEEK 2-6 TIMES A WEEK ABOUT 1 TIME A DAY 2-3 TIMES A DAY, ALMOST EVERY DAY 4 OR MORE TIMES A DAY, ALMOST EVERY DAY 160 AIA-TRAILER NEEDLE-RISK BEHAVIOR Coding of Components Dirty Needle Use (Q 1.b, Q 1.c) 0=no 1 =yes Dirty Needle Use (Q 2) 0 = never 1 = less than 4 times/month 2 = one time/week 3 = 2 — 6 times/week 4 = daily 5 = multiple times/day Dirty Needle Sharing (number of persons) (Q 2.b) 1 2 3-5 6 -10 more than 10 wnmbhwn=—=oOo won onounnn Dirty Needle Sharing (strangers) (Q 2.a.4) 0 = none = less than 4 times/month 2 = one time/week 3 = 2 — 6 times/week 4 = daily 5 = multiple times/day TRAILER-A, Page 5 IBR (8/89) 161 AIA-TRAILER SEX-RISK BEHAVIOR Coding of Components Sex Partners (number) (Q 3.a) -5 -10 more than 10 0 1 2 3 6 nNHhwWwN=-=O mun nnn Sex While Intoxicated (Q 3.b) 0 = none 1 = less than 4 times/month 2 = 1 time/week 3 = 2 —- 6 times/week 4 = daily 5 = multiple times/day Sex with IVDU (frequency) (Q 3.c.1)* Sex with Stranger (frequency) (Q 3.c.2)* Anal Sex (frequency) (Q 3.c.3)* Trade Sex (frequency) (Q 3.d)* * Same code scheme as Q 3.b. TRAILER-A, Page 6 IBR (8/89) 162 Acknowledgment Supported by the National Institute on Drug Abuse Grant #DA-88-04. Authors Scott Ray, Ph.D.t Research Director Adelbert Jones, Ph.D.§8* Co-Principal Investigator Vernon J. Shorty, M.S. W.§* Principal Investigator Joseph Bouie, B.C.S.W., M.S.W., Ph.D.T Research Associate Gail Wise, M.S.WT Interventionist/Interviewer Supervisor Sheryl Ratcliff, B.C.S.W., M.S.WT Interviewer Supervisor/Database Manager Southern University of New Orleans 6400 Press Drive New Orleans, LA 70126 $Desire Narcotic Rehabilitation Center, Inc. 3307 Desire Parkway New Orleans, LA 70126 *Florida A&M University Tallahassee, FL. 32307 163 RELIABILITY OF THE SOUTHWEST RESEARCH GROUP AIA TRAILER FORM Adelbert Jones, Scott Ray, and Vernon J. Shorty Background The AIDS Initial Assessment (AIA) questionnaire was developed by NOVA Research Company for the National Institute on Drug Abuse (NIDA) for use in the National AIDS Demonstration Research (NADR) Project and other related efforts. A counterpart, the AIDS Follow-up Assessment (AFA) questionnaire, was developed for follow-up assessment of clients six months after the administration of the AIA and experimental intervention. These pre- and post-test instruments are utilized in NADR programs to evaluate the effects of educational interventions targeted to reducing behaviors that increase the risk of contracting and/or transmitting the human immunodeficiency virus (HIV) among high-risk populations (e.g., IVDUs, sexual partners of IVDUs, prostitutes). Use of these instruments has become fairly standard in other related NIDA-sponsored research as well as in related research sponsored by other agencies (e.g., the Centers for Disease Control [CDC]. The Southwest Region Trailer Form (SWRTF)* was developed by Dwayne Simpson and associates of the Institute of Behavioral Research (IBR) at Texas A&M University with the input of Southwest Region NADR grantees to accompany and compensate for selected deficiencies in outcome measures in the AIA and AFA questionnaires. This instrument is attached as an appendix. The focus of this research is to complete a preliminary assessment of the reliability of the SWRTF. Methodology Sample and Procedures The AIA and the SWRTF were administered to 28 IVDUs recruited by outreach workers in the New Orleans NADR program. These clients received no intervention and no HIV test. Clients were interviewed three to ten days later by a different interviewer with the same instrument. * See Appendix A of the preceeding paper, Pretest Effects of the AIA among Treatment and Nontreatment Populations, pages 157-162. 164 Analysis Analysis consisted of an item-by-item cross-tabulation of test and retest responses. Summary statistics were computed on each contingency table, including the (1) chi-square significance probability, (2) symmetric Somer’s D, (3) Pearson’s r , (4) percentage of responses remaining the same from test to retest, (5) percentage of responses representing change toward more risky behavior, and (6) percentage of responses representing change toward less risky behavior. Results The results of the analyses enumerated above are summarized in Table 1. Slightly less than half of the items tested produced the same response on the retest as much as 50% of the time. Test- retest correlations are generally low. Retest responses were more likely to indicate movement toward more risky behaviors. Table 1. Test-Retest Correlations and Reliability Percentages Item % Same % Lower % Higher ~~ Chi-Square Somer’s Pearson’s Risk Risk P D R 1A 25.0 35.7 39.3 3767 .34 44 1B 10.7 46.2 42.9 .8256 22 33 1C 21.4 32.1 46.4 7137 .20 17 1D 75.0 14.3 10.7 .2268 .13 .09 2 46.4 25.0 28.6 .9072 .26 .29 2A1 28.6 28.6 42.9 7391 .13 .25 2A2 28.6 35.7 35.7 9474 .02 .25 2A3 21.4 28.6 50.0 .1078 13 48 2A4 35.7 25.0 39.3 .8563 .02 .28 2A5 53.6 14.3 32.1 .4301 .07 .20 2B 32.1 21.4 46.4 .6837 .03 .03 2C 35.7 25.0 39.3 .5646 .00 12 3 46.4 21.4 32.1 .1929 25 37 3A 35.7 25.0 39.3 3619 33 .39 3B 21.4 28.6 50.3 .6564 .27 32 3C1 42.0 28.6 28.6 .2022 35 .56 3C2 57.1 14.3 28.6 .7103 21 .10 3C3 75.0 10.7 14.3 .9253 .02 .02 3D 53.6 25.0 21.4 .5625 .02 .04 4 53.6 25.0 21.4 1.0000 .04 .04 4A 66.7 25.0 8.3 .7866 .00 .00 4B 50.6 25.0 25.0 .5488 .16 13 4C 70.0 20.0 10.0 .8703 15 12 4D 100.0 0.0 0.0 .0000 .00 .00 4E 100.0 0.0 0.0 .0000 .00 .00 5 28.6 39.3 32.1 .1613 .07 .08 6 28.6 35.7 35.7 .8798 .07 .09 TA 53.6 21.4 25.0 5115 17 .19 7B 57.1 21.4 21.4 3338 .10 .16 7C 42.9 28.6 28.6 5316 17 .19 7D 50.0 21.4 28.6 .7837 .04 .09 TE 78.6 17.9 3.6 .0051 S51 53 3 78.6 3.6 17.9 1.0000 .07 .09 8 39.3 32.1 28.6 .2013 .24 .24 8A 100.0 0.0 0.0 .0000 1.00 1.00 8B 100.0 0.0 0.0 .0000 1.00 1.00 9 25.9 40.7 33.3 .3829 .02 .06 165 Discussion These results are highly limited, primarily because of the low number of clients studied. There is great variation in test-retest reliability from item to item, but the results generally show a low level of test-retest correlation. There are three probable explanations for the low level of reliability. First, many of the clients studied may not have clear notions of the frequency in which they engage in what have become routine behaviors. Second, traditional fixed-format-response interview schedules are, in general, likely to fail to meaningfully communicate substantive questions to this population. Third, there may be a pretest effect that leads clients to reflect and reconsider their responses between the administration of the two tests. Acknowledgment Supported by the National Institute on Drug Abuse Grant #DA-88-04. Authors Adelbert Jones, Ph.D.1* Co-Principal Investigator Scott Ray, Ph.D.§ Research Director Vernon J. Shorty, M.S.W.* Principal Investigator Desire Narcotic Rehabilitation Center, Inc. 3307 Desire Parkway New Orleans, LA 70126 §Southern University of New Orleans 6400 Press Drive New Orleans, LA 70126 *Florida A&M University Tallahassee, FL. 32307 166 REPORT ON RELIABILITY OF THE AIDS INITIAL ASSESSMENT QUESTIONNAIRE Max H. Myers, Frederick R. Snyder, E. Earl Bryant, and Paul A. Young This study of the reliability of the AIDS Initial Assessment questionnaire was undertaken as a cooperative effort among the National Institute on Drug Abuse (NIDA), NOVA Research Company (NOVA), and nine NADR grantees. The procedures for the collection of these data were based on a compilation of suggestions obtained from five regional research meetings held in February through April 1989. These procedures are discussed below in order to assist in interpretation of the data. For purposes of this study, reliability was defined as the consistency with which respondents answered the same question at two different points in time. This definition indicates that a test- retest method of reliability assessment, as opposed to internal consistency methods (e.g., Cronbach’s alpha or split-half), be used. For all variables except those in the AIDS Information Sheet, these latter approaches were deemed inappropriate because of the wide range of topics covered in the AIA (or even in sections of it). The prescribed test-retest interval was three to ten days after the initial AILA—long enough to minimize the effects of memory and short enough to reduce the likelihood of events that might alter responses on a second administration of the AIA. In this regard, participating sites were requested not to engage clients in HIV counseling and testing or planned intervention during the retest interval, since these activities might influence respondents’ answers at time of second interview. Since the purpose of the study was to estimate the reliability of the measuring instrument, different interviewers were to be used at initial and retest sessions for any single respondent. This procedure assumed that all interviewers were equally well trained and that a “reliable” questionnaire would elicit consistent responses over time from a given respondent, regardless of the interviewer. Participating sites did the initial coding of the questionnaires and sent hard copies of all interviews to NOVA. NOVA staff then performed final editing and coding of the questionnaire data to increase the consistency of data coding so that it would not attenuate the reliability estimates of the items. Materials and Methods The nine participating sites contributed a total of 239 pairs of interviews. Although the study plan required administration of the interview no sooner than three days and no later than ten days after the initial interview, we included interview pairs that were in the interval of two through fourteen days. Twenty-five respondents interviewed outside this range were excluded from the analysis. An additional 18 interview pairs were excluded because they did not meet NADR study eligibility rules that: (1) intravenous drug users (IVDUs) should have injected drugs during the six months prior to interview and should not have been enrolled in a formal drug-treatment program within 30 days of interview; and (2) sexual partners must not have injected drugs during 167 the past six months and must have reported having sex with one or more IVDUs during the past six months. One hundred ninety-six pairs were therefore available for this reliability analysis. The number of respondents was adjusted to account for skip patterns in the interview and to exclude respondents with missing values. These exclusions were done on a variable-by-variable basis. Ninety-five percent of the respondents were IVDUs, 72% were male. Forty-three percent were White, 35% Hispanic, 19% Black, and 3% other race/ethnicity. Reliability for each variable was assessed by three different measures: percent observed agreement, kappa with associated 95% confidence limits, and the Pearson correlation coefficient. In some instances, all three measures are presented; in others, only the measure(s) judged to be appropriate is (are) presented. In general, percent observed agreement and kappa statistics are shown for variables with nominal or ordinal categories, and Pearson correlations are indicated for continuous variables as well as those with ordinal responses. The percent observed agreement for a variable is defined as the ratio (x 100) of the number of respondents giving exactly the same answer on both the first and second interview to the total number of respondents. For example, for the variable “Ever used crack cocaine,” 165 of 196 respondents (84%) indicated the exact same answer on both interviews. Percent observed agreement of 80 or more represents acceptable reliability. The second reliability measure, kappa, is based in part on the percent observed agreement; however, it also provides an adjustment for the fact that a certain portion of observed agreement response could be due to randomly chosen answers (Siegal and Castellan 1988). Kappa is calculated as follows: kappa = B-F 100 -P. where Py is the percent observed agreement and Pe is percent expected agreement, derived from the overall frequency with which categories of a nominal or ordinal variable are reported. For example, when respondents were asked whether they had ever previously used crack cocaine, 53% percent reported no and 47% reported yes. Pe for this variable (percent expected to report the same answer on both interviews 1 and 2) is 100 [(.532)+(.472)]=50. Exact agreement for reporting crack cocaine use was 84%. Thus 84 - 50 100 - 50 This value of kappa indicates that observed agreement for use of crack cocaine exceeded expected agreement by 68%. kappa = = (0.68 If observed agreement exceeds expected agreement, kappa will be positive, with a maximum value of 1.00. Equality of observed and expected agreements would yield 0.00, implying that observed agreement is no better than random choice. Negative values of kappa, which are mathematically possible, would imply less than expected agreement. Assigning qualitative values to kappa is a subjective, but necessary, process that allows one to assess the results and to predict the implications. Other authors (Saltzman et al. 1987, and Landis and Koch 1977) have indicated that values of kappa between 0.41 and 0.60 represent moderate agreement; 0.40 or lower, poor to fair; and over 0.60, substantial to excellent. For interpreting our study results, we chose 0.50 or higher as a region for kappa that implied an acceptable level of reliability. 168 While examining our results, we discovered that if the expected agreement was over 90%, low values of kappa were sometimes observed, even though observed agreement was very high. On further investigation, we found that in this situation the value of kappa was extremely sensitive to slight changes in percent observed agreement. It appears that in cases like this, one should rely on percent observed agreement to properly interpret reliability. The Pearson correlation coefficient provides a third reliability measure: the extent to which respondents who reported high values on initial interview also reported high values on the second (and inversely). We report Pearson correlations for variables with ordinal scales as well as for those measured on a continuum. Pearson correlations of 0.70 or over are judged to represent good-to-excellent reliability. Cronbach’s alpha (Cronbach 1951), a measure of internal consistency, was used to evaluate the groups of items contained in the AIDS Information Sheet. This measure provides an assessment of the contribution of each variable to the total concept represented by each group of variables. Results In deciding how to assess consistency of responses one variable at a time, we chose to examine the data in their basic form rather than to aggregate responses into summary categories. For example, for the question “Thinking back over the past six months, please tell me how often you shot drugs at your own place?” the possible response choices were: “always,” “more than half the time,” “half the time,” “less than half the time,” and “never.” We could have constructed algorithms for counting as reliable responses those that were only one category different on the two interviews. While this strategy might improve the appearance of the reliability measures, it would not serve the stated purpose of the study, namely, to quantitatively determine the reliability of each question of the AIA. To facilitate discussion of study results, we constructed Table I, which displays the results for the principal variables that contribute to demographic characteristics, drug use, needle risk, sexual risk, and sentinel diseases. The following discussions of reliability for individual or groups of variables are directed to the results shown in Table 1 .1 While most of the results and discussion deal with reliability of basic variables, we present in Table 2 results for risk variables that were derived from groups of basic variables. In discussing our results, we judged a variable as being reported with acceptable reliability if any one of the three measures was at or above the arbitrarily established “critical” levels: 80% for observed agreement, 0.50 for kappa, and 0.70 for the Pearson correlation. In fact, in a few instances, we leaned toward “acceptable” when a value was several points below the established norms. In any event, the actual values are presented so that readers can use alternative rules for making reliability judgments. 1 A complete list of all AIA variables and their reliabilities is available upon request from the authors. 169 Demographic Characteristics This set of variables includes major classifications like gender and race/ethnicity and month and year of birth, which are used to calculate age. Indicators of socioeconomic status also are included. Except for “work situation,” all demographic variables had high reliability as determined by at least one of our three indicators. “Work situation,” however, showed only a 64% exact agreement between the first and second interviews—which was below the criterion of 80%; the kappa statistic (0.48) was only slightly below the 0.50 value for acceptability. Overall, these items elicited reliable responses from subjects. Drug Use Items in this section of the AIA provide a detailed description of the drugs a respondent has used, both intravenously (IV) or nonintravenously (non-IV), the frequency with which each drug has been used in the past six months by either route of administration, and the age at which each drug was first injected (if applicable). As background, clients were asked the age at which they were first intoxicated and the age when they first used any drug other than alcohol. These items were reliably reported as indicated by the correlation coefficients of 0.81 and 0.83, respectively. Ever Clients were asked to provide a simple “yes/no” response as to whether they had ever used each of the drugs provided in the list. Except for “other opiates or narcotics” (76%) and “tranquilizers” (76%), all drugs ever used had a percent exact agreement of 80% or higher. The kappa statistics were 0.51 and 0.52 for “other opiates” and “tranquilizers,” respectively, indicating acceptable reliability. In most cases where the percent exact agreement was high, the kappa statistic was also high (i.e., above 0.50). Two exceptions are worth noting: “alcohol” had a percent exact agreement of 97% but a kappa of only 0.43, and for “marijuana” the statistics were 93% and 0.38 for percent exact agreement and kappa, respectively. These two variables provide good examples of how extreme distributions (e.g., virtually everyone reports having used alcohol) cause kappa, or most other measures of association, including a Pearson correlation, to give erratic results. In this situation, we relied on percent observed agreement and concluded that questions regarding having ever used a drug elicited reliable responses. Frequency of Noninjected Drug Use Four drugs used in a noninjected manner—alcohol, marijuana, crack cocaine, and cocaine—were chosen as a function of their importance in the drug-abuse field. Only respondents who reported having ever used a particular drug were included in the reliability analysis of the reported frequency with which that particular drug was used. As shown in Table I, none of these four drugs demonstrated adequate observed agreement, nor does the kappa statistic indicate adequate reliability. However, the Pearson correlations of 0.75 and 0.68 for alcohol and marijuana, respectively, indicate that frequency of use of these two drugs was reliably reported. 170 F f Inj The important drugs in this category, based on AIA responses from over 12,000 IVDUs, are heroin, cocaine, and heroin and cocaine mixed (i.e., speedball). Like the reported frequency of non-IV drug use, the reported frequency with which these drugs were reported showed low percent observed agreement and low values of kappa. However, the Pearson correlations for these drugs were acceptable—0.68, 0.75, and 0.76 for cocaine, heroin, and speedball, respectively. Situations like this arise when a majority of respondents demonstrate a shift in reported frequency from the first to second interviews in the same direction (i.e., a systematic, as opposed to a random, shift in reported frequency of drug use). Such a situation, which is not uncommon in educational and psychological testing, was observed with data from this study. We conclude that frequency of injection of heroin, cocaine, and speedball was reported at an acceptable level of reliability. Needle Use This major group of variables was divided into five categories: (1) where respondent injects drugs; (2) with whom respondent shares needles; (3) renting/borrowing needles and sharing paraphernalia; (4) needle disposition; and (5) needle-cleaning practices. Responses to all these variables were given in terms of relative frequency (i.e., “always,” “more than half the time,” “about half the time,” “less than half the time,” “never”). Where Respondent Injects Drugs This set of variables examined the relative frequency with which respondents injected drugs at various locations. Based on all three measures of reliability, none of these variables was reliably reported. ith Whom Respondent Shares Need] This set of variables asked the relative frequency with which the respondent shared needles with each type of person: “no one,” “spouse/sexual partner,” “running partner,” “friends,” and “strangers”. The data indicate that most of these items were not reliably reported. Two exceptions were the reported frequency of sharing needles with strangers (percent exact agreement equals 80) and frequency of sharing needles with spouse/sexual partner (Pearson correlation = 0.65). Reliability for these variables as a group, however, was generally unacceptable. This set of questions concerned the relative frequency with which the respondent engaged in various needle-use and other drug-injection-paraphernalia practices, focusing on renting/ borrowing/sharing such equipment. None of the three measures of reliability indicated adequate consistency of responses from first to second interview. 171 -Disposition These variables were designed for obtaining information regarding passing of needles and equipment to other persons after self-injection. As a whole, reliability for this group of variables was unacceptable. Possible exceptions to this are “give/lend to sexual partner” (Pearson correlation = 0.67), “sell without cleaning” (observed agreement = 90%), and “reuse myself without cleaning” (observed agreement = 78%). Needle-Cleaning Pract This set of items focuses on new-needle use and the relative frequency with which respondents use various methods to clean needles that are not new. In general, these variables were not reliably reported. In two instances, frequency of “bleach use” and “tap water” to clean needles approached the established cut-off, with Pearson correlations of 0.65 and 0.69, respectively. Overall, the data suggest that the relative frequencies with which respondents engage in various behaviors related to their needle-use practices (including location, sharing, renting, disposition, and cleaning) are not reliably reported. It is interesting to note that, for all these items, the same response format (Card B) is used. One possible explanation for the lack of consistent responses may be that the response card is difficult to understand. Sexual Practices This set of questions focused on number of partners, whether or not these partners were IV drug users, condom use, and the frequency with which respondents engaged in various sexual acts, both with and without condoms. General Questions These items focus on number, gender, and IV-drug-use status of partners, and whether respondent has traded sex for money or drugs. All these variables are reliably reported, as indicated by the percent exact agreement (range = 85 to 100%), kappa (range = 0.53 to 1.00), and/or Pearson correlation (range = 0.92 to 1.00). Frequency of Sexual Practices This set of questions was used to obtain data on the frequency with which various sexual acts were performed, both with and without a condom or latex protection. The response choices (Card A) were: “less than four times per month;” “one time per week:” “two to six times per week;” “one time per day;” “two to three times per day;” and “four or more times per day”. Because the number of female respondents was low and the number of male respondents who reported male-to-male sexual activity in this sample was too low to permit valid analyses, only sexual practices involving a male respondent with a female partner are presented and discussed. Only a small portion of the sample of males (n=27) reported condom use, making interpretation of the reliability of reported frequency of sexual practices with a condom tenuous. Except for vaginal and oral sex, the remaining sexual practices are reliably reported, as indicated by the percent observed agreement. In addition, several of these have acceptable correlation coefficients 172 (anal, oral/vaginal, and oral/anal insertive), and one item (vaginal sex during partner’s menstrual period) had a kappa value above the 0.50 cut-off. Similar results were obtained with the reported frequency of sexual practices without a condom. Vaginal and oral sex were not reliably reported using any of the three measures of reliability, while the remaining sexual practices had high levels of percent exact agreement (range = 84 to 92%). Also, the kappa coefficient was above 0.50 for “vaginal sex during menstrual period” and “oral/anal insertive” practices. None of the Pearson correlations reached acceptable levels. The fact that those sexual practices that were most often reported (i.e., vaginal and oral sex) are the least reliably reported may indicate that the acceptable reliabilities obtained for the other sexual practices were artificially inflated, because 90% or more of respondents reported “none” for such activities. Health These items refer to whether respondents indicated that they had been told by a doctor or nurse that they had each of the diseases/conditions listed. As indicated by the percent observed agreement, these responses were consistent from first to second interview (range = 89 to 99%). For those items where only a few affirmative responses were given (e.g., AIDS-related complex), the kappa statistic is uninformative. AIDS Information Sheet This section of the questionnaire contains 16 items designed to assess respondents’ knowledge of human immunodeficiency virus (HIV) and AIDS, particularly behaviors associated with transmission and infection. The 16 items were divided, a priori, into three scales containing questions focusing on: (1) needle use (items 4, 8, 10, 15, and 16); (2) sexual practices (items 2, 3, 11, 13, and 14); and (3) general aspects about HIV (items 1, 5, 6, 7, 9, and 12). To assess the reliability of these scales, a measure of internal consistency, Cronbach’s alpha, was used to evaluate responses to the initial interview. This method was deemed appropriate because the AIDS Information Sheet is analogous to an educational test. Furthermore, it is possible to determine the correct answer to many of the items from the interview itself. Thus, an initial interview could be viewed as an event that would likely alter respondents’ answers to items on the AIDS Information Sheet at second interview. Cronbach’s alpha for the needle-use, sexual-practices, and general-knowledge scales were 0.36, 0.16, and 0.41, respectively, suggesting low reliability for these knowledge items (a value of 0.70 or more is usually considered acceptable). However, careful study of the formula? used to calculate these coefficients indicates that when the total scale score variance is low (as is true for all three scales) relative to the sum of the item variances, the reliability of the scale also will be low. Thus, these data suggest that the AIDS Information Sheet provides little discrimination among respondents. Thus, in the presence of a uniformly high level of knowledge reflected by the current questions, additional items may be needed that explore knowledge about more subtle Fre (ar) [eas where: n = number of items in the scale; p = proportion of persons who answer item correctly; and q = 1-p. 173 aspects of the relationship of HIV infection and prevention with specific behaviors. Such items might allow a more precise distinction of levels of knowledge among IVDUs. Derived Variables Derived variables were constructed from questions contained in the AIA in the areas of needle- use and sexual behaviors. These derived variables attempt to summarize important factors related to risk of HIV infection/transmission by combining discrete pieces of information contained in individual AIA items. Reliability data for these variables are presented in Table 2. Ni -Risk Variabl Three derived variables were constructed in the area of needle risk: (1) number of persons with whom the IVDU shares needles; (2) use of rented or borrowed needles; and (3) use of new needles and/or bleach-cleaned needles. For each of these variables, both the percent exact agreement (77, 81, and 77%, respectively) and the kappa statistic (0.55, 0.54, and 0.47, respectively) are very near or above the cut-off points, indicating adequate reliability. This is in contrast to the individual items used in constructing these derived variables, none of which demonstrated adequate reliability. A summary risk index was constructed from these three derived variables. This index classifies individuals as being at low, intermediate, or high risk of HIV infection as a function of needle- use behaviors. This summary index demonstrated adequate reliability (percent exact agreement = 79 and kappa = 0.54). iv xual-Risk Variabl A number of variables relevant to risk of HIV infection attributable to sexual behaviors were constructed from individual AIA items. Separate derived variables were constructed for males and females. The important concepts addressed by these derived variables were: (1) number of sexual partners who are IVDUs; (2) types of sexual activities in which individual engages (i.e., vaginal, oral, and anal); (3) whether the sexual act was insertive or receptive; and (4) frequency of condom use (i.e., never, sometimes, always) associated with each type of sexual activity. Males. Besides the number of IVDU sexual partners, derived variables were constructed for each type of sexual activity—vaginal, oral, and anal-insertive sex; and oral and anal-receptive sex—linked with frequency of condom use, defined as “never,” “sometimes,” and “always.” Based on the percent observed agreement (range = 80 to 98%), all these derived variables demonstrate a substantial degree of reliability. The kappa statistics also indicate that these variables are measured reliably, except for the variable assessing receptive anal sex (kappa = 0.39). This latter case is another example of an uninformative kappa value resulting from a high percent expected agreement relative to the percent observed agreement. Females. For females, the number of IVDU sexual partners and the receptive form of each sexual activity with its associated condom use were derived. All derived variables demonstrated substantial reliability, whether assessed by percent observed agreement (range = 78 to 91%) or the kappa statistic (range = 0.55 to 0.82). 174 SLI Table 1. Reliability for Selected Variables ___ Percent Agreement Pearson Variable n Observed Expected Kappa (95% CLs) Correlation Demographics Month of birth 196 98 9 0.98 (0.93, 1.00) --- Year of birth 196 --- --- --- --- --- 1.00 Gender 196 100 60 1.00 (0.83, 1.00) --- Race/Ethnicity 196 95 35 0.93 (0.83, 1.00) --- Highest grade of school 196 88 30 0.83 (0.74, 0.92) en Major source of income 186 73 20 0.66 (0.59, 0.74) --- Work situation 196 64 30 0.48 (0.39, 0.57) --- Living place 196 78 32 0.68 (0.58, 0.77) --- Current enrollment in a formal drug treatment program (yes/no) 195 99 99 -0.01 (-1.39, 1.00) --- Drug Use Age first intoxicated 184 --- --- --- --- --- 0.81 Age first used drug other than alcohol 194 --- --- --- --- --- 0.83 Drugs Ever Used Alcohol 196 97 96 0.43 (-0.21, 1.00) --- Glue/paint thinner/toluene 196 87 60 0.68 (0.51, 0.85) --- Marijuana 196 93 89 0.38 (-0.01, 0.77) --- Crack cocaine 196 84 50 0.68 (0.54, 0.82) --- Cocaine 196 94 87 0.56 (0.20, 0.93) --- Amphetamines 195 80 52 0.59 (0.44, 0.73) --- Heroin 196 96 70 0.88 (0.66, 1.00) --- Heroin and cocaine mixed 195 94 59 0.86 (0.69, 1.00) --- Non-prescription methadone 194 89 65 0.69 (0.50, 0.88) --- Other opiates or narcotics 194 76 50 0.51 (0.37, 0.66) --- Barbiturates 196 81 50 0.61 (0.47, 0.75) --- Tranquilizers 194 76 50 0.52 (0.37, 0.66) --- PCP 196 92 60 0.81 (0.63, 0.98) --- Hallucinogens/psychedelics: MDA 194 87 50 0.74 (0.60, 0.88) -- Nitrites and poppers 196 87 67 0.62 (0.42, 0.82) --- 9L1 Table 1. Reliability for Selected Variables (contd.) ___ Percent Agreement Pearson Variable n Observed Expected Kappa (95% CLs) Correlation Frequency of Non-IV Drug Use (past 6 months) Alcohol 185 44 15 0.34 (0.28, 0.40) 0.75 Marijuana 175 51 21 0.39 (0.31, 0.46) 0.68 Crack cocaine 76 37 19 0.22 (0.11, 0.33) 0.44 Cocaine 93 59 30 0.42 (0.29, 0.55) 0.24 Frequency of IV Drug Use (past 6 months) Cocaine 164 42 18 0.29 (0.22, 0.37) 0.68 Heroin 155 50 16 0.40 (0.33, 0.47) 0.75 Heroin and cocaine mixed (speedball) 131 52 19 0.41 (0.32, 0.49) 0.76 Needle-Use Behaviors Frequency of injecting at My own place 182 48 22 0.34 (0.26, 0.42) 0.59 Friend’s residence 181 51 27 0.33 (0.24, 0.42) 0.41 Party/social gathering 183 72 59 0.30 (0.12, 0.47) 0.50 Dealer’s residence 182 66 52 0.29 (0.14, 0.44) 0.56 Shooting gallery 182 70 52 0.38 (0.23, 0.53) 0.54 Abandoned building 181 70 46 0.45 (0.31, 0.58) 0.54 Street/park/alley/rooftop 181 68 46 0.41 (0.27, 0.54) 0.46 Frequency of injection with Spouse/sexual partner 183 64 38 0.41 (0.30, 0.53) 0.65 Running partner 183 49 29 0.27 (0.18, 0.37) 0.30 Friends/acquaintances 182 57 33 0.36 (0.26, 0.46) 0.43 Strangers 182 80 69 0.36 (0.15, 0.58) 0.48 No one (injected alone) 183 37 21 0.20 (0. 13, 0.28) 0.31 Frequency of needle practices Renting used needles 183 69 52 0.36 (0.21, 0.51) 0.32 Borrowing used needles 183 55 35 0.31 (0.20, 0.41) 0.49 Sharing cooker/cotton 183 48 22 0.33 (0.25, 0.40) 0.52 Table 1. Reliability for Selected Variables (contd.) LLT ___Percent Agreement___ Pearson Variable n Observed Expected Kappa (95% CLs) Correlation Frequency of needle practices (contd.) Sharing rinse water 183 49 22 0.35 (0.27, 0.43) 0.53 Obtain needle/syringe in sterile wrapper ~~ 182 46 22 0.31 (0.23, 0.39) 0.41 Frequency of needle disposition practices Give/lend to running partner 184 51 28 0.32 (0.23, 0.41) 0.40 Give/lend to sexual partner 184 66 39 0.44 (0.33, 0.56) 0.67 Give/lend to friends/others 182 49 32 0.26 (0.16, 0.36) 0.54 Throw away 183 36 21 0.18 (0.11, 0.26) 0.40 Sell without cleaning 184 90 87 0.25 (-0.13, 0.62) 0.38 Clean, then sell/give away 182 55 43 0.22 (0.09, 0.35) 0.34 Reuse myself without cleaning 183 78 69 0.31 (0.09, 0.52) 0.33 Clean, then reuse myself 183 45 24 0.28 (0.19, 0.36) 0.48 Frequency of using new needle 183 55 28 0.38 (0.29, 0.47) 0.48 Frequency of cleaning needle before injecting 137 60 41 0.32 (0.18, 0.46) 0.52 Frequency of cleaning needle with: Bleach 114 51 21 0.38 (0.28, 0.47) 0.65 Alcohol 114 46 32 0.21 (0.09, 0.34) 0.46 Boiled water 114 75 68 0.22 (-0.05, 0.49) 0.33 Tap water 114 43 21 0.28 (0.19, 0.37) 0.69 Sexual Practices Had sex in past 6 months? 195 96 78 0.82 (0.55, 1.00) --- Number of sexual partners 165 --- --- --- --- --- 0.97 (past 6 months) Gender of sexual partner 71 100 53 1.00 (0.75, 1.00) --- (if 1 partner) Partner an IV drug user? 70 90 52 0.79 (0.55, 1.00) --- (if 1 partner) Number of female partners ~ 78 --- --- --- --- --- 0.94 Table 1. Reliability for Selected Variables (contd.) Percent Agreement____ Pearson Variable n Observed Expected Kappa (95% CLs) Correlation Sexual Practices (contd.) Number of male partners 78 --- --- --- --- -- 1.00 Number of female partners who are IV drug users 50 --- --- --- --- --- 0.92 Number of male partners who are IV drug users 34 --- --- --- --- --- 0.96 Sex for money during the past 6 months 79 92 55 0.83 (0.59, 1.00) --- (multiple partners) Sex for drugs during the past 6 months 78 85 67 0.53 (0.21, 0.85) --- (multiple partners) Frequency of Kinds of Sexual Acts = Male respondent, female partner oo (with condom) Vaginal 27 37 21 0.20 (0.01, 0.40) 0.66 Oral 27 67 62 0.12 (-0.36, 0.60) 0.27 Anal 27 78 62 0.42 (-0.06, 0.90) 0.79 Vaginal during menstrual period 27 81 61 0.52 (0.05, 1.00) 0.17 Oral/vaginal 27 93 89 0.31 (-0.78, 1.00) 0.95 Oral/anal insertive 27 96 93 0.49 (-0.87, 1.00) 1.00 Oral/anal receptive 27 89 86 0.21 (-0.72, 1.00) 0.12 Male respondent, Female partner (without condom) Vaginal 106 47 19 0.34 (0.25, 0.44) 0.48 Oral 106 58 25 0.45 (0.34, 0.56) 0.43 Anal 106 85 71 0.49 (0.19, 0.78) 0.40 Vaginal during menstrual period 106 84 66 0.53 (0.27, 0.79) 0.58 Oral/vaginal 106 88 82 0.30 (-0.11, 0.71) 0.35 Oral/anal insertive 106 92 83 0.55 (0.13, 0.98) 0.63 Oral/anal receptive 106 87 81 0.29 (-0.11, 0.69) 0.32 6LI1 Table 1. Reliability for Selected Variables (contd.) ___ Percent Agreement Pearson Variable n Observed Expected Kappa (95% CLs) Correlation Health Ever told by doctor/nurse had Pneumonia 196 91 62 0.76 (0.58, 0.94) --- Hepatitis 196 94 63 0.84 (0.66, 1.00) --- Tuberculosis 196 97 87 0.80 (0.44, 1.00) --- Endocarditis 196 98 97 0.39 (-0.48, 1.00) --- Genital Herpes 195 98 97 0.39 (-0.48, 1.00) --- Gonorrhea 196 89 63 0.71 (0.52, 0.89) --- Syphilis 196 96 85 0.75 (0.42, 1.00) --- Chlamydia 196 96 94 0.31 (-0.25, 0.87) --- AIDS-related complex 196 98 98 -0.01 (-0.99, 0.96) --- AIDS 196 99 97 0.80 (-0.07, 1.00) --- 081 Table 2. Derived Variables Percent Agreement Variable n Observed Expected Kappa (95% CLs) Needle Risk Number persons share needles with 158 71 49 0.55 (0.40, 0.71) Rent/borrow used needles 183 81 59 0.54 (0.37, 0.71) Use of new/bleach-cleaned needles 185 77 56 0.47 (0.30, 0.63) Summary Index 158 79 55 0.54 (0.37, 0.71) Sexual Risk Males Number of IVDU sexual partners 141 86 52 0.70 (0.53, 0.88) Insertive vaginal 142 86 54 0.70 (0.52, 0.87) Insertive oral 142 80 47 0.63 (0.48, 0.78) Insertive anal 142 87 69 0.59 (0.34, 0.84) Receptive oral 142 96 91 0.55 (0.04, 1.00) Receptive anal 141 98 97 0.39 (-0.48, 1.00) Summary Index 141 84 53 0.66 (0.48, 0.83) Females Number of IVDU sexual partners 54 91 48 0.82 (0.57, 1.00) Receptive vaginal 54 91 69 0.70 (0.29, 1.00) Receptive oral 54 78 48 0.57 (0.32, 0.83) Receptive anal 54 87 71 0.55 (0.13, 0.97) Summary Index 54 87 48 0.75 (0.49, 1.00) References Cronbach, L.J. Coefficient alpha and the internal structures of tests. Psychometrika 16: 297- 334, 1951. Landis, J.R., and Koch, G.G. The measurement of observer agreement for categorical data. Biometrics 33: 159-174, 1977. Saltzman, S.P.; Stoddard, A.M.; McCusker, J.; Moon, M.W.; and Mayer, K.H. Reliability of self-reported sexual behavior risk factors for HIV infection in homosexual men. Public Health Rep 102: 692-697, 1987. Siegal, S., and Castellan, N.J., Jr. Nonparametric Statistics for the Behavioral Sciences 2d ed. New York: McGraw-Hill Book Company, 1988. Acknowledgments Supported by the National Institute on Drug Abuse Contract #271-88-8231. Authors Max H. Myers Senior Biostatistician Frederick R. Snyder Statistician E. Earl Bryant Senior Survey Statistician Paul A. Young Principal Investigator NOVA Research Company 4600 East-West Highway Suite 700 Bethesda, MD 20814 181 CHAPTER 1V HIV-TESTING ISSUES HIV-antibody testing and counseling, an option offered to all NADR program clients, presents a host of clinical, legal, and ethical issues. Included in this section are three papers that approach HIV testing from diverse angles. Strawn discusses client-related considerations confronted by researchers participating in an HIV-testing program. She emphasizes that counselors should be well trained for their role and be able to evaluate each client’s ability to deal with test results. Included in her paper is a summary of objectives of the counselor-training program developed and offered by the New Haven NADR grantee. Roggenberg and colleagues present data from their study of the relation between HIV-antibody testing and AIDS-risk behaviors among IVDUs. No statistically significant behavioral differences were found between tested and nontested clients; enhanced interventions, tailored to the needs of participants, are viewed as a more promising means of effecting behavior change. In the final paper in this section, Nemeth—Coslett discusses the importance of HIV test data to the outcome of the NADR Project. She restates NIDA policy concerning this issue; namely, that testing, regardless of its importance to the client and to the project, must be voluntary. A nominal payment for blood collection, common practice for research involving invasive procedures, is acceptable; payment as an incentive to return for test results is not. 183 HIV COUNSELING AND TESTING: ISSUES IN A RESEARCH CONTEXT Jill M. Strawn Introduction The Community Health Education Project (CHEP) is attempting to reach intravenous drug users (IVDUs) and their sexual partners through a mobile health van, door-to-door and neighborhood canvassing, a storefront center, and staff placement in community agencies known to serve our target population. All participants in the study are offered HIV counseling and testing. The dynamics of testing clients for research purposes, as well as their own self-knowledge, are complex. The people we reach generally have neither sought us out nor have they necessarily been planning on HIV-antibody testing. Their level of knowledge about the test and their emotional preparedness for the consequences vary greatly. The HIV-Antibody Test HIV-antibody testing was initiated in 1985 to protect the national blood supply (Centers for Disease Control [CDC] 1988). Each unit of blood in the system is tested for HIV antibodies before being administered to a needy recipient. If the blood shows the presence of antibodies, it is either discarded or used solely for research purposes. Prospective donors with a history of high-risk behaviors for HIV infection are screened by interview and are no longer allowed to give blood. While the blood supply is now much safer than it was prior to HIV testing, infected blood still can be undetected because of the delay between the date of infection and development of antibodies. The mean time period for antibody production is 6-12 weeks; however, there are reported cases of delayed production of several months to 16 months (Ranki et al. 1987). This is clearly a drawback to relying exclusively on the test either for screening the blood supply or for informing persons at risk of their possible exposure to HIV. Thus, when antibodies are not detected and someone is told that his or her test is “negative,” it could mean there has been no exposure or that there has not been sufficient time for antibody development. When someone receives a “positive” test result, the presence of antibodies indicates the person has been exposed to the virus, is probably carrying the virus, and is capable of infecting others. Recently there has been a change in public and political response to antibody testing (Goldblum and Marks 1988). Initially there was great fear of discrimination and concern about the accuracy and usefulness of test results to the infected individual and about the risk of significant psychological distress of knowing that one was infected (American Association of Physicians for Human Rights 1985). Testing has become more reliable, is offered anonymously across the 184 country, and perhaps most important, is a prerequisite for entering early treatment of HIV infection. Azidothymidine (AZT) is now routinely offered to individuals testing antibody- positive whose T-cell counts fall below a specified level. Aerosolized pentamidine is available as a prophylactic measure against pneumocystis carinii pneumonia (Goldblum and Marks 1988), and other medications are available through experimental protocols or through the not-so- underground network of “buying clubs.” As these changes have taken place, people at risk have been more willing to voluntarily get tested. Political opposition, particularly among the gay community, has softened and even done an about-face. Some groups are now encouraging HIV-antibody testing specifically because of the availability of early treatment. Other advantages to being tested are to: (1) help decide whether to become pregnant or to terminate a pregnancy; (2) assist in a medical diagnosis; (3) decrease anxiety about AIDS (if the results are negative and the person is at low risk); and (4) motivate behavior change for the safety and health of the tested individual and the protection of his/her partner(s). There are also significant drawbacks that might make testing unproductive or detrimental for particular individuals: (1) a negative test result in a high-risk individual may, in some cases, reinforce denial of vulnerability; (2) there is a risk of discrimination if testing is not done anonymously; even when testing is done anonymously, if someone shares the test results with persons who do not respect the confidentiality of the information, the information may be spread to people who are not knowledgeable or sympathetic; and (3) there is a potential for negative psychological reaction to HIV testing because of the mistaken belief that HIV infection means death. Psychological Distress Some people who have been tested experience nightmares and other sleep disturbances, self- imposed social withdrawal, social ostracism, relationship difficulties, acute and chronic anxiety, hypochondriasis, and depressive symptoms and suicide (Ostrow et al. 1989; Ricklefs 1988; Strawn, in press; Goldblum and Seymour 1987). Those individuals with a history of significant anxiety, depression, and acting-out behavior are of particular concern. Should their test result be positive, it is possible to precipitate a crisis to which their response could, in the extreme, lead to acting-out behavior, including suicide. Indeed, suicide rates are higher among HIV-infected individuals (Perry and Markowitz 1986; Marzuk et al. 1988) and IVDUs (Kosten and Rounsaville 1988) than in the general population. There are several points along the HIV- infection continuum that seem to be critical, vis-a-vis suicide (Goldblum and Moulton 1986). Receiving a positive antibody test appears to be one of them. Since pre-existing mental health is known to be one of the strongest predictors of future health (Kessler and Greenberg 1981), it is imperative that those responsible for pretest counseling be skilled at psychological assessment. Some of the questions that need to be asked are: (1) Is the test in the person’s best interest; i.e., does he/she have more to gain than to lose in taking it? (2) Before being tested, how much time does he/she need to assimilate what the test means and to determine the possible emotional consequences if the test were positive? (3) Can he/she gather necessary emotional support to deal with waiting until results are available (often several weeks) and with positive test results? (4) 185 Whom should he/she tell if the test is positive, and how? and (5) Under what circumstances should the counselor discourage testing? The greatest burden falls to the pretest counselor. HIV counselors have reported that it is unclear how much a client is capable of “taking in” once he or she has heard the words, “Your test is positive” at a post-test counseling session (Perry and Markowitz 1988). In addition, when clients come in to hear their results, there is often such anticipatory anxiety, that no meaningful counseling can be done before results are given. Given this common experience, it seems that the most important rational thinking and talking about the test will take place before the person is tested, perhaps while they are waiting for the results, and maybe after they recuperate from the shock of testing positive. Since it seems unwise to gamble about the presence of adequate coping strengths, standardized pretest counseling by skilled persons is critical. Placing such emphasis on pretest counseling does not mean that post-test counseling is unnecessary or meaningless. In fact, when giving positive test results, the counselor must be skilled at deciding how much time clients need to focus on their emotional response to the results and whether/how much they can participate in developing a specific plan for coping with them. If possible, a plan for the client is mutually agreed upon and put in writing. Depending on the counselor assessment, contact is made by phone one to three days later, and a return appointment is scheduled for a week or two later. Sometimes partners are involved in this post- test counseling. During the initial adjustment period after the client receives test results, the counselor assesses coping capacity and attempts to intervene, if necessary. Counselors Given the tremendous responsibility of pre- and post-test counseling, the choice, training, and supervision of counselors are important considerations. The criteria for hiring people for such a position must be identified. HIV counseling is not like all other counseling, and one should not assume that someone who has a counseling background in another specialty can do HIV counseling without further training. Some individuals find it impossible to take a nonjudgmental stance regarding sexual and drug behaviors because of their beliefs and values. Thus, the interviewing of potential candidates for a position that would include pretest and post-test counseling should be done by someone who can assess counseling skills or potential and the candidate’s capacity for a nonjudgmental approach to other people. Counselor Training Program After the counselor has been hired, training needs and resources must be identified and a training program developed. Some individuals may need to learn basic counseling skills, HIV information, and HIV counseling techniques. Others may only need the HIV information and HIV counselor training. Organizations in some areas of the country with high incidence of HIV infection may offer courses and certification in HIV counseling. If this is not an option, a program can be developed utilizing skilled counselor trainers and experienced HIV counselors (Appendix A). The training program should involve actual practice, first in role-play and then with clients. The counselor/trainer should be observed during a counseling session by the trainee, and roles should then be reversed. 186 Once the trainee is ready to see clients alone, a clinical supervision agreement needs to be worked out for the counselor’s ongoing support and learning. Case conferences are a good format for group supervision if there is more than one counselor in the agency. This strong emphasis on clinical skills for counselors may seem burdensome for research programs in which education is the primary focus. However, if HIV testing is done casually (as if it were any other blood test), the consequences for our clients could be grave. Each program should involve staff members in a discussion that includes the following questions: (1) What is the purpose of the HIV-antibody testing? (2) In whose interest is it being done? (3) How can the project get the research data it requires while respecting the clients’ rights and needs? and (4) How can the project provide skilled pre- and post-test counseling in the most cost-efficient manner? Since the NADR Project is attempting to reach IVDUs and partners, individuals who are primarily members of ethnic or racial minorities, there are additional sensitivities. Each racial/ethnic group reacts differently to HIV infection. African American and Latino communities, for example, have responded much more slowly and less vocally than the White gay population (Dalton 1989). It is particularly challenging to attempt to understand these unique reactions and to plan education, services, and research programs that respect the way each community views the epidemic. Support resources for those testing positive are not adequately in place for minorities, yet members of these groups express a pronounced reluctance to use the counseling and support services offered by organizations perceived as gay oriented. Thus, there is an ethical dimension to increasing the numbers of seropositive minorities who are aware of their status without providing them with appropriate support (Udin 1988). It has not been determined that knowing one’s serostatus changes risky behavior in those at risk for HIV. Counseling and education regarding safer sex and needle use can be provided to everyone, regardless of whether they are tested. 187 Appendix A. Counselor Training Program I. Areas of Knowledge A. Human immunodeficiency virus (HIV) 1. Spectrum of HIV infection; symptoms of infection and disease progression; most common opportunistic diseases 2. Routes of transmission, including specific risk behaviors and likelihood of infection by each; prevention strategies Effect of HIV on the immune system; antigen-antibody interaction Current approaches to treatment, including experimental drugs and AZT Cofactors in HIV infection; health behaviors that would increase likelihood of staying well; wellness-counseling resources B. HIV testing 1. What the test can and cannot do 2. How a positive and negative test can be interpreted 3. Validity and reliability of ELISA, Western Blot, and other confirmatory tests 4. Time involved in taking and interpreting the test; difference between incubation period and window of opportunity 5. Confidentiality 6. Political, social, and ethical issues C. Psychosocial aspects of HIV infection ®NAL Lifestyle issues related to HIV AIDS anxiety and phobia AIDS as a catalyst for conflict regarding sexual behaviors Hyphochondriasis Depression and suicide Stigmatization Impact on relations with family and significant others Motivators for behavior change Support services for clients with HIV infection and how to access them II. Skills Required of HIV Counselors A. Communication skills 1. 2. 3. Active listening Interviewing Teaching 188 IV. (Appendix A, continued) B. Assessment skills 1. Client's social and psychological status 2. Client’s ability to understand the HIV-antibody test and its consequences 3. Appropriateness of test for client: timing, coping strengths, and support C. Ability to integrate information re HIV for particular client to make changes in high-risk activities Ability to structure counseling session in designated time alotted Ability to facilitate decision making through appropriate interviewing and information sharing Ability to decide when referrals are necessary @ m mg Ability to document counseling data in required manner Personal Qualities Required of HIV Counselors A. Genuine feelings of warmth for the person(s) being counseled (i.e., unconditional personal regard) Capacity for empathic understanding of the client’s internal frame of reference Ability to be human and real Comfort with sexuality and ability to discuss with client in manner which puts him/her at ease Capacity to stay calm in the face of increased client anxiety Advocacy mindset @ ®» # ov av Recognition of personal limitations Qualifications of HIV Counselors A. Professional degree/certification B. Counselor training (preferably formal) C. Experience in counseling role with appropriate supervision Counselor Training Trainee becomes familiar and conversant with information listed in Areas of Knowledge (see previous page); suggested learning tools are reading materials, videotapes, audiotapes, attendance. Practical experience is gained through role-playing, watching experienced counselor with clients, and being observed while counseling. Discussion of these sessions focuses on refinement of all skills involved. Trainer approves the progression to solo counseling when trainee is ready. Clinical supervision is provided on an ongoing basis in group format, individual format, or both. 189 References American Association of Physicians for Human Rights. Resolution Regarding Uses of HTLV- III Antibody Testing. San Francisco, CA: American Association of Physicians for Human Rights, 1985. Centers for Disease Control. Update: Serologic testing for antibody to human immunodeficiency virus. MMWR 36(52): 833-839, 1988. Dalton, H. AIDS in blackface. Daedalus 118(3): 205-228, 1989. Goldblum P., and Marks, R. The HIV testing debate. Focus: A Guide to AIDS Research and Counseling 3(12): 1-3, 1988. Goldblum, P., and Moulton, J. AIDS-related suicide: A dilemma for health care providers. Focus: A Guide to AIDS Research and Counseling 2(1): 1-3, 1986. Goldblum, P., and Seymour, N. Whether to take the test: Counseling guidelines. Focus: A Guide to AIDS Research and Counseling 2(5): 1-3, 1987. Kessler, R., and Greenberg, D. Linear Panel Analysis: Quantitative Models of Change. New York: Academic Press, 1981. Kosten, T., and Rounsaville, B. Suicidality among opioid addicts: 2.5 year follow-up. Am J Drug Alcohol Abuse 14(3): 357-369, 1988. Marzuk, P.; Tierney, H.; Tardiff, K.; Gross, E.M.; Morgan, E.B.; Hsu, M.A.; and Mann, J.J. Increased risk of suicide in persons with AIDS. JAMA 259(9): 1333-1337, 1988. Ostrow, D.; Joseph, J.G.; Kessler, R.; Soucy, J.; Tal, M.; Eller, M.; Chmiel, J.; and Phair, J.P. Disclosure of HIV antibody status: Behavioral and mental health correlates. AIDS Educ Prev 1(1): 1-11, 1989. Perry, S., and Markowitz, J. Psychiatric interventions for AIDS-spectrum disorders. Hosp Community Psychiatry 37(10): 1001-1006, 1986. Perry, S., and Markowitz, J. Counseling for HIV testing. Hosp Community Psychiatry 39(7): 731-739, 1988. Ranki, A.; Valle, S.L.; Krohn, M.; Antonen, J.; Allain, J.P.; Leuther, M.; Franchini, G.; and Krohn, K. Long latency precedes overt seroconversion in sexually transmitted human immunodeficiency virus infection. Lancet 589-593, September 12, 1987. Ricklefs, R. Bleak prognosis: The specter of AIDS is haunting the lives of thousands who test ‘HIV Positive.” Wall Street J February 11, 1988. pp. 1w, le, col. 1. 190 Strawn, J. Psychosocial consequences of HIV infection. In: Durham, J., and Cohen, F., eds. The Person with AIDS: Nursing Perspectives. New York: Springer Publishing, in press. Udin, S. “Minority Issues Related to HIV Antibody Test.” Position paper, San Francisco, CA: Multicultural Prevention Resource Center, 1988. Acknowledgment Supported by the National Institute on Drug Abuse Grant #R 18DA05758-02. Author Jill M. Strawn, R.N., M.S.N. Director of Agency Outreach APT Foundation, Inc. 904 Howard Avenue New Haven, CT 06519 191 THE RELATION BETWEEN HIV-ANTIBODY TESTING AND HIV RISK BEHAVIORS AMONG INTRAVENOUS DRUG USERS Linda Roggenburg, Beverly Sibthorpe, Helen Tesselaar, Jeanne Gould, and David Fleming Introduction Through human immunodeficiency virus (HIV) counseling and testing, public-health workers are trying to change the HIV risk behaviors of intravenous drug users (IVDUs). This paper evaluates the relationship between HIV-antibody testing and safe shooting and sexual practices among IVDUs in Portland, Oregon, based on data from a needs assessment for a National AIDS Demonstration Research (NADR) grant funded by the National Institute on Drug Abuse (NIDA). We found that in this population, a history of HIV testing was not associated with perception of HIV risk, current sexual behavior, or needle-sharing practices. Methods From December 1988 through March 1989, 157 out-of-treatment IVDUs were interviewed. Thirty-nine percent of the interviews were conducted at the county jail, 36% were referred by a street outreach worker, 18% occurred at county clinics, and 6% at two private welfare agencies. The interview included questions about drug and needle use, assessment of personal risk of contracting HIV, sexual practices, and HIV-testing history. Participation was voluntary and confidentiality was assured. All coding was done by the medical anthropologist who conducted the interviews. The data, entered on a database system, were analyzed using SPSS-PC. Only 3 of the 102 HIV-antibody-tested respondents received positive results, so they were not separated out for analysis. Chi-square analyses were performed on two-by-two tables to determine statistical significance. Results The respondents ranged in age from 17 to 64 years old, with a mean age of 30. Sixty-two percent were male. Over half were White (61%); one-quarter were Black (25%). Seven percent were Native American, 5% Hispanic, and the remaining 2% were members of other minority groups. Although the majority (58%) had not graduated from high school, nearly one-third (30%) had attended some college. Demographic Comparisons Approximately two-thirds (65%) of the respondents had been tested at least once for HIV infection: 105 had been tested, 52 had not (Table 1). Groups did not differ by demographic 192 variables including age (mean age: 31 years tested, 30 years untested); gender (male: 59% tested, 71% untested); race (White: 65% tested, 57% untested; Black: 24% to 25%, respectively); and education (high school graduates: 57% tested, 56% untested). Risk and Shooting and Sexual Practices Respondents were asked, “Based on what you know about it, do you think your risk of being infected with the AIDS virus is: zero, slight, moderate, or great?” Forty-three percent of the tested group considered their risk to be moderate to great, compared to 33% of the untested group. Thus, 57% of the tested group and 67% of the untested group considered their risk of contracting AIDS to be slight to nonexistent. Safe shooting was defined as never sharing needles or always cleaning shared needles with bleach or alcohol. Fifty-nine percent of the tested group and 63% of the untested group reported sharing and not cleaning some of the time. In each group, 69% reported having multiple sexual partners in the past year. Of these respondents with multiple sexual partners, one-quarter or less reported always using condoms (25% tested, 14% untested). To determine the percentage of each group having unprotected, multiple-partner sex, the percentage not always using condoms (75% tested, 86% untested) was multiplied by 0.69, which corresponds to the percentage of those who reported having multiple sexual partners in the past year. It was found that 52% of the tested group (.69 x .75) and 59% of the untested group (.69 x .86) had unprotected, multiple-partner sex in the previous year. Persons Seeking Testing Because of Concerns Regarding Lifestyle There are two reasons someone might have been tested for the HIV antibody. One is because a third party, such as a plasma center, medical professional, or penal institution, requested or required it. The other is that the individual sought testing of his/her own volition because of concerns about a high-risk lifestyle. Consequently, we evaluated whether people who had sought testing might have responded more to the testing process. There was no significant difference between the lifestyle-tested respondents and the untested respondents regarding shooting safety. Forty-four percent of the lifestyle-tested group reported never sharing, compared to 50% of the untested group (Table 2). Of the lifestyle-tested group reporting multiple sexual partners (75%), only 8% reported always using a condom. In contrast, 25% of the group that had been tested who reported having multiple partners reported always using a condom. Given the limited sample sizes, these differences, although suggestive, were not significant. Conclusions In this population of IVDUs, history of HIV-antibody testing was not associated with age, gender, race, or education. Testing was also not associated with current needle-use or sexual practices, either in the population as a whole or in the specific subset of IVDUs who had sought testing due to concerns about their lifestyles. 193 Table 1. A Comparison of Tested and Untested IVDUs (expressed in percent) Tested Untested Characteristic (n=105) (n=52) Age Categories Less than 25 years 29 33 25 to 34 years 41 38 35 to 44 years 29 27 45 to 54 years 1 2 55 years or older 1 0 Gender Male 59 71 Female 41 29 Racial Group White 65 57 Black 24 25 All others 11 18 Education 51 17 4 79 M—49 49 17 34* *p<0.05. 270 Table 9. Harlem AIDS Project Preliminary Data September 1989 Participation and Return Rates for Intervention Group Session Participation Rate Number (in Percent) 1 82 2 761 3 74% 97% TReturn rate based on Session #1. § Return rate based on Session #2. perception of the level of staff commitment and concern, as well as clients’ interest in the activities of the groups. Subsequent analyses, focusing on the clients’ group-evaluation form and the process notes, may be helpful in obtaining further information regarding the return rate. Some Preliminary Impressions Based on staff impressions and the preliminary data collected thus far, some preliminary conclusions have emerged: e The project was implemented as planned. It has been demonstrated that clients will respond to the type of street and hospital outreach efforts used to recruit them for interviews, and about 80% will attend at least one risk- reduction training session. Ethnographic data indicate that the project is positively viewed by clients who feel project staff are interested in them and concerned about their well-being. e Clients are in need of many types of services, welfare and health related, and many are crack users. e Clients have experienced many traumas and risks in their lifetime, e.g., loss of family members, abuse, and homelessness. This may have an impact on their perception of the risk of AIDS and their ability to implement risk- reduction behaviors. Individuals who are confronted with high risks in their lives on a regular basis may perceive the threat of HIV infection as simply another risk, with a lower probability of occurring than many of the others. Questions regarding some of these preliminary impressions have been incorporated in the follow-up instrument (e.g., data on clients’ perception of risk). These will be included in the multivariate data analyses to assess their impact on measures of behavioral change. 271 Acknowledgment Supported by the National Institute on Drug Abuse Grant #R 18DA05746. References Botvin, G.J.; Baker, E.; Renick, N.L.; Filazzola, A.D.; and Botvin, EM. A cognitive- behavioral approach to substance abuse prevention. Addict Behav 9: 137-147, 1984. Des Jarlais, D.C., and Friedman, S.R. The psychology of preventing AIDS among intravenous drug users: A social learning conceptualization. Am Psychologist 43: 865-870, 1988. New York City Department of City Planning, Office of Planning Management and Support, Community District Needs. Fiscal Year 1989 Manhattan. New York, New York, 1989. Author Sherry Deren, Ph.D. Principal Investigator Narcotic and Drug Research, Inc. 11 Beach Street New York, NY 10013 272 INTERVENTION STRATEGIES FOR SEXUAL PARTNERS AT PROYECTO COMPANEROS Lynne N. Harrold Introduction This paper summarizes the intervention strategies for female sexual partners of intravenous drug users (IVDUs) at Abt Associates, Inc.’s, demonstration site in Juarez for the study of “AIDS Outreach to Female Prostitutes and Sexual Partners of IV Drug Users.” The National Institute on Drug Abuse (NIDA) funds this three-year project, which is carried out in three sites: Juarez, Mexico; San Juan, Puerto Rico; and Bridgeport, Connecticut. All sites offer counseling and voluntary HIV testing. The Juarez site is administered by the United States-Mexico Border Health Association (USMBHA). USMBHA is an El Paso-based affiliate of the Pan American Health Organization that develops and implements various health-promotion projects along the border. Proyecto Comparieros (Partners Project) is the name of the Juarez program. Juarez, Mexico, is a border town across the Rio Grande River from El Paso, Texas, and has a population of approximately 1.2 million. An ethnographic study conducted for this project estimates that as many as 5,000 IVDUs live in Juarez. The reported prevalence and incidence of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) have been very low. As of September 1989, there had been 36 reported cases of HIV infection among individuals living in Juarez (O. Castillo, personal conversation, September 25, 1989). Compaiieros faces a unique challenge. The AIDS epidemic in Juarez is still in its infancy. Asa result, many of the project’s clients believe AIDS is something that cannot affect them, especially as few know of anyone who is seropositive. Although AIDS information is readily available to them, clients fail to recognize the seriousness of the AIDS threat because it is still unseen. As one sexual partner of an IVDU told project staff, “AIDS is an epidemic in the U.S. only” (personal interview, April 25, 1989). This contradiction between the client’s denial and participation in Proyecto Compaiieros is paradoxical. As a result of the AIDS information discussed, clients have begun to accept their risk. Although this risk awareness is seldom vocalized, it is expressed in a particular behavioral change. Needle cleaning is now prevalent among the clients’ IVDU partners. Yet, for some women, denial continues throughout participation in the project. As one client said, “I don’t believe in it” (street prostitutes, personal interview, April 26, 1989). Fear of HIV infection may be the reason behind risk denial and participation. 273 Outreach The sexual partners of IVDUs live in many neighborhoods in or around Juarez. They are usually mothers of several young children and are economically dependent on their partners. AIDS Initial Assessment (AIA) data show that 55% of the sexual partners interviewed by Comparieros staff reported being “homemakers” or “unemployed.” Several factors account for this. First, tradition leads Mexican women to be emotionally and economically dependent on their sexual partners. Second, poor education and limited career opportunities hinder attempts by women to be financially independent. Sixteen percent of the sexual partners reported “no schooling” and 55% reported “grades 1-8” as the highest grade of schooling completed. Reaching sexual partners of IVDUs is a challenge that requires patience, persistence, and the cooperation of the IVDUs. Alma and Domingo Alarcon, recovering heroin addicts with strong ties to the drug community, are helping to meet this challenge. They formerly worked at a treatment program as counselors. Now, as outreach workers, they canvass the neighborhoods as a team, usually meeting male IVDUs through three male IVDUs whom they know well. Other target areas include a local jail and factories. The first step is getting to know the IVDUs and talking to them about AIDS, needle cleaning, and condom use. Eventually, Alma tries to make contact with their sexual partners. Building trust is a crucial step in this process, as most men are initially distrustful and refuse to refer their partners to the program. Women are generally more receptive to the project than are men, because it provides basic health information, prenatal health care, and laboratory tests such as Pap smears. Most men say that AIDS information would scare their partners. At least a month of constant contact with the male IVDU is needed before contact can be made with his sexual partner. Once contact is made, the women are invited to join a small group. These groups are closed so that members are not continually entering and leaving the group throughout the eight sessions. An influx of new faces may have a negative impact on the client’s willingness to discuss AIDS, family issues, and other personal and emotional concerns. Open groups are also offered; these differ from closed groups in that new people may join in at any time. They tend to be large educational sessions held at factories or at the project office. The discussions are informal and informative. Several closed groups for sexual partners have been held in Casetas, a small town located 45 minutes from Juarez and across the United States border from Fabens, Texas. Most of the local roads are unpaved, and other than a few small stores, one elementary school, and two churches, there are no services available. In particular, there are no local police; only the Mexican Federal police serve this jurisdiction. Casetas is a known point of drug trafficking between Mexico and the United States. Many of the men living in Casetas are involved in the drug trade and are themselves IVDUs. For the first two meetings held in Casetas, the women told their partners they were attending pottery lessons. Fear of punishment motivated the lie. Regular attendance at the group sessions has proved difficult for most of the women. Many of them are not aware of their risk and others tell project staff “I can’t go today” or “My husband won’t let me” (E. Moya, personal conversation, April 26, 1989). Some express fear of domestic violence, and one participant in the Casetas program has been the victim of such violence. One encouraging note is that one 274 woman who completed the curriculum has started her own group, where women can talk to each other about health issues. Intervention Outreach and interventions need to be culturally sensitive and tailored to the needs and educational levels of their participants. When told that their sexual partners could possibly infect them, clients reject the idea as contradictory to their cultural beliefs. Research with minority women in New York City found that unemployed women consider their sexual partner the economic provider and sexual decision maker of the relationship. Anything that affects his role as sexual decision maker affects her financial security (Worth 1988). As women learn more about AIDS, their denial of the risk for HIV infection may give way to fear. On the AIA, 63% of the sexual partners interviewed believe they have “some chance” or “high chance” of becoming infected with HIV. Education or other forms of intervention must provide coping mechanisms to respond to that fear as well as reasonable suggestions for behavior change. Initially, the intervention design called for open discussion groups leading to involvement in a series of eight closed support groups. Group discussions build communication skills and encourage risk acknowledgment. In the New York City study, the empowerment gained through women’s groups led to the adoption of some risk-reduction behavior change in drug- free women (Worth 1988). During the first year, individual contact, counseling, service delivery, and referral emerged as equally important group-intervention strategies. Comparieros is community based and as a result, continually strives to be responsive to the community. Rebeca Ramos, Community Coordinator of Comparieros, devised a curriculum to address the misinformation and myths prevalent among clients. Her educational philosophy emphasizes client participation in each phase of the process, which includes discussions of AIDS prevention, basic health care, and psychosocial issues. Comparieros’s project goals are discussed with women at the first meeting and at specific intervals throughout the eight sessions. Client participation is encouraged at every step. The curriculum has explicit instructions for the educator on ways to encourage participation and learning within the group. Listening to the questions and ideas of those within the group is of paramount importance. “When the participants talk, never tell them they are wrong . . . time for the participants’ own contributions should also be offered” (Ramos 1988). The staff adjust to the needs and educational level of the women, presenting the information accordingly and making it relevant to their situation. At the first meeting, clients are given basic information about AIDS: (1) what it is; (2) how it is transmitted; and (3) how to protect themselves against infection. Misinformation among the clients is common. One client told project staff that there was a cure for AIDS, based on something she saw on “The People’s Court,” a popular television show (sexual partners, personal interview, April 26, 1989). Even those who acknowledge the risk of HIV and AIDS commonly believe that only prostitutes or homosexual men can be infected with the virus. Even after discussing risk behaviors and HIV infection, many still deny the existence of AIDS and HIV in their community. The tendency to deny risk has also been found in a Seattle, Washington, study of younger IVDUs (Jacobs et al. 1988). In the words of a prostitute, “I am afraid of it [AIDS], but I don’t believe in it” (street prostitutes, personal interview, April 26, 275 1989). However, her actions contradict her words. She insists that all her customers use condoms and it is her customers, not her regular sexual partners, whom she believes can infect her with HIV. The challenges for Comparieros staff are to overcome the women’s denial and disbelief and to manage the resultant fear. In the second meeting, the myths and realities regarding AIDS and HIV are reviewed and other sexually transmitted diseases (STDs) are discussed. Many of the women have little knowledge of their own bodies. Slides and simple language are used to facilitate a clear and explicit description of STDs. In one class, none of the women had ever heard of STDs and they were unaware that any diseases could be transmitted by sexual intercourse. Drug use, needle use, and needle sharing are the topic of the third class. Vitamins and legal drugs are frequently injected in Juarez; thus, time is spent explaining that all needles should be cleaned, regardless of the substance being injected. Emphasis is placed on ways to clean needles with supplies the women have on hand. As a result of the outreach in Casetas, more IVDUs are using bleach. One outreach worker said, “Most of the guys I've talked to are using bleach to clean their works” (D. Alarcon, personal conversation, April 24, 1989). The fourth class is titled “Who I Am.” Discussion centers around family, self-esteem and taking control of one’s life. In Mexico, the woman's role has traditionally been to take care of her husband and children, placing her needs second to those of her husband and family. Furthermore, Latina women tend to resist seeking help unless there is a crisis (Worth 1988). In this session, the educator encourages the women to think about their role in the family and their own needs. It is difficult to encourage the women to speak up, especially if they fear physical violence. Educators are careful to adapt their presentations to the realities of clients’ lives. Condoms and other methods of birth control are discussed next. Most of the women have never seen a condom, diaphragm, or any other birth-control device. None of the women have used condoms (AIDS Initial Assessment [AIA] questionnaire 1988). The educators point out the effectiveness and cost of each device or option, and respond to concerns the women raise. Some women have expressed fear that the condoms would remain inside them after intercourse. Other women are concerned their partners will refuse. According to an outreach worker, many men living in Casetas refuse to use condoms. They don’t see the need and complain that “they don’t feel right” (D. Alarcon, personal conversation, April 24, 1989). One class is devoted entirely to the HIV test. When asked why they had not taken the HIV test on the AIA, most women reply that it is because of fear. Twenty-nine percent of the sexual partners said they were afraid they would “get AIDS from the test” (AIA 1988). Forty-three percent did not take the test because they were afraid others would find out. Thirty-three percent said they were afraid others would learn they “had AIDS” (AIA 1988). Staff require clients to receive counseling before and after taking the HIV-antibody test; those testing seropositive face serious consequences such as being abandoned by their family and social network. In the seventh class, AIDS and the family are discussed. Discussions range from how to take care of someone who is seropositive to being comfortable with someone who has AIDS. For these women, the possibility of having to deal with AIDS and HIV infection is very real. The educator explains ways to support a person who is seropositive or living with AIDS. In 276 addition, the meaning and consequences of a positive test result are reviewed. This session helps to prepare women for the future and to reduce their fear. The final session is an opportunity for curriculum participants to discuss any of the issues raised over the past seven weeks. Self-esteem issues are often reviewed at this time, as clients express great interest in this topic. After the final discussion, the participants, who are dressed in their Sunday best, participate in a graduation ceremony. Each is given a diploma certifying that she has completed the Comparieros curriculum. A small reception takes place after the ceremony. Cake and juice are supplied by the project and each woman receives a gift package containing perfume, lipstick, and other toiletries, as well as a photograph of herself receiving her diploma. The outreach workers, as well as the project’s clients, praise the project’s educational program. “I like the approach that we are using because we talk about health in general and include AIDS as part of our intervention. In that way we get to talk about drugs, family planning, STDs, etc.,” said one outreach worker (A. Alarcon, personal conversation, April 25, 1989). Proyecto Compaiieros has had success with open and closed groups as a means to reach and maintain contact with sexual partners. More than 40 closed groups and 100 open groups were held during the first year of the project. One reason for the success of these groups is the dedication and commitment of the staff. They follow up with members of the groups and schedule meetings at times convenient for the clients. For example, one graduation party was held at midnight. Second, staff have tapped into existing social networks. One group contained one mother and four of her daughters, and most groups rely on one participant to bring in friends and/or family members. Third, the female members of a family well connected into the drug culture in Juarez completed the curriculum classes. That led to acceptance by others and set a standard to follow. The project offers aerobics and information about nutrition, beauty, and health care in addition to the curriculum. Previously, English as a second language and stress-management classes were offered, but these were dropped due to a lack of client interest. Medical care (e.g., simple laboratory tests like Pap smears and diabetes screening), referrals, and counseling are also available. These services encourage continued contact with Comparieros after the groups end. Conclusion Proyecto Comparieros is the first AIDS-prevention organization in Juarez. It has been warmly received by local prostitutes and sexual partners of IVDUs. The project provides AIDS information that is critically needed by the public and medical professionals alike. As an example of the latter need, one staff member worked at a local hospital where, she recounted, nurses refused to enter the room of an AIDS patient without surgical gowns, gloves, and masks (I. Urzua, personal conversation, April 26, 1989). Locally, the project staff workers are seen as the AIDS experts, and clients appreciate the project’s information and services. One prison inmate exclaimed, “When I get out I'd like to volunteer for a similar job!” (female prison inmates, personal interview, April 24, 1989). Proyecto Compaiieros has been successful in reaching sexual partners of [IVDUs because of the experience and sensitivity of the staff, the excellent curriculum, and the availability of counseling, testing, and other needed services. Education sessions take place when and where it 277 is convenient for the clients. The staff are nonjudgmental and tailor the information to the client. Educators encourage the sexual partners to discuss their fears about asking their IV-drug-using partners to use condoms. The diversity of topics discussed in the sessions enables the clients to understand the many issues related to AIDS prevention and transmission. As a result of the project’s curriculum and other intervention tools, behavioral changes have occurred. Intravenous drug users in Casetas now report using bleach, and several prostitutes now always use condoms with their clients. More subtle attitudinal changes have been expressed among the sexual partners of IVDUs. Some women have considered using condoms or talking to their partners about condoms as a result of their participation in our program. References AIDS Initial Assessment Questionnaire (AIA) 8.0. NOVA Research Company, National AIDS Demonstration Research Project, National Institute on Drug Abuse, Community Research Branch, December 1988. Jacobs, S. “Intervention Ethnography in Two Communities at High Risk for AIDS.” Paper presented at the Annual Meeting of the Society for Applied Anthropology, Tampa, Florida, April 1988. Ramos, R. “AIDS Risk-Reduction Curriculum for Sexual Partners and IV Drug Users.” Unpublished paper, Proyecto Comparieros, El Paso, TX, 1988. Worth, D. “Self-Help Interventions with Women at High Risk of HIV Infection.” Unpublished paper, Montefiore Medical Center, NY, April 1988. Acknowledgment Supported by the National Institute on Drug Abuse Contract #271-88-8224. Author Lynne N. Harrold, B.A. Research Assistant Abt Associates, Inc. 55 Wheeler Street Cambridge, MA 02138 278 THE HISTORY AND DEVELOPMENT OF A CONSORTIUM FOR RESEARCH AND PREVENTION OF AIDS IN SOUTHERN ARIZONA Sally J. Stevens, Peggy Glider, Antonio Estrada, and Julie Erickson Introduction The prevention and spread of human immunodeficiency virus (HIV) among minority groups is a major thrust in public health. In a surveillance report conducted by the Centers for Disease Control (CDC) in May 1989, 43% of the AIDS cases reported were from ethnic minorities, particularly Black and Hispanic (CDC 1989). Close to 50% of these cases were directly or indirectly related to intravenous (IV) drug use. Furthermore, 75% of the children who have acquired AIDS through maternal transmission are Black or Hispanic. HIV infection in the majority of these children can be traced directly to their mother’s IV drug use or indirectly to the sexual partners of the mother (New York City Department of Health 1988). The urgency of the AIDS crisis has inspired public health officials to call for a range of interventions designed specifically to target individuals from ethnic minorities whose behaviors place them at risk for HIV infection (Koop 1987; Hopkins 1987). The challenge to health workers is a unique one that calls for a range of intervention designs that, if yet unproven, are at least promising. Intravenous drug users (IVDUs) within the minority communities are often very difficult to reach. Attempts to draw them into education sessions offered at social service agencies and public schools have not been effective. Taking programs directly to the target populations via community outreach appears to be more effective in reaching this at-risk population. Jones and Downing (1988) identify three general approaches for outreach work: (1) leafletting; (2) getting to know gatekeepers; and (3) being escorted by an insider. Responses to these approaches are complicated by many other factors, including how well the outreach workers know the community and the type of community in which outreach is being conducted. In an attempt to respond to the urgent need for HIV-prevention work targeting the IVDUs and their sexual partners within the minority communities of southern Arizona, a number of agencies developed a consortium approach to outreach work. Several of the social service agencies in Tucson and Nogales, Arizona, had already developed positive relationships within various minority communities within southern Arizona. It was believed that such relationships would facilitate outreach work in the area of AIDS prevention. Thus, in September 1988, the Community Outreach Project on AIDS in Southern Arizona (COPASA) was formed by six social-service agencies in southern Arizona and the College of Medicine of the University of Arizona. 279 Consortium Membership The specific responsibilities within COPASA were divided as follows: Amity, Inc., serves both as the administrative agency for COPASA and also facilitates outreach in the criminal justice system. It was selected for the latter role because of the positive working relationships it had already established with many agencies involved in the criminal justice system. Amity manages a successful therapeutic community (TC) for substance abusers within the county jail. Amity’s long-term TCs for substance abusers serve adjudicated adolescents, adults on probation and parole, adults on intensive probation, and adults awaiting sentencing. Amity’s pre-existing positive relationship with criminal-justice administrators would, COPASA leaders believed, facilitate setting up outreach for HIV research and prevention in the county jail and the work-release center, and for clients on probation and parole. CODAC Behavioral Health facilitates outreach to persons on drug treatment waiting lists. CODAC was selected for this role because of its positive relationship with many of the drug treatment centers in Tucson. The approximate time that an individual seeking residential drug treatment must remain on a waiting list is nine months. Many of those awaiting treatment fit the entrance criteria to COPASA. It was assumed that CODAC would be able to network with social service agencies that provide substance-abuse services and enroll persons who fit the COPASA entrance criteria on waiting lists. LaFrontera was selected to facilitate the sexual partner component of the outreach project because many of this agency’s services already target this population. LaFrontera is well known and well accepted within the minority population, especially among minority women. Pima County Health Department was selected to provide outreach services to hospitals and health-care centers since it had already set up an AIDS program and had established working relationships with some of the Tucson hospitals and health-care centers in areas such as AIDS education and HIV counseling and testing. Southern Arizona Behavioral Health Services (SEABHS) was selected to provide all outreach services in Nogales, Arizona. SEABHS had established positive working relationships with many of the networking agencies in Nogales. SEABHS is located on the U.S./Mexican border, and it was thought that the community outreach project could best be facilitated by an agency located in the specific community. The Tucson AIDS Project (TAP) was selected to provide the street outreach component of COPASA because it already had an active and ongoing street outreach component. The staff from the Tucson AIDS Project and the name of the Project are familiar to many of the target population, particularly IVDUs and prostitutes. The Tucson AIDS Project had already built a trusting relationship with the people on the streets, in bars, and in parks. Many potential COPASA participants had previously accepted bleach and condoms from the TAP outreach workers. The College of Medicine of the University of Arizona was contracted to provide for the research and evaluation component of the project. It was decided that the University could best provide the expertise needed to facilitate proper research design and data analysis for the entire project. 280 Additional Planning Issues After determining which agencies were interested in being part of COPASA and which agencies best fit the needs of the National AIDS Demonstration Research (NADR) Project, the individuals involved in planning the consortium had to deal with still other issues. During the development and pilot stages of the project, issues such as turf, target population, and competition between components of the consortium arose. Much of the outreach overlapped; for example, some of the potential COPASA clients were on probation (criminal justice component) and on a drug treatment waiting list (waiting list component). Clear guidelines therefore needed to be developed to ensure consistency among the member agencies. A mutually agreeable plan for a referral system between agencies had to be developed. One of the positive aspects of a consortium is that it brings together individuals and agencies with many different specific areas of expertise. To tap the expertise of individuals from the various participating agencies, several committees were set up to address issues such as: (1) the pros and cons of HIV-antibody testing in Arizona; (2) content of the AIDS-education session; and (3) standardization of the two interventions. Working from NIDA guidelines, the research model (a modification of Becker’s Health Belief Model and Pender’s Health-Protecting Behavior Model), and the specific areas of expertise that the various staff/agencies brought to the project, an innovative outreach and intervention plan was designed. Client Response to AIA and Level of AIDS Knowledge Thus, upon the opening of the project, many issues had been resolved; however, some concerns lingered. Two concerns that were not resolved during the planning stage included: (1) the possible negative effect that the AIDS Initial Assessment (AIA) might have on the participant; and (2) the amount of AIDS transmission/prevention information that the participant had acquired prior to entering COPASA. Concerning the former, many staff feared that the questions on the AIA might bring up emotionally sensitive issues and cause psychological distress for the participants. Given these concerns, the outreach workers were instructed to question all participants regarding how they felt about the AIA and the perceived emotional impact that the AIA might have had on them. This question was posed orally to the participant directly following the administration of the AIA and prior to the educational intervention. The open-ended forms were content analyzed to determine the range of reaction to the AIA. Data were analyzed by two independent raters who provided inter-rater reliability of .96. Responses to the interview are categorized in Table 1. Responses to the AIA varied dramatically among agencies. Several factors might account for this discrepancy. Initially, COPASA staff wondered if outreach workers from the various agencies were asking the questions regarding the reaction to the AIA in the same way, or with the same intensity. Further investigation revealed that although all outreach workers asked the same questions as outlined for them, some probed further than others by clarifying or restating the question. A second consideration was that participants on drug treatment waiting lists might be more motivated to examine personal issues than others who did not want to give up their lifestyles. Thus, CODAC evidenced 72% positive responses, as compared with the 20%, 24%, and 48% evidenced by other agencies. The outreach workers were given additional training regarding standardization of the research questions, and further analysis of discrepancies in responses will be conducted at a later date. 281 Table 1. Responses to the AIA Interview! (May - July 1989) Outreach Agencies Nature of CODAC SEABHS LaFrontera TAP Responses (n=25) (n=5) (n=134) (n=77) Positive 72 20 24 48 Neutral 12 40 14 pI Negative 4 40 60 21 No response 0 0 1 0 Money 12 0 1 0 Totals 100 100 100 100 "Expressed in percents. Positive: The AIA went well, liked interviewer, it was okay, interesting, comfortable, informative, a breeze, real cool, good attitude, very positive, strange but fun. Neutral: The interview went as expected, not too bad, better than expected, boring, noncommittal, okay, I guess. Negative: Scared, nervous, too personal, embarrassing, shocked, annoyed, suspicious, defensive, concemed, confused, did not like the interviewer, pretty intense, too long. No response: The participant did not provide any feedback to the AIA. For the money: The cash incentive was the participant’s only motive for completing the AIA. 282 Given that southern Arizona has a low incidence of HIV infection compared with other parts of the country and that AIDS-education projects are few, it was thought that COPASA participants’ awareness of HIV transmission and prevention would be relatively low. To test this hypothesis, a preliminary assessment concerning knowledge of HIV infection, transmission, and prevention was conducted with incoming clients in a drug treatment center. Results of this needs assessment indicated a wide variability in the level of knowledge that substance abusers entering treatment have about AIDS. Given these results, the COPASA outreach worker was asked to document the level of AIDS information that the participant needed. The outreach worker was asked to question the participant briefly prior to the educational session regarding what he/she knew about AIDS and, more specifically, of how AIDS is transmitted and how it can be prevented. Results of the open-ended questions were categorized into three levels: (1) participant needed a great deal of information; (2) participant had some information but needed more accurate information; and (3) participant needed very little information. Of the first 300 participants in the COPASA project, 159 participants had very little knowledge of how AIDS is transmitted or prevented. Another 103 participants had some knowledge of transmission and prevention of AIDS. Only 38 clearly knew basic AIDS information regarding transmission and prevention. It appears that IVDUs and their sexual partners in southern Arizona, have some knowledge about AIDS but are not clear about the details of transmission and prevention. Identification of what information clients had prior to enrolling in COPASA indicated wide variability. Some clients understood that one needed to clean needles, but were not sure of the desired method of cleaning, i.e., water and bleach. Other clients indicated they understood that AIDS could be transmitted through sexual intercourse, but did not know that AIDS could not be spread by casual contact. References Centers for Disease Control. HIV/AIDS Surveillance Report, June 1989. Hopkins, D.R. Public health measures for prevention and control of AIDS. Public Health Rep 102: 463-467, September—October 1987. Jones, S., and Downing, M. “Cracking the Community.” Unpublished paper, San Francisco, CA, 1988. Koop, C.E. Surgeon General's report on acquired immune deficiency syndrome. Public Health Rep 102: 1-2, January-February 1987. New York City Department of Health. AIDS Surveillance Unit: AIDS Surveillance Update. New York: New York City Department of Health, May 25, 1988. Acknowledgment Supported by the National Institute on Drug Abuse Grant #5R18DA05748. 283 Authors Sally J. Stevens’ Principal Investigator Peggy Glidert$ Co-Investigator Antonio Estrada$ Co-Principal Investigator Julie Erickson$ Co-Investigator/Research Director Amity, Inc. COPASA 316 South 6th Avenue Tucson, AZ 85701 $University of Arizona Rural Health Office 3131 East 2nd Street Tucson, AZ 85716 284 AN INNOVATIVE APPROACH FOR AIDS RESEARCH, PREVENTION, AND EDUCATION IN THE CRIMINAL-JUSTICE SYSTEM Sally J. Stevens, Peggy Glider, Julie Erickson, and Antonio Estrada Introduction In recent years, concern has escalated surrounding the spread of AIDS within the jails and prisons. Much of this concern stems from the often-reported high frequency of behaviors among the inmate population that are known to spread human immunodeficiency virus (HIV) infection. The fear that HIV infection will run rampant in these closed communities has led to the implementation of a variety of policies, many of which have little basis in the current AIDS research available from the fields of medicine, prevention, or education. Rather, they are generally a reaction to the fear and misconceptions still surrounding this disease. Some fear seems justified. The incidence of AIDS among incarcerated populations has been increasing rapidly. A study conducted by the U.S. Department of Justice, National Institute of Justice, in 1987 found a 190% increase of seroprevalence among inmates between 1985 and 1987 (Hammett 1988). As of October 1988, over 2,047 inmates in State and Federal prisons had been diagnosed with AIDS; at least 1,088 of these inmates have died (National Prison Project [NPP] 1988a). This report states that the incidence rates are predictably high due to the concentration of incarcerated individuals with histories of high-risk behaviors, particularly intravenous drug use. In a separate study conducted by the National Institute of Justice, percentages of positive test results for cocaine use among men arrested in various cities ranged from 40% in Portland, Oregon, to 83% in New York City (U.S. Conference of Mayors 1989). While not all of this cocaine use is intravenous, the seriousness of these statistics should not be minimized. Some of the fear, however, is ungrounded. This increase in seroprevalence may, in part, be due to increased HIV-antibody testing within the prison system rather than increased transmission of the virus among inmates. A study conducted by the Maryland Division of Corrections found an infection rate among inmates of 0.5% per year. These results demonstrate that the infection rate is due primarily to transmission prior to incarceration (Wormser 1987). This increase is also known to be fairly consistent with the increase in seroprevalence within the general population (Greenspan 1989). The fear of transmission from inmates to corrections officers also seems to be unfounded, as there are no reported cases of such transmission to date (Greenspan 1989). Mandatory HIV-antibody testing within correctional institutions has been debated by policy makers. The goal of mandatory testing is containment of the virus. Those who support mandatory testing believe that by identifying those individuals who are HIV-antibody-positive, 285 the threat from these individuals can be minimized by placing them in quarantine or special housing. Unfortunately, such special provisions also tend to involve removal of other privileges such as work release, furlough, and recreation. Furthermore, such provisions are not usually based on a clear understanding of the routes of transmission but on the irrational fears of corrections officers or other inmates. A number of court cases are pending based on the alleged loss of civil rights due to this treatment of individuals who are HIV-antibody-positive, or who have AIDS (NPP 1988a). Some advocate testing to provide information to inmates regarding their HIV status on the basis that it will offer an opportunity for behavior change and early medical intervention. Unfortunately, little is known about the relationship between test results and changes in high- risk behaviors among this population (Andrus et al. 1989). The provision of medical attention within correctional institutions is also frequently inadequate. According to Hammett (1988), state prisoners with AIDS lived only half as long as did individuals with AIDS outside the institutions (New York State Commission on Corrections 1987). While both containment of an epidemic and improvement of personal health are important aspects of testing, further information clearly is needed if one is to base testing on these premises. Provision of AIDS education is also of concern to policy makers. Issues include how to best reach those at risk, what information should be presented, and the best format for presenting this information. Education must also be considered for several populations within the system. Corrections officers and others within the criminal justice system (i.e., lawyers, judges, and parole and probation officers) are frequently uneducated or minimally educated concerning issues of HIV infection, yet they make decisions and set policies regarding HIV infection and AIDS that influence the lives of thousands of inmates. Education must be provided on a consistent basis to this group. The inmates must be educated regarding HIV risk factors and how they can protect themselves and others. Sexual partners and needle-sharing partners of those incarcerated would benefit similarly from this type of education, as they may not receive the education necessary to understand their own risks or to receive the required medical attention if they are already HIV-antibody-positive. Clearly, what is needed is an overall educational plan within the criminal justice system that will prevent the spread of HIV infection within the institution and throughout the community as these individuals return to their families, friends, and neighborhoods. Appropriate education will also help in the establishment and implementation of reasonable and humane policies for this population. Methods To address the concerns and some of the ungrounded fears, several National Institute on Drug Abuse (NIDA) National AIDS Demonstration Research (NADR) programs are currently developing and testing outreach and education/intervention approaches within the criminal justice system and other segments of the community. One of these projects, the Community Outreach Project on AIDS in Southern Arizona (COPASA) is a consortium of seven agencies in the Tucson, Arizona, area that have pooled their areas of expertise and community involvement to target intravenous drug users (IVDUs) and their sexual partners on the streets, through the health system and treatment waiting lists, in housing projects, and through the criminal justice system. One agency, Amity, Incorporated, has an extensive history of working with the criminal justice system and providing education, counseling, and advocacy to substance abusers. Amity is responsible for the criminal-justice component of the NADR grant and has approached outreach 286 to the criminal-justice system by targeting three specific groups in need of AIDS education: (1) criminal-justice workers; (2) inmates; and (3) sexual partners of IVDUs. At the start of the project, a needs assessment was conducted to evaluate AIDS education and services within the correctional system of Tucson, Arizona. AIDS education was generally limited to a film shown to new inmates during an orientation. Education provided to corrections officers, both on the streets and within the institutions, was also minimal. A team of outreach workers who were trained in AIDS counseling, began to establish a network “among the corrections officers at all levels—ity, county, State, and Federal. Joint meetings and trainings were held between the COPASA staff and parole, probation, and intensive probation supervision officers, members of the sheriff’s department, and members of the police department. These trainings focused on basic AIDS information for the officers and on the ways in which the COPASA staff could work within the criminal justice system to educate IVDUs, the targeted population. To date, most of the outreach has been conducted within the county jail and within a facility for those on work release (SACRC). Inmates are told about the project and receive a packet of general AIDS information upon arriving at the jail; this material is reinforced during a meeting with a staff member of SACRC. Those interested in participating in the project are put in touch with the outreach team, which maintains a regular counseling schedule within the various programs and facilities. The outreach workers do an initial screening of all inmates interested in the project to determine their eligibility for the project (IV drug use within the past six months and no treatment for drug use in the past 30 days). At this screening, the project is explained and eligible inmates are invited to participate. Inmates who decide not to participate are still given basic AIDS information. An interview appointment to complete the AIDS Initial Assessment (AIA) is arranged for those inmates choosing to be part of this project. The AIA is conducted by trained interviewers rather than by the outreach workers; this helps to maintain the objectivity and the integrity of the research design. Once the AIA is completed, the participant is randomly assigned to one of two treatment conditions. The standard condition provides a one-hour session during which basic AIDS information (AIDS 101) is presented. An individual risk assessment is performed for each participant to determine his or her current level of risk and what current behavior patterns need to be changed in order to protect the participant and others from the possible spread of HIV infection. The pros and cons of HIV-antibody testing are discussed. This test is not currently available to inmates upon request; however, they are informed of the various anonymous testing sites in the community that they may visit upon release from the institution. Resources within the institution and the Tucson community are also discussed, including those resources available for significant others who may be at risk while the individual is incarcerated. At the conclusion of the session, the participants schedule a six-month AIDS Follow-up Assessment (AFA). The enhanced treatment condition includes the standard session plus five two-hour group sessions that focus on such topics as self-esteem, health, and behavior modification. In addition to the groups, each person assigned to the enhanced condition receives one individual counseling session with an outreach worker between the second and fourth group meetings. These individual sessions provide an opportunity for the participants to discuss any problems or issues 287 that they may have felt uncomfortable discussing in a group setting. Following the fifth group session, the six-month AFA is scheduled. While the need for correct information regarding this issue is seen as necessary for the protection of self and others, this is frequently not sufficient to get the inmates (or IVDUs on the streets) involved in the program. Participants therefore receive an inducement to participate in the project. A $10 incentive is paid for the completion of the AIA and for completion of each of the AFAs (given at six and twelve months). At the onset of the project, participants are paid following each of the standard and group intervention sessions. Beginning September 1, 1989, the intervention fee incentive was changed to create more of a case-management system. Participants are still paid the $10 for each AIA and AFA assessment, but instead of being paid for participating in counseling, they are offered the services of a case manager who helps them find services and resources in the community for themselves and their significant others. In addition, a voucher for food or clothing is given to each participant following completion of the counseling sessions. This case-management system has had varied effects. For those in the county jail and those on parole or probation, participation rates have not changed greatly. They are willing to participate and collect the voucher upon their release. This has not been the case for the work-release facility. While participation was extremely high during the first year of the project (actual outreach was conducted for the last 22 weeks of that year), it has slowed considerably in the first month of the second year. These individuals are out in the community during the day and do not seem motivated to participate in the program during the evenings. Perhaps many of those in the jail see the project as a diversion during the day rather than as an important health matter related to personal safety or change. The exact reasons for the slowed participation in the work-release facility are being explored so that alternative motivations can be introduced. This group is extremely important to reach because they are working in the community while they complete their sentences and are making the transition back to their families and significant others, thus potentially placing themselves and others at risk for the spread of HIV infection. Results Since outreach began in April 1989, approximately 75 inmates in the county jail have participated (37 in the standard condition and 38 in the enhanced). Virtually 100% of those in the enhanced condition have completed all six sessions. Two inmates were moved to the State prison prior to completion of all sessions. Ten percent of the participants have been women, all of whom are Caucasian. Of the men, 10% are Black, 3% are Native American, 35% are Hispanic, and 52% are Caucasian. Similar demographics exist for the 75 participants from the work-release facility; however, all are men. While the same program exists in both facilities, those on work release are eligible for HIV-antibody testing and, thus, testing is strongly encouraged at SACRC. The initial screening is also done with all work-release inmates rather than just providing them with a packet about the program at their orientation to the institution. 288 Conclusion While there are still some difficulties with the project (i.e., case management vs. fees, lack of the HIV-antibody test as an option for inmates, inability to distribute condoms and bleach within the institutions, and inadequate resources in the institution or the community), COPASA has made an impact on the criminal-justice system. This impact includes more awareness and accurate knowledge among the corrections officers and other personnel, the incarcerated, and those on probation or parole. How much of this information will be translated into action (i.e., ongoing, appropriate policies and procedures within the system) and into behavior change from high-risk behaviors for the participants is yet to be determined. The first six-month AFAs, which will assess behavior change, are to be administered in October 1989. Fairly high levels of satisfaction following the intervention have consistently been reported by the participants. COPASA staff continue to reach out to the various sectors of the criminal justice system, refining the intervention as needed, in an attempt to stem the spread of HIV infection. References Andrus, J.K.; Fleming, D.W.; Knox, C.; McAlister, R.O.; Skeels, M.R.; Conrad, RE; Horan, J.M.; and Foster, L.R. HIV testing in prisoners: Is mandatory testing mandatory? Am J Public Health 79(7): 840-842, 1989. Greenspan, J. HIV infection among prisoners. Focus: A Guide to AIDS Research and Counseling 4(6): 1-4, 1989. Hammett, JM. AIDS in Correctional Facilities: Issues and Options. Washington, D.C.: National Institute of Justice, 1988. National Prison Project. AIDS in Prison Bibliography. Washington, D.C. National Prison Project, 1988a. National Prison Project. Inmates and Officers. AIDS & Prisons: The Facts. Washington, D.C.: National Prison Project, 1988b. New York State Commission on Corrections. AIDS: A Demographic Profile of New York State Inmate Mortalities, 1981-1986. Albany, NY: New York State Commission on Corrections, 1987. U.S. Conference of Mayors. AIDS/HIV in correctional settings: The Philadelphia experience. AIDS Information Exchange 6(4): 1-10, 1989. Wormser, G.P. Lessons from prisoners with AIDS. NY Med Q 7(2): 51, 1987. Acknowledgment Supported by the National Institute on Drug Abuse Grant #5R18DA05748. 289 Authors Sally J. Stevens, Ph.D.t Principal Investigator Peggy Glider, Ph.D.1$ Co-Investigator Julie Erickson, Ph.D.$ Co-Investigator/Research Director Antonio Estrada, Ph.D.$ Co-Principal Investigator t Amity, Inc. Matrix Community Services 1030 North Fourth Avenue Tucson, AZ 85751 $University of Arizona Rural Health Office 3131 East 2nd Street Tucson, AZ 85716 290 AIDS EDUCATION IN THE JAIL SETTING: ACHIEVEMENTS AND FRUSTRATIONS Edward Hernandez and Steve Radvick Introduction Between April and October 1989, The Circle’s Education Risk Assessment (ERA) program in Phoenix, Arizona, has administered approximately 290 AIDS Initial Assessment (AIA) questionnaires and 220 AIDS Follow-up Assessment (AFA) questionnaires, and provided AIDS-related education to 170 persons, with an additional 120 in the comparison group. In November, we will begin the first round of six-month follow-up interviews. By most measures, the program has functioned quite well and is enjoying the fruits of good planning and careful execution. The education and risk-reduction efforts directed at incarcerated intravenous drug users (IVDUs) are a vital component of the National Institute of Drug Abuse’s (NIDA) response to the AIDS epidemic. The IVDU represents approximately 30% of adult AIDS cases and is the nation’s fastest-growing group of persons infected with the human immunodeficiency virus (HIV). Also, the IVDU population is the primary vector by which HIV infection is transmitted heterosexually. Education and risk-assessment/reduction interventions with this population present practitioners with a unique and difficult set of challenges. To anyone familiar with the lifestyle of the IVDU, it is evident that one of the most effective intervention points is during an extended period of incarceration. During detention, the IVDU is obviously more available for extended interventions and is usually more coherent. The level of effectiveness of any project is dependent on sound planning and careful execution. There is no setting where this is more true than in a detention facility. Initial Considerations The first hurdle faced by any institutionally based project is gaining access to the facility. This is typically resisted on many levels for different reasons; however, effective strategies can be developed to increase the likelihood of gaining access. This process should include the assessment of the political climate, the identification of key personnel, outlining incentives for the support of the project, and consideration of the pros and cons of creating an advisory committee. Once access to the facility has been assured, the program must be able to function effectively in that environment. This brings about a whole new set of issues. At the operational level, issues 291 that must be anticipated are: (1) developing support of the institution’s line staff and administration; (2) working within the physical limitations of the facility; (3) turf battles with existing in-house programs; (4) availability and transport of inmate participants; (5) careful selection of the project’s institutionally based staff; and (6) high rates of staff turnover in the detention facility. Above all, institutionally based programs and staff must remain flexible and adaptable in order to function effectively. The ERA AIDS-Education Program This section of the paper will summarize what we think is happening in the classroom as we interact with the participants and deal with very personal and basic issues. The participants have been prepared for these sessions by the interviewers who administer the project’s two survey instruments, the AIA and AFA. This experience leaves no doubt in their minds that we will be dealing with serious stuff. The participants have randomly self-selected either the education or comparison group. Although some participants have only experimented with IV drugs, the majority of those in our program are current IVDUs who will most likely return to drugs once they are released. Some are using drugs even while they are in jail. When the education sessions are about to begin, participants’ names are called over the loudspeaker by the detention officers—they are identified as the “Circle Group.” They feel special because, when necessary, they are pulled off work detail, excused from other duties, or just saved from the daily boredom that is jail. Once in the classroom, we have a policy of shaking hands with each participant as we introduce ourselves and ask for their name. By the time the session begins, there is very little resistance to the process and to the strangers who will be dealing with very personal matters. Each participant has volunteered for the program and feels fortunate to have been selected for the intensive education group. We always begin the first session by not just introducing ourselves and the program, but also by asking that each participant tell the group who he or she is and something interesting about himself or herself. This gently forces each person to try and define himself or herself as a person and it provides the participant a chance to become a real, active part of the group and not just a silent observer. Very often, the introduction that they give about themselves involves their identification as an IVDU. As each class “graduates,” the participants act as recruiters; therefore, the level of trust of those who attend is extremely high. Participants talk freely about their experiences with IV drug use, both positive and negative. There are some individuals who rhapsodize at length about their highs and how they know, deep in their hearts, that they will never be able to give them up. Many heads nod in agreement with silent “amens” to such statements. However, there are still others who will simply and forcefully state that they have been on drugs for x number of years, but that they have to “get off drugs.” Their minds, their experiences, and their innermost convictions are all saying “no,” while their environment, their friends, and their appetites are saying “yes.” It is this group that needs more attention. We believe that an important part of the dynamic of the group-education process is that the spontaneous, inner motivation to stop using IV drugs has resulted from many factors, not their 292 participation in our group. They choose to announce their decision here, however, because they feel that something can be done here. Our program capitalizes on this by offering a one-and- one-half-hour session on “How to Change High-Risk Behaviors” and a one-on-one session whose principal theme is “Personalizing the Risk.” These are, however, by no means, adequate or sufficient for long-term success. Many of these participants have been shooting drugs for 5, 10, 15, or more years, and a seven-hour course is just not sufficient to change long-term behaviors. This subset of participants might benefit from a longer, more comprehensive approach that will treat them while they are ready, willing, and able to participate without jeopardizing their jobs, families, or other outside commitments that can interfere with treatment. All treatment centers and modalities with which we are familiar emphasize that inner motivation must be present for intervention to be effective. We are witnessing a source of such individuals who are ready, have come to grips with their particular problem of addiction, and are willing to do something about it. Our program does have a list of outside agencies where comprehensive treatment is available. Realistically, though, unless the person has been mandated to attend as part of their sentence, (and hence the treatment is being paid for by the county), there is little chance that he or she will have the resources to pay for either short- or long-term treatment. This does not mean that we must develop a whole new program. Rather, we must supplement the existing program with a full-time substance-abuse component that will deal with inmates on both a group and individual level. This is merely supplementing an already existing and working program with the elements that are necessary to make the difference between a good program and an excellent one. Other points must be considered, such as how to make the intervention culturally specific, how to develop and maintain support groups for those who are released, and how to deal with the economic and legal issues of a drug-free lifestyle. These substantive issues cannot be addressed at this time. What is apparent, regardless of these other major issues, is that in the midst of working with addicts, whom society frequently dismisses as self-destructive and lacking a will to live, we are coming face to face with people who live, breathe, and hope. They are people who have managed to survive in spite of themselves, and who wish, most of all, to thrive like you and me. Explanations of why certain people choose to use drugs and share needles are varied. They often include the fact that using IV drugs is generally a socially rewarding activity. Many addicts tell of the bonding that takes place as they buy and share the drugs with a “friend” or a group of “friends.” The group never considers the risk and each person is thereby relieved of the responsibility for their behavior. In the jail setting, however, these individuals have been separated from their friends on the outside—that group no longer has the control that it would normally have. As inmates undergo detoxification, their feelings and thoughts are much clearer than they have been in a long time. They form new associations with other ex-users and are able to determine that it would be in their best interest to stay clean permanently. This group in the jail is now supporting them in their new attitude. This is a fantastic step! The message promotes prevention of HIV infection—even among persons who still use drugs. However, in each group there are always some who want to quit using drugs. The strength of the group helps them to stay clean. 293 We are not so naive as to believe that there is not a little of the con artist in some of our participants, and that some people just tell us what they think we want to hear. This is most likely to be true in the group setting. However, it is not as likely in the one-on-one session. By that time, we have met for at least five hours as a group; we have gotten to feel comfortable with each person and they have come to feel comfortable with us. When we meet one-on-one, we find that many participants want therapy, some form of treatment that will rid them of a habit that is truly a love-hate relationship; one that they can neither live with, nor live without. While we believe that education is an essential part of the battle against HIV infection, we also realize that education alone is not sufficient. Unless and until there is a concomitant change in behavior, handing out brochures, condoms, and bleach will not be effective. If they are to have a truly significant impact on the risk behaviors of the prison population, educational interventions must include a counseling component. Education, combined with counseling, would produce longer-lasting results because it would provide participants with the tools necessary to sustain risk-reduction behaviors in the outside world. Acknowledgment Supported by the National Institute on Drug Abuse Contract #271-88-8229. Authors Edward Hernandez, M.A. Health Educator Steve Radvick, M.I.M. Site Coordinator Education and Risk Assessment Project 2210 North Seventh Street Suite A Phoenix, AZ 85006 294 BELLE GLADE, FLORIDA: THE NATIONAL AIDS DEMONSTRATION RESEARCH (NADR) PROJECT’S ONLY RURAL AIDS-INTERVENTION PROGRAM Clyde B. McCoy, Edward J. Trapido, Nancy Lewis, and Elizabeth L. Khoury Introduction While early reports of AIDS and human immunodeficiency virus (HIV) infection focused much attention on homosexual communities and intravenous drug users (IVDUs) in large urban areas such as San Francisco and New York City, the highest cumulative incidence rate of AIDS in the United States has been reported in Belle Glade, Florida, a small, rural, agricultural community in western Palm Beach County. The first cases of AIDS in Belle Glade were reported in 1985, and through December 1989, a cumulative total of 329 cases of AIDS had been reported from the Belle Glade area, which includes the surrounding small communities of Pahokee, Canal Point, and South Bay. This total represents nearly one-third of the 1,036 cases of AIDS that have been reported in Palm Beach County (State of Florida Department of Health and Rehabilitative Services 1990), although the Belle Glade area accounts for only slightly over 4% of the county’s population (McKinnon, personal conversation, 1989). During this same period of time, 39% of the cases of AIDS that have been reported from the Belle Glade area have been attributed to heterosexual contact (Morello, personal conversation, 1990}, significantly higher than the 5% attributed to this mode of transmission nationwide (Centers for Disease Control [CDC] 1989). Relatively few cases of AIDS from this area, to date, have been attributed to homosexual contact (16%) (Morello, personal conversation, 1990), in further contrast to the trends observed elsewhere in the United States. Health-department officials have indicated that the current case fatality rate of 65% reported for the Belle Glade area, although lower than previous reports, is felt to be a somewhat conservative estimate of the true rate because of the transient nature of the population (Morello, personal conversation, 1990). Nonetheless, this rate is higher than both the 60% reported for the rest of Florida (State of Florida Department of Health and Rehabilitative Services 1990) and the 54% reported for the United States (CDC 1989). It is also of concern to note that in Belle Glade, the number of cases of AIDS that have been attributed to heterosexual contact is greater among males than among females, another trend not yet observed in other areas of this country (Table I). In addition, the ratio of male-to-female AIDS cases, much lower than that observed elsewhere in the United States, has continued to decline, from 5.2:1 as of April 1985, to 2.2:1 through December 1989 (Morello, personal conversation, 1990). 295 Table 1. Adult AIDS Cases by Sex and Exposure Category in Belle Glade, Florida, through December, 1989 Exposure Category Male Female Total Percent Homosexual/Bisexual Male 50 re 50 16.2 IVDU 62 57 119 38.6 Homosexual/Bisexual IVDU 16 —-_ 16 52 Heterosexual Contact 85 35 120 39.0 None of the Above 0 3 3 1.0 Total 213 95 308 100.0 Source: Palm Beach County Health Department Located on the southern shore of Lake Okeechobee (F igure 1) in the heart of Florida's agricultural belt, Belle Glade was once known as the “Winter Vegetable Capital of the World.” More recently, however, traditional vegetable crops have been largely replaced by sugar cane, which is particularly well suited to growing in muck and is best cut by hand. This physically demanding and dangerous work is performed mainly by “offshore workers,” sugar cane cutters from Mexico, areas of the Caribbean (predominantly Jamaica, the Bahamas, and Haiti), and other regions of the United States (Dorschner 1990). Due to the annual influx of migrant workers, the population of Belle Glade, estimated at approximately 18,000, nearly doubles during the harvest season, which begins in October and usually extends for about nine months. A major truck route for transporting the agricultural produce from this area runs through Belle Glade. As a result, a large population of young, transient males resides in the area. Drug trafficking as well as a burgeoning sex industry have also become a part of the social environment (Wilkinson 1989). The average per-capita income in Belle Glade in 1980 was $5,654, and more than 25% of the population reported income below the poverty level (United States Bureau of the Census 1987). Low levels of education are also common in Belle Glade. The incidence of disease, in general, and of sexually transmitted diseases (STDs) (frequently cited as cofactors for HIV transmission), in particular, is extremely high relative to the size of the population (Ferguson and Loftis 1985; Trapido et al. 1990). As early as 1985, 15% of 33 STD-clinic attendees and 11% of 109 medical-clinic attendees in Belle Glade tested seropositive for the antibody to HIV (Lieb et al. 1988). Although not everyone in Belle Glade is poor and not all of the region’s poor are sick, this area suffers a disproportionate share of disease (Ferguson and Loftis 1985). Despite the high quality of health care that can be obtained in Palm Beach County, most of the county’s health-care facilities are concentrated in the eastern (and more affluent) coastal half of the county; the overall availability of and access to health care in the western half of the county are relatively poor (Ferguson and Loftis 1985). 296 Figure 1. Jacksonville Q ° ¢/ West PaiIm Beach Belle Glade of Fort Lauderdale Miami Since the extremely high cumulative incidence of AIDS reported in Belle Glade could not be explained by the model that had proved useful elsewhere (e.g., San Francisco, New York City, and other urban areas), initial speculation arose concerning previously unrecognized routes of transmission and mechanisms for infection. In particular, the question of whether HIV could be transmitted by mosquitos or other insect vectors received much publicity, although subsequent investigations and analyses failed to substantiate any such hypotheses (Castro et al. 1988). More recently, according to Dr. Deanna James, Director of the C.L. Brumbeck Community Health Center serving Belle Glade and the surrounding area, while it is possible that HIV may have first entered this population through intravenous (IV) drug use (of the first 30 cases of AIDS reported from this area, 43% occurred among IVDUs), it appears that the virus has continued its rapid spread within this community through heterosexual contact (Lasalandra 1989). As part of the response to the unusually high incidence of AIDS and HIV infection that continues to be observed in this area, the South Florida AIDS Research Consortium was asked by the National Institute on Drug Abuse (NIDA) and the State of Florida Department of Health and Rehabilitative Services (HRS) to extend its ongoing Community Outreach Project in Miami (one of the NADR project sites) to Belle Glade. The purposes of the study were to reduce unsafe 297 AIDS-related behavior in Belle Glade and to provide valid scientific data from which to assess, at least in part, the epidemiology of HIV infection in this community. Project Description and Methods A saturated community model is used for the recruitment of both drug users and sexual partners in Belle Glade. Study subjects were initially recruited from those areas in Belle Glade where previous investigations had found the incidence of AIDS and HIV infection to be the highest. These areas, near the center of town, were also believed to have a high prevalence of IV drug use. Recruitment has subsequently progressed from this area to outlying areas of the community. Because parenteral drug use was found to be less widespread than had been originally anticipated in Belle Glade, requirements for eligibility in the study were expanded to also include those individuals who reported any use of drugs, whether injected or noninjected, within the six months prior to contact, and the sexual partners of such individuals. Eligible individuals are recruited for the study by an indigenous outreach worker, using a networking approach. Recruitment is limited to individuals residing in Belle Glade; migrant workers are not eligible because of the longitudinal nature of the study. After initial contact is made, prospective participants are given an appointment at the assessment center, which is located near the center of town. Due to the high prevalence of AIDS and HIV infection in Belle Glade and the impossibility of denying participation to any individual from this small community, individuals who drop by the assessment center without having been referred are also accepted as clients, provided they meet the eligibility criteria. Study subjects are randomly assigned to either a standard or an enhanced intervention according to the day of the week on which they arrive at the assessment center; consequently, individuals who arrive in groups or with partners are assigned to the same intervention. Since the interventions deal with interpersonal relationships, keeping people in their natural groups acknowledges the social nature of sexual and/or drug-using behaviors and increases the acceptability of the program to the study subjects, thereby reducing the refusal-to-participate and dropout rates (McCoy et al. 1990). All study subjects, after giving informed consent, receive pretest counseling, HIV-antibody testing, and an extensive baseline interview known as the AIDS Initial Assessment (AIA) questionnaire. This nationally used questionnaire was designed to elicit information from which to assess drug-use and sexual risk behaviors for HIV transmission, including demographics, migration history, drug-related behaviors, sexual behaviors, and health status and disease histories. In addition to the standard AIA questionnaire, supplemental questions were developed specifically for this location in order to address the uniqueness of HIV transmission in Belle Glade. Study subjects in both the standard and enhanced interventions receive an initial one-hour group counseling session. The purpose of this session is to increase awareness about AIDS and about those behaviors that may place individuals at increased risk for either acquiring or transmitting the virus. Study subjects discuss their knowledge about AIDS and personal/social AIDS-related experiences. A video presentation entitled, AIDS: A Bad Way to Die (The Taconic Video Center 1986), is followed by a group discussion in which the participants are encouraged to 298 share their reactions and to identify commonalities with the characters in the film. The Belle Glade project director has indicated that this film has been very well received by the study participants. Word of it has piqued the curiosity of the community and has been instrumental in prompting a substantial number of individuals from the Belle Glade area to volunteer as potential study subjects. Pamphlets relating to AIDS, drug use, and safer sex are distributed at the close of this counseling session. Two weeks after the initial assessment, all study subjects receive individualized post-test counseling and HIV test results. Individuals in the enhanced intervention group subsequently receive two additional counseling sessions. The purpose of the additional counseling is to reinforce the information from the initial session and to provide skills training with which the study subjects can better negotiate behavioral changes. The second session immediately follows notification of HIV test results. It includes a film, Needletalk (The New York City Department of Health 1987), as well as practical demonstrations of needle cleaning and condom use, followed by a group discussion that focuses on the effects of the addiction lifestyle/subculture and how it can interfere with maintaining reduced risk behavior. The third counseling session begins with the film, Black People Get AIDS, Too (Multicultural Prevention Resource Center 1987), which provides information relative to the spectrum of HIV infection, the cofactors in AIDS progression, the effects of alcohol and drug use on the immune system, and the way in which alcohol and drug use can impair judgment and affect behavior. This session is designed to help the individual identify specific problem areas in his/her life that might interfere with the maintenance of reduced risk behavior. At the conclusion of this final session, the counselor helps the individual develop realistic solutions to resolve these problems. To determine any changes in levels of risk behavior, study subjects are reassessed at six-month intervals using a follow-up questionnaire. Subjects who previously tested negative for antibody to HIV receive pretest counseling and are retested at this time. Our initial experience in this activity has demonstrated one of the advantages of implementing a research design of this type in a rural community such as Belle Glade. Although only recently begun, early indications are that follow-up in this project will be highly successful. This is most likely due to the small size and the relative isolation of Belle Glade. The data presented in the following analysis are taken from the responses of study subjects in Belle Glade to the AIA questionnaire. Serostatus was determined by the results of ELISA tests for antibody to HIV (confirmed by Western Blot). To minimize the potential for observation bias, serostatus was determined by laboratory personnel who were blinded to all characteristics of the study subjects. Descriptive statistics were computed, including measures of central tendency and percents. T-tests were used to assess the differences in means for continuous response variables, and Yates’s corrected chi-square was used to assess the association between categorical response variables. Results Between May and August 1989, 113 study subjects were enrolled in the Belle Glade Community Outreach Project. Selected demographic characteristics of the study subjects are presented in Table 2. Similar numbers of males and females were enrolled in the study (58 study subjects were male, 54 were female, and one study subject cannot be commented on due to 299 Table 2. Selected Demographic Characteristics of the Belle Glade Sample (N=113) Characteristic N % Age 18-23 9 8.0 24-29 30 26.5 30-35 29 25.7 3641 17 15.0 4247 14 124 48-53 8 7.1 54-59 4 35 260 2 1.8 Sext Male 58 51.3 Female M 47.8 Race/Ethnicity Black 102 90.3 White 5 44 Hispanic 6 53 Education® High school 25 22.7 TDoes not include one study subject due to confidentiality concerns. Missing values were excluded. confidentiality concerns). Although more than half (52.2%) of the study subjects were between the ages of 24 and 35, study subjects ranged from 18 to 63 years of age, with female study subjects significantly younger than male study subjects. The average age among male study subjects was 39.0 years (median age of 38.5 years), while the average age among female study subjects was 31.2 years (median age of 30.5 years). Of the study subjects, 90.3% were Black, 5.3% were Hispanic, and 4.4% were White. Almost all (97%) were born in the continental United States. More than three-quarters (77.3%) of the study subjects reported that they had completed less than a high-school education, with 29.1% having completed less than eighth grade. Among study subjects, fewer than one-quarter (23.0%) reported that they were regularly employed on a full-time basis, more than one-third (33.6%) of the study subjects indicated that they were either unemployed or employed only occasionally, while 13% claimed that illegal activities were their major source of income. The frequencies of drug use during the six months prior to interview reported among Belle Glade study subjects are presented in Figure 2. A large majority (83.2%) of the study subjects reported that they had used crack within the six months prior to the interview. More than half (57.9%) of these study subjects reported at least daily use during this same period of time, with half (49.5%) reporting that, on average, they had used crack more frequently than twice per day during the six months prior to the interview. Alcohol use was reported by 84.1% of study subjects, with median usage being two to six times a week. Although marijuana use was reported by more than half (57.5%) of the study subjects, median usage (fewer than four times a month) was much less frequent than that for either crack or alcohol. Reports of the use of other drugs (including heroin and other forms of cocaine) among these study subjects were rare. 300 10€ Figure 2. Frequency of Drug Use during the Six Months prior to Interview Reported by Study Subjects in Belle Glade Percent 1.1 Never Weekly orless times/week Crack Percent 2-6 45: 40- 351 25+ 20+ 151 10+ 57.9 2Daily Never (n=113) Percent 301 Never Weekly 2-6 2Daily orless times/week Alcohol 41.4 Weekly 2-6 >Daily or less times/week Marijuana Reports of either IV drug use or homosexual/bisexual activity were also relatively rare. Although 18 study subjects (15.9%) reported that they had ever used drugs intravenously, only six study subjects (5%) reported that they had used drugs intravenously within the six months prior to interview. Among male study subjects, five (9%) reported having had a male sexual partner within the six months prior to interview. However, three of these five individuals also reported a large number of female sexual partners during this same period of time, and two of these three also reported a previous use of IV drugs. Despite the paucity of IV drug use and homosexual/bisexual contact in the study sample, 29.3% of the study subjects tested positive for HIV antibody. Among study subjects, 24% of the males and 33.3% of the females were seropositive at the time of interview (Table 3), with female seropositives significantly younger than male seropositives. At the time of interview, nearly one-third (30.3%) of the Black study subjects were seropositive for antibody to HIV. Of five Whites among the study subjects, two were seropositive. None of the Hispanic study subjects tested positive for antibody to HIV at the time of interview (Table 3). Figure 3 presents the number of sexual partners reported by study subjects for the six months prior to interview. The mean number of sexual partners reported for this period of time was 7.1 (median of three). Thirty (26.5%) study subjects reported having had only a single sexual partner, seven (6.2%) reported having had no sexual partners, and seventy-six (67%) reported having had multiple sexual partners during the six months prior to interview. Of the latter group, more than half (54%) reported having had five or more sexual partners during this same period of time. Among study subjects who reported having had multiple sexual partners during the six months prior to interview, nearly one-third (30%) were seropositive at the time of interview; however, more than one-quarter (27.6%) of those study subjects who did not report multiple partners (i.e., reported either no sexual partners or only a single partner) during this period were seropositive at the time of interview, as well. Among the 76 study subjects who reported multiple sexual partners within the six months prior to interview, a large majority (87%) reported that they had exchanged sex for money within this same period of time, with 83% of the males and 94% of the females responding affirmatively. More than one-third (35%) of these study subjects were seropositive at the time of interview. A similar, although less extreme, trend was observed with regard to the exchange of sex for drugs. Of the study subjects who reported multiple sexual partners in the six months prior to interview, nearly half (49.3%) reported having exchanged sex for drugs, with 45% of the males and 54% of the females responding affirmatively. More than one-quarter (27%) of these study subjects were seropositive at the time of interview. Among those study subjects who reported at least daily use of crack, 43.6% also reported having had five or more sex partners within this same time period. In addition, the exchange of sex for drugs was significantly associated with crack use, and of those study subjects who reported having exchanged sex for drugs, 58% reported having used crack at least daily. Among study subjects who reported at least daily use of crack, a majority (58.5%) reported having exchanged sex for money and a substantial proportion (39.6%) reported having exchanged sex for drugs within the six months prior to interview. 302 Table 3. Serostatus’ at the Time of Interview by Gender and Race/Ethnicity in the Belle Glade Sample (N=113) Serostatus Gender/Race + - Total Gender Male 12 38 50 Female 16 32 48 Total 28 70 988 Race/Ethnicity Black 27 62 89 White 2 3 5 Hispanic 0 5 5 Total 29 70 99 T Includes only those study subjects for which there was complete information for serostatus. § Does not include one study subject due to confidentiality concems. Figure 3. Number of Sexual Partners during the Six Months prior to Interview Reported by Study Subjects in Belle Glade 35 + (n=113) 31 30 A 25 20 A Percent 15 - 10 A 0 1 24 5-9 10-14 15-19 20-24 25+ Sexual Partners 303 Discussion There is now accumulating evidence for the spread of the AIDS and HIV epidemic beyond the original urban centers and high-risk groups where it was first reported, to heterosexuals in both small and medium-sized, nonurban and rural areas (Gardner et al. 1989). Health-department data for western Palm Beach County indicate that of the 308 adult cases of AIDS reported from this area, 38.6% have been attributed solely to IV drug use and 39.0% have been attributed to heterosexual transmission. However, AIDS cases reported to health-department officials in Belle Glade reflect past patterns of HIV infection; although case reports to date are almost equally divided between IV drug use and heterosexual contact as risk factors for infection, preliminary analyses of these data have suggested that heterosexual contact is the predominant route of transmission of HIV among study subjects (Trapido et al. 1990). This subsequent analysis, with recruitment of study subjects still in progress, lends further support to that conclusion and also suggests that heterosexual transmission will come to play an increasingly important role in the spread of HIV. In addition to the impact of heterosexual transmission of HIV among study subjects, the most noteworthy feature of the current sample is the conspicuous absence of drug-injecting behaviors. In contrast, incidence data from health-department reports indicate that new cases of AIDS continue to occur among IVDUs in Belle Glade (Table 4). However, it is important to remember that the risk for HIV infection is a function of behaviors rather than membership in risk groups per se. The absence of IVDUs among these initial study subjects does not preclude the presence of other high-risk behaviors. Much to the contrary, among these study subjects, other high-risk drug- and sex-related behaviors were commonly reported, predominantly at high levels. For example, 83.2% reported having used crack (which has been implicated in the spread of HIV, as well as other STDs) within the six months prior to interview. Of these study subjects, a majority (57.9%) reported having used crack at least daily during the same period of time. According to Dr. Willard Cates (Goldsmith 1988), Director of the Division of Sexually Transmitted Diseases at the CDC, “Because sexual services are frequently used as barter for the drug, crack [sic] is spreading whatever STD happens to be most prevalent in the core group even more widely into the lowest-income communities.” Further, 67.3% of the study subjects reported having had multiple sexual partners during the six months prior to interview. Among these study subjects, a great number also reported having exchanged sex for money (87%) and/or drugs (49.3%) during the same period of time. Although the data that have been presented here neither contradict nor confirm the health- department data (as they address different stages of the epidemic), the absence of IVDUs among study subjects warrants further consideration. One plausible explanation, which is consistent with the remarks of Dr. Deanna James, could be that HIV entered this community through the IV-drug route and that most of the core group of injectors in Belle Glade were infected in the early stages of the epidemic (i.e., prior to 1985). This would account for the large number of cases of AIDS that have occurred to date among IVDUs in the Belle Glade area. If this were the case, secondary spread of the virus could have already occurred, which might then be reflected in the large number of cases of HIV infection in the absence of either homosexual/bisexual contact and/or injecting behaviors among current study subjects. Given this scenario, and 304 Table 4. Incidence of Adult AIDS Cases by Exposure Category in Belle Glade April 1988-January 1990 April January Incidence Exposure Category 1988+ 19901 N % Homosexual/Bisexual Male 31 50 19 12.7 IVDU 51 119 68 45.3 Homosexual/Bisexual IVDU 8 16 8 53 Heterosexual Contact 56 120 54 36.0 None of the Above 2 3 1 0.7 Total 148 308 150 100.0 Source: Palm Beach County Health Department. considering the long and variable latency period for HIV, IVDUs in Belle Glade might have, by now, progressed from infection to the clinical expression of AIDS. In this case, they would be more likely to have sought medical treatment, which would be reflected in the health-department data. It is also possible that there are cases of AIDS in Belle Glade that have gone either undiagnosed or unreported due to the limited access to health care (particularly among the indigent, who may not be IVDUs) in this area, or, as with the case-fatality rate, the transient nature of the population. (Reporting guidelines specify that AIDS case reports be based on residence at the time of the diagnosis of the first AIDS-indicator diseases [CDC 1989].) In addition, some reports (Stoneburner et al. 1988) have suggested that, since the emergence of the AIDS epidemic, IVDUs have experienced higher mortality rates from other (i.e., non-AIDS) causes. Finally, although the initial recruitment area was believed to be characterized by a high prevalence of IV drug use, it may be that IVDUs in the Belle Glade area are not located precisely in the area where recruitment began. These data indicate the need for further ethnographic assessment of this community. In addition to the small sample size, the data presented here may be subject to various sources of bias. Due to the rural setting of Belle Glade, the effects of these biases may be somewhat different than in the more urban settings of the other NADR programs. For example, since Belle Glade is a small, rural, and relatively isolated community where IVDUs have been “blamed” for the introduction of HIV and the subsequent epidemic, the stigma associated with being classified as an IVDU may have resulted in misclassification bias and the prevalence of injecting behaviors may be underestimated in the current sample. The effect of misclassification bias might, furthermore, be exaggerated as the community has become even more knowledgeable about behaviors that are likely to increase the risk for HIV infection (specifically, in the case of Belle Glade, drug-injecting behaviors). Such awareness may have reduced the prevalence of the reporting of these behaviors rather than the actual engaging in them (Handsfield 1988; Turner 1989). 305 Finally, since a substantial portion of the study subjects were self-selected, these data must be interpreted cautiously: selection bias might operate against those who had previous knowledge of their serostatus. A potential study subject who was aware of his or her serostatus, particularly an individual who was seropositive, might be either more or less inclined to participate in this demonstration than an individual who did not have such knowledge. At the same time, individuals who had participated in activities that could place them at risk for HIV infection may be either over- or under-represented. Although the current sample may not be representative of the entire population of Belle Glade, the prevalence of reports of high-risk drug- and sex-related behaviors among nonparenteral drug users in this community is a cause for concern. Since reports of either IV drug use or homosexual/bisexual activity were relatively rare, the possible role of heterosexual transmission of HIV among study subjects, and in the community, cannot be discounted. The low ratio of male-to-female cases of AIDS (while not necessarily evidence for the heterosexual transmission of HIV), together with the large number of cases among females that have been attributed to IV drug use in the Belle Glade area, is not inconsistent with the absence of other risky behaviors among study subjects. These data suggest the need for a comprehensive response to the threat of HIV infection in this community; that it is not only IVDUs and their sexual partners who are in need of targeted education and intervention, but also other nonparenteral drug users, who may not be as well aware that their behaviors may place them at risk for HIV infection. References Castro, K.G.; Lieb, S.; Jaffe, H.W.; Narkiunas, J.P.; Calisher, C.H.; Bush, T.J.; Witte, J.J.; and the Belle Glade Field Study Group. Transmission of HIV in Belle Glade, Florida: Lessons for other communities in the United States. Science 239: 193-197, 1988. Centers for Disease Control. HIV/AIDS Surveillance Report, December 1989. Dorschner, J. White gold: The sweet smell of excess. Tropic Magazine. The Miami Herald, January 28, 1990. pp. 9-13, 17-18. Ferguson E., and Loftis, R. Disease is a fact of life in slums of the Glades. The Miami Herald. August 12, 1985. pp. C11-C12. Gardner, L.I, Jr.; Brundage, J.F.; Burke, D.S.; McNeil, J.G.; Visitine, R.; and Miller, R.N. Evidence for spread of human immunodeficiency virus epidemic into low prevalence areas of the United States. J Acquir Immune Defic Syndr 2: 521-532, 1989. Goldsmith, M. Sex tied to drugs = STD spread. JAMA 260(14): 2009, 1988. Handsfield, H.-H. Heterosexual transmission of human immunodeficiency virus. JAMA 260(13): 1943-1944, 1988. Lasalandra, M. AIDS ‘could wipe out’ Belle Glade Blacks: ‘Anonymous sex,” drug abuse must be stopped, experts say. The Palm Beach Post, August 8, 1989. pp. 1A, 8A. 306 Lieb, S.; Castro, K.G.; Calisher, C.H.; Withum, D.G.; Buff, E.E.; Schable, C.A.; Monath, T.P.; Jaffe, H.W.; and Witte, J.J. Human immunodeficiency virus infection in a rural community. J Fl Med Assoc 75(5): 301-304, 1988. McCoy, C.B.; Chitwood, D.D.; Khoury, E.L.; and Miles, C.E. The implementation of an experimental research design in the evaluation of an intervention to prevent AIDS among IV drug users. J Drug Issues 20(2): 213-219, 1990. McKinnon, J. Spring 1989, personal conversation. Morello, K. Palm Beach County Health Department. January 1990, personal conversation. State of Florida Department of Health and Rehabilitative Services. The Florida AIDS/HIV Report. No. 65, January 2, 1990. State of Florida, Division of Economic and Demographic Research, Joint Legislative Committee. Data presented at the Florida Demographic Estimating Conference. Tallahassee, Florida, Spring 1989. Stoneburner, R.; Des Jarlais, D.C.; Benezra, D.; Gorelkin. L.; Sothern, S.R.; Friedman, S.R.; Schultz, S.; Marmor, M.; Mildvan, D.; and Maslansky, R. A larger spectrum of HIV-1 related disease in intravenous drug users in New York City. Science 242: 916-919, 1988. Trapido, E.J.; Lewis, N.; and Comerford, M. HIV-1 and AIDS in Belle Glade, Florida: A re- examination of the issues. Am Behav Scientist 33(4): 531-564, March/April, 1990. Turner, C.F. Research on sexual behaviors that transmit HIV: Progress and problems. AIDS 3 (suppl. 1): S63-S69, 1989. United States Department of Commerce. County and City Data Book. Bureau of the Census. Washington, D.C.: Supt. of Docs., U. S. Govt. Print. Off., 1987. Wilkinson, A. Big Sugar: Seasons in the Cane Fields of Florida. New York: Alfred A. Knopf, 1989. 307 Acknowledgment Supported by the National Institute on Drug Abuse Grant #R18-A053349-02. Authors Clyde B. McCoy, Ph.D. Principal Investigator Edward J. Trapido, Sc.D. Analysis Coordinator Nancy Lewis, M.S. Research Associate Elizabeth L. Khoury, M.A. Research Associate Health Services Research Center Sylvester Comprehensive Cancer Center University of Miami School of Medicine Medical Arts Building, Room 309 1550 NW 10th Avenue Miami, FL 33136 and South Florida AIDS Research Consortium University of Miami School of Medicine Medical Arts Building, Room 309 1550 NW 10th Avenue Miami, FL. 33136 308 ENHANCED AIDS-PREVENTION COUNSELING FOR INJECTION DRUG USERS INCORPORATING HIGH-THREAT APPEALS AND PERSONAL CONTRACTING Nancy H. Corby, Fen Rhodes, and Jesse Horn Introduction An enhanced counseling intervention for injection drug users (IDUs) has been developed by the Long Beach component of the National AIDS Demonstration Research (NADR) Project to supplement basic AIDS education and skills training provided to IDUs in association with HIV- antibody pretest and post-test counseling. The enhanced program consists of two counseling sessions that incorporate high-threat appeals and personal-behavior contracting to influence compliance with HIV risk-reduction recommendations. The severe consequences and personal relevance of AIDS are emphasized through a videotape featuring Long Beach IDUs in various stages of HIV disease. Participants are assisted in defining goals and developing behavioral contacts for reducing their personal HIV risk and are encouraged to monitor and report progress in achieving these goals. For IDUs claiming no current personal risk, the intervention includes a peer-education alternative designed to influence the sexual and drug-use practices of high-risk acquaintances and to strengthen the commitment of participants to personal AIDS risk reduction. This report describes the rationale for combining threat with behavioral contracting and the specific content of the intervention using this approach. Background The HIV-prevention activities described in this report are aimed at IDUs who are not currently enrolled in any type of drug treatment program and who have not been recruited on the basis of prior interest or commitment to AIDS risk reduction. With such a population, achieving consistent participation in educational and counseling programs is problematic, and an intervention was therefore sought that could be effectively delivered in relatively few sessions. The potential efficacy of brief health counseling for IDUs is supported by the research of Gibson and his colleagues (1989), who found that two sessions of individual counseling and follow-up achieved measurable positive effects in terms of reducing risk behaviors reported by drug users in a treatment program. The present enhanced program of risk-reduction counseling and education consists of two individual counseling sessions that follow two additional sessions of standard risk-reduction education presented in the context of HIV pre- and post-test counseling. A key element of the enhanced intervention is the communication and personalization of AIDS threat to IDU participants. This aspect of the enhanced intervention is based in part on protection-motivation theory, as articulated by Maddux and Rogers (1983). According to the 309 theory, the perception of a health threat causes fear, which in turn initiates a generalized coping appraisal, resulting in a coping response. Health threat itself is a function of the individual's perception of his or her own personal vulnerability and of the severity of the disease in question. (Threat has also been emphasized in other models of health-behavior change that typically recognize that perceived threat can be an effective motivator of behavior change [Cleary 1987; Dembroski et al. 1978; Job 1988; Dabbs and Leventhal 1966; Leventhal 1970].) The particular coping response chosen by individuals in the face of a health threat depends upon their perceptions and beliefs regarding the relative effectiveness of available coping options (response efficacy) and their perceived personal power to implement those options (self-efficacy) (Rippetoe and Rogers 1987). Protection-motivation theory is explicit in stating that adoption of the behavioral recommendations must result in a reduction of the anxiety that has been aroused as a consequence of the threat. While this usually occurs for behaviors perceived by individuals as potentially efficacious, it is not always the case. For IDUs, it is important to ensure that specific risk-reduction recommendations result in reduction of threat-aroused anxiety, since it is commonly believed that increased drug usage is the coping mechanism most frequently employed by members of this population to reduce anxiety. Data from two studies examining the use of high-threat AIDS messages for IDUs support the utility of this approach. In the counseling intervention for IDUs reported by Gibson et al. (1989), participants were shown pictures of the severe consequences of HIV infection as a part of their successful intervention. In a recent study of AIDS-education messages (Rhodes and Wolitski 1990), IDUs expressed a strong preference for fear-oriented AIDS-education posters, rating a group of high-fear posters as more effective for motivating condom use than a comparable group of low-fear posters. The enhanced counseling program also draws upon Bandura’s social-learning theory (Bandura 1977) in the utilization of modeling, rehearsal, role-playing, and social reinforcement to increase participants’ perceptions of personal power and control and to develop specific AIDS-prevention skills. The modeling principles of social-learning theory have been directly applied in developing the training modules in bleach use and condom skills that are incorporated as a part of the standard educational intervention that precedes enhanced counseling. Informal behavioral contracting is employed in the enhanced intervention to provide a structure within which a meaningful degree of personal compliance with HIV-risk reduction recommendations can be achieved over the short term. The use of behavioral or personal contracting has its roots in clinical practice, specifically, in behavior therapy and behavior modification (Tharp and Wetzel 1969; O’Banion and Whaley 1981). This technique has been employed extensively with adolescents and adults in the context of individual as well as group therapy, and it has been used with some success with a variety of addictive behaviors, including overeating, smoking, and alcohol and drug use (Krasnegor 1979; Stitzer et al. 1983). In recent years, personal contracting has been also employed with patients in methadone maintenance programs as a means of reducing illicit drug use and facilitating other desirable outcomes (Dolan et al. 1985; Dolan et al. 1986; Magura et al. 1987). 310 Intervention Content—Session One Communication of AIDS Threat The severe physical deterioration often associated with full-blown AIDS and the injecting drug user’s personal risk of HIV infection is communicated through a videotape developed specifically for this purpose. The 12-minute video also addresses issues of personal efficacy and response efficacy. Entitled “Shooting Smart,” the video was filmed on the streets of Long Beach and features local IDUs who were willing to discuss their HIV infection on camera. These individuals discuss how they contracted HIV, how being HIV-antibody-positive has affected their lives, and the serious risk that others place themselves in by sharing needles. Several of the persons interviewed had been diagnosed with AIDS and had developed serious visible symptoms. The fact that one person died a few days after being taped is also mentioned in the video. The video was evaluated during its production using focus groups of IDUs. As a result of comments from these groups, more information about the severe consequences of AIDS was included, and specific instances of serious HIV-related illness were shown. In the two-session counseling intervention that follows the video, the counselor and the participant discuss the video, the participant’s reaction, and any questions that the participant may have. The counselor then summarizes the main points made in the video: (1) You can become infected with HIV by sharing needles or having sex with someone who is infected; (2) Up to one out of every eleven IDUs in Long Beach may already be infected with HIV; (3) You can’t tell who has HIV by the way he or she looks. Most infected people don’t look sick, and many don’t even know they are infected; (4) Once you get HIV, you have it for life. Medication can help, but there is still no cure; and (5) Don’t share needles unless you use bleach. Use condoms when you have sexual intercourse. Should the participant react strongly to the video or become upset, the counselor reassures the participant by emphasizing that HIV infection can be prevented. Personal Risk-Reduction Contract At this point, the specific ways the participant may be at risk for becoming infected with HIV are discussed. The counselor and participant together generate a list of the participant’s current behaviors that contribute to HIV-infection risk. The frequency, predictability, and context of these behaviors are then identified. The differential risks of the potential sources of HIV transmission listed by the participant are discussed, and misunderstandings about the risk of different activities are corrected as necessary. The participant is then asked to state which of these high-risk practices are most important to change, and an agreement to modify one or more behaviors is elicited. Together, the participant and counselor develop a personalized risk- 311 reduction plan with clear goals that are achievable and will ensure some degree of success. For example, a participant would be encouraged to choose an immediate goal of talking with his or her sex partner about condom use rather than initially committing to a goal of consistent condom use on every occasion of intercourse. Situations in which high-risk behaviors occur are also discussed. Participants who know that they only share needles with a certain friend, for example, can predict with greater accuracy when they should be carrying bleach. Specific barriers that might interfere with the adoption of risk-reduction behaviors, such as not having bleach or condoms readily available, are also identified. Methods of avoiding or overcoming these barriers are developed by the participant and counselor. Training in partner-negotiation skills are also an integral part of the enhanced intervention. Some of the behaviors that participants are encouraged to modify, such as condom use and needle sharing, are heavily influenced by the attitudes and preferences of other individuals. In teaching participants how to negotiate reduced-risk practices with others, the counselor models appropriate responses and sometimes involves the IDU in role-plays that demonstrate specific negotiation skills for persuading partners to use condoms or bleach. Peer-Educator Contract A substantial proportion of participants report they have already changed their behavior and firmly deny that they are at risk for HIV infection. In these instances, they are asked to help educate high-risk friends and acquaintances. The importance of informing everyone who is at risk about how to avoid infection is stressed. While the focus of this approach is on changing the behavior of others, the reinforcement of the participant’s commitment to his/her own risk prevention is an unstated goal. The participant’s friends and acquaintances are discussed in terms of possible HIV risk. As with the personal-risk approach, the relative frequency, predictability, and contexts of the various risk behaviors are evaluated. The counselor then assists the participant in developing specific goals with regard to influencing others. Specific strategies for approaching target individuals are devised, including times and places where this will occur. The participant then identifies personal barriers to implementing the education (e.g., reluctance to give advice, forgetting to carry bleach) and discusses ways to overcome these barriers. Appropriate techniques (teaching, discussing, demonstrating) are rehearsed, depending on the goals specified by the participant. The actual words and phrases that the participant will use in talking to others about AIDS are practiced until the participant is comfortable with them. Role-playing and modeling are often used during the process. In both the personal risk-reduction and peer-education approaches, the behavioral plan is jointly developed by the counselor and participant. Each participant is given a personal goal card listing the agreed-upon goals. An appointment is made for the next visit two weeks later. Condoms and bleach are provided to each participant at the end of the session. Intervention Content—Session Two At the return appointment, the participant’s progress toward the behavioral goals is reviewed and the difficulties that were encountered are discussed. Progress toward the participant’s behavioral goals is praised by the counselor. The participant is asked about specific problems encountered 312 in putting the risk-reduction or peer-education behaviors into practice and encouraged to suggest strategies for improving the effectiveness of the plan. The counselor translates the suggestions into specific objectives and the original risk-reduction or peer-education plan is modified to incorporate the changes. The new behaviors are rehearsed together with any specific skills that may be relevant. The modified risk-reduction plan is reviewed with the participant to ensure full understanding and personal endorsement. The counselor attempts to obtain a commitment from the participant to continue risk-reduction or peer-education efforts. The participant is asked to watch the video again and to identify those segments he or she believes will be most useful in educating others about the dangers of AIDS. Finally, the participant is offered more condoms and bleach and is reminded of the availability of social service referrals and of the month he or she is due for follow-up. Program Evaluation Experimental Study The efficacy of the enhanced counseling intervention is being evaluated in an experimental design comparing three conditions: (1) basic AIDS-eduction and risk-reduction information presented in association with pre- and post-test counseling; (2) basic education and counseling plus enhanced counseling with the high-threat video, and (3) basic education and counseling plus enhanced counseling with no video. Changes in injection and sexual risk behaviors between the pretest and post-test are assessed by the NIDA AIDS Initial Assessment (AIA) questionnaire and the AIDS Follow-up Assessment (AFA) questionnaire, administered six months later. A previously researched 16-item scale measures perceived personal vulnerability, disease severity, response efficacy, and self-efficacy. Participants are also asked to rate how afraid they are of AIDS using a 100-point scale. The attitude and belief measures are administered, in addition to pre- and post-test, immediately following both of the enhanced intervention sessions as a check for effectiveness of the threat manipulation. A total of 600 clients are participating in the comparative study. Participant Reactions Participants reacted very favorably to the enhanced counseling intervention. The videotape has been frequently mentioned as having significant influence on personal attitudes and behavior. Counselors report that many clients have strong emotional reactions to the videotape. Spontaneous comments by participants indicate that the video is more credible and has a stronger impact because it includes local IDUs and shows Long Beach neighborhoods. Viewers report that the video was a key factor in convincing them that AIDS is a very real risk in their own lives. This realization has been specified as a primary motivator by some participants who have increased their sterilization of needles with bleach. The comments of participants also show that their behavior has been influenced by the graphic depiction of AIDS as a disease with very severe consequences. Many have indicated that seeing persons with visible symptoms of HIV infection in hospice or hospital settings left them with a strong desire to avoid a similar fate. Reactions to the behavioral-contracting activities have generally been positive. A number of participants have stated that they appreciated the time spent on this activity because it showed that 313 the counselor was really interested in their life and was willing to help them discover solutions to risk-reduction barriers. Upon returning, many reported that they had increased their use of bleach and that they had either tried condoms or had discussed them with their partner. Few indicated, however, that they had successfully adopted consistent condom use. Individuals who have received the peer-educator training typically are willing to speak with a significant number of persons about the danger of HIV infection. Most participants have expressed a sincere desire to act as informal peer educators and indicate at follow-up that doing so was not extremely difficult. Many report at follow-up that they have approached at-risk acquaintances about HIV prevention and indicate that they have convinced others to use bleach and to accept free bottles of bleach and condoms. A substantial number of participants have also stated at the final session that they intend to continue educating other IDUs about AIDS. References Bandura, A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall, 1977. Cleary, P. Why people take precautions against health risks. In: Weinstein, N.D., ed. Taking Care: Understanding and Encouraging Self-Protective Behavior. New York: Cambridge University Press, 1987. pp. 199-149. Dabbs, J.M., Jr., and Leventhal, H. Effects of varying the recommendations in a fear-arousing communication. J Pers Soc Psychol 4: 525-531, 1966. Dembroski, T.; Lasater, T.M.; and Ramirez, A. Communicator similarity, fear-arousing communications, and compliance with health care recommendations. J Appl Soc Psychol 8: 254-269, 1978. Dolan, M.P.; Black, J.L.; Penk, W.E.; Robinowitz, R.; and DeFord, H.A. Contracting for treatment termination to reduce illicit drug use among methadone maintenance treatment failures. J Consult Clin Psychol 53: 549-551, 1985. Dolan, M.P.; Black, J.L.; Penk, W.E.; Robinowitz, R.; and DeFord, H.A. Predicting the outcome of contingency contacting for drug abuse. Behav Therapy 17: 470-474, 1986. Gibson, D.R.; Lovelle-Drache, J.; Derby, S.; Garcia—Soto, M.; Sorensen, J.L.; and Melese— d’Hospital, I. “Brief Counseling to Reduce AIDS Risk in IV Drug Users: Update.” Paper presented at the Fifth International Conference on AIDS, Montreal, Quebec, June 1989. Job, R.F.S. Effective and ineffective use of fear in health promotion campaigns. Am J Public Health 78: 163-167, 1988. Krasnegor, N.A, ed. Behavioral Analysis and Treatment of Substance Abuse. Rockville, MD: National Institute on Drug Abuse, 1979. Leventhal, H. Findings and theory in the study of fear communications. In: Berkowitz, L., ed. Advances in Experimental Social Psychology. Vol. V. New York: Academic Press, 1970. pp. 119-186. 314 Maddux, J.E., and Rogers, RW. Protection motivation and self-efficacy: A revised theory of fear appeals and attitude change. J Exp Soc Psychol 19: 469-479, 1983. Magura, S.; Casriel, C.; Goldsmith, D.S.; and Lipton, D.S. Contracting with clients in methadone treatment. J Contemp Soc Work 68: 485-493, 1987. O’Banion, D.R., and Whaley, D.L. Behavior Contracting: Arranging Contingencies of Reinforcement. New York: Springer Publishing Company, 1981. Rhodes, F., and Wolitski, R.J. Perceived effectiveness of fear appeals in AIDS education: Relationship to ethnicity, gender, age, and group membership. AIDS Educ Prev 2: 1-11, 1990. Rippetoe, P.A., and Rogers, R.W. Effects of components of protection-motivation theory on adaptive and maladaptive coping with a health threat. J Pers Soc Psychol 52: 596-604, 1987. Stitzer, M.L.; Bigelow, G.E.; and McCaul, M.E. Behavioral approaches to drug abuse. In: Hersen, M., ed. Progress in Behavior Modification. Vol. 14. New York: Academic Press, 1983. pp. 49-123. Tharp, R.G., and Wetzel, RJ. Behavioral Modification in the Natural Environment. New York: Academic Press, 1969. Acknowledgment Supported by the National Institute on Drug Abuse Grant #1R18DA05747-02. Authors Nancy H. Corby, Ph.D. Co-Principal Investigator Fen Rhodes, Ph.D. Principal Investigator Jesse Horn Follow-up Specialist AIDS Research and Education Project Psychology Department, Room 440 California State University 1250 Bellflower Boulevard Long Beach, CA 90840-0901 315 INTERPERSONAL COGNITIVE PROBLEM-SOLVING INTERVENTIONS WITH ADDICTS Jerome J. Platt and Stephen D. Husband Introduction Substantial evidence exists that many intravenous drug users (IVDUs) have accurate information about the ways in which the human immunodeficiency virus (HIV) is transmitted and the infection acquired. Additionally, it appears that many IVDUs are aware of the necessary measures to be taken in order to minimize the likelihood of transmission of HIV. Nonetheless, a number of studies have demonstrated that exposure to and acquisition of such knowledge alone do not necessarily result in significant changes in the high-risk behaviors of IVDUs; in fact, any such behavior changes have been found to be relatively modest. To be effective, any AIDS- related knowledge gained by IVDUs must translate into changes in high-risk behavior. While many IVDUs know how to decrease their risk of exposure to and infection with HIV, a substantial number of them appear to be deficient in translating knowledge they acquire into appropriate behavioral change. This observation may not be particularly surprising to anyone who has worked with IVDUs; nonetheless, it emphasizes that addiction is a process that is very much mediated by cognitions as well as by external contingencies. There is some evidence, however, that relevant cognitive skills can be taught successfully to heroin addicts and that behavioral change can take place (Platt et al. 1977; Platt et al. 1980). Skills Deficiencies in IVDUs Substance abusers generally have been described as deficient in the cognitive and behavioral skills necessary for coping with problems that arise in day-to-day living, particularly in the area of interpersonal cognitive problem-solving (ICPS) thinking (e.g., Platt 1986, 1987a; Appel and Kaestner 1979; Platt et al. 1973). For example, addicts tend not to plan ahead, consider the potential consequences of their behavior, or generate options and alternatives if their initial strategy is frustrated. The main concepts of ICPS are described by Spivack et al. (1976) and, as applied to addicts, in Platt (1986, 1987b) and Platt and Hermalin (1990). A central tenet underlying ICPS is that problems are unavoidable in daily life and that coping effectively and appropriately with these problems is essential to adaptive human functioning. Any understanding of the reasons why a particular individual functions adaptively or maladaptively must therefore take into account an individuals problem-solving skills repertoire. ICPS is concerned with the process involved in resolving problems rather than on particular outcomes. In other words, ICPS emphasizes how 316 one thinks and successfully (or unsuccessfully) approaches and resolves problems, rather than the content of what one thinks regarding a particular problem or situation. ICPS is a cognitive-behavioral approach designed to remediate deficits in the thinking process, primarily in situations involving interpersonal problems. Emphasis is placed on teaching individuals to become better problem solvers by focusing on six basic components that help to “mediate the quality of our social adjustment” (Spivack et al. 1976). These areas are: (1) problem recognition and identification; (2) generation of alternative solutions to problem situations; (3) assessment of the likely consequences of intended actions; (4) thinking through the step-by-step process by which a goal is reached; (5) understanding the cause-effect nature of relationships between events; and (6) perspective taking, or the capacity to take into consideration the thoughts, feelings, and motives of other people in a problem situation. ICPS training generally is given in the context of a small-group setting of no more than 10-15 participants. It is led by a professional trainer. Using the Training in Interpersonal Problem- Solving (TIPS) procedure (Platt et al. 1988), training usually lasts for approximately 10 sessions of 1 to 1 1/2 hours each. D’Zurilla and Goldfried (1971) have stated that “much of what we view clinically as ‘abnormal behavior’ or ‘emotional disturbance’ may be . . . ineffective behavior and its consequences” (p. 107). Similarly, Spivack and Shure (1982) have posited that “a key element in any theory of social adjustment or psychopathology is the quality of social relationships and capacity to cope with interpersonal problems” (p. 324). From these statements, it can therefore be argued that individuals who demonstrate deficiencies in problem-solving thinking skills are significantly more at risk for maladjustment and deviant behavior than individuals who do not have such deficiencies. Indeed, this has been demonstrated to be the case with a number of high-risk populations, including young heroin addicts (Platt et al. 1973; Appel and Kaestner 1979); alcoholics (Intagliata 1977, 1978); suicidal adolescents and adults (Schotte and Clum 1987); and adolescent and adult psychiatric patients (Platt and Spivack 1974; Platt et al. 1974). Given that cognitive problem-solving deficits exist in many IVDUs, it is perhaps not surprising that prevention and rehabilitation programs that have not focused on these deficits have not been particularly effective in significantly reducing relapse rates (e.g., Botvin 1983; Schaps et al. 1981). At the same time, the link between IV drug use and the transmission of HIV has been firmly established. The well-documented spread of AIDS and HIV among IVDUs underscores the magnitude of the AIDS crisis and the urgency of the need for effective responses to it. Indeed, the specter of AIDS has given renewed impetus to professionals involved in drug- addiction research and treatment. ICPS Interventions The importance of ICPS skills in avoiding problem situations or undesirable consequences was illustrated by Flaherty et al. (1983) in a study of adolescent girls and pregnancy. In their sample, teenage girls who used contraceptives had the highest scores in generic interpersonal problem-solving skills, while pregnant girls had the lowest scores. Similarly, Steinlauf (1979) found that the number of unplanned pregnancies in a woman's history “was significantly and negatively related to means-ends problem-solving ability and a belief in internal control” (p. 268). 317 Using the ICPS model, Platt et al. (submitted for publication) reported that a 10-session vocational-preparedness problem-solving training program doubled the rate of employment at the six-month follow-up interval for out-of-work methadone clients receiving the intervention. Although the employment rate for the experimental group had diminished by the time of the 12- month follow-up, indicating the need for some type of “booster” intervention, the effect of the ICPS training was clear. Platt et al. (1982) reported a strong trend indicating that outpatient methadone clients retained problem-solving skills for over a year following participation in training. Platt et al. (1980) found that incarcerated IVDUs who had participated in problem-solving training demonstrated greater resistance to conformity pressures, a diminished need for high levels of stimulation and excitement, and increased self-control when compared with baseline scores. Additionally, at two-year follow-up, this experimental group evidenced significantly lower arrest and recommitment rates than comparable controls. Application of ICPS to the Newark and Jersey City National AIDS Demonstration Research (NADR) Programs Because problem-solving training appears to have an effect on the behavior of IVDUs, it seemed reasonable to extend the generic problem-solving training by adding an AIDS-education component. This was accomplished, and a new training manual, TIPS-AIDS, was created (Platt et al. 1989) for the NIDA-funded NADR programs in Newark and Jersey City, New Jersey. In these projects, outreach workers contact as many IVDUs as possible and encourage them to come to methadone clinics or a storefront for HIV testing, counseling, and treatment for their addiction. A large number of these IVDUs also are being offered the TIPS-AIDS training in an effort to reduce their risk of transmitting and/or contracting HIV. The goal of TIPS-AIDS training is to assist IVDUs in making the crucial connection between acquiring knowledge and translating it into behavior. Utilizing a small-group training model, IVDUs are presented with information and strategies to think through and discuss with other IVDUs less-risky ways of managing real-life behavior with respect to AIDS and transmission of HIV. Program Outline The training program is delivered in nine sessions and focuses on cognitive skills such as problem recognition, means-end thinking, alternative thinking, causal thinking, and consequential thinking. This training is provided, along with AIDS and HIV health-education material, in a package that is designed to foster small-group interaction and dynamics. The program is manual-driven and highly structured, and includes specific directions and examples for use by the group leader, group exercises, and AIDS-education materials. It is designed to both minimize contamination in the delivery of the intervention and to allow for meaningful evaluation of the impact of the TIPS training. The contents of each of the training sessions is summarized below. 318 Session 1 During the first session, the leader spends a significant portion of the time describing the format, rules, and goals of the group, as well as answering questions from group members regarding procedures and expectations. A brief AIDS-education discussion is included in this session to ensure that all group members begin the training with a minimum knowledge regarding HIV and AIDS and to dispel any myths and misunderstandings. Because group members likely have experienced a range of therapies and treatments, the leader is instructed to be particularly careful in making the distinction between Training in Interpersonal Problem-solving Skills and other therapies. The leader emphasizes that TIPS is not therapy and that the group members are not patients. One of the leader’s goals during this session is to begin to establish a productive and trusting atmosphere within the group. The leader reassures the group members that everyone has problems and that TIPS training has been used in a variety of settings with a number of different kinds of people. Session II In the second session, members begin to identify and discuss problems in general, and personal drug use and AIDS-related concerns in particular. Group members participate in tasks designed to emphasize the distinction between facts and the opinions and interpretations regarding facts that we all make. The exercises have been selected carefully so that the leader may introduce AIDS-education information, particularly the identification of high-risk behaviors, in the course of the group discussion. The final exercise allows the leader to explain the use of bleach in cleaning needles. Session III During the third session, as with all succeeding sessions, the leader begins to build on the skills already covered and discussed by the group. Group members practice obtaining information relating to a problem through observation and asking relevant questions; this is accomplished through exercises and personal examples elicited from members. The topic of safer sex is introduced, and the group is instructed in the proper use of a condom. The session ends with an exercise in which the group plans a trip for two IVDUs who are determined to avoid all high-risk behaviors. Session IV The fourth session marks the beginning of a series of sessions that focus on communication skills. The leader concentrates on the nonverbal aspects of communication and the important role they play in the problem-solving process. Following the theme from the previous session, the group practices different ways in which people and faces can be remembered. The exercises for this session include recognizing facial expressions and the feelings likely to be related to them and generating a variety of expressions. 319 Session V The second phase of the communication-skills segment, verbal communication, is introduced in session five. The discussion is intended to raise the awareness of the group that differences of opinion exist between people and to focus on ways in which one can recognize opinions. Part of this session is spent on learning to talk about problems in a clear and concise manner, with emphasis on things such as vocal inflections and quality and the impact these have on the listener. Session VI In this session, the group begins to practice generating alternative solutions to a variety of problem situations. The pitfalls of jumping to conclusions are explored through a series of exercises that illustrate the importance of taking time before making and acting on a decision. Examples are drawn from problems that occur in the everyday lives of group members, and the leader emphasizes the importance of generating a number of potential alternative solutions to a problem before deciding on a course of action. The practice involved in this session provides the foundation for the more advanced problem-solving skills that are introduced in the final sessions. Session VII In this session, the group begins to critically appraise the potential consequences of various alternative solutions. Emphasis is placed on problem solving in a step-by-step manner, and it is stressed that labeling particular decisions as “good” or “bad” is less important than determining “goodness” or “badness” as a function of the likely outcome of following a particular decision’s course of action. Group exercises involve active participation in solving practice as well as real-life problems, such as receiving HIV test results and assessing the likely consequences of various decisions. The steps of problem solving are presented in their entirety at this point, and the group begins to put into use the skills learned in previous sessions. Session VIII The focus of this session is on means-end thinking, or the process of identifying the sequential steps involved in the problem-solving process. Goals and the means to achieve them are discussed and practiced, and effort is directed toward preparing the group members to put their individual plans into action. The session concludes with a detailed discussion of group members’ personal problems and their desired goals. Session IX The leader reviews the process of problem solving and what has been learned over the previous sessions. The leader offers group members the opportunity to give their individual opinions and evaluations of the TIPS program. As time permits, the remainder of the session is spent practicing skills and reinforcing group members’ use of the problem-solving process. 320 Conclusion ICPS and the associated TIPS-AIDS training group appear to hold real hope for teaching IVDUs not only the problem-solving process but also ways in which information they have acquired about HIV and AIDS may be realistically applied to their lives and the risks they face every day. Through the Newark and Jersey City NADR programs, it is hoped that the implementation of TIPS training with IVDUs will help to slow the spread of AIDS and transmission of HIV through this population by providing addicts with the necessary information about this disease and the means with which to alter their behaviors and implement the information in their lives. Initial findings suggest a high degree of client acceptance of this intervention. Current efforts are directed toward the collection of data within a carefully controlled research design in order to determine the effectiveness of this intervention strategy in changing high-risk behaviors among IVDUs. References Appel, P., and Kaestner, E. Interpersonal and emotional problem-solving among narcotic drug abusers. J Consult Clin Psychol 47: 1125-1127, 1979. Botvin, G. Prevention of adolescent substance abusers through the development of personal and social competence. In: Glynn, T.; Leukefeld, C.; and Ludford, J., eds. Preventing Adolescent Drug Abuse. NIDA Research Monograph 47, Pub. No. (ADM)86-1280. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1983. pp. 115-140. D’Zurilla, T., and Goldfried, M. Problem solving and behavior modification. Journal of Abnorm Psychol 78: 107-126, 1971. Flaherty, E.W.; Maracek, J.; Olsen, K.; and Wilcove, G. Preventing adolescent pregnancy: An interpersonal problem-solving approach. In: Hermalin, J., and Hess, R., eds. Innovations in Prevention. New York: The Haworth Press, Inc., 1983. Intagliata, J. Increasing interpersonal problem-solving skills of an alcoholic population. Dissertation Abstracts Int 37: 4146, 1977. Intagliata, J. Increasing the interpersonal problem-solving skills of an alcoholic population. J Consult Clin Psychol 46: 489-498, 1978. Platt, J.J. Heroin Addiction: Theory, Research, and Treatment. 2d ed. Melbourne, Florida: Krieger, 1986 (second printing, 1988). Platt, J., and Hermalin, J. Social skill deficit interventions for substance abusers. Psychol Addict Behav, in press. Platt, J.J.; Labate, C.; and Wicks, R.J., eds. Evaluative Research in Correctional Drug Abuse Treatment. Lexington, MA: Lexington Books/D.C. Heath, 1977. 321 Platt, J.J.; McKim, P.; and the TIPS Working Group. “T.I.P.S.—Training in Interpersonal Problem Solving: Enhanced Health Promotion and AIDS Prevention Program Trainer’s Manual.” Unpublished manuscript, Camden, NJ, 1989. Platt, J.J., and Metzger, D.S. Cognitive interpersonal problem-solving skills and the maintenance of treatment success in heroin addicts. Psychol Addict Behav, 1: 5-13, 1987a. Platt, J.J., and Metzger, D.S. Role of Work in the Rehabilitation of Methadone Clients. Final Report (Grant #R01DA0444901). Washington, D.C.: National Institute on Drug Abuse, 1987b. Platt, J.J.; Metzger, D.S.; Hermalin, J.; Husband, S.D.; and Cater, J. “The Success of a Vocational Intervention Program for Methadone Clients.” (submitted). Platt, J.; Morell, J.; Flaherty, E,; and Metzger, D. Controlled Study of Methadone Rehabilitation Process: Final Report (Grant #RO1DA01929). Washington, D.C.: National Institute on Drug Abuse, 1982. Platt, J.; Perry, G.; and Metzger, D. Evaluation of a heroin addiction treatment program within a correctional environment. In: Ross, R., and Gendreau, P., eds. Effective Correctional Treatment. Ontario, Canada: Butterworth, 1980. pp. 421-435. Platt, J.; Scura, W.; and Hannon, J. Problem-solving thinking of youthful incarcerated heroin addicts. J Community Psychol 1: 278-281, 1973. Platt, J.J., and Spivack, G. Means of solving real-life problems: I. Psychiatric patients versus controls, and cross-cultural comparisons of normal females. J Community Psychol 2: 45- 48, 1974. Platt, J.J.; Spivack, G.; Altman, N.; Altman, D.; and Peizer, S. Adolescent problem-solving thinking. J Consult Clin Psychol 42: 787-793, 1974. Platt, J.J.; Taube, D.O.; Metzger, D.S.; and Duome, M.A. Manual for Training in Interpersonal Problem-Solving (TIPS). J Cognitive Psychotherapy 2(1): 1-30, 1988. Schaps, E.; Bartolo R.; Moskowitz, J.; Palley, C.; and Churgin, S. A review of 127 drug abuse prevention program evaluations. J Drug Issues 17-43, 1981. Schotte, D., and Clum, G. Problem-solving skills in suicidal psychiatric patients. J Consult Clin Psychol 55: 49-54, 1987. Spivack, G.; Platt, J.J.; and Shure, M. The Problem-Solving Approach to Adjustment. San Francisco: Jossey-Bass, 1976. Spivack, G., and Shure, M. The cognition of social adjustment. In: Lahey, B., and Kazdin, A., eds. Advances in Clinical Child Psychology. Vol. 5. New York: Plenum Press, 1982. 322 Steinlauf, B. Problem-solving skills, locus of control, and the contraceptive effectiveness of young women. Child Dev 50: 268-271, 1979. Acknowledgments Supported by the National Institute on Drug Abuse Grants #89-234-NAR-00 and #89-235- NAR-00. Authors Jerome J. Platt, Ph.D. Director, Center for Addiction Research Stephen D. Husband, Ph.D. Assistant Professor of Clinical Psychiatry Center for Addiction Research University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine Department of Psychiatry 401 Haddon Avenue Camden, NJ 08103 323 A CASE STUDY OF AN AIDS-ENHANCED PSYCHOEDUCATIONAL GROUP: RESISTANCE OF IVDUs AND THEIR SEXUAL PARTNERS TO BEHAVIOR CHANGES FOR AIDS PREVENTION Emma Plaga, Carol Tobkes, and Edith Springer AIDS group education is an integral part of the Harlem AIDS Research Project. It is designed to affect risk behaviors of intravenous drug users (IVDUs) and their sexual partners. To achieve this objective, a series of three psychoeducational group sessions, each approximately one-and- one-half hours in duration, was developed. Each session focuses on different aspects of AIDS. These focused groups are considered by health professionals to be the most effective means of educating the public about health-related subjects such as AIDS. The content of each group is drawn from preselected material and includes the use of videotapes designed specifically for our target population. Although Session I can and does stand alone, those who wish to attend Sessions II and III must attend the first session. It is during these subsequent sessions that the respondents begin to enter into a more experiential form of education. For example, in Session III, respondents role-play high-risk situations drawn from personal experiences. For this exercise, in particular, it is critical that members have attended both previous sessions; members must have, in other words, a clear understanding of AIDS: what it is, how it is transmitted, and what must be done to prevent transmission of the virus. The focus of this paper is Session III, which covers possible risk-reduction activities the respondents can implement in their own lives, such as cleaning their drug-use paraphernalia and using condoms. The clearest indication of the possibility of these changes comes from the degree of enthusiasm with which the respondents involve themselves in the role-plays that are part of this session. In order to demonstrate more clearly these group dynamics, let us analyze a theoretical session. The group is composed of three men and three women ranging in age from 27 to 57. One is a Hispanic male IVDU, accompanied by his wife (also Hispanic). They have been married for 10 years and have no children. Another woman is White, and her partner is a Black male IVDU. They have been associated with each other for the past six years. The other members, one Black male and one Black female, are unknown to each other. Both are acknowledged IVDUs and have been so for the past 10 years. All members have attended Sessions I and II—four of them attended the sessions together, and two attended separate groups during the past two weeks. Each member of the group knows that there will be a role-play to demonstrate negotiation techniques for use in social situations that place them at high risk for AIDS. One such role-play involves two IVDUs: one insists on cleaning drug-use paraphernalia, while the other rejects the 324 idea, never having done it before. Another role-play concentrates on condom use. All members have the opportunity to play each part and are encouraged to say whatever they think might occur in a real-life situation. The session runs smoothly until the racially mixed couple is asked to perform the role-play. The man flatly refuses to engage in either role-play. His female partner follows suit. The group leader then asks the man why he objects. His reasons include fear of rejection by friends if he insists on needle cleaning, ostracism by these same friends on whom he may someday depend, and deeply entrenched behavior patterns from the onset of drug use that limit needle cleaning to the use of cold water. As for the condom use, he objects with: “Why should I now use a condom, when I have been sexually active with my partner for the past six years without ever using one?” As a result of these objections, other group members become more resistant and more critical of the material presented on AIDS, claiming that it simply could not work in the world in which they live. Recognizing that group learning is an interactional process, the group leader makes no interventions or interruptions. After the group members have vented their feelings, the group leader asks them if they see some way to resolve the feelings of conflict they experienced, while still protecting themselves from HIV infection by cleaning drug-use paraphernalia and using condoms. It soon becomes apparent to the group leader that the respondents see more negative factors in changing their behaviors than in maintaining the status quo. “We will just have to take our chances on being those lucky ones who don’t get the virus.” A “poverty of spirit” is seemingly so deeply ingrained in each respondent that planning or anticipating a future is something he or she cannot permit. Lives are chaotic and unmanageable. IVDUs, in particular, lack a sense of empowerment: they no longer have control of their lives. Having regressed to (or for some, having never developed beyond) an infantile state, they wait for someone to take care of them. The AIDS epidemic requires that each individual take responsibility for not getting the virus, not transmitting it, if possible, and stopping the progression of HIV. Simply asking this of an IVDU is overwhelming. Helplessness is fought with resistance. This, along with incredibly difficult environmental and social factors with which IVDUs cannot cope—i.e., housing, food, jobs, relationships, social isolation, community stigma—makes the resistance to dealing with AIDS even more difficult to overcome. Education is the best tool we have to prevent the transmission of HIV infection and to make those engaging in high-risk activities aware of risk-reduction measures they can take. The challenge we face is how to overcome their resistance to practicing what we teach. 325 Acknowledgment Supported by the National Institute on Drug Abuse Grant #R18DA05746. Authors Emma Plaga, B.S.N., M.A,, Prof. Dip., R.N. Health Educator Carol Tobkes Health Educator Edith Springer, A.C.S.W. Clinical Consultant Narcotic and Drug Research, Inc. 11 Beach Street New York, NY 10013 326 CODEPENDENTS: AIDS INTERVENTION AND DRUG-ABUSE TREATMENT | Deena D. Watson The grantee of the Dallas National AIDS Demonstration Research (NADR) Project is DARCO Drug Services, a nonprofit organization with longstanding experience as an outpatient drug- treatment program. It is not surprising, therefore, that we felt at the onset of our program that one of our greatest strengths would be direct intervention. We also felt that our experience in working with drug addicts would serve to guide our outreach efforts. And, with the development of a dedicated, hard-working, concerned, and responsible outreach staff, it has. We found that engaging the target population depended on their recognition that we cared about them as individuals. We were able to do this by building on the reputation of the drug-treatment program and by the ability of our outreach workers. Like many of the NADR programs, we also offered nominal cash incentives to participants. The $20 incentives were presented in consideration of the subject’s time and effort in providing research data. To ensure that our participants being tested for HIV antibodies had a full opportunity to understand the meaning of these tests, we withheld payment until the post-test counseling session. Even in the first three months of trial operations, more than 95% of interviewees have returned for post-test counseling. Our Neighborhood Outreach Workers observed that the majority of respondents were intravenous drug users (IVDUs) who used heroin. They also observed that many IVDUs who were hesitant at first contact but sought second contact were most interested in our offer of free methadone-assisted treatment. Preliminary figures on 607 cases indicate that 388 (64%) were IVDUs who injected heroin or heroin and cocaine. Information given to outreach staff also suggested that most of the respondents had few resources, did not access health services, were not currently involved with the criminal-justice system, and had either never engaged in drug treatment or had not done so in recent years. Thus, it was a currently hidden or otherwise inaccessible population. Preliminary AIDS Initial Assessment (AIA) tabulations indicate that 184 (47%) of 388 heroin or heroin-and-cocaine cases have some treatment history and that 95% have been in jail or prison at some time. There appears to be little, if any, real difference between those with some mention of treatment history and those with none, although AIA responses show those in the former group to have a slightly higher likelihood of being male, White, having jail or prison experience, having been older at the age of first drug use but having started injecting drugs earlier, and reporting even more frequent drug use than the latter. In general, this IVDU population fits the pattern of the chronic addict that might be assumed to be resistive to treatment or, as Barry Brown has stated, “inadequately motivated for treatment.” However, our expectations and experience to date contradict that assumption. Because we 327 considered drug treatment an essential ingredient in effective AIDS risk reduction, we incorporated free drug treatment with AIDS-education activities in our plans. Instead of deterring IVDUs (or sexual partners) from participation in the AIDS project, drug treatment was frequently mentioned as the reason for volunteering for the AIA and for HIV-antibody tests. Those self-reports are supported by available data. NOVA has reported that 83% of Dallas interviewees are IVDUs. Of that target group (IVDUs), almost 75% have entered methadone treatment and another 10% entered drug-free treatment. Whether it was because the treatment was offered free, because it was immediately available, or because the IVDUs sensed an acceptance of their responsibility to make the decision, this “surprising” interest in drug treatment has provided us with the opportunity to test strategies that we believe are most likely to effect AIDS risk reduction in this population. Intervention volunteers are randomly assigned to an AIDS-education and counselor-facilitated support group or to an enhanced-intervention group. Both intervention strategies extend over a 90-day period, although the latter is conducted more frequently in that time period. Our enhanced intervention groups are an adaptation of the Training in Interpersonal Problem Solving (TIPS) approach that we developed with the encouragement and assistance of Jerome Platt, Robert Baxter, Martin Iguchi, and Harvey Musikoff of the Newark/Jersey City NADR program. For IVDUs, it is almost always provided in conjunction with a drug-treatment regimen. We do not yet have data on the effectiveness of either strategy. However, comparing these people with our other treatment clientele, we note many characteristics that often present barriers to behavior change. They want immediate results. They have few resources on which to build; regular transportation to the clinic, for example, is a common need. They are unfamiliar with group processes or clinic rules. The trust that they have placed in the outreach staff members must be transferred to the treatment staff. These have led to attrition in our treatment- intervention population, which is always disappointing. Yet, by the end of September, 210 (58%) of the 362 methadone clients recruited through the NADR program remained in treatment, and 36 (70%) of the 51 program clients admitted to drug-free treatment remained enrolled. We still do have the opportunity to “literally save lives.” Acknowledgment Supported by the National Institute on Drug Abuse Grant #1R18DA05176-01. Author Deena D. Watson, M.A. Principal Investigator DARCO Drug Services, Inc. 2722 Inwood Road Dallas, TX 75235 328 A COMMUNITY-ORGANIZATION APPROACH TO HIV RESEARCH, EDUCATION, AND PREVENTION Joseph Bouie, Vernon J. Shorty, Adelbert Jones, and Scott Ray Introduction This paper will present a community-organization model and process that will enable any community to use its existing units and systems to achieve human immunodeficiency virus (HIV) research, education, and prevention goals through collective effort. Because of the impact of HIV on all aspects of the community, it is essential to involve all community HIV units and systems in HIV research activities. This is necessary to develop a bridge to interagency networking for future prevention, education, and treatment strategies. The Collective-Capacity Model and Systems Theory The theoretical anchor of this approach is the collective-capacity model and a view of communities from a systems perspective. The collective-capacity model (sometimes referred to as the process model) is geared to building and/or strengthening a community, social integration among people, and agencies (Meenaghan and Ryan 1982). Within the collective-capacity model, there are two major assumptions: (1) cooperative relations are desirable and achievable; and (2) people can and will get involved. A second theoretical anchor for this approach is a view of community from a systems perspective. According to Warren, a community is that combination of social units and systems that performs the major social functions having locality relevance (Warren 1963). A system, according to von Bertalanffy, is a whole with parts that are interrelated and interdependent (von Bertalanffy 1940). Collectively, these viewpoints provide a basis for two major assumptions of this community-organizing approach: (1) community refers to social activities (through units and systems) that afford people access to areas of activity that are necessary in day-to-day living; and (2) the units and systems are ideal sources to interact with the people of a particular community. Community-Organizing Structure In organizing for collective involvement in HIV research, it is necessary to establish and mobilize a core group within the community. The researcher must work directly with and through this group to reach other people and organizations in the community. In the Desire Narcotic Demonstration Project, the core group (Figure 1) consists of: (1) schools (Southern University at New Orleans); (2) churches; (3) the criminal-justice system; (4) hospitals; (5) street workers; and (6) public-housing/tenant councils. 329 Figure 1. Desire Narcotic Rehabilitation Center's Approach to HIV Research, Education, and Prevention Community-Organization Approach The Core Group Criminal Street Public Housing/ Schools Churches Justice Hospitals Workers Tenant Councils New Orleans HIV Network - Charity Hospital - New Orleans/AIDS Task Force - Upjohn Health Care Services - Hotel Dieu Hospital Hospice - Louisiana AIDS Community Network - Project Lazarus - Other Community Service Providers Phases of the Process - Planning - Identification - Recruitment - Education - Motivation - Evaluation Copyright © 1989 Joseph Bouie, Ph.D., Vernon Shorty, M.A., Adelbert Jones, Ph.D., Scott Ray, Ph.D. 330 Four criteria were used in selecting core group members. Each person or organization chosen (1) had a particular contribution to make to the research study; (2) had links with numerous organizations and people; (3) was representative of the community in terms of demographics and special interests; and (4) had a fairly high level of interest (Meenaghan and Ryan 1982). While the core group is the mechanism for contacting other community members and organizations, input within the structure is from an open-system perspective; i.e., input can flow freely from all units and systems. Process Essential to this approach are a series of phases that facilitate the development of the community organization structure and, ultimately, goal achievement. These phases represent activities of the researcher in facilitating the cooperative effort and are referred to as the organizing process. “Process,” as used here, refers to intellectual projections of how people are expected to behave in response to problems viewed within a specific framework of values and goals (Brager and Specht 1973). For this study, the community organization process is a statement of behavioral expectations of those people and organizations who comprise the New Orleans HIV Network. While these phases are interrelated and interdependent, they can function both individually and simultaneously. The phases of the process are: (1) Planning: identifying and defining the problem (i.e., implementing the Community Outreach Project) and linking problem identification to goal development (identifying the role of core group and network members); (2) Identification: identifying the members who will comprise the core group and network members; (3) Recruitment: solicitation of membership and commitment to the research project; (4) Education: providing information and/or training to core group and network members; (5) Motivation: cultivating commitment and energy to actualizing research project goals; and (6) Evaluation: evaluating the community-organization approach. We are employing the Goal-Attainment Model of Evaluation (Meenaghan and Ryan 1982). This model has five steps: (1) specification of the goal to be measured; (2) specification of the sequential set of performances that, if observed, would indicate that the goal has been achieved; (3) identification of which performances are critical to goal achievement; (4) description and specification of the indicator behaviors that will inform the evaluator that the goal has been met; and (5) testing of whether each indicator behavior is associated with each other. 331 References Brager, G., and Specht, H. Community Organizing. New York: Columbia University Press, 1973. p. 68. Meenaghan, T., and Ryan R.M. Macro-Level Practice in the Human Services. New York: The Free Press, 1982. pp. 76-80. von Bertalanffy, L. Der Organismus als physikalisches System betrachtet. Naturwissenschaften, 28: 521ff, 1940. Warren, R. The Community in America. Chicago: Rand McNally and Co., 1963. pp. 9-20. Acknowledgment Supported by the National Institute on Drug Abuse Grant #DA-88-04. Authors Joseph Bouie, Ph.D.1 Research Associate Scott Ray, Ph.D.t Research Director Vernon Shorty, M.A.§* Principal Investigator Adelbert Jones, Ph.D.§* Co-Principal Investigator Southern University of New Orleans 6400 Press Drive New Orleans, LA 70126 §*Desire Narcotic Rehabilitation Center 3307 Desire Parkway New Orleans, LA 70117 332 COMMUNITY ORGANIZING AS A PRIMARY INTERVENTION TO REACH IV DRUG USERS AND THE SEXUAL PARTNERS OF IV DRUG USERS George Freeman, Jr. and P. Catlin Fullwood Introduction At present, the National AIDS Demonstration Research (NADR) Project of the National Institute on Drug Abuse (NIDA) encompasses 63 programs that are providing AIDS information and education to intravenous drug users (IVDUs) and the sexual partners (SPs) of IVDUs. The intervention of choice for most of these projects is the community health outreach model. In this model, AIDS information and education are often provided directly to the drug user(s) and/or the sexual partner by a street outreach worker. In many cases, program staff act as a liaison " between the community and the outreach workers. Their task is to prepare the community for the work, gain access to resources, and enlist the assistance of key individuals in the delivery of information. Often times, this type of intervention entails community organizing. Unfortunately, very little effort has been devoted to understanding the role of this type of intervention, developing a model from which to apply the intervention, or tracking the end result of such interventions. The work is seen as part and parcel of the community health outreach work. Within these 63 NADR programs, only one has been designated to implement a community- organizing effort as one of two primary interventions. The Seattle NADR program has both community organizing and community health outreach workers (CHOWS) in two separate interventions. This paper provides an in-depth report of the Seattle community-organizing effort and of some of the considerations necessary for such an intervention to be applied. Project CATCH-ON Project CATCH-ON is a collaborative effort between several organizations in Seattle/King County. The lead agency is the Seattle/King County Department of Public Health AIDS Prevention Project. The other players in the collaboration are: the People of Color Against AIDS Network (POCAAN); the Northwest AIDS Foundation; the King County Division of Alcohol and Substance Abuse (Department of Public Health); the Group Health Cooperative; and the University of Washington Alcohol and Drug Abuse Institute. Each of these groups plays a different role in the effort to reach IVDUs and the SPs of IVDUs. e As the lead agency, the AIDS Prevention Project is responsible for the overall administration of the grant. 333 ® POCAAN was originally contracted to provide two community organizers to work with the CHOW component of our research. This approach was modified, and the community-organizing effort became a primary intervention (to be discussed in greater length in the body of this paper). ® The Northwest AIDS Foundation provides a case manager to respond to the social-service needs of HIV-antibody-positive individuals, those with ARC, and those with AIDS. * The King County Division of Substance Abuse Services similarly provides a case manager. This individual works primarily at the systems level, identifying key individuals within the substance-abuse field. He or she may assist study participants in their efforts to obtain substance-abuse treatment. * The Group Health Cooperative is a health maintenance organization that is responsible for the CHOWSs’ efforts. They are located in downtown Seattle and work with the lively street scene in that area. ® The University of Washington Alcohol and Substance Abuse Institute (ADALI) is responsible for recruiting participants and conducting interviews, for ethnographic research of the two areas, and for data collection and evaluation. The Target Sites In Seattle, a different site was selected for each of the interventions. The sites lend themselves to the type of intervention being used—community health outreach or community organizing. The community health outreach occurs in the downtown core of Seattle, where IV drug use and sales are very visible. The target population consists primarily of indigent street people and low- income people residing downtown. The community-organizing effort is located in a south Seattle neighborhood known for a high level of substance abuse. The neighborhood is appropriate for this type of intervention, as drug use and sales take place in the privacy of individuals’ homes and automobiles. The network of drug sales and use is well established, yet invisible. The neighborhood is also home to a number of community organizations and social services aimed at low-income people. It is within the context of this collaborative effort that we try to reach intravenous drug users and the sexual partners of IVDUs. Community Organizing Community organizing is difficult to define in terms of one model or theory. As many as 13 different definitions of community organizing have been established (Nute and Senter 1989). With such a plethora of definitions, Rothman (1972) suggests we not speak of an overall, encompassing theory of community organizing and planning, but rather that we speak of “community-organization methods.” Whether using a model or a specific set of methods, a guiding philosophy is helpful. It is best if this philosophy arises from the community organization conducting the work. 334 POCAAN’s philosophy suits the types of intervention being utilized. POCAAN’s mission statement reads: The People of Color Against AIDS Network is a multi-racial AIDS education coalition committed to creating comprehensive services grounded in the cultural mores, customs, and languages of communities of color in Washington State. POCAAN is committed to working with specific racial and geographic communities as they struggle to meet the AIDS challenge through the creation of prevention, education, and support strategies which remove the barriers forged by sexism, racism, homophobia, and which limit our abilities to access health care services and educational risk-reduction messages concerning AIDS. An indirect goal of POCAAN’s coalition building effort is to bring people together across color, gender, sexual orientation, agency affiliation, and community lines. POCAAN provides a forum for dispelling myths and fears, and for enabling people of color to work together in unity. The AIDS pandemic presents a critical focal point for coalition building and sharing between lesbian/gay people of color and heterosexual people of color (Fullwood 1987). Based on the foregoing organizational philosophy, an appropriate model can be selected. Choosing a model or method from which to shape interventions in the community can also be determined by a strategy called the “five Cs”: cause, change targets, change agency, channels, and change strategy (Kotler 1972). The goal of the NADR Project (behavior change for IVDUs and the SPs of IVDUs) has determined the first three of these five Cs. The cause is the AIDS epidemic and the potential spread of AIDS among IVDUs and their SPs. The change targets are IVDUs and the SPs of IVDUs. Using community organizing as a primary intervention creates a second target, that being community groups and organizations. The third C, POCAAN, serving as the change agency, was also determined prior to implementing the intervention. What remains for discussion are the final two Cs: channels and change strategy. These last two comprise the interventions used by POCAAN to reach the target population. With these predetermined factors in mind, choosing a model for community action is somewhat narrowed. The model or models chosen must reflect the parameters determined by these factors. Of the various options in models, two best suit the prescribed parameters of this study: social planning and community development. Social-Planning Model The social-planning model of community organizing is one that “presupposes rational solutions to rational problems through fact gathering and application.” It relies primarily on information to create an intervention within the community. The role of the planner is one of gathering information and coordinating efforts based on the information gathered. The “experts” provide the necessary skills to resolve the problem as it has been defined by the community and by the information provided. The role of the community is often defined by the planner (Rothman 1972). We know from experience using social planning to create social change that, without community support and participation, these plans often fall short of the desired goals. The objective of our community-organizing effort is to bring our level of expertise into the community to deal with a 335 problem that is already defined. The goal is to have members of the community, once they have received the necessary information, take responsibility for generating and conducting the interventions to reach the target population. For this goal, the community-development model is more appropriate. Community-Development Model Community development as a model of community organizing relies upon a broad-based community network to achieve a solution to an identified problem. The community sets the agenda, develops an intervention(s) appropriate for the community, develops local leadership, and is process oriented. Program direction is set and controlled by the group. The role of the community organizer is that of facilitator or liaison, in contrast to the more directive role of the organizer in the social-planning model. Social-Action Model A third model of community organizing, social action, is also implemented through this outreach effort, but is not adopted as fully as the other two models. The social-action model “presupposes a disadvantaged segment of the population that needs to be organized” (Rothman 1972). This model often attempts to redistribute power and to reallocate resources from the more traditional status-quo groups. The roles of advocate and activist are often associated with this approach, and techniques such as rallies and marches are used to create change. The overall outcome of the present research design and POCAAN’s organizational philosophy lend to the use of these three models as a means of conducting a community-organizing effort to reach the target population. The agenda has already been set and the method for reaching the goals has been established, yet within these parameters is the flexibility to take this set agenda and manipulate it to achieve other desired outcomes as established by the different communities identified by this project. Theory into Action Applied community-organizing efforts must have a well-laid foundation based on an accurate assessment of the community. Borrowing from one definition of community organizing as a means to “activate the community to recognize an issue and to be mobilized to address the issue” (Community Organization and Mobilization Working Group), such an assessment provides us with a step-by-step method of approaching community organizing. These steps are: (1) identification of the problem; (2) involvement in the planning process; (3) priority setting; (4) decision making; (5) implementation of change strategies; (6) involvement in organization development; and (7) resource generation, management, and control. One of the first steps in creating such an effort is a community analysis. The analysis is used to identify key organizations and individuals. It can help determine if the organizations chosen are appropriate for the intervention. Depending upon how it is conducted, it can serve as the initial introduction of the organization (in this case, POCAAN) into the community. Finally, it can serve as a strong point of overlap with the ethnographic research. A thorough knowledge of the subsystems and identification of resources available and gaps in community skills that may 336 impede progress toward the desired goals will eliminate a great deal of difficulty further down the road (Miller 1981). The most convenient means of conducting a community analysis in the Rainier Valley was by phone. After establishing 10 different categories of organizations, a structured phone interview (Figure 1) of the organizations identified for each category was conducted. The organizer would then call the agency, identify himself or herself, and begin the structured interview. After completing the interview, the organizer would talk about our program and schedule an appointment to meet with the contact person or the person identified as the key individual. A second, follow-up interview may be conducted to evaluate the progress of the community- organizing efforts. Questions asked during this interview cover the content and extent of information received from the project since its last contact with the organization, the type of information the organization would like to receive, ways in which interactions with its own clients have changed as a result of its contact with POCAAN, barriers to AIDS education in the community, and the organization’s self-perceived role in combatting AIDS. Figure 1. Social-Service Agencies in the Rainier Valley Area Agency Name: Phone No.: Contact Person: Position/Dept.: Date: Interviewer: AIDS Training: Staff Size, Race/Gender: Catchment Area: Demographics (age range, sex % male to female, income level) Services Provided: Comments: 337 It is of utmost importance that agency personnel be treated with respect and that the mutual benefit of working with one another be acknowledged. This mutuality of need cannot be stressed enough. It is necessary to acknowledge the mission, expertise, and agenda of the organization. It is equally important to identify areas of overlap. Without this bond, there is no point in continuing the relationship. Developing a Work Plan The immensity of the community-organizing task, as defined by NIDA, can be quite overwhelming for a small staff. Working in the field of AIDS in and of itself often leads to burnout for service providers as well as for those involved in prevention and education. Therefore, it is necessary to construct a buffer of some sort between the staff and the constantly expanding needs associated with a community-organizing effort for AIDS education and prevention. One means of doing this is the creation of a work plan. A work plan offers a method of making manageable the task associated with the job. It provides the staff with work that can be accomplished in a relatively short period of time with clear objectives. Progress can be measured, not so much in terms of the effectiveness of the intervention but in the conducting of the intervention. Whether or not the intervention bears fruit is a separate issue. The work plan should consist of activities that fall into the category of process variables. The evaluation of the effectiveness of an intervention is based upon the process and the outcome. In this case, behavior change of IVDUs and the SPs of IVDUs is the desired outcome. As a method of achieving behavior change, community organizing is a slow process. It requires a change in the norms of a community and in the agendas of agencies and that of community- based organizations. It is a process of dealing with complex systems that interact with and may influence the behaviors of our target populations. Therefore, process variables must be evaluated along with actual behavioral change not only of the target populations but also of the community organizations and groups. Since evaluation is an important component of the NADR Project, the work plan should be developed in conjunction with the research and evaluation component of the team. In addition, measures for evaluation should be constructed that will gather the necessary information for effective evaluation of the process and desired outcomes. These measures should be workable to those completing them, such as the community organizers or members of the community organizations, as well as for the data analysts. The work plan should also reflect the information gleaned from ethnography and the community analysis. Strategies Community organizing has an entire arsenal of techniques and strategies to accomplish the desired goals. Ideally, these strategies reflect the model of community organizing and the philosophy of the agency. When in doubt as to which one is of greater benefit, remember the axiom, “To thine own self be true . ..” One of the objectives of the community-organizing effort in Seattle is to develop responsibility of the local community for the major tasks related to the problem. This can be accomplished by establishing a relationship with the existing coalitions; increasing the visibility of the agency and the issue through news editorials, position statements, and the local media; increasing the 338 frequency with which the issue is discussed in community meetings addressing health and social problems; and increasing the number of multiorganization-sponsored events (Community Organization and Mobilization Group). In other words, one must identify one’s allies and then, with their assistance, bring the issue to the attention of the community. Initial work is completed to move toward resolving the problem. Another strategy is the development of a community-based board. This board can be drawn from the various subsystems in the community so that their specific agendas will be addressed. It is useful to have such a community board identify its mandate with regard to the issue and to specify the relationship of the board to the organization itself. This is helpful in that the board’s activities may be directed in part by the organization or, if not directed, probably coordinated. The office must therefore be prepared to provide technical assistance, support, and training for the community board as well as ready access to resources. Hiring Despite the most effective planning, the desired outcome can only be reached if those delivering the intervention are effective messengers. In this project, hiring has been one of the most difficult tasks. The role of community organizer requires versatility in working with diverse groups, dedication to community education, and a belief that communities are able to effectively respond to the problem at hand. Staff should have a good working knowledge of AIDS and IV drug use. This will be very important in conveying accurate information to organizations and groups. It helps to support the notion that the community organizers are experts in the field. The staff should reflect the racial, ethnic, gender, and sexual orientation of the communities being served. Hiring should attend to norms within the communities. Training In some cities, training resources for community organizing are available. There are organizations whose sole purpose is community organizing and training community organizers. If this is not the case, training community organizers is much more difficult. As is true of community organizing, training opportunities must be created by seeking out the key individuals who have such expertise, relying upon training resources from funding sources, and creating training experiences. If the last of these methods is used, the vehicle for providing training can also serve as a means of increasing the level of community awareness of the organization and the issue. Summary POCAAN is the initial change agent in the community-organizing model of intervention. One goal of this intervention is to provide impetus to members of the various communities in the Rainier Valley to reach out to IVDUs and the SPs of IVDUs. The goal is to encourage behavior change—i.e., the adoption of safer sexual behaviors (abstinence, using a latex barrier to prevent the exchange of bodily fluids), and/or safer drug use (abstinence, no longer sharing drug paraphernalia used to inject drugs, cleaning “rigs” with bleach). The community-organizing effort attempts to achieve these goals by: (1) establishing a network of the organizations in the 339 target area, providing appropriate training regarding AIDS and drugs, and highlighting the need for such education among the organizations’ constituencies; (2) promoting the establishment of coalitions to address the goal of reaching IVDUs and the SPs of IVDUs; (3) establishing a group of community-based educators in the organizations and groups as well as from the target population and training these individuals in outreach efforts; and (4) encouraging and advocating an increased power base among those in disenfranchised groups to gain greater access to resources to be used to intervene in the HIV epidemic. To this end, POCAAN has provided information regarding AIDS to members of the various community groups in the Rainier Valley. We have provided an assessment of the resources available for social and health services as well as for the formal and informal groups that exist in the target site. In this assessment, we try to determine the degree of knowledge about AIDS and drug use. By providing materials, training, and expertise, we attempt to shape the organizations’ and groups’ future behavior regarding AIDS and drug use. POCAAN further provides expertise to help those groups and organizations develop action plans for intervention with those at risk for HIV infection due to high-risk behaviors, lack of information, and lack of skills to effectively use the appropriate behaviors. Finally, POCAAN provides information and expertise for direct intervention with IVDUs and the SPs of IVDUs through the use of focus groups and the creation of advisory groups comprised of our two target populations. All of these interventions are conducted within the framework of three different models of community organizing: the community-development model, the social-planning model, and the social-action model. The overall philosophy of POCAAN guides the selection of models and interventions. We have created a two-pronged effort that (1) works with community organizations and groups to generate an interest to intervene with IVDUs and the SPs of IVDUs; and (2) attempts to organize the target population to help them meet their needs and communicate those needs to the interested organizations. References Community Organization and Mobilization Working Group. Unpublished document, 1987. Fullwood, P.C. “People Of Color Against AIDS Network Philosophy.” Unpublished manuscript, Seattle, WA, 1987. Kotler, P. The five C’s: Cause, change agency, change target, channel, and change strategy. In: Zaltman, G.; Kotler, P.; and Kaufman, I., eds. Creating Social Change. New York: Holt, Rinehart, and Winston, 1972. pp. 233-254. Miller, M. “The Analysis of the Community.” Unpublished paper from Organize Training Center, San Francisco, CA, 1981. Nute, S., and Senter, S. “Community Organization as an Approach to Reduce the Risk of HIV Infection among Intravenous Drug Users and their Sexual Partners.” Unpublished manuscript, 1989. p. 5. Rothman, J. Three models of community organization practice. In: Zaltman, G.; Kitler, P. and Kaufman, I, eds. Creating Social Change. New York: Holt, Rinehart and Winston, 1972. 340 Acknowledgment Supported by the National Institute on Drug Abuse Grant #DA05752. Authors George Freeman, Jr., Ph.C. Program Manager P. Catlin Fullwood Executive Director People of Color Against AIDS Network (POCAAN) 5100 Rainier Avenue, South Seattle, WA 98118 341 SPONSORING ADDICT SELF-ORGANIZATION (ADDICTS AGAINST AIDS): A CASE STUDY Gregory Carlson and Richard Needle Introduction A number of theoretical and conceptual models exist that support addict self-organization as a public-health prevention intervention. Use of social learning theory emphasizing peer support and self-help has been reported as being helpful in AIDS-prevention interventions with intravenous drug users (IVDUs) (Magura 1989). Klovdahl (1985) has identified the importance of social networks in influencing change in member behavior. Fisher and Misovich 1989 have emphasized the importance of peer leaders in initiating change. The social networks of addicts tend to be cohesive, homogeneous, and, therefore, particularly vulnerable to attitudinal and behavioral changes initiated by the network (Des Jarlais and Friedman 1987). Resource- mobilization theory (Friedman and Casriel 1988) identifies a number of conditions that exist among addicts that should enhance their ability to self-organize. Strategies potentially helpful to outside organizations seeking to facilitate the organizing process have been described in detail (Selwyn 1988). A number of potential barriers to self-organization have also been described. Williams (1986) has identified the lack of formal organization among minority high-risk IVDUs as a key limiting factor. The time-consuming demands of an addictive lifestyle may also significantly limit the time available for organizing activities (Friedman et al. 1987). Treatment agencies are another possible source of discouragement, particularly when IVDUs not currently in treatment begin to gain power and community support (Friedman et al. 1987; Des Jarlais et al. 1986). Historically, active drug users have not organized themselves into self-interest or advocacy groups. This may be because drug use is an illegal activity and due to negative social attitudes that discourage self-disclosure or self-identification as a drug user. Organizations that have developed in the United States have been limited to former-user or self-help groups (Narcotics Anonymous, Cocaine Anonymous, Alcohol and Drug Abuse Prevention Treatment [ADAPT], etc.), which have not been open to persons engaged in active drug use. In other countries, collective drug-user organizations have evolved (i.e., Junkiebodens in the Netherlands) and have been effective in challenging social policies as well as in providing a mechanism for disseminating public-health information. While there exists ample rationale for use of addict self-organization as a public-health prevention strategy, the reasons why more do not exist, or why prevention agencies have avoided sponsorship, is unknown. The Twin City IV Drug/AIDS Prevention and Research Demonstration Project undertook an experiment in sponsorship of an addict self-organization for the following reasons: (1) to increase contact with IVDUs at high risk for infection; (2) to improve dissemination of risk- 342 reduction information to a high-risk audience not accessible via other means; (3) to use peer pressure and role modeling in a new prevention intervention; (4) to access members of the target population able to assist in the evaluation of prevention efforts; and (5) to increase understanding of why addict self-organizations succeed or fail. Conceptual Model An initial assumption was that IVDUs existed along a continuum between *“nonambivalent users” and “nonambivalent abstainers” (Figure 1). It was reasoned that while the nonambivalent abstainers (NAAs) were the easiest to organize, they needed human immunodeficiency virus (HIV)-prevention interventions the least, as they were already exposed to prevention information in treatment and were likely to practice risk reduction as a result of value and attitude changes associated with recovery. On the other hand, nonambivalent users (NAUs) would be very difficult to organize but would be most likely to benefit from a self-organization intervention. It was also reasoned that methadone-maintenance patients formed an ideal transition group between NAUSs and NAAs. This is because methadone patient groups have some members who would meet criteria for both groups. In addition, methadone patients could organize in a highly visible way with less fear of overt negative social reaction. They would be more tolerant than abstinent treatment groups of potential members who continued to use drugs. Finally, methadone patients in Twin City programs had successfully organized on two occasions during the previous 10 years in efforts to change local methadone-program policies. Based on the relevant literature and local experience, we developed the following hypotheses: (1) that methadone-maintenance patients would be the most likely group to successfully organize; (2) that members would quickly organize around a “common cause” (e.g., needle exchange or elimination of treatment waiting lists); and (3) that the chaos of an addictive lifestyle would significantly impede efforts at addict self-organization. Interestingly, all three hypotheses were proven false. Figure 1. Continuum of Intravenous Drug Users Non-Ambivalent Methadone Non-Ambivalent Using Maintenance Abstainers 343 Sampling Strategy To test these initial assumptions, several IVDUs representing various points along our conceptual continuum were invited to a meeting with project staff. We will refer to our key informants as Mr. A, Ms. B, Mr. C, and Ms. D. The purpose of the meeting was to solicit advice as to the feasibility of addict self-organization and comments as to how to initiate a group. There was no initial effort to recruit these IVDUs into actual involvement in the development of a group and there was no promise of support from the project. The following is a summary of events and observations following this initial meeting. Observations March 31, 1989: Initial meeting with key insiders. Ms. B fails to appear due to drug use from the previous night. Others endorse feasibility of collective self-organization and volunteer services. April 6, 1989: Mr. A, his spouse, and Ms. D form a work group. They represent themselves as health-department employees and have printed 150 copies of an Addicts Against AIDS (AAA) brochure. They also look for an office to rent in neighborhood community centers. Mr. C chooses to function independently as an outreach worker advocating safe needle use in neighborhood crack houses. April 14, 1989: Meeting at Mr. A’s house to discuss support the project might provide for AAA group. Mr. A decides to seek sponsorship through a relative who is a minister in a local church. Issues of needle exchange and payment for services are introduced. April 19, 1989: The project advisory group raises ethical issues concerning sponsorship of AAA, particularly any consideration of financial incentives. A community treatment program appears particularly threatened by the possible formation of the group in its neighborhood. Consensus is reached limiting direct monetary support but providing other resources likely to be helpful in developing an AAA group. May 4, 1989: Meeting at Mr. A’s home included six persons, discussion of church sponsorship, focus, organization hierarchy, funding, etc. May 11, 1989: Meeting at Mr. A’s house, 12 participants present, continuation of 5/4/89 discussion. Proposal to be submitted 5/18/89. May 18, 1989: Proposal submitted to project by church to provide administrative support and space to AAA group. Mr. A asked for a reimbursement based on 20 hours per week of effort for himself and spouse. May 25, 1989: Agreement is made according to above terms including arrangement that Mr. A and church sponsor will undergo National Institute on Drug Abuse (NIDA) Outreach Training. Weekly meetings continue at Mr. A’s house. 244 June 1, 1989: Controversy occurred when Mr. A and the church sponsor are “locked- out” of the Outreach Training session by subcontracted trainer. Weekly meetings of six to eight IVDUs continue at Mr. A’s house. June 7 and 14, 1989: AAA meeting location is changed to church location. Participation by IVDUs ceased. June 21 and 28, 1989: When meetings returned to Mr. A’s home, participation returned to previous level (six to ten IVDUs/week). July, 1989: Risk-reduction education began as focus of group. Sexual-partners group formed spontaneously and was facilitated by Mr. A’s wife. Racial overtones emerged. Risk-reduction materials (bleach, condoms, educational brochures, etc.) distributed through AAA group. Decision made not to distribute syringes. Group refused to allow interview by network television. August, 1989: Group agreed to participate in peer-based counseling program. Group used to pilot effectiveness of intervention and to pilot interview instruments. Due to success of above sessions, the peer-outreach worker assumed the role of monitor and facilitator. Proposal made by several members to have “floating meetings” at other members’ houses. September, 1989: Agreement renegotiated to include recruitment of IVDUs for HIV testing, use of group for “mobile” testing, incentives for new members, and expansion of peer-based training/volunteer program. Discussion Unexpected Findings A number of unanticipated events occurred early in the sponsorship. The initial enthusiasm for the self-organization idea and the amount of individual effort expended in the absence of formal support or promise of monetary reward were unexpected. The coalition between Mr. A (NAU) and Ms. D (NAA) was equally unexpected, as was the degree of interest and involvement by hard-core IVDUs throughout the project. While it is premature to generalize from this initial experience, it may be true that a significant psychological secondary gain may exist in this type of activity, and that existing subculture boundaries and rules are modified as a result of involvement. It was expected that IVDUs active in recovery (self-help) programs would find regular involvement with active drug users a potential threat to their sobriety and that they would eventually opt for other, less “high-risk” prevention activities. While this did occur, it was unexpected when several active IVDUs sought drug treatment as a direct result of discussions that occurred in the AAA group. Addict self-organization functioning as a treatment intervention was unanticipated. 345 Ethical Issues Ethical issues raised by the advisory group centered around concern of formal project involvement with persons who were possibly using drugs. An advisory board member affiliated with a local treatment program was particularly upset that the organization was starting in his neighborhood, and he expressed fear that he might be associated with its sponsorship. Lack of support by those associated with treatment was predicted by Friedman and Casriel (1988), but it was not anticipated that other advisory members would find the intervention controversial. While there was consensus about the significant prevention potential of the AAA group, there was dissension on the appropriateness of the project having any formal involvement with persons unable to demonstrate a significant period (one to two years) of abstinence. This issue was eventually resolved through establishment of limitations on project support. However, one wonders if this type of controversy isn’t one reason why other projects working with active IVDUs may have avoided sponsoring similar groups. Legitimization As a result of the questions of legitimacy raised by the advisory board, the services of a neighborhood church were engaged. The church provided meeting space, telephone/receptionist services, light clerical services, and the monitoring of risk-reduction materials and funds. This remedy to concerns about legitimacy and project visibility in the community was a convenient solution to a public-relations problem, but was nearly fatal to the development of the addict organization. A key question to those considering sponsorship is whether or not support should be limited to minimal resources (i.e., risk-reduction materials) or expanded to include meeting space, meeting facilitation and content, and reimbursement for key insider time and incurred costs. Our experience would argue for prudent, but substantial, support for addict self- organizations. The experience to date suggests that addict self-organizations are not likely to develop without aggressive support. Formal or informal relationships with individuals perceived as drug users is inherently controversial, even when conducted within the context of sound prevention efforts. Attempts to overcome this basic fact may have the potential to do more harm than good. Sponsors may need to tolerate a certain amount of controversy when the prevention payoff is potentially significant. Organization Visibility Related to the issue of legitimization is organization visibility. Our AAA group was uncomfortable with the prospect of media exposure and preferred to keep a very low profile. This is understandable, given the negative reaction from representatives of local treatment programs. Strategies that keep exposure at a minimum may imply efforts to conceal inappropriate involvement, while high exposure is sure to increase the controversial nature of sponsoring these organizations, especially at the beginning. We deferred decisions about publicity to members of the group, however, sponsors need to be aware that the potential exists for disagreement between group members and the sponsor in this area. 346 Ownership and Responsibility An ongoing topic of deliberation and discussion within both the AAA group and the sponsoring project was self-organization ownership and responsibility. Sponsorship activities were initially intended to maximize a sense of ownership among participants, particularly in early group meetings where the agenda attempted to determine reasons for participant involvement. Unfortunately, group members were untrained and inexperienced in both group process and in self-organizing. It was tempting to overfacilitate these groups or to impose an agenda in reaction to a format that was, at times, chaotic and disorganized. Resisting this temptation proved to be the appropriate course of action when the group, in later meetings, asked for assistance with structure and content. The use of the group as a “test site” for project counseling interventions helped bring a focus to an otherwise freewheeling and often counter-educational format, while providing an excellent “real world” laboratory for evaluation of new HIV-counseling interventions. Use of an outreach worker as a peer facilitator proved to be an important way to provide these critical services without adversely affecting ownership. Our limited experience suggests that addicts, in general, may lack basic self-organization (and group-facilitation) skills and that these need to be provided by the sponsor. This appears likely to be more successful if a peer facilitator is used. Sponsors of collective self-organizations may need to determine in advance their degree and type of involvement in this regard. Selection of Outcome Measures Our initial interest was specific to the question of whether or not addicts could organize around HIV-prevention issues. It was encouraging that this occurred rather easily, despite the limitations on evaluating the effectiveness of AAA meetings alone as an HIV-prevention intervention. The use of the group in the recruiting of IVDUs for HIV testing and in the training of AAA members for work as volunteer peer educators provided outcome measures which effectively argued for continued support by the project. Sponsors should probably keep initial expectations low, then set specific criteria for continued sponsorship. In our experience, this helps bring a focus and meaning to the group, while providing a clear rationale for project involvement. Conclusions Our brief and limited experience in sponsoring an addict self-organization group has led us to conclude the following: sponsorship of addict self-organization is possible and is likely to be controversial. Addict self-organizations are not self-initiating, and sponsors will likely have to provide initial structure and ongoing assistance, especially with group facilitation. This is likely to be more effective if it is noninstitutional and peer based. In addition, some form of compensation or reimbursement may be necessary in order to sustain participation involvement and effort. Unanticipated outcomes of these groups may include treatment interventions, “expert” consultation to project staff, and recruitment of IVDUs for related activities such as ethnographic observations, evaluation of research instruments, and recruitment of prevention volunteers. We are now incorporating addict self-organization into various components of our overall project. The AAA group currently assists in the recruitment of high-risk IVDUs for HIV- antibody testing, and trained AAA members participate as volunteers in peer-education and 347 counseling interventions. A second group has begun meeting in another inner-city neighborhood and requires no support from the project other than the use of an outreach worker as a facilitator. We plan to follow these two groups and to further evaluate their effectiveness. We believe that addict organizations have significant potential in HIV prevention and research. References Des Jarlais, D.C., and Friedman, S.R. Target groups for preventing AIDS among IV drug users. J Appl Soc Psychol 17(3): 251-268, 1987. Des Jarlais, D.C.; Friedman, S.R.; and Strug, D. AIDS and needle sharing within the IV-drug use subculture. In: Feldman, D., ed. The Social Dimensions of AIDS: Methods and Theory. New York: Praeger Publishing Company, 1986. pp. 111-125. Fisher, J.D., and Misovich, S.J. Social influence and AIDS-preventative behavior. Appl Soc Psychol Annual Vol. 9, 1989. Friedman, S.R., and Casriel, C. Drug users’ organizations and AIDS policy. AIDS Public Policy J 3(2): 30-36, 1988. Friedman, S.R.; Selan, B.H.; and Des Jarlais, D.C. The special problems of intravenous drug users as persons at risk for AIDS. Med Times 115(9): 39-46, 1987. Klovdahl, A.S. Social networks and the spread of infectious disease: The AIDS example. Soc Sci Med 21(11): 1203-1216, 1985. Magura, S. Education/support groups for AIDS prevention with at-risk clients. Social Casework: J Contemp Soc Work 3: 10-20, 1989. Selwyn, P. Sterile needles and the epidemic of Acquired Immune Deficiency Syndrome: Issues for drug abuse treatment and public health. Adv Alcohol Subst Abuse. 7(2): 99-105, 1988. Williams, L.S. AIDS risk reduction: A community health education intervention for minority high risk group members. Health Educ Q 13(4): 407-421, 1986. 348 Acknowledgment Supported by the National Institute on Drug Abuse Grant #1R18DA05763. Authors Gregory Carlson, B.A. Co-Principal Investigator Richard Needle, Ph.D. Principal Investigator Twin Cities IV Drug/AIDS Research and Demonstration Project Department of Family Social Science University of Minnesota 396 McNeal Hall 1985 Buford Avenue St. Paul, MN 55108 349 CHAPTER VII RESEARCH FINDINGS Through research and publications, the impact of the NADR Project is reaching beyond the geographic boundaries of the 63 program sites. While much of the work to date is preliminary, authors such as those whose work appears here are already making important contributions that will improve understanding of the risk behaviors of IVDUs and how to intervene to effect changes in those behaviors. Needle and colleagues begin with a report of a study aimed at determining whether trends in increased crack and cocaine use, STDs, and HIV infection already observed in several major metropolitan areas may also emerge in cities where the HIV seroprevalence remains low. Demographic differences in these practices were notable; HIV seropositivity was disproportionately represented in the Black community. These authors conclude that the dynamics of social networks, as well as risk behaviors, must be taken into account when explaining variations in HIV status. Colon et al. next report on needle-sharing behavior among Puerto Ricans. They find some differences in needle-sharing behaviors between Mainland and Island Puerto Ricans that may be related to the availability of injection equipment. Williams explores and documents age-related differences in drug-use and sexual behaviors among IVDUs in Houston and concludes that age of the user is an important factor to take into account in intervention design. Weddington and colleagues from NIDA’s Community Research Branch describe a study that sought to determine the effect of awareness of serostatus would have on IVDUSs’ retention in treatment and on mood states of cocaine addicts. They call for further studies of the relationship between HIV testing and psychological status. Kotarba and Williams next explore the health-care resources of women at risk for HIV infection. Families and friends proved to be important health resources; prostitutes were found to be agents of health-care control for one another. Women also frequently turned to spiritual or mystical health resources. The varied findings lead the authors to emphasize the need for innovation in the design of AIDS-intervention programs for women. Kroliczak, reporting on the first year of Horizontes, which operates in San Diego and Laredo, notes that condom use and appropriate needle cleaning has increased and needle sharing has decreased among the client population. In the following paper, Johnson and Williams report findings that describe different patterns of drug use and drug subcultural involvement between Houston NADR clients who use IV cocaine and those who use heroin. The heroin users’ drug- use patterns are regular, progressive, and chronic; they occupy a place in an established heroin subculture. Cocaine users, on the other hand, often move “in” and “out” between the subculture and the straight world; addiction is not the central theme of a majority of users’ lives but rather is a function of modulation by everyday-life events. Nelson and colleagues present an overview of their work in Cincinnati. Known as REACH (Reaching Everyone! AIDS and Cincinnati’s Health), the program was preceded by an extensive publicity campaign. High-risk needle-use activity was found to be lower in this city 351 than other NADR program sites; findings did confirm Cincinnati’s reputation as a town where the practice of injecting opioid drug tablets is fairly widespread. Downey and colleagues share findings gathered from more than 2,000 clients interviewed at three methadone-maintenance programs in the Northeast. Preliminary data underscore the complexity of the population and the need for tailored interventions. Reinhart and Rosenthal, presenting results from a similar population of methadone-maintenance clients, show that the interventions developed and implemented by the program have had a positive impact on participants. Virginia McCoy, in a report on behavior change among female sexual partners of intravenous drug users, offers evidence of positive behavioral changes in both sexual and drug-use behaviors. The information provided is, moreover, being presented in such a way that it is retained for at least six months. A second report from Florida, by Chitwood et al., confirms that IVDUs are responding to intervention and are decreasing behaviors that place them at risk for HIV infection. Additional work with larger populations will be needed to determine which interventions are most effective and to assess gradients in behavior change. 352 USE OF CRACK AND COCAINE, SEXUALLY TRANSMITTED DISEASES, AND HIV INFECTION Richard Needle, S. Susan Su, and Linda Gust Introduction Recent trends related to intravenous drug-use (IVDU) behavior, high-risk sexual practices, and sexually transmitted diseases (STDs), especially syphilis, present the potential for rapid heterosexual spread of the human immunodeficiency virus (HIV), particularly in areas with currently high HIV seroprevalence (Cates and Bowen 1989). IVDUs comprise the second- most-frequent exposure category among those persons with acquired immunodeficiency syndrome (AIDS) cases in the United States (Centers for Disease Control [CDC] 1989a). The cumulative incidence of AIDS cases from IV drug use in heterosexual males and females is 21% (N=22,188) of the total AIDS cases; cases are disproportionately higher among Blacks and Hispanics than among Whites (CDC 1989b). HIV seroprevalence among IVDUs is highest in the Northeastern region of the United States (Hahn et al. 1989); in some northeastern cities, the incidence of HIV infection among IVDUs now exceeds new cases of AIDS among gay/bisexual men (CDC 1989b). Many of the heterosexual and perinatal cases of AIDS can be linked directly to IVDUs (Haverkos and Edelman 1988). Beginning in 1986 and 1987, after a five-year decreasing trend in syphilis cases, some states in the Northeast and in selected states such as Florida and California, some of these same geographical areas with the highest prevalence of AIDS cases and seroprevalence rates among IVDUs, have reported an increase in the incidence of syphilis (CDC 1987; CDC 1988). The increase in syphilis incidence was greatest for Blacks and Hispanics, and increases were greater for females than males. Data indicated that people with syphilis and other sexually transmitted diseases that result in genital ulceration, such as herpes and chancroid, are two to five times more likely to become infected with HIV (Cameron et al. 1988; Holmberg et al. 1988; Chirgwin et al. 1989). The increasing incidence of STDs and HIV infection in the heterosexual population may reflect changes in patterns of drug use. It is plausible that the increases in HIV seroprevalence among IVDUs and simultaneous increases in syphilis among heterosexuals are associated with injecting cocaine, smoking of crack, trading of sex for drugs, and engaging in other at-risk sexual practices (CDC 1988; National Research Council 1989). Use of cocaine by injection and use of crack began to dominate in the high-prevalence areas in the early to mid-years of the 1980s (Des Jarlais et al. 1988). Drug use in groups, particularly at “crack houses,” combines risk factors for potential spread of HIV infection and STDs (National Research Council 1989). There are some data suggesting a link between cocaine use and STDs and HIV (McCalls et al. 1989; Cohen et al. 1989; Chaisson et al. 1989). In both Philadelphia and Connecticut, the proportion of cases of 353 syphilis in men who reported sexual contact with men decreased, and the proportion of cases of syphilis among heterosexual men and women increased in persons reporting drug use and prostitute contact (CDC 1988). To date, most attention has focused on the incidence and prevalence of drug use, sexual practices, STDs, and HIV infection in higher-prevalence cities. A number of explanations have been advanced to account for the differences in HIV-seroprevalence rates between different geographical regions and differences among racial and ethnic variations. It has been suggested that the variation in time when HIV was first introduced in different areas accounts for the geographic distribution of HIV among IVDUs (Des Jarlais et al. 1988; Lange et al. 1988). The differences in the prevalence of AIDS cases and HIV infection among IVDUs in various racial and ethnic groups can be accounted for in part by differences in the behavioral risk and, possibly, by environmental factors, and not genetic factors (Selik et al. 1988). In this paper, we focus on the incidence and prevalence of drug use, sexual practices, STDs, and HIV infection in Minneapolis-St. Paul, Minnesota. Specifically, at the macro level, we examine the epidemiological data from Minnesota State agencies to determine whether a lower prevalence area such as Minneapolis-St. Paul will replicate the trend of higher-prevalence areas in terms of an increase in crack cocaine and cocaine use and a simultaneous increase in STDs and HIV infection. At the micro level, we examine the relationship between crack and cocaine use, STDs, and HIV infection by using survey data of 219 IVDUs not in treatment recruited from the Twin Cities, Minnesota, for the National AIDS Demonstration Research (NADR) Project, funded by the National Institute on Drug Abuse (NIDA). Methods Data Macro-level Data: Epidemiological Data on Drug Use. STDs, and HIV Infection STD surveillance data from the Minnesota Department of Health and drug indicators from various State agencies were used to examine trends in Minnesota. Specifically, we examined the data routinely collected from case reports for STDs (1985-1989) and HIV infection (1981-1989) reported to the Minnesota Department of Health in accordance with rules governing the reporting of communicable diseases (Disease Control Newsletter Insert 1985). In addition, we studied drug-indicator data from various sources, including hospital emergency room drug mentions from 1986 through December 1988 as reported on the Drug Abuse Warning Network (DAWN) of NIDA; drug-treatment admission data from four metropolitan area drug-abuse treatment facilities as reported on Drug and Alcohol Abuse Normative Evaluation Systems (DAANES) to the Chemical Dependency Program, Division of the Minnesota Department of Human Services, through March 1989; and data on drug seizures from the Minnesota Health Department Laboratory as reported by local law enforcement agencies. Micro-level Data: Survey Data of IVDUs and HIV. -Antibody-Testing Results Survey data of 219 IVDUs collected by the Twin Cities IV Drug/AIDS Research and Demonstration Project were used. Participants were recruited through street outreach and agency contact activities. For each participant, the AIDS Initial Assessment (AIA) questionnaire 354 was administered. The AIA is an instrument designed by NIDA to evaluate the behavioral risks of IVDUs and the sexual partners of IVDUs. It is being used by 29 NIDA-funded NADR programs across the country, and data have been obtained on 10,174 IVDUs (NOVA Research Company 1989). The semistructured, interviewer-administered instrument requests self- reported data from respondents eligible for participation in the project (IVDUs not in treatment, sexual partners of IVDUs, and prostitutes). Detailed information is elicited about drug-using behavior (lifetime and recent drugs used, route of administration, needle sharing, setting of IV drug use, and with whom drugs are shot) and sexual behavior (including reports of STDs over the participants lifetime and six months prior to the AIA). A test-retest reliability study has been carried out by NIDA, and preliminary results indicate that the responses to the AIA are highly reliable. In addition, data on HIV-antibody-testing results are merged with the AIA data to determine the relationship between crack/cocaine use and STDs and HIV infection. In the Twin Cities study, after the AIA interview, each respondent recruited for the project is offered the opportunity to participate in HIV-antibody testing. The project has been approved by the University’s Committee on Human Subjects, and a Grant of Confidentiality has been obtained from the Federal Government to ensure that the research group can maintain confidentiality of reports. Serum samples are tested by the enzyme-linked immunosorbent assay (ELISA) to determine HIV-antibody status. Reactive specimens are tested by the Western Blot. Trained nurses from STD clinics in Hennepin County and in the City Health Department of St. Paul administer the AIA questionnaires and take the blood samples. Respondents are paid $15 for participating in the AIA questionnaire, and another $15 for returning in two weeks to obtain information about their HIV serostatus. At that time, post-test HIV counseling and interventions are provided for volunteer participants. A case-management system is in place for HIV-seropositive individuals. The data reported here are obtained at the initial visit to an HI'V-testing site. Sample of the Survey Population Two hundred nineteen adult IVDUs have participated in the project since May 1989. About three-fifths (59%) are Black, and the remainder are American Indian (21%), White (15%), and Hispanic (5%). According to 1980 U.S. Census data, Blacks, American Indians, and Hispanics together make up only 5% of the total Minnesota population and 10% of the total Twin Cities population (Minnesota State Planning Agency 1987). Eighty percent of the respondents are male. The average age is 34.08 years (s.d. = 6.66), with 26% under the age of 30. The majority (52%) are between 30 and 39 years of age. It is difficult to report with any confidence that our sample is representative, since the total number of IVDUs in the Twin Cities metropolitan area can only be roughly estimated, and the characteristics of IVDUs not in treatment are unknown. The data presented in this paper may clearly reflect biases resulting from the over-representation of Black male IVDUs and under- representation of female IVDUs. Special caution should be exercised in interpreting and generalizing the study results. Nevertheless, the acquisition of data on IVDUs not in treatment, such as ours, is a necessary complement to most of the current research on this population, which is based on treatment samples and has different kinds of biases complicating the interpretation. 355 Data-Analysis Plan For macro-level data, we focus on the trend analyses. For micro-level survey data, because we are in the early stages of data collection and because of the relative scarcity of cases of STDs and HIV seropositivity, we cannot perform meaningful multivariate statistical analyses or stratify the sample based on some important demographic characteristics or epidemiological variables. We have limited our analyses mainly to descriptive statistics and bivariate analyses of the chi-square test. More specifically, this presentation will focus on: (1) examining the differences between various racial (Black IVDUs vs. non-Black IVDUs), gender (male IVDUs vs. female IVDUs), and age groups (19-29 vs. 30-39 vs. 40 or older) in crack/cocaine-using behavior, STDs, and HIV infection when the number of subgroups permit; and (2) testing the bivariate associations between crack/cocaine use and STDs, between at-risk drug-using behavior and STDs, between at-risk sexual practices and STDs, between STDs and HIV infection, and between crack/cocaine use and HIV infection. Results Macro-level Data Trends in Crack/Cocaine U Drug-indicator data from various State agencies indicate that crack/cocaine began to dominate the Minneapolis-St. Paul metropolitan area illicit-drug-use situation in 1986. Data from DAWN on hospital emergency-room drug mentions show a substantial increase in cocaine, exceeding mentions for other drugs such as marijuana or heroin. In the first quarter of 1986, there were 25 mentions for cocaine, 15 for marijuana, and 4 for heroin; by the last quarter of 1988, there were 120 mentions for cocaine, 20 for marijuana, and 15 for heroin (Falkowski 1989). In 1986, for mentions by route of administration, there were more emergency-room mentions resulting from IV drug use (45%) than for drugs taken orally (23%), but in 1987 the data were reversed, with more emergency-room mentions for smoking crack than for using cocaine intravenously. Data from DAANES indicate there has been an increase over the past few years in the percentages of admissions for treatment of cocaine-related problems (Falkowski 1989). Women were more likely to enter treatment for cocaine-related problems (34%) than men (30%) (Coleman and Petsch 1989). Cocaine was much more likely to be reported for Black clients entering treatment than for non-Black clients. Black clients were more likely to be treated for drug dependency or abuse (78%) other than alcohol dependency or abuse, while White clients were more likely to be treated for alcohol dependency or abuse (57%) than for drug dependency or abuse. Increasing numbers of arrests related to cocaine use have also been reported in each of the last several years. r Sexuall State surveillance data reveal that the number of early syphilis cases reported substantially increased in 1983 and, since then, early syphilis cases had been decreasing annually until 1988 (Williams 1989). During the first six months of 1989, there was a 28% increase compared to the same period in 1988. The rate of reported cases for 1989 in Minnesota is likely to exceed cases reported in 1988, which would be the highest number reported since 1984 (Williams 356 1989). Most of the cases were from the Twin Cities metropolitan area. Data for the years 1985 to 1989 by race and gender are informative (Table 1), indicating that the increase in morbidity is being reported in the Black population, particularly for Black females. Of importance is that much of this increase has occurred in individuals under the age of 29. Table 1. Early Syphilis Cases by Gender and Race (expressed in percent) Race and Gender. Year White Black Other Total Male Female Male Female Male Female Cases 1985 36 13 23 18 3 7 72 1986 45 9 16 16 9 5 68 1987 38 19 19 10 10 5 75 1988 12 14 19 19 6 10 108 1989* 22 12 25 38 3 0 75 *January — June. Source: Minnesota Department of Health. As for gonorrhea, reported morbidity has decreased in Minnesota annually since 1975. According to the data for the first six months of 1989, the decrease is continuing (Williams 1989). Nevertheless, as shown in Table 2, while there was a significant decrease between 1983 and 1988 in reported gonorrhea among the White population, especially White gay men, there was a significant increase in cases among Black males and females aged 15-19 and 30-39 (Williams 1989). Table 2. Percent Change of Gonorrhea Cases by Age, Race, and Gender 1983 - 1988 (expressed in percent) Race and Gender Age White Black Male Female Male Female 15-19 -54.9 24.0 +39.5 +6.6 20-29 -75.3 -15.0 -6.4 N/C 30-39 -73.7 -384 +53.0 +37.8 Source: Minnesota Department of Health. 357 Finally, from the Health Department data, reported chlamydia cases have dramatically increased each year since 1986, the first year the data for chlamydia were available. The data for the first six months of 1989 indicate that there will be an increase again in 1989. Epidemiological Data of AID Infection Reported cases of AIDS in Minnesota (N=600) have not yet reflected the changing drug-using practices; most reported cases to date have been among the gay/bisexual population (82%). Few cases have been reported among heterosexual IVDUs (3%). Nonetheless, increasing numbers of HIV-seropositive results are being reported from the IVDU population; of the 1,007 cases of HIV reported as of September 1989, 14% (N=141) were from the IV-drug-user population (Minnesota Department of Health 1989). The HIV/AIDS epidemiology in Minnesota today is in line with the trends seen much earlier in this decade in the high-prevalence U.S. cities. In Minnesota, AIDS is having a disproportionate impact on some racial and ethnic communities. Blacks comprise 9.4% of the AIDS cases and 17% of the non-AIDS cases of HIV infection, while they make up only 1.3% of the total Minnesota population. Hispanics make up 2.9% of the AIDS cases and 4% of the non-AIDS cases of HIV infection, while they are less than 1% of the State population. American Indians represent less than 1% of the AIDS cases and 2% of the non-AIDS cases of HIV infection, and they represent less than 1% of the total State population. Further, Black and American Indian females have been disproportionately represented among IV-drug-user AIDS cases and non-AIDS cases of HIV infection. The first IVDU AIDS case in Minnesota was reported in 1983. By 1986 four cases were reported among IVDUs; by 1987, there were 11 cases. Five new cases among IVDUs were reported in 1988 and, as of November 1989, a total of 18 of the state’s 600 cases have been among IVDUs. In 1987, 11 cases were reported. In 1988, the first year for which State data were reported for HIV serostatus, there were 117 cases. To date, the cumulative incidence of HIV infection among IVDUs is 166. Laumann et al. (1989) suggested that HIV prevalence is underestimated in the Midwest. Micro-level Data -Using Beh Data from the AIA indicate that the great majority of the IVDUs (80.4%) reported having used crack cocaine. Table 3 presents the differences in crack use among various groups of respondents of differing gender, age, and race. Greater percentages of Black IVDUs reported using crack than did non-Black IVDUs (90% vs. 62.9%, chi-square = 21.74, p<.001). Male IVDUs were also more likely to report using crack than were female IVDUs (81.8% vs. 67.4%, chi-square = 3.48, p<.10). No difference, however, was found in crack use among different age groups. The data also indicate that IVDUs recruited for this project are polydrug users. Of the IVDUs who used crack cocaine, 76% also snorted cocaine and 95% injected cocaine in the last six months. 358 Table 3. Association between Crack Use and Demographic Characteristics Characteristic Crack Use Ever Chi-square (in percent) Race Black 90.0 Non-Black 62.9 21.74 1 Gender Male 81.8 Female 67.4 348 § Age 18 -29 80.0 30-39 78.1 >40 80.0 0.12 * p<0.001. §p<0.10. *Not significant. Syphilis and Other STD Data from the AIA show that 47% (N=103) of all IVDUs reported ever having one or more STD. Fourteen percent reported ever having more than one STD. Gonorrhea is the most frequently reported STD among both male and female IVDUs. About 44% of male IVDUs and 23% of female IVDUs reported being told that they had gonorrhea. Table 4 presents the differences in reported lifetime STDs among various racial, gender, and age groups. The data show that Black IVDUs were more likely than non-Black IVDUs to report ever having STDs (58.5% vs. 30.3%, chi-square = 15.66, p<.0001). Though male IVDUs were slightly more likely to report ever having STDs than were female IVDUs (50% vs. 35%), the gender difference was not significant. Finally, although more IVDUs in their 30s reported STDs than did their younger or older counterparts, no age difference was found in self-reported STDs. HIV-Antibody-Testing Results Data on HIV-antibody-testing results show that 12 (5.5%) of the 219 IVDUs are seropositive. Ten of the seropositives are male, of whom nine are Black and one is Hispanic. Of the two seropositive females, one is Black and the other White. None of the American Indians tested for the HIV antibody has been positive. 359 Table 4. Association between STDs and Demographic Characteristics Characteristic STDs Ever Chi-square (in percent) Race Black 58.5 Non-Black 30.3 15.66 T Gender Male 50.0 Female 34.9 2.59 § Age 18 -29 36.7 30-39 52.6 >40 46.7 4.02 ¢ p<0.001. Not significant. The Association | Crack/Cocaine Use and STL Table 5 presents the summary test results of the association between crack/cocaine use and STDs. The frequency of crack use in the six months prior to the AIA was associated with ever having been told of STDs. More specifically, 72% (daily or more) in the last six months reported that nurse, compared with 43% of those who used crack less frequently. The difference was significant (chi-square = 7.47, p<.01). Further, more frequent injecting of cocaine (daily use) of IVDUs who have used crack frequently they had been told of STDs by a doctor or Table 5. Association between Crack/Cocaine Use and STDs Drug STDs Ever Chi-square (in percent) Crack Use Six Months Prior to AIA < Daily 43.4 > Daily 71.9 7.47 1 Noninjected Cocaine Use Six Months Prior to AIA < Daily 43.5 2 Daily 51.7 8.57 § Injected Cocaine Use Six Months Prior to AIA < Daily 42.8 2 Daily 65.0 7.74 § p<0.01. $p<0.05. 360 was associated with a greater likelihood of reporting ever having STDs. About 65% of IVDUs who reported injecting cocaine on a daily basis reported having one or more STD, compared with 43% of those who injected cocaine less frequently (chi-square = 7.74, p<.05). Those reporting daily cocaine snorting were also more likely to report ever having one or more STD than those who snorted cocaine less frequently (52% vs. 44%, chi-square = 8.57, p<.05). The A iation n At-Risk -Using Behavior TD Table 6 shows the test results of the association between at-risk drug-using behavior and STDs. The data suggest that IVDUs who shot drugs with others (sexual partner, running partner, strangers, or friends) were not more likely to report ever having STDs. The setting in which the IVDUs shot drugs, however, was found to be associated with STDs. More specifically, about 59% of IVDUs who shot drugs in shooting galleries reported ever having STDs, compared with 449% of IVDUs who did not shoot drugs in shooting galleries. The difference was significant at the p<.10 level (chi-square = 3.04). Finally, IVDUs who borrowed used needles or syringes from someone else were also found to be more likely to report ever having STDs than those who did not share needles (chi-square = 3.48, p<.10). IVDUs who shared cookers or cotton with someone else, however, were not more likely to report ever having STDs than those who did not share works. Table 6. Association between Drug-Using Behavior and STDs Behavior STDs Ever Chi-square (in percent) Shooting With whom? Sexual partner (no) 47.1 (yes) 46.9 ot Running partner (no) 47.1 (yes) 47.3 ot Friends (no) 45.3 (yes) 48.0 05% Strangers (no) 44.9 (yes) 55.1 1.20% Where? On th'e street (no) 454 (yes) 52.8 0.61f In a shooting gallery (no) 43.7 (yes) 59.2 3.04% In an abandoned building (no) 46.5 (yes) 50.0 06f Sharing Needles/Works Rented used needles (no) 43.4 (yes) 54.8 2.10% Borrowed used needles (no) 39.3 (yes) 53.2 3.48% Shared cooker/cotton (no) 45.6 (yes) 47.8 02f Not significant. $p<0.10. 361 The Association between At-Risk Sexual Practices and STDs Table 7 presents the test results of the association between at-risk sexual practices and STDs. The data indicate that IVDUs who reported exchanging sex for money were more likely to report ever having STDs than those IVDUs who did not exchange sex for money. The difference, however, was not significant. IVDUs who reported trading sex for drugs were also more likely to report ever having STDs than those IVDUs who did not (74.1% vs. 45.3%, chi-square = 6.03, p<.05). IVDUs who reported never using condoms in the last six months were not more likely to report ever having STDs than their counterparts who reported using condoms in the last six months. Also, no difference in reported STDs was found between IVDUs who had multiple sexual partners (five or more) and IVDUs who had less than five sexual partners. The Association between STDs and HIV Infection A significant relationship was found between ever having syphilis and HIV seropositivity at p=-10 level. About 19% of IVDUs who have ever been told of syphilis by a doctor or nurse tested positive for HIV infection, compared to 4% of those who have never had syphilis. The relationship was even more significant for Black male IVDUs. Approximately 27% of Black male IVDUs who have had syphilis tested positive for HIV infection compared to 5% of those who have never had syphilis (chi-square = 4.23, p<.05). No significant relationship, however, was found between ever having STDs, including genital herpes, gonorrhea, syphilis, and chlamydia, and HIV seropositivity. About 9% of IVDUs who used crack frequently (daily or more) in the last six months tested positive for HIV infection, compared with 5% of those IVDUs who used crack less frequently. The difference was not significant. Similarly, IVDUs who snorted cocaine or injected cocaine frequently (daily or more) had about the same chance of testing positive for HIV infection, compared to their counterparts who used cocaine less frequently (6% vs. 4%). Table 7. Association between Sexual Practices and STDs Behavior STDs Ever Chi-square (in percent) Sex for money (no) 48.3 (yes) 70.6 2.131 Sex for drugs (no) 45.3 (yes) 74.1 6.03% Number of sexual partners 1-4) 46.3 5) 54.5 2.417 Condom use in last six months (no) 44.1 (yes) 52.6 1.14% Not significant. $p<0.05. 362 Discussion and Conclusion This study was undertaken to determine whether a lower-prevalence area such as Minneapolis- St. Paul will replicate trends of higher-prevalence areas in terms of increased crack/cocaine use, STDs, and HIV infection. The data from various sources suggest an emerging epidemic among IVDUs in Minnesota. Data indicate that since 1986 there has been an increase in cocaine and crack use, in STDs, particularly syphilis, and in AIDS cases and non-AIDS cases of HIV infection among IVDUs. Our AIA data indicate that IVDUs who used crack or cocaine frequently were more likely to have STDs than those IVDUs who used crack or cocaine less frequently. Those IVDUs who reported STDs, in particular, syphilis, were also more likely to be HIV-antibody positive than IVDUs who did not have STDs. While crack/cocaine use was not directly related to HIV seropositivity in this sample, the drug-using behavior and sexual practices of crack/cocaine IV users appear to increase the risks for STDs and may ultimately result in coming into contact with HIV- seropositive persons. Data from both the macro and micro levels indicate that there are demographic differences in the prevalence of STDs, HIV, and crack/cocaine use. The HIV cases have been occurring most frequently in the Black IVDU population; this group also reports the highest frequency of crack cocaine and cocaine use and STDs. In our study to date, of a total of 12 HIV-seropositive persons, only 2 have been found in the non-Black population. Yet, IVDUs in the non-Black population are also involved in high-risk drug-using and sexual behaviors. How then do we account for these differences? It is clear that HIV seropositivity is disproportionately represented in the Black IV-drug-using population. Drugs are used in group settings, and drug experiences are often characterized by needle sharing, trading sex for drugs, and other at-risk sexual behaviors. We agree with Friedman et al. (1989), that the behavior patterns of individuals alone are inadequate for explaining the variation of HIV prevalence among different racial and ethnic groups. We conclude that the differences in HIV seroprevalence between racial or ethnic groups are accounted for not only by the individual risk behaviors of IVDUs, but also by the dynamics of social networks. In the low-prevalence areas, social networks of IVDUs are somewhat isolated, and the network is comprised of members of similar racial/ethnic, age, or gender characteristics. The low prevalence in certain areas such as the Twin Cities may be a function of low rates of interaction among IVDUs across a larger number of networks. Klovdahl (1985) suggests that the larger the number of network linkages an individual maintains, the more rapid and extensive the spread of HIV becomes. By identifying the characteristics of social networks of IVDUs, we can better understand the spread, containment, and control of HIV infection. Data of social- network characteristics of IVDUs are currently being collected. The findings of our study further suggest that it is essential to combine risk-reduction information about STDs and HIV at every educational opportunity, whether in STD clinics, family-planning programs, or outreach programs on the street. HIV information must be systematically introduced in STD clinics, and STD-reduction information must be incorporated into counseling and testing programs for HIV. 363 References Cameron, D.W.; D’Costa, L.J.; Ndinya-Achola, J.O.; Piot, P.; and Plummer, F.A. “Incidence and Risk Factors for Female to Male Transmission of HIV.” Paper presented at Fourth International Conference on AIDS, Stockholm, Sweden, June 1988. Cates, W., Jr., and Bowen, G.S. Education for AIDS prevention: Not our only voluntary weapon. Am J Public Health 79: 871-874, 1989. Centers for Disease Control. HIV/AIDS Surveillance Report, October 1989b. Centers for Disease Control. Increases in primary and secondary syphilis—United States. MMWR 36: 393-397, 1987. Centers for Disease Control. Syphilis and congenital syphilis—United States, 1985-1988. MMWR 37: 486-489, 1988. Centers for Disease Control. Update: Acquired immunodeficiency syndrome associated with intravenous drug use—United States, 1988. 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Holmberg, S.D.; Stewart, J.A.; Gerber, A.R.; Byers, R.H.; Lee, F.K.; O'Malley, P.M.; and Nahmias, A.J. Prior herpes simplex virus type 2 infection as a risk factor for HIV infection. JAMA 259: 1048-1050, 1988. Klovdahl, A.S. Social networks and the spread of infectious diseases: The AIDS example. Soc Sci Med 21: 1203-1216, 1985. Lange, W.R.; Snyder, F.R.; Lozovsky, D.; Kaistha, V.; Kaczaniuk, M.A.; Jaffe, J.H.; and the ARC Epidemiology Collaborating Group. Geographic distribution of human immunodeficiency virus markers in parenteral drug abusers. Am J Public Health 78: 443— 446, 1988. Laumann, E.O.; Gagnon, J.H.; Michaels, S.; Michael, R.T.; and Coleman, J.S. Monitoring the AIDS epidemic in the United States: A network approach. Science 244: 1186-1189, June 1989. McCalls, S.; Delke, 1.; Feldman, J.; Stevens, R.; and Salwen, M. “Cocaine Use and Sexually Transmitted Diseases including HIV. Poster presented at the Fifth International Conference on AIDS, Montreal, Quebec, June 1989. Minnesota Department of Health. AIDS Weekly Surveillance Report. Minneapolis, MN: AIDS Epidemiology Unit, October 1989. Minnesota State Planning Agency. Population Notes. St. Paul, MN: Office of the State Demographer, November 1987. National Research Council. AIDS: Sexual Behavior and Intravenous Drug Use. Washington, D.C.: National Academy Press, 1989. NOVA Research Company. Monthly Administrative Report. AIDS Research National Data Coordination and Evaluation Center, Bethesda, MD: NOVA Research Company, September 1989. Selik, R.M.; Castro, K.G.; and Pappaioanou, M. Racial/ethnic differences in the risk of AIDS in the United States. Am J Public Health 78: 1539-1545, 1988. Williams, G. “Sexually Transmitted Diseases in Minnesota.” Minneapolis, MN, 1989. Unpublished manuscript, 365 Acknowledgment Supported by the National Institute on Drug Abuse Grant #R18DA05763. Authors Richard Needle, Ph.D., M.P.H. Principal Investigator S. Susan Su, Ph.D. Director of Research and Evaluation Linda Gust, B.S. Research Associate Department of Family Social Science University of Minnesota 396 McNeal Hall 1985 Buford Avenue, Suite 97 St. Paul, MN 55108 366 NEEDLE-USE BEHAVIOR AMONG PUERTO RICAN IV DRUG USERS Héctor Col6n, Rafaela Robles, and Tomds Matos Introduction AIDS has come to us through behavioral practices that have not been the subject of wide research. Aside from a few notable publications, the research literature does not contain guidance on how to prevent human immunodeficiency virus (HIV) transmission. Scientific publications in the field of drug abuse have concentrated on its etiology and treatment and on its association with delinquency. Interest in drug-injection behavior had been, until recently, restricted to a few urban ethnographers (Preble and Casey 1969; Akins and Beschner 1980; Hanson et al. 1985). Most of the existing research on drug use in Puerto Rico goes back to the mid-seventies, when concern about a sudden increase in marijuana use occurred, especially among adolescents (Robles et al. 1978; Departamento de Servicios Contra la Adiccion 1981). Garcia and Col6n (1989) have recently estimated that some 38,000 people abuse illegal drugs in Puerto Rico (Table 1). This figure amounts to 2.2% of the population between 14 and 64 years of age. The extent of intravenous (IV) drug use in the Island however, has yet to be estimated. This lack of reliable data on IV drug use has been felt most acutely in Puerto Rico, where IV drug use is the primary means of transmission of HIV. More than 60% of AIDS cases reported in Puerto Rico have been directly related to IV drug use (Table 2), and Puerto Rico ranks second only to Washington, D.C., in AIDS incidence. As the table shows, the high concentration of IV drug users (IVDUs) among AIDS cases seems to be largely a phenomenon of northeastern States, the region with which Puerto Ricans interact most intensely (Robles et al. 1980; Bonilla and Col6n 1979). The National AIDS Demonstration Research (NADR) efforts of the National Institute on Drug Abuse (NIDA) have provided researchers with the first large-scale opportunity to study needle sharing and other drug-injection behavior. Basic questions such as with whom, how often, where, and under what conditions, are beginning to receive answers, albeit in a preliminary fashion. Furthermore, the outreach approach of these projects has permitted quantitative data to be enriched by first-hand observations. This paper is a study of existing needle-sharing patterns among IVDUs in Puerto Rico. It compares preliminary data collected as part of a risk-reduction demonstration research program with similar national-level data. A detailed understanding of these patterns will be needed for planning and designing preventive interventions as well as for culture-specific risk analysis. 367 Table 1. Drug-Abuse Prevalence Estimates for Puerto Rico 1977-1987 Primary 1977-79 1980-82 1983-85 1985-87 Drug Marijuana 9,674 22,494 28,110 18,140 Error margint 2,519 5,856 7,315 4,720 Cocaine § § § 15,328 Error margin § $ § 3,989 Heroin 4,029 5,894 5,685 4,127 Error margin 704 1,030 994 721 All of the above 13,703 28,388 33,795 37,595 Error margin’ 2,615 5,946 7,382 6,222 TError margins calculated for a 95% confidence level. §No estimates could be calculated due to low number of admissions. Source: Garcia and Col6n, 1989. Table 2. AIDS Incidence and Percent of Total AIDS Cases Who Have Reported IV-Drug-Use History by Selected States State AIDS Incidence Percent IVDUs Puerto Rico 414 66.7 New York 34.7 419 New Jersey 30.8 57.3 Connecticut 13.6 44.3 District of Columbia 85.0 16.1 Florida 23.8 24.2 California 20.7 13.8 Georgia 15.4 18.6 Texas 13.6 15.4 truly 1988 though June 1989, rate per 100,000 persons. Source: Garcia and Colén, 1989. Methods The complexities and nuances of drug injection, like those associated with any social behavior, escape easy modeling or interpretation. As we undertake the study of those behaviors, it is important to remember that we are not dealing with random samples; thus, the data collected, apart from self-reporting and other evident biases, cannot be considered wholly representative of the total population in question. Participants in the Puerto Rico NADR program have been recruited by trained ex-addicts through direct interaction at copping areas, shooting galleries, public-housing projects, and urban neighborhoods. The goal of recruitment is not to achieve 368 representativeness, but variability, within the target population, and the main aim is to study ways in which to reduce the transmission of HIV. The data for this paper were collected from IVDUs not in treatment recruited through the outreach efforts described above and interviewed using NIDA’s AIDS Initial Assessment (AIA) schedule, between February 1988 and June 1989. National data were provided by NOVA Research Company, the National Data Coordination and Evaluation Center. For purposes of comparative analysis, the IVDU population has been subgrouped according to race/ethnicity, and in the case of Puerto Ricans, place of recruitment. The population under study consisted of 9,894 IVDUs: 4,960 Blacks, 2,199 Whites, 1,533 non-Puerto Rican Hispanics, 872 Puerto Ricans recruited within the continental United States, and 330 Puerto Ricans recruited in the Island. Results There are no large differences in terms of age or gender among IVDUs interviewed (Table 3). Mainland Puerto Ricans have a slightly larger concentration of younger people in the sample, Blacks a somewhat larger percentage of older interviewees, and Whites a greater proportion of female IVDUs. The homogeneity in the study population with respect to age and gender does not extend to frequency of injection at the time of the interview (Table 4). Both Island and Mainland Puerto Ricans have a markedly greater proportion of individuals injecting daily (84.2% and 79.6%, respectively). The sample of other Hispanics follow with 62%. The proportion of Blacks and Whites injecting daily was slightly under 50%. Sharing needles with a running partner does not seem to be as common among Puerto Rican IVDUs as among IVDUs in the United States. Only 13.9% of IVDUs interviewed in Puerto Rico report sharing needles with their running partners half the time or more. Within the continental United States, Puerto Rican IVDUs share more frequently (23.5%), while a higher percentage (33%) of non-Puerto Rican IVDUs in the States frequently share needles with running partners. This is especially true among other Hispanics, 41.7% of whom report frequently sharing with running partners. Table 3. Gender and Age of IVDUs (expressed in percent) Island Mainland P. Rican P. Rican Other Hisp. White Black (N=330) (N=879) (N=1,534) (N=2,194) (N=4,950) Gender Female 21.8 21.5 18.4 334 22.8 Male 78.2 78.5 81.6 66.6 77.2 <35 59.7 68.1 63.4 62.7 43.3 > 35 40.3 31.9 36.6 37.3 56.7 Table 4. Shooting Frequency (expressed in percent) — Island Mainland Shooting P. Rican P. Rican Other Hisp. White Black Practices (N=330) =872) (N=1,529) (N=2,184) (N=4,929) Not shooting now 0.9 1.8 4.8 10.4 5.0 < daily 14.9 18.6 33.2 40.9 45.1 2 daily 84.2 79.6 62.0 48.7 49.9 Field observations in copping areas and shooting galleries in Puerto Rico have not found a clear demarcation between having a pana (running partner) and a somewhat larger and looser group of friends or acquaintances with whom drug-related activities are performed. Except for Island IVDUs, all other groups reported sharing needles more frequently with running partners than with other friends. The largest differences, in terms of needle-sharing patterns, were found among sexual partners. Black and White IVDUs reported the highest percentages of needle sharing with sexual partners. Within these two groups, needles were shared with sexual partners as often as with running partners. Non-Puerto Rican Hispanics followed. Puerto Rican IVDUs both from the Mainland and from the Island trailed behind, with Island Puerto Ricans reporting sharing with sexual partners the least (Table 5). The stark contrast in needle sharing with sexual partners, evident in the fact that only 13.2% of Puerto Rican IVDUs, vs. 29.7% of non-Puerto Rican Mainland IVDUs, report often sharing needles with their sexual partners may be attributable to a lower proportion of women among Puerto Rican IVDUs, which, in turn, may be due to subsisting cultural differences. Table 5. Needle-Sharing Partners’ (expressed in percent) Island Mainland P. Rican P. Rican Other Hisp. White Black (N=330) (N=876) (N=1,534) (N=2,192) (N=4,939) Sexual partners 1.5 15.3 23.6 354 29.0 Running partners 13.9 23.5 41.7 32.3 30.5 Friends 17.0 18.2 34.6 23.2 20.0 Strangers 42 6.0 6.9 3.9 3.6 TA positive response means that the individual has shared needles half or more of the time during the past six months. 370 Island IVDUs are less likely to share needles with a single partner, be it a sexual partner or a running partner. Mainland Puerto Ricans occupy an intermediate position between all other Mainland groups of IVDUs and the Island sample (Table 6): Only 1.8% of the Island group reported a single sharing partner. Corresponding proportions for Mainland Puerto Ricans were 10.5%, and for all other Mainland IVDUs, 17.3%. Other Hispanics shared even more frequently with a single partner (20.4%). Puerto Ricans report the highest rates of not sharing needles. Island IVDUs had the highest proportion who never shared needles (42.7%), followed by Mainland Puerto Ricans (26.8%). Other Mainland IVDUs showed similar smaller sizes, averaging 20.1%. Table 6. Number of Needle-Sharing Partners during Previous Six Months (expressed in percent) Island Mainland P. Rican P. Rican Other Hisp. White Black (N=330) (N=876) (N=1,534) (N=2,192) (N=4,939) None 42.7 26.8 20.0 16.8 21.7 One 1.8 10.5 20.4 19.9 15.1 2 two 55.5 62.7 59.6 63.3 63.2 Needle sharing may be more strongly related to scarcity/availability than to social norms. Compared with most areas in the continental United States, needles and syringes are easily purchased in Puerto Rico. IVDUs’ access to needles directly purchased from drugstores is limited only by pharmacists’ interest in keeping IVDUs from the premises. Thus, copping areas offer this service through needle salespeople. These areas characteristically have “new” needles for sale, and they are also commonly sold in shooting galleries. “New” needles sold in the street cost as much as needles rented at shooting galleries. As a result, IVDUs in Puerto Rico often possess their own needles, and shooting galleries are used mainly for their safety and privacy. Cookers and rinse water are shared more often than needles and syringes: only 34.5% of IVDUs in Puerto Rico report sharing needles often, but 56.1% often share cookers and 40.3% share rinse water. Non-Puerto Rican IVDUs in the United States share works at roughly the same rate: 44% often share needles, 44% cookers, and 39% rinse water. The pattern for continental Puerto Rican IVDUs corresponds better with that of other Mainland IVDUs than with that of Island IVDUs: 32.5% often share needles, 41.1% cookers, and 34.2% rinse water. The same pattern occurs with new needles; frequent use of new needles in the Island was reported by 86% of IVDUs, while the average for the United States was 76%. Mainland Puerto Ricans trailed slightly, with a 72.2% rate of new-needle use. No large differences were found with respect to use of rented or borrowed needles, although Hispanics tended to borrow or rent more frequently than members of other groups (Table 7). Lower rates of needle sharing and more frequent use of new needles in Puerto Rico contrast even more sharply with Mainland data when use of shooting galleries is taken into consideration (Table 8). Mainland Puerto Ricans reported more frequent use of shooting galleries than other Mainland IVDUs (27.7% vs. 17%, respectively), but not as dramatic a difference as that of 371 Island IVDUs, 65.8% of whom often use shooting galleries. Among non-Puerto Rican Mainland IVDUs, 58% frequently shoot drugs at their own place, while this is the case for 41% of Puerto Ricans, both in the Mainland and in the Island. Still, more frequent use of their own place than shooting galleries was reported by all IVDUs, including Mainland Puerto Ricans, with the sole exception of Island Puerto Ricans. Further comparisons might show less- independent living arrangements among Puerto Ricans as a possible explanation of this difference: 32.5% of IVDUs interviewed on the Island reported living with their parents, and an additional 20.9% live with other adult relatives. Such homes might well be unsuitable places for shooting drugs. Table 7. Sharing Works during Previous Six Months’ (expressed in percent) Island Mainland P. Rican P. Rican Other Hisp. White Black (N=330) (N=876) (N=1,534) (N=2,192) (N=4,939) Shared rinse water 40.3 34.2 50.2 42.6 34.6 Shared cookers/cotton 56.1 41.1 49.0 46.7 38.7 Rented/borrowed needles 16.4 20.0 33.7 244 18.8 Shot up without sharing 35.5 325 39.8 48.7 43.5 Used new needles 86.0 72.2 72.8 66.8 81.3 TA positive response indicates the person has engaged in the behavior in question half the time or more. Table 8. Shooting Settings’ (expressed in percent) — Island Mainland P. Rican P. Rican Other Hisp. Whites Blacks (N=330) =876) (N=1,534) (N=2,192) (N=4,939) Own place 43.9 40.3 60.8 63.2 56.7 Friend’s place 314 29.0 44.7 35.5 42.2 Social gathering 3.9 4.8 11.8 9.9 8.3 Dealer’s place 9.1 7.1 15.9 15.1 10.4 Shooting gallery 65.8 27.7 16.9 10.4 17.6 Abandoned building 20.0 25.9 17.5 10.1 14.1 Street 12.1 14.2 22.8 12.8 8.3 tA positive response indicates the individual has shot up half the time or more at the setting in question during the past six months. 372 Shooting at a friend’s place is less frequent among Puerto Rican IVDUs than among other groups studied. Thus, in terms of shooting localities, Puerto Ricans both on the Island and on the Mainland show the same pattern that is different than that of all other continental IVDUs: less-frequent use of home and a friend’s place, and more-frequent injecting at shooting galleries and abandoned buildings. Although we do not have comparable Mainland data, it is important to report that HIV-antibody tests show a seroprevalence of 47.2% among the Island sample. Thus, we are dealing with a population at an advanced stage of HIV transmission. Summary and Conclusions NADR data up to this point show IVDUs recruited and interviewed in Puerto Rico to be injecting drugs more frequently than their counterparts in the States. Needle sharing between two running or sexual partners is not as prevalent as a looser network of friends or acquaintances with whom needles are shared. Sharing needles was reported less often in Puerto Rico, and use of new needles was slightly higher. No differences were found between Island and Mainland IVDUs in terms of renting or borrowing needles. In contrast to this, a substantially larger proportion reported frequent use of shooting galleries in Puerto Rico, and sharing of cookers was also more prevalent among this group. All members of all the groups studied are at high risk of HIV transmission due to drug-injection behavior; however, no one group reflects higher risks in all or most risk factors. Further risk analysis is needed to achieve an understanding of particular cultural and socioecological factors differentiating IV drug behavior, specifically local rules and norms and their interaction with availability/scarcity of resources. As evidenced by the results discussed above, while such data are proving to be of immense value, they often raise more questions than they answer. References Akins, C., and Beschner, G., eds. Ethnography: A Research Tool for Policymakers in the Drug & Alcohol Fields. Rockville, Maryland: National Institute on Drug Abuse, 1980. Bonilla, F., and Col6n, H. Mami borinquen me llama: Puerto Rican return migration. Migration Today 3(2): 25-34, 1979. Centers for Disease Control. HIV/AIDS Surveillance Report, August 1989: 1-16. Departamento de Servicios Contra la Adiccién. Magnitud del problema de la adiccion en Puerto Rico. Hato Rey, 1981. Garcia, M., and Colén, H. Estimacion de la Extension del Abuso de Drogas en Puerto Rico. Hato Rey: Departamento de Servicios Contra la Adiccién, 1989. Hanson, B.; Beschner, G.; Walters, J.M.; and Bovelle, E.L, eds. Life with Heroin: Voices from the Inner City. Lexington: DC Health and Company, 1985. 373 Preble, E., and Casey, J.H. Taking care of business—The heroin user’s life on the street. Int J Addict 4: 1-24, 1969. Robles, R.; Martinez, R.E.; and Moscoso, M. A Study of Adolescent Drug Behavior in Puerto Rico. San Juan: University of Puerto Rico, 1978. Robles, R.; Martinez, R.E.; and Moscoso, M. A Study of Puerto Rican Return Migration: Impact on the Migrant and the Island. San Juan: University of Puerto Rico, 1980. Acknowledgment Supported by the National Institute on Drug Abuse Grant #DA05743. Authors Héctor Col6n, M.A. Co-Investigator Rafaela Robles, Ed.D. Principal Investigator Tomas Matos, M.A. Analyst Department of Anti-Addiction Services Research Institute, 4th Floor 414 Barbosa Avenue Hato Rey, PR 00917 374 DRUG USE AND SEXUAL BEHAVIOR DIFFERENCES AMONG “YOUNG” AND “OLD” INTRAVENOUS DRUG USERS IN HOUSTON, TEXAS Mark L. Williams Introduction In many investigations of intravenous drug use and human immunodeficiency virus (HIV) seroprevalence there is a strong reason to classify individuals according to demographic and behavioral variables. For example, studies have shown that HIV infection rates vary significantly by race or ethnicity (Curran et al. 1988; Hahn et al. 1989; Centers for Disease Control [CDC] 1988). There are also important behavioral differences between cocaine and heroin users that have a bearing on seroprevalence (Chaisson et al. 1989). Even gender differences may be an important factor associated with HIV infection (Murphy 1987). While demographic characteristics such as race, ethnicity, and gender are important in identifying distinctions among those at risk for HIV infection only because certain characteristics are likely associated with high-risk behaviors, age is one characteristic that undoubtedly has a strong influence on behavior. Young people may be more prone to risk taking than older people. The old are considered to be more sedentary and conservative in their approach to life (Hockhauser 1989). The purpose of this report is to present preliminary findings on a comparison of two groups of intravenous drug users (IVDUs), one between the ages of 18 and 25 and another over the age of 40. One hundred forty-one persons were in the former group and 254 in the latter, for a total study population of 395. Although there are not clear demarcations for what constitutes “young” and “old” among IVDUs, ethnographic research indicates that IV drug users over the age of 40 are “old” and those under the age of 25 are “young.” This report will look at two behaviors: intravenous drug use and sexual activity. These two behaviors are the primary factors responsible for transmitting HIV. If behavioral differences exist between these two age groups, it would seem reasonable that age must be considered when planning HIV-prevention strategies among targeted populations. Methodology The participants in this study were selected from those participants in a larger study on intravenous drug use and HIV seroprevalence among IVDUs and their sexual partners in Houston, Texas. Participants were recruited by trained street outreach workers or by referral from members of drug-using networks. All respondents included in this study had injected illicit drugs at least once during the six months prior to participation and had not been in drug treatment for 30 days. 375 Participants were asked to respond to the AIDS Initial Assessment (AIA) interview. Interviews were conducted by trained interviewers in a one-to-one setting. Interviews took approximately one hour, and respondents were paid $10 for their time. For this study, participants were classified as “young” if they were between the ages of 18 and 25. Those classified as being part of the “old” generation were over the age of 40. The range of ages over 40 is from 40 to 72, although most over 40 cluster between 40 and 45. About 80% of the participants in both groups are males. The older group comprised mostly Black participants, while the younger group comprised mostly Whites. However, there is no statistically significant difference between the racial/ethnic compositions of the two age groups. There were also no statistically significant differences along demographic variables such as housing, place of residence, job status, or sources of income. Results Drug Use Among users in this study, the injected drug of choice was cocaine. Ninety-six percent of the users under 25 years of age and an equal percentage of those over 40 years of age reported having injected cocaine in the six months prior to being interviewed. However, polydrug injection (the injection of more than one drug during the six months prior to being interviewed) was much more common among those over 40. Sixty-five percent of the participants over 40 reported having injected both cocaine and heroin during the six months before being interviewed. A minority of those under 25 reported having injected both cocaine and heroin (Table 1). In Houston, IVDUs who use both cocaine and heroin do not inject these substances simultaneously as a speedball, rather they inject the drugs at separate times. The use of only heroin by either group is relatively uncommon; 5% of those over 40 and 3% of those under 25 reported injecting only heroin. Table 1. Drugs Injected During the Six Months Prior to Interview (rounded to the nearest percent) Age of Respondent} Drug 18-25 years 240 years (N=141) (N=254) Cocaine only 59 31 Polydrugs® 37 65 Heroin only 3 5 x2 = 31.77; p<0.0001. Total number of respondents (N) = 395. $Cocaine, heroin, and speedball. 376 Frequency of injection, determined by how often a respondent reported injecting drugs, varied between the two age groups. Those who reported injecting less than four times per month were coded as injecting less than weekly (Table 2). Those reporting one to six injections weekly were coded as weekly injectors. Respondents reporting more than seven injections weekly were coded as daily injectors. Table 2. Frequency of Injection (rounded to nearest percent) Age of Respondent’ Drug 18-25 years 240 years (N=141) (N=254) .05), but there was a trend for more seropositive than seronegative subjects to complete treatment (chi square=3.087, p=.079). Seropositive subjects reported higher mood-distress scores than did seronegative ones, except for “vigor.” The differences, however, were not statistically significant except for “anger/ hostility.” There was a lowering of POMS scores by subjects in both groups compared to scores obtained at intake, but the time effect was not significant. Comment The findings of this study are encouraging in that knowledge of serostatus did not affect retention in treatment for cocaine addicts. Although seropositive subjects reported higher levels of distress during the early phase of treatment, the differences were not statistically significant over the course of treatment except for “anger/hostility.” Anger is an understandable response to learning that one is infected with a potentially deadly virus and that one can potentially infect other persons indefinitely. All seropositive subjects who participated in treatment voluntarily disclosed their serostatus to counselors without prompting, usually during the first meeting. Our study had limitations. The sample size was small and consisted of cocaine addicts who volunteered for a medication study at an outpatient research facility. The observation time was limited. Retention was a major limiting issue, as reactions of dropouts were not measured. The particular setting of the study and the emphasis on counseling may have affected our results. Nonetheless, the results of our study may help reduce the hesitancy of drug-treatment staff members to encourage or offer HIV-antibody testing to clients and reveal the results to them. Further research will provide additional information regarding psychological reactions to HIV testing as the procedure becomes more widely used in drug-abuse treatment. 381 References Centers for Disease Control. Public Health Service guideline for counseling and antibody testing to prevent HIV infection and AIDS. MMWR 36: 509-515, 1985. Derogatis, L.R.; Lipman, R.L.; and Covi, L. The SCL-90: An outpatient psychiatric rating scale. Psychopharmacol Bull 9:13-28, 1973. McNair, D.M., and Doppleman, L.F. Profile of Mood States. Manual. San Diego: Educational and Industrial Testing Service, 1971. Ostrow, D.G.; Joseph, J.G.; Kessler, R.; Soucy, J.; Tal, M.; Eller, M.; Chmiel, J.; and Phair, J.P. “Disclosure of HIV Antibody Status: Behavioral and Mental Health Correlates.” Paper presented at the Fourth International Conference on AIDS, Stockholm, Sweden, June 1988. Perry, S.; Jacobsberg, L.G.; Fishman, B.; Frances, A.J.; Novick, A.B.; and Tein, R.R. “Psychological Responses to HIV Serological Testing.” Paper presented at the Annual Meeting of the American Psychiatric Association, San Francisco, CA, May 10, 1989. Rhame, F.S., and Maki, D.G. The case for wider use of testing for HIV infection. N Engl J Med 320: 1248-1254, 1989. Rounsaville, B.J.; Gawin, F.H.; and Kleber, HD. Interpersonal psychotherapy adapted for ambulatory cocaine abusers. Am J Drug Alcohol Abuse 11: 171-191, 1989. Weddington, W.W., and Brown, B.S. Acceptance of HIV-antibody testing by persons seeking outpatient treatment for cocaine abuse. J Subst Abuse Treat 5: 145-149, 1988. Authors William W. Weddington, M.D. Project Officer Charles A. Haertzen, Ph.D.} Research Psychologist Judith M. Hess, M.A § Research Coordinator, Outpatient Treatment Barry S. Brown, Ph.D.f Chief, Community Research Branch National Institute on Drug Abuse Parklawn Building, 9A-30 5600 Fishers Lane Rockville, MD 20857 § Addiction Research Center National Institute on Drug Abuse P.O. Box 5180 Baltimore, MD 21224 382 EVERYDAY HEALTH-CARE ACTIVITIES AMONG WOMEN AT RISK FOR AIDS Joseph A. Kotarba and Mark L. Williams Introduction Although the AIDS epidemic continues to grow in the United States, prevalence rates among the original at-risk population, i.e., male homosexuals, have leveled off (Curran et al. 1988). Public-health policy makers, researchers, and service deliverers have shifted their attention towards other groups at high risk of human immunodeficiency virus (HIV) infection; specifically, intravenous drug users (IVDUs) and—the focus of this paper—women. Of the 94,280 cases of AIDS diagnosed in the United States as of May 1989, 8,297 (8.8%) have been women (Centers for Disease Control [CDC] 1989). From a public-health perspective, women comprise a critical piece in the AIDS puzzle, since they lie at the intersection of several lines of AIDS transmission. Women acquire AIDS primarily from IV drug use (52%) or from having sex with infected male partners (29%) (CDC 1989). Today, AIDS among children is almost always contracted through delivery from infected mothers (Landesman et al. 1987). In addition, 70% of infected women are Hispanic or Black, dramatically illustrating the disproportionately high impact the disease has had on those two minority communities (Guinan and Hardy 1987). Efforts to locate at-risk women and to develop strategies for AIDS intervention have been almost exclusively based on viewing or conceptualizing these women in terms of the social roles that place them at risk: IVDU, prostitute, or sexual partner of male IVDUs. For example, the National AIDS Demonstration Research (NADR) Project was established to locate IVDUs and their sexual partners, and to deliver educational services, bleach, condoms, etc., to them (Feldman and Biernacki 1988). As Romero (1989) has noted, the various outreach projects operating through this program not only attempt to make contact and interact with potential female clients only as drug users, but assume that these women maintain lifestyles similar to male IVDUs. Thus, outreach workers often try to locate female clients on the streets where male drug users congregate when, in fact, these women spend the majority of their time at home or at work (Romero 1989). Similarly, outreach workers attempt to make contact with prostitutes at locations where prostitutes are working and while they are working (Seidlin et al. 1988). In general, researchers and outreach workers construct the patient or client roles of at-risk women as mirror reflections of the roles that place them at risk for HIV infection. Other social roles—such as mother, daughter, or employee—that these women may occupy at other times of their everyday lives, and that could be the basis for effective AIDS intervention, are largely ignored. The Female Sexual Partners Unit of the Mid-City Consortium to Combat AIDS in San Francisco appears to be one of the few exceptions to this trend. Through its “SPIRITS” project, this group has tried to establish outreach strategies that fit the “culture” of women “. . . whose 383 daily worries might also include homelessness, hunger, illness, and physical abuse” (Romero 1989). A likely avenue for AIDS intervention that has been largely ignored consists of the typical health- care resources used by at-risk women in their everyday lives. We would expect these resources, both institutionalized and indigenous, to be the kinds of health care at-risk women perceive as available, affordable, familiar, and, perhaps, effective. In the remainder of this paper, we will present data from an ethnographic study of at-risk women in Houston, Texas, that illustrate the range of health-care modalities and resources they ordinarily use. Although our analysis is preliminary, we will conclude this paper with suggested strategies for AIDS intervention conducive to these everyday health-care activities. Methods The data presented in this paper were obtained through ethnographic research conducted by a community-based AIDS-prevention and demonstration project in Houston, Texas, funded by the National Institute on Drug Abuse (NIDA). The general goals of this project include: (1) assessing the level of HIV among intravenous drug users, their sexual partners, and prostitutes; and (2) collecting evaluative data on the effectiveness of experimental intervention strategies, largely of local design. The Houston project, known as the Community AIDS Prevention Project (CAPP), operates three outreach centers in inner-city gay, Black, and Hispanic communities to locate clients in areas having a known high incidence of IV drug abuse. An essential component of intervention is the redirection of the IVDUs’ behavior through street- based, one-on-one education about the relationship between drug use and AIDS. There are three specific sources for the data presented here. First, a series of in-depth ethnographic interviews with women at risk were conducted (Jorgensen 1989). Respondents were located in a stratified manner, so that the sample represented all three targeted ethnic groups, the complete age range of CAPP clientele (18 years to 44 years), all varieties of drugs and drug use, styles, all occupations, and all parental statuses. These 47 interviewees were remunerated. The interviews were conducted at the respondents’ convenience and lasted approximately one hour each. The interview schedules focused on a number of biographical themes, including health and health-care-use histories. Second, focused interviews with informed, expert community gatekeepers were conducted (N=8). These gatekeepers included health-care workers, social-service workers, religious leaders, and hospital emergency-room staff. Third, all interview data were triangulated and assessed for quality through the ethnographers’ constant presence in the field, resulting in numerous conversations with outreach workers and others with practical insight into the nature of women’s health care in the targeted areas. Friends/Coworkers Friends are an important source of health care and information. The friends reported by our respondents are almost exclusively female. Prostitutes reported that most of their friends are other prostitutes, whereas IVDUs tend to have a wider range of friends not limited to other IVDUs. Friendships among prostitutes focus on health issues relevant to work. For example, an 18-year-old White female prostitute was stabbed in a fight with the girlfriend of a john. Instead of seeking medical care, the injured woman had another prostitute clean and bandage the 384 wound for her because “it wasn’t that bad a cut.” A 32-year-old White female commonly shares apartments with male drag queens. These roommates give her advice on what kinds of condoms to use, as well as how to raise the issue of condoms with customers. She will not take any other health advice from them because she claims that, although they dress as women, they have no intrinsic, experiential understanding of women’s health concerns. In general, respondents note the importance of discussing health problems in trusted confidence. Prostitutes are particularly concerned about the way even the hint of illness can ruin business. As a 22-year-old White female noted, “Out here I definitely know better than to say anything physically that’s wrong with me, because it's gonna be all over the fuckin’ strip.” Interestingly, prostitutes commonly serve as agents of health-care control over each other. A 21- year-old Black female indicated that she angrily confronted another prostitute in the area who passed gonorrhea on to a john she knows and demanded to know why she didn’t go to a doctor for treatment. The concern is violence. For example, a 20-year-old White female was given $40 by a john to beat up another prostitute who had infected him with gonorrhea. Johns may also return to batter a suspected prostitute themselves. Public versus Private Care Our respondents routinely used both public and private medical services, but for different purposes. Most prostitutes, especially those with much experience, consulted public clinics for treatment of sexually transmitted diseases. Again, respondents commonly went to—or were taken to—the emergency room of the local public hospital for treatment of trauma. Most respondents, however, indicated that they had access to and occasionally used private physicians for personal health problems not related either to drug use or prostitution. The principle here seems to be the effort to keep one’s work- or lifestyle-related maladies separate from personal illnesses. The overall function of this effort is to maintain a sense of integrity, that the woman is something more and different, at least to herself, than just a prostitute or junkie. In general, those prostitutes who are not heavy drug users have available funds to use for private health care. Services provided by the Texas Department of Corrections are important for those respondents who serve time as prisoners, and they comprise approximately one-third of our sample. Pharmacists Respondents projected a general reluctance to consult physicians except when absolutely necessary, either occupationally or personally. Due to their work and lifestyles, these women are ordinarily at risk of colds, flu, the sniffles, and other minor ailments. Pharmacists become important alternate resources in this regard. The general rule, however, is to consult a pharmacist for illness who is not the provider of their condoms in order to eliminate the stigma of prostitution and contamination of a useful health-care relationship. Religious Resources To the degree to which our respondents consider their drug use an addiction and a moral problem, they are likely to consult religious resources at some point for healing. A 32-year-old 385 White female reported that she had tried faith healing to get rid of her drug addiction. She recalled: I'm going to churches and having people lay hands on me to heal heroin demons out of me, and that's how desperate I was. Nothing was working. I'd go to (a treatment center) and I really enjoyed (a treatment center). All my friends were there and I'd like it, but I would leave and go get high, or I' d leave church and I'd go get high. Friendship networks largely determine the nature of religious or mystical health resources. A 36-year-old White female has a male neighbor who uses crystals to help heal him of cancer and AIDS. Through him, she has begun to wear crystals as prevention against drug-related illnesses, such as hepatitis. Hispanic respondents raised in the Catholic faith generally indicate that they do not turn to the Church for help with either their lifestyle problems or illnesses. The risk of shame is too great. Yet, consulting curandera is commonly mentioned, especially among recent migrants to the U.S. who are limited in their health-care options as a result of either a lack of “papers,” language proficiency, or money. Family Faniily relations are extremely important health resources for our respondents. Family tends to be relevant in two types of cases: (1) issues regarding the health of respondents’ children; and (2) the use of parents as resources during personal health crises. Most female respondents, whether prostitutes or drug users, do not go for regular pelvic examinations. Many of them had their last pelvic examination, pap smear, and test for STDs when they delivered their last child. Only one respondent indicated that she had an abortion. Unlike most women, who maintain fairly regular contact with physicians because of the health- care needs of their children, only three respondents had custody of their children. Most children were in the custody of other family members, grandmothers in particular. Among Black respondents without custody, there was a good likelihood of close consultation between them and custodians regarding health-care decisions for children. Among White respondents, however, this type of consultation is rare and custody tends to be exclusive. There is no clear pattern among Hispanic mothers. Most respondents do not routinely consult their parents for advice or material assistance during illness. However, the majority do admit that they have turned to, or would turn to, parents for help during a real illness crisis. While Black and Hispanic women routinely cite mother as the “safety net” family member, several White respondents noted that they would turn to their fathers for help in a real crisis. For example, the 36-year-old White female mentioned that her father is very understanding about the problems created by her drug problem, but her mother would “throw it back in her face” if she presented a drug-related ailment to her. Conclusion A distinct limitation of the study at this early point is the lack of data on female sexual partners who are neither prostitutes nor IVDUs. Yet the central finding is clear: Women at risk of AIDS consult a wide range of health-care services. In addition to the types of resources listed above, 386 our respondents have indicated that they make use of health resources available to most women through the mass media, such as women’s magazines and television programs directed towards women. Not all of their health activities are directly related to their social status as workers in the sex industry or drug users, as exemplified by the attention given to children’s health-care needs. Obviously, there are ethnic differences among respondents, but not many social class differences since virtually all respondents could be considered members of the lower or lower- working class. These preliminary findings suggest innovative AIDS-intervention programs for women are needed. All people make sense of and attempt to control specific illnesses and risks of illness by means of the common-sense knowledge, theories, and assumptions regarding health and illness available to them (Locker 1979). AIDS-intervention workers should discover the indigenous health-care practices used by at-risk women in their targeted communities and funnel AIDS information and instruction through the agents involved in the accomplishments of these practices. As we have observed in Houston, these agents include both public and private physicians, emergency-room personnel, pharmacists, obstetricians, pediatricians, religious practitioners, and prison health officials, among others. Perhaps the most difficult to reach, yet most promising, targets should be parents, especially mothers. Efforts could be made to reach them, perhaps through various church or community memberships or through mass media messages directed towards “parents who love their at-risk daughters.” References Centers for Disease Control. HIV/AIDS Surveillance Report, June 1989. Curran, J.W.; Jaffe, H.W.; Hardy, A.M.; Morgan, W.M.; Selik, R.M.; and Dondero, T.J. Epidemiology of HIV infection and AIDS in the United States. Science 239(4840): 610- 616, 1988. Feldman, H.W., and Biernacki, P. The ethnography of needle sharing among intravenous drug users and implications for public policies and intervention strategies. In: Battjes, R.J., and Pickens, R.W., eds. Needle Sharing Among Intravenous Drug Users: National and International Perspectives. NIDA Research Monograph 80. DHHS Pub. No. (ADM) 88- 1567. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1988. Guinan, M.E., and Hardy, A. Women and AIDS: The future is grim. JAMWA 42: 157-158, 1987. Jorgensen, D.L. Participant Observations: A Methodology for Human Studies. Newbury Park, CA: Sage Publications, 1989. Landesman, S.; Minkoff, H.; Holman, S.; McCalla, S.; and Sijin, O. Serosurvey of human immunodeficiency viral infection in parturients. JAMA 258(19): 2701-2703, 1987. Locker, D. Symptoms and Illnesses. London: Travistock, 1979. Romero, M. “The Use of Women’s Culture in AIDS Outreach.” Paper presented at the annual meeting of the Western Social Science Association, Albuquerque, NM, 1989. 387 Seidlin, M.; Krasinski, K.; Bebenroth, D.; Intri, V.; Paolino, A.M.; and Valentine, F. Prevalence of HIV infection in New York call girls. J Acquir Immune Defic Syndr, 1(2): 150-154, 1988. Acknowledgment Supported by the National Institute on Drug Abuse Grant #SR18TA05156-3. Authors Joseph A. Kotarba, Ph.D. 1$ Director of Ethnographic Research Mark L. Williams, Ph.D.t Principal Investigator §University of Houston Department of Sociology Houston, TX 77204 tAffiliated Systems Corporation 1200 Post Oak Boulevard, #540 Houston, TX 77056 388 PRELIMINARY FINDINGS REGARDING AIDS INTERVENTION AMONG HISPANICS IN THE SOUTHWEST UNITED STATES Alice Kroliczak Background and Significance Horizontes began in March 1988 as an AIDS outreach and research project designed to prevent the spread of AIDS among Hispanic intravenous drug users (IVDUs) in San Diego, California; Laredo, Texas; and San Juan, Puerto Rico. Shortly after the project’s inception, it was noted that the high prevalence of AIDS in San Juan made the IV-drug-user population there very distinct from the same target population in the southwest United States. For this reason, the preliminary results of the Horizontes—San Juan project will be discussed in another paper. Although Hispanic IVDUs in both San Diego and Laredo have different characteristics, in many respects it is possible to speak about them from a comparative perspective. Their ethnic composition is basically Mexican in origin, and both are tied to drug-trafficking activities in states contiguous with the U. S.-Mexican border. The goals of Horizontes are to provide AIDS education and outreach to IVDUs not in treatment and at risk of contracting human immunodeficiency virus (HIV) infection, to gather information about HIV seroprevalence among the at-risk IV-drug-user population not in treatment, to encourage members of this target population to modify their at-risk sexual and drug-use behavior, and to measure the impact of an AIDS education and outreach effort among such a hard-to-reach population. The cities of San Diego and Laredo were chosen as targets for AIDS outreach and intervention because of their large IV-drug-user populations, most of whom were Hispanic. At the inception of the Horizontes project, no other city in the United States had a program directed solely toward its Hispanic population. This paper presents preliminary results from the first year of the Horizontes program. Additional background information regarding the project is found in Figure 1. Methods Horizontes is based on an ethnographic model developed in Chicago in the 1970s to stop the injected use of heroin. During the first year of the project, relatively unstructured AIDS- education interventions were directed toward IVDUs not in treatment in three research sites in San Diego (i.c., San Ysidro, National City, and Sherman Heights—Figure 2 under enhanced intervention networks) and four in Laredo (i.e., South Laredo, Azteca, El Catorce, and Las Colonias—Figure 3 under enhanced intervention networks). These seven sites were selected by 389 Target Population: Project Time Period: Locations: Risk Behaviors for IVDUs: Figure 1. Overview of Horizontes IVDUs not in treatment March 1988 through February 1991 San Juan, Puerto Rico San Diego, California Laredo, Texas Unsafe sex Sharing needles and works Figure 2. Research Networks: San Diego Standard Intervention Network East San Diego Enhanced Intervention Networks Figure 3. Research Networks: Laredo Standard Intervention Network Ghosttown Enhanced Intervention Networks San Ysidro Area Sherman Heights Area South Laredo Area El Catorce Area San Ysidro Logan Heights Three Points Ladrillera Imperial Beach Shelltown Santo Nino El Catorce Palm City Sherman Heights El Chacon Canta Rana Nestor Golden Hill Monines Del Sol Encanto Azteca Area El Trece Barrio Logan El Azteca Seven Lights/ National City Area Paradise Hills o utr Los Amores National City onto Chula Vista Las Colonias Area Otay Guadaloupe El Siete Viejo El Puente Blanco the project’s ethnographers because they were known to have a high volume of IV-drug-use activity. The target population was IVDUs not in treatment, most of whom had engaged in high- risk behaviors such as unsafe sex and the sharing of needles and works. Outreach workers, some of them ex-IVDUs, were hired to make inroads into the IV-drug-user networks based on their own contacts there. Outreach workers made initial contacts on the street within the research areas, using a snowball sampling technique. A network model was used whereby outreach workers used their own contacts among the target population to lead to additional contacts within the same population. They screened these contacts for participation in the study, using IV drug use within the last six months as the major criterion for admission. Outreach workers gathered basic demographic information from the users at the point of initial contact and gave them an orientation to the project, then offered them the opportunity to participate in the study. 390 Participation during the first, or pilot, year of the study consisted of taking a one-hour AIDS Initial Assessment (AIA) interview; receiving condoms, bleach, and AIDS-education brochures; receiving oral AIDS-education sessions regarding how to change unsafe sex and needle-sharing behaviors; and taking a one-hour AIDS Follow-up Assessment (AFA) interview six months after the initial interview. Participants were also asked to submit to HIV testing at initial and follow- up interview time. Participation during years two and three of the project would involve a more structured intervention, as outlined in Figure 4. Figure 4. Intervention Design: Project Years 2 and 3 Standard Intervention Enh Intervention 1. Initial Contact Initial Contact 2. AIA Interview (first month) AIA Interview (first month) 3. HIV Testing HIV Testing 4. Initial Intervention Initial Intervention 5. No Follow-Up Street Follow-Up 1 6. No Follow-Up Street Follow-Up 2 7. AFA Interview (sixth month) AFA Interview (sixth month) 8. HIV Testing HIV Testing Data collection started in early October 1988 and will be completed by the end of August 1990. During the first year of the research, trained interviewers administered AIA questionnaires to 488 IVDUs in San Diego and 291 in Laredo. All respondents gave voluntary and informed consent for participation. Initial interviews were conducted at the site offices in Sherman Heights and Laredo proper, in parks or local settings within the research areas; follow-up interviews were conducted in these same places as well as in prisons within a 50-mile radius that housed Horizontes clients. Incentives of $15 were given to clients after both interviews. In San Diego, HIV testing and pre- and post-test counseling services were provided by the San Diego Health Department at the main Horizontes office. These services are scheduled to begin in Laredo during year two of the project. Outreach workers also collected ethnographic information in a daily log. In addition, ethnographers observed the outreach areas in both cities on a part-time basis and gathered information about the client population and drug activity in these areas. The full data-collection plan for interviews is found in Table 1. Results Although only descriptive information is available from the data, it is obvious that the Horizontes project has already made an impact on the IV-drug-user community in both cities. Outreach workers have distributed condoms, bleach, and AIDS-education brochures to more than 4,000 IVDU contacts in San Diego and more than 500 in Laredo since the inception of the project. 391 Table 1. Data Collection Plan: Initial and Follow-Up Interviews San Diego Number of Interviews Year Date AIA AFA Year 7/11/884/14/89 (Actual) 488 0 Year 2 4/17/89-2/28/90 (Goal) 800 (250) § 888 (488)F (550) * (125) ¢ @75)* Year 3 3/1/90-8/31/90 (Goal) 0 400 (125)% @75)* Total 1,288 1,288 Laredo Number of Interviews Year Date AIA AFA Year 1 10/4/88-4/14/89 (Actual) 291 0 Year 2 4/17/89-2/28/90 (Goal) 650 (250) § 633 (nt (400) * (112) (230) Year 3 3/1/90-8/31/90 (Goal) 0 308 (138)% 170)* Total 941 941 tYear 1. §Standard Intervention. *Enhanced Intervention. Demographic Characteristics of IVDUs The demographic characteristics of the IVDUs who participated in the study are illustrated in Tables 2-5. The majority of contacts in both cities were Hispanic and male. During the pilot year in both cities, the largest proportions were male (76%) and Catholic (67% in San Diego; 86% in Laredo). The average (mean) age of study participants was higher in San Diego (36 years) than in Laredo (33 years). HIV Test Background As illustrated in Table 6, small proportions of the study participants had an HIV-antibody test prior to their participation in the Horizontes project (34% in San Diego; 15% in Laredo). All had been tested within the two years preceding the project. More than half, however, had not returned to the test site for their test results. At the time of their initial interview (AIA) with Horizontes, the majority of respondents (87% in San Diego; 71% in Laredo) thought they had 392 Table 2. Demographic Data: San Diego and Laredo Site San Diego! I Characteristics Year 1 Year 2 Year 1 Year 2 (n=3,770) (n=392) (n=322) (n=206) n (%) n (%) n (%) n (%) Gender Male 2,828 (75) 298 (76) 248 (17) 187 91) Female 942 (25) 94 (24) 74 (23) 19 ©) Age Mean 39 (--) 33 (—) 335 (—) 29 (-—) Median =) 32 (=) ) 26 (-) Race/Ethnicity Hispanic 3,016 (80) 255 (65) 322 (100) 202 98) White 566 (15) 94 (24) 0 ©) 4 2) Black 113 3) 31 8) 0 ©) 0 ©) Other 75 2) 12 3) 0 0) 0 ©) San Diego total contacts = 4,162. $Laredo total contacts = 528. Table 3. Gender and Religion of IVDUs (expressed in percent) Site Characteristics San Diego Laredg Year 1 Year 2 Year 1 Year 2 (n=488) (n=286) (n=291) (n=169) Gender Male 76 78 76 92 Female 24 22 24 8 Religion Catholic 67 56 86 84 Protestant 21 30 6 7 Other 3 4 5 4 None 9 10 3 5 393 Table 4. Educational Level of IVDUs' (expressed in percent) Site___ Level of San Diego Laredo Education Year 1 Year 2 Year 1 Year 2 (n=488) (n=286) (n=291) (n=169) Less than High School 62 56 86 86 Graduated or Attended Higher Education Institution 36 42 14 13 Graduated from College 2 2 0 1 AIA data only. Table 5. Average Age of IVDUs' Site__ San DiegQ ___Laredo Age Year 1 Year 2 Year 1 Year 2 (n=488) (n=286) (n=291) (n=169) Mean 36 36 33 32 Median 34 34 32 29 TAIA data only. Table 6. HIV Testing and Seroprevalence among IVDUs Site San Diego Laredo Testing/ Year 1 Year 2 Year 1 Year 2 Serostatus (n=488) (n=280) (n=291) (n=169) n (%) n (%) n (%) n (%) Had an HIV Test Prior to This Program 164 (34) 34 (12 4 (15) 20 (12) Tested within Two Years Prior to Horizontes 164 (34) 34 (12) 44 (15) 20 (12) Received HIV Test Results Prior to Horizontes 57 (12) 22 8) 27 9) 12 8) Thought They had Some Chance of Developing AIDS 426 (87) 245 (86) 207 (71) 128 (76) 394 some chance of developing AIDS. Furthermore, although many of the San Diego clients agreed to be tested during the first project year, only a small proportion returned for their test results and turned over the results to Horizontes. Of these, all tested negative for HIV antibody. Forty-two participants in San Diego in Year 1 knew their status; all were negative. Two hundred forty-one clients in that city in Year 2 knew their status—of whom three were HIV-antibody-positive. No data were available for Year 1 in Laredo; in Year 2, 68 participants were aware of their status; of those, one individual was seropositive. Intravenous Drug Use The mean age for first usage of drugs in this sample was 16 for San Diego IVDUs and 17 for those in Laredo. Half of the participants in San Diego had used drugs before the age of 15; half of Laredo participants had used drugs before age 16. In both cities, shooting drugs seemed to start at a later age, with the mean age for starting IV drug use being 20 years in San Diego and 21 in Laredo. In San Diego, 50% of the sample started shooting before they reached 18 years of age, while in Laredo, half started before the age of 19 (Table 7). A larger proportion of the San Diego IVDUs (65%) reported that they were daily injectors compared with those from Laredo (46%). Figures 5a and 5b illustrate the average frequency of injection at the time of both initial and follow-up interviews. Although no significance tests for differences were conducted, the reported frequency of speedballing between AIA and AFA time seems to have increased in both cities. Risk-Taking Behaviors Sexual Activity At the time of their initial interview, the vast majority of IVDUs in both cities reported having sex in the last six months; however, by the time of their follow-up interviews, smaller proportions reported being sexually active (Table 8). Regardless of the number of sexual partners they had at the time of their initial interview, the majority of users in both cities reported never using condoms when having sex in the past six months (Tables 9a and 9b). Larger proportions of clients with multiple partners reported using condoms since their involvement in the Horizontes project compared with proportions reporting condom use prior to their participation in the project. Needle Cleaning and Shari At the time of their initial interview, more than half (84% in San Diego; 62% in Laredo) of those injecting reported having shared needles within the last six months. However, smaller proportions in both cities reported such sharing at the time of their follow-up interview (Tables 10a and 10b). However, of those sharing needles, the proportion who reported always cleaning properly tripled at the time of the follow-up interview, along with a decline in the proportion of those reporting that they never cleaned their needles properly. 395 Table 7. Age at First Drug Use and First Intravenous Drug Use' Site San DiegQ Laredo Year 1 Year 2 Year 1 Year 2 (n=488) (n=286) (n=291) (n=169) First Drug Use Mean age 16 16 17 17 Median age 15 15 16 16 First Intravenous Drug Use Mean age 20 20 21 20 Median age 18 19 19 18 TAIA data only. Figure 5a. Average (Mean) Frequency of Injection among San Diego IVDUs 4 times a day, AIA Year 1 (n=488 almost daily i ( ) i AFAYear1 (n=115) 2.3 times a B AIA Year 2 (n=286) day, almost daily Once a day 2-6times a week Once a month Less than 4 times a month None Heroin Cocaine Heroin & Cocaine 396 4 times a day, almost daily 2-3times a day, almost daily Once a day 2-6 times aweek Once a month Less than 4 times a month None Figure 5b. Average (Mean) Frequency of Injection among Laredo IVDUs B AA vYear1 (n=291) AFA Year 1 (n=24) Bl AIA Year2 (n=169) Heroin Cocaine Heroin & Cocaine Table 8. IVDUs Having Sex in Six Months Prior to AIA and AFA San Diegg Laredo Year 1 Year 2 Year 1 Year 2 % (n) % (n) % (n) % () Yes 87 (426) 86 (246) 91 (266) 92 (155) No 13 (62) 14 (40) 9 (25) 8 (14) Total 100 (488) 100 (286) 100° (291) 100 (169) AFA Yes 80 OO — (=) 79 (19) — (=) No 20 23 — (=) 21 © — (9) Total 100 (114) —_— (=) 100 (4) a Note: AFA data for Year 2 clients are not yet available. 397 Table 9a. Condom Use by Number of Partners: San Diego Condom Use Total Never <1/2 the Time >1/2 the Time Always (m) % % % (n) % Single Partner AIA Year 1 250 83 (208) 8 (20 3 8) 6 (14) Year 2 146 85 (125) 5 ©) 3 @ 7 (10) AFA Year 1 64 72 (46) 22 (14) 2 0) 503 Multiple Partners AIA Year 1 172 69 (119) 18 (31) 9 (16) 3 (6) Year 2 100 64 64) 19 (19 4 @ 13 (13) AFA Year 1 27 48 (13) 7 2 33 ©) 11 (3) Table 9b. Condom Use by Number of Partners: Laredo Condom Use Total Never <1/2 the Time >1/2 the Time Always @) % (nm) % (nm) % % (0) Single Partner AIA Year 1 166 83 (137) 5 © 4 @ 8 (13) Year 2 84 76 64) 12 (10) 6 ®) 6 (5) AFA Year 1 11 82 ©) 9 1) 0 ©) 9290) Multiple Partners AIA Year 1 100 75 (75) 12 (12) 4 @ 9 9 Year 2 70 70 (49) 13 ©) 3 2) 14 (10) AFA Year 1 8 50 @ 25 2) 0 ©) 25 (2) 398 Table 10a. Changes in Needle-Use Behaviors of IVDUs between AIA and AFA Interviews: San Diego, Year 1 Needle -Use AIAT AFA % Change Behavior (n=488) (n=115) % ) % ) Do Not Share Needles 16 (76) 28 (32) 12t Share Needles 84 412) 72 (83) 12 Never clean properly 22 91) 6 5) -16 t Sometimes clean properly 68 (282) 65 (54) -3 Always clean properly 9 (39) 29 (24) 20 t tPercent change in desired direction. Table 10b. Changes in Needle-Use Behaviors of IVDUs between AIA and AFA Interviews: Laredo, Year 1 Needle -Use AIAT AFA % Change Behavior (n=291) (n=24) % (n) % (n) Sharing Needles 62 (181) 46 aan -16 t Of Those Sharing . . . Never clean properly 50 91) 18 Q 321 Sometimes clean properly 4 62) 36 4) 2 Always clean properly 15 (28) 45 5) 30 f tPercent change in desired direction. Health Status If we examine the health status of the San Diego and Laredo respondents as seen in Table 11, we find small proportions reporting previous diseases or health conditions related to unsafe sexual activity or IV drug use, with the proportions being higher in San Diego. The largest proportion (29% in San Diego; 13% in Laredo) reported having had hepatitis, while in both cities, gonorrhea and pneumonia ranked close behind. Finally, the impact of the Horizontes outreach program can be seen upon examining the sources of AIDS information reported by the IVDUs in both cities. Respondents in both cities identified the Horizontes intervention program as the primary source of AIDS information, while they 399 Table 11. Previous Diseases Reported by IVDUs at AIA Interview (expressed in percent) Site San Diego Laredo Year 1 Year 2 Year 1 Year 2 (n=488) (n=286) (n=291) (n=169) Gonorrhea 16 16 10 2 Pneumonia 16 23 6 4 Hepatitis 29 30 13 10 Syphilis 6 7 2 5 Tuberculosis 4 5 2 5 Endocarditis 2 2 0 4 Genital Herpes 2 2 1 3 ARC 0 0 0 0 AIDS 0 0 0 0 reported that places that provide AIDS counseling and testing, jail or prison, and their church were the least likely sources of such information (Tables 12a and 12b). Table 12a. Sources of AIDS Information Reported by IVDUs San Diego (expressed in percent) Source of AIA AFA Information Year 1 Year 2 Year 1 (n=488) (n=286) (n=115) Outreach Workers 59 51 65 Intervention Programs 77 69 98 Brochures, Fliers, etc. 82 75 84 On the Street/Word of Mouth 74 76 69 Billboards 67 60 62 Newspapers/Magazines, etc. 76 76 69 Television 77 79 74 Radio 49 43 45 Relatives and Friends 56 57 mn Other Health-care Facilities 50 44 45 Places that Provide AIDS Counseling and Testing 34 37 28 Drug-Treatment Programs 50 47 41 Church/Temple 15 14 13 Jail or Prison 49 46 29 400 Table 12b. Sources of AIDS Information Reported by IVDUs Laredo (expressed in percent) Source of AIA AFA Information Year 1 Year 2 Year 1 (n=291) (n=169) (n=24) Outreach Workers 83 53 9% Intervention Programs 85 53 98 Brochures, Fliers, etc. 5 59 84 On the Street/Word of Mouth 51 52 69 Billboards 52 57 62 Newspapers/Magazines, etc. 62 63 69 Television 70 78 74 Radio 38 41 45 Relatives and Friends 46 45 — Other Health-care Facilities 27 27 45 Places that Provide AIDS Counseling and Testing 26 21 28 Drug-Treatment Programs 38 28 41 Church/Temple 7 13 13 Jail or Prison 21 30 29 Discussion The preliminary results described in this paper demonstrate the successful impact of using an outreach and AIDS-education approach to IVDUs not in treatment in San Diego and Laredo. Outreach workers made contact with thousands of IVDUs across the two cities, IVDUs who were quite receptive to the project’s outreach staff and the AIDS-prevention education being offered. Further, the data indicate that condom usage has begun to increase among IVDUs with multiple partners in these cities. In addition, proportions reporting needle sharing have decreased during the first year of the Horizontes project, and much higher proportions of IVDUs in both cities report that they are now cleaning their needles properly. Further analyses of potential behavior differences between HIV-antibody-positive and -negative respondents and other subgroups of study participants will be done using data from the second and third years of the project. This latter data will also be used to test for the impact of a more structured AIDS- education intervention using a standard and enhanced intervention research design. Acknowledgment Supported by the National Institute on Drug Abuse Contract #271-88-8232. Author Alice Kroliczak, Ph.D. Principal Investigator KOBA Institute, Inc. 1156 15th Street, NW, Suite 200 Washington, DC 20005 401 FREQUENCY MODULATION AS AN EXPLANATION OF COMMON PATTERNS OF INTRAVENOUS COCAINE-AMPHETAMINE USE Jay Johnson and Mark Williams Introduction Controlling the spread of AIDS is one of the paramount public-health concerns in the United States today. The most rapidly increasing rate of AIDS diagnoses is among intravenous drug users (IVDUs) (Centers for Disease Control [CDC] 1989). Human immunodeficiency virus (HIV), the virus that causes AIDS, is most commonly transmitted from one IVDU to another through the sharing of contaminated syringes (Curran et al. 1988). Unfortunately, the IV-drug- using subculture has predominantly been viewed as homogeneous—IVDUs were heroin addicts (e.g., Stephens 1985). Consequently, public-health initiatives are often structured on an understanding of IV-drug-using or at-risk behaviors as they relate to heroin addiction. Recent studies, however, suggest cocaine is as likely to be the drug of choice for injection as heroin (Williams 1989). Cocaine is a different drug, and it is likely that IV cocaine users will not exhibit the same at-risk behavior patterns as IVDUs who inject heroin (Johnson 1980; Chaisson et al. 1989). Controlling AIDS among IV drug users requires an understanding of how the typical behavior patterns exhibited by IVDUs, particularly those that facilitate needle sharing, vary according to the IV user’s drug of choice. The purpose of this article is to report recent research findings that detail different patterns of drug use and drug subculture involvement between IV cocaine-amphetamine and heroin users enrolled in the Houston National AIDS Demonstration and Research (NADR) program. Method The data presented in this study were collected as part of Houston’s ongoing AIDS demonstration and research project. This project operates through outreach centers located in three inner-city communities (White-gay, Black, and Hispanic) with a known incidence of intravenous drug use. Respondents who participated in this study were contacted through the outreach centers; thus, some of the respondents represent “hidden” or “invisible” IV users in that they had little, if any, direct contact with drug treatment facilities or other service agencies. The data derive from in-depth interviews and participant observations. The interviews lasted approximately 60 minutes and followed a standard protocol. Respondents were asked to reconstruct their intravenous-drug-use histories from the first time they injected until the time of the interview. They were asked to detail the circumstances and reasons surrounding times when 402 they quit and started injecting drugs. Interviewees were also asked to respond as informed experts about their world. The interviews were recorded on tape and transcribed. The transcriptions were entered into a computer data-management system specifically designed for this research. The system assisted in easily storing, retrieving, and arranging the relevant interview data. Each respondent was identified by his or her demographic face-sheet data followed by his or her biography in a time-line format on a spread sheet resembling a matrix table. The spread sheet also facilitated quick reference to transcriptions of respondent quotes. This assisted the researchers in an analysis process of identifying and coding for any periods of IV drug involvement and abstinence as well as all the types of everyday-life events surrounding such periods. From the cyclic process of proposing types of events and reinspecting the data to ensure that each type included the scope and range of examples in the data, a general explanation for observed behavior patterns emerged. This cycling-back process is an integral component of grounded theory construction (Glazer and Strauss 1967). The respondents were 23 IVDUs: 5 heroin users and 18 cocaine and amphetamine users. Respondents were classified as either IV heroin or cocaine-amphetamine users according to their self-reported drug of choice. Although the respondents had used many different drugs separately and in combination and could be called polydrug users, they all tended to use one particular drug intravenously that, for various reasons, provided them with a desired effect. The IV cocaine-amphetamine users were nine men and nine women, and each gender group was constituted by three groups of Blacks, Whites, and Hispanics. The youngest of the IV cocaine and amphetamine users was 21 years old and the oldest 41; the mean age was 30. The heroin users were three males, one White and two Hispanic, and two females, one White and one Hispanic. The youngest was 35 years old and the oldest 55; the mean age was 44. Findings The drug-use and subculture involvement patterns of the heroin users in this study verify much of the findings on heroin addiction reported in the research literature (Lindesmith 1968; McAuliffe and Gordon 1976; Stephens 1985; Bovelle and Taylor 1985). Among this study’s IV heroin users, career heroin use patterns seem progressive, regular, and chronic. This can be attributed to the desire to avoid withdrawal symptoms, the search for an ever-elusive high, and the user’s role or position in an established heroin subculture. Since IV heroin users are relatively rare in Houston, we were not able to locate heroin users who voluntarily traversed the straight and drug-using worlds like those reported by Biernacki (1986), Hanson et al. (1985), and Powell (1973). The only periodic interruptions in these heroin users’ routines are the unanticipated events of street life, such as jail or a drug shortage. Even when the IV heroin users are caught in such circumstances, they still view themselves as engaged in the street IV heroin subculture. On the other hand, the drug careers of IV cocaine-amphetamine users in this study exhibit periods of use and nonuse, back and forth, and “in” and “out” involvements with the subculture and the straight world. Unlike the heroin users, the IV cocaine-amphetamine users tend to move between the straight and IV-drug-using worlds easily, quickly, and frequently. They spend substantial amounts of time engaged in the activities of one world or the other and refer to their 403 movement between the straight and IV-drug-using worlds as “falling in and out of it,” “crossing the line,” “a downfall,” or “an every-now-and-then thing.” As such, these IV cocaine- amphetamine users appear able to adjust their drug-use behavior according to non-drug-related everyday events in their lives. They seem to anticipate, plan, and organize their visits between the two worlds. Drug use, addiction, or the world surrounding injection are not central, overriding themes of these users’ lives. A representative example is one 32-year-old Black male IV cocaine user who, when he first came to Houston and started working in the early seventies, began shooting cocaine. He quit when he entered the military. After his stint in the military, his marriage ended in divorce; he then came back to Houston looking for work and resumed injecting IV cocaine. He quit injecting cocaine after he remarried and got a job outside Houston. He resumed using IV cocaine when he lost the job and his second marriage ended in divorce. He was arrested and spent some time in jail. As a result of that experience, he quit using cocaine for a while after he was released. Then he began “hanging with that same crowd” and resumed injecting cocaine. In another example, a 37-year-old White female quit injecting amphetamines when she learned that she was pregnant. She stopped injecting speed for six years and waited “until my daughter was in school” before becoming involved again with IV drugs. During the six years, she pursued a career as a paralegal secretary. Factors Influencing Drug-Use Involvement Factors that have been identified as regulating this study’s IV cocaine-amphetamine drug users’ “in” and “out” involvement with IV drug use are the ethnopharmacology surrounding the drugs 0 ohnson 1990), employment, proximity, significant relationships, pregnancy, bad experiences, controlled environments, the prevailing drug market, and burnout. An ethnopharmacological factor accounting for this study’s IV cocaine-amphetamine users’ interworld movement and drug-use patterns is that to a certain degree, they exert control over their drug habits. They believe different drug pharmacologies provide them with different degrees of control. As one 23-year-old Black male cocaine user said, “Heroin is a must have. Cocaine is a want. You crave for it. You ain’t gonna die if you don’t have it. Heroin, the body go into convulsions. . ..” IV users in this study refer to the craving associated with cocaine or amphetamine withdrawal as “a mind thing,” because users can train their minds to not want the drug. This control is absent among heroin respondents, who must inject in order to avoid physical withdrawal sickness but who maintain an imaginary claim that they are not addicted. Employment is another factor that appears to inversely regulate this study’s IV cocaine users’ patterns. Unlike the heroin users in this study and in other research (Fields and Walters 1985), who support much of their addiction through criminal activities they call “hustles,” the IV cocaine-amphetamine-using respondents claim to support their habits through steady work or employment. Those who hold regular jobs will quit shooting drugs if they lose their jobs and until they find new jobs. So, where steady employment might redirect other types of drug users’ energies away from involvement in a using subculture, steady work functionally supports, and unemployment prohibits, IV cocaine- amphetamine users’ periodic drug use and visits into the subculture. 404 During the periods when this study’s IV cocaine-amphetamine users are injecting drugs, they will prioritize drug use after work and schedule their drug use around work. Work is defined as more than a job; for example, child care would also be work. This is different from the heroin users, who must routinely inject, usually before the workday, in order to “get the sick off” (i.e., avoid withdrawal). Drug use is more important to them than work or a job. This study’s heroin users have chronic employment problems because the mental clouding caused by heroin interferes with normal work. The IV cocaine-amphetamine respondents unanimously deny ever using drugs on or before the job. During the work week, they inject occasionally and only at night after first discharging their work-day responsibilities. They claim that they inject the majority of their coke and speed on weekends so as not to interfere with their normal work week. Since cocaine and amphetamines cause sleeplessness, the IV users inject drugs on “runs” lasting the entire weekend and recharge their “batteries” during the work week. This study’s IV users of cocaine and amphetamines claim they cannot continuously and progressively inject these drugs for an indefinite period of time, like heroin users can with heroin. For the IV cocaine-amphetamine users, within their larger periods of cocaine-amphetamine use, there are smaller periods of use and abstinence. A resulting belief among the IV cocaine- amphetamine-using respondents is that periodic involvement with IV drugs and the subculture is normal and expected. Faces frequently appear, disappear, and reappear. This is not unexpected, unusual, or uncommon. Proximity to the IV-drug-using subculture appears associated with a propensity to use drugs intravenously. IV cocaine-amphetamine users in this study will move out of the inner-city locations that harbor their injection subculture when they pursue jobs and a normal family life. Subsequently, users cease injecting drugs until they return to areas of inner-city Houston where IV use takes place. Heroin users, on the contrary, try to stay close to their drug sources and must include a constant source for drugs in any long-term travel or relocation plans. Other factors that can dramatically alter the course of both IV cocaine-amphetamine and heroin users’ drug use are the behaviors or orientations of intimates in significant relationships (e.g., girlfriend, boyfriend, spouse, parent). Heroin users tend to establish long-term intimate relationships on the basis of mutually supporting each other’s habit. An opposite scenario occurs more often among the IV cocaine-amphetamine users who become involved with someone who does not approve of their drug use. Users find it easier to quit IV drugs than to “lose” the other person. Since the cocaine-amphetamine user never shows obvious heroin-like withdrawal sickness, the other person may never suspect his or her mate was a drug user. For example, two IV cocaine-amphetamine-using men in this study said that they would never reveal their past for fear the other person would leave the relationship. The men claimed their sex partners never knew about their IV drug use. That IV cocaine-amphetamine use or withdrawal can be hidden even from intimate partners further supports the notion that users are capable of moving frequently between the straight and IV-drug worlds without being detected by the straight world. An equally common scenario, particularly among Black male users, is the breakup of a relationship, which releases an ex-user to return to the injection subculture and to resume 405 shooting drugs. The opposite scenario of a boyfriend, girlfriend, or spouse initiating a user, restarting an ex-user, or facilitating IV drug use, can also be the case. Pregnancy was a factor that encouraged the older White female IV cocaine-amphetamine users to quit. After the baby was delivered or their primary parent care was no longer necessary, they would resume shooting at the prepregnancy rate. On the other hand, the trend among the younger Black and Hispanic users was to continue shooting cocaine and amphetamines periodically throughout the pregnancy. They were more like the female heroin users in this study, who continued to use heroin or methadone at the pre-pregnancy rate. However, the IV cocaine-amphetamine and heroin mothers who used IV drugs during their pregnancies claimed their drug use slowed because the drug experience seemed less pleasurable. The respondents attributed this to the physiological changes of pregnancy. A bad experience may convince some IV cocaine-amphetamine users to quit shooting drugs and leave the IV-using world. The bad experience must be something that actually happened to the user or that was personally witnessed by the user. There are generally two types of bad experiences: drug induced, such as an overdose or events related to the subculture of drug use (e.g., rip-offs, drug-induced violence, seeing another user overdose, prostituting oneself for drugs or drug money, or just the “whole junky scene”). This study’s cocaine-amphetamine users tend to become fearful of repeating the experience and, for a time, reduce their involvement with IV drugs and the subculture. Heroin users continue their drug activities, viewing bad experiences as a normal part of the heroin routine. In many cases, however, this study’s cocaine-amphetamine users forget the bad experiences as soon as they return to injecting drugs and the subculture. A second type of bad experience may occur when a drug user enters a “controlled environment” such as jail, the military, or Job Corps. This is the number-one deterrent to all forms of intravenous drug use and therefore rates as a distinct regulating factor. Short jail terms appear to be more of a deterrent than do longer terms. Long jail terms are ineffective in stopping users from using IV drugs. IV drugs are readily available in jail, and the longer the jail term, the more reason there is to seek a drug-induced escape. Long-term prisoners will not have any appreciable time added to their sentences should they be caught shooting. What seems to work most effectively are short sentences that can be extended should the user be caught shooting drugs in jail. Some heroin users continued to inject even while in prison. In addition, this study’s heroin users typically resumed their drug use the day that they were released from jail. They refer to this as “having a date with a needle and a spoon.” For this study’s heroin users, jail is not a way to re-enter the straight, non-drug-using world; instead, it is a routine, normal part of their life. On the other hand, the traumatic experience of jail caused all the cocaine-amphetamine-using respondents in this study to stop injecting while in prison, even when drugs were available. After their release, most IV cocaine-amphetamine first-offender respondents said they left the drug subculture, rarely shot up, and led a straight non-drug-using life for weeks or months, because, “I just did not want to go back,” or “I didn’t want to do more time.” Several respondents went to prison for non-drug offenses. They claimed that the prison authorities were not aware they were IVDUs. This study’s IV cocaine-amphetamine users seem more likely to 406 view their incarceration as punishment for their involvement with drugs even if it was not directly caused by using drugs. Changes in the illicit drug trade are another factor that causes some IV cocaine-amphetamine users to quit. The reasons cited are that the quality of drug went down, it became unavailable, or the price was too high. This contrasts with the behavior of IV heroin users who, when faced with a drug shortage, will switch to alternative opiates or seek out methadone maintenance. As Beschner and Walters noted, methadone maintenance is just another facet of the daily heroin- injection subculture (Beschner and Walters 1985). Some reasons that the IV cocaine-amphetamine using respondents cited for temporarily quitting drugs fall under the rubric of burnout. Users complained that they grew weary of the life they were leading and just desired a change. “Tired” is a word often used. Although a single event might act as a catalyst, becoming tired seems to be the result of several events rather than of a single key event. A feeling of tiredness may be induced by the pharmacological properties of cocaine and, especially, amphetamines, which accelerate body fatigue (Dackis and Gold 1985; Miller et al. 1989). As was noted by this 36-year-old Black female cocaine-amphetamine IVDU, “...it’s like you ‘drove tired’.” Over an extended period of weekly or monthly use, the action of these drugs may deplete the brain’s storehouse of natural chemicals until no amount of the injected drug will produce the desired effect. This would explain the periodic quitting of some users because they perceive the quality of drug as poor. The periods of nonuse allow the brain to regenerate and accumulate another store of natural chemicals. Discussion A “frequency-modulation” explanation emerged from this study, according to which the frequency with which IV cocaine-amphetamine users inject drugs and involve themselves in the drug subculture is a function of modulation by everyday-life events. That is, the variety in the IV-drug-use behavior observed is reduced or increased based upon the variety of factors regulating the behavior. As such, this study’s IV cocaine-amphetamine users’ behavior may be shown to operate according to the logic of cybernetics and sine curve mathematics (Asby 1973; Boynton 1980). Unlike a monocausal sine function, periodic IV cocaine-amphetamine-using behavior is a function of various separate or combined factors. Across time, the drug-use careers of this study’s heroin users appear more or less stable, systematic, constant, and linear. The portrayal of heroin-use patterns can be illustrated by a graph of a hypothetical example in Figure I. On the other hand, from the biographical accounts that the IV cocaine-amphetamine users give, a common cyclical pattern emerges that may be repeated numerous times throughout users’ careers. After initiation into IV use, users became progressively more involved in the drug- injecting subculture. At some point, a factor or a series of factors causes them to “pull out” and quit using drugs. They progressively engage in the straight, non-drug-using world. Then something leads them back to injecting drugs and the drug subculture. Regardless of the factors regulating users in and out of the subculture, their return focuses on the drug(s). This back-and- forth movement can be represented in the graph of a hypothetical IV cocaine-amphetamine user in Figure 2. 407 Figure 1 The X-axis represents time; the Y-axis represents involvement in the IV-heroin-using subculture. The line moving across the graph is an average street heroin user: (1 2) 3) 4) ® ©) initiation into I'V heroin use; arrest and jail; release from jail and resumption of heroin use; a sudden drug shortage; enrollment in methadone maintenance; identification of a drug source, and so forth. The beginning points and end points will always be 0. The size and directions of the curves will vary by individual user. Y IV Drug Involvement 0 408 Figure 2 The S-axis represents time; the Y-axis represents involvement in the IV-heroin-using subculture. The Y-axis is divided by 1 as the imaginary line that IV cocaine-amphetamine users cross. The line is equidistant from two extremes of absolute involvement: -1 for the IV-drug subculture; and +1 for the non-drug-using straight world. The line moving across the graph is an average street cocaine-amphetamine user: (1) 2) G3) 4) ®) ©) initiation into IV use; progressive involvement in injecting drugs; a new job, travel, pregnancy, etc.; pursuit of a normal or straight life, job, family, etc.; disruption of (4); resumption of IV drug use and so forth. The curves in this graph can assume an infinite number of variations depending on the user, but the beginning points and end points will always be 0. Y +1 IV Drug Involvement OFT Time 409 The frequency-modulation explanation for IV cocaine-amphetamine use patterns presents a number of public-health issues. Recent surveys indicate that IV cocaine use is much more prevalent than heroin use (Chaisson et al. 1989; Williams 1989). IV cocaine-amphetamine users are more likely to be HIV infected (Williams 1989), and are much more likely to contract HIV through the sharing of contaminated injection equipment (Johnson 1990). Frequency modulation shows that IV cocaine-amphetamine users have demonstrated the ability to move frequently, quickly, and repeatedly into the straight non-drug-using world. They also keep their IV drug use hidden, undetected, and invisible from the straight world, especially from their non- IV-drug-using sexual partners. As such, they pose a potential public-health risk as carriers of HIV into non-IV-drug-using heterosexual populations at large. Using established health-care and service agencies to deliver a preventive AIDS intervention would prove ineffective with a good many IV cocaine-amphetamine users. Many users rarely have contact with such organizations, and those who do usually escape detection. The IV cocaine-amphetamine users’ frequent movement in and out of networks makes tracking this population for research or follow-up intervention very difficult. The opposite is true of heroin users, who are relatively easy to locate for intervention because they are visible, stable, follow a predictable routine, and are in constant contact with heroin-user networks, the criminal justice system, and drug-treatment agencies. A cursory overview of the findings provides some direction for more definitive research on the factors that modulate IV drug use. For example, a better understanding of how pregnancy slows or stops IV drug use would provide important information in light of a growing number of IV- drug-using mothers who give birth to HIV-infected babies. Public-health policy makers could use this information to develop effective IV-drug-use and AIDS-intervention programs with pregnant women. Another factor that warrants further research is how significant relationships can induce periods of IV drug use or abstinence. Insight on this aspect of IV drug use could provide clinicians and outreach personnel with new and better behavioral interventions to reduce the incidence of IV drug use and the spread of AIDS. Through a more elaborate and extensive understanding of the various modulating factors and how they regulate IV cocaine-amphetamine use, policy makers can more accurately anticipate the optimum times for implementing AIDS-prevention efforts. This would also contribute to a more efficient use of resources. The task for epidemiological researchers is to develop sine curve equations that approximate the frequency modulation types depicted in ethnographic findings. Ethnographers can assist by refining what is known about identified everyday-life events or factors that modulate frequencies and by discovering new ones. Through this process, meaningful numbers generated from health-survey data can be plugged into equations. These equations should help to forecast the different points in time when IV cocaine-amphetamine use should peak. New HIV infections should follow those time periods in which large numbers of IV cocaine-amphetamine users are engaged in situations that facilitate needle sharing. By determining the different IV drug use peaks, one can predict approximately when new outbreaks of HIV infection may occur. Given that the most pervasive form of IV drug use operates according to modulating waves, one hypothesis for future research is that IV cocaine- and amphetamine-related new HIV infection outbreaks should follow in waves that mirror periodic drug-use behavior. 410 This article has attempted to use ethnographic data to show that IV cocaine-amphetamine-drug- use patterns are different from patterns of heroin use. IV cocaine-amphetamine use appears to change according to the everyday-life considerations of the users. This frequency-modulation explanation is an attempt to use ethnographic data to develop a current and accurate depiction that assists the other components of AIDS- and IV-drug-use research and prevention. It is hoped that this information and future research will enhance the ability of policy makers to develop timely and effective interventions. References Asby, W.R. An Introduction to Cybernetics. London: Methuen, 1973. Beschner, G., and Walters, J.M. Just another habit?: Heroin users’ perspective on treatment. In: Hanson, B.; Beschner, G.; Walters, J.M.; and Bovelle, E.I,, eds. Life with Heroin: Voices from the Inner City. Lexington, Massachusetts: Lexington Books, 1985. Biernacki, P. Pathways from Heroin Addiction: Recovery without Treatment. Philadelphia: Temple University Press, 1986. Bovelle, E.L., and Taylor, A. Conclusions and implications. In: Hanson, B.; Beschner, G.; Walters, J.W.; and Bovelle, E.I, eds. Life with Heroin: Voices from the Inner City. Lexington, Massachusetts: Lexington Books, 1985. Boynton, G.R. Mathematical Thinking about Politics: An Introduction to Discrete Time Systems. New York: Longman, 1980. Centers for Disease Control. HIV/AIDS Surveillance Report, August 1989. Chaisson, R.E.; Biernacki, P.; Osmond, D.; Brodie, P.B.; Sande, M.A.; and Moss, A.R. Cocaine use and HIV infection in intravenous drug users in San Francisco. JAMA 261: 4, 1989. Curran, J.W.; Jaffe, HW.; Hardy, A.M.; Morning, W.M.; Selik, R.M.; and Dondero, T.J. Epidemiology of HIV infection and AIDS in the United States. Science 239: 610-616, 1988. Dackis, C.A., and Gold, M.S. New concepts in cocaine addiction: The dopamine depletion hypothesis. Neurosci Behav Rev, PG AND VOL. #? 1985. Fields, A., and Walters, J.M. Hustling: Supporting a heroin habit. In: Hanson, B.; Beschner, G.; Walters, J.M.; and Bovelle, E.I, eds. Life with Heroin: Voices from the Inner City. Lexington, Massachusetts: Lexington Books, 1985. Glazer, B.G., and Strauss, A. The Discovery of Grounded Theory. Chicago: Aldine, 1967. Hanson, B.; Beschner, G.; Walters, J.M.; and Bovelle, E.I. Life with Heroin: Voices from the Inner City. Lexington, Massachusetts: Lexington Books, 1985. 411 Johnson, B.D. Toward a theory of drug subcultures. In: Letteri, D.J.; Sayers, M.; and Pearson, HW., eds. Theories on Drug Abuse. National Institute on Drug Abuse. Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1980. Johnson, J. Ethnopharmacology: An interdisciplinary approach to the study of intravenous drug use and the HIV. J Contemp Ethnog, in press, 1990. Lindesmith, A.K. Addiction and Opiates. Chicago: Aldine, 1968. McAuliffe, W.E., and Gordon, R.A. A test of Lindesmith’s theory of addiction: The frequency of euphoria among long-term addicts. In: Coombs, R.H.; Fry, L.J.; and Lewis, P.G., eds. Socialization in Drug Abuse. Cambridge, Massachusetts: Schenkman, 1976. Miller, N.S.; Millman, R.B.; and Gold, M.S. Amphetamines: Pharmacology, abuse and addiction. Adv Alcohol Subst Abuse 8(2): 53-69, 1989. Powell, D.H. A pilot study of occasional heroin users. Arch Gen Psychiatry 28: 586-594, April, 1973. Stephens, R.C. The sociocultural view of heroin use: Toward a role-theoretic model. J Drug Issues. 15(4): 433-446, Fall 1985. Stephens, R.C., and McBride, D.C. Becoming a street addict. Hum Organization 35(1): 87- 93, 1976. Williams, M.L. “IV Drug Abuse and HIV Infection in Houston, Texas.” Paper presented at the First Houston Crackdown, Houston, Texas, June 21, 1989. Acknowledgment Supported by the National Institute on Drug Abuse Grant #SR18TA05156. Authors Jay Johnson, M.S., M.A. Ethnographer Mark Williams, Ph.D. Principal Investigator Affiliated Systems Corporation 1200 Post Oak Boulevard, #540 Houston, TX 77056 412 REACHING EVERYONE! AIDS AND CINCINNATI'S HEALTH (REACH) YEAR-ONE DATA E. Don Nelson, Ronn D. Rucker, Bill Epps, Leonard T. Sigell, and Stanley E. Broadnax Introduction and Background The National AIDS Demonstration Research (NADR) program in Cincinnati, known as “Reaching Everyone! AIDS and Cincinnati’s Health” (REACH), began on October 1, 1988. As of April 1989, the REACH project was fully staffed, and the first AIDS Initial Assessment (AIA) interview was administered April 6, 1989. As of October 1, 1989, 828 subjects had been interviewed using the AIA instrument. Of these, 672 were intravenous drug users (IVDUs), 154 were sexual partners (SPs), and two were members of neither group. Thirty-nine AIDS Follow-up Assessments (AFAs) were completed as of October 1, 1989 (26 IVDUs and 13 SPs). As of October 1, 1989, Project REACH outreach workers had contacted a total of 2,842 IVDUs, 1,917 SPs, and 2,971 others, for a total of 7,730 outreach contacts. Everyone interviewed with the AIA instrument is given an AIDS Knowledge Test, followed by an educational session conducted by the education component of the REACH project. The education session consists of a discussion of the AIDS Knowledge Test and viewing and reacting to a videotape entitled “AIDS: Changing the Rules.” The subjects are also given a packet of practical information on preventing the spread of human immunodeficiency virus (HIV). The packet includes detailed information on how to clean needles and syringes, as well as how to use condoms. The packet also contains three condoms. The REACH program administers an AIDS Knowledge Test both before and after an education session. The pre/post data from the first 239 interviews show that the education component has a positive impact. Specifically, the pre-education AIDS Knowledge Test mean score was 12.6, and the post-education AIDS Knowledge Test mean score was 15.0. These results are encouraging and consistent with the findings of other AIDS Targeted Outreach Model (ATOM) and NADR sites, which indicate that adequately planned and carefully delivered educational programs can have an impact on the HIV/AIDS knowledge base of IVDUs and SPs of IVDUs. The year-one recruiting strategy for the REACH project was to announce the presence of the program to the general public via print and electronic media, and to the social-service system via announcements, telephone contacts, and correspondence. Clients who had gone through the program encouraged others to participate via “word of mouth.” REACH outreach workers targeted eight neighborhoods for intensive outreach activities. These communities included Walnut Hills, Price Hill, Over-the-Rhine, Mt. Auburn, West End, Avondale, Evanston, and Madisonville. Targeted efforts in these areas generated considerable interest in and awareness of 413 the REACH program in the community, as is evidenced by the October 1989, four-week waiting list for AIA interviews. Outreach contact data indicate that sexual partners of IVDUs are an important target population (17%) for the REACH project. AIA data indicate that SPs are successfully contacted by street outreach workers and are presenting to the REACH project for interviews, education, and follow-up interviews. Responses to the question “How did you hear about the project?” from the AIA indicate that “outreach worker” contact is an important source of referral for IVDUs and SPs. The statistical measures in use at the REACH project are the AIA, AFA, AIDS Knowledge Test, and outreach (IVDU, SP, and “other” contacts). Less formal measures of the impact and effectiveness of the Cincinnati REACH project are obtained from narrative descriptions collected by the outreach workers and other REACH staff. For example, the management of some 80 “Stop-N-Go” stores in the Greater Cincinnati area agreed to place REACH posters in the store windows and to place flyers about Project REACH on the counters. This is in addition to numerous other public-awareness activities that serve prevention, education, and referral functions. Details of these accounts are kept in a process file called the REACH “Chron” file. The “Chron” file contains written accounts of the experiences of REACH staff, contacts, and others associated with the program. The “Chron” file also contains training sessions presented by REACH staff, as well as accounts of the project as reflected in the local media. Characteristics of members of the study population and their perception of their likelihood of contracting AIDS are presented in Tables I and 2, respectively. Table 1. Overview of Study Population (N=349) % of Sample Gender Male 83 Female 17 Race Black 96 White 4 Risk Behavior Intravenous drug user 80 Sexual partner of IVDU 20 Highest Education 8th grade 4 9-11th grade 46 12th grade 25 Some college 23 College graduate 2 414 Table 2. Perceived Likelihood of Developing AIDS in Relation to Needle-Use Practices, AIDS Information Sources, and HIV-Antibody Testing Status (expressed in percent) No Chance Some Chance High Chance = N/A Always discard equipment after use 35.6 22.3 17.4 24.7 Source of Information’ Television 42.5 41.1 30.4 ee Newspaper 10.3 13.8 8.7 — Pamphlet 30.4 8.7 21.1 RN HIV-Antibody Tested Not tested 72.4 72.4 43.5 en Tested 27.6 27.6 56.5 . TOther sources account for 100%. 9 &¢ It is of interest that the subjects’ self-perception of risk (e.g., “no chance,” “some chance”), seems to be consistent with needle-use behavior. Those subjects who perceived themselves as having no chance of getting AIDS used works and threw them away more often (35.6%) than those who perceived themselves as having a high chance of getting AIDS (17.4%). In relation to sources of information about AIDS, 42.5% of the subjects who obtained their information from television felt they had “no chance” of getting AIDS, while 30.4% felt they were at high risk. Inversely, of those who obtained their information from newspapers, 10.3% felt they had no chance of getting AIDS, while 21.1% perceived themselves as being at high risk. Those who self-perceived a high risk were more likely to have been HIV-antibody tested (56.5%) than those who saw themselves as having no chance (27.6%). Table 3 provides information about the self-report rates of STDs in the study population. Gonorrhea was the most common, at 42.8%. Needle-use phenomena for the Cincinnati NADR site show that 63% of those interviewed never shot drugs with a stranger. A significant portion of subjects (26.4%) always used a new needle in a sterile wrapper. Many others used a sterile needle with some frequency. Similarly, 26.6% of subjects reported that they always used works and threw them away. The location at which the interviewee “shot up” is given in Table 4. The “ever used” frequencies for several drugs are given in Table 5. Compared to other locations, the data from Cincinnati show relatively low rates for crack. Heroin-use rates are midrange compared to other NADR sites. The incidence of “heroin alone” of 59% includes snorted heroin. The 53.6% “ever injected” is for injected heroin. The “other opiates” category shows a significant number of interviewees using nonheroin opiates (opioids). In Cincinnati, 415 Table 3. Self-Reports of STDs in Study Population (expressed in percent) Condition Cases Reported Genital herpes 2.3 Gonorrhea 42.8 Syphilis 6.0 Chlamydia 8.9 AIDS Related Complex (ARC) 0.6 Table 4. Needle-Use Behavior of Study Population (expressed in percent) Frequency Behavior Never <1/2Time 1/22 Time >1/2 Time Always N/A Shot drugs with a stranger ~ 63.0 12.3 3.7 14 0.6 19.0 New needle in sterile wrapper every time 10.9 6.6 9.5 27.2 26.4 19.4 Used “works” and threw away 8.0 18.9 12.3 14.9 26.6 19.3 Shot up at own place 17.8 13.5 10.1 22.7 16.4 29.5 Shot up at friend’s home or apartment 16.3 25.5 14.0 15.5 9.5 19.2 Table 5. Drug-Use Frequency of Study Participants Drug of Choice Reported Incidence Cocaine (any): 89.1 Crack 54.2 Injected cocaine 75.9 Amphetamine (any): 51.6 Oral 47.3 Injected 20.1 Heroin: Alone 59.0 Injected 53.6 Speedball (heroin/cocaine) 41.5 Snort heroin and cocaine 58.5 Other opiates (any): 67.9 Oral 46.1 Injected 53.6 Tranquilizers 40.1 PCP 14.6 LSD/MDA/hallucinogens 29.5 Volatile nitrites 18.1 416 commonly-used drugs in this category are Dilaudid®, Meperidine®, Tylox®, Percodan®, and Percocet®. These data are consistent with the street mythology that Cincinnati is a “pill town”: a metropolitan area where dissolved or suspended opioid drug tablets are injected intravenously. The frequency of injection of heroin in the past six months is shown in Table 6. Frequency varies widely, as seen in other NADR sites. On-Site HIV Screening In July 1989, REACH began offering HIV-antibody screening, and pre- and post-test counseling at the 411 Oak Street location. The initial arrangement, which referred clients to the health department’s anonymous site for testing, proved to be an undesirable alternaive for clients. As of October 1, 1989, 97 HIV-antibody tests had been performed at the REACH office; four of those were positive. Hospital Outreach With the addition of a public-health nurse, the REACH program is now able to recruit additional clients from hospital emergency rooms. In Cincinnati, participants are recruited from the University Hospital, which, in this case, also serves as the county hospital. Results Data from the first 349 AIAs, representing the period from April to June 1989, are presented in Table 7. Table 6. Heroin-Injection Frequency of Study Participants (expressed in percent) Frequency Reported Rate Never 29.2 <4x/month 11.7 1x/week 4.3 2-6x/week 1.7 1x/day 2.6 2-3x/day 1.4 24x/day 2.3 N/A 48.8 Table 7. Mean Age of First Injected Drug Use Injected Drug Age Cocaine 27 Amphetamines 22 Heroin 21 417 Conclusions Cincinnati’s IVDUs and sexual partners of IVDUs are relatively conservative and well educated. The needle-use patterns reflect a population that seldom engages in high-risk, needle-sharing behavior, and often uses new, sterile needles. Most of the people interviewed at REACH came from inner-city areas. Of the eight targeted zip-code zones, four produced five or more interviewees in the first 239 AIAs. In addition, five other zip-code zones were the source of more than five interviewees. Self-perception of self-risk among participants seems to be consistent with the self-report of behavior regarding high-risk needle use. Reports of STD rates seem consistent with those of other NADR sites. Injection patterns in Southwest Ohio support the hypothesis that Cincinnati is a “pill town.” Acknowledgment Supported by the National Institute on Drug Abuse Grant #SH84SP00868-03. Authors E. Don Nelson, Pharm. D.t Research Director Ronn D. Rucker, Ed.D.§ Program Director Bill Epps, M.A.* Outreach Director Leonard T. Sigell, Ph.D.T Professor of Pharmacology Stanley E. Broadnax, M.D.$ Principal Investigator "Project REACH §Cincinnati Health Department *Cincinnati Central Community Health Board (CCHB) University of Cincinnati College of Medicine and Drug and Poison Information Center 411 Oak Street, Suite 308 Cincinnati, OH 45219 418 PRELIMINARY FINDINGS FOR THE AIDS TARGETED OUTREACH MODEL TO INTRAVENOUS DRUG USERS IN THREE NORTHEASTERN METHADONE PROGRAMS Ann M. Downey, Willie H. Davis, Hillard Davis, Tina Stackhouse, and Fred Royster Introduction According to the Centers for Disease Control (CDC) monthly HIV/AIDS Surveillance Report, 115,158 cases of acquired immune deficiency syndrome (AIDS) have been reported and 68,441 people have died of AIDS as of November 1989 (CDC 1989). Intravenous (IV) drug use has been the cause of nearly one-third of the AIDS cases in the United States and Europe, with the human immunodeficiency virus (HIV), the virus that leads to AIDS, recently spreading among IV drug users (IVDUs) in developing countries such as Thailand, Brazil, and Argentina (Des Jarlais and Friedman 1988). New York City has the largest number of AIDS cases among IVDUs in the developed world. More than half of the estimated 200,000 drug injectors in New York City are infected with HIV (Des Jarlais et al. 1989). HIV infection and AIDS are now major causes of morbidity and mortality in the United States. Because of the large number of Americans already infected, morbidity and mortality will continue to increase in the next few years and remain high in young and middle-aged men, particularly in Black and Hispanic minorities, among whom a large number of IVDUs are infected with the virus. More information is needed on the incidence and prevalence of HIV infection, especially at the local and State levels, where prevention efforts must be targeted, implemented, and evaluated. The major modes of HIV transmission are known, as epidemiologic evidence clearly demonstrates that HIV is transmitted in three ways: (1) through sexual activity; (2) through injection of infected blood; and (3) through perinatal transmission (Curran et al. 1988). Users of illicit drugs are at risk for HIV infection because of certain practices associated with drug use— specifically, needle sharing among IVDUs, using drugs in combination with sexual activity, and exchanging sex for drugs. The prevention of HIV transmission depends on the reduction and/or elimination of high-risk behaviors related to certain drug-use and sexual practices. Comprehensive programs that involve targeted health-education efforts, as well as individual and community-based intervention projects that include HIV counseling and testing have been implemented. IVDUs will play an increasingly important role in the future of the AIDS epidemic, as they are the second-largest group to be infected with HIV and the most likely to transmit it via heterosexual and perinatal modes in the United States and Europe (Des Jarlais et al. 1988). As many as 73% 419 of all cases of heterosexual transmission of AIDS have involved an IVDU, and 50% of children with AIDS have a parent who uses IV drugs (Des Jarlais et al. 1985). AIDS-education and -intervention strategies with IVDUs will be critical in slowing the spread of HIV infection, as there are an estimated 1.1 to 1.3 million IVDUs in the United States today. As the cases of AIDS among IVDUs increase, drug-treatment modalities will need to expand their role in developing policies and procedures that address HIV infection, AIDS Related Complex (ARC), and AIDS. Fortunately, substance-abuse programs provide a unique environment for the development and implementation of intervention strategies, including educational modules and skills training, to help IVDUs learn how to alter their high-risk behaviors (Galea et al. 1988). Rationale and Background Access to drug-abuse treatment is the cornerstone for controlling the spread of HIV infection. Nevertheless, many drug-treatment programs have not yet instituted effective AIDS-prevention efforts and are not equipped to care for the psychosocial needs of clients. IVDUs do appear to fear AIDS enough to change or modify their behaviors and to reduce their risk by entering drug treatment. According to Des Jarlais and colleagues (1987), over 50% of the drug users seeking treatment cited “fear of AIDS” as one of the reasons for entering drug treatment. Intervention strategies for controlling the spread of AIDS among IVDUs via drug-treatment centers, as cited by Craven (1988), include: (1) access to drug treatment; (2) access to HIV-antibody counseling and testing for IVDUs and their partners; (3) preferential admission for seropositive IVDUs; (4) special programs for pregnant addicts and adolescents; (5) access to condoms and sterile needles; and (6) education programs for IVDUs and their partners on AIDS risk reduction. More specifically, the reduction of HIV transmission through IV drug use is being directed by the U.S. Public Health Service (PHS) via the following (Report of the Second Public Health Service AIDS Prevention and Control Conference 1988): (1) Working to expand the number of IV-drug-treatment slots to a level sufficient to treat the total accessible drug users at any one time. (2) Expanding efforts to improve the quality and effectiveness of drug treatment by increasing retention rates, decreasing relapse rates, developing quality-of-care guidelines, supporting research on new pharmacotherapies, and increasing flexibility of existing methadone regulations. (3) Supporting the recruitment and training of enough drug-treatment personnel to handle increased workloads. (4) Increasing outreach and educational efforts for both IVDUs and their partners and supporting research on more effective outreach measures. (5) Increasing efforts to provide effective information about the value of cleaning drug paraphernalia in reducing the risk of disease transmission. (6) Supporting efforts to link drug-abuse-treatment services with primary health-care services. 420 (7) Supporting research to identify models for integrated and cost-effective service delivery. (8) Supporting research to clarify the extent, nature, and natural history of IV drug use and needle sharing, with special attention paid to cultural differences. (9) Supporting research on the role of drugs of abuse as cofactors in the spread of HIV infection, including the effect of drug use on risk-taking behavior. Smith (1987) has importantly indicated that now and in the immediate future, substance-abuse- treatment professionals will play a major and expanding role in the AIDS epidemic. AIDS and drug use are multidimensional problems that require a multifaceted and a multidisciplinary response. Drug-treatment professionals will need to regularly and continuously update themselves with regard to the latest AIDS and drug-treatment preventions and interventions, in addition to HIV testing and pre- and post-test counseling procedures. Substance-abuse programs, such as the “AIDS Targeted Outreach Model (ATOM): Increasing the Capability of Methadone Maintenance Programs,” funded by the National Institute on Drug Abuse (NIDA), will need to play a far greater role in the determination of AIDS and drug-treatment policies, insofar as the AIDS epidemic will increasingly dictate public policy for treatment of drug abuse and chemical dependency (Smith 1987). The purpose of this paper is to describe the methadone- maintenance model for AIDS targeted interventions and to report preliminary program findings. Program Goals, Aims, and Objectives The overall goal of the AIDS Targeted Outreach Model: Increasing the Capability of Methadone Maintenance Programs is to test and evaluate the capability and/or effectiveness of methadone treatment programs in reaching specific target populations (i.e., IVDUs, sexual partners of IVDUs, prostitutes who are IVDUs, and/or sexual partners) to prevent the spread of HIV infection and to promote the adoption of risk-reduction behaviors. Specific aims and objectives of this model are to: (1) Establish and/or expand AIDS-related outreach and treatment services. (2) Reduce the risk of contracting and spreading AIDS among IVDUs and their sexual partners via the adoption of safer sexual practices and the cessation of the use of contaminated paraphernalia. (3) Reinforce the importance and benefits of engaging in risk-reduction behaviors to prevent the spread of HIV infection. (4) Encourage the high-risk individuals to participate in HIV-antibody testing and counseling. (5) Positively influence the knowledge, attitudes, beliefs, skills, and behaviors for those at risk to prevent the transmission of AIDS and improve their health. (6) Educate both treatment clients and those persons obtained via outreach efforts that they are at risk for HIV infection unless they take 421 precautionary measures and/or engage in risk-reduction behaviors (i.e., needle cleaning, condom use). (7) Reinforce community AIDS-education messages via culturally sensitive methods and assist high-risk individuals in altering their high-risk behaviors and practices (i.e., unsafe sex, sharing works). (8) Provide specialized AIDS-prevention outreach and HIV-antibody testing and counseling to IVDUs and their sexual partners or contacts. (9) Research and educate IVDUs (in and out of treatment) and their sexual partners/contacts regarding the prevention of HIV infection. (10) Encourage reduction of the number of sexual partners, greater condom use, increased cleaning of needles and works, and greater use of HIV- antibody testing and counseling. Program Components Since the scope of the HIV epidemic in the New York metropolitan area and New Jersey is so great, the ATOM program is being implemented and evaluated in three northeastern cities. NIDA has funded this three-year demonstration project in Atlantic City and Jersey City, New Jersey, and East Meadow (Nassau County), New York. The intervention aims to evaluate the effectiveness of three methadone sites in reaching IVDUs and sexual partners of IVDUs, in promoting the adoption of risk-reduction behaviors, and in preventing the spread of AIDS. Specific program components at each of the three methadone sites (Figure 1) include: (1) outreach, (2) treatment, and (3) aftercare. Major activities within each of the components are also listed in Figure I. Outreach is the primary intervention strategy. Chief functions of the outreach workers at the three sites are: (1) dissemination of risk-reduction materials on AIDS prevention, such as pamphlets on needle cleaning, safer sex, and risk of AIDS to the unborn; 2) distribution of condoms and instructions on their use, as well as bleach and directions on how to clean and sterilize needles; (3) HIV testing and pre- and post-test counseling; (4) administration of the AIDS Initial Assessment (AIA) and AIDS Follow-up Assessment (AFA) questionnaires; and (5) referrals. AIDS-intervention efforts are being directed to the target groups within each component as follows: mponen ® IVDUs not in treatment ® Sexual partners of IVDUSs not in treatment ® IVDUs in treatment for less than 30 days * Both IVDU and a sexual partner ® Prostitutes who are IVDUs ® Prostitutes who are sexual partners of IVDUs. 422 Figure 1. Program Components for the ATOM: Increasing the Capability of Methadone Programs in Three Northeastern U.S. Cities Program Components J J J Outreach Treatment Aftercare Disseminate Risk- Reduction « Methadone * Reduction of Client Dosage Materials (Safe Sex, Needle Maintenance « Monitoring Client Progress Cleaning, and Risk to Unborn) * Drug Detox * Counselor/Client Meetings « Distribute Condoms, Bleach * Support Group Meetings * HIV Counseling and Testing (AA, NA, etc.) * AIA Interview/AFA Follow-up « Make Referrals Treatment Component ® IVDUs in treatment for less than 30 days. Aftercare Component e IVDUs who have met the respective site criteria to move from intensive methadone treatment to a lower dosage within the aftercare support program. Methods Population This study, which was initiated in September 1987 as one of NIDAs first five ATOM contracts, is being conducted within three methadone programs in the Northeast: Institute of Human Development (IHD) in Atlantic City, New Jersey; Spectrum Health Care in Jersey City, New Jersey; and the Nassau County Department of Drug and Alcohol Addiction in East Meadow, New York. This particular ATOM contract targets IVDUs and their partners via methadone programs in order to implement AIDS-prevention education and risk-reduction efforts. IHD in Atlantic City, New Jersey, is a private, nonprofit organization that has been in operation for the past 20 years. This substance-abuse facility provides the following types of treatment: (1) outpatient drug free, (2) outpatient alcohol treatment, (3) outpatient methadone maintenance, (4) outpatient 21-day detoxification, (5) residential treatment services, and (6) a half-way house. IHD sees 425 clients daily. Spectrum Health Care, Inc., which is located in Jersey City, New Jersey and in Newark, New Jersey, is a private drug-treatment facility funded by the New 423 Jersey State Department of Health, CDC, NIDA, and Hudson County. This drug-treatment center presently has 1,000 clients and has been in operation for five years, providing outpatient heroin detoxification and methadone maintenance. The third methadone program, located in East Meadow, New York, at the Nassau County Medical Center, is part of the Nassau County Department of Drug and Alcohol Addiction Substance Alternative Clinic. They are funded for 420 client slots by the New York State Division of Substance Abuse. Drug treatment consists mainly of methadone maintenance, cocaine-addiction treatment, and aftercare, along with a variety of counseling groups offered for children of substance abusers (COSA), HIV-antibody- positive individuals, healthy ARC patients, cocaine users, etc. The sample upon which preliminary findings are reported includes 2,223 respondents from all three intervention sites: IHD (N=434); Spectrum Health Care (N=1,246); and Nassau County Department of Drug and Alcohol Addiction (N=543). The mean age of the respondents was 33, with a mean educational level of eleventh year of high school. Seventy-three percent of the sample were male, and 27% were female. Eighty percent were Black, 13% were White, and 7% Hispanic. Seventy-three percent were unemployed. Fifty-nine percent of the sample had never been married, 15% were married, 1% were living with a partner, 13% were separated, 10% divorced, and 2% were widowed. Fifty-three percent of the sample had no children; the remaining 47% had from one to five children. Design The Precede Model Planning and Evaluation Framework (Green et al. 1980) has been adapted to depict AIDS targeted interventions within substance-abuse or drug-treatment programs (Figure 2) (Green et al. 1980). The model provides an orderly planning approach to dealing with specific health problems, focusing on specific objectives and behaviors, and explicit health education. This ATOM program intervenes upon IVDUs and/or sexual partners of IVDUs in three northeastern cities to implement both AIDS-prevention education and HIV screening, testing, and pre- and post-test counseling. Procedures Participants are recruited by outreach workers at each of the three respective methadone sites to complete the AIA and to be interviewed by trained staff. The AIA questionnaire is an in-depth survey that takes approximately 45 minutes to complete. It assesses demographic characteristics, AIDS knowledge, and attitudes and behaviors related to drug-taking and sexual practices. The AIA consists of five major sections: demographics, health and AIDS, drugs, sex, and decreasing the risk of AIDS. Specific questions address such items as needle-sharing habits, drugs injected, cleaning or sterilizing works, specific things done to reduce the chance of transmitting HIV, sexual practices, and sources of AIDS-prevention information. After completing the AIA interview and HIV-antibody-test precounseling sessions, program participants have the opportunity to be screened and have blood drawn for the HIV-antibody test. Respondents are located via a written form six months after the initial contact to complete the AFA. This instrument contains questions from the AIA as well as items designed to assess the participant’s knowledge of AIDS risks and transmission and his or her assessment of the project. Table 1 shows the number and percent of AIA respondents according to site and target group. 424 Sy Figure 2. Precede Model Framework for the ATOM: Increasing the Capability of Methadone Programs in Three Northeastern U.S. Cities AIDS- Intervention Determinants of Behavior Impact Program Predisposing Factors - Knowledge - Attitudes - Beliefs - Values - Perceptions Motivation Communications: - IV Drug Users - Partners of IV Drug Users ATOM Sites Enabling Factors Preventive Behavior Adantic City, New Jersey |p| - Accessibility of - Safer Sex Practices Jersey City, New Jersey HIV Screening/ - Elimination of IV East Meadow, New York Education Drug Use and/or - Availability of Reduction in Needle Resources Sharing (counseling, etc.) - Skills (coping, etc.) Outcomes Health Problem Social Problem Reduction in —p| Reduction in - Transmission of HIV - Morbidity and Infection Mortality Rates - Incidence and from AIDS in the Prevalence of AIDS US. in the U.S. Intervention ———— p= Intermediate Variables —#» Behavioral Outcomes ——— gm» Health and Social Outcomes Adapted from Precede Model (Green, et al., 1980) ‘Table 1. Number and Percent of AIA Respondents by Site and Target Group -—Site/City Target Inst. for Human Spectrum Nassau Total Group Development Health Care County (Atlantic City, NJ) (Jersey City, NJ) (E. Meadow, NY) N % N % N % N % IVDU not in treatment 227 52.3 670 53.8 199 36.9 1,006 494 Sexual partner of IVDU 40 9.2 151 12.1 56 104 247 11.1 Prostitute wn ee 70 5.6 41 7.6 111 5.0 IVDU and sexual partner of IVDU 162 37.3 339 27.2 220 40.7 721 32.5 IVDU in treatment 2 0.5 15 1.2 24 4.4 41 1.8 Other 3 0.7 1 0.1 —— oe 4 0.2 Total 434 100.0 1,246 100.0 540 100.0 2,220 100.0 The major intervention strategy being implemented via outreach efforts is identified in Figure 3. Outreach workers distribute kits containing condoms and bleach, and pamphlets on AIDS- prevention education that include instructions on condom use, safer sex, cleaning and sterilizing needles and works, along with information on the risk of AIDS to the unborn child and other related matters. Outreach workers go to bars, poolrooms, laundromats, grocery stores, and other community gathering places to talk with individuals, build rapport, and assess their needs. The AIDS-intervention work taking place at each of the drug-treatment centers is explained by the outreach workers; efforts are made to interest individuals in participating in the research project by signing up for the AIA, along with voluntary HIV-antibody testing, which involves pre- and post-test counseling sessions. Participants are informed that they will receive $10-15 for taking the AIA, and that release of HIV-antibody-test results will entail signing a consent and release form. If a respondent also wants to enter drug treatment and has completed the AIA interview, he or she is given a coupon for free 21-day detoxification, and admission papers are completed. The client is then given an appointment card dated three weeks from the HIV test date to come in for their test results and post-test counseling. They are informed of the confidential nature of these counseling sessions. The meanings of positive and negative tests are explained, as are procedures to be followed if they are HIV-antibody positive or negative. If they are HIV-antibody negative, they are told that they should probably be tested again within three to six months. Participants who have their blood drawn receive a $10-15 payment. Respondents who return to the treatment center to fill out the AFA are paid $10-15 for their participation. At this time, necessary referrals are made or the client may be admitted to drug treatment, if he or she has not previously done so and now so desires. 426 Figure 3. Intervention Strategy for the ATOM Program: Increasing the Capability of Methadone Programs in Three Northeastern U.S. Cities Intervention Strategy 4 Outreach « Disseminate Risk-Reduction Materials (safer sex, needle cleaning, and risk to unborn Distribute Condoms, Bleach AIA Interview/AFA Follow -up HIV Counseling and Testing Make Referrals J J J Spectrum Nassau County IHD (Jersey City, N.J.) (East Meadow, N.Y.) (Atlantic City, N.J.) AIA/AFA HIV AIA/AFA HIV AIA/AFA HIV Evaluation Evaluation of the ATOM program includes both formative and summative procedures to assess the effectiveness of using methadone programs to reach IVDUs and their partners to promote the adoption of risk-reduction behaviors to stop the spread of AIDS. Process, impact, and outcome evaluation procedures are employed. Process evaluation is a qualitative form of assessment that involves staff (i.e., social workers, outreach workers) and the clients at each of the three methadone programs. It addresses the questions of Who? What? Where? When? and How? regarding the intervention-implementation process. This type of evaluation is important to the overall summative evaluation of the intervention effects. Impact evaluation, which documents short-term changes and reflects an assessment of specific program objectives, including changes in the participants’ knowledge, attitudes, beliefs, and behaviors, is employed via administration of the AIA/AFA interview questionnaires. Outcome evaluation, which generally assesses long- term, generalizable results of program operations and determination of the reduction of clinical risk factors, can be assessed via HIV-antibody testing and counseling. 427 Results AIA A total of 2,688 AIAs have been completed across all sites, with the following breakdown: Spectrum Health Care (N=1,444); IHD (N=624); and Nassau County Department of Drug and Alcohol Addiction (N=620). Of the 2,688 AIAs completed, data have been analyzed for certain items on 2,223 questionnaires. Responses for all three sites (N=2,223) related to knowledge of HIV transmission and the participant’s reply to the question “What are the ways people get AIDS?” included the following results as far as drug-taking behavior: 63% mentioned needle sharing, 28% mentioned sharing works, 43% mentioned the need to clean both needles and works, and 14% mentioned to avoid injecting drugs. With regard to the question on behavior changes made to reduce the risk of AIDS, Table 2 shows the results across all sites to the following inquiries: (1) Have changes been made? (2)What type of changes have been made? and (3) Have you maintained the changes? Approximately 80% of the total sample indicated “changes had been made.” In looking at the specific types of changes, 16 behavioral examples are given, whereby the participants identified the degree to which they had implemented behavior changes (i.e., stopped doing, doing less, etc.). The highest percentage (39.5%) noted that they had stopped needle sharing but had not reduced IV drug use. Approximately the same percentage (39%) revealed they were using safer sexual practices more often. Another noteworthy change, even though relatively low, was the fact that approximately 20% stated they were cleaning their needles more often. As far as behavioral maintenance, 55.1% of the sample indicated that they had “totally” maintained their behavioral changes regarding drug-taking and sexual practices. Approximately 30% stated they had “largely” maintained their changes with respect to high-risk drug-taking and/or sexual behaviors. Only 2% of the sample said that they had reverted back to old or high- risk behaviors. Results to the AIA question “Have you ever injected drugs?” were reported in the following manner: 91.6% answered “yes” at IHD (N=395); 92.1% responded “yes” at Spectrum Health Care (N=1,108); and 91.4% said “yes” in Nassau County (N=390). Findings across all three methadone programs revealed that 91.8% of the individuals had injected drugs. In response to the question “Have you changed the way you clean needles?” 61.4% of the Atlantic City sample responded “yes,” 48.1% in Jersey City said they had changed the way they clean needles, and 44.6% in East Meadow gave a positive response. Thus, for all three methadone sites, approximately 50% had changed their needle-cleaning behavior. Regarding the question “Do you share works?” 33.3% of the total sample (N=2,020) reported “yes.” On this particular item, as seen in Table 3, there was some difference between the respondents in Atlantic City, and those at the other two sites. At the Atlantic City site, 63.4% reported they shared works, while a much lower percentage, 22.8% and 30.9%, respectively, reported the “sharing of works” in Jersey City and East Meadow. 428 Table 2. Behavior Changes Made To Reduce AIDS Risk" (expressed in percent) Stopped Do Do Just No Type of Changes Made Doing Less More Mentioned Mention Seek medical advice 0.6 1.9 5.6 4.7 87.2 Sex with homosexual partner 1.1 0.8 0.1 5.0 93.0 Sex with heterosexual partner 3.0 13.9 34 1.0 78.6 Sex with IVDU heterosexual partner 5.6 8.3 1.2 2.3 82.7 Sex with people who look healthy 1.7 3.8 6.3 2.0 86.2 Sex with people whose behavior I know 2.5 4.1 8.0 24 83.0 Use of safer sex practices 39 1.6 39.0 8.7 46.8 IV drug use 5.0 13.1 1.7 1.0 79.2 Needle sharing—no reduced IV drug use 39.5 12.7 0.8 1.9 45.2 Needle Sharing—reduced IV drug use 9.8 7.1 0.6 1.7 80.7 Going to shooting galleries 94 23.1 0.2 1.7 85.7 Social contact with other drug users 2.7 8.8 1.9 1.9 84.8 Social contact with homosexuals 1.7 14 0.2 4.5 92.2 Cleaning needles 24 2.6 21.6 6.2 67.2 Cleaning needles more effectively 1.8 1.7 11.1 3.5 81.9 Other (N=131) —— ee _ uy — Question Totally Largely Some A Little No Have you maintained the changes? 55.1 30.2 8.3 4.5 2.0 Of the 2,169 participants interviewed, 79.7% (N=1,728) of the respondents answered “yes” to the question “Have changes been made?” and 23.3% (N=441) answered “no.” Table 2 is based on responses of the 1,728 individuals who reported making changes to reduce AIDS risk. Table 3. Number and Percent of AIA Respondents by Site and “Works-Sharing” Share Works Do Not Share Works Total Site/City N (%) N (%) N (%) Institute for Human Development (Atlantic City, NJ) 267 (63.4) 154 (36.6) 421 (100.0) Spectrum Health Care (Jersey City, NJ) 252 (22.8) 852 (71.2) 1,104 (100.0) Nassau County (East Meadow, NY) 153 30.9) 342 (69.1) 495 (100.0) Total 672 (33.3) 1,348 (66.7) 2,020 (100.0) 429 In response to the question “Have you changed your sexual practices or behaviors?” 40.1% of the Atlantic City sample reported “yes” (Table 4), while 56.3% from Jersey City and 53.9% from East Meadow indicated a change in sexual practices. Approximately 50% of the total sample indicated a change in their sexual behavior. When asked “What is your most trusted information source on AIDS?,” 26.9% of the total sample indicated “television,” 18.9% responded “brochure or poster,” 14.6% said “newspapers or magazines,” 15.5% said “treatment program,” and 24.1% noted “other.” Table 4. Number and Percent of AIA Respondents by Site and Sexual Practices Have you changed your sexual practices? Site/City Yes No Total N (%) N (%) N (%) Institute for Human Development (Atlantic City, NJ) 173 40.1) 258 (59.9) 431 (100.0) Spectrum Health Care (Jersey City, NJ) 685 (56.3) 532 43.7) 1,217 (100.0) Nassau County (East Meadow, NY) 277 (53.9) 237 (46.1) 514 (100.0) Total 1,135 (52.5) 1,027 (47.5) 2,162 (100.0) HIV-Antibody Testing Figure 4 shows the number of individuals who have voluntarily participated in HIV-antibody testing, the number of respondents returning for their test results, and seroprevalence rates for each of the methadone programs. The return rates for Jersey City and East Meadow are very low (approximately 10%), while in Atlantic City, nearly 50% returned for their test results. Low return rates for HIV-test results are common and can be attributed to a variety of factors, including individual reasons (e.g., fear, denial), as well as other variables, such as personnel, procedures, and quality of pre- and post-test counseling. Descriptive data regarding the initial HIV-antibody-test results, as noted in Figure 4, will be reported for the Jersey City intervention site. As of October 1989, 447 individuals had received HIV-antibody testing and counseling in the Spectrum Health Care program. In examining the Spectrum HIV-test results matched to the AIA questionnaires and analyzed to date, a sample of 314 participants was derived. An analysis of the demographics of this sample revealed that the highest percentage of seropositive individuals (41.8%) were between 30 and 34 years of age and the next-highest number of HIV-positives (30.7%) were in the 35-39 age group. Eighty-three percent (127) HIV-test respondents who were seropositive were male; 24 (15.7%) females were HIV-antibody positive. Among the 152 seropositive persons, 82.1% were Black, 8.6% were White, and 7.9% were Hispanic, with the remaining either Native American or Other. Sixty-one percent of those who were seropositive had 10-12 years of education (high school), and 20.3% had more than a high-school education. Fifty-nine percent of those classified as HIV-antibody 430 Figure 4. HIV-Antibody Test: Preliminary Results across Three Sites NUMBER TESTED Spectrum Nassau County HD (N=447) (N=450) (N=618) NUMBER RETURNING FOR HIV TEST RESULTS NA Ne ly Spectrum Nassau County IHD N=43 N=40 N=328 SEROPOSITIVE RATES SL \/ Jy Spectrum Nassau County IHD 46% 24% 34% 431 positive had never been married, 15% were separated, 9.2% were divorced, and 6.5% widowed. Among the seropositive individuals, 61.8% had no children, while 38.2% reported having one or more children. Summary and Conclusions IVDUs are the second-largest group of individuals to be infected with HIV in both the United States and Europe. Since there are an estimated 1.1 to 1.3 million IVDUs in the United States, the implications for the potential threat of HIV infection via both heterosexual and perinatal transmission are enormous. Because both New York and New Jersey are high-prevalence regions for IV drug use, NIDA has funded AIDS-intervention research projects in these regions. This paper has described the NIDA-funded contract, AIDS Targeted Outreach Model: Increasing the Capability of Methadone Maintenance Programs in Three Northeastern Cities. An overview of program components, goals, and objectives has been presented, and specific interventions and evaluation procedures at the three methadone sites (Spectrum Health Care, Jersey City, New Jersey; Institute for Human Development, Atlantic City, New Jersey; and Nassau County Department of Drug and Alcohol Addiction in East Meadow, New York) have been delineated. Some preliminary findings regarding the initial AIA and HIV-antibody-test results have also been provided. Based upon these results, it is concluded that AIDS and drug-abuse prevention are complex, multidimensional issues, requiring an increasingly expanding role for drug- treatment facilities throughout the United States. ATOM programs, such as the methadone- maintenance model, are vital in stopping the spread of HIV and AIDS. References Centers for Disease Control. HIV/AIDS Surveillance Report, December 1989: pp. 1-16. Craven, D.E. AIDS in intravenous drug users. In: Kulstad, R., ed. AIDS 1988 AAAS Symposia Papers. Washington, D.C.: The American Association for the Advancement of Science, Pub. No. 88-19, 1988. Curran, J.W.; Jaffe, H.W.; Hardy, A.M.; Morgan, W.M.; Selik, R.M.; and Dondero, T.J. Epidemiology of HIV infection and AIDS in the United States. Science 239: 610-616, February 1988. Des Jarlais, D.C., and Friedman, S.R. HIV infection among persons who inject illicit drugs: Problems and prospects. J Acquired Immune Deficiency Syndromes 1(3): 267-273, 1988. Des Jarlais, D.C.; Friedman, S.R.; and Hopkins, W. Risk reduction for the acquired immunodeficiency syndrome among intravenous drug users. Ann Intern Med 103: 755- 759, 1985. Des Jarlais, D.C.; Friedman, S.R.; Novick, D.M.; Sotheran, J.L.; Thomas, P.; Yancovitz, S.R.; Mildvan, D.; Weber, J; Kreek, M.J.; Maslansky, R.; Bartelme, S.; Spira, T.; and Marmor, M. HIV-1 infection among intravenous drug users in Manhattan, New York City, from 1977 through 1987. JAMA 261: 1008-1112, 1989. 432 Des Jarlais, D.C.; Friedman, S.R.; and Stoneburner, R.L. HIV infection and intravenous drug use: Critical issues in transmission dynamics, infection outcomes, and prevention. Rev Infect Dis 10(1): 151-158, 1988. Des Jarlais, D.C.; Wish, E.; Friedman, S.R.; Stoneburner, R.; Yancovitz, S.R.; Mildvan, D.; El-Sadr, W.; Brady, E.; and Cuadrado, M. Intravenous drug use and the heterosexual transmission of the human immunodeficiency virus: Current trends in New York City. NY State J Med 87(5): 283-286, 1987. Galea, R.P.; Lewis, B.F.; and Baker, L.A. A model implementing AIDS education in a drug abuse treatment setting. Hosp Community Psychiatry 39(8): 886-888, 1988. Green, L.; Kreuter, M.; Deeds, S.; and Partridge, K.B. Health Education Planning: A Diagnostic Approach. Palo Alto, California: Mayfield Publishing Company, 1980. Report of the Second Public Health Service AIDS Prevention and Control Conference. Executive Summary. Public Health Rep 103, Supplement No.1 (Revised): 3-9, November 1988. Smith, D.C. The role of substance abuse professionals in the AIDS epidemic. Adv Alcohol Subst Abuse 7(2): 175-195, 1987. Acknowledgments Supported by the National Institute on Drug Abuse Contract #271-87-8210. Authors Ann M. Downey, M.S., Ph.D. Project Director Willie H. Davis, M.B.A. Principal Investigator Hillard Davis, M.S. Statistician Tina Stackhouse, B.S. Administrative Assistant Fred Royster, B.S. Data Entry and Analysis Birch & Davis Associates, Inc. 8905 Fairview Road Suite 300 Silver Spring, MD 20910 433 PRELIMINARY FINDINGS: CHANGES IN DRUG USE, NEEDLE USE, AND SEXUAL BEHAVIOR AMONG INTRAVENOUS DRUG USERS George R. Reinhart and Arlen M. Rosenthal Introduction This paper presents some preliminary results from the first two years of the AIDS Outreach to Therapeutic Community Contacts and Clients contract awarded to Marathon Corporation in Providence, Rhode Island. The project is being conducted at three different therapeutic communities (TCs): Marathon House, located in Providence; Project Return in New York City; and Second Genesis in Washington, D.C. Macro Systems is responsible for data entry, data processing, and data analyses for all three sites. Data collection for this project began in February 1988. Nearly 3,000 intravenous drug users (IVDUs) and their sexual partners (SPs) have now been enrolled in the program. Data were collected at each site using the National Institute on Drug Abuse’s (NIDA) AIDS Initial Assessment (AIA) questionnaire, the AIDS Follow-up Assessment (AFA) questionnaire, and an instrument developed by the TC project staff that documents the implementation of 18 forms of intervention performed by outreach workers. Therapeutic communities are logical places to spearhead the AIDS intervention effort with IVDUs. Oftentimes, treatment programs are the only resource to which a drug user can turn for help, regardless of the problem. TC staff understand addicts, and staff members who are former addicts make good role models. Staff have extensive contact with drug-dependent people— those in treatment as well as those on the street. The TC serves more than just its residents. TCs reach out to the community and have an impact on users who: (1) are not able or willing to become residents; (2) are on waiting lists to enter the TC; (3) had been residents but dropped out of the program; (4) contact the program but have not sought treatment; and (5) are at risk in the community known by residents and staff. Our preliminary results are promising. They show that the intervention programs and practices developed and implemented by the project have a positive impact on the participants. Generally speaking, the preliminary results indicate that the level of high-risk behavior for human immunodeficiency virus (HIV) infection and transmission has been reduced, and that these reductions correlated positively with the length of the intervention. 434 The Intervention Model The intervention model consists of 18 modules. Developed by staff following NIDA and Centers for Disease Control (CDC) guidelines on acquired immune deficiency syndrome (AIDS) risk reduction and incorporating a special knowledge of the drug subculture developed through the working relationship with IVDUs that occurs within TCs, these modules include: Injected drug use and AIDS Needle hygiene Sexual transmission of HIV Safe and unsafe sexual practices Reinoculation Pediatric AIDS Drugs and alcohol and AIDS Nutrition Stress reduction Pregnancy and AIDS Symptoms of AIDS Health cofactors and AIDS Diseases of AIDS HIV testing HIV infection Drug cofactors and AIDS Use of good judgment Virology. Some modules were used more frequently than others. For example, those on injected drug use and AIDS, sexual transmission, and safe/unsafe sexual practices were very popular. The median length of intervention for these modules was one-half hour. Each participant generally takes part in five intervention sessions, for a total of five hours of intervention. However, the amount of intervention ranged from one hour to over nine hours, and the number of intervention sessions ranged from one to seven. Demographic Characteristics This report is a preliminary analysis of the 242 participants for whom AIA, AFA, and intervention data have been collected. These data are new—some of the AFA and intervention data are less than a month old. Although the data represent participants from all three sites, this preliminary analysis will not detail differences among sites. Of the 242 participants, 70% were male. The majority (64%) of the respondents were Black. Twenty-one percent were White, 13% were Hispanic, and 2% were Asian or Native American. The participants ranged in age from 18 to 55 years. One percent were in their teens, 22% were in their twenties, 60% were in their thirties, 12% were in their forties, and 5% were 50 years or older. Fifty-seven percent of the respondents reported that they had received less than a high- school education, 25% reported that they had completed high school, and 4% had taken some college courses. 435 Only 23% of these respondents said that they were employed at the time of the AIA interview. Nearly two-thirds (65%) were unemployed, and 12% were not in the labor force. At the time of the AFA interview, 32% of the respondents were working and 59% were unemployed. At the time of the AFA interview, 33% of the respondents were living in their own houses, and 41% were living in another person’s house or a boarding house. Eight percent were in shelters, 1% were homeless, and 16% were living in another place, most often as residents of a TC. Just over one-third of the respondents were in some form of drug treatment at the time of the AFA interview, and many had been in treatment for some time since their AIA interview (Table 1). Several respondents indicated that they were on waiting lists for various forms of treatment. Table 1. Respondents Currently in Detoxification Type of Program Number of Clients Detoxification units 20 Therapeutic Communities 33 Jail-based program 4 Methadone-maintenance program 18 Outpatient or other type of program 7 Changes in Drug Use There was a considerable decrease in drug use between the administration of the AIA and the AFA. The number of people who reported having injected drugs of any kind decreased from 180 (75% of all respondents) to 114 (47% of all respondents). In addition, the percentage of active drug injectors who reported using daily or more frequently decreased between the administration of the AIA and the AFA for all major injected drugs (Table 2). Table 2. Percentage of Respondents Injecting Drugs Daily or More Frequentlyat Time of AIA and AFA AIA Percentage AFA Percentage Injected Drug Injecting Daily Injecting Daily Heroin 51 47 Cocaine 38 19 Speedball 34 23 436 At the time of administration of both the AIA and AFA, nearly every participant used some form of noninjected drug. However, just as with injected drugs, there was a substantial decrease in the percentage of daily or more frequent users of major noninjected drugs (Table 3). Table 3. Percentage of Respondents Using Noninjected Drugs Daily or More Frequently at Time of AIA and AFA AIA Percentage AFA Percentage Noninjected Drug Using Daily Using Daily Alcohol 34 30 Marijuana 12 5 Crack 42 19 Cocaine 23 9 When interpreting these data, it is important to keep in mind that 33 respondents (14%) were in a drug-free residential treatment facility at the time of the AFA and that others may have spent time in drug-free treatment during the interval between the AIA and AFA. Nevertheless, these data demonstrate a substantial decrease in drug use for persons who fully participated in the program. Changes in Needle Use and Hygiene The changes in patterns of needle use and needle hygiene between the AIA and AFA do not reflect the changes in injected drug use. In fact, if percentages were used to display these data, the message given would be misleading. At the time of the AIA, 180 respondents (75%) were active needle users. By the time the AFA was administered, the percentage of needle users had dropped to 47% (114 active users). There was little change in the number of persons who borrowed or rented needles between the AIA and AFA. Instead, these data indicate that there is a “hard core” of drug users who have not changed their needle-use behavior (Table 4). Table 4. Number of Injectors by Type of Frequent Needle Use AIA No. Doing AFA No. Doing Type of Needle Use 50% or more 50% or more Renting needles 19 19 Borrowing needles 24 34 Sharing cooker 71 57 Sharing rinse water 60 52 Using sterile needles 55 47 Using legal needles 29 3 437 At the time of the AIA, 100 (55%) persons reported cleaning their works with any frequency. At the time of the AFA, only 57 (50%) persons reported cleaning their works. Most respondents reported using multiple methods of needle hygiene at both questionnaire administrations. There were very few differences in patterns of needle hygiene. Changes in Patterns of Sexual Behavior At the time of the AIA questionnaire administration, 86% of males and 95% of females we.e engaged in some form of sexual activity. For three-fourths of the sexually active males and two- thirds of the sexually active females, this sexual activity consisted of a relatively monogamous relationship with a partner of the opposite sex and a few sexual encounters with friends and acquaintances. A small number of both men and women engaged in prostitution, although females were much more likely than males to engage in this behavior. Nearly 60% of the males and over three-fourths of the sexually active females engaged in sex with known IVDUs. The level of condom use was very low for both sexes; only 16% of males and 15% of females reported using condoms half the time or more frequently. At the time of the AFA, the level of sexual activity of the 242 respondents had dropped. Only 64% of the respondents reported engaging in any sexual activity since the administration of the AIA. Most (63%) active respondents reported having only one sexual partner; only 14% reported having four or more sexual contacts. It should be noted that 33 respondents were in residential treatment at the time of the AFA and an additional 63 persons had taken part in some residential treatment since the administration of the AIA. At the time of the AFA administration, only one-third of the respondents reported that their sexual partner injected drugs, and 57% reported using condoms half the time or more frequently. These data indicate that there had been a 32% reduction in the level of sexual activity with IVDUs and a 41% increase in condom use since the administration of the AIA. The Impact of the Intervention on Changes One of the working hypotheses of this project was that each module would have a different impact on changes in participant behavior. For example, increased exposure to the module on injected drug use and AIDS, we hypothesized, would produce a decrease in injected drug use. The modules on sexual transmission and safe/unsafe sex practices were hypothesized to modify sexual practices. However, this hypothesis has not been demonstrated by these preliminary data. Although individual modules did not seem to have an impact on any specific behaviors, the impact of the total intervention did have a positive effect on some participant outcomes. Generally speaking, the longer the time of the total intervention, the greater the positive change. For example, for injected heroin, cocaine, speedball, and other drugs, increased intervention was associated with decreased use. For alcohol, crack, marijuana, and other noninjected drugs, there was a similar relationship. Only in the case of noninjected cocaine was this pattern absent. For this analysis, the data were aggregated into ordinal measures and associations measured by Kendall’s Tau C. Although many of the associations were not statistically significant, they were in the predicted direction. 438 The same relationship held true for renting and borrowing used needles, and sharing cookers and rinse water. However, it did not hold true for any form of needle hygiene. In addition, there was no clear relation between the length of intervention and safer sex practices. We are encouraged by these preliminary findings, which show that the participants in the project, nearly all of whom were active IVDUs when they were introduced to the program, eliminated or reduced both their injected and noninjected drug use. Furthermore, these preliminary data indicate that the level of intervention is positively related to these changes. Acknowledgment Supported by the National Institute on Drug Abuse Contract # 271-87-8211. Authors George R. Reinhart, Ph.D. Associate Arlen M. Rosenthal, M.A. Consultant Macro Systems, Inc. 8630 Fenton Street Silver Spring, MD 20910 439 BEHAVIOR CHANGE IN SEXUAL PARTNERS OF INTRAVENOUS DRUG USERS (IVDUs) H. Virginia McCoy Introduction The objectives of Miami’s community-outreach program for female sexual partners are: (1) to decrease human immunodeficiency virus (HIV)-transmission risk behaviors, such as frequency of risky sexual practices and the number of sexual partners; and (2) to increase safer sex practices. Sexual partners and intravenous drug users (IVDUs) participate in either a standard or enhanced program, which provides pre- and post-HIV-test counseling sessions as well as a packet of informational brochures about AIDS, drug treatment, and health. Those who participate in the enhanced program attend three intensive group-counseling sessions conducted over a two-week period. Previous studies have indicated that intervention programs could be successful in increasing the knowledge of IVDUs (Ginzburg et al. 1986; Lewis and Galea 1986), homosexuals (Turner et al. 1989), and the general population, such as college students (Edgar et al. 1988). This paper will present data on behavioral changes that have occurred following structured intervention for 148 female sexual partners who have participated in our program. The same 148 females are represented in both the baseline and follow-up data. Knowledge Table I shows that out of a possible score of 16 on a knowledge test, female sexual partners at initial assessment scored a mean of 11.0; six months following the intervention, they scored a mean of 13.6. The overall score improved by three questions, with much less spread, by the follow-up time period. We were interested specifically in female sexual partners’ knowledge about sexual activities and about their partners’ drug use. Table 2 shows that they improved their knowledge about sex- related risks for HIV in each of four areas: (1) having a single partner; (2) use of latex condoms; (3) unprotected sex with a partner who was HIV-antibody-positive; and (4) sex with bisexuals. The one exception is the safety of oral sex. Table 3 reflects knowledge of drug-related risks for HIV among those women who did not themselves inject drugs. Improvements in their knowledge about using water and bleach to kill the virus and sharing works were seen over the six-month period. There was no improvement in their knowledge about sealed works. It is interesting to note that all of the women correctly answered the question about sharing works with someone who is HIV-antibody-positive. 440 Table 1. Total Score on AIDS Quiz' Measure Baseline Follow-Up Mean 11.0 13.6 Median 11.0 14.0 Mode 11.0 14.0 Standard Deviation 2.2 1.6 THighest possible score = 16. Table 2. Knowledge of Sex-Related Risks for HIV Transmission Baseline Follow-Up Sex-Related Risks N (%) N (%) One Partner—Can’t Get AIDS Answered correctly 105 (70.9) 127 (85.8) Answered incorrectly 43 (29.1) 21 (142) Latex Condom—Can’t Get AIDS Answered correctly 103 (71.0) 128 (86.5) Answered incorrectly 45 (29.0) 20 (13.5) Oral Sex—Can’t Get AIDS Answered correctly 108 (76.6) 97 (65.5) Answered incorrectly 40 (234 51 (345) Sex and Bisexuals—Get AIDS Answered correctly 135 (95.7) 139 (93.9) Answered incorrectly 13 4.3) 9 (6.1) Unprotected Sex with Persons with AIDS—Get AIDS Answered correctly 144 (97.3) 146 (98.6) Answered incorrectly 4 2.7 2 (1.4) Table 3. Knowledge of Drug-Related Risks for HIV Transmission Baseline Follow-Up Drug-Related Risks N (%) N (%) Sealed Works } Answered correctly 116 (80.0) 97 (65.5) Answered incorrectly 29 (20.0) 51 (345) Water for Works—XKills AIDS Answered correctly 127 (88.8) 145 (98.0) Answered incorrectly 16 (11.2) 3 (2.0) Bleach for Works—XKills AIDS Answered correctly 59 (444) 122 (824) Answered incorrectly 74 (55.6) 26 (17.6) Sharing Works with Persons with AIDS—Get AIDS Answered Correctly 142 (97.3) 148 (100.0) Answered Incorrectly 4 2.7 0 (0.0) 441 Sexual Behavior Changes Having specific knowledge about risk-reduction activities is not sufficient to change behaviors, especially complex behaviors (Meichenbaum 1977) or multiple-risk behaviors. Therefore, specific skills are taught in our intervention to enable the client to apply risk-reduction behaviors (Becker and Joseph 1988). These skills include how to correctly use condoms, how to negotiate the use of condoms with a partner, encouragement to reduce the number of sexual partners, and instruction in using safer sex practices. The proportion of sexual partners who use condoms is increasing (Table 4). This is consistent with other studies that show that other populations increase their use of condoms after they have been instructed in the proper techniques (Padian et al. 1987). Turner et al. (1989) have hypothesized that the reasons that some women do not use condoms are that they or their partners don’t like to use them. About half of the women in both groups give this as a reason for failure to always use condoms. There was very little change over the six-month period occurring in the number of women who reported not using condoms because of their own dislike of them. However, the proportion who reported that their partners don’t like using condoms increased by 10%. On the positive side, we might attribute the increase to the fact that more sexual partners are attempting to negotiate use of condoms with their partners and finding out they don’t like them. The number of sexual partners has decreased over the six-month period. The mean number at initial assessment was 3.9; at follow-up, 3.0. More than half of the female sexual partners in our study now report having no IVDU partners, while almost half have one non-IVDU partner (Table 5). Both are major increases over the previous six months. Sexual practices with little or no risk increased, while those with the most risk decreased (Table 0), not taking into account the IVDU status of the partner. For example, at baseline, three women practiced vaginal sex with a condom. This increased to 29 at follow-up, representing an improvement in this behavior. Most of the population practice vaginal sex without a condom, but this decreased from 91 to 78 by follow-up. Almost half (49.3%) improved the use of less- risky sexual practices. Table 6 also implies an increase in the use of condoms for various sexual practices. The previous discussion centered on the objectively observed changes that have occurred over the six-month period. We also asked the sexual partners whether they believed they had made changes in their sexual practices and what these changes were. There were 104 self-observed changes in sexual behaviors (Table 7), and only the decrease in use of condoms is a definite negative change. The vast majority of the changes made were in the direction of safer sex. The increase in sexual activity reported by two people does not necessarily indicate unsafe sexual practices. As indicated in Table 8, 63 sexual partners credited our project with some change in sexual behavior, and 73 changes were reported, indicating that some respondents reported more than one change. A decrease in sexual activity (34.2%) or changing partners (15.1%) were reported most often. All of the reported changes were toward safer sexual activities. 442 Table 4. Condom Use by Female Sexual Partners Baseline Follow-Up Condom Use Frequency N (%) N (%) Never 9% (64.9) 64 (43.2) Ever 52 (35.1) 84 (56.8) Female Sexual Partners’ Attitudes toward Condoms Baseline Follow-Up Attitudes N (%) N (%) Self Dislike 73 (49.3) 76 (51.4) No dislike reported 75 (50.7) 72 (48.6) Partner Dislike 66 (44.6) 82 (554) No dislike reported 82 (554) 66 (44.6) Table 5. Injection Partners’ No. of Partners Baseline Follow-Up 0 1 88 1 123 48 2 24 12 164.4% improved this behavior and 7.3% declined. (Calculated by determining the number eligible to improve [decline].) Noninjection Partners’ No. of Partners Baseline Follow-Up 0 98 40 1 22 72 22 28 36 37.3% improved this behavior and 60.8% declined. (Calculated by determining the number eligible to improve [decline].) 443 Table 6. Sex-Risk Behaviors of Female Sexual Partners’ Sexual Behavior Baseline Follow-Up No Risk Behavior 10 13 Vaginal—with Condom 3 29 Vaginal and Oral—with Condom 2 8 Vaginal—No Condom 91 78 Vaginal and Oral—No Condom 29 12 Anal—with Condom 2 1 Anal—No Condom 11 7 149.3% improved this behavior and 10.2% declined. (Calculated by determining the number eligible to improve [decline].) Table 7. Self-Assessment of Change in Sex Life at Six- Month Follow-Up’ Sexual Behavior Change N % Changed sex practices (not specified) 45 43.3 Increased sex 2 1.9 Decreased sex 19 18.3 Changed type of sex 10 9.6 Started using condoms 8 7.7 Increased use of condoms 9 8.7 Decreased use of condoms 1 1.0 Changed partners 4 3.8 Decreased number of partners 6 5.7 Total 104 100.0 fCategories are not mutually exclusive. Table 8. Perceived Changes in Sex Life Due to This Program at Six-Month Follow-Up! Sexual Behavior Change N % Stopped sex 7 9.6 Decreased sex 25 34.2 Started using condoms 7 9.6 Increased condom use 7 9.6 Changed partners 11 15.1 Decreased partners 9 12.3 Changed practices 7 9.6 Total 73 100.0 Categories are not mutually exclusive. Drug-Use Behavior Changes Table 9 indicates the level of use of noninjected drugs, comparing those who had not used drugs in the previous six months with those who had used drugs, at least with some low frequency, in the previous six months. A decrease in drug-using behavior occurred for all drugs except alcohol. One particular note is the reduction of about one-third of cocaine use among women. Of the 56 women who responded to the questions about their self-assessment of changes in noninjected drug use, only seven indicated a change toward increased drug use, as shown in (Table 10). Forty-eight indicated they had decreased or stopped using drugs altogether. Forty respondents reported that their drug use had changed because of our project. Table 11 shows that 87.5% of them decreased their drug use. Table 9. Noninjected Drug Use by Female Sexual Partner Baseline Follow-Up Drug Use N (%) N (%) Alcohol Did not use in previous six months 30 (21.6) 30 (21.9) Used in previous six months 109 (78.4) 107 (78.1) Marijuana Did not use in previous six months 36 (27.5) 55 (423) Used in previous six months 95 (72.5) 75 (57.7) Crack Did not use in previous six months 41 (43.2) 48 (50.5) Used in previous six months 54 (56.8) 47 (49.5) Cocaine Did not use in previous six months 51 47.7) 75 (70.1) Used in previous six months 56 (52.3) 32 (299) 445 Table 10. Self-Assessment of Change in Noninjected Drug Use at Six-Month Follow-Up’ Drug Use Changes N % Stopped use 10 17.9 Decreased use 38 67.9 Increased use 7 12.5 Other 1 1.8 Total 56 100.1% fCategories are not mutually exclusive. $Categories add to more than 100% due to rounding. Table 11. Perceived Changes in Drug Use due to NADR Program Information at Six-Month Follow-Up! Drug-Use Change N % Stopped drug use 3 7.5 Stopped noninjected use 2 5.0 Decreased use 35 87.5 Total 40 100.0 Categories are not mutually exclusive. Conclusion These preliminary data indicate some very positive behavioral changes among female sexual partners, over the short run, in both sexual activities and drug-using activities. It is important that our project provide an intervention that produces positive changes in HIV risk-reduction activities. Table 12 gives us an early indication that the information we provide is being presented in such a way that it is being retained for six months. In every category, more than two-thirds and, more often, more than three-quarters of the female sexual partners believe they learned about sex practices, needle cleaning, and viral spread from our project. They also indicated that they had obtained useful information about AIDS and the HIV-antibody test, as well as about their own personal risks and those to their unborn children. 446 Table 12. Perception of Project Information Received at Six-Month Follow-Up N %_ Information on transmission of virus to unborn Yes 111 75.0 No 37 25.0 Information on condom use Yes 128 86.5 No 20 13.5 Information on safer sex Yes 113 76.4 No 35 23.6 Information on cleaning needles Yes 123 83.1 No 25 16.9 Description of AIDS Yes 112 75.7 No 36 24.3 Information on infections Yes 102 68.9 No 46 31.1 Information on how virus is spread Yes 122 82.4 No 26 17.6 Recognizing own risk Yes 111 75.0 No 37 25.0 Facts about HIV testing Yes (105) 70.9 No 43) 29.1 Information on project help Yes (123) 83.1 No 25) 16.9 Information on community services Yes 96) 64.9 No 52) 35.1 References Becker, M.H., and Joseph, J.G. AIDS and behavior change. Public Health Rev 16: 1-11, 1988. Edgar, T.; Freimuth, V.S.; and Hammond, S.L. Communicating the AIDS risk to college students: The problem of motivating change. Health Educ Res 3(1): 59-65, 1988. Ginzburg, HM; French, J.; Jackson, J.; Hartsock, P.I; MacDonald, M.G.; and Weiss, S.H. Health education and knowledge assessment of HTL V-III diseases among intravenous drug users. Health Educ Q 13(4): 373-382, 1986. Lewis, B.G., and Galea, R.P. A survey of the perception of drug abusers concerning the Acquired Immune Deficiency Syndrome (AIDS). Health Matrix 4(2): 14-17, 1986. 447 Meichenbaum, D. Cognitive Behavior Modification: An Integrative Approach. New York: Plenum, 1977. Padian, N.; Marquis, L.; Francis, D.P.; Anderson, R.E.; Rutherford, G.W.; O’Malley, P.M.; and Winkelstein, W. Male-to-female transmission of human immunodeficiency virus. JAMA 258: 788-790, 1987. Turner, C.F.; Miller, H.G.; and Moses, L.E. AIDS Sexual Behavior and Intravenous Drug Use. Washington, D.C.: National Academy Press, 1989. Acknowledgment Supported by the National Institute on Drug Abuse Grant #5R 18DA05349-03. Author H. Virginia McCoy, Ph.D. Community Coordinator Health Services Research Center University of Miami Schoo! of Medicine Community Outreach Project Medical Arts Building, Room 309 1550 NW 10th Avenue Miami, FL. 33136 448 BEHAVIOR CHANGES OF INTRAVENOUS DRUG USERS AFTER AN INTERVENTION PROGRAM Dale D. Chitwood, Mary Comerford, Elizabeth L. Khoury, and Judith A. Vogel Introduction There is a clear and critical need to target intravenous drug users (IVDUs) with risk-behavior reduction programs that seek to reduce injection- and noninjection-drug-use behaviors and sexual behaviors that place those users at high risk for exposure to human immunodeficiency virus (HIV). In the absence of an effective biomedical intervention or vaccine, the cessation/reduction of risk behaviors is the only method we have to retard the spread of HIV- related disease. Specific high-risk needle-use behaviors that have been found to be associated with HIV seroprevalence among IVDUs include frequency of injection (D’Aquila et al. 1989; Marmor et al. 1987; Schoenbaum et al. 1989; Brown et al. 1989), frequency of sharing needles (Chaisson et al. 1989; Schoenbaum et al. 1989), and use of shooting galleries (D’Aquila et al. 1989; Marmor et al. 1987; Schoenbaum et al. 1989; Chitwood et al. 1990). An increased number of sexual partners has also been associated with HIV seropositivity among IVDUs (D’Aquila et al. 1989; Schoenbaum et al. 1989). IVDUs who are not in treatment are at particularly high risk for acquiring and/or transmitting HIV and other retroviruses. It is estimated that at any given time, there are several IVDUs who are not in treatment for every one who is in treatment (National Institute on Drug Abuse [NIDA] 1990). For IVDUs who cannot or will not enter drug treatment, it is essential that strategies to reduce the risk of HIV infection to themselves and to others be developed, implemented, and evaluated. The risk-reduction demonstration project in Miami was one of the initial NIDA Community Outreach Research Demonstration Sites that was funded to address this public-health crisis (McCoy et al. 1990). The purpose of this paper is to assess whether there has been a reduction in risk behavior among IVDUs who are participating in the Miami intervention project. Methods IVDUs who had not been in a treatment program for the last six months were recruited from the “street” by outreach workers. All IVDUs who agreed to participate were evaluated at an AIDS assessment center. After securing informed consent, trained interviewers administered the AIDS Initial Assessment (AIA) questionnaire to each subject. Included in the AIA were questions 449 about the participants’ personal drug histories as well as questions to measure injection practices such as frequency of injection, frequency of sharing, needle-cleaning practices, and shooting gallery use. Subjects also were questioned on sexual behavior, including number of partners and condom use. The interview was conducted in conditions where privacy could be maintained, and the subjects were assured that all information would be kept strictly confidential. Study participants were pretested, counseled, and had blood drawn to determine the presence of antibodies to HIV. Subjects were then randomized to one of two intervention modalities. The standard intervention consisted of HIV-antibody post-test counseling as outlined by the Centers for Disease Control (CDC). The alternative intervention consisted of three sessions, totaling four hours, and was conducted by trained AIDS interventionists. These sessions included educational information on AIDS and the transmission of HIV as well as skills demonstrations to teach subjects how to properly clean needles and effectively use condoms. Six months after the baseline interview, study participants returned to the assessment center and the AIDS Follow-up Assessment (AFA) questionnaire was administered to determine if there had been a change in risk behavior between intervention and follow-up. This study reports the risk-behavior changes of the first 214 IVDUs who had completed baseline and six-month interview schedules. The purpose of this analysis is to determine whether there is a net positive effect of the project, regardless of the type of intervention received. Therefore, all IVDUs are grouped together without regard for which intervention they received. Baseline and six-month follow-up data were matched for each individual, and the percentages of subjects who had decreased and increased high-risk behaviors were computed. Among those individuals who initially reported less than the maximum level of risk, or more than the minimum level or no risk level, both the percentage and direction of change were measured. This measure was computed both for “persons at risk” for an increase in risk behavior and for “persons at risk” for a decrease in a given behavior. For example, persons at risk for an increase in injection behavior from the month before intervention to the month prior to the six-month follow-up include all IVDUs except those who reported at the baseline interview that they were injecting four or more times a day. They were excluded because they already were in the highest risk category and could only maintain or reduce risk, not increase risk. Conversely, persons at risk for a decrease in injection frequency include all IVDUs except those who reported no injection in the month prior to the intervention, i.e., they could not reduce risk below the “no injection” category. Results The demographic characteristics of the study population are indicated in Table I. The majority (79%) of the sample was male. The racial/ethnic composition of the group was 75% non- Hispanic Black, 7.5% Hispanic, and 16.8% non-Hispanic White. Seventy-three percent were over the age of 30. Twenty-three percent of the group tested positive for antibody to HIV. Changes in risk behavior are shown in Table 2 for those behaviors related most directly to acquiring or transmitting HIV. All percentages of an increase and decrease in risk behavior are reported for the population at risk and not the total study population. 450 Table 1. Demographics of IVDU Study Subjects Who Have Completed the Six-Month Follow-Up (N=214) Percent Gender Male 79.0 Female 21.0 Race/Ethnicity Non-Hispanic Black 75.2 Hispanic 7.5 Non-Hispanic White 16.8 Other 0.5 Age Under 30 27.1 Over 30 72.9 Serostatus Positive 229 Negative 77.1 Table 2. Change in Risk Behavior of IVDU Study Subjects in the Six Months after Intervention Pop. Decrease Pop. Increase Behavior at Risk in Risk at Risk in Risk Behavior Behavior ™N) (%) ™) % Frequency of Injection in Last Month 198 64.6 154 15.6 Sharing Needles 167 72.5 141 20.6 Use of Shooting Gallery 69 79.7 207 14.0 Number of Sex Partners 200 42.0 196 28.1 Number of IVDU Sex Partners 138 69.6 207 14.0 Condom Use 180 50.0 69 26.1 451 Of those at risk, 64.6% indicated a decrease in injection frequency in the month prior to the follow-up assessment, while only 15.6% indicated an increase. A larger percentage decreased (72.5%) than increased (20.6%) their frequency of sharing needles in the six-month interval after participating in the intervention. Likewise, a larger percentage reported a decrease (79.7%) in shooting gallery use than reported an increase (14.0%) in this same time period. Changes in the practice of cleaning needles with bleach were also assessed. The population at risk included those individuals who were continuing to share needles at follow-up. Among 50 persons who, at the baseline interview, indicated that they did not always clean their needles, 22 reported an increase in the frequency of needle cleaning with bleach. Among 20 persons who were cleaning their needles at the baseline interview and therefore were at risk for changing their behavior, 9 indicated that the frequency with which they cleaned their needles had decreased at the six-month follow-up (data not shown). Sexually active IVDUs were more likely to report a decrease (42.0%) in the number of sex partners in the six months prior to follow-up than to report an increase (28.1%). However, this decrease was greater (69.6%) when the number of IVDU sex partners was considered. A sizable decrease in risk behavior in relation to frequency of condom use was indicated, with 50.0% reporting more frequent usage and 26.1% reporting less frequent usage than at the baseline interview. Table 3 examines changes in usage of three noninjected drugs most commonly used by the IVDUs in this study. Between intervention and follow-up, a larger percentage of the at-risk population decreased, rather than increased, its use of crack and marijuana. However, those reporting an increase in alcohol use (35.7%) outnumbered those who reported a decrease in alcohol use (34.2%). Table 3. Noninjected Drug Use among IVDU Study Subjects in the Six Months after Intervention Pop. Decreased Pop. Increased Drug at Risk Use at Risk Use MN) (%) ™N) (%) Crack Cocaine 166 47.0 131 36.6 Alcohol 190 34.2 112 35.7 Marijuana 153 50.3 157 23.6 Discussion The purpose of the preliminary analysis reported here was to determine if changes had occurred six months after the intervention was offered. If it could be shown that changes were occurring as a result of the program, it would be reasonable to assume that the interventions were effective and to continue the project to assess the relative impact of each intervention arm. The type of intervention (i.e., standard or alternative) was not a factor in this analysis. 452 There is evidence in this analysis that IVDUs are responding to intervention programs and are decreasing behaviors that place them at higher risk for HIV infection. This was seen clearly in needle-use behaviors. Compared with the behaviors they had reported at the baseline interview, the IVDUs in this sample decreased their frequency of injection, of needle sharing, and of shooting gallery use in the interval prior to follow-up. Some reduction in the use of noninjected drugs also was seen. A larger proportion of subjects reported a net reduction in the frequency of crack use in the six months after intervention than reported an increase in crack use. Decrease in crack use is particularly important because crack is a major drug of misuse and could become the drug of choice when IVDUs reduce or cease their injection behavior. Marijuana use and noninjected cocaine use also decreased. No reduction in alcohol use was seen. Changes in sexual behaviors were also observed. Forty-two percent of the participants at risk reported having fewer sexual partners in the period after intervention than in the period before intervention. In addition, almost 70% of the respondents reported a decrease in the number of sexual partners who were also IVDUs. Of the population at risk, 50% reported increased condom use; only 26% reported a lower frequency of condom use. Sexual partners who are IVDUs are at increased risk for HIV infection themselves. A decrease in the number of partners who are IVDUs can be seen as a risk-reduction measure. In a study conducted in the Bronx, New York, an increased number of IVDU sex partners was found to be associated with higher seroprevalence among IVDUs (Schoenbaum et al. 1989). IVDUs appear to be willing to change behaviors to reduce their risk of becoming HIV infected. As early as 1984, data from New York City suggested that some IVDUs were making AIDS- related behavior changes (Friedman et al. 1986). Similar observations have been made in San Francisco (Chaisson et al. 1987) and Connecticut (Farley et al. 1989). It is now necessary to determine which method or methods of intervention are most effective with the various cultural and ethnic groups of IVDUs. Because of the small sample sizes accrued at this time, it was not possible to determine which intervention was more effective. In addition, it was not possible to determine differential effects of the intervention on various subpopulations of IVDUs. The next step in determining efficacy of the risk-reduction programs lies in the analysis of risk-behavior change for gender and ethnic groups. The data in this study must be regarded as preliminary. While behavior change was assessed, gradients in those behaviors were not. Small changes in frequency counted as much as larger changes in frequency of behavior. To thoroughly assess the value of the risk-reduction program, the magnitude of change must be taken into consideration. In addition, this is a follow-up of six months and it is not yet known whether the observed behavior changes made will be sustained. These results, however, are encouraging and indicate that IVDUs will change specific high-risk behaviors to lower their risk of HIV infection. 453 References Brown, L.S.; Chu, A.; Nemoto, T.; and Primm, B.J. Demographic, behavioral, and clinical features of HIV infection in New York City intravenous drug users (IVDUs). Presented at the Fifth International Conference on AIDS, Montreal, Canada, June 4-9, 1989. Chaisson, R.E.; Bacchetti, P.; Osmond, D.; Brodie, B.; Sande, M.A.; and Moss, A.R. Cocaine use and HIV infection in intravenous drug users in San Francisco. JAMA 261: 561-565, 1989. Chaisson, R.E.; Moss, A.R.; Onishi, R.; Osmond, D.; and Carlson, J.R. Human immunodeficiency virus infection in heterosexual intravenous drug users in San Francisco. Am J Public Health 77: 169-172, 1987. Chitwood, D.D.; McCoy, C.B.; Inciardi, J.A.; McBride, D.C.; Comerford, M.; Trapido, E.; McCoy H.V.; Page, J.B.; Griffin, J.; Fletcher, M.A.; and Ashman, M.A. HIV seropositivity of needles from shooting galleries in South Florida. Am J Public Health 80: 150-152, 1990. D’Aquila, R.T.; Peterson, L.R.; Williams, A.B.; and Williams, A.E. Race/ethnicity as a risk factor for HIV-1 infection among Connecticut intravenous drug users. J Acquired Immune Deficiency Syndromes 2: 503-513, 1989. Farley, T.; Peterson, L.; Cartter, M.; and Madler, J. Trends in HIV seroprevalence, risk behavior and concern about AIDS among intravenous drug users (IVDUs) entering methadone maintenance (MM) programs. Presented at the Fifth International Conference on AIDS, Montreal, Canada, June 4-9, 1989. Friedman, S.R.; Des Jarlais, D.C.; and Sotheran, J.L. AIDS health education for intravenous drug users. Health Educ Q 13: 383-393, 1986. Marmor, M.; Des Jarlais, D.C.; Cohen, H.; Friedman, S.R.; Beatrice, S.T.; Dubin, N.; El-Sadr, W.; Mildvan D.; Yancovitz, S.; Mathur, U.; and Holzman, R. Risk factors for infection with human immunodeficiency virus among intravenous drug abusers in New York City. AIDS 1: 39-44, 1987. McCoy, C.B.; Chitwood, D.D.; Khoury, E.L.; and Miles, C.E. The implementation of an experimental research design in the evaluation of an intervention to prevent AIDS among IV drug users. J Drug Issues 20: 213-219, 1990. National Institute on Drug Abuse. Program Announcement DA90-02, 1990. Schoenbaum, E.E.; Hartel, D.; Selwyn, P.A.; Klein, R.S.; Davenny K.; Rogers M.; Feiner, C.; and Friedland, G. Risk factors for human immunodeficiency virus infection in intravenous drug users. N Engl J Med 321: 874-879, 1989. 454 Acknowledgment Supported by the National Institute on Drug Abuse Grant #R18-A05349-02. Authors Dale D. Chitwood, Ph.D. Co-Principal Investigator Mary Comerford, M.S.P.H. Senior Research Associate Elizabeth L. Khoury, M.A. Research Associate Judith A. Vogel, M.A. Research Associate University of Miami Health Services Research Center Sylvester Comprehensive Cancer Center University of Miami School of Medicine 1550 NW 10th Avenue, Room 309 Miami, FL 33136 and South Florida AIDS Research Consortium 1611 NW 12th Avenue Miami, FL 33106 455 fr U.SGOVERNMENT PRINTING OFFICE:1901-281-820/44113 1697449 U. C. BERKELEY LIBRARIES WAAR C0bL9459337