What We Have Learned -- Projects 1

What We Have Learned ... 1990-1995:

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What We Have Learned...1990-1995

BEHAVIORAL SURVEILLANCE AND RISK ASSESSMENT RESEARCH

Behavioral surveillance involves the collection of population-based information for the purpose of monitoring rates of specific high risk behaviors that are associated with the acquisition of disease. Risk assessment uses population-based information collected by periodic surveys or archival data to measure the likelihood of rates of diseases associated with specific behaviors or sub-populations.

Project: #1 Analysis of Self-Reported Data from Women Attending 39 Planned Parenthood Clinics throughout Pennsylvania in 1987

Purpose:

The overall study seeks to identify behaviors associated with risk for STD, including human immunodeficiency virus. This analysis examines whether women who become sexually active at an early age are more likely to engage in risky sexual behavior as adults and to have a history of STD.

Results:

Women who became sexually active between the ages of 10 and 14 years were almost 4 times more likely to report having 5 or more sexual partners in the past year (OR=3.8; 95% CI=2.6-5.6); 3 times more likely to report having sex with bisexual intravenous drug-using or HIV-infected men (OR=3.5; 95% CI=2.4-5.0); and twice as likely to report a history of STD within the last 5 years (OR=2.3; 95% CI=1.8-3.0) compared with women who became sexually active when they were 17 years of age or older. Also, controlling for education and duration of sexual activity, Black women were more likely to report a history of STD but less likely to report having 9 or more sexual partners during the past 5 years or a risky partner.

Implications:

Age at first intercourse can be a useful marker for risky sexual behavior and history of STD and can be a useful tool for allocating resources to clients most in need of intervention programs. Clinicians should provide STD evaluation for female clients who report early coitus. Interventions to delay the onset of sexual activity should be developed and evaluated.

Publications:

Greenberg JG, Magdar L, Aral S. Age at first coitus: a marker for risky sexual behavior in women. Sexually Transmitted Diseases 1992:331-334.

Key Words:

Women, adolescents, risk behavior, survey-targeted, Pennsylvania, Family Planning, female sex partners, IDUs.

Project: #2 Analysis of 1988-1991 General Social Survey:

Factors Associated with Sexual Risk Behavior

Purpose:

To determine which factors are associated with sexual risk taking in a nationally representative sample of the United States population.

Results:

The General Social Survey results indicate that age, marital status, sex, alcohol consumption, and race are the strongest and most consistent predictors of sexual risk. Education, income, church attendance, and smoking have bivariate associations with risk, but are not significantly related in the multivariate models. In the year previous to the survey an estimated 3-6 million adults had 5 or more sex partners and 5-8 million had sex with a stranger.

Implications:

The results indicate the extent of sexual risk taking and the factors related to it in the general population. The use of nationally representative data is important because few representative studies of this kind have been conducted, and the characteristics of persons at risk for STDs and HIV are different from those attending public STD clinics, where much STD research takes place. This has implications for the design of interventions targeting the general public.

Publications:

Anderson JE and Dahlberg LL. High risk sexual behavior in the general population: results from a national survey 1988-1990. Sexually Transmitted Diseases 1992;19(6):320-325.

Key Words:

Nationwide, survey-national, risk behaviors

Project: #3 Analysis of Counseling and Testing Data, National Health Interview Survey, and CDC CT Database

Purpose:

To 1) measure the extent of HIV testing--both from public programs and from private physicians and hospitals--in the general population and in persons who may be at increased risk for HIV infection; and 2) identify differences in rates of receiving counseling and testing between population subgroups.

Results:

Data from the annual National Health Interview Survey indicate that between 1987 and 1993 the percent of the U.S. population over age 18 that reported an HIV antibody test increased from 15 to 38%. Almost two-thirds of recent diagnostic tests were obtained from private doctors and hospitals. Persons who obtained tests from public programs were more likely to report receiving HIV counseling than those receiving tests from private doctors and hospitals. Among those at increased risk of HIV infection, those living outside of metropolitan areas reported lower levels of testing.

Implications:

The nationally-representative National Health Interview Survey data provide information on tests obtained from public programs and private providers. Government programs only have information on public tests, but the majority of HIV tests have been obtained in the private sector.

Lower rates of counseling reported for private physicians and hospital (where the majority of tests were obtained) underscores the need for private practitioners to be able to provide appropriate HIV prevention messages, referrals, and other services. Services need to be enhanced for persons at risk of HIV living outside of metropolitan areas.

Publications:

Anderson JE, Hardy AM, Campbell CH. Counseling and testing services in the U.S.: public and private providers. Abstract . 1992, VIIIth International Conference on AIDS, Amsterdam.

CDC. HIV counseling and testing services from public and private providers-- United States, 1990. MMWR 1992;41(40):743, 749-752.

Anderson JE, Hardy AM, Cahill K, Aral S. HIV antibody testing and posttest counseling in the U.S.: data from the 1989 National Health Interview Survey. American Journal of Public Health 1992;82(11):1533- 1535.

Anderson JE, Fichtner R, Campbell CH. How many HIV positive persons in the U.S. have been tested for HIV antibodies? Abstract PO-D25-4155 1993, IXth International Conference on AIDS, Berlin.

Anderson JE, Brackbill R, Wilson RW. Who gets tested for HIV?: National Health Interview Survey data 1987-1993. 1994, Annual Meeting of the American Public Health Association, Washington, DC.

Anderson JE. CDC data systems collecting behavioral data on HIV counseling and testing. Public Health Reports accepted for publication, December 1994.

Anderson JE, Brackbill R, Wilson RW. Diagnostic HIV antibody testing in the U.S., 1987-1993: the role of private physicians and public programs. submitted to AIDS, June 1995.

Key Words:

Nationwide, survey-national, counseling and testing, health care providers

Project #4: Behavioral Risk Factor Surveillance System (BRFSS): Attitudes about HIV/STDs, HIV Testing and Counseling, Sexual Behavior, and Social Context

Purpose:

To examine state specific rates of HIV testing and counseling, self-perceived risk for HIV infection, attitudes about condoms, sexual behavior, self-reported STDs, and social context predictors of HIV/STD risk behaviors.

Results:

Findings from the 1993 BRFSS document a high degree of state-specific variability in self-reported HIV-antibody tests in the United States. However, in most states approximately three-fold more persons reported having obtained their HIV test from a private provider than from a public site; however, persons from a private provider were substantially less likely to have received counseling than those who obtained tests at a public site.

Collaborative efforts between CDC and state AIDS and STD programs have resulted in the official sanctioning of sexual behavior question modules and social context question modules for the 1996 BRFSS. The sexual behavior module includes questions on number of partners in past year, use a condom last time had sex and whether for contraception or disease prevention, and having an STD diagnosed in the past two years and where treated. The social context module includes a series of questions that measure economic and social stability. Preliminary results show that the social context may be a better predictor of sex behavior than standard demographic measures. For instance, a person who moves more frequently has more sex partners, which is not related to income or education.

Implications:

Over the period of the next several years (i.e. 1996 to 1998), state specific data on sexual behavior and social context will become available. These data will be very useful for the development of a behavioral surveillance network.

Publications:

CDC. HIV Counseling and Testing - United States, 1993. MMWR, March 10, 1995, 44(9):169-174.

Valdiserri RO, Holtgrave, DR, Brackbill RM. Knowledge of HIV testing availability among American adults. American Journal of Public Health 1993;83(4):525-28.

CDC. Sexual Behavior and Condom Use - District of Columbia, January - February, 1992. MMWR 1993;42(20):390-1,397-8.

CDC. HIV/AIDS Knowledge and Awareness of Testing and Treatment -- Behavioral Risk Factor Surveillance System, 1990, MMWR, 1991;40(No.46):794-804.

CDC. Community Awareness and Use of HIV/AIDS Prevention Services Among Blacks and Hispanics: Connecticut 1991, MMWR, 41(43), 1992, pp. 825-829 (with M. Adams and others).

Key Words:

Surveillance, attitudes, sexual behavior, counseling and testing.

Project: #5 Comparison of Written and Audio Methods for Assessing STD/HIV Risk in STD Clinic Patients

Purpose:

To determine how the method of assessment affects patient self-report of STD/HIV risks.

Results:

More risk factors were revealed in both the written and audio self-administered questionnaires (SAQ) than in face-to-face interviews (FTFI). There were no differences in the number of risk factors reported in the two SAQ groups, however, the difference in the mean number of reported risks between the audio SAQ and the FTFI was greater than that between the written SAQ and the FTFI. Women were more likely to acknowledge more risk factors in a SAQ than in the FTFI. The number of discordant responses in which risk was identified in the FTFI but not in the SAQ was weakly correlated with being in the written SAQ group, having less education, and being male.

Audio SAQ had fewer missing responses than written SAQ. More patients in the audio group reported unprotected vaginal sex with a non-steady partner and sex partners suspected or known to have HIV infection or AIDS than in the written SAQ group. More audio SAQ than FTFI respondents reported a history of STD, sex with someone who was known or suspected to be HIV-infected, alcohol use during sex, unprotected vaginal sex with a non-steady partner, and unprotected anal sex with a steady or non-steady partner.

The written SAQ group reported a history of STD and having had a one-night stand more often than did the audio SAQ group. More written SAQ than FTFI respondents reported alcohol use during sex, unprotected vaginal sex with a non-steady partner, and unprotected receptive anal sex with a non-steady or steady partner. Many patients who skipped a risk factor item in the written SAQ reported during the FTFI that they did not have that risk--except for responses about STD history and unprotected vaginal sex with a steady partner.

Implications:

Audio SAQ may obtain more complete data and identify more HIV risk than written SAQ, particularly among persons with less education. The study findings should be considered when reviewing current methods of STD clinic patient assessment. Replacing or supplementing traditional FTFI assessments with written or audio SAQ should result in more reliable risk assessments, more efficient use of clinician/staff time, improved pre- and post-test counseling, and improved referral and partner notification services. Research is warranted about whether audio questionnaires overcome barriers to the completion and accuracy of HIV risk surveys, particularly whether the audio SAQ is more effective in eliciting and identifying risk than the written SAQ when administered to a population with a lower level of education and in waiting rooms rather than in private rooms.

Publications:

Boekeloo BO, Schiavo L, Rabin DL, et al. Self-reports of HIV risk factors by patients at a sexually transmitted disease clinic: audio vs written questionnaires. American Journal of Public Health 1994;84:754-760.

Products:

None.

Key Words:

STD Clinic clients, risk behaviors, service enhancement, audio assessment, self administered assessment

Project: #6 Condom Use and Rates of STDs: Data From Cycle IV National Survey of Family Growth (1988)

Purpose:

To analyze the consistency and continuation of condom use for contraception, use of condoms in conjunction with other contraceptive methods, and reported use of condoms to avoid infection.

Results:

Only a minority of sexually active, never-married women report condom use and few report using condoms consistently. Women with characteristics traditionally associated with increased risk of infection with STD/HIV appear to be less likely to report condom use and less likely to report using condoms consistently. Women who report use of condoms to prevent STDs are: more likely to report consistent condom use; less likely to cease using condoms; and more likely to initiate consistent condom use.

Implications:

Findings suggest the need for innovative programming targeted for specific sexually active populations to promote both initiation and consistent use of condoms. Questions are needed on national surveys that accurately measure condom use for disease prevention as well as contraception.

Publications:

Potter LB, Anderson JE. Patterns of condom use and sexual behavior among never-married women. Sexually Transmitted Diseases 1993;30(4):201-208.

Potter LB, Anderson JE. Double indemnity: combined use of condoms and effective contraception. Presented at the annual meetings, Population Association of America, 1992.

Key Words:

Nationwide, survey-national, women, condoms.

Project: #7 Condom Use: Data from the 1990 National Survey of

Family Growth

Purpose:

To examine condom use specifically for disease prevention by a national sample of reproductive-age women: 1) to measure the extent of condom use for disease prevention, 2) to identify the characteristics associated with condom use for disease prevention, and 3) to discuss implications for STD and HIV prevention efforts.

Results:

Of the unmarried women surveyed, 40.5% recently had used condoms for disease prevention and 29.6% reported using them every time or most times. Reproductive-related factors were strongly related to condom use for disease prevention as were favorable attitudes toward the effectiveness of condoms.

Implications:

Prevention programs should develop messages for women who have adopted effective contraception but may be at risk. Prevention programs should promote knowledge of the effectiveness of condoms in disease prevention among high risk populations. Standard approaches for measuring condom use in survey research should be developed to provide accurate information that is useful to programs and can be compared across surveys.

Publications:

Anderson JE, Brackbill R, Mosher WD. Factors related to condom use for disease prevention among unmarried women. submitted to Family Planning Perspectives, June 1995.

Key Words:

Surveillance, attitudes, sexual behavior, counseling and testing.

Project: #8 Cycle V (1994) National Survey of Family Growth: Questionnaire Items STD- and HIV-Related Behavior and Prevention

Purpose:

To collaborate with the National Center for Health Statistics to develop questionnaire items for this national survey of reproductive age women to measure behavioral outcomes related to STD and HIV prevention, including measurement of condom use for contraception and disease prevention.

Results:

Suggested questions and comments were provided during the development phase. Interviewing took place during late 1994 and early 1995. Data are being cleaned and analyzed. Preliminary results are not yet available.

Implications:

The survey will provide national data that are not available elsewhere for designing and evaluating programs, and for comparison with local surveys.

Publications:

None

Key Words:

Nationwide, survey-national, women, condoms.

Project: #9 Evaluation of the DIS Interview Process

Purpose:

To evaluate the communication between CDC trained Public Health Associates working as Disease Intervention Specialists (DIS) and patients they have recently interviewed by identifying discrepancies in responses of clients and concerns identified by clients which relate directly to the competence of the DIS.

Results:

Data indicated that 62% of syphilis interviews lasted less than 1 hour and 62% elicited 2-4 sex partners, 73% of the patients felt that the information discussed would be kept confidential, 86% understood the STD information presented by the DIS, but 86% felt they did not have enough time to ask questions. Overall, patients reported feeling comfortable providing personal, sexual, and drug use information to the DIS. However, patients were significantly less comfortable discussing their drug use behaviors with the DIS than in providing personal identification information. In addition, patients reported that the DIS seemed to be capable and willing to help them, and felt that the DIS were comfortable discussing their personal, sexual, and drug use behaviors with them. The majority of patients reported providing the DIS with accurate information regarding their sexual behaviors (94%) and their drug use behaviors (88%). However, when asked if there were any sex partners that they did not tell the DIS about, three (9%) of the patients answered "yes"--not telling the DIS of one or two other partners.

Implications:

These results have implications for the recruitment, training, and development of federally employed DIS. CDC needs to place more emphasis during DIS training on methods for eliciting names and identifying information of the patient's sex partners. Cross-training DIS in the elicitation of drug abuse and illicit drug behavior information is highly recommended. The reasons patients give for poor responses to DIS questions about risk behaviors, sex partners, and so forth can be used by program planners to refine DIS training and improve partner notification outcomes.

Publications:

CDC. Technical guidance on HIV counseling. MMWR 1993;42(RR-2):11-17.

Richter DL, Lindley LL, Sanchez LC, et al. Evaluation of STD disease intervention specialist syphilis interview process. Abstract 056. 1994, DSTD/HIVP Grantee Meeting, Washington, DC.

Products:

CDC. HIV Counseling, Testing and Referral: Standards and Guidelines. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

Key Words:

DIS, STD Clinic clients, partner notification, staff training, Atlanta, Chicago, Los Angeles.

Project: #10 HIV/AIDS/STDs in Correctional Facilities: Issues and Options

Purpose:

To document HIV/AIDS/STD prevention and treatment practices and policies in U.S. correctional facilities.

Results:

Various jurisdictions have differing approaches to HIV prevention and control. Whether testing should be mandatory or voluntary, whether housing should be integrated or segregated by HIV serostatus, and whether condoms, bleach, or clean needles should be made available to prisoners. Education and risk-reduction counseling are the most widely employed modes of prevention, but their effectiveness is largely undetermined.

Implications:

The rates of HIV infection and risky behavior among incarcerated women and inmates younger than 25 suggest that prevention efforts should be conducted in facilities for these populations. Risk reduction strategies should be tailored to the inmate's risk factors. Public health, corrections, and substance abuse agencies should collaborate in prevention efforts. Prevention efforts' impact on behavior should be evaluated.

Publications:

Hammett, T. 1994 Update: HIV/AIDS and Sexually Transmitted Diseases in Correctional Facilities. Abt Associates, Inc., Cambridge, MA, June 1995.

Hammett, T. HIV/STDs in Juvenile Facilities: Research in Brief. Abt Associates, Inc., Cambridge, MA, June 1995.

CDC. HIV/AIDS education and prevention programs in adult prisons and jails and juvenile confinement facilities--United States, 1994. MMWR,scheduled for publication April 5, 1996.

Key Words:

Adolescents, incarcerated populations, education, collaboration, nationwide, survey-targeted.

Project #11 HIV Prevention and Treatment Practices of Primary Care Physicians in the United States

Purpose:

To determine the HIV prevention and treatment practices of primary care physicians in the United States.

Results:

Less than half of the surveyed primary care physicians asked patients about STDs, condom use, sexual orientation, or number of sex partners. Physicians were more likely to ask these questions of adolescent than adult patients. The percentage of physicians who indicated they would encourage HIV testing varied by patient risk category. About two-thirds of the physicians would provide the test themselves and believed they had an obligation to take care of an HIV-infected patient. Almost all physicians would counsel HIV-infected patient to reduce the risk for transmission; somewhat fewer would counsel the patient to notify sex partners.

Implications:

To more effectively use patient encounters as a means of HIV prevention, physicians must be knowledgeable about the virus and its transmission, aware of the importance of HIV risk assessment, and prepared to counsel patients based on their risk. Medical schools and professional organizations should continue to emphasize HIV/AIDS prevention in training, programs, and policy.

Publications:

CDC. HIV prevention practices of primary-care physicians--United States 1992. MMWR 1994;42:988-992.

Kerr SH, Valdiserri RO, Loft J, et al. Primary care physicians: what are their prevention practices? submitted to American Journal of Preventive Medicine.

Ellen JM, Gans JE, Kerr SH, Valdiserri RO, Millstein SG. The role of continuing medical education and community resources in the intentions of physicians to encourage HIV antibody testing for adolescents. submitted to Archives of Pediatrics and Adolescent Medicine.

Key Words:

Health care providers, counseling and testing, attitudes, nationwide, survey-targeted.

Project: #12 Sexual Behavior and Condom Use Among Street Youth in Hollywood, California

Purpose:

To determine the prevalence and correlates of sexual risk behavior and condom use among street youth in Hollywood based on the 1991 Sex and Drug Use Survey of Young Adults, Los Angeles.

Results:

Nearly all (96%) of the respondents were sexually experienced. Half of the males and one-third of the females had engaged in "survival sex". One-fourth of males and 14.6% of females had injected drugs at some time in their lives. 45% of males and 30% of females reported using a condom the last time they had sex. Among males, condom use was associated with higher education and having had an HIV test. For females, younger age, never being pregnant and exchanging sex for money, food, or lodging were related to condom use.

Implications:

The street youth population is at high risk for HIV and STD infection. Programs especially need to promote condom use among females and males with lower education levels, who have lower rates of condom use. Intervention messages should have a different focus for male and female street youth. Messages directed toward females should promote condoms for pregnancy as well as disease prevention.

Publications:

Anderson JE, Freese TE, Pennbridge JN. Sexual risk behavior and condom use among street youth in Hollywood. Family Planning Perspectives 1994;26(1):22-25.

Key Words:

Hollywood, CA., Adolescents, condoms, risk behaviors, survey- targeted, sexual exchange.

Project: #13 Use, Acceptance, and Use-Effectiveness of Condoms in Preventing HIV and STD Transmission (The Kern County Special Study)

Purpose:

To assess the patterns of use, rates of acceptance, and use-effectiveness of condoms in prevention HIV and gonorrhea, particularly among Black and Hispanic youth and to evaluate the effectiveness of enhanced instructions, skills training, and behavioral rehearsal among STD clinic clients who fail to adopt effective prevention strategies at first follow-up.

Results:

The 1971 prospective study in Sacramento showed that 1) STD clinic clients infected with STDs are more likely to report a history of inconsistent condom use than were uninfected clients, 2) previously infected clients were more likely than uninfected clients to accept free condoms at study enrollment, and 3) clients who accepted condoms and reported use after enrollment were just as likely to have an STD at follow-up as clients who refused condoms. Black and Hispanic youth were more likely to report inconsistent condom use and to be diagnosed with an STD.

The repeat study in Kern County in 1992 documented that private physicians report disproportionately more white men with gonorrhea. Between 1971 and 1992, the proportion of STD clinic clients diagnosed with gonorrhea or syphilis declined 50%. However, Black men were more likely to be diagnosed with gonorrhea or trichomonas; White men were more likely to be diagnosed with herpes, chlamydia, or genital warts; and Hispanic men were slightly more likely to be diagnosed with syphilis, non-gonococcal urethritis, or other STDs. Black women were more likely to be infected with gonorrhea, and White women were more likely to be infected with gardnerella. Clients with gonorrhea reported having more sex partners than uninfected clients did. More Hispanic men than white men named just one sex partner. More Black men and Hispanic and White women reported three or more sex partners.

Reports of condom use were eight-times higher in 1992 than in 1971, but there was no difference in use-effectiveness of condoms at baseline (1992). Reported condom use more than doubled among STD clinic clients in California, Increases were particularly dramatic among young women and clients diagnosed with gonorrhea. In 1992 most of the female STD clinic patients reported some form of contraceptive use; although more White women reported ever using condoms and more Black and few White women relied on douching for contraception.

Study participants received a standard (condoms only) or enhanced (condoms and use demonstration, counseling, and communication/negotiation skills training) intervention. In 2 weeks to 2 months after the intervention, more enhanced than standard intervention participants increased condom use for vaginal sex (44% vs 25%) and reduced their number of sex partners from 2 or more to 0 or 1 (18% vs 7%). STD clinic clients who did not participate in an intervention did not show any change in these behaviors.

Implications:

The 1971 study indicated that merely providing STD clinic clients with condoms was insufficient in promoting and assuring proper condom use among high risk youth. Additional instruction about proper and consistent use, skills training, and behavioral rehearsal were needed. The 1992 study acted on these recommendations and refined them to include the need for culturally and ethnically appropriate STD/HIV risk reduction interventions for at risk youth. Identifying specific sexual risk behaviors may help characterize women at increased risk for STD/HIV infections and permit appropriate targeted programs for them. Enhanced intervention (averaging 20 minutes) can be incorporated into STD clinic settings.

Publications:

Darrow WW, Harris B, Schaffner A, et al. Condom use reported by STD clinic patients: 1971 & 1992. Abstract WS-D29-5. 1993, IXth International Conference on AIDS, Berlin.

Darrow WW. Condom use and use-effectiveness in high-risk populations. Sexually Transmitted Diseases 1989;16:157-160.

Darrow WW. Venereal infection in three ethnic groups in Sacramento. American Journal of Public Health 1976;66:4465-450.

Darrow WW, Approaches to the problem of venereal disease prevention. Preventive Medicine 1976;5:165-175.

Darrow WW. Attitudes toward condom use and the acceptance of venereal disease prophylactics. In: Redford MH, Duncan GW, Prayer DJ, eds. The Condom--Increasing Utilization in the United States. 1974. San Francisco Press: San Francisco, California.

Products:

A video instructing correct condom use and diskette version of guidelines for implementing the instruction, skills training, and behavioral rehearsal intervention are available from Benita Harris, CDC/NCPS, Mailstop E-58, 1600 Clifton Road, Atlanta, GA 30333.

Key Words:

Adolescents, African American, Hispanic, STD clinic clients, behavior change, counseling, condoms, gonorrhea, education, skill building, video, Sacramento, CA, Kern County, CA., Condom distribution.

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