Sexual Risk Behaviors, AIDS Knowledge, and Beliefs about AIDS among Runaways Mary Jane Rotheram-Bonts, PhD, and Cheryl Koopman, PhD
Intducion In 1988, runaways in New York City (NYC) were found to have human immunodeficiency virus type 1 (HIV-1) seropositivity rate of 6.7 percent.1 This finding identified runaway youths as a high-risk group for HIV-1 infection. To design effective prevention programs, more information is needed on the sexual risk behaviors of these youths. However, empirical data documenting their risk behaviors are limited to a few items in epidemiological studies of runaways.2-4 Knowledge of AIDS and beliefs about AIDS prevention are relevant to reducing HIV-1 infection.5.6 Therefore, the goals of this paper were to document runaways' current sexual risk behaviors, knowledge, and beliefs about preventing AIDS, and to examine the relationships among these findings.
Meods Sample The sample includes consecutive admissions to two of three residential shelters for runaway youths in Manhattan and Brooklyn over an 8-month period in 198889, for a total of 64 males and 66 females. They were recruited by two young adult Black interviewers, one male and one female, ofwhom both had intensive training in psychosexual assessment.7 Two runaway males refused to participate in the study. Each sample contained primarily Black (65 percent) and Hispanic youths (28 percent). They ranged in age from 11 to 17, and 70percentwere born in NYC. The average age was 15.7 (SD = 1.5), and the median education completed was sophomore year of high school. Only 22 percent of runaways had ever lived "on the street"; however, 75 percent had not lived with a parent or guardian for at least 2 weeks.
Sexual Risk BehaviorAssessment A semistructured interview guide, the Sexual Risk Behavior Assessment Schedule-Youth (SERBAS),8 was used to elicit information about sexual behavior.
In this study, assessments of current sexual activity were limited to acts in which the exchange of semen orvaginal fluid was possible (i.e., oral, anal, and penile-vaginal intercourse), although these acts may not be of equal risk. Sexual behaviors assessed over the previous 3 months included abstinence, number of sexual partners, number of sexual encounters, and frequency of condom use (assessed on a 4-point scale based on number of sexual encounters divided by instances of condom use). Test-retest reliability conducted on items readministered to 22 runaways after 1 week was high (r ranged from 0.71 to 1.00).
General Knowledge about AIDS A true-false instrument containing 62 items was used to assess general AIDS knowledge. The process of developing the instrument helped to address its validity, resulting in high internal consistency and test-retest reliability, as described elsewhere.9 This instrument covers six domains: definitions, outcomes, risk behavior, transmission, prevention, and HIV-1 testing.
Belfs about PreventingAIDS Beliefs about AIDS and safer sex practices were assessed with 39 Likerttype items. This measure was developed in parallel procedures with the AIDS knowledge instrument. Previous research9 using this instrument with runaway adolescents showed that it has high internal consistency. It covers five domains: peer support for safe acts, selfefficacy, self-control, perceived threat, and expectation of acting to prevent pregnancy, which is included because some of Address reprint requests to Mary Jane Rotheram-Borus, Box 29, Division of Child Psychiatry, ColumbiaUniversity, 722W. 168th Street, New York, NY 10032. Drs. RotheramBorus and Koopman are affiliated with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia-Presbyterian Medical Center, Columbia University. This paper, submitted to the Journal February 1, 1990, was revised and accepted for publication June 13, 1990.
Februaxy 1991, Vol. 81, No. 2
Public Health Briefs
beliefs about preventing AIDS were also high (X = 121.4, SD = 14.1, [reflecting a 70 percent positive endorsement of safe acts]). There were no significant differences between the male and the female runaways on these measures. Although the sexual risk behaviors were not significantly related to overall AIDS knowledge, condom use showed a weak inverse relation to perceived threat (B = -.17, 95 percent CI = -.33, -.01), and expecting to act to prevent pregnancy was positively associated with condom use (B = .14, 95 percent CI = .07, .22) and with abstinence (B = .05, 95 percent CI = .02, .07).
Discussion
the major strategies for preventing pregnancy (abstinence, avoiding sexual intercourse, and condom use) also reduce risk for HIV-1 infection.
Data Analysis The frequencies of high-risk sexual behaviors were calculated for male and female runaways. One male and three females who reported exclusively homosexual activity were removed from analyses of sexual risk behaviors because their sexual behavior was not comparable to that of the heterosexual runaways. Chi square tests were computed on sexual risk behaviors, splitting the data on the number of sexual partners and number of sexual encounters at the joint median. T-tests examined gender differences on AIDS knowledge and on overall and domain scores for beliefs about AIDS prevention. Regressions were computed between overall knowledge and belief domain scores with sexual risk behaviors.
February 1991, Vol. 81, No. 2
Resuts The majority of these high-risk youths had been sexually active in the previous 3 months (see Table 1). Sexually active males reported a median of 2.7 sexual partners and 9.0 sexual encounters, and sexually active females reported a median of 1.3 sexual partners and 5.3 sexual encounters; 65 percent of the females and 32 percent of the males had only one partner. Among the sexually active youths, consistent condom use was low, although 47 percent of males and 44 percent of females reported using a condom the last time they had sexual intercourse. No runaways reported bisexual activity in the previous 3 months. Table 2 shows the overall AIDS knowledge scores and overall and domain-specific beliefs of male runaways and female runaways. Youths showed moderately high general knowledge (X = 45.4, SD = 7.6, [a score that reflected 73 percent accurate knowledge]). Positive
Because previous research3 has shown that intravenous (IV) drug use is not high among runaways in NYC, sexual activity is likely to be their primary risk behavior for HIV-1 transmission. The runaways' sexual risk behaviors, AIDS knowledge, and beliefs about AIDS do not provide a sufficient explanation for the high seroprevalence rate reported in 1988 (6.7 percent). Even though the runaways evaluated in this study were drawn from a residential shelter other than the one where the 6.7 percent seroprevalence rate was found, there is no reason to believe that the youths in our sample differ from those in the prevalence study. They were similar in age, ethnicity, and socioeconomic status, and many had been seen at the shelter where the seroprevalence study was conducted. While most (65 percent) had been sexually active during the previous 3 months, the rate was not dramatically different from the percentage of a comparable sample of high school students who had been sexually active in the previous 6 months (58 percent).'0 Although condom use was relatively inconsistent, again, it was not different from condom use among adolescents in general.11 Sexually active runaway girls typically have reported only one partner in the past 3 months. Furthermore, runaways' moderately high knowledge and positive beliefs about AIDS prevention were similar to those of high school samples.10,12 This pattem of results suggests the need for more detailed studies examining the social networks from which these youths draw their sexual partners. Future research must also examine this population's drug use, including IV drug use, needle sharing, and crack use, as well as their exchange of sex for drugs or money.
American Joumal of Public Health 209
Public Health Bneifs These data do point to the importance of developing specialized programs for male runaways. Males have significantly more sexual partners comparedwith runaway females, consistent with findings on the number of lifetime sexual partners in a national sample of male adolescents.13 However, the percentage of males in the study who used a condom the last time they had sexual intercourse (47 percent), was less than reported by adolescent males in a national survey (58 percent).14 Consistent with previous research,15 we found moderate relationships between beliefs about preventing AIDS and sexual risk behaviors. Although as a group, the runaways had a fairly high knowledge of AIDS and had positive beliefs about AIDS, some youths were relatively uninformed. Interventions with these youths may impact behavior. O
An earlier draft of this paper was presented at the V International Conference on AIDS, June 1989, in Montreal.
References 1. Daley S: New York City street youth: Living in the shadow of AIDS. New York Times 1988 Nov 14: Bi, B4. 2. Council on Scientific Affairs: Health care needs of homeless and runaway youths. JAMA 1989; 262:1358-1361. 3. Shaffer D, Caton CLM: Runaway and homeless youth in New York City. New York: Ittleson Foundation, 1984. 4. Yates GL, MacKenzie R, Pennbridge J, Cohen E: A risk profile comparison of runaway and non-runawayyouth. Am J Public Health 1988; 78:820-821. 5. Kelly JA, St. Lawrence JS, Hood HV, Brasfield, TL: Behavioral intervention to reduce AIDS risk activities. J Consult Clin Psychol 1989; 57:6067. 6. Kelly JA, St. Lawrence JS, Brasfield TL, etaL Psychological and demographic characteristics of gay men who do or do not engage in unsafe sex. In Abstracts: V International Conference on AIDS. Ottawa,
9.
10.
11.
12.
13.
Ontario, Canada: International Develop-
Acknowledgments This work was supported in part by grant 5-P50MH43520 from NIMH-NIDA, Anke A. Ehrhardt, principal investigator. We also acknowledge the contributions of J. Bradley, P. Cristina, J. Cohen, T. Exner, E. Grace, R. Gruen, C. Haignere, R. Henderson, M. Matthieu, H. Meyer-Bahlburg, M. Rosario, P. Shrout, A. Siverls, and J. St Hill.
ment Research Centre, 1989; 714. 7. Gruen RS, Calderwood M, Meyer-BahlburgHFL, EhrhardtAA: Psychosexual assessment in AIDS research. In: Abstracts: V International Conference on AIDS. Ottawa, Ontario, Canada: International Development Research Centre, 1989; 739. 8. Meyer-Bahlburg HFL, Ehrhardt AA, Exner TM, Gruen RS: Sexual Risk Behavior
14.
15.
Assessment Schedule-Youth. New York: New York State Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1988. Koopman C, Rotheram-Borus NJ, Henderson R, Bradley JS, Hunter J: Assessment of knowledge of AIDS and beliefs about AIDS prevention among adolescents. AIDS Educ Prev 1990; 2:58-70. Goodman E, Cohall AT: Acquired immunodeficiency syndrome and adolescents: Knowledge, attitudes, beliefs, and behaviors in a New York City adolescent minority population. Pediatrics 1989; 84:36-42. Rickert VI, Jay MS, Gottlieb A, Bridges C: Adolescents and AIDS: Females' attitudes and behaviors toward condom purchase and use. J Adolesc Health Care 1989; 10:313-316. Department of Health and Human Services: HIV-related beliefs, knowledge, and behaviors among high school students. MMWR 1988; 37:717-721. National Research Council: AIDS: Sexual Behavior and Intravenous Drug Use. Washington, DC: National Academy Press, 1989. Sonenstein FL, Pleck JH, Ku LC: Sexual activity, condom use, and AIDS awareness among adolescent males. Fam Plann Perspect 1989; 21:152-158. Hingson RW, Strunin L, Berlin BM, Heeren T: Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health 1990; 80:295-299.
Security Measures for AIDS and HIV r_.
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Carl G. Torres, PhD, Mark E. Tumer, MPH, John R Harkess, MD, and Gregory R Istre, MD
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Introduction
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Public health surveillance for acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HV) infection has accentuated the need for confidentiality and security of health records. This study describes the measures being taken across the country to ensure the security of information regarding patients with AIDS and HIV infection reported to public health departments. Security measures were evaluated according to the cumulative number of AIDS cases reported, whether partner notification services were provided, and whether HIV seropositive reporting by name was also required.
Metods The study population comprised all 66 AIDS surveillance offices responsible for reporting to the Centers for Disease Control as of July 1, 1989. These offices were located in 13 city/county health departments, all 50 state health departments, the District of Columbia, Puerto Rico, and Guam. Confidential questionnaires solicFrom the Epidemiology Service, Oklahoma State Department of Health. Address reprint requests to Mark E. Turner, MPH, Epidemiology Service, Oklahoma State Department of Health, P.O. Box 53551, 1000 N.E. Tenth Street, Oklahoma City, OK 73152. This paper, submitted to the Journal February 13, 1990, was revised and accepted for publication April 10, 1990.
February 1991, Vol. 81, No. 2
Intducion In 1988, runaways in New York City (NYC) were found to have human immunodeficiency virus type 1 (HIV-1) seropositivity rate of 6.7 percent.1 This finding identified runaway youths as a high-risk group for HIV-1 infection. To design effective prevention programs, more information is needed on the sexual risk behaviors of these youths. However, empirical data documenting their risk behaviors are limited to a few items in epidemiological studies of runaways.2-4 Knowledge of AIDS and beliefs about AIDS prevention are relevant to reducing HIV-1 infection.5.6 Therefore, the goals of this paper were to document runaways' current sexual risk behaviors, knowledge, and beliefs about preventing AIDS, and to examine the relationships among these findings.
Meods Sample The sample includes consecutive admissions to two of three residential shelters for runaway youths in Manhattan and Brooklyn over an 8-month period in 198889, for a total of 64 males and 66 females. They were recruited by two young adult Black interviewers, one male and one female, ofwhom both had intensive training in psychosexual assessment.7 Two runaway males refused to participate in the study. Each sample contained primarily Black (65 percent) and Hispanic youths (28 percent). They ranged in age from 11 to 17, and 70percentwere born in NYC. The average age was 15.7 (SD = 1.5), and the median education completed was sophomore year of high school. Only 22 percent of runaways had ever lived "on the street"; however, 75 percent had not lived with a parent or guardian for at least 2 weeks.
Sexual Risk BehaviorAssessment A semistructured interview guide, the Sexual Risk Behavior Assessment Schedule-Youth (SERBAS),8 was used to elicit information about sexual behavior.
In this study, assessments of current sexual activity were limited to acts in which the exchange of semen orvaginal fluid was possible (i.e., oral, anal, and penile-vaginal intercourse), although these acts may not be of equal risk. Sexual behaviors assessed over the previous 3 months included abstinence, number of sexual partners, number of sexual encounters, and frequency of condom use (assessed on a 4-point scale based on number of sexual encounters divided by instances of condom use). Test-retest reliability conducted on items readministered to 22 runaways after 1 week was high (r ranged from 0.71 to 1.00).
General Knowledge about AIDS A true-false instrument containing 62 items was used to assess general AIDS knowledge. The process of developing the instrument helped to address its validity, resulting in high internal consistency and test-retest reliability, as described elsewhere.9 This instrument covers six domains: definitions, outcomes, risk behavior, transmission, prevention, and HIV-1 testing.
Belfs about PreventingAIDS Beliefs about AIDS and safer sex practices were assessed with 39 Likerttype items. This measure was developed in parallel procedures with the AIDS knowledge instrument. Previous research9 using this instrument with runaway adolescents showed that it has high internal consistency. It covers five domains: peer support for safe acts, selfefficacy, self-control, perceived threat, and expectation of acting to prevent pregnancy, which is included because some of Address reprint requests to Mary Jane Rotheram-Borus, Box 29, Division of Child Psychiatry, ColumbiaUniversity, 722W. 168th Street, New York, NY 10032. Drs. RotheramBorus and Koopman are affiliated with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia-Presbyterian Medical Center, Columbia University. This paper, submitted to the Journal February 1, 1990, was revised and accepted for publication June 13, 1990.
Februaxy 1991, Vol. 81, No. 2
Public Health Briefs
beliefs about preventing AIDS were also high (X = 121.4, SD = 14.1, [reflecting a 70 percent positive endorsement of safe acts]). There were no significant differences between the male and the female runaways on these measures. Although the sexual risk behaviors were not significantly related to overall AIDS knowledge, condom use showed a weak inverse relation to perceived threat (B = -.17, 95 percent CI = -.33, -.01), and expecting to act to prevent pregnancy was positively associated with condom use (B = .14, 95 percent CI = .07, .22) and with abstinence (B = .05, 95 percent CI = .02, .07).
Discussion
the major strategies for preventing pregnancy (abstinence, avoiding sexual intercourse, and condom use) also reduce risk for HIV-1 infection.
Data Analysis The frequencies of high-risk sexual behaviors were calculated for male and female runaways. One male and three females who reported exclusively homosexual activity were removed from analyses of sexual risk behaviors because their sexual behavior was not comparable to that of the heterosexual runaways. Chi square tests were computed on sexual risk behaviors, splitting the data on the number of sexual partners and number of sexual encounters at the joint median. T-tests examined gender differences on AIDS knowledge and on overall and domain scores for beliefs about AIDS prevention. Regressions were computed between overall knowledge and belief domain scores with sexual risk behaviors.
February 1991, Vol. 81, No. 2
Resuts The majority of these high-risk youths had been sexually active in the previous 3 months (see Table 1). Sexually active males reported a median of 2.7 sexual partners and 9.0 sexual encounters, and sexually active females reported a median of 1.3 sexual partners and 5.3 sexual encounters; 65 percent of the females and 32 percent of the males had only one partner. Among the sexually active youths, consistent condom use was low, although 47 percent of males and 44 percent of females reported using a condom the last time they had sexual intercourse. No runaways reported bisexual activity in the previous 3 months. Table 2 shows the overall AIDS knowledge scores and overall and domain-specific beliefs of male runaways and female runaways. Youths showed moderately high general knowledge (X = 45.4, SD = 7.6, [a score that reflected 73 percent accurate knowledge]). Positive
Because previous research3 has shown that intravenous (IV) drug use is not high among runaways in NYC, sexual activity is likely to be their primary risk behavior for HIV-1 transmission. The runaways' sexual risk behaviors, AIDS knowledge, and beliefs about AIDS do not provide a sufficient explanation for the high seroprevalence rate reported in 1988 (6.7 percent). Even though the runaways evaluated in this study were drawn from a residential shelter other than the one where the 6.7 percent seroprevalence rate was found, there is no reason to believe that the youths in our sample differ from those in the prevalence study. They were similar in age, ethnicity, and socioeconomic status, and many had been seen at the shelter where the seroprevalence study was conducted. While most (65 percent) had been sexually active during the previous 3 months, the rate was not dramatically different from the percentage of a comparable sample of high school students who had been sexually active in the previous 6 months (58 percent).'0 Although condom use was relatively inconsistent, again, it was not different from condom use among adolescents in general.11 Sexually active runaway girls typically have reported only one partner in the past 3 months. Furthermore, runaways' moderately high knowledge and positive beliefs about AIDS prevention were similar to those of high school samples.10,12 This pattem of results suggests the need for more detailed studies examining the social networks from which these youths draw their sexual partners. Future research must also examine this population's drug use, including IV drug use, needle sharing, and crack use, as well as their exchange of sex for drugs or money.
American Joumal of Public Health 209
Public Health Bneifs These data do point to the importance of developing specialized programs for male runaways. Males have significantly more sexual partners comparedwith runaway females, consistent with findings on the number of lifetime sexual partners in a national sample of male adolescents.13 However, the percentage of males in the study who used a condom the last time they had sexual intercourse (47 percent), was less than reported by adolescent males in a national survey (58 percent).14 Consistent with previous research,15 we found moderate relationships between beliefs about preventing AIDS and sexual risk behaviors. Although as a group, the runaways had a fairly high knowledge of AIDS and had positive beliefs about AIDS, some youths were relatively uninformed. Interventions with these youths may impact behavior. O
An earlier draft of this paper was presented at the V International Conference on AIDS, June 1989, in Montreal.
References 1. Daley S: New York City street youth: Living in the shadow of AIDS. New York Times 1988 Nov 14: Bi, B4. 2. Council on Scientific Affairs: Health care needs of homeless and runaway youths. JAMA 1989; 262:1358-1361. 3. Shaffer D, Caton CLM: Runaway and homeless youth in New York City. New York: Ittleson Foundation, 1984. 4. Yates GL, MacKenzie R, Pennbridge J, Cohen E: A risk profile comparison of runaway and non-runawayyouth. Am J Public Health 1988; 78:820-821. 5. Kelly JA, St. Lawrence JS, Hood HV, Brasfield, TL: Behavioral intervention to reduce AIDS risk activities. J Consult Clin Psychol 1989; 57:6067. 6. Kelly JA, St. Lawrence JS, Brasfield TL, etaL Psychological and demographic characteristics of gay men who do or do not engage in unsafe sex. In Abstracts: V International Conference on AIDS. Ottawa,
9.
10.
11.
12.
13.
Ontario, Canada: International Develop-
Acknowledgments This work was supported in part by grant 5-P50MH43520 from NIMH-NIDA, Anke A. Ehrhardt, principal investigator. We also acknowledge the contributions of J. Bradley, P. Cristina, J. Cohen, T. Exner, E. Grace, R. Gruen, C. Haignere, R. Henderson, M. Matthieu, H. Meyer-Bahlburg, M. Rosario, P. Shrout, A. Siverls, and J. St Hill.
ment Research Centre, 1989; 714. 7. Gruen RS, Calderwood M, Meyer-BahlburgHFL, EhrhardtAA: Psychosexual assessment in AIDS research. In: Abstracts: V International Conference on AIDS. Ottawa, Ontario, Canada: International Development Research Centre, 1989; 739. 8. Meyer-Bahlburg HFL, Ehrhardt AA, Exner TM, Gruen RS: Sexual Risk Behavior
14.
15.
Assessment Schedule-Youth. New York: New York State Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1988. Koopman C, Rotheram-Borus NJ, Henderson R, Bradley JS, Hunter J: Assessment of knowledge of AIDS and beliefs about AIDS prevention among adolescents. AIDS Educ Prev 1990; 2:58-70. Goodman E, Cohall AT: Acquired immunodeficiency syndrome and adolescents: Knowledge, attitudes, beliefs, and behaviors in a New York City adolescent minority population. Pediatrics 1989; 84:36-42. Rickert VI, Jay MS, Gottlieb A, Bridges C: Adolescents and AIDS: Females' attitudes and behaviors toward condom purchase and use. J Adolesc Health Care 1989; 10:313-316. Department of Health and Human Services: HIV-related beliefs, knowledge, and behaviors among high school students. MMWR 1988; 37:717-721. National Research Council: AIDS: Sexual Behavior and Intravenous Drug Use. Washington, DC: National Academy Press, 1989. Sonenstein FL, Pleck JH, Ku LC: Sexual activity, condom use, and AIDS awareness among adolescent males. Fam Plann Perspect 1989; 21:152-158. Hingson RW, Strunin L, Berlin BM, Heeren T: Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health 1990; 80:295-299.
Security Measures for AIDS and HIV r_.
........-. :~~~~~~~~~~~~.
Carl G. Torres, PhD, Mark E. Tumer, MPH, John R Harkess, MD, and Gregory R Istre, MD
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Introduction
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Public health surveillance for acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HV) infection has accentuated the need for confidentiality and security of health records. This study describes the measures being taken across the country to ensure the security of information regarding patients with AIDS and HIV infection reported to public health departments. Security measures were evaluated according to the cumulative number of AIDS cases reported, whether partner notification services were provided, and whether HIV seropositive reporting by name was also required.
Metods The study population comprised all 66 AIDS surveillance offices responsible for reporting to the Centers for Disease Control as of July 1, 1989. These offices were located in 13 city/county health departments, all 50 state health departments, the District of Columbia, Puerto Rico, and Guam. Confidential questionnaires solicFrom the Epidemiology Service, Oklahoma State Department of Health. Address reprint requests to Mark E. Turner, MPH, Epidemiology Service, Oklahoma State Department of Health, P.O. Box 53551, 1000 N.E. Tenth Street, Oklahoma City, OK 73152. This paper, submitted to the Journal February 13, 1990, was revised and accepted for publication April 10, 1990.
February 1991, Vol. 81, No. 2
