"High risk" behaviors were believed to be sex with multiple partners (90.8%), exchange of blood or semen (86%), and IV drug abuse (85%). Behaviors which helped prevent HIV-transmission were also relatively well known. Respondents noted that preventive behaviors included "stop shooting drugs" (82.8%), engaging only in "safer sex" (58.5%), restricting sex to a closed relationship (68.5%), and cleaning "works" (57.8%).

Despite knowledge of AIDS and high-risk and preventive behaviors among IV drug abusers, however, personal behavior does not reflect this knowledge. Data from a recent survey of current and former IV drug abusers in Washington, D.C., indicates that over 52% are sharing needles and/or "works", and over 22% did not consistently clean borrowed works prior to using them. In addition, among those who clean works immediately prior to personal use, over 50% use ineffective cleaning techniques such as rinsing in tap water only. Similar data on sexual practices indicate continued high-risk sexual practices with over 60% of survey respondents having continued sexual relations with more than one partner (10% having sex with six (6) or more different partners). Over 85% never use condoms during vaginal intercourse.

Based on these findings, it can be noted that IV drug abusers recognize high-risk behaviors in relation to HIV-transmission, but continue to practice high-risk sexual and drug abuse behaviors. They recognize risk, but their actions do not reflect a personal response to this risk. IV drug abusers, therefore, comprehend the theoretical risk but do not personalize the risk as indicated by the continued practice of high-risk behaviors. Clearly knowledge alone does not translate into behavior change. It appears that the lack of perceived risk, either due to comprehension issues or personal denial, must also be overcome to effect behavior change.

Non-comprehension of the risk as opposed to denial of the risk are thus two potential issues effecting behavior change. One must undertand the risk, before denial of the risk can occur. Based on IV drug user focus group pretesting of two (2) NIDA publications, the following was determined in relation to comprehension and understanding of AIDS and AIDS etiology.

о

Many IV drug abusers had reading and comprehension difficulties with terms which they felt were "too technical". These terms included "HTLV-III/LAV", "HIV", Kaposi's Sarcoma, and "Pneumosystic Carinii Pneumonia". Many respondents stated that they wouldn't continue reading written materials, or listen to audio messages, after being "tripped up" over these terms.

There was often confusion about the meaning of the AIDS anti-body test.
Respondents were confused about the differences between the AIDS virus,
HIV, HTLV-III/LAV, and the AIDS antibody, what the AIDS antibody test was
for, and why someone should get the test.

The link between AIDS virus transmission via IV drug abuse and sexual activity was unclear to many focus group members. Often, respondents felt that it was only possible to transmit AIDS through one of these behaviors, but not both. In general, respondents understood how AIDS could be transitted through the sharing of their works, but were unsure what the role of specific sexual activities was, and were relatively uninformed about high risk sexual behaviors as a mode of AIDS transmission.

Denial is an issue even when AIDS transmission and the role of high risk sexual and drug abusing behaviors is comprehended. Denial is a personal but undefined function which is unique to each person. Given the fact that the pre-test, survey, and some ancedotal data reflect a relatively "sophisticated" level of knowledge about HIVtransmission among IV drug abusers, denial is clearly evident as evidenced by behaviors as well as data on perceived personal risk for AIDS. Combined NIDA pre-test and Washington, D.C. survey results indicate that over 50% of current and recent IV drug abusers do not think that they are personally at risk for AIDS, with almost 15% unsure or don't know. This is clearly inconsistent with data from the same respondents which indicates a knowledge of how AIDS is transmitted and personal practices of continued high-risk drug and sexual behaviors.

Other factors inherent in the "make-up" of the IV drug abuser and the drug abusing community must be considered in terms of knowledge, messages receptiveness, and personal denial. These factors include:

If drug abusers continued IV drug use but elected the risk avoidance behaviors (of not sharing works, cleaning "borrowed" works before personal usage, or using condoms), they would possibly alienate themselves from their support network. For drug abusers, altering social norms within the drug community would imply "mistrust", or be contrued as a negative reflection on "drug buddies" or sexual partners. Many IV drug abusers would not wish to practice "safer" behaviors if it would threaten the few support networks they have of fellow drug users and sexual partners, and

IV drug abusers are traditionally nonreceptive to all kinds of health education messages. The AIDS issue is yet another of many problems which they have avoided facing or denied by continuing the use of IV drugs. AIDS may simply be "added to the list", along with overdosing, hepatitis, endocarditis, etc. A 1986 California study conducted by J. Newmeyer and H. Feldman on IV drug user receptivity to AIDS risk. "These individuals view AIDS as just one of many life-threatenting risks in pursuing a career in

heroin use." Similar sentiments were expressed by Mr. Robert Baxter, an epidemiology consultant at the New Jersey Department of Health, who is quoted in the February 16, 1986 New York Times as stating, "The life of a drug addict is so fraught with danger - overdosing, hepatitis, getting busted or ripped off, AIDS is just one more hassle, an occupational hazard."

The most effective strategy to prevent HIV infection in IV drug abusers is to eliminate IV drug abuse altogether. For individuals who continue to inject drugs, a cessation of needle sharing and the use of sterile needles and syringes, in addition to increased use of condoms, as an example, is essential. The following characteristics of IV drug abusers also hinder the adoption of these important behaviors to stop AIDS transmission:

O

Drug abusers in general (and IV abusers in particular) do not have an organized constituency, or support, self-help, or advocacy groups.

IV drug abuse is traditionally regarded as being associated with selfdestructive activities.

IV drug abusers are generally recognized and identified only when they make contact with the criminal justice or drug treatment/rehabitation systems. They are difficult to reach through traditional health communication channels.

More specifically, factors inherent in the severely addictive, illegal, and ritualist process of IV drug abuse also hinder efforts to get IV drug abusers to stop using drugs, stop sharing works, or sterilize equipment used to administer drugs. These include:

о

An inability to legally obtain sterile equipment for administrating drugs, often resulting in sharing behaviors.

The expediency and desperation to take drugs, particularly in times of acute withdrawal, increasing sharing behavior or the use of non-sterile "works".

Misinformation in the IV drug abusing community about high-risk sharing behaviors within a small or closed group, and sexual transmission of HIV.

2)

Ex-IV drug abusers, sexual partners of current and ex-IV drug abusers, their significant others, and sexually active heterosexuals.

These target groups present some of the same issues regarding AIDS education and high-risk behavior intervention that are evident in current IV drug abusers. The most significant barrier to education and behavior change is providing accurate information about the sexual transmission of AIDS, the "link" of high risk drug abuse behavior and sexual transmission, and overcoming misinformation and false beliefs about high-risk sexual behaviors. In particular, heterosexuals, particularly those with multiple partners, must be made aware of the risk to themselves.

Barriers to education and behavior change for these populations are often the same as one would expect to find for other issues of major public health concern. The same problems of comprehension, denial, and social/personal "pressure", as discussed in relation to IV drug abusers, is also an issue with non-IV drug abusers. These barriers include a lack of information, overcoming false/incorrect information, and overcoming various moral, personal, and often religious beliefs, as AIDS education touches upon many social "taboos" (such as drug use and sexual practices) which are often not well received by many people.

For populations who are not in clearly defined high-risk groups (such as non-IV drug abusing heterosexuals), denial is also difficult to overcome. They must understand the risk before they can clearly deny it. Blacks and Hispanics, as an example, comprise a disproportionately high percentage of AIDS cases, in spite of the media's frequent portrayal of the disease as a white, middle-class, Gay male disease. Many of the ethnic minority groups do not even recognize their risk, so therefore do not recognize the risk reduction activity. Similar problems are generally reported among women, and non-drug abusing heterosexuals of both sexes and all races.

The perception of risk due to heterosexual transmission has heightened, but perhaps not as acutely as it should. Recent surveys of public attitude seem to indicate than many have altered their sexual behavior, and the use of condoms (as an example) is

increasing. However, the receptiveness of these populations to the message, and the strength of the message, is still somewhat uncertain.

b) Problems with Different Materials and Media

Not all media reach all potential target groups for the AIDS messages. Some populations are more receptive, as an example, to visual response, while others are more receptive to, as examples, one-to-one counseling and education. Barriers to the use of different AIDS education materials and media are on two levels:

(1)

(2)

The receptiveness of different target groups to particular media and materials, and

An unwillingness (or refusal) of different media to distribute, broadcast, reproduce, etc., AIDS education materials (often due to the connection with illegal drug use and/or sexual practices). These barriers not only negatively effect the potential distribution of materials through all available channels, but hinders essential pre-testing (or "market testing") necessary for the development of effective messages.

Clearly, the materials must be in a form that will be received by the potential target groups. Given the unique nature of these target groups (most particularly current IV-drug abusers), little research is available to determine which materials are the "best" for each population.

c)

Problems With the AIDS Message Focus and/or Form

As stated, particularly graphic or specific AIDS education messages and information may be determined to be "inappropriate" for distribution or dissimenation through particular communications channels or media. This clearly impedes the ability to target unique and particular messages. As an example, the message "Don't Shoot Drugs" may be deemed acceptable or appropriate for posters on subways--but "Don't Come Inside Him/Her" may be inappropriate for this medium. This example (albeit simplistic) illustrates the barriers to message development without even considering what the focus of AIDS education messages should be. More specifically, the basic question with regard to the message is still unclear--what should be advocated? What should the "official posture" be?

The AIDS high-risk behavior change messages are a subject of often heated debate. Some potential alternatives include: