Evaluating AIDS Prevention Programs Expanded Edition (1991) / Chapter Skim
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C Methodological Issues in AIDS Survey
C Methodological Issues in AIDS Survey
Pages 207-316
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From page 207... ...
INTRODUCTION Surveys or, more generally, He memos of asking questions and recording answers, continue to be one of the most important methods for obtaining essential information about Be epidemiology of AIDS and ~V, He behaviors Hat spread ~V, and the effectiveness of AIDS prevention efforts. Previous reports of our committee have included numerous examples of surveys and obsenabons about the methodological difficulties that often attend these measurements.
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From page 208... ...
the definition of the population to be studied and the drawing of a target sample from that population; (2) the execution of the sample design, that is, finding the persons in the target sample and enlisting their cooperation in the survey; (3)
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Many of the behaviors are actively concealed because they are considered illicit (IV drug use is illegal throughout the nation, and many sexual behaviors of interest in preventing HIV transmission are illegal in some states)
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requires asking questions about these risky behaviors. This activity, In tum, raises a host of methodological issues that are germane to survey research of aU types plus some questions Hat are specific to surveys of drug use and sexual behavior.
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METHODOLOGICAL ISSUES ~ 21t Fallibility of Measurement in Other Sciences Fallibility and error are not confined to behaviors measurements, as evidenced by the decade-Ion" controversy suuTounding the population statistics produced by the decennial censuses.3 Furthermore, just as fallibility of measurement is not limited to behavioral measurements, neither is it I:m~ted to surveys or social statistics. For example, Hunter (1977)
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What is the potential for general spread of HIV infection? Can an HIV epidemic be sustained Trough heterosexual contact alone?
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This section considers the feasibility of sex and seroprevalence surveys as a means of measuring the distribution of sexual behaviors that risk HIV transmission and the distnbution of HIV itself in general populations. Although such surveys may be designed in a variety of ways, all of the studies discussed here employ the same general procedures for participant selection: an unambiguous definition of the population to be studied and a form of sampling from this population that allows the probabilities of selection to be known.
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The rationale for using response rates as a "yardstick" to assess the accuracy of survey estimates is twofold: (~) high response rates reduce the influence of selective participation in surveys and hence the potential for bias in the estimates, and (2)
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It attempts to answer three main questions: (1) What response rates have been achieved In recent surveys of sexual behavior?
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It also reveals several opportunities for learning more about patterns of participation and nonparticipation. Participation in Sex Surveys Data Collection Procedures and Response Rates Each of the surveys listed in Table C-1 asked respondents to report on certain aspects of their past and present sexual behavior.
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218 a' o 0 = Cal :t Cal to ;> m C~ x a o 3 I: a: ._ CO ._ C)
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221 ~ c ~ ~ E ~ ~ -c ~ ~ E 5 o ° E to · _ — · ~ ~ ~ .= C~ o o o ~ o Z 3 ~ ~ ~ ~ ~ ~0 ~ ;` ^ v, D C e ~ e a ^ e ~ E 3 0 8 E c a E c V~3a~v~= ~s~sOa=~=a ~ ~ C)
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From page 222... ...
The response rates for face-toface and telephone interviewing were calculated by dividing the number of completed interviews by the total number of sample persons. For surveys that used an SAQ, the response rate is the number of completed SAQs divided by the number of sample persons.
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It is therefore crucial to document any claims of representativeness by a careful study of patterns of nonresponse. No obvious association between response rate and the three methods of data collection was found, although response rates in the telephone surveys appear to be somewhat lower than those in surveys using other procedures.
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From page 224... ...
Nonetheless, they share certain characteristics that may help to explain why they achieved relatively high rates of participation: they are each part of a series of periodic surveys Mat have consistently had good response rates; the sexual items consist of a relatively small set of "add-on" questions; Me surveys are conducted by the same survey organ~zations5 and to some extent by the same supervisory and field staff that have been responsible for previous surveys in the senes, and Me field procedures include provisions for large numbers of callbacks and special attention to Me conversion of revisers. The 1988 GSS is Me fourteenth in a series of annual opinion surveys conducted by the National Opinion Research Center (NORC)
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From page 225... ...
The field staff completed 1,481 interviews during the 10-week period for a total survey response rate of 77.3 percent. Of those who completed the interview portion of the suney, 93.9 percent returned the SAQ, yielding an SAQ response rate of 72.6 percent.
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This number of completed interviews yielded a total survey response rate of approximately 79 percent (figured by multiplying He 82.1 percent response rate among NSFG sample persons by a 96 percent enumeration response rates in the NHIS)
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From page 227... ...
and computer-assisted telephone inteNiew}ng CATS. Compansons between face-to-face and telephone interviewing in the context of national surveys indicate that the overall response rates for telephone surveys are on the order of 5 percent lower than those expected in personal interviews (Groves and Kahn, 19791.
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From page 228... ...
The generally lower response rates of telephone surveys, along with studies of respondent reactions to the two founts of interviewing, suggest that the rapport and trust between interviewer and respondent attained in faceto-face surveys are harder to achieve in the telephone interview. Thus, it is reasonable to expect somewhat lower rates of participation in telephone surveys that contain explicit sexual content, compared with similar surveys using face-to-face interviewing or a combination of face-to-face interviewing and an SAQ.
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From page 229... ...
Although there is no mention of the number of households that were not contacted or of the eligibility rate per contacted household, the authors hazard the opinion that "Ewlith a sample size of 500, results were protectable to the universe of selfidentifying gay and bisexual men in San Francisco within +4.5% at the 95% level of confidence" (Communication Technologies, Inc., 1987:25~. The 1985-1986 Seattle survey was a pilot study of the use of telephone interviewing to collect data on sexual behavior In subgroups of the general population who were likely to be at risk of acquiring HIV infection.
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was quite low—about 33 percent no doubt because fieldwork was completed in five days and only three callbacks were permitted. Low response rates are not unusual In short-term commercial surveys; nevertheless, they provide little indication of what can be achieved in more rigorously executed telephone surveys.
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From page 231... ...
Experience with sex surveys conducted by telephone is too Innited, however, to determine the levels of participation that can be achieved in such surveys and whether the lower response rates in the available cases are a generic feature of telephone surveys or simply the result of early and somewhat idiosyncratic first attempts. In view of Me substantially lower cost of telephone versus face-toface surveys, as well as the limited scope of current experience, carefully designed experiments should be encouraged to test the feasibility of this methodology for surveys of sexual behavior in general populations.
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From page 232... ...
Choosing an optimum design requires extensive experimentation win alternative combinations Of design characteristics. Among the challenges are determining tile best ways: to introduce the study to sample persons and the general public, to maintain anonymity, to collect blood specimens, to ask questions about risk factors, to compensate respondents for the time required for panicipation, and to minimize fears of disclosure.
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From page 233... ...
were the first cycles of longitudinal studies that involved periodic collection of blood specimens, extensive personal interviews to obtain risk factor information, and, In one case, routine physical examinations in a clinic setting. Not surprisingly, there is a gradient of response rates In these four studies that corresponds roughly to He intensity and duration of the participation required from each respondent: the response rates for blood samples range from 46 to 81 percent.
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From page 234... ...
At the end of the recruitment phase, 1,034 sample persons had completed their first clinic visit, representing a response rate of 56.2 percent (of approximately 1,839 eligible sample persons, including an estimated 157 eligible men in sample households In which the initial household enumeration could not be completed3. In 1986, CDC conducted a seroprevalence survey in Belle Glade, Florida, as part of an investigation of the causes of an AIDS outbreak in that area (see survey no.
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The Allegheny County pilot study indicates Hat relatively high response rates can be obtained In seroprevalence surveys Hat involve public
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From page 236... ...
. The committee's review likewise indicates Nat tile response rates achieved In contemporary sex and seroprevalence surveys i6Nonresponse bias is the deviation between the distribution of responses obtained from persons who participated in the survey and who responded to the survey question, and the response that would have been obtained if all persons in the target sample had participated in the survey and answered tile question.
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From page 237... ...
If the mantal status of male r~onrespondents is known (from, for example, a household enumeration interview) and if there were a good bossism for the belief that, for any particular marital status, the sexual behaviors of respondents and nonrespondents were similar, sample estimates of the distribution of sexual behavior might be adjusted, using imputation or maximum likelihood procedures, to adjust for this nonresponse bias.
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From page 238... ...
or about revealing one's HIV serostatus In the best executed surveys. Current knowledge about the structure of nonresponse bias In sex and seroprevalence surveys comes from two kinds of compansons: compansons of survey estimates with census data and internal analysis of the correlates of different levels of nonresponse.
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From page 239... ...
To understand the sexual and drug-using behaviors that are at issue in survey research on HIV transmission, one must ultimately confront the uncertainties introduced by this question-and-answer process. Terms and Concepts In discussing the complex array of factors that can distort survey (and i8A mayor aim of the NCHS pilot studies for the national HIV seroprevalence survey is the investigation of He nonresponse bias in surveys that seek to estimate HIV prevalence.
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(This type of nonresponse is discussed in the preceding section.) Nonsampling factors that affect measurements include misunderstanding of questions, respondent unwillingness to reveal sensitive information, interviewer mistakes in reading questions, clerical and other errors made during coding and processing of data, and so forth.
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From page 241... ...
, there is good reason to suspect that the problems encountered In studying sexual behavior are ur~que In some respects.22 There appears to be little that is theoretically unique, however, about the problems of random error and the resultant unreliability In survey measurements of sexual behavior, and there is ample evidence in the literature (see below) that respondents do provide reasonably consistent responses to survey questions on sexual behaviors.
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From page 242... ...
That is to say, questions such as, "Have you had sexual contact to orgasm win another man in the last week? " may be more prone to bias induced by the sensitivity of the topic than by the respondents' inability to understand He question or remember the event.
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Nonetheless, some inferences may be made with relative certainty if one is prepared to make assumptions about the direction of reporting biases. Inference in the Presence of Bias It could reasonably be argued that the preponderant source of bias In reports of sexual behaviors or Mug use for many (but not all)
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From page 244... ...
are, after all, of considerable interest. Indeed, these estimates figure centrally in two of the most important research challenges of the epidemic's second decade: detenrun~ng whether there are declines over time in the incidence of sexual behaviors that risk transmitting HIV, and assessing the effectiveness of AIDS education and prevention programs by comparing the behaviors of persons who participate In those programs with the behaviors of Dose who do not.
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From page 245... ...
Indeed, it might plausibly be argued that the same social and psychological pressures used by intervention programs to encourage behavioral change also make it less likely that respondents will report these same behaviors.25 Thus, the group receiving an intervention may also have its reporting bias modified In the direction of less complete reporting of risky behaviors.126 Approaches to Validation Measures of sexual behaviors may have much In common with measurements of subjective phenomena (e.g., attitudes, options, intentions) .27 Although sexual behavior can, in theory, be observed, there are only a few special circumstances in which the testimony of independent observers could be used to validate respondents' self-reports.28 Outside these special circumstances, Were are no obvious independent measurements that could provide a basis for directly assessing the extent of bias in selfreports of sexual behavior.
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From page 246... ...
It recommended a careful review of these data systems and, if necessary, an increase in resources to improve them (Turner, Miller, and Moses, 1989:167~. Furthermore, for any group, the trends in STD rates over time will reflect phenomena such as the changes, if any, in the behaviors of group members that expose them to infection, trends in the rates of STDs among the population from which the group selects its new sexual contacts, and changes In reporting practices.
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From page 247... ...
· Construct validity refers to the extent to which a set of measurements relate to one another in a coherent way as specified by some (formal or informal) theory.
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From page 248... ...
direct observations of We same phenomenon, the presence of a very high or even perfect correlation does not, in itself, guarantee that the survey measurement is not contaminated by significant biases. Consider, for example, hypothetical reporting biases that caused the frequency of anal sex to be underreported by 20, 40, and 60 percent from its "true" incidence In Free measurements.
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EMPIRICAL STUDIES OF SEXUAL BEHAVIORS Validation There is only a very limited range of evidence that can be collected to provide independent corroboration of the validity of self-reported sexual behaviors. In the past, three broad types of research evidence have been collected: · partner reports, in which regular sexual partners respond to the same questions as the study respondent; · "invalidation evidence," which is derived from longitudinal studies in which it is possible to obtain some measure of reporting accuracy by examining the temporal patterns for impossible temporal sequences (e.g., persons who report having engaged In sexual intercourse when interviewed at age 15 but who report at a later age Hat Hey have never had intercourse)
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250 ~ APPENDIX C TABLE C-2 Findings of Kinsey et al.'s (1948) validation study of sexual behaviors reported by spouses.
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With some exceptions, these studies do not cover as comprehensive a range of sexual behaviors as Kinsey explored. They are, nonetheless, perhaps of more relevance for understanding the qualities of the behavioral data that are routinely used In AIDS research.
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252 et x o 0 of .= v 0 o .~ ~5 s m a' x U
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253 Cl: u 'A ° ~ _ 2' ° _ C I -3 e _ ~ g ~ i, ~ ~ ', I' ~^ _ ' ~ ~ ~ L ' Y ~ , 2 I, I _ · ' hi, ~ ~ ~ ·, ~ _ ~ ~ _ ~4~3i ·~1l is A; 3 ~ ~ ~ ~ ~ ~ ~ ~ ~ , D ~ -, _ ~ _ ~ ~ C C-> a: o Cat C)
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From page 254... ...
, for example, requested that the gay men in their study report Me total number of sexual encounters they had with a particular partner and the total number of times (or percentage of encounters) during which they engaged in specific sexual behaviors.
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(It should be emphasized that the criterion measure was not the polygraph judgment but rather the subjects' behavior in "correcting" their answers to the questionnaire when confronted with the polygraph.135 Table C4 presents selected results from this study. It win be seen that for every measurement a substantial fraction of the sexual behaviors that were finally reported were reported only after the possibility of lie detection was introduced.
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From page 256... ...
who: (a) report selected sexual behaviors where confronted with lie detector, (b)
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From page 257... ...
There are, however, two examples that demonstrate We important point that survey measurements of sexual behaviors can produce reliable measures of behavior In well-defined populations. Proportion of Teenagers Who Are Sexually Active The most thorough demonstration is offered in the literature on teenage sexual activity (an area Hat fortunately received some Investment prior to AIDS to pursue studies to understand patterns of sexual behavior)
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From page 258... ...
Adjustments were made (e.g., eliminating population segments that were not included in all surveys) to make Be studies as comparable as possible; the adjusted proportions of women reporting sexual activity by each age are shown in Figure C 3.37 This plot shows that there is a very close correspondence between two of Me three surveys and that He third survey (~e National Longitudinal Survey of Young produces estimates Hat are quite similar for ages 12 to 15 and IS to 19; however, it provides substantially lower estimates of sexual activity for this cohort of women at ages 16 and 17.
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From page 259... ...
It has come to be a well-accepted notion in the literature on survey measurements (as it long has been In analytical measurements In other disciplines) that variability in measurements among procedures, investigators, and laboratories cannot be determined by a simple extrapolation of the variances observed In measurements from a single experiment.
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From page 260... ...
As noted in Table C-1 Me GSS obtained one of the highest response rates of the surveys reviewed by the committee and We Los Angeles Times survey obtained the lowest. · The surveys differed In the wording of questions, survey content, and mode of a~n~nistration (phone survey versus self-adm~stered questionnaire in a face-to-face survey)
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From page 261... ...
The tabulation of these repeated measurements against the original survey responses provides an index of Me reliability of the survey measurements. That is, it provides a way of assessing the consistency of survey response.
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From page 262... ...
Saltzman and colleagues (1987) , for example, report test-retest reliabilities for two a~n~rustrations of a questionnaire asking about sexual orientation, sexual behaviors, and change in sexual behaviors.
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From page 263... ...
Inconsistent responses within interviews averaged 7.8 percent for intercourse and 8.3 percent for reports of masturbation in He first survey,46 but there was substantial variation by race and sex. For both intercourse and masturbation, the greatest inconsistency in reporting was observed among black males.47 EMPIRICAL STUDIES OF DRUG-USING BEHAVIORS Many of the methodological issues investigators face in studying drug use behaviors are identical to those found in studying sexual or other sensitive or illegal behaviors (see, for example, Siegel and Ballman, 1986; Kaplan et al., 1987; Zich and Temoshok, 1987; Kaplan, 19891.
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264 cO -~ca o ~ m x U
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point out Hat the lack of standardized measures, combined win the heterogeneity of the population of drug users and He impaired cognitive functioning that may result from extensive drug use, tends to make survey research In this population a difficult task. A drug user who is ~nebnated, for example, cannot be expected to recall needle-sharing episodes accurately.
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From page 268... ...
. Measurement Bias As with sexual behaviors, a major problem In measuring the risk behaviors of Injection drug users is that researchers usually cannot observe the behaviors of interest directly.
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From page 269... ...
METHODOLOGICAL ISSUES ~ 269 for example, followed 865 criminally involved drug users and employed various methods to assess the reliability and validity of self-reports of cymbal and ~ug-taking behavior. Overall, their results indicated that, although the self-reports tended to have a downward bias, 74 percent of respondents accurately reported their drug use during the previous four weeks.
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From page 270... ...
for which urinalysis can reliably detect it, one finds instances of major studies In which underreporting biases of up to 13 percentage points were found (McGIothlin, Anglin, and Wilson, 1977; N = 4971. On the other hand, one major study (W.
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From page 271... ...
271 At: I_ o oo Cat Cal of Cal so U
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272 lo ~ C: ~ .c .
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From page 274... ...
As with self-reports of sexual behaviors, differential reporting bias is a danger in the use of self-reports of drug use behaviors. In evaluation studies, for example, subjects assigned to an ~ntenention (versus a control)
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From page 275... ...
Feasibility First, based on the empirical evidence presented In the first section of this appendix, there appears to be little question that such surveys can enlist the cooperation of the vast majority of the American public. Carefully designed surveys inquiring about sexual matters, for example, appear to be capable of obtaining response rates that rival those of commercial and academic surveys on less sensitive topics.
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From page 276... ...
. Reliability There is a fairly large body of research reporting on the consistency of responses over short periods of time in survey reports on venous AIDS risk behaviors.
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From page 277... ...
Lange and colleagues (1988) , for example, recently reported that, according to self-reports collected in survey interviews, only 70 percent of IV drug users In New York City had shared needles at some time In their life.
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From page 278... ...
Skills Demonstrations A further supplement to self-reports are skins demonstrations in which subjects show their ability to practice preventive behaviors. For example, a test of a prevention program with injection drug users has used demonstrations of the ability to clean needles and use condoms properly as outcome measures (Heitzman et al., 1989~.
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From page 279... ...
, there is little doubt that researchers' appreciation of the problems that attend key measurements can be sharpened by greater use of exploratory studies prior to the launching of major surveys. Among the techniques that can be profitably employed are ethnographic studies and focus groups whose aim is to explore the frames of reference and language that respondents use in approaching a given topic area; pretests and pilot studies that explore the respondents' understanding of prel~minary versions of questionnaires; and cognitive research strategies Mat detail the limits of recall and the strategies respondents use in answering questions that demand recall of events that are not Erectly accessible (e.g., how many sexual encounters have you had with John in the past S8For example, masturbation, inser~ve and receptive oral sex, insertive and receptive anal sex, and so form.
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From page 280... ...
; they are not easily adapted for use in estimating continuous vanables (e.g., number of sexual partners) .60 Binary, respondents may not understand or follow S9Even where the total sample size is large, use of randomized response techniques may yield estimates for subpopulations (e.g., unmanied males, ages 21-30)
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From page 281... ...
Although there have been convincing demonstrations of their ability to increase response rates and to reduce bias in some instances (Goodstadt and Gruson, 1975) , the evidence from other studies has been equivocal (e.g., Bradburn et al., 1979:~-13~.
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From page 282... ...
The pilot phase of the research included among its aims exploration of the dimensions of the topics that were to be included in the survey, clarification of appropriate language to be used in posing questions, identification of sensitive issues and ways of gathering data on these topics, and prelim~nary examination of the impact of interviewer characteristics (e.g., gender, sexual onentation) on the willingness of respondents to discuss their sexual behaviors.
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From page 283... ...
Indeed, simple tactics, such as asking respondents to restate In their own words what was meant by an individual survey question, can be tremendously useful in identifying survey questions Hat do not have equivalent meanings for all respondents (or, equally important, do not have the same meaning for respondents and the investigatory. Although much can be done using these procedures, some ~nvestigators have ~n~oduced more systematic data gathering into the pretest process.
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From page 284... ...
In that regard the committee notes that two examples used previously may be atypical of the types of information in which AIDS researchers are most interested. Questions regarding chronological age and sexual activity during the past day (or week)
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From page 285... ...
For example, in estimating frequency of sexual activity over a prolonged period, the respondent may concentrate on a particular short time interval (e.g., the last week or two) and then multiply.
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From page 286... ...
The last year in particular has witnessed publication of several studies that used such techn~ques to evaluate and improve survey measurements of heal~-related and other events (Brewer, Dull, and Jobe, 1989; Lessler, Tourangeau, and Salter, 1989; Means et al., 1989; Tucker et al., 1989~. Yet, although these techniques offer researchers new possibilities to "take account" of the effect of the recall strategy and belief factors in assessing responses, such a task is difficult and may present problems for which there are no easy solutions.
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From page 287... ...
Examples of Studies Related to HIV Transmission Male-Male Sexual Contacts Anthropological research among Mexicans and Mexican Americans in southern Califo~a67 provides a telling example of the benefits of an ethnographic approach to data gathenng. Studies of sexual behavior in Mexico indicate Hat Mexican men who engage In same-gender sex have 67By August 1989, 1,151 cases of AIDS had been recorded in Orange County, mainly among homosexual (67.8 percent)
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From page 288... ...
can certainly identify "dope fiends among their numbers," they also recognize and distinguish several other types of drug users: "addicts" who pursue drugs constantly but who often have families and jobs and thus participate to some extent in the "straight" world; "hope fiends" who are either unable or unwilling to pursue money to support their habit but who hang around drug
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From page 289... ...
study of black IV drug users in Denver also challenges the common stereotype of the drug addict. In Denver, Koester found heroin habits that rarely required more than a $50 a day to sustain, and the petty thefts that supported the drug user's habits were often directed at over addicts.
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From page 290... ...
The researcher has an ethical responsibility to ensure that identities are protected and Mat the study causes no harm, an objective that the subjects of the study often monitor and probe. AIDS research presents a special methodological challenge as anthropolog~sts investigate the worlds of men and women who have bisexual and same-gender sexual relations or who may be IV drug users and their sex parkers, prostitutes and their clients, male hustlers, prison inmates, 69Analysis of anthropological data is tempered by an awareness that knowledge in various societies is distributed and controlled in different ways.
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From page 291... ...
As a participant observer, the e~nographer documents the kinds of questions, attitudes, and theories the former drug users express, training them to do the same in their own daily reports. In turn, the ethnographer learns about drug use from these outreach workers, and their presence facilitates his or her acceptance as an outsider asking questions on sensitive issues (Mason, 1988; Weibel, 1988~.
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From page 292... ...
For an epidemiologist, however, the chart provides an index of the number of people at risk for HIV infection because it records the frequency of sexual intercourse, He categories of sexual partners (those who live together, those who are lovers or more casual pawners, and those involved in prostitution) , and whether contraceptives are used.7~ Regional comparisons, which are commonly used In ethnographic research, have been rare In the anthropology of HIV infection.
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From page 293... ...
Given New York's much higher seroprevalence among IV drug users, documentation of these widely varying conditions of injection equipment use provides some contextual understanding of the spread of the virus and the diffenng character of the epidemic in each location (Watters, 1989~. Although most social research on AIDS has concerned the behaviors that put people at risk for HTV infection, a recent review of the ethnographic literature on sexual behaviors (Cassidy and Porter, 1989)
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From page 294... ...
Gaps and Deficiencies in Current Ethnographic Research The current flurry of anthropological research on sexual behavior and drug use suffers from the absence of a sustained scholarly tradition in both fields. Although there is more research on sexual behavior than on drug use, the study of sexuality has focused for several decades on sexual meanings and beliefs and has tended to ignore sexual behaviors.
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From page 295... ...
and the way in which laws that make carrying a syringe a crime increase the probability that drug users will adopt risky behaviors (Koester, l989a,b)
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From page 296... ...
The committee recommends that researchers who conduct behavioral surveys on HIV transmission make increased use of ethnographic studies, pretests, pilot studies, cognitive laboratory investigations, and other similar developmental strategies to aid in the design of large-scale surveys. The committee recommends that, where appropriate, researchers embed experimental studies within behavioral surveys on HIV transmission to assess the effects of key aspects of the survey measurement process.
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From page 297... ...
(1989) Declining incidence of acute hepatitis B among drug users in Amsterdam may indicate a change in risk behavior.
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From page 298... ...
(1989) Methadone maintenance for AIDS-affected IV drug users: Psychiatric factors and outcome three months into treatment (abstract)
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From page 299... ...
(1989) Demographic and behavioral features of HIV infection in intravenous drug users in New York City drug treatment programs: 1985-1988.
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From page 300... ...
(1989) Cocaine use and HIV infection in intravenous drug users.
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From page 301... ...
(1989) Perception of risk and HIV infection among intravenous drug users (IVDUs)
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From page 302... ...
(1989a) Intravenous drug users and maintenance of behavior change.
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From page 303... ...
(1988) The ethnography of needle shanug among intravenous drug users and implications for public policies and intervention strategies.
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From page 304... ...
(1989) Risk factors for HIV-1 infection among street-recruited intravenous drug users in New York City.
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From page 305... ...
(1989) Endocarditis, subcutaneous abscesses, and other bacterial infections in intravenous drug users and their association with skin-cleaning at drug injection sites.
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From page 306... ...
(1988) Psychological assessment and AIDS research with intravenous drug users: Challenges in measurement.
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From page 307... ...
(1989a) The risk of HIV transmission from sharing water, drug-mixing containers and cotton filters among intravenous drug users.
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From page 308... ...
(1973) Methodological issues in drug usage surveys: Anonymity, recency, and frequency.
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From page 309... ...
(1988) Risk factors for HIV and HBV infections in intravenous drug users.
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From page 310... ...
Development of a strategy to combat HIV contagion among San Francisco intravenous drug users.
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From page 311... ...
(1990) Intravenous drug use and HIV infection in Miami.
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From page 312... ...
(1988) HIV infection in intravenous drug users: A follow-up study indicating changes in risk-taking behaviour.
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From page 313... ...
(1989) Use of a fingerstick paper-absorbed blood sample for HIV serosurveys in intravenous drug users.
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From page 314... ...
(1989) Dete~ll~inants of sexual risk reduction in female IV drug users recruited from the street.
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From page 315... ...
(1989) Observations on the importance of social context in HIV transmission among intravenous drug users.
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From page 316... ...
(1988) HIV seroprevalence in syringes of intravenous drug users using syringe exchanges in Sydney, Australia, 1987.
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