report on guest AIDS survey

Public health officials estimate that an increasing number of homeless persons in Massachusetts are infected with HIV. For shelter providers, this knowledge represents an urgent service mandate: to decrease the risk factors associated with transmission of HIV in the homeless population and to improve the quality of care available to those who are infected.

The Life Lines Project was funded in 1989 by the federal Centers for Disease Control, through the Massachusetts Department of Public Health. The program is supported by and located at the Shattuck Shelter, a 186 bed shelter for homeless adults in Boston. The Life Lines Project seeks to decrease the transmission of AIDS among the homeless by coordinating prevention activities in the Massachusetts shelter system and by developing a model of prevention education which specifically targets the needs of homeless individuals.

In spite of growing attention to the problem of HIV infection among the homeless, little is known about AIDS awareness or the effectiveness of AIDS prevention activities in the homeless population. In order to reduce this knowledge gap and to provide the project with a baseline from which effective program planning could evolve, the Life Lines Project sponsored a survey of homeless persons at a shelter and a night time drop-in center for the homeless in Boston. This report describes the results of this Life Lines AIDS Awareness Study.

Methodology

Ninety-one homeless persons were interviewed at two locations: the Shattuck Shelter and the Boston Night Center. The amount of AIDS prevention activity to which guests had been exposed at these locations was expected to differ.

The Shattuck Shelter is a 186-bed shelter in Boston's Jamaica Plain community, offering a wide range of service programs and health care facilities for the homeless, including respite beds for homeless persons discharged from local hospitals. The offices of the Life Lines AIDS Prevention Project are at the Shattuck Shelter. Project and shelter staff have engaged in a range of prevention activities, including discussion groups, daily distribution of condoms and bleach vials (for cleaning needles), frequent distribution of literature and staff training.

The Boston Night Center provides a night-time resting and socializing area for 60 homeless adults in downtown Boston. Most activities occur in a small room used during the day as a cafeteria; staff serve food, encourage guests to engage in conversation and refer guests to medical and other services. A registered nurse provides some AIDS prevention activities,
including condom distribution and small educational groups. The Life Lines Project provides technical support as well as educational and risk reduction materials.

These two shelters were selected to provide a contrast between a setting for homeless persons where more AIDS prevention activities had occurred and a setting where these activities had been less common. One indication of the difference in prevention activities between these two settings is the number of condoms distributed between August and November, 1990: on average, 1.25 condoms per guest each month at the Night Center and 2.88 per guest each month at the Shattuck Shelter.[1]

The higher level of prevention activities at the Shattuck Shelter is also reflected in differences in other prevention activities: prevention posters were displayed at the Shattuck Shelter but not at the Night Center; condoms and bleach vials were available daily on an anonymous basis at the Shattuck Shelter but only weekly at the Night Center; greeting cards with prevention information had been distributed on four occasions at Shattuck but only once at the Night Center. Shattuck guests in its "stabilization" program for alcoholics were required to attend weekly AIDS education groups, while voluntary meetings for other guests were held monthly; the Night Center held voluntary weekly AIDS education meetings. In neither shelter were AIDS education groups attended by more than a few people. Clearly, the Night Center does not represent a "control" condition where AIDS prevention activities had not occurred, but it is a setting where prevention activities had been less common.

A team of seven current or former UMass/Boston graduate students interviewed guests during August and September, 1990. One-third of the Shattuck Shelter's guests were selected for interviews using a systematic random sampling procedure. Conditions at the Boston Night Center did not permit a random sampling procedure; instead, interviewees were selected nightly on an availability basis. The total number of interviews completed was nearly equivalent to the total number of persons using the Center on any particular night. All subjects signed a consent form before the interview and received three dollars after the interview. In both locations, the refusal rate was approximately one in five.

The interview schedule contained 155 fixed-choice questions (some with multiple parts) and required 45 to 90 minutes to complete. Questions were designed to provide a comprehensive assessment of AIDS awareness, AIDS prevention activities, and related attitudes and behaviors. Other interview sections measured other physical and mental health problems, social supports, income supports, residential experience and satisfaction with shelter services.

Two indices were constructed in order to facilitate data analysis. The AIDS Prevention Index represents the number of prevention activities that the respondent had observed at the shelter. The AIDS Knowledge Index is the percent of 18 questions about AIDS that the respondent answered correctly.

Most of the report describes the distribution of AIDS awareness at the two shelters, including level of knowledge, level of comfort with proactive prevention efforts, perception of prevention activities, interest in learning about AIDS and worry about AIDS. In addition, the report identifies the characteristics and attitudes of individuals that are associated with AIDS awareness. Possible influences examined are self-reported reading ability, length of time homeless and at the shelter, involvement in shelter programs, physical and mental health, substance abuse, social supports, and age, race and sex.

These analyses are used to identify the impact of the Life Lines project on AIDS awareness. Specifically, conclusions about program impact will be based on: (1) the difference between the Shattuck Shelter and the Night Center in AIDS knowledge, AIDS prevention activities, perceived behavioral impact of AIDS prevention activity and worry about HIV infection; (2) the relation between awareness of prevention activities and AIDS knowledge and orientation; (3) the relation between participation in prevention activities and AIDS knowledge and orientation.

The report concludes with a list of implications for program planning.

AIDS Prevention

Respondents were asked if they had noticed four specific AIDS prevention activities at the shelter, as well as about their interest in participating in AIDS education and prevention activities. An index of perceived prevention activities was constructed from all relevant questions for use as a summary measure, while data from the index components and from other questions also are presented separately.

Components

As anticipated, guests perceived a much higher level of AIDS prevention activities at the Shattuck Shelter than at the Night Center (table 1). In fact, awareness of at least one AIDS prevention activity--distribution of condoms--was nearly universal at the Shattuck Shelter. Two-thirds had noticed bleach bottles for drug users, the other prevention activity occurring on a daily basis, while about half had received prevention information and a special greeting card, on a holiday, with a condom. The corresponding percentages at the Night Center ranged from one half (noticed condoms) to less than one third (received prevention information or a card with a condom)

Table 1

AIDS Prevention Activities

Percent of Guests Aware of Shattuck Night Ctr

Prevention Activities

Have Read Info at Shelter 52% 30%

Noticed Condoms Available 92% 51%

Received Card with Condom 46% 26%

Noticed Bleach Bottles 68% 36%

The two shelters also differed in the proportion of guests who had been tested for HIV infection and who had attended an AIDS education meeting, although the differences were smaller in size (table 2). One-third of the Shattuck guests had been tested for HIV infection, compared to one-quarter of those at the Night Center. One-seventh of the Shattuck guests had attended an AIDS education meeting, compared to one-twentieth of those at the Night Center. At both shelters, between one-quarter and one-third either did not want to be tested for HIV infection or had heard of an AIDS education meeting but had declined to attend.

Table 2

Participation in AIDS Prevention

Like to Get Tested Shattuck Night Ctr

Have Been Tested 31% 24%

Yes 33 49

Not Sure 12 5

No 24 22

(51) (37)

Attended AIDS Educ. Meeting

Attended 14% 5%

Haven't Heard About One 55 65

Heard But Didn't Go 31 30
(51) (37)

Between two-thirds and three-quarters of the guests at both shelters felt comfortable with most of the steps involved in lessening their risk of HIV infection (table 3). Guests felt particularly comfortable taking a condom from a basket, speaking to a staff member about AIDS, and about attending an AIDS education meeting--somewhat more at the Shattuck Shelter.

About two-thirds of the Shattuck Shelter guests were interested in learning more about AIDS and a similar proportion thought AIDS education activities were considerably or extremely important. The comparable proportions were slightly lower at the Night Center.

Table 3

Comfort with AIDS Prevention

Feel Comfortable - Prevention Shattuck Night Ctr

Taking Condom from Basket 76% 86%

Asking Male Staff for Condom 65% 75%

Asking Female Staff for Condom 61% 61%

Taking Bleach from Basket 67% 54%

Asking Staff Member for Bleach 63% 62%

Speak to Staff about AIDS? 78% 92%

Like to Learn More 67% 60%

Would Attend AIDS Meeting 72% 86%

Importance of AIDS Education

NOT AT ALL 10.4% 10.8%

SLIGHTLY 6.3 13.5

MODERATELY 14.6 10.8

CONSIDERABLY 10.4 18.9

EXTREMELY 58.3 45.9

(48) (37)

The social climate for persons living with AIDS was viewed as roughly comparable at both shelters: about three-quarters of the guests thought that persons infected with HIV were treated more poorly than others (table 4). Between one-fifth and two-fifths believed that AIDS education had affected their own behavior or that of others; a perception that was held more widely at the Shattuck Shelter. Almost all guests at the Night Center and three-quarters of guests at the Shattuck Shelter thought that the program staff should do more to prevent AIDS.

Table 4

Evaluation of AIDS Prevention

Evaluation of AIDS Prevention Shattuck Night Ctr

If AIDS, Treated Poorly 79% 73%

Shelter Staff Should Do More 74% 92%

AIDS Educ. Affected Behav. 28% 19%

AIDS Educ. Affected Others 38% 30%

Overall

An overall indication of the extent of prevention activities at the two shelters is provided by a count of the number of prevention activities that shelter guests had observed. The distributions of this count for the two shelters are presented in Figure 1. On average, Shattuck guests were aware of 60 percent of the prevention activities mentioned, compared to 34 percent among the Night Center guests. The distributions were skewed in opposite directions, with many Night Center guests aware of no prevention activities and many Shattuck guests aware of all five.

Figure 1

Number of AIDS Prevention Acts Aware of^*

----------+******************

.00 I 4 I (11) *

----------+******************

---------------*

1.00 I(6) 6 *

---------------*

------------------*-+

2.00 I(7) 8 I

------------------*-+

---------------*----------------------+

3.00 I(6) * 15 I

---------------*----------------------+

----------*---------+

4.00 I(4) * 8 I

----------*---------+

-----*----------------------+

5.00 I(2) * 11 I

-----*----------------------+

I.........I.........I.........I.........I

0 4 8 12 16

Frequency

^*Dashed bars indicate Shattuck Shelter respondents, asterisks indicate Night Center respondents. Frequencies in parentheses are for the Night Center.

Valid cases

Shattuck 52

Night Center 38

AIDS Awareness

Respondents' knowledge and concerns about AIDS were measured with a series of statements concerning HIV transmission and the development of AIDS, and several questions concerning worry about AIDS. Respondents were also asked whether they knew anyone with AIDS. Responses to the knowledge statements were scored as correct or incorrect and then combined to create an AIDS knowledge index.

Components

Many guests knew the most basic facts about AIDS and how to prevent it, and the level of basic knowledge did not differ substantially between the two shelters. Almost all guests knew that you could get HIV from unsafe sex or sharing needles with an infected person (table 5).[2] No more than one in five thought, mistakenly, that people can get HIV from casual contact: a toilet seat used by an infected person, being near or hugging an infected person, eating food prepared by an infected person. However, one-quarter believed that you could get HIV from an insect bite, two in five believed that you could get HIV from kissing an infected person, and three in five believed that you could get HIV from giving blood.

Table 5

AIDS Knowledge

Percent Who Believe These Shattuck Night Ctr

Things Can "Give you AIDS"

Being Near Infected People 21% 18%

Hugging an Infected Person 8% 14%

Being Bitten by an Insect 26% 29%

Having Sex with Infected Person 98% 95%

Sharing Needles with Drug Users 100% 95%

Giving Blood 61% 65%

Toilet Seat Used by Infected 16% 19%

Kissing Infected Person on Mouth 37% 41%

Eating Food Prepared by Infected 22% 22%

Almost all the guests knew that you could do a lot to avoid HIV, including using condoms and limiting the number of sex partners; about three quarters knew that drug users could avoid getting HIV and almost nine in ten knew that AIDS is not confined to gay men (table 6). About two-thirds understood the basics of the development of AIDS--that you could still feel healthy after being infected and that there is no cure; even more knew that only a blood test tells whether you have HIV and that people do not die soon after they are infected.

Although there were almost no differences between the two shelters in knowledge of how people get HIV, Night Center guests were somewhat less well informed about AIDS not being just a gay men's disease, about the fact that people do not die soon after they have been infected, and about the value of condom use even after infection with the AIDS virus. Night Center guests also were somewhat more fatalistic about the odds of getting AIDS, although they were slightly better informed about the fact that people can remain healthy for a long time after they are infected.

Table 6

Beliefs about AIDS

Percent Agreeing with

Statements About AIDS^* Shattuck Night Ctr

I'll Probably Get AIDS^** 12% 25%

There's No Cure for AIDS 61% 58%

Infected People Can Still Feel Healthy 67% 78%

AIDS Only Affects Gay Men 2% 11%

The More Sex Partners, More Risk of AIDS 94% 92%

No Way Drug Users Can Avoid AIDS 26% 25%

I'm Afraid Around Infected People^** 44% 30%

It Helps a Lot to Use a Condom 94% 100%

Only a Blood Test Tells if Infected 88% 84%

People Can Do a Lot to Avoid Infection 94% 92%

Men Can't Get AIDS From Sex with Woman 10% 16%

People with AIDS Die Soon After Infected 12% 35%

A Condom Doesn't Help After Infection 66% 54%

^**Item not included in AIDS Knowledge Index.

Many guests, just under half, worried a lot at both shelters about HIV, and an equal proportion perceived such worry among other guests (table 7). About one-third did not worry at all about HIV. There were no substantial differences between the two shelters in propensity to worry about HIV.

Table 7

"Worry About Getting AIDS"

Shattuck Night Ctr

Percent Who "Worry

About Getting AIDS"

A LOT 44.0% 44.7%

SOMEWHAT 20.0 18.4

NOT AT ALL 36.0 36.8

100.0% 99.9%^*

(50) (38)

Percent Who Think

Other Guests "Worry

About Getting AIDS"

A LOT 44.2% 40.0%

SOMEWHAT 34.9 28.6

NOT AT ALL 20.9 31.4

100.0% 100.0%

(43) (35)

^*Percents may not add to 100 due to rounding error.

Overall

Guests' knowledge of HIV transmission information was assessed by calculating the percentage of 20 AIDS knowledge items in the survey that were answered correctly (see tables 5, 6). The score distributions are presented in graphic form separately for the two shelters (figure 2). The mean score for the Shattuck Shelter, 76 percent correct, was almost identical to the mean for the Night Center, although the distribution of scores was more clustered toward the high end at the Shattuck Shelter.

Figure 2

Percent Correct on AIDS Knowledge Test

***

40 * *

***

--------*

50 I 3 *

--------*

----------*

60 I 4 *

----------*

---------------------*-----------+

70 I(8) * 13 I

---------------------*-----------+

----------------*-----------+

80 I(6) * 11 I

----------------*-----------+

----------------------------*---------+

90 I(11) * 15 I

----------------------------*---------+

----------*--+

100 I(4) *5 I

----------*--+

I.........I.........I.........I.........I

0 4 8 12 16

Frequency

^*Dashed bars = Shattuck Shelter respondents, asterisks indicate Night Center respondents. Night Center frequencies in parentheses.

Shattuck Mean = 76.725 Std dev = 12.892 N = 51

Night Center Mean = 74.541 Std dev = 15.800 N = 37

Knowledge of someone with AIDS is a likely influence on knowledge of AIDS facts and worry about HIV. As indicated in table 8, more than half of the Shattuck guests knew someone with AIDS, compared to just over one-third of the Night Center guests. This knowledge could, of course, reflect a greater awareness of AIDS at the Shattuck Shelter due to the Life Lines project, or a larger presence of AIDS patients due to the respite beds at the shelter for indigent persons discharged from the adjacent Shattuck Hospital and other hospitals.

Table 8

Know Anyone With AIDS?

Shattuck Night Ctr

YES 55.8 36.8

NOT SURE 1.9 2.6

NO 42.3 60.5

(52) (38)

Influences on AIDS Awareness

Awareness of prevention activities at the shelter was not in itself associated with the AIDS knowledge score, but it was positively associated with interest in learning more about AIDS (see appendix 1). Those who knew less about AIDS worried more about HIV infection. However, those who worried more about infection were also more interested in learning about AIDS. In addition, knowledge about AIDS was higher among those who knew someone with AIDS, but this relationship occurred only at the Shattuck Shelter; knowing someone with AIDS was not associated with more knowledge about AIDS at the Night Center.

Interest in being tested for HIV increased with feeling comfortable with AIDS prevention activities, interest in further AIDS education and worry about HIV. The same factors were associated with a belief that AIDS education activities had affected the respondent's behavior. Those with higher levels of AIDS knowledge seemed to be more pessimistic about the effect of AIDS education on other shelter guests.

AIDS knowledge was independent of many individual characteristics: time homeless, time using the shelter, literacy and contact with service agencies. However, AIDS knowledge declined with symptoms of depression at the Shattuck Shelter, while interest in AIDS education increased with depression symptoms (table 9). At both shelters, AIDS knowledge was lower among minorities than among whites, but interest in AIDS education was particularly high among minorities.

Table 9

Influences on AIDS Knowledge and Interest

Percent with High Level of:

AIDS Knowl. Prev. Interest

Not Depressed 56%(45) 33%(45)^*

Depressed 39%(41) 55%(40)

White 54%(41) 27%(41)^*

Minority 40%(47) 61%(46)

^*Significant at the .05 level.

Different individual characteristics help to explain variation in other aspects of AIDS awareness (table 10). Length of time homeless was associated with fewer reports of a behavioral impact of shelter-based AIDS prevention efforts. Less perceived social support was associated with more worry about HIV but less report of having changed behavior in response to AIDS prevention activities. Younger people were somewhat more worried about HIV.

Table 10

Influences on Behavior Change, Worry

Percent with High Level of:

Behavior Change Worry

Homeless less than 1 Yr. 36%(32)^* 35%(51)

Homeless more than 1 Yr. 10%(29) 24%(29)

Low Social Support 39%(44)^* 44%(43)^*

High Social Support 19%(43) 16%(43)

Under 35 Years Old 29%(38) 40%(37)

35 Years Old or More 29%(48) 22%(48)

Conclusions

The goals of the Life Lines AIDS Awareness Study were to describe AIDS awareness at two shelters, to identify the individual characteristics associated with AIDS awareness, to evaluate the impact of the Life Lines Project, and to develop the policy implications of the findings. The conclusions are organized around the first three of these goals, with the policy implications presented in a separate section.

Description of AIDS Awareness

The homeless persons surveyed knew many of the basic facts about AIDS prevention but varied in their awareness of specific transmission and health care issues. Almost all respondents understood the danger of unprotected sex and unclean needles, but almost two-thirds thought that giving blood was a hazard and a significant minority believed that kissing, insect bites and food were potential sources of HIV infection.

The value of condoms and other prevention measures was widely recognized, but a large number were unaware of the long latency period of the disease and of the ability of drug users to avoid infection; most strikingly, more than half were not aware that a condom was helpful even after infection.

Overall, the level of AIDS awareness did not differ between the two shelters. However, respondents reported much more prevention activity at the Shattuck Shelter than at the Night Center. Almost all guests at Shattuck had noticed the availability of condoms, two-thirds had noticed bleach vials and a majority had read information about AIDS at the shelter. The corresponding percentages at the Night Center were twenty to forty percent lower. Guests at Shattuck were more likely to have attended an AIDS education meeting and to have been tested for HIV.

Interest in AIDS prevention activities was high at both shelters. Almost four in five were interested in being tested for HIV or already had been tested. Most had not attended an AIDS education meeting, but the reason seemed to be that they hadn't heard of these meetings: about three-quarters said they would attend an AIDS education meeting if it was at a convenient time, two-thirds wanted to learn more about AIDS and thought AIDS education was considerably or extremely important.

Social inhibitions did not seem to create a major barrier to the effectiveness of AIDS prevention activities: just one-third of the respondents were reluctant to ask for condoms or bleach and less than one-quarter were unwilling to take condoms anonymously or to speak to staff about AIDS.

Individual Correlates of AIDS Awareness

The findings reported here and a supplementary factor analysis (not reported) suggest that what has been termed "AIDS awareness" in this report actually has multiple dimensions; that is, there are distinct "clusters" of attitudes concerning different aspects of AIDS awareness. One dimension is primarily cognitive and involves an association between knowledge about AIDS and reduced worry about HIV. Another dimension involves prevention activity directly: exposure to prevention activities, feeling comfortable about prevention activities, and perception that others worry about HIV. A third dimension concerns interest in AIDS prevention and AIDS education, which is also related to exposure to prevention activities. A fourth dimension involves perceptions of behavior change in self and others as a result of AIDS prevention activities, which is also related to feeling comfortable with prevention activities.

If AIDS awareness is a multidimensional phenomenon, different strategies are likely to be required to influence different awareness dimensions. This is also suggested by the differing relationships between individual characteristics and particular aspects of AIDS awareness: AIDS knowledge was higher among whites and those who were less depressed, but interest in AIDS education was higher among minorities and those who were more depressed. Younger age and lower levels of social support were both associated with more worry about becoming infected. Gender, literacy and contact with other service agencies were not related to any aspects of AIDS awareness.

Impact of the Life Lines Project

Did the Life Lines AIDS Prevention Project have an impact on AIDS prevention activities or AIDS awareness? There was substantial evidence of a positive project impact on prevention activities: (1) About ten percent more of the respondents at Shattuck than at the Night Center reported that AIDS education efforts had affected their own behavior and the behavior of other shelter guests. (2) About twenty percent fewer Shattuck respondents thought shelter staff should do more to prevent AIDS, compared to the Night Center. (3) Awareness of AIDS prevention activities was much more common at Shattuck than at the Night Center. (4) More of the respondents who wanted to be tested for HIV had been tested at Shattuck. (5) More of the respondents who had heard of an AIDS education meeting had actually attended one at Shattuck. (6) More of the Shattuck respondents thought AIDS education was extremely important. (7) Fewer Shattuck respondents believed that they would eventually get AIDS. In addition, exposure to AIDS prevention activities was associated with more interest in AIDS prevention and less worry about HIV infection.

There was much less evidence of project impact on AIDS knowledge: (1) There was no difference in overall AIDS knowledge between the two shelters; Shattuck respondents seemed better informed on only two measures--they were less likely to think that AIDS was a gay men's disease or that people die soon after they are infected with HIV. (2) There was no difference in amount of worrying about HIV between the two shelters. (3) There was no relationship between the amount of prevention activity to which the respondent had been exposed and their overall knowledge about AIDS.

The interpretation of one other important difference between the two shelters is less clear. Shattuck guests were much more likely to know someone who had AIDS; whether this could have been due to the medical respite beds at Shattuck or to more open discussion about AIDS stimulated by prevention activity, it suggests a greater openness to future AIDS prevention efforts.

It is understandable that the Life Lines project appeared to have a greater influence on awareness of and interest in prevention activities than on knowledge of AIDS prevention facts, since the most frequent and visible project activities, distribution of condoms and bleach vials, were themselves oriented more to prevention than to knowledge. Attendance at AIDS education meetings was uncommon and unlikely to have had a noticeable impact on the total shelter population; furthermore, those who had received project literature, like those who had attended meetings, may not have read or understood the material.

But the ultimate goal of the Life Lines AIDS Prevention Project is to reduce risk behavior, not simply to increase knowledge about risk. Indications of the project's impact on prevention activities and individual behavior are thus potentially of much greater significance than would be indications of project impact on knowledge about the role of insects, kissing or food preparation in HIV transmission.

Judgments of the project's effect must also be tempered due to three methodological limitations. First, the survey did not attempt to measure directly participation in prevention activities--so the criteria used to identify project effects are not direct indicators of project goal achievement. Second, the comparison between the Shattuck Shelter and the Night Center, which underlies most of the conclusions about project effects, was not a comparison between a shelter where AIDS education had occurred with one where it had been absent. Use of a true "control group" for comparisons may have revealed more project effects. Finally, the Boston Night Center was not a true random sample. All conclusions based on the Night Center data must be treated as only tentative.

Policy Implications

1. The distribution of condoms and bleach on an anonymous basis seems to have been very effective. When it was done on a regular basis, guests were aware of it and few guests felt any inhibition about taking condoms or bleach. On the other hand, some were reluctant to ask staff for condoms or bleach. Every shelter should consider adopting a practice of regular, anonymous distribution of these critical AIDS prevention supplies.

2. Basic AIDS facts have been communicated effectively to homeless persons. This suggests that education efforts can be effective; expanded educational efforts may be able to broaden knowledge about HIV transmission.

3. Risk reduction must be the ultimate goal of AIDS prevention efforts. Making prevention materials more accessible and increasing knowledge about HIV transmission are necessary, but not sufficient steps to slow the spread of AIDS.

4. Many guests had not received AIDS prevention literature. Since distribution of literature is relatively easy, more effective distribution methods should be adopted. Although receipt of literature does not guarantee reading or understanding, it is an important first step toward increasing knowledge about AIDS.

5. Interest in AIDS education, including education meetings, was very high, but participation in AIDS education meetings had been very low. More efforts should be made to publicize these meetings, to schedule them at convenient times, and to try different formats that could relax inhibitions to participating.

6. Few guests had been tested for HIV, but most of those who hadn't been tested wanted to be tested. Testing for HIV should be available as a part of any shelter-based medical program, together with support services for those guests who test positive. Opportunities for testing should be publicized widely so that all those who are interested can participate.

7. Most guests believed that individuals infected with the AIDS virus were stigmatized by others. Clearly, preserving confidentiality of HIV status must be seen as critical for the success of a testing program. In addition, efforts should be made to increase tolerance of and understanding about HIV infection.

8. More education is needed to inform shelter guests about the value of condom use even after HIV infection, as well as about the actions that drug users can take to avoid HIV.

9. Black and Hispanic guests are at greater risk for contracting AIDS, according to general population statistics, and should be the subject of special education efforts: on average, these guests were less well informed about AIDS but were more interested in learning about AIDS than guests who were white.

10. Younger people are likely to be at more risk of HIV infection. The somewhat higher level of worry about HIV expressed by young people in this study suggests that they should be targeted for more AIDS prevention activities. Social gatherings that are more attractive to young people may provide an appropriate vehicle for reaching out more effectively to them about AIDS prevention.

11. Depression influences AIDS awareness in ways that should be taken into account in mental health and AIDS prevention programs. Guests who feel depressed tend to know less about AIDS and may perhaps best be approached about AIDS in the context of delivering mental health services.

12. It is important to make episodes of homelessness as brief as possible. The feelings of hopelessness associated with longer spells of homelessness seem to decrease interest in trying to prevent infection with HIV and lessen behavior change in response to shelter-based prevention efforts.

13. In order to have a large impact on knowledge about AIDS among homeless persons, large scale programs over extended time periods probably are necessary. However, the difficulty of increasing knowledge beyond the most basic level should not deter such efforts, as misconceptions about HIV transmission inevitably increase the risk of HIV infection. It may be important to place greater emphasis on visual and verbal methods of distributing information, so that those who read poorly are reached.

14. Evaluation of the impact of prevention activities on the target population should make an effort to measure extent of participation in risky behaviors directly.

15. Knowing someone with AIDS was associated with more AIDS awareness. AIDS prevention programs might consider sponsoring discussions led by persons living with AIDS, probably from outside the shelter.

16. There was only a weak association between self-reported drug use and behavioral change in response to AIDS prevention efforts. More intense efforts are needed to reach this key subgroup.

Appendix 1

Correlations Among Selected AIDS Awareness Indicators

KNOWAID PREVENT COMFORT INTEREST WORRY Othr Worry

KNOWAID 1.0000 -.0570 .0413 -.1467 -.3938 .1917

( 88) ( 88) ( 87) ( 87) ( 86) ( 78)

P= . P= .299 P= .352 P= .088 P= .000 P= .046

PREVENT -.0570 1.0000 .1221 .2816 .0216 -.1646

( 88) ( 91) ( 87) ( 87) ( 86) ( 78)

P= .299 P= . P= .130 P= .004 P= .422 P= .075

COMFORT .0413 .1221 1.0000 .0241 .0137 -.1575

( 87) ( 87) ( 87) ( 86) ( 85) ( 78)

P= .352 P= .130 P= . P= .413 P= .451 P= .084

INTEREST -.1467 .2816 .0241 1.0000 .1883 -.0908

( 87) ( 87) ( 86) ( 87) ( 85) ( 78)

P= .088 P= .004 P= .413 P= . P= .042 P= .215

WORRY -.3938 .0216 .0137 .1883 1.0000 -.1581

( 86) ( 86) ( 85) ( 85) ( 86) ( 76)

P= .000 P= .422 P= .451 P= .042 P= . P= .086

Others .1917 -.1646 -.1575 -.0908 -.1581 1.0000

Worry ( 78) ( 78) ( 78) ( 78) ( 76) ( 78)

Abt AIDSP= .046 P= .075 P= .084 P= .215 P= .086 P= .

Know -.1954 -.2202 -.0692 -.1494 .0751 -.0912

Someone ( 88) ( 90) ( 87) ( 87) ( 86) ( 78)

w/AIDS P= .034 P= .019 P= .262 P= .084 P= .246 P= .214

Not Like -.1154 -.1140 -.2156 -.3002 -.2053 .2304

to be ( 88) ( 88) ( 87) ( 87) ( 86) ( 78)

Tested P= .142 P= .145 P= .022 P= .002 P= .029 P= .021

Ed. .1076 -.1370 -.1377 -.2409 -.2438 .1326

Affected( 87) ( 87) ( 86) ( 87) ( 85) ( 78)

Own Beh.P= .161 P= .103 P= .103 P= .012 P= .012 P= .124

Ed. .2064 -.1354 -.2190 -.1843 -.1329 .1167

Affected( 87) ( 87) ( 86) ( 87) ( 85) ( 78)

Others P= .028 P= .106 P= .021 P= .044 P= .113 P= .154

Imp. of -.1772 .2809 .1700 .7070 .3077 -.1836

AIDS Ed ( 85) ( 85) ( 84) ( 85) ( 83) ( 76)

P= .052 P= .005 P= .061 P= .000 P= .002 P= .056

Appendix 2

SURVEY OF SHELTER GUESTS: 1990

AIDS

This next section contains questions about AIDS, Acquired Immune Deficiency Syndrome. I'd like to ask what you have heard about AIDS and what your concerns are.

37. These days, there's a lot of talk about AIDS, Acquired Immune Deficiency Syndrome. How much do you worry about getting AIDS? ...

A LOT............1

SOMEWHAT.........2

NOT AT ALL.......3

38. How much do you think other people here at the shelter worry about getting AIDS?...

A LOT............1

SOMEWHAT.........2

NOT AT ALL.......3

39. Do you know anyone with AIDS?

YES..............1

NOT SURE.........2

NO...............3

40. Now I'm going to read a list of things that people sometimes do. I'd like you to tell me whether you think each of these things can give you AIDS. Just answer yes or no.

YES NO (MAYBE)

Being near infected people....................1 2 3

Hugging an infected person....................1 2 3

Being bitten by an insect.....................1 2 3

Having sex with an infected person............1 2 3

Sharing needles with drug users...............1 2 3

Giving blood..................................1 2 3

A toilet seat used by an infected person......1 2 3

Kissing an infected person on the mouth.......1 2 3

Eating food prepared by an infected person....1 2 3

41. And now can you tell me whether you agree or disagree with the following statements about AIDS? Just tell me whether you agree or disagree.

AGREE DISAGREE

Sooner or later, I'll probably get AIDS..........1 2

There's no cure for AIDS.........................1 2

Infected people can still feel healthy...........1 2

AIDS only affects gay men........................1 2

The more sex partners, the more the risk of AIDS.1 2

There's no way a drug user can avoid AIDS........1 2

I'm a bit afraid of being around infected people.1 2

It helps a lot to use a condom (rubber)..........1 2

Only a blood test tells if you are infected......1 2

People can do a lot to avoid getting AIDS........1 2

Men can't get AIDS from sex with a woman.........1 2

People with AIDS die soon after they're infected.1 2

A condom doesn't help once you're infected.......1 2

And now a few questions about AIDS prevention at the shelter.

42. Have you read any information about AIDS here at the shelter?

YES..............1

NOT SURE.........2

NO...............3

43. Have you noticed condoms, that is, rubbers, available for people here at the shelter?

YES..............1

NOT SURE.........2

NO...............3

44. Have you ever received a greeting card with a condom and candy from staff here?

YES..............1

NOT SURE.........2

NO...............3

45. Would you yourself feel comfortable taking a condom from a basket by the door?

YES..............1

NOT SURE.........2

NO...............3

46. Would you feel comfortable asking a male staff member for a condom?

YES..............1

NOT SURE.........2

NO...............3

47. Would you feel comfortable asking a female staff member for a condom?

YES..............1

NOT SURE.........2

NO...............3

48. Have you noticed bleach bottles, for cleaning needles, available for people here at the shelter?

YES..............1

NOT SURE.........2

NO...............3

49. Would you yourself feel comfortable taking bleach from a basket by the door?

YES..............1

NOT SURE.........2

NO...............3

50. Would you feel comfortable asking a staff member for bleach?

YES..............1

NOT SURE.........2

NO...............3

51. Would you speak to a staff member here about AIDS, if you thought you might have it?

YES..............1

NOT SURE.........2

NO...............3

52. Would you like to get tested for AIDS?

YES..............1

NOT SURE.........2

NO...............3

HAVE BEEN TESTED.4

53. Would you like to learn more about AIDS?

YES..............1

NOT SURE.........2

NO...............3

54. Have you ever attended an AIDS education meeting here, or haven't you heard about any?

ATTENDED.........1

HAVEN'T HEARD....2

HEARD, DIDN'T GO.3

55. Would you attend an AIDS education meeting here in the future if it were at a convenient time?

YES..............1

NOT SURE.........2

NO...............3

56. Do you think that people with AIDS are treated pretty poorly by other people who know they have AIDS?

YES..............1

NOT SURE.........2

NO...............3

57. Do you think the shelter staff should do more to tell people about AIDS?

YES..............1

NOT SURE.........2

NO...............3

58. Have AIDS education efforts here affected your own behavior?

YES..............1

NOT SURE.........2

NO...............3

59. Does it seem to you that AIDS education efforts here have affected the behavior of other guests?

YES..............1

NOT SURE.........2

NO...............3

60. How important to you now is AIDS education? Is it..._______ important?

Not at all............1

Slightly..............2

MODERATELY............3

CONSIDERABLY..........4

EXTREMELY.............5

F^OOTNOTES

^{^[1]}These figures are averages (arithmetic means). Some guests took more than the average number of condoms and some took less.

[2]The phrase "getting AIDS" was used in the interviews instead of the more accurate wording, "becoming infected with HIV," in order to maintain consistent wording throughout the interview and reduce semantic confusion.