As part of an extensive study of drug users, AIDS, and HIV, the virus that causes AIDS, researchers at the University of Alaska Anchorage have assembled data measuring the risk perceptions of individuals in Anchorage who are at some actual risk for contracting HIV. These data may have some implications for correctional systems. Inmates appear to be at increased actual risk of HIV infection because of the nature of prison life. During confinement inmates have less access to clean needles or condoms than the general population, yet research indicates that within prisons, despite efforts at control, illicit drug use and sexual activity continue. Other research indicates that HIV seroprevalence rates among incoming inmates in U.S. correctional facilities are high compared to rates for the general public (Table 1).
Early HIV prevention efforts revealed that information alone was not enough to effect the changes in behavior necessary to slow the spread of the disease. Beyond a certain level, increasing what a person knows about AIDS does not seem to affect behavior. This finding led researchers to look for other factors related to behavior change.
One promising variable is risk perception. Several theories of health behavior suggest that it is an individual's perception of risk rather than the actual risk involved that determines behavior. Hence it is important to assess the risk perception of those at greatest actual risk.
The UAA study sought to determine factors related to the perceived risk of AIDS among a sample of drug users from the Municipality of Anchorage. Information obtained from 1002 users participating in the study between October 1991 and April 1994 was examined. All participants were eighteen or older, showed evidence of recent drug use (through positive urinalysis or needle marks) and had not been in treatment during the preceding thirty days. Males were 69 per cent of the sample; females, 31 per cent. Forty-one per cent were Caucasian (non-Hispanic); 36 per cent were Black (non-Hispanic); 17 per cent, Alaska Native or American Indian; and 6 per cent, Hispanic, Asian, Pacific Islander or unknown. Seventy per cent of the sample had been arrested at least once.
Participants were classified according to actual AIDS risk associated with drug use. Those who had injected a drug any time during the previous month (IDUs) were classified as high risk - 30 per cent; all others (non-IDUs) were classified as low risk for drug behavior. (The 70 per cent who were non-injectors were primarily crack smokers.)
Participants were also classified according to sexual behavior. Higher actual risk from sexual behavior was associated with more partners, more IDU partners and less condom use.
To determine their level of risk perception, participants were asked what they believed their chance of contracting AIDS was. Almost three-quarters of the subjects reported either "no chance" or "some chance" of contracting the disease - and were classified as having low risk perception. Those reporting their risk as "half" chance or "high" chance were classified as having high risk perception. (The overall low perception of risk among study participants may be due to the relatively low HIV seroprevalence in Anchorage.)
The actual risk variables were then analyzed in conjunction with the risk perception variables, both individually and in combination. The results show that higher risk perception was associated with higher actual risk, when the variables were analyzed singly; that is, those who were IDUs, those who had more sex partners, or those who had more IDU sex partners, were more likely to see themselves at higher risk. In addition, those individuals who had been arrested more than once perceived themselves at higher risk for HIV infection. (This perception may be related to the fact that arrest often results in incarceration, and perception of risk may grow during incarceration. Also, those engaging in the riskiest behavior may be more likely to be arrested.)
When actual risk variables were analyzed in combination, IDUs, individuals with multiple sex partners, and people with more than one arrest were more likely to perceive themselves at high risk of HIV infection.
These results of the analysis suggest that, overall, while perceived risk of HIV infection is low, the level of perception is related to actual risk from both drug use and sexual behavior among this sample of drug users in Anchorage. This may be encouraging from a prevention standpoint if, as theorists suggest, those who perceive themselves at risk are most likely to change their behavior.
However, one result from the analysis was more worrisome. IDUs, considered as a group solely on this variable, did not exhibit an increased perception of risk in association with an increase in the number of sexual partners, although they did recognize the increased danger associated with their drug usage patterns. Perhaps compared to the elevated risk IDUs perceive from their injection drug use, the added danger from having multiple sex partners appears negligible. Hence, prevention programs targeting IDUs might emphasize the risk associated with unsafe sexual behavior without minimizing that incurred from injecting drugs.
The significance of these findings depends upon the nature of the relationship between perception of risk and behavior change. Research examining this link and refining the picture of those at most risk can contribute to further development of AIDS prevention programs aimed at drug-users or other groups, including those within the correctional system.
Andrea M. Fenaughty is a post-doctoral fellow with the University of Alaska Anchorage. Holly A. Massay is a graduate student in clinical psychology. Dennis G. Fisher is an associate professor in the Department of Psychology at University of Alaska Anchorage.