AESOP Monograph (11/98)

WHAT WE HAVE LEARNED

FROM

THE

AIDS EVALUATION OF

STREET OUTREACH PROJECTS

A SUMMARY DOCUMENT

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Atlanta, Georgia 30333

CDC

CENTERS FOR DISEASE CONTROL

AND PREVENTION

Copies of this publication can be obtained by

writing Office of Communications, NCHSTP

Centers for Disease Control and Prevention

1600 Clifton Road, N.E., Mailstop E-06

Atlanta, GA 30333

faxing 404–639–8628

or calling NCHSTP Voice Information System

1–888–232–3228

Press 2, 5, 1, and 1 as prompted

and request

What We Have Learned from AESOP.

HAT

AVE

EARNED

FROM

THE

AIDS E

VALUATION

TREET

UTREACH

ROJECTS

A S

UMMARY

OCUMENT

Edited by

Judith B. Greenberg, PhD

Division of STD Prevention

and

Mary S. Neumann, PhD

Division of HIV/AIDS Prevention

National Center for HIV, STD, and TB Prevention

Centers for Disease Control and Prevention

Atlanta, Georgia

1998

ITE

OLLABORATORS

Agency Principal Investigator

ADAPT, New York Daniel Fernando, PhD

Children’s Hospital Michele Kipke, PhD

of Los Angeles

County of Los Angeles John Schunhoff, PhD

Department of Anna Long, PhD,

Health Services Project Director

Georgia Department Claire Sterk, PhD

of Human Resources

Philadelphia Health Rose Cheney, PhD

Management Corporation

San Francisco Department Alice Gleghorn, PhD

of Public Health

University of Illinois, Chicago Wayne Wiebel, PhD

School of Public Health Bob Nettey, MD,

Project Director

Victim Services Agency, Helene Lauffer

New York Michael Clatts, PhD,

Co-Investigator

CDC Collaborators

John E. Anderson, PhD, Coordinator

Judith Greenberg, PhD, Project Ofﬁcer

Robin MacGowan, MPH, Project Ofﬁcer

Jo Valentine, MSW, Project Ofﬁcer

Other CDC Contributors

Linda Kay, MPH

May Kennedy, PhD

Mary Spink Neumann, PhD

Lloyd Potter, PhD

John Santelli, MD

Kathy Stark, BS

Linda Wright-DeAgüero, PhD

CKNOWLEDGMENTS

The editors thank Marie Morgan, from the Division of HIV/AIDS

Prevention, for her hours of collaboration with stylistics, layout,

and prooﬁng of the many iterations of this manuscript. We also

thank Lynda Doll, PhD, and T. Stephen Jones, MD, from the Divi-

sion of HIV/AIDS Prevention–Intervention Research and Support,

for their detailed comments on earlier versions.

ONTENTS

Introduction

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1

Annotated Bibliography

- - - - - - - - - - - - - - - - - - - - - - 9

Articles

A Probability Sampling for Assessing the

Effectiveness of Outreach for Street Youth

- - - - - - - - -17

Michele D. Kipke, Susan O’Connor, Burke Nelson,

and John E. Anderson

A Storytelling Model Using Pictures for HIV

Prevention with Injection Drug Users

- - - - - - - - - - - -29

Anna Long, Judith Greenberg, Gladys Bonilla,

and Ronald Weathers

Elements of an Intensive Outreach Program for

Homeless and Runaway Street Youth in

San Francisco

- - - - - - - - - - - - - - - - - - - - - - - - - - -47

Alice A. Gleghorn, Kristen D. Clements, and

Marc Sabin

Association between Self-Identiﬁed Peer-Group

Afﬁliation and HIV Risk Behaviors among

Street Youth

- - - - - - - - - - - - - - - - - - - - - - - - - - - -61

Michele D. Kipke, Jennifer Unger, Raymond Palmer,

Ellen Iverson, and Susan O’Connor

Enhanced Street Outreach and Condom Use

by High-Risk Populations in Five Cities

- - - - - - - - - - -83

John E. Anderson, Judith Greenberg, and

Robin MacGowan

Products and Contacts for

Intervention Replication

- - - - - - - - - - - - - - - - - - - - 111

NTRODUCTION

The AIDS Evaluation of Street Outreach Projects (AESOP) was a 5-

year study designed by the Centers for Disease Control and Pre-

vention (CDC) in collaboration with researchers representing

agencies at eight sites. This cooperative study, which included

community-based organizations and health departments, was

conducted from October 1991 through September 1996. Its pur-

pose was to support studies to describe outreach services to injec-

tion drug users (IDUs) and youth in high-risk situations, calculate

the costs of such services, and develop and evaluate enhanced on-

the-street services for these populations. Collaborators at ﬁve of

the eight sites (Atlanta, Chicago, Los Angeles, New York, and Phil-

adelphia) focused on outreach to IDUs. At three sites (Los Ange-

les, New York, and San Francisco), the focus was youth.

ETHODS

The research was conducted in several phases. During the

forma-

tive phase

of approximately 1 year, the sites conducted the com-

munity assessment process (CAP) to gain maximum information

about the targeted community, including how services were deliv-

ered to these populations, and to develop speciﬁc enhancements

to outreach that could be delivered on the street to the same pop-

ulations. To assist the staff at the sites, CDC collaborated with

LTG Associates, Inc., a private contractor, to adapt the community

identiﬁcation (CID) method. This method included interviews with

groups of persons who interacted with the target population as

well as interviews with members of the population themselves. A

detailed description of CID can be found in Tashima, 1966. Using

the formative research, sites developed interventions plus a design

for evaluating them.

After the formative phase, AESOP entered the

evaluation phase

A quasi-experimental design (a study and a comparison area) was

used for each of the eight communities. Each area was to have

adequate numbers of the target group and some ongoing level of

street outreach. Cross-sectional, closed-ended surveys of the target

populations in the control and comparison areas were conducted

AESOP

before and after the development and implementation of interven-

tion enhancements. These surveys measured risk behavior, expo-

sure to outreach, and readiness for behavioral change. Staff at

each site conducted at least two preenhancement rounds of inter-

views at intervals of approximately 3 months between January

and August of 1993 and two postenhancement rounds between

1994 and 1995, once the enhancements had been fully imple-

mented for at least 3 months.

Sampling of IDUs and youth was conducted so that it would be as

representative as possible; interviews were conducted at locations

frequented by these populations. Researchers in each city identi-

ﬁed and deﬁned primary sampling units (PSUs) within the study

and comparison areas. The PSUs could be of two types: ﬁxed sites

(shelters, meal programs, drop-in centers) and on-the-street sites

(congregating areas; drug-buying, or "copping," areas; shooting

galleries). The PSUs were observed at multiple times of the day to

determine the relative number of potential respondents at each

site. The number of interviews to be obtained from each PSU was

set to be proportional to this measure of size. If the sample con-

tained ﬁxed sites (e.g., drop-in centers, shelters) and on-the-street

locations, a predetermined percentage of interviews were set for

ﬁxed and on-the-street domains. Interviewing within PSUs was

systematically scheduled by time of day and day of week so that

all relevant times would be represented. Within PSUs, respon-

dents were selected by using systematic methods, such as select-

ing every n

potential respondent by predetermined counting.

Once persons were selected, a screening questionnaire was

administered to determine eligibility, and the complete question-

naire was administered to those who were eligible.

NHANCEMENTS

AESOP enhancements differed by site because of the diversity of

participating outreach programs, geographic diversity, and the

inclusion of youth and IDUs. Enhancements were focused on the

outreach workers and encompassed a wide range of strategies:

increased training (e.g., training in stages of change, training in

the ﬁnger-stick method for HIV testing); additional resources such

NTRODUCTION

as a storytelling model with pictures for engaging the clients in

risk assessment (see article by Long et al. in this monograph),

referral tracking cards and incentive packages; a mobile van;

improved direct supervision; improvements in recordkeeping of

the delivery of outreach services and referrals; coordination of out-

reach services with other agencies at a particular site; expanded

services, including the addition of specialized staff such as a refer-

ral specialist; a storefront location for more comprehensive ser-

vices to youth (see article by Gleghorn et al. in this monograph);

changes in selection criteria for hiring outreach workers or super-

visors; and social and emotional support to minimize burnout.

Three to seven enhancement strategies were developed at each

site. Quality assurance procedures were developed for on-the-

street monitoring of outreach workers to ensure that enhance-

ments were being delivered as intended.

Eligible IDUs were deﬁned as persons within the geographical

boundaries of the study areas who had injected illegal drugs in the

past 3 years. At three sites with lower numbers of IDUs —Atlanta,

Los Angeles, and Philadelphia—up to 30% of the sample were

allowed to be persons who had used crack cocaine within the past

month. Eligibility for youth was based on age (12 to 23 years) and

lack of permanent residence (recurrently without shelter during

the past year or without permanent shelter during the past 2

months) or use of the street economy for support (drugs, prostitu-

tion, panhandling, crime).

EHAVIORAL

PIDEMIOLOGY

INDINGS

1. The initial rounds of survey research indicated that the AESOP

populations engaged in much higher levels of sexual risk

behavior than the levels found in general population surveys.

2. After AESOP enhancements, the percentages of those who had

used condoms during their most recent intercourse ranged

from 57.9% to 71.8% for casual partners. Those percentages

approach the year 2000 health objectives: 50% for unmarried

sexually active persons, 60% for sexually active women aged

AESOP

15 to 19 years, 75% for sexually active men aged 15 to 19

years, and 60% for IDUs. Rates for steady, or main, partners

remained low.

3. Among the high-risk populations studied, the highest rate of

condom use was observed for anal sex, followed by vaginal and

oral sex.

4. Outreach workers from a variety of agencies reached a size-

able percentage of IDUs in their communities and supported

them in seeking medical care, especially in seeking counseling

and testing for HIV and treatment for drug use. One third to

two thirds of respondents who had seen an outreach worker

from any program in the preceding 6 months reported having

received referrals for these two services. One third to one half

of respondents reported that they then sought these services.

5. In addition to sexual practices, street youth are at risk

through high rates of drug use that includes sharing of

syringes.

6. Youth in contact with street outreach are much more likely to

have sought health care, HIV counseling and testing, or treat-

ment for a sexually transmitted disease (STD) or for substance

use than are youth who are not in contact with street out-

reach.

7. Among street youth, a history of STD is signiﬁcantly associated

with current substance use and having multiple sex partners.

8. Homelessness and crack use are associated with lower levels

of stage of change for not sharing needles.

9. IDUs are more likely to report safer drug behavior than safer

sex behavior and tend to be at a higher level of stage of change

for not sharing needles than for condom use.

MPLICATIONS

FOR

ESEARCHERS

1. Cross-sectional data on street populations do not reveal the

time frame or process by which persons become acculturated

to and integrated into the street economy, which includes

trading of sex and drugs. The degree to which clients are

NTRODUCTION

acculturated and the length of time they have been on the

street may inﬂuence their willingness or ability to change their

behaviors.

2. Research should be planned separately for street populations

of youth and IDUs (e.g., separate goals for interventions, sepa-

rate questionnaires, and separate intervention enhancements).

3. Many factors can affect the delivery of services to street popu-

lations – weather, police activity, riots, changes in laws, urban

relocation because of special events, even the death of a cul-

tural icon, such as Jerry Garcia of the Grateful Dead band.

After Garcia’s death, large numbers of youthful

Deadheads

disappeared from the San Francisco street scene. These fac-

tors should be recorded as they happen, and they should be

considered in data analysis.

4. Surveys of target populations frequently measure only the

elimination of risk behaviors (e.g., ceasing substance use) and

often do not consider reductions in risks (e.g., not injecting in

shooting galleries) or preparations to change (e.g., intention to

buy bleach). Including such gradations of change in surveys

can provide more sensitivity in measuring behavior change at

the community level.

5. The effects of dosage or number of exposures to outreach and

of rates at which innovations diffuse in communities are impor-

tant variables to measure in community-level interventions.

6. Measures of reduced risk can become outmoded during a

study (e.g., guidelines for bleaching needles changed during

AESOP), and research methods should be ﬂexible enough to

allow for this.

7. In studying homeless populations, investigators should in-

clude length of time homeless as a variable.

MPLICATIONS

FOR

ERVICE

GENCIES

1. High percentages of street populations reported contact with

outreach workers, although many reported continued high-

risk behaviors. For many persons, street outreach may not be

sufﬁcient for behavioral change.

AESOP

2. Among street youth, substance use and having multiple sex

partners are signiﬁcantly associated with a history of STD;

therefore, in a clinical setting, an STD diagnosis for a person

from this population may be a marker for other high-risk sex

and drug-using behaviors.

UTCOME

VALUATION

INDINGS

1. Theory-based street outreach approaches can be used by

trained indigenous outreach workers.

2. Evaluation of street outreach programs is inherently difﬁcult

and requires multiple approaches.

3. There are several types of street outreach, ranging from brief

contacts to more in-depth encounters between workers and

clients.

4. Street outreach can be an effective mechanism for referring

high-risk persons to treatment.

5. Street outreach distribution programs can affect condom use

by high-risk populations.

a. Having a condom at the time of interview was the strongest

and most consistent predictor of condom use at most recent

intercourse.

b. Obtaining condoms from outreach workers was indirectly

associated with condom use because this factor was

strongly related to carrying a condom.

c. Higher level of stage of change (consideration or intention)

for condom use by persons who do not use condoms is

linked to outreach exposure.

6. Costs of street outreach can be measured: at the AESOP sites,

the costs, relative to the medical costs of AIDS cases, were low.

If 2 of 10,000 contacts reduced their high-risk behavior so as

to avoid HIV transmission, outreach would yield a net beneﬁt.

NTRODUCTION

7. Among the AESOP sites, the average cost of outreach contact

for high-risk youth was nearly twice that for IDUs. Much of

the increased cost was for facilities (e.g., drop-in centers) and

materials (e.g., food, travel vouchers, hygiene kits).

8. Outreach workers from a variety of agencies reach a sizeable

percentage of IDUs in their communities and support them in

seeking medical services, especially in seeking HIV counseling

and testing and drug treatment.

MPLICATIONS

FOR

ERVICE

GENCIES

1. Street outreach can be expanded to include a variety of ser-

vices, including HIV counseling and testing on the street, the

use of varied theory-based interventions (e.g., staging clients

for risk-reduction messages), even advocacy.

2. Since the interpersonal dynamics of steady and casual sexual

partnerships are different, condom promotion messages

should be tailored to the type of sexual relationship the client

has.

3. After-care referrals, such as support groups and drug coun-

seling services, need to be emphasized to accommodate the

high numbers of IDUs exiting drug treatment.

UTURE

ESEARCH

UESTIONS

1. Is street outreach more effective with certain types of drug

users (e.g., on the basis of consumption method or drug of

choice)?

2. What types of sex take place at different venues (e.g., vaginal

sex at crack houses, oral sex at adult bookstores, anal sex at

parks)?

3. Which is the antecedent: drug use or prostitution? Does the

antecedent differ by ethnicity, age, or sex?

AESOP

Reference

Tashima, N., Crain, C., O’Reilly, K.R., & Sterk-Elifson, C. (1966).

The community identiﬁcation (CID) process: A discovery

model.

Qualitative Health Research,

6, 23-48.

NNOTATED

IBLIOGRAPHY

EHAVIORAL

PIDEMIOLOGY

INDINGS

FROM

ASELINE

NTERVIEW

ATA

)

Anderson, J.E., Cheney, R., Clatts, M., Faruque, S., Kipke, M., Long,

A., Mills, S., Toomey, K., & Wiebel, W. (1996). HIV risk

behavior, street outreach and condom use in eight high-risk

populations. AIDS Education and Prevention, 8(3), 191-204.

The populations surveyed engaged in high levels of sexual risk

behavior: 20% to 46% reported two or more sex partners in the

past month. Most of the injection drug users and high-risk

youth were at risk through unprotected sex with main part-

ners; 56% to 75% reported protected vaginal sex with casual

partners. Of this group, 58% to 84% had been tested for HIV

infection, compared with 25% of the national adult population.

Having a condom at time of interview was the most consistent

predictor of condom use during most recent intercourse. A

variable percentage of injection drug users had shared needles

in the past month (10% to 53%). Many respondents had been

in contact with street outreach programs and had received

condoms, bleach, and other materials from workers.

Anderson, J.E., Cheney, R., Faruque, S., Long, A., Toomey, K., &

Wiebel, W. (1996). Stages of change for HIV risk behavior:

Injecting drug users in ﬁve cities. Drugs and Society, 9(1/2), 1-17.

Respondents from the street-based samples interviewed at the

ﬁve AESOP sites that were focused on injection drug users had

a very high level of risk for HIV, in terms of sex and drug-using

risk behavior. The level of stage of change for condom use was

higher for casual partners than for main partners. Having a

condom at interview was the most consistent predictor of

respondent’s level of stage of change for condom use. Home-

lessness and crack use were associated with lower level of stage

of change for not sharing needles. Program staff need to be

aware of the predominant level of readiness to change in order

to design and implement effective programs.

AESOP

CDC. (1993). Assessment of street outreach for HIV prevention—

Selected sites, 1991-1993. MMWR, 42 (45), 873, 879-880.

This report is a description of the ﬁrst 2 years of the AESOP

project and includes results from the initial round of closed-

end interviews. Results indicated that 17% to 65% of injection

drug users and 23% to 46% of youth in high-risk situations

(YHRS) reported talking with an outreach worker; 14% to 58%

of IDUs and 11% to 26% of YHRS had received HIV prevention

literature; 16% to 58% of IDUs and 22% to 39% of YHRS had

received free condoms; and 13% to 55% of IDUs and 7% to

10% of YHRS had received bleach kits from outreach workers.

These ﬁndings suggest that IDUs and YHRS can be identiﬁed

and reached through outreach programs; will talk with

outreach workers about HIV prevention; and will accept HIV

prevention literature, materials, and referral services from

outreach workers.

Clatts, M.C., Bresnahan, M., Davis, W.R., Springer, E., & Backes, G.

(1997). The harm reduction model: An alternative approach to

AIDS outreach and prevention for street youth in New York City.

In P. Ericson et al. (Eds.), Harm reduction: A new direction for

drug policies and programs. Toronto: University of Toronto Press.

The authors provide a demographic and behavioral proﬁle of

street youth in New York City and discuss the history of AIDS

prevention services for these young people. A network of

outreach programs developed for AESOP, the Youth At Risk

Cooperative, and the foundation for the network’s training

program for outreach workers in the harm reduction model

are described. Case study material from staff who integrated

the model into case management activities provides a con-

structive demonstration of the potential of the harm reduction

model as a service-delivery strategy for street youth.

ANNOTATED BIBLIOGRAPHY

Clements, K., Gleghorn, A., Garcia, D., Katz, M., & Marx, R. (1997).

A risk proﬁle of street youth in northern California: Implications

for gender-speciﬁc human immunodeﬁciency virus prevention.

Journal of Adolescent Health, 20(5), 343-353.

Most of the youth were heterosexual, white, male, and without

stable housing. Of the total, 60% had had vaginal sex in the

past 30 days; only 44% had used a condom during their most

recent sexual encounter. One third of the sample reported

having injected drugs. Compared with males, females were

equally likely to use injection and noninjection drugs but were

more likely to be sexually active, to have been given a

diagnosis of a sexually transmitted disease, and were less

likely to report consistent condom use. Females without

stable housing were less likely to have used condoms during

their most recent vaginal intercourse. These ﬁndings suggest

an urgent need for gender-speciﬁc prevention efforts and

increased housing options for youth.

Gleghorn, A.A., Marx, R., Vittinghoff, E., & Katz, M. (in press).

Association between drug use patterns and HIV risks among

homeless, runaway, and street youth in Northern California.

Drug and Alcohol Dependence.

The drug use and HIV risk behaviors of homeless, runaway,

and street youth were compared. Youth who were using any

heroin, speed, or cocaine exhibited more sexual risks than did

youth who were not using; primary stimulant users and those

who used a combination of heroin and stimulants showed

greatest sexual risk. Those who injected combinations of

heroin and stimulants engaged in higher levels of risky

injection practices, including frequent injections and back-

loading syringes, than did primary heroin or primary

stimulant injectors. HIV prevention interventions should be

tailored to drug-use patterns, because youth who use

combinations of heroin and stimulants may require more

intensive services.

AESOP

Kipke, M.D., O’Connor, S., Palmer, R., & MacKenzie, R.G. (1995).

Street youth in Los Angeles: Proﬁle of a group at high risk for

human immunodeﬁciency virus infection. Archives of Pediatric

and Adolescent Medicine, 149(May), 513-519.

Of the youths, 70% were sexually active (average of 11.7 sex

partners during past 30 days). High-risk sex and drug-using

behaviors were prevalent and interrelated in this sample of

urban street youth. Substance-using youth were 3.6 times

more likely to use drugs during sex, 2.2 times more likely to

engage in survival sex, and 2.5 times more likely to report a

sexually transmitted disease. Youth with multiple partners

were more likely to report a previous sexually transmitted

disease and survival sex. New and innovative educational

promotions and prevention interventions for this population

are needed.

Kipke, M.D., Palmer, R.F., LaFrance, S., & O’Connor, S. (1997).

Homeless youths’ descriptions of their parents’ childrearing

patterns. Youth and Society, 28, 415-431.

No one parenting style was associated with homelessness

among the sample. An equal percentage of youth reported

having supportive or emotionally available and having

intrusive or emotionally unavailable parents or caretakers.

However, most of the youth enrolled in this study did report

having parents or caretakers who could be described as

intrusive, emotionally unavailable, detached, and who had

problems with substance use or the law. Gaining a better

understanding of family conﬂict and its relationship to

homelessness and the behaviors of homeless youth is critically

needed to develop effective prevention interventions as well as

appropriate services.

ANNOTATED BIBLIOGRAPHY

Kipke, M.D., Unger, J., O’Connor, S., Palmer, R.F., & LaFrance, S.R.

(1997). Street youth, their peer group afﬁliation and differences

according to residential status, subsistence patterns and use of

services. Adolescence, 32(127), 655-669.

Five street youth groups were identiﬁed: punks and

skinheads, druggies, hustlers, gang members, and loners. The

results demonstrated unique patterns with respect to places

where they stayed or slept, their means of support, and use of

services according to peer group afﬁliation.

Martinez, T.E., Gleghorn, A., Marx, R., Clements K., Boman, M., &

Katz, M.H. (1998). Psychosocial histories, social environment,

and HIV risk behaviors of injection and noninjection drug using

homeless youths. Journal of Psychoactive Drugs, 30 (1), 1-10.

Injection drug use is a common risk behavior for HIV infection

among homeless, runaway, and street youth. Youth who

injected drugs were more likely than youth who did not inject

drugs to report traumatic psychosocial histories, including

parental substance use and forced institutionalization, use of

alcohol and other noninjection drugs, a history of survival sex,

and the use of abandoned buildings as shelter. These ﬁndings

underscore the need for multifaceted service and prevention

programs to address the varied needs of these high-risk youth.

NHANCEMENTS

Cheney, R., & Merwin, A. (1995). Integrating a theoretical

framework with street outreach services: Issues for successful

training. Public Health Reports, 110(Suppl. 1), 1-5.

The authors discuss three key components necessary to

integrate a behavioral research perspective (in this instance,

the stages-of-change model) into the design of outreach

programs: (a) training for successful service delivery, (b)

training for a theory-guided intervention, and (c) feedback and

evaluation. The third component measures the beneﬁts of

staff training to the outreach workers and to their ability to

apply in the ﬁeld what they have learned.

AESOP

Valentine, J., & Wright-DeAgüero, L. (1996). Deﬁning the

component of street outreach for HIV prevention – The contact

and the encounter. Public Health Reports, 111(Suppl. 1), 69-74.

The discussion suggests techniques for enhancing the

encounter between outreach workers and clients by using the

conceptual framework of the social-work helping relationship.

Five elements of the encounter are deﬁned and developed:

screening, engagement, assessment, service delivery, and

follow-up. The encounter represents an enhancement of the

traditional street outreach interaction and a more systematic

approach to promoting the behavioral change goals of AESOP.

ETHODS

Clatts, M.C., Davis, W.R., & Atillasoy, A. (1995). Hitting a moving

target: The use of ethnographic methods in the development of

sampling strategies for the evaluation of AIDS outreach

programs for homeless youth in New York City. In E.Y. Lambert,

R.S. Ashery, & R.H. Needle (Eds.), Qualitative methods in drug

abuse and HIV research (NIDA Research Monograph 157, NIH

Publication No. 95-4025). Rockville, MD: National Institute on

Drug Abuse.

This chapter shows how ethnographic methods that include

participant observation and life history interviews were used

as a sampling strategy and a means of obtaining less

accessible information. Interviews included how youth met

everyday needs and consequently how they participated in the

street economy. In addition to identifying important

geographic and temporal gaps in services, the data provided

useful information about a population of youth about whom

little is known.

ANNOTATED BIBLIOGRAPHY

UTCOME

Gleghorn, A.A., Clements, K.D., Marx, R., Vittinghoff, E., Lee-Chu, P.,

& Katz, M. (1997). The impact of intensive outreach on HIV

prevention activities of homeless, runaway, and street youth in

San Francisco: The AIDS Evaluation of Street Outreach Project

(AESOP). AIDS and Behavior, 1(4), 261-271.

The authors evaluate the impact of an HIV prevention

intervention combining street outreach, storefront prevention

services, and subculture-speciﬁc activities for street youth in

intervention and comparison sites before and during

implementation of the intervention. Youth at both types of

sites reported high rates of risky sex and drug-using

behaviors. The intervention did not affect HIV risk behaviors

but was independently associated with increased contact with

outreach workers and increased referrals for services. Higher

levels of contact with outreach workers were associated with

following through with HIV-related referrals and using new

syringes. Youth-oriented needle exchange increased the use of

new syringes.

Greenberg, J., MacGowan, R., Neumann, M.S., Long, A., Fernando,

D., Cheney, R., Sterk, C., & Wiebel, W. (under review). The

relationship between street outreach referrals and accessing

medical services by injecting drug users. Health & Social Work.

This analysis, from 3,237 structured interviews conducted

with injection drug users (IDUs) at ﬁve sites between January

1994 and October 1995, examines contact with outreach

workers, the most common medical referrals received and

acted on as a result of this contact, and whether more

frequent contact was associated with increased acting on

medical referrals. Of the IDUs interviewed, 42% to 67% had

talked with an outreach worker in the past 6 months and

reported referrals to a number of medical services, especially

HIV counseling and testing and drug treatment. IDUs with

more than three contacts with outreach workers during the

past 6 months were more likely to seek services. To maximize

the effect of outreach on acting on referrals, training for

outreach workers should address techniques for follow-up

with referred IDUs; identifying and overcoming barriers to

AESOP

seeking medical services, especially those for minority clients;

after-care referrals for clients exiting drug treatment

programs; and the importance of treatment for sexually

transmitted diseases in reducing risk for HIV infection.

MacGowan, R.J., Sterk, C.E., Long, A., Cheney, R., Seeman, M., &

Anderson, J.E. (1998). New needle and syringe use and use of

needle exchange programmes by street recruited injection drug

users in 1993. International Journal of Epidemiology, 27, 302-

308.

Street-recruited injection drug users were interviewed in ﬁve

U.S. locations in 1993. Most (75% to 95%) reported that it was

easy to get a new syringe. For their most recent injection, 45%

to 77% had used a new syringe, and 2% to 18% had used a

syringe previously used by another injector. The use of needle

exchange programs (NEPs) ranged from 8% to 16% in Chicago,

Philadelphia, and Los Angeles County. Factors associated

with NEP use differed across sites, which suggests that the

dispersion of NEPs and the removal of legal barriers that

restrict access to sterile syringes may be more important to

increasing the use of sterile syringes and NEPs.

Wright-DeAgüero, L.K., Gorsky, R.D., & Seeman, G.M. (1996). Cost

of outreach for HIV prevention among drug users and youth at

risk. Copublished in Drugs and Society, 9 (1/2), 185-197; and

in T. Trotter II (Ed.), Multicultural AIDS prevention programs.

Binghamton, NY: Harrington Park Press.

The authors present the results of a cost analysis at eight sites

that provide outreach services to injection drug users and

street youth. They assessed the potential beneﬁt of HIV

prevention through outreach services by comparing outreach

costs with the costs of treating an HIV-infected person. The

average cost of outreach services was $13.30 per contact.

Costs per contact were 78% higher for street youth than for

drug users. Comparing cost per contact with HIV treatment, if

only 2 in 10,000 outreach contacts reduce their risky behavior

to avoid the transmission of HIV, these programs compare

favorably with other HIV prevention strategies in terms of cost.

A PROBABILITY SAMPLING

FOR ASSESSING THE EFFECTIVENESS OF

OUTREACH FOR STREET YOUTH

Michele D. Kipke

, Susan O'Connor

, Burke Nelson

and John E. Anderson

†

In 1991, the Division of Adolescent Medicine of Children’s Hospital

Los Angeles received funding from the Centers for Disease Control

and Prevention (CDC) as part of the cooperative agreement for the

AIDS Evaluation of Street Outreach Projects (AESOP) (CDC, 1993).

The purpose of this project was to conduct research to character-

ize street youth and their involvement in HIV risk-related sex and

drug-using behaviors and to develop, implement, and evaluate the

enhancement of street outreach interventions for this population.

Few studies have evaluated the sex and drug-using behaviors of

urban street youths, and no attempt has been made to systemati-

cally evaluate the effectiveness of outreach activities for this popu-

lation. Furthermore, studies have largely relied on convenience

sampling, which may underestimate the degree to which these

youth are engaging in the kinds of behaviors that put them at risk

for HIV infection. For example, runaway or homeless youth have

been recruited from shelters and drop-in centers (Anderson,

Freese & Pennbridge, 1994; Rotheram-Borus & Koopman, 1991;

Rotheram-Borus et al., 1992).

Convenience sampling can identify only the youth who are using

services; thus, the ﬁndings from these studies can be generalized

only to youth who are willing to use such services, not the esti-

mated 65% of runaway or homeless youth who are living on the

streets and not using services (Kipke, O’Connor, Palmer &

LaFrance, 1993). Although probability sampling methods have

*Division of Adolescent Medicine, Children’s Hospital of Los Angeles, Los Angeles,

California

†

Division of HIV/AIDS Prevention–Intervention Research and Support, National

Center for HIV, STD, and TB Prevention, Centers for Disease Control and

Prevention, Atlanta, Georgia

AESOP

been used to survey homeless adults (Burnam & Koegel, 1988;

Robertson, Westerfelt & Irving, 1991), little effort has been made

to apply these sampling methods to homeless youth. To evaluate

the effectiveness of street outreach activities, it was essential to

develop probability sampling methods that enable researchers to

better describe youth, particularly out-of-school and out-of-home

youth who spend most of their time on the streets.

OBJECTIVES AND OVERVIEW OF SAMPLING DESIGN

Our objective was to recruit a sample representative of the target

population (i.e., to develop a method for selecting homeless youth

such that homeless youth at each site would have an equal or a

known probability of being selected for the sample). Numerous

researchers have relied on shelters for their sampling frame. How-

ever, there are several problems with this practice. First, although

some youth stay in shelters, many others move around frequently

and use shelters infrequently, if at all. Second, it is estimated that

there may be 2,000 homeless youth in Los Angeles County at any

time and that 10,000 homeless youth may be on the streets of Los

Angeles during any one year (United Way Planning Council, 1981).

In Los Angeles, approximately 140 shelter beds are available for

this population. Thus, the size of the population exceeds the size

of that shelter system. Finally, there are other services, such as

drop-in and meal services, that are used by a greater proportion of

the homeless youth population and with greater frequency than

are shelter services. Although shelters and drop-in services have

different biases, adding the latter to a sampling frame would

nevertheless be expected to increase the percentage of the total

population covered.

We understood, however, that constructing a sampling frame that

comprised only shelter and drop-in service locations would pose

similar problems. Perhaps the most important bias is that home-

less youth who do not use services would be excluded. Thus,

street and natural hangout locations would need to be included in

the sampling frame in order to identify the homeless youth who

were not using services. Although it is impossible to establish a

sampling frame that would include every homeless youth, we

A PROBABILITY SAMPLING

developed a sampling frame that included both service agency and

street locations in an effort to minimize bias and maximize our

ability to survey a wide spectrum of youth who were representative

of the target population.

SAMPLE POPULATION AND TARGET COMMUNITIES

The target population were youth who were 12 to 23 years of age

and who (a) had been living on the streets without their families

for 2 or more consecutive months or (b) were fully integrated into

the "street economy." By deﬁnition, youth integrated into the

street economy meet their subsistence needs through one or more

of the following survival strategies: prostitution or survival sex

(deﬁned as the exchange of sex for money, food, a place to stay,

clothes, or drugs), pornography, panhandling, stealing, selling sto-

len goods, mugging, dealing drugs, or engaging in scams or cons.

A cross-sectional survey was conducted in two communities where

runaway or homeless youth were known to congregate: the Holly-

wood area of Los Angeles (the study community, where the

enhanced outreach interventions were introduced) and the down-

town area of San Diego (the control community). In both com-

munities, comparable sampling frames and recruitment strategies

were used to identify and survey street youth for the purpose of

evaluating the effectiveness of enhanced interventions for street

outreach. In this paper, we focus on the Hollywood sampling

frame and sampling units.

CONSTRUCTION OF SAMPLING

The sampling frames were constructed by using information

obtained during the community assessment process (CAP) and

from systematic ﬁeld observation. The goal of this phase was to

identify high-volume locations and high-frequency times of the

day and days of the week for surveying the target population.

Information from the community assessment and ﬁeld observa-

tions yielded (a) lists of street corners where the target population

AESOP

is known to hang out, (b) other locations where the target popula-

tion could be found (e.g., parks, alleys, restaurants), and (c) agen-

cies that provide shelter and drop-in services.

All service sites for runaway or homeless youth in Hollywood,

including two shelters and ﬁve drop-in centers, were included in

the “ﬁxed” sampling frame. Drop-in centers included agencies

that provide day and night drop-in services to street youth in

Hollywood. During a 2-month period, ﬁeld staff observed and

recorded the number of youth using these services according to

the day of the week and time of day.

Outreach workers and research interviewers conducted open-

ended interviews with street youth and observed street activity in

order to locate street hangouts with the highest number of home-

less youth and to determine the times and days when the volume

was highest. Along the boulevards of Hollywood, these staff ﬁrst

identiﬁed 104 street corners or alleys, 4 parks, and 3 fast-food res-

taurants as potential sampling sites. Large segments of the main

boulevards were broken into 3-block segments. Thus, the number

of natural sites was reduced to 73 street corners, 4 parks, and 3

fast-food restaurants. Once hangouts were deﬁned, ﬁeld staff

noted street youth activity at these locations throughout the day.

Additional ﬁeld observation was conducted, by the ﬁeld research

team and outreach workers from service agencies for youth, in

order to further reﬁne the street sampling frame. (Sample Street

Observation and Summaries of Service Use are in Appendix A.)

Given our broader deﬁnition of street youth (i.e., integrated into

the street economy) and the literature, which has largely relied on

samples recruited from shelter and drop-in centers, we chose to

oversample youth from natural and hangout sites by recruiting

70% of the sample from natural sites (thereby oversampling by

20% from these sites) and 30% from ﬁxed sites.

SAMPLING ASSIGNMENTS

A computer program was developed to randomly select and order

locations for interviewing teams (comprising 2 to 4 members).

This program took into account two important aspects of the sam-

A PROBABILITY SAMPLING

pling design. First, with evidence that nearly 65% of street youth

are not using services, the selection was weighted to ensure that a

larger proportion of street locations were chosen (70%), thereby

increasing the probability of recruiting youth who were not using

services. Second, all ﬁxed and natural locations in the pool of

potential sampling sites were proportionally weighted on the basis

of the number of youth that typically congregated at that location.

Thus, locations with a higher volume of youth had a greater prob-

ability of being selected by the computer random selection pro-

gram than had locations with lower volumes. Assignments also

were made according to high-frequency times of the day and days

of the week. Assignments were generated weekly.

SAMPLING UNITS AND SELECTION OF RESPONDENTS

IXED

ITES

Consistent with probability sampling methods used in surveying

homeless adults (Burnam & Koegel, 1988; Robertson, Westerfelt &

Irving, 1991), the overall sampling design for the ﬁxed sites

involved estimating the relative proportions of the homeless youth

population that passed through the shelters and drop-in centers

in a month. These estimates were used to determine the relative

weighting for each agency. Sampling assignments to ﬁxed sites

were weighted according to the type of service and the estimated

proportion of the study population that used the service in a

month (e.g., 13% of the street youth population are believed to use

sheltering services). Thus, in our study the probability of selection

was proportional to the estimated unduplicated number of youth

who used each service in a month. In Hollywood, three shelters

and ﬁve drop-in centers were identiﬁed.

For respondent selection at each of the ﬁxed sites, interviewers

ﬁrst reviewed the agency's sign-in roster to determine how many

youth were in the agency. Interviewers then randomly selected

potential respondents from the agency sign-in sheet. They used a

predetermined random start number and began selecting respon-

dents by using a sampling fraction (i.e., the number of youth to

count off, beginning with the random start-numbered youth on

the agency list). Going down the list, interviewers then selected

AESOP

additional youth on the list according to the sampling fraction.

The sampling fraction was determined by dividing the number of

youth signing into the agency by the number of interviewers; the

number of youth selected equaled the number of interviewers (see

the Sampling Fraction Table, Appendix B).

Interviewers then asked the intake worker to introduce them to

the selected respondents. If a potential respondent declined to

participate in the study, a new respondent was selected by choos-

ing the next consecutive youth on the list after the one who

declined. Replacement continued in this manner until all appro-

priate respondents were selected and agreed to be interviewed.

ATURAL

ITES

During the initial community assessment, teams compiled an

exhaustive list of natural street locations and hangouts along ﬁve

boulevards within a 12-square mile area of Hollywood. In select-

ing respondents, interviewer teams ﬁrst determined the number of

potential respondents at a site speciﬁed by the sampling assign-

ment (i.e., in a block segment, on the street corner, in the alley or

park) by counting the number of youth who seemed to be 12 to 24

years of age at the location. They then determined the sampling

fraction by looking at the sampling fraction table and locating the

fraction that corresponded with the total number of youth counted

at that site. For example, if there were two interviewers and 10

potentially eligible youth at the site, the sampling fraction would

be 1/5. Youth were "counted out" (from left to right), starting from

a predetermined random start number and selected according to

the sampling fraction (see Appendix B). If the number of potential

respondents was equal to or fewer than the number of interview-

ers, all youth were approached and asked to complete a screening

instrument. As in sampling in ﬁxed sites, a youth who refused to

participate in the study was replaced by the next consecutive

youth after the one who declined. On the street, this means

selecting the youth nearest and to the right of the refuser. Youth

who entered the sampling site after the initial selections were not

approached for recruitment.

A PROBABILITY SAMPLING

DISCUSSION

There are a number of advantages and disadvantages in using a

probability sampling design for street-based epidemiologic

research. Perhaps one of the greatest disadvantages is the cost

associated with developing and implementing such a design. A

community assessment of service agencies is required to estimate

accurately the number of youth who are using services. Extensive,

systematic ﬁeld observations are required to initially identify natu-

ral sites. Relative weightings are then constructed on the basis of

population estimates. Ongoing observations are then required to

monitor the ﬁeld to ensure that new hangouts are added and that

low-volume sites are continually dropped from the sampling

frame. Finally, this sampling design requires a greater amount of

time for recruitment and interviewing than would be required by

convenience sampling.

There are, however, clear advantages in using probability sam-

pling. Research involving representative samples of runaway or

homeless youth, particularly youth who are not using services,

has been greatly needed. These results can be generalized to the

larger street youth population of a study area. Probability sam-

pling is perhaps the best method for obtaining samples represen-

tative of the target population, hence for accurately estimating

population characteristics.

ACKNOWLEDGMENTS

This study was supported by the Centers for Disease Control and

Prevention, cooperative agreement U62/CCU907198. The views

expressed are those of the authors, not necessarily the funding

agency. Special thanks go to Judith Greenberg, Steven R.

LaFrance, Richard MacKenzie, Susanne Montgomery, Marjorie

Robertson, and members of the Los Angeles research team

(Michael Cohen, Marcus Kuiland-Nazario, Raymond Palmer, Sara

Parker, Audruin Pittman, German Rodriguez, and Lily Rodriguez).

AESOP

References

Anderson, J., Freese, T., & Pennbridge, J. (1994). Sexual risk

behavior and condom use among street youth in Hollywood.

Family Planning Perspectives, 26(1), 22-26.

Burnam, M.A., & Koegel, P. (1988). Methodology for obtaining a

representative sample of homeless persons: The Los Angeles

Skid Row Study. Evaluation Review, 12, 117-152.

CDC. (1993). Assessment of street outreach for HIV prevention—

Selected sites, 1991-1993. MMWR, 42(45), 873, 879-880.

Kipke, M.D., O'Connor, S.L., Palmer, R., & LaFrance, S. (1993,

October). Street youth, outreach and HIV risk: Facing the

challenge in two communities. Presented at American Public

Health Association meeting, San Francisco, CA.

Robertson, M.J., Westerfelt, A., & Irving, P. (1991, November).

Research note: The impact of sampling strategy on estimated

prevalence of major mental disorder among homeless adults in

Alameda County, CA. Presented at American Public Health

Association meeting, Atlanta, GA.

Rotheram-Borus, M.J., & Koopman, C. (1991). Sexual risk beha-

viors, AIDS knowledge, and beliefs about AIDS among run-

aways. American Journal of Public Health, 81, 208-210.

Rotheram-Borus, M.J., Meyer-Bahlburg, H.F.L., Rosario, M.,

Koopman, C., Haignere, C.S., Exner, T.M., Matthieu, M.,

Henderson, R., & Gruen, R.S. (1992). Lifetime sexual beha-

viors among predominantly minority male runaways and gay/

bisexual adolescents in New York City. AIDS Education and

Prevention, (Suppl. Fall), 34-42.

United Way Planning Council. (1981). Runaway youth situation in

Los Angeles County: A general overview. Los Angeles: The

United Way.

APPENDIX A

SAMPLE STREET OBSERVATION AND

UMMARIES OF SERVICE USE

STREET OBSERVATION SUMMARY

Hollywood Boulevard

10:00am

11:00 am

Noon

1:00 pm

2:00 pm

3:00 pm

4:00 pm

5:00 pm

6:00 pm

7:00 pm

Totals

Sycamore 2 2 0103

Orange 0 0 2010 3

Orchid 0 4 0320 9

Hillcrest 0 0 0006 6

Highland 3 5 2005 15

McDonald’s 2 4 0354 18

McCadden 0 1 3010 5

Las Palmas 0 7 0018 16

Cherokee 0 0 0047 11

Whitley 1 0 0000 1

Tomy’s 2 0 2313 11

Hudson 0 2 0317 13

Wilcox 0 0 0406 10

Cahuenga 0 0 0003 3

Ivar 2 2 1020 7

Vine 0 5 0003 8

El Centro 0 0 0200 2

Gower 2 2 0010 5

No. Sheets 3 4 0 1323

Totals 14 34 0 10 19 19 55

AESOP

HOLLYWOOD DROP-IN CENTERS

SUMMARY OF HIGH-VOLUME TIMES AND DAYS

Gay and Lesbian Community Services Center (GLCSC)

NOTES: I called GSCSC at 1:30 on 10/22, and there were 3 youth in the agency. I

was told that 2 to 5 had been in the agency all day. I suggest that we do not use

GLCSC as a ﬁxed site for interviewing.

9:00 am

10:00 am

11:00 am

Noon

1:00 pm

2:00 pm

3:00 pm

4:00 pm

5:00 pm

Totals

Thu 10/1 220000110 6

Fri 10/2 51202210013

Mon 10/5 34411010014

Tue 10/6 131011100 8

Wed 10/7 31403210014

Thu 10/8 123020000 8

Fri 10/9 23104221015

Mon 10/12 41521010014

Tue 10/13 42205112017

Wed 10/14 41300113013

Thu 10/15 10601221013

Totals 30 20 31 3 20 11 12 8 0

APPENDIX A

Los Angeles Youth Network

NOTES: I called LAYN at 2:00 on 10/22, and there were 10 youth in the agency. I

was told that there had been many more earlier in the day but that most had gone

to the YMCA. I suggest that we use LAYN as a ﬁxed site interiew location on Mon-

days and Wednesdays, any time between noon and 4:00pm.

9:00 am

10:00 am

11:00 am

Noon

1:00 pm

2:00 pm

3:00 pm

4:00 pm

5:00 pm

Totals

Thu 10/8 1546453200 39

Fri 10/9 1354323400 34

Mon 10/12 1837226240 44

Tue 10/13 1275231250 37

Wed 10/14 1812642550 43

Thu 10/15 1312362320 32

Totals 89 21 26 20 22 17 18 16 0

AESOP

APPENDIX B

SAMPLING FRACTION TABLE

AIDS Evaluation of Street Outreach Project

Children’s Hospital of Los Angeles

Street Locations Agencies

No. of

Youth

No. of

Intercepts Fraction

No. of

Youth

No. of

Intercepts Fraction

1 1 1/1 1 1 1/1

2 2 1/1 2 2 1/1

3 2 1/2 3 3 1/1

4 2 1/2 4 4 1/1

5 2 1/3 5 4 1/2

6 2 1/3 6 4 1/2

7 2 1/4 7 4 1/2

8 2 1/4 8 4 1/2

9 2 1/5 9 4 1/3

10 2 1/5 10 4 1/3

11 2 1/6 11 4 1/3

12 2 1/6 12 4 1/3

13 2 1/7 13 4 1/4

14 2 1/7 14 4 1/4

15 2 1/8 15 4 1/4

16 2 1/8 16 4 1/4

17 2 1/9 17 4 1/5

18 2 1/9 18 4 1/5

19 2 1/10 19 4 1/5

20 2 1/10 20 4 1/5

21 2 1/11 21 4 1/6

22 2 1/11 22 4 1/6

23 2 1/12 23 4 1/6

24 2 1/12 24 4 1/6

25 2 1/13 25 4 1/7

A STORYTELLING MODEL

USING PICTURES FOR HIV PREVENTION

WITH INJECTION DRUG USERS

Anna Long

, Judith Greenberg

†

, Gladys Bonilla

and Ronald Weathers

The importance of storytelling in the modeling of behavior and

teaching people about their lives has been extensively addressed

by the late Joseph Campbell, a foremost authority on mythology

(most recently, Campbell, 1988). Empirical research in the self-

help community also suggests the importance of personal stories.

Rappaport (1993) compared the personal stories told during meet-

ings of a mutual help group for mentally ill persons with the sto-

ries told by patients receiving professional care for mental illness.

The ﬁrst group saw themselves as a part of a “caring and sharing”

community and as givers as well as receivers who hoped for posi-

tive change. By contrast, the patients’ stories “often revolve

around learning to see one’s self as sick and dependent on medi-

cation to control behavior.” Similarly, the stories that people tell

about their lives in groups such as Alcoholics Anonymous (AA)

permit the members to take on the ideology of the group as part of

their personal identities. Telling stories of “hitting bottom” and of

recovery serve as testimony to the importance of the AA philoso-

phy of sobriety (Bean, 1975).

Using this storytelling framework, investigators in Los Angeles

County, one of eight AESOP sites, developed a unique outreach

intervention strategy. Injection drug users (IDUs) were encour-

aged to tell their own stories about risk behaviors to outreach

workers after looking at a series of abstract illustrations related to

themes of risk and risk-prevention behaviors for acquiring HIV.

These illustrations were produced by a local Los Angeles artist,

*Office of AIDS Programs and Policy, Los Angeles County Department of Health

Services, Los Angeles, California

†

Division of STD Prevention, National Center for HIV, STD, and TB Prevention,

Centers for Disease Control and Prevention, Atlanta, Georgia

AESOP

whose grasp of the street drug culture was translated into draw-

ings that were used to encourage people to discuss risky sex and

drug-using behaviors.

CHOOSING THE STORYTELLING INTERVENTION

ORMATIVE

RESEARCH

The AESOP project began with a two-part formative study to guide

the identiﬁcation of speciﬁc risk-reduction needs and correspond-

ing interventions for IDUs in Los Angeles County. Using data from

various sources (research on IDUs conducted in the county, epide-

miologic and drug-use data), we described the IDU population,

reported what was known about their risk behaviors, and speciﬁed

the current outreach programs that addressed their HIV risk-

reduction needs.

That initial overview revealed considerable variation in the num-

ber and the demographic characteristics of IDUs in the different

parts of the county. The IDUs were as diverse in their cultural

and ethnic backgrounds as the county’s 4,083 square miles are in

their geographic features. There were also variations in the pro-

grams that community-based organizations had developed to

respond to the needs of IDUs in their particular communities.

The community assessment process (CAP) constituted the second

part of the formative research. These activities focused on develop-

ing more current insight into the IDU population through in-depth

interviews with IDUs themselves; outreach workers; agency repre-

sentatives with knowledge of the IDU community, such as social

service workers and law enforcement ofﬁcers; and persons who

interact with IDUs but are not part of the formal service delivery

system, such as shopkeepers, taxi drivers, and hotel clerks. The

interviews were focused on IDUs’ knowledge, attitudes, and beliefs

about HIV; sex and drug-using behaviors of IDUs and their risks

for HIV infection; risk-reduction practices of IDUs; assessment of

services used by IDUs; barriers and facilitators to service use; and

ideal intervention strategies.

A STORYTELLING MODEL

The CAP revealed the range of risk behaviors of the target popula-

tion. It showed that (a) despite considerable knowledge about HIV,

most IDUs required additional information and strategies that

would help them consistently practice appropriate risk-reduction

behaviors; (b) uniformity was lacking in attitudes toward and

intentions to reduce their risk for HIV; and (c) IDUs would not

change their risk behaviors, regardless of the information they

had about HIV, until they were ready. The notion of readiness

that echoed in many of the CAP interviews was a key factor in our

selecting the stages-of-change model from behavioral theory

(Prochaska & DiClemente, 1986, 1992; Prochaska, DiClemente &

Norcross, 1992) to help us develop the interventions. Finally, out-

reach workers and IDUs indicated a need for materials that would

be suitable for the prevention needs of different groups.

Overall, the formative research revealed that the proposed inter-

ventions should be (a) adaptable to the ethnic, cultural, and lin-

guistic diversity of Los Angeles County IDUs; (b) inexpensive and

reproducible enough to maximize the possibility of adoption by

outreach programs that serve IDUs; (c) comprehensive enough to

address the needs of IDUs across a spectrum of HIV awareness

and risk-reduction practices; (d) accessible enough to facilitate

HIV counseling and testing on-site; and (e) able to provide feed-

back on whether IDUs sought the services to which they were

referred.

Using the formative research, we designed an intervention with

three components: (a) storytelling allowing the outreach worker to

help the IDU recognize personal HIV risk behaviors and learn

about or reinforce intentions to reduce risk behaviors; (b) a referral

tracking system to help outreach workers follow up on the IDUs’

use of the services to which they were referred; and (c) an outreach

worker-administered HIV testing program that facilitated ﬁnger-

sticks on the street to enable outreach workers to test a target

population reluctant to seek this service in clinical settings.

ATIONALE

FOR

TORYTELLING

During the formative research, we routinely observed the setting

in which outreach workers delivered their services to IDUs. One

observation, consistent throughout the county, concerned the use

AESOP

of pictures as a common method of communicating ideas in the

communities where outreach was conducted. In many communi-

ties, particularly communities of color, murals, usually painted by

local artists, adorned the walls of public and private buildings,

cinder-block fences, and freeway overpasses. These murals

tended to be colorful, highly complex, and symbolic. Thus, the

use of visual art in the communities where outreach was con-

ducted was viewed as an important consideration in designing the

intervention. The fact that many IDUs mentioned the need for

new materials or for materials that better reﬂected their communi-

ties also inﬂuenced the design and format of the visuals. The need

for HIV interventions with an emphasis on cultural appropriate-

ness has been documented (Stevenson, McKee & Josar, 1995;

Weeks, Schensul, Williams, Singer & Grier, 1995). It was deter-

mined that the required pictures needed to be complex enough to

engage the viewer, to stimulate introspection, and to span the eth-

nic and cultural diversity of Los Angeles County IDUs. We

excluded written messages from the visuals so that the outreach

worker and IDU dyad could work together to develop a story for

each picture.

In contrast to the generic role-model stories used in CDC’s com-

munity demonstration projects for HIV prevention (McAlister,

1997), storytelling allowed the IDUs, assisted by outreach work-

ers, to generate their own stories from a set of illustrations. The

IDUs’ stories often told of speciﬁc risk behaviors that the IDU

might have been engaging in, the consequences of these behav-

iors, and risk-reduction strategies to be reinforced by the outreach

worker. The outreach worker would begin by asking the IDU what

was happening in a particular picture. Three key sentences were

used to help the IDU: “Tell me what is happening in the picture.”

“What are the people doing?” “What are they saying?”

ELATIONSHIP

THE

TORYTELLING

ODEL

EVEL

TAGE

HANGE

The storytelling also allowed the project to incorporate the theoret-

ical foundation of the stages-of-change model. Outreach workers

used the storytelling as a prelude to questions that speciﬁed each

of the ﬁve stages of change through which people typically

progress when changing behaviors: precontemplation, contempla-

A STORYTELLING MODEL

tion, ready-for-action, action, or maintenance. (See Fishbein and

Rhodes [1997] for how the stages-of-change model can be applied

in HIV prevention.) Once the clients had been placed in one of the

ﬁve stages, a clear and succinct risk-reduction message appropri-

ate for that stage was given.

DEVELOPING THEMES FOR STORYTELLING ILLUSTRATIONS

Because the formative research showed that condoms and bleach

continued to be used inconsistently, we designed the illustrations

to address three speciﬁc risk-reducing behaviors: (a) consistent

use of condoms, (b) consistent use of new injection equipment,

and (c) consistent bleaching of shared injection equipment. A

multistage process, drawing on the in-depth interviews with IDUs

in the second part of the formative research, was used to produce

the illustrations: (a) determining the IDUs’ view of the behaviors

that placed them at risk of contracting HIV; (b) identifying themes

in IDUs’ open-ended responses associated with risk-taking behav-

iors; (c) rating these themes for importance and applicability to

IDUs, by a sample of IDUs and outreach workers; (d) selecting

risk-behavior themes on which to focus the illustrations; (e) identi-

ﬁcation of an appropriate artist; (f) repeatedly testing sketches

with IDUs and then reﬁning the illustrations; (g) producing ﬁnal

illustrations; (h) training outreach workers to use the illustrations;

and (i) implementing and evaluating the intervention (see List 1).

Using the information from the CAP in-depth interviews with

IDUs, we selected 40 narrative themes. Many were the verbatim

statements of active IDUs. A convenience sample of 20 IDUs from

two communities closest to where the AESOP research would be

conducted and the outreach staff (10 in all) at two agencies serv-

ing these communities were asked to rate each of the 40 narrative

themes on three scales: (a) the degree to which the theme was

applicable to their community of IDUs; (b) the degree to which the

theme was important to their community; and (c) whether or not

the theme should be included in new materials. Feedback from

outreach workers was important because of their expertise in

working with the target population. On the basis of this review, sex

and drug themes were prioritized for inclusion in the illustrations.

AESOP

LIST 1

EVELOPING ILLUSTRATIONS FOR INTERVENTION

Characteristics of Ideal Intervention

1. Adaptable to multiple cultures and languages

2. Flexible to address clients’ range of needs and

preparedness

3. Inexpensive and easy to reproduce

Steps in Appropriate Interventions

1. Collect formative information on clients’ needs

and current interventions.

2. Use the comprehensive baseline report of HIV

epidemiology and drug use.

3. Conduct a community assessment of IDUs and

service agencies.

Development of Visuals

1. Survey IDUs to determine their perceived HIV

risk behaviors.

2. Recognize themes from IDUs open-ended responses.

3. Rate IDU themes by IDUs and outreach workers.

4. Select major risk-behavior themes.

5. Select and orient an artist.

6. Repeat ﬁeld testing and reﬁne illustrations.

7. Produce ﬁnal illustrations.

8. Train outreach workers.

9. Implement and evaluate.

A STORYTELLING MODEL

RIORITY

HEME

FOR

EXUAL

EHAVIOR

The sex theme given highest priority by IDUs and outreach work-

ers was "My woman would be offended if I started talking about

condoms." This theme had been a consistent issue not only for

male but also for female IDUs and may have been related to the

lack of condom use during vaginal sex with main partners that

was consistently recorded in the Los Angeles AESOP survey data.

Conversations with IDUs and outreach workers had indicated that

(a) male IDUs were frequently concerned about using condoms

with their main partners because their partners might become

suspicious about their ﬁdelity; (b) female IDUs were not always in

control of the decision to use condoms with main partners,

although they might have more control in using condoms with

casual partners; and (c) both men and women were concerned

about their partner’s possible reaction to their request to use con-

doms. Possibilities for addressing this theme in the storytelling

intervention were (a) increasing men's and women's awareness

that their partners may be equally concerned about the other's

perceptions of suggestions to use condoms and (b) modeling skills

used to discuss and negotiate condom use.

RIORITY

HEME

FOR

NJECTION

EHAVIOR

The injection theme that received the highest priority rating from

IDUs and outreach workers was “I use my own outﬁt [injection

equipment] most of the time.” The baseline survey data supported

this statement. Data indicated that most respondents had used a

brand-new outﬁt for their most recent injection or one that had

not been used by anyone else. However, 21% reported using a

shared needle "sometimes," "almost every time," or "every time"

they injected. Two of the remaining ﬁve priority themes related to

the availability of bleach or new injection equipment were "When

I'm sick, I can't waste time looking for bleach or a new outﬁt" and

"What do you do when there is no bleach around?"

Providing users with strategies for dealing with the theme of using

one’s own outﬁt most of the time was an important focus of the

storytelling model. The strategies included (a) reinforcing sole use

of an outﬁt; (b) reinforcing the desire to avoid situations in which

outﬁts are used by a group; and (c) examining other situations

AESOP

related to sharing, speciﬁcally, sharing when experiencing symp-

toms of withdrawal and sharing when one’s outﬁt is blocked or

otherwise nonfunctional, and developing strategies to avoid inject-

ing in those situations.

PRODUCING ILLUSTRATIONS

ELECTING

THE

RTIST

The intervention required the services of an artist who could pro-

duce illustrations similar to the indigenous art produced through-

out the county and who could visually represent the complexity of

the messages selected for focus. Once an artist whose work gener-

ated a similar feeling of depth, complexity, and engagement had

been found, the next challenge was to explain to the artist the

need for the materials and the messages to be conveyed.

We took him through a process to increase his understanding of

the risk behaviors that the target population engaged in and of the

barriers to risk reduction that IDUs faced. First, a session was

held to familiarize the artist with the statistics on Los Angeles

County IDUs. This included a discussion of the diversity of the

target population, variation in risk behaviors, and the critical

problems of the IDUs contacted during outreach. Second, written

stories based on the two priority themes were provided to the art-

ist to help him understand the narrative themes.

Several sketches were produced for the "I Don't Share" message.

It was determined that the needle-sharing message would require

three pictures to convey its complexity. The artist, using informa-

tion about risk behaviors and barriers to reduction, developed

three sketches.

NVOLVING

THE

ARGET

OPULATION

AND

INE

-T

UNING

THE

LLUSTRATIONS

The rough black-and-white sketches were taken into the ﬁeld for

testing with current IDUs. Two sites afforded a setting amenable

to in-depth interviews with the IDUs. IDUs were shown one

A STORYTELLING MODEL

sketch and asked to tell the interviewer what was happening in

the picture. Stories and explanations by the IDUs were analyzed

for content by members of the AESOP staff. The three injection-

related illustrations generated stories that were surprisingly close

to the messages that had been selected for focus. From the pre-

liminary sketches, the artist painted watercolor versions to be

tested in the ﬁeld.

Testing the watercolors indicated a need to adjust the colors, not

only for emphasis of speciﬁc aspects of the illustration but also to

reﬂect the multicultural setting in Los Angeles. Several ﬂesh

tones were thus used for the people in the pictures. Some ﬁgures

were presented as neither male nor female to allow outreach work-

ers to use the illustrations to depict individuals of either sex and

of any ethnicity (see Figures 1, 2, and 3).

Although completing the three illustrations that addressed differ-

ent aspects of the “I don’t share message” was relatively simple, it

proved difﬁcult to make an appropriate illustration to address sex-

related risk behaviors. The initial sketches presented to AESOP

staff members were either too broad or did not focus on HIV. One

sketch presented to the target population, although it addressed

the complexity of sex-related risk behaviors, did not focus sufﬁ-

ciently on HIV. A second sketch, much closer to the original "Not

with my man or woman" story, still did not focus attention on HIV.

Despite the initial intention to exclude text from the visuals, it was

determined that the word HIV needed to be added to the ﬁnal

sketch. With the addition of HIV, the message became very clear

to the IDUs who tested the illustration (see Figure 4).

Figure 1.

Figure 2.

Figure 3.

Figure 4.

AESOP

TRAINING OUTREACH WORKERS

TO USE STORYTELLING AND ILLUSTRATIONS

Several factors were considered in designing the outreach worker

training. It was clear from the ﬁeld observations and formative

research data that some outreach workers were reluctant to use

new methods to reach clients. Many outreach workers had been

in the forefront of responding to the HIV/AIDS crisis early in the

epidemic and considered their background and experience in pro-

viding street outreach services to IDUs more applicable than the

interventions developed by researchers. There was a strong con-

cern that research-based interventions simply "would not work" in

the ﬁeld. It was clear that the training would need to build upon

workers’ current wealth of knowledge rather than attempting to

supplant their tools and talents with new interventions.

Moreover, to move from the storytelling model to staging clients for

risk-reduction messages, outreach workers required working

knowledge of the theoretical foundation of the interventions. Thus,

outreach workers needed to be trained to use the pictures on the

street, both to elicit risk-behavior information and to teach and

reinforce risk-reduction behaviors. It was decided that two train-

ing sessions would be held—the ﬁrst on the use of the illustra-

tions and the second on staging clients for readiness to adopt

three risk-reduction behaviors (see List 2).

During the ﬁrst training session, trainers introduced outreach

workers to the purpose and the use of the illustrations in assess-

ing the client's needs and current risk behaviors and to the

stages-of-change model. They presented drafts of the illustrations

and gave outreach workers the opportunity to practice using the

materials with one another through role playing. The emphasis

during the ﬁrst session was on outreach workers’ becoming com-

fortable with using the illustrations in a variety of contexts.

During the ﬁrst training session, some outreach workers, espe-

cially many of the veteran staffers, expressed apprehension about

using the illustrations. Some stated that they would feel "silly" or

"stupid" showing people pictures and asking them "a lot of ques-

tions." Others expressed concern that it would be too time con-

suming to use all four illustrations during every one of their

A STORYTELLING MODEL

LIST 2

ONTENT OF TRAINING SESSIONS FOR

UTREACH WORKERS

Session 1: Teaching and Reinforcing Risk-

Reduction Skills with Illustrations

Purpose of illustrations

Review draft illustrations

Assessing client needs and risk behaviors

Providing risk-reduction messages and strategies

Introduction to stages-of-change model

Using illustrations to get information

Using illustrations as a teaching tool

Role-playing exercise

Questions and discussion

Session 2: AESOP Stages-of-Change Training

Review of illustration-using intervention

Review of stages-of-change model

Review of risk behaviors and risk-reduction behaviors

Steps in staging clients

screening the client

assessing the risk behavior

assessing intentions

Exercises

identifying client’s level of stage of change

obtaining additional information

AESOP

outreach contacts and encounters. It was explained that the illus-

trations were designed for intensive work with clients and that not

all illustrations would be used during each encounter. The initial

training session included discussions on selecting speciﬁc clients

and situations in which to use the intervention and on selecting

appropriate illustrations to use with speciﬁc clients. Outreach

workers were encouraged to practice using the draft illustrations

with one another until the second training session.

The second session focused on formalizing the client staging pro-

cedure. Once the storytelling model had been implemented, out-

reach workers learned to use standard questions and forms to

specify and record clients’ levels of stage of change. Outreach

workers were given an opportunity to practice staging clients with

one another, and their proﬁciency was assessed.

IMPLEMENTATION

Final, full-color illustrations were printed on 4" 3 5" cards. Before

distributing the cards, AESOP staff members personalized the

cards for each outreach team by adding a label bearing the name,

address, and phone number for the outreach program. The cards

and staging sheets were then delivered to the outreach team.

AESOP staff members accompanied each outreach team as the

outreach teams began using the cards. Staff members observed

outreach workers’ use of the card, judged whether outreach work-

ers had determined the correct stage, and spoke brieﬂy with the

outreach worker’s client. Members of the AESOP staff reviewed

initial interactions with the outreach worker and provided feed-

back to try to maximize outreach workers' effectiveness in imple-

menting the intervention.

As the outreach workers used the cards, it became clear that

much of the initial intent in the planned design of the visual had

been realized. According to extensive observations by the research

team, the storytelling intervention was engaging and held the

attention of target populations longer than standard outreach did.

The illustrations stimulated the IDUs to examine their HIV risk

behaviors, and IDUs began to relate their own stories of risk

behavior to the pictures. Outreach workers became adept at using

A STORYTELLING MODEL

the cards to engage clients who were reluctant to discuss their HIV

risk behaviors or to focus the attention of a client on a particular

consequence of that client’s. One unanticipated effect of the visu-

als was the promotion of group discussions in the ﬁeld. Once one

IDU would become engaged with the picture, peers would become

curious and join in the conversation. At times, three or four cli-

ents engaged in group discussions regarding possible interpreta-

tions of the illustrations, frequently pointing out different aspects

of HIV risk behaviors as well as methods of prevention.

CONCLUSIONS

The cultural and social diversity of the Los Angeles County IDU

population required a strategy that was adaptable, inexpensive,

and portable to sites and segments of the target population

throughout the county. The advantage of the storytelling

approach was that it could be presented in a variety of outreach

settings, could be implemented with persons at various literacy

levels, and could be easily adapted to the cultural needs of each

segment of the target population. It was also a natural lead-in to

staging clients for risk reduction.

The development of any risk-reduction intervention requires care-

ful consideration of the target population’s needs as well as of the

settings in which learning and behavior change take place. Pro-

grams considering the storytelling model are cautioned to work

carefully with the target community, outreach workers, and other

service providers during each step of development and implemen-

tation. It is important to remember that the messages, illustra-

tions, and format of the illustrations must be consistent with the

needs of the target population.

AESOP

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sensitive AIDS education and perceived AIDS risk knowledge:

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A STORYTELLING MODEL

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Education and Prevention, 7(3), 251-264.

ELEMENTS OF AN

INTENSIVE OUTREACH PROGRAM

FOR HOMELESS AND RUNAWAY STREET YOUTH IN

SAN FRANCISCO

Alice A. Gleghorn

, Kristen D. Clements

, and Marc Sabin

†

In 1991, the Centers for Disease Control and Prevention (CDC) ini-

tiated the AIDS Evaluation of Street Outreach Projects (AESOP), a

program designed to evaluate the effectiveness of intensive HIV

prevention outreach programs for high-risk populations. Nation-

ally, AESOP comprised three youth sites and ﬁve sites for injection

drug users. Details of the overall AESOP project are provided else-

where (Anderson et al., 1996). The San Francisco Department of

Public Health–AIDS Ofﬁce contracted with the Haight-Ashbury

Free Medical Clinics to develop ongoing HIV prevention outreach

programs tailored to the youth subcultures and many marginal-

ized youth who congregate in that neighborhood.

Before the implementation of AESOP, no consistent outreach

efforts were speciﬁcally targeting youth in the Haight-Ashbury

neighborhood of San Francisco. Therefore, AESOP presented the

opportunity to design a comprehensive HIV prevention program

for homeless and runaway street youth. The result was an inno-

vative set of community-level interventions that developed from

needs and ideas expressed by the youth. We describe the multi-

faceted intervention developed by the Haight-Ashbury Youth Out-

reach Team (HAYOT) and the AESOP staff. Although HAYOT

continues to provide services to youth, the intervention period was

September 1993 through October 1995 (the AESOP study period).

*San Francisco Department of Public Health–AIDS Office, San Francisco, California

†

Haight-Ashbury Free Medical Clinics, Incorporated, San Francisco, California

AESOP

THE INTERVENTION

The intervention included traditional street outreach (CDC, 1993),

a youth center developed to provide HIV prevention services, and

youth subculture-speciﬁc prevention activities and educational

materials. Although elements of each of these three components

were present throughout the study period, the program focus dif-

fered over time to meet the needs and interests of youth. The ini-

tial emphasis of the intervention was basic street outreach. As

youth attendance at youth center activities increased, staff time

on the streets decreased. Youth involvement in the development

of subculture-speciﬁc activities and materials (Schein, Yeager,

Young, Shapiro & Gleghorn, 1996; Slotnick & Daly, 1996)

changed according to youth interest.

TREET

UTREACH

CTIVITIES

Staff outreach. Street outreach was conducted by community

health outreach workers (CHOWs) and peer health educators.

CHOWs went out on the streets to contact youth with another

CHOW or a trained peer. All outreach staff attended outreach

worker training sponsored by the City and the County of San

Francisco. Peers did not go out without a CHOW. During the ini-

tial 3 months of the project, CHOWs typically spent 30 hours per

week doing street outreach; during later phases of the interven-

tion, staff spent approximately 15 hours per week doing outreach

on the streets.

Contact locations. Outreach activities took place in a six-block

area of Haight Street and in two parks that border this area. Sites

where youth frequently congregated included street corners,

parks, and outside local businesses. Sites were speciﬁed in pre-

liminary research.

Contact target. CHOWs visually assessed youth in contact loca-

tions to determine which youth might be part of the target popula-

tion of homeless or runaway youth or youth involved in the street

economy. Target youth were typically distinguished by the condi-

tion of their clothing, particularly shoes, and poor hygiene. Youth

who were panhandling were also targeted.

ELEMENTS OF AN INTENSIVE OUTREACH PROGRAM

Contact restrictions. CHOWs did not approach youth who

seemed to be actively involved in a drug transaction, youth partic-

ipating in a violent action, youth interacting with the police, or

youth involved in any situation that made the CHOW feel unsafe.

Youth who seemed under the inﬂuence of drugs or youth with

active psychosis were not approached if the CHOW did not feel

safe. CHOWS offered information on the center’s services to youth

who panhandled in lieu of handouts.

Basic street contact. Basic street contact was deﬁned as a brief

(usually 30 seconds) interaction between the CHOW and target

youth in street locations. Following the model of basic street out-

reach (CDC, 1993), the interactions typically had four elements:

(a) introduction—the CHOW told the youth his or her name and

introduced himself or herself as an outreach worker from the

HAYOT; (b) check-in—the CHOW asked how the youth was doing

and whether the youth needed anything; (c) information—the

CHOW told the youth the location of the youth center and gave the

youth a schedule of services (showers, meals, women’s time); and

(d) distribution of materials—the CHOW gave the youth condoms

and bleach kits. Since the beginning of outreach activities,

CHOWs have distributed information sheets on needle exchange

locations. CHOWs began distributing a referral sheet, a ﬂyer with

information on services for youth in the Haight, in October 1994.

Although condoms were distributed, a basic street contact gener-

ally did not involve discussion of sexual behaviors unless initiated

by the youth. On the basis of the conversation, CHOWs would

encourage a youth who seemed to need more extensive contact to

come to the HAYOT center at the youth’s convenience to talk with

an outreach worker. Occasionally, the CHOW accompanied the

youth to the center for an immediate extended session (described

in later section). Also on rare occasions, the CHOW would give a

youth referral information on the street, without an extended session.

HAYOT Y

OUTH

ENTER

CTIVITIES

The Youth Center is centrally located in the target area, one level

above the street, in a renovated Victorian house that also houses

other ofﬁces. The Youth Center has several ofﬁces, a kitchen,

shower facilities, a small room for individual counseling, a larger

room for group discussions, a hall with displays of resource

AESOP

materials and youth art, and an outdoor deck and eating area.

The center offers HIV prevention services and limited youth-

support services. The Youth Center, developed to provide out-

reach services for youth for AESOP, is ofﬁcially a branch of the

Haight-Ashbury Free Medical Clinics, Incorporated. The center is

staffed by a coordinator, two to four CHOWs, and two to three peer

outreach workers. One intern from a local university has also

worked at the center.

Extended sessions. The most common prevention service at the

Youth Center was extended sessions, which were deﬁned as any

discussion of center services or a youth-identiﬁed problem

between CHOWs and a youth at the center. These contacts lasted

from 10 minutes to 1½ hours. The issues raised by youth most

commonly involved medical concerns, HIV or sexually transmitted

disease (STD) issues (including testing), housing, drug use and

treatment, and legal problems. Extended sessions were usually

initiated by youth who came to the center for assistance. Approx-

imately 80% of those who came to the center for support services

(described later in this section) and approximately 50% of youth

who had had a basic street contact also had an extended session.

During the extended session, CHOWs typically tried to address the

youth’s immediate needs ﬁrst (e.g., overdose issues, medical care,

housing, and employment) and then discussed HIV prevention in

terms of sex and drug-using behaviors. If necessary, CHOWs dem-

onstrated how to use a condom or use bleach to clean drug equip-

ment. Such demonstrations were often used to initiate discussion.

Referrals. Approximately 75% of youth were given referrals dur-

ing extended sessions. Referrals were made for services provided

by agencies other than the center. Most commonly, the CHOW

made the appointment for the youth (if appropriate) and wrote the

location, phone number, and appointment time on an appoint-

ment card. Most referrals were for medical services, STD testing

or treatment, obstetrics and gynecology, HIV testing, drug treat-

ment, housing, and employment. All referrals included appoint-

ments unless the agency was closed at the time of the extended

session or the agency had drop-in hours only. Most referrals were

to agencies in close proximity to the Haight neighborhood. Bus

tokens were commonly given to help the youth keep the appoint-

ment; sometimes incentives such as T-shirts were given later if

the youth could prove that he or she had kept the appointment.

ELEMENTS OF AN INTENSIVE OUTREACH PROGRAM

Very rarely, the CHOW took a youth to the referral appointment,

but this was not encouraged by HAYOT.

Harm-reduction groups. In October 1994, the center began con-

ducting harm-reduction groups. Youth were offered incentives

(usually pizza) to be part of a small working group that was

responsible for creating educational materials. Youth ﬁrst listed

the topics that were important to them, and then they chose the

topic that they wanted to work on during a particular session.

Topics have included abscess care, needle exchange, safer shoot-

ing practices, safer sex, alcohol abuse, and overdose. After choos-

ing a topic, youth worked together to come up with the

information that they wanted to include on a harm-reduction edu-

cational card. After the cards were planned, HAYOT staff were

responsible for producing the harm-reduction cards. Staff tried to

have the card ready within 2 days after the harm-reduction group

meeting. Completed cards were placed in the center with the other

educational materials, and CHOWs distributed them on the

streets while doing outreach. CHOWs made a special attempt to

ﬁnd youth who had participated in the creation of the cards to

show them the end product and get their feedback. If youth were

interested, CHOWs gave them a stack of cards to distribute to

their peers. Twelve harm-reduction cards were developed and dis-

tributed during the study. Every card bore the HAYOT address

and phone number, and youth were encouraged to hold onto as

many cards as possible. Community events were planned at which

youth were given prizes for possessing harm-reduction cards.

Women’s groups. In September 1995, the center began conduct-

ing prevention groups for young women. Female HAYOT staff

recruited young women to develop education-information cards

speciﬁcally for their female peers. During the study, four cards

were developed by these groups. The topics included pregnancy

and local prevention services for women. The procedure for the

development and distribution of the women’s cards was the same

as that for the harm-reduction cards.

Educational materials. Two types of educational materials were

available at the center. Informational pamphlets from local agen-

cies offering a variety of services were displayed, and youth could

take these with them. In addition, the 12 harm-reduction cards

AESOP

and 2 of the women’s cards created by and for youth were avail-

able at the center.

Educational videos. The center also showed educational videos

when youth were waiting for an extended session or other ser-

vices. If HAYOT staff members believed a youth would beneﬁt

from a particular video, they had that youth watch the video

before or after an extended session. Eight videos dealing with

street life, drug use, or safer sex were available at the center. Also

available was an educational video made for HAYOT by the rock

group, the Grateful Dead, targeting Deadhead youth (described in

Materials for Youth Subcultures). During the rainy season,

HAYOT staff occasionally rented a movie that addressed youth-

relevant topics, such as drug use, and showed it to a larger group

of youth. Discussion groups with staff, which focused on issues

raised by the movie, typically followed the screening.

Drug treatment. Because few youth-oriented drug-treatment

services were available, the center offered limited drug-treatment

services for youth trying to terminate drug use. Services through

the center included discussions with youth about drug use and

drug treatment issues, and a structured, 21-day nonmethadone

medical drug-treatment program conducted in conjunction with

Haight-Ashbury Free Medical Clinics, Inc. If youth were 18 years

of age and interested in a methadone program, they were referred

to another program (Haight-Ashbury Free Clinics does not offer

methadone programs).

Youth interested in the HAYOT drug-treatment program scheduled

an intake appointment with a senior staff member. These intake

appointments took approximately 1½ hours and were limited to

two per week. The intake consisted of information for admission

to the clinic program. After the intake, center staff accompanied

youth to the Haight-Ashbury Free Medical Clinic, where they

received a physical exam, saw a psychiatrist, and were given med-

ication to ease withdrawal symptoms. By seeking drug-treatment

services through HAYOT, youth were able to skip the usual wait-

ing list for treatment. After youth were enrolled in the drug-

treatment program, they checked in at the center at noon each

day. Youth had a brief counseling session at the center before

going to the clinic to pick up their medication. Youth who arrived

more than 15 minutes late were not able to get medications that

ELEMENTS OF AN INTENSIVE OUTREACH PROGRAM

day. Youth enrolled in the program could receive center support

and prevention services at any time during center hours. If they

needed more extended counseling, center staff helped them get an

appointment with a psychiatrist at the Haight-Ashbury Free Medi-

cal Clinic.

After 21 days, a youth who was drug-free could continue to come

to the center for counseling and assistance with housing and

employment. Youth who relapsed during the 21-day period could

continue the clinic program throughout the 21-day period. After

21 days, a youth who had relapsed or was still using could not

reenter the program for an additional 30 days. Youth also were

encouraged to attend Alcoholics Anonymous or Narcotics Anony-

mous meetings as well as other counseling. Support groups were

attempted at the center but were discontinued because of a lack of

interested youth and a lack of adequate staff.

General merchant contact. When the project was initiated in

September 1993, general contact was begun. Most of the mer-

chants on Haight between Masonic and Stanyan were contacted in

person by CHOWs and given information about the location and

the services offered to youth through HAYOT. Selected merchants

whose businesses were patronized by youth had ongoing relation-

ships with the project. Twenty merchants allowed the HAYOT to

put HIV posters targeting Deadhead and punk youth in their

stores. Two merchants gave food coupon vouchers to HAYOT,

which distributed them as incentives (e.g., for participation in

harm-reduction groups). Five merchants assisted the project by

distributing condoms supplied by HAYOT in their stores. Two of

these merchants also began supplying bleach to youth as of Janu-

ary 1994. As of August 1995, an estimated 250 bottles of bleach

and 12,000 condoms had been distributed to neighborhood

merchants.

Community events. Six community events took place during the

study period. These events had HIV prevention themes and tar-

geted youth, local merchants, or youth service providers.

Event 1, held in January 1994, targeted youth. The main focus of

the event was the Grateful Dead HIV prevention video that was

developed for the project (described in Materials for Youth Subcul-

tures). Youth were invited to come to the center for a premiere

AESOP

showing (60 youth came). A local merchant donated 60 coupons

for free ice cream, and the Grateful Dead donated 12 concert tick-

ets for a rafﬂe that accompanied the event. Food and refreshments

were followed by an introduction to the video and then a showing.

After the video, there was time for comments from the youth.

Event 2, held in July 1994, also targeted youth. Youth were

invited to come to the center for food and to pick up socks (30

came). Youth were separated into different rooms to discuss dif-

ferent issues related to youth services, drug use, and living in

squats. The information was recorded and used in the develop-

ment of a zine (described in Materials for Youth Subcultures) tar-

geting punk or squatter youth.

For Event 3, held in September 1994, merchants were invited to

the center (5 came). Food was offered, and HAYOT staff showed

them the Grateful Dead and punk posters (described in Materials

for Youth Subcultures). Although only 5 merchants came to the

event, 20 merchants in the community agreed to put the posters

in their place of business.

Event 4, also held in September 1994, targeted service providers.

Other community-based organizations that work with youth were

invited to the center for an open house (40 people came). Food

was served, and HAYOT rafﬂed program T-shirts. The main pur-

pose of the event was to network and keep referral relationships

with other agencies strong.

Event 5, held in September 1995, targeted service providers. This

event was similar to Event 4; its primary goal was strengthening

referral networks. Forty providers attended the event, at which

food was served and T-shirts were rafﬂed.

Event 6, also held in September 1995, targeted youth. The pur-

pose of the event was for youth to complete an open-ended survey

to evaluate HAYOT and the services they received there. Fifty

youth attended the event and completed the surveys. Incentives

for youth consisted of T-shirts, food, and socks.

ELEMENTS OF AN INTENSIVE OUTREACH PROGRAM

OUTH

UPPORT

ERVICES

Limited support services were offered at scheduled times during

regular center hours. These services—showers, meals, and

women’s time—were provided, unless otherwise noted, on a ﬁrst-

come, ﬁrst-served basis.

Showers. Services, scheduled on separate days for males and

females, included access to the shower and the provision of sham-

poo, soap, and a towel. Showers were offered in 2-hour blocks

four times a week—twice for women, twice for men. The center

can accommodate approximately ﬁve youth per hour for showers.

Meals. Meals were provided 2 days per week for 1 hour. They

consisted of food obtained from the food bank that week. In order

to serve as many youth as possible, youth were encouraged to

take portable food (for example, soft drink cans, sandwiches, and

fruit) with them, rather than eating all food on the premises. To

maintain center security, meal admission was limited to 10 youth

inside the center at a time. The center typically served 30 youth

per meal.

Women’s time. To facilitate contact with young women, the cen-

ter initiated a special time for women to visit the center and dis-

cuss their concerns. Women’s time ran for 3 hours once a week

and overlapped with one of the women’s shower times. All women

who came to the center for women’s time were admitted. Two

female staff members (one peer and one CHOW) were available

during women’s time; male staff remained out of sight during

these hours. Services included conversations with staff, snacks,

showers, and OB/GYN information and referrals.

ATERIALS

FOR

OUTH

UBCULTURES

Preliminary ethnographic research distinguished two predominate

youth subcultures in the study area: hippie or Deadhead youth

and punk or squatter youth. Approximately half of the youth in

AESOP identiﬁed with one of these two groups. Each group has

distinctive value system, norms for appearance, artistic and musi-

cal preferences, and acceptance of different types of drug use.

Because of these subcultural differences, HIV prevention materi-

AESOP

als were developed for each group. A variety of products were pro-

duced for each subculture. The Grateful Dead band cooperated in

the production of two products for hippie and Deadhead youth: a

video and a condom cover. Posters were developed from focus

groups of youth from each subculture. A core group of punk or

squatter youth developed zines and a referral card oriented to

their peers. We used the following seven steps in developing these

materials:

1. Gained an understanding of the community

2. Focused on a subculture

3. Organized a core group from the subculture

4. Supported the core group’s development and

production of activities or materials

5. Supplied the core group with the necessary resources

6. Evaluated the ﬁnished product

7. Developed new products

Deadhead video. AESOP staff collaborated with HAYOT and the

Grateful Dead to produce a 5-minute video promoting condom use

and safe needle hygiene among the band’s followers. The AESOP

coordinator, working with the Grateful Dead’s publicist, secured

an interview with band member Bobby Weir to discuss HIV risk

behaviors and prevention strategies, which would serve as the

centerpiece of the video. Before the interview, AESOP and HAYOT

staff held focus groups with Deadhead youth living on the street to

formulate questions for Mr. Weir. Project staff interviewed Mr.

Weir and then shot footage of Deadhead youth before a Grateful

Dead concert in discussion about their own risk behavior. The

resultant footage was shown to another focus group, and the

youth selected the segments they thought would have the most

effect. The ﬁnal video integrated concert footage, clips of young

Deadheads talking about their risk for HIV, and Bobby Weir dis-

cussing HIV prevention strategies. A major community event was

held before the premiere of the video at the HAYOT Center, and a

number of tickets to the next Grateful Dead concert (donated by

the Grateful Dead) were rafﬂed to youth. To take part in the rafﬂe,

the youth had to complete a short HIV questionnaire and then dis-

ELEMENTS OF AN INTENSIVE OUTREACH PROGRAM

cuss their answers with the outreach workers. The video was also

shown at the center to interested youth. As of November 1995,

150 youth had seen the video.

Deadhead condoms. AESOP worked in coordination with the

Grateful Dead’s publicist to secure the use of their “Steal Your

Face” logo on condom packets. The condom packets bore the logo

and included instructions for condom use and referral numbers

for HAYOT, the California Youth Crisis Line, and the National

AIDS Hotline. A total of 10,000 condom covers were produced. By

the end of the study period, 5,000 condoms had been distributed

by HAYOT.

Posters and T-shirts. Hippie, Deadhead, punk, and squatter

youth worked with community artists and AESOP and HAYOT

staff to produce two HIV prevention education posters. A series of

focus groups were held separately with youth from each subcul-

ture group. In the focus groups, youth actively participated in cre-

ating slogans and designs that would appeal to their peers.

Community artists were recruited to donate their time to design

images. The tentative poster designs were reviewed in youth focus

groups and one-on-one interviews, and suggested changes were

incorporated. Five hundred posters and 200 T-shirts were pro-

duced and distributed to youth and community merchants in

1994 and 1995.

Dope Productions. The zines and referral cards described in the

next two sections were produced by a core group of punk and

squatter youth who organized and named themselves Dope Pro-

ductions. Dope Productions grew out of a series of focus groups

designed to elicit input from youth about materials development.

Youth expressed a desire to continue this type of work and sug-

gested forming an informal production company committed to cre-

ating educational materials by youth for other youth. The name

Dope Productions, agreed upon by a group of 12 street youth,

refers to dope as slang for any type of drug as well as a colloquial-

ism meaning “exceptional.”

Zine. A zine is a type of underground magazine that originated in

the punk subculture. HAYOT and AESOP collaborated with a

group of young injection drug users living in abandoned buildings

to produce, design, write, and distribute a zine speciﬁcally for

AESOP

their community. Initially, the youth were individually recruited

from the streets and from three squats to take part in a commu-

nity event designed to form a core group committed to writing and

editing the publication. Ice cream vouchers, pizza, and socks were

offered as incentives for participation in the initial meeting. The

core group discussed harm-reduction theory and how it could be

applied to reduce the risks their peers faced. The youth were then

trained in basic computer graphic skills and worked with two

facilitators to organize other youth to produce writing and art.

Articles in the zine addressed the needs, concerns, and beliefs of

the squatting population; topics ranged from prostitution and

squatting ethics to safer shooting techniques. Youth integrated

comprehensive harm-reduction information about needle hygiene,

needle exchange, and condom use, as well as service referrals,

throughout the publication. By the end of the AESOP study, two

issues of the zine had been produced, and 200 copies of each had

been distributed to street youth in San Francisco.

Referral card. Youth from the zine core group worked with an

AESOP organizer to put together a hand-held resource card specif-

ically designed for youth on the street in the Haight. Three youth

discussed the array of services available in the city and then,

working with the organizer, drew up a list of those most important

and accessible to Haight street youth. Then youth reviewed the

services, listing the pros and cons of each. Very short reviews of

11 essential services were ﬁtted into a small accordion-folded

card. The card began with the most basic, practical, and easily

accessible services and moved on to other services. Also described

were the procedures by which youth could easily access that par-

ticular service. The card covered a range of youth outreach ser-

vices: where to shower and snack, free food, nighttime services,

youth shelters, youth needle exchange, medical clinics, women-

speciﬁc services, and youth services outside the Haight. Youth

contributed images and helped to design the artwork on the front

cover. By the end of the study, outreach workers had distributed

300 referral cards to youth.

In our evaluation of youth exposure to, and interest in, subcul-

ture-speciﬁc HIV prevention materials (Gleghorn, 1997), we found

that these materials may have differential appeal for the various

youth subgroups. In general, targeted subgroups had the highest

exposure rates for materials oriented to their subculture. How-

ELEMENTS OF AN INTENSIVE OUTREACH PROGRAM

ever, hippie or Deadhead materials seemed to have broad appeal,

as measured by exposure among the subgroups; hippie and Dead-

head youth had lower exposure to, and higher rejection of, materi-

als designed for punk and squatter youth. Youth who chose not to

identify with a speciﬁc subculture also showed moderate levels of

exposure to, and acceptance of, the subculture-speciﬁc prevention

materials. Although the use of subculture-speciﬁc HIV prevention

materials holds promise for reaching high-risk street youth, future

research should explore factors related to the rejection of materi-

als and whether youth acceptance of outreach materials trans-

lates into participation in HIV prevention activities and decreased

risk behaviors.

SUMMARY

After AESOP ended, HAYOT received other funds to continue their

outreach efforts. By combining street outreach, Youth Center

activities, and subculture-speciﬁc materials, the program devel-

oped a comprehensive intervention that increased youth contact

with outreach and prevention services (Gleghorn et al.,1997). Fol-

lowing the seven steps to involve youth in developing HIV preven-

tion activities, innovative, subculture-speciﬁc interventions

continue to evolve through the HAYOT. The comprehensiveness of

the program contributed to the program’s success in reaching

high-risk youth.

ACKNOWLEDGMENTS

This study was supported by Centers for Disease Control and Pre-

vention cooperative agreement U62/CCU907200. The interven-

tion in this study was developed by the Haight-Ashbury Youth

Outreach Team (HAYOT) in collaboration with the San Francisco

Department of Public Health–AIDS Ofﬁce (SFDPHAO). We thank

the following for assistance with this project: Amber Berquist,

David Deery, Amanda Frank, and Julian Proctor, (HAYOT staff);

Matthew Boman, Clare Brown, Ralph Dickinson, Heather Hamil-

ton, Leatha Jones, Tia Elena Martinez, Sue Miller, Henry Padilla,

AESOP

Lorna Sumaraga, and Amy Symons (SFDPHAO interviewers); Will-

iam Cann, Arthur DeGuzman, Matthew Dodman, Aida Flandez,

Delia Garcia, Lisa Graybill, Vince Guilin, Jan Gurley, Mitchell

Katz, Tim Kellogg, Ruth Kinney, Priscilla Lee-Chu, David Makof-

sky, Rani Marx, Stephen Mills, Kyle Ranson, Eric Vittinghoff, and

Andy Weisskoff (SFDPHAO staff); Michael Clatts and Michele

Kipke (AESOP youth-site investigators); and John E. Anderson,

Judith Greenberg, and Matthew Seeman (CDC).

References

Anderson, J.E., Cheney, R., Clatts, M., Faruque, S., Kipke, M.,

Long, A., Mills, S., Toomey, K., & Wiebel W. (1996). HIV risk

behavior, street outreach and condom use in eight high risk

populations. AIDS Education and Prevention, 8 (3), 191-204.

CDC. (1993). Assessment of street outreach for HIV prevention —

Selected sites, 1991-1993. Morbidity and Mortality Weekly

Report, 412, 873, 879-880.

Gleghorn, A.A., Clements, K.D., Marx, R., Vittinghoff, E., Lee-Chu,

P., & Katz, M. (1997). The impact of intensive outreach on HIV

prevention activities of homeless, runaway, and street youth

in San Francisco: The AIDS evaluation of street outreach

project (AESOP). AIDS and Behavior, 1(4), 261-271.

Schein, J., Yeager, T., Young, A., Shapiro, R., & Gleghorn, A.

(1996). Straight dope: The making of a community level

intervention [video produced by the San Francisco

Department of Public Health–AIDS Ofﬁce].

Slotnick, J., & Daly, J.P. (1996). The making of a community

level intervention. In E. Iverson & J.P. Daly (Eds.), The making

of a community level intervention. Los Angeles: Redwood Press.

ASSOCIATION BETWEEN SELF-IDENTIFIED

PEER-GROUP AFFILIATION AND

HIV RISK BEHAVIORS

AMONG STREET YOUTH

Michele D. Kipke, Jennifer Unger, Raymond Palmer,

Ellen Iverson, and Susan O’Connor

Well into the second decade of the acquired immunodeﬁciency

syndrome (AIDS) epidemic, infection with the human immunodeﬁ-

ciency virus (HIV) is the leading cause of death among Americans

aged 25 to 44 years. As of June 1996, 548,102 cases of AIDS had

been reported to the Centers for Disease Control and Prevention

(CDC), and 343,000 deaths had been attributed to AIDS or AIDS-

related causes (CDC, 1996). Clearly, efforts to quell the epidemic

have been unsuccessful. Adolescents are increasingly being rec-

ognized as a segment of the population that is at high risk for HIV

infection (Vermund, 1997). Because of the long latency between

infection and the onset of symptoms (mean, 12 years), many of the

19,997 infected persons in the 20-to-24 age group are likely to

have been infected during their adolescence (Kipke, Futterman &

Hein, 1990).

Inner-city “street” youth have recently been recognized as a seg-

ment of the adolescent population that is at particularly high risk

for HIV infection (Kipke, O’Connor, Palmer & MacKenzie, 1995).

The street youth population comprises youth who are out of

school and unemployed, involved in the juvenile justice system,

runaway or homeless, a member of a gang, undocumented, or

involved in drug dealing and street prostitution. These youth are

believed to be on the streets for myriad reasons, including poverty

in the home that necessitates their working on the streets to sup-

plement the family income, rejection by parents or guardians, vio-

lence in the home, or drug or alcohol use by family members

Division of Adolescent Medicine, Children’s Hospital of Los Angeles, Los Angeles,

California

AESOP

(Bond, Mazin & Jiminez, 1992). Although the exact size of this

population is unknown, it is estimated that 750,000 to 1.5 million

youth run away from their homes each year (U.S. Department of

Health and Human Services, 1983). Of these youth, one quarter

are believed to be chronically homeless (i.e., without a family to

return to and without a permanent or stable residence). It is esti-

mated that as many as 4% of the runaway or homeless youth pop-

ulation are currently HIV infected (Rotheram-Borus, Koopman &

Ehrhardt, 1991).

There are a number of reasons why the street youth population

may be at increased risk for HIV infection. First, there is growing

evidence to suggest that an alarming number of these youth abuse

alcohol and use other substances, including drugs that they inject

(Fullilove et al., 1993; Kipke, Montgomery & MacKenzie, 1993;

Robertson, 1989; Yates, Pennbridge, Cohen & MacKenzie, 1988).

Alcohol and other drug use has been highly correlated with HIV

risk-related sexual behaviors among these youth (Kennedy,

Greenberg, Clatts, Kipke & Mills, 1994; Kipke et al., 1995). Sec-

ond, many of these youth are involved in “survival sex” (i.e., the

exchange of sex for food, shelter, clothes, money, drugs, or money

to purchase drugs) (Anderson, Pennbridge & Freese, 1994;

Rotheram-Borus et al., 1992). It is estimated that nearly 45% of

the street youth population engage in survival sex and that con-

dom use is sporadic and inconsistent with “paying partners”

(Anderson et al., 1994; Kipke et al., 1995). Youth involved in sur-

vival sex are therefore likely to be at increased risk for exposure to

HIV through unprotected sexual intercourse with multiple high-

risk sex partners.

A third possible reason, which is just now being explored, is peer-

group afﬁliation and the inﬂuence of peer norms or perceived peer

norms that may further encourage risky sex and drug-using

behaviors and discourage protective, or preventive, behaviors.

This reasoning is consistent with the suggestion that peers inﬂu-

ence adolescents to engage in a variety of problem behaviors

(Brown, Clasen & Eicher, 1986; Elliott, Ageton, Huizinga, Knowles

& Canter, 1983; Jessor & Jessor, 1977). For example, adolescents

who smoke, drink alcohol, and are sexually active usually have

friends who participate in these same behaviors (Biglan et al.,

1990; Dinges & Oetting, 1993; Ennett & Bauman, 1993; Mosbach

& Leventhal, 1988; Newcomb & Bentler, 1989; Oetting & Beau-

PEER-GROUP AFFILIATION AND HIV RISK BEHAVIORS

vais, 1986). According to peer cluster theory (Oetting & Beauvais,

1986), peers are a primary inﬂuence on the drug-using behaviors

of adolescents. Peers who use drugs together form groups; the

group uses drugs at particular times and places; and the members

of the group share ideas, values, and beliefs about drugs. Peer

groups may consist of crowds or large groups of youth, small

groups of friends, or dyads such as best friends or couples, which

are characterized by the primary activities and attitudes of their

members. Peer clusters are often close, and members have been

found to signiﬁcantly inﬂuence one another; within drug-using

peer clusters, drugs play an important part in deﬁning the group,

shaping typical behaviors, and maintaining the group identity and

structure (Oetting & Beauvais, 1986).

Other research suggests that adolescents tend to identify with dis-

crete groups (Larkin, 1979; Light & Keller, 1979), that youth give

names to the groups with which they identify (Mosbach & Lev-

enthal, 1988; Sussman et al., 1990), and that group membership

is closely tied to behavior (Dolcini & Adler, 1994). Two studies

investigated whether identiﬁcation with discrete adolescent

groups was predictive of tobacco use. Mosbach and Leventhal

(1988) and Sussman et al. (1990) assessed group identiﬁcation by

asking adolescents to identify the one peer group that they felt

most a part of. The names were then grouped into ﬁve main cate-

gories: hot-shots, regulars, jocks, skaters, and dirts. Hot-shots, or

popular teens, were described as leaders in school activities, such

as academic activities. Regulars were described as resembling the

“normal,” or “typical,” teen. The jocks were described as having a

strong interest in team sports activities. Skaters were described

as placing importance on outdoor skateboarding. Finally, the

dirts were described as exhibiting problem-prone attitudes or

behaviors that included low self-esteem, risk-taking behaviors,

and drug use. Both studies found that youth who identiﬁed them-

selves as belonging to the dirts were more likely than other groups

to smoke cigarettes. In a longitudinal study, 7th grade group self-

identiﬁcation predicted 8th grade cigarette smoking, whereas 7th

grade cigarette smoking did not predict 8th grade group self-iden-

tiﬁcation (Sussman et al., 1994).

In a recent study conducted with street youth, acculturation to

the streets and integration into the street economy were largely

inﬂuenced by associations with other street youth (LaFrance,

AESOP

Pennbridge & Casey, 1992). Using qualitative research methods,

the researchers suggested that the street youth population is het-

erogeneous and comprises several street youth subcultural

groups. Although the self-identiﬁcation of youth “new-to-the-

street” was deﬁned according to their culture of origin (i.e., their

speciﬁc ethnic group or community afﬁliation), fully acculturated

youth were afﬁliated with one of the street youth subcultural

groups. LaFrance proposed that street-acculturated youth aban-

don the cultural afﬁliation they leave home with to embrace a new

street identity based on their identiﬁcation with a subcultural

street group. Most of the street-acculturated youth were afﬁliated

with one of ﬁve street groups: (a) punks or skinheads, character-

ized by their antiestablishment attitudes and opinions and physi-

cal appearance (e.g., multicolored hair or shaved heads, multiple

piercings); (b) hustlers, characterized by their involvement in sur-

vival sex or prostitution; (c) druggies, characterized by their use,

including injecting, dealing, and sharing of drugs; (d) gang mem-

bers, or youth who are members of a gang; and (e) loners, or youth

who reportedly do not afﬁliate with other groups or are rejected by

groups because of their inability to conform to group norms or

rules. Loners were also described as having more serious mental

health problems. Each street youth group demonstrated its own

unique pattern of survival with respect to places they stayed or

slept, means of ﬁnancial support and economic subsistence, and

their use of medical and social services. Thus, although the expe-

riences and backgrounds of street youth may be diverse, this

research suggests that most of these youth share a need for accep-

tance and support from other youth who are hanging out or living

on the streets. Youth who are new to the streets may search for

and join other street youth as a means of protection (i.e., there is

safety in numbers). Peers may therefore provide not only compan-

ionship but guidance in how to survive on the streets. Peers may

also inﬂuence the development of risk-taking behaviors.

The purpose of this study was to conduct epidemiologic research

to further characterize the street youth population with respect to

these street youth groups and more speciﬁcally the effect of self-

identiﬁed peer-group afﬁliation on youths’ use of alcohol and

other drugs and involvement in HIV risk behaviors. A common

methodologic limitation of research conducted with runaway or

homeless youth is the reliance on convenience samples recruited

PEER-GROUP AFFILIATION AND HIV RISK BEHAVIORS

from shelter and drop-in centers. These ﬁndings cannot be gener-

alized to youth who do not use these services, who may account

for as much as 60% to 70% of this population (Kipke, O’Connor,

Palmer & LaFrance, 1993), or to street youth who are not home-

less but who are otherwise largely “hidden.” To overcome this lim-

itation, we used a stratiﬁed probability sampling design to recruit

youth from shelters and drop-in centers as well as from street and

other natural hangout locations.

Our study adds to the literature by (a) assessing street youth, with

whom little research has been conducted, (b) using a representa-

tive sampling design with service and natural hangout sites, (c)

using self-identiﬁed peer-group afﬁliation to deﬁne membership,

and (d) using street youths’ own reports to estimate peer drug use

and risk behavior (rather than relying on perceptions of peers’

behavior). We hypothesized that there would be reported differ-

ences with respect to alcohol and other drug use and involvement

in HIV risk-related sex and drug-using behaviors according to

street group afﬁliation. This research was conducted in the Holly-

wood area of Los Angeles, California, an urban setting with a large

street youth population and an area where runaway and homeless

youth are known to congregate (Kipke et al., 1995).

METHOD

ETTING

, S

AMPLING

ESIGN

AND

ECRUITMENT

ROCEDURES

Youth were eligible to participate in the research if they were 12 to

23 years of age and (a) living on the streets without their families

for 2 or more consecutive months or (b) fully integrated into the

"street economy." By deﬁnition, youth integrated into the street

economy meet their subsistence needs through participation in

one or more of the following survival strategies: prostitution or

survival sex (deﬁned as the exchange of a sexual favor for money,

food, a place to stay, clothes, or drugs), pornography, panhan-

dling, stealing, selling stolen goods, mugging, dealing drugs, or

engaging in “scams” or “cons.”

AESOP

An initial ﬁeld assessment was conducted to estimate the number

of street youth in Hollywood on any given day, the percentage of

youth believed to use shelters and drop-in centers, and to identify

natural hangouts. On the basis of the ﬁndings from this assess-

ment, two distinct yet similar sampling frames were developed:

one recruited from 8 "ﬁxed," or service, sites (e.g., shelter, drop-in,

and meal programs) and one from 73 "natural" street or hangouts

(e.g., street corners or highly populated blocks, parks, alleys, bars,

fast-food restaurants). Field research, observation, and service

provider data further suggested that sampling in shelters and

drop-in centers alone would miss a considerable percentage of the

street youth in Hollywood who were disinclined to use these ser-

vices. Given our broader deﬁnition of street youth (i.e., integrated

into the street economy) and studies that have relied largely on

samples recruited from shelters and drop-in centers, we con-

structed our sampling design to recruit hard-to-reach subpopula-

tions of street youth, including street youth who were not

homeless and street youth who might not be using the services of

shelters and drop-in centers. This was accomplished by over-

sampling from natural street and hangout sites: we recruited 70%

of the sample from natural sites (thereby oversampling by 20%

from these sites) and 30% from ﬁxed sites.

A Statistical Analysis Software (SAS) computer program (SAS

Institute, Cary, North Carolina) was developed to randomly select

and order locations for interviewing teams (each comprising two to

four members). This program took into account two important

aspects of the sampling design. First, with evidence that nearly

65% of street youth are not using services, the selection was

weighted to ensure that a larger proportion of street locations were

chosen (70%), thereby increasing the probability of recruiting

youth who were not using services. Second, all ﬁxed and natural

locations in the pool of potential sampling sites were proportion-

ally weighted, based on the number of youth who typically congre-

gated at that location during the initial ﬁeld assessment. Thus,

locations with a higher volume of youth had a greater probability

of being selected by the computer random selection program than

locations with lower volumes. Assignments were also made

according to high-frequency times of day and days of the week.

Assignments were made weekly.

PEER-GROUP AFFILIATION AND HIV RISK BEHAVIORS

Youth selected for recruitment were asked 12 questions to deter-

mine eligibility. If eligible, youth were asked to participate in a 15-

to 20-minute structured interview called the AIDS Evaluation of

Street Outreach Projects (AESOP) Street Intercept. A subset of

items was developed to assess peer-group afﬁliation. These items

were examined relative to other items in the AESOP Street Inter-

cept that assessed youths' involvement in HIV risk-related sex and

drug-using behaviors, their contact with outreach workers, and

their use of shelters and drop-in centers. Youth received $3 in

fast-food vouchers for completing the screening instrument and

$7 in vouchers for completing the Street Intercept. Data were col-

lected by a team of interviewers (aged 21 to 25 years) who had

extensive training and experience in ﬁeld research techniques (e.g.,

identifying and engaging potential clients, interviewing techniques).

The data reported here were collected by using a subset of items

that assessed respondents’ self-identiﬁed peer-group afﬁliation,

lifetime and recent (past 30 day) use of illicit substances, and

involvement in HIV risk-related sexual behaviors. These data was

obtained from youth enrolled in the study during ﬁve 2-month

cross-sectional waves of data collection: January and February

1993 (Wave 1, n = 204), May and June 1993 (Wave 2, n = 205),

November and December 1993 (Wave 3, n = 163), March and April

1994 (Wave 4, n = 177) and October and November 1994 (Wave 5,

n = 211). Data were collected in waves according to a schedule

developed for this CDC-funded cooperative agreement research

project. Across these ﬁve waves, 1,455 youth were approached; of

those, 1,163 volunteered to complete the screening instrument.

Of youth who were screened, 154 were ineligible (14%), and 275

(19%) refused to participate. The most common reason for refus-

ing to participate in the study was that the youth were "too busy"

(e.g., hustling, dealing drugs) to complete the survey. These

response rates should be considered a minimum estimate, given

that not all potential respondents were perceived as approachable

(e.g., because an illegal drug transaction was taking place). Pre-

liminary analyses revealed no signiﬁcant differences in refusal

rates by gender or race. There were, however, signiﬁcant age dif-

ferences in refusal rates; younger youth aged 12 to 15 years were

least likely to refuse to participate compared with those aged 16 to

18 years (P < .001) who in turn were less likely to refuse to partic-

ipate than were the older youth, aged 19 to 23 years (P < .001).

AESOP

Peer-group afﬁliation was assessed by giving respondents a list of

street youth groups compiled from earlier ethnographic research.

Respondents were asked, “Who would you say you are most like or

spend the most of your time with?” The research received formal

institutional review board approval, and all clients signed an

informed consent form before completing the screening and sur-

vey instruments.

ATA

NALYSIS

All analyses were performed by using the SAS for personal com-

puters. Demographic variables (age, gender, race) were used to

characterize the street youth groups. Rates of drug use were com-

puted for self-reported recent use (past 30 days) of alcohol and

marijuana (at least once per week), lifetime use of other sub-

stances (i.e., cocaine; crack cocaine; methamphetamine, or

"speed;" heroin; the combination of heroin and cocaine, or "speed-

ball”; opium; D-lysergic acid diethylamide, or LSD; mushrooms;

peyote; and phencyclidine, or PCP), lifetime involvement in injec-

tion drug use, and needle-sharing and needle-cleaning behaviors

during most recent injection. Using a risk-and-dependency spec-

trum (Gable, 1993), we grouped drugs into three broad categories

according to their dependency potential—lethal dose, effective

dose, and acute toxicity: (a) high risk and high dependency

(HRHD), (b) high risk and low dependency (HRLD), and (c) low risk

and low dependency (LRLD). Gable found a differential margin of

safety between drug groups. HRHD drugs (i.e., cocaine, crack

cocaine, methamphetamine, heroin and cocaine in combination,

heroin alone, opium, and alcohol) are described as having a mod-

erate-to-severe risk of fatality and a moderate-to-very-high poten-

tial for dependency. HRLD drugs (i.e., mescaline and ecstasy)

have the same range of fatality risk as HRHD drugs yet have a

decreased potential for dependency. Alternatively, LRLD drugs

(i.e., LSD, mushrooms, peyote, and marijuana) have a low-to-neg-

ligible risk of fatality and a much lower dependency potential than

have HRHD drugs.

Sexual behaviors included number of sex partners, involvement in

sexual intercourse while high on drugs or alcohol, and involve-

ment in survival sex (ever). We deﬁned a sexual encounter as

engaging in vaginal or anal intercourse. Other indices of HIV risk

PEER-GROUP AFFILIATION AND HIV RISK BEHAVIORS

assessed included prior infection with sexually transmitted dis-

ease (STD) and perceived risk for infection with an STD or HIV.

Previous research conducted with runaway or homeless youth

suggests the need to distinguish primary and other sex partners

(Anderson et al., 1994). The survey instrument therefore made

this distinction: a primary partner was deﬁned as a "main or

steady sex partner or someone that is important or special” (e.g.,

girl- or boyfriend, or lover), and other partners were deﬁned as

"someone other than your main partners" (e.g., casual or survival

sex partners). Condom use at most recent sexual encounter with

each partner type was computed.

Chi-square analyses were performed to determine signiﬁcant dif-

ferences across the ﬁve waves of data collection. These analyses

revealed that the proportion of youth in each peer group differed

by wave (chi square = 69.9, P < .001). Speciﬁcally, youth inter-

viewed in the later waves were more likely to be punks or skin-

heads (51% of Wave 5 vs. 23% in Wave 1), and youth interviewed

in the earlier waves were more likely to be in the “other” afﬁliation

category (32% in Wave 1 vs. 15% in Wave 5). Therefore, we con-

trolled for wave in all subsequent analyses. It is also important to

note that this research was conducted as part of an evaluation of

street outreach services and that the enhanced interventions were

delivered after the second wave of data collection. By controlling

for wave in later analyses, we also controlled for potential inter-

vention effects on the behaviors of youth within these peer groups.

Next, multiple regression analyses were performed with SAS gen-

eral linear models to determine whether peer-group afﬁliation was

a signiﬁcant predictor of alcohol and other drug use and of sex

and drug-using behaviors. The ﬁnal regression model, which was

signiﬁcant at P < .05, used Tukey’s honestly signiﬁcant difference

(HSD) to identify which groups differed on the dependent variables

at the .05 level. Finally, odds ratios were computed in logistic

regression models to calculate the relative risk of engaging in each

behavior for youth in each peer group compared with youth in all

other peer groups.

AESOP

RESULTS

AMPLE

HARACTERISTICS

Youth ranged in age from 13 to 23 years; nearly 80% were aged 16

to 21 years (Table 1). Most of these youth were male (71%), and

the males were signiﬁcantly older than the females (t = 7.81,

P < .0001). More than half (51%) were Caucasian, and 49% were

members of ethnic minority groups: African American (20%), Lat-

ino (15%), Native American (5%), Asian/Paciﬁc Islanders (2%), or

another ethnic minority group (6%). Of the 752 youth in the

study, 69% reported that at the time of the interview they were liv-

ing on the streets, in a squat or shelter, or in an abandoned build-

ing. Of youth who were living on the streets or without a place of

their own, most had done so for 1 year or more (51%); 14%

reported having been without a place to stay or a place of their

own for 6 months to 1 year; and 35% for less than 6 months. Of

the 31% who had some other place to stay at the time of the inter-

view, 69% had lived in their own house or apartment within the

past 12 months, and 62% had stayed with family or some other

relative. However, most of these youth reported having been pre-

cariously housed at some time during the past 12 months, either

by staying at a friend’s house or apartment (80%), with a boyfriend

or girlfriend or lover (58%), in a foster home or group home (28%),

or at a halfway house or treatment center (10%).

In response to the list of peer groups, 36% responded that they

were most like or identiﬁed with punks or skinheads, 14% with

gang members, 12% as loners, 10% as hustlers (most were

involved in the sex trade), and 7% as druggies (most were involved

in drug running or dealing). Of youth who did not identify with one

of these groups, 9% identiﬁed with some other speciﬁed group

(e.g., surfers, Deadheads [followers of the Grateful Dead rock

band], gay or lesbian youth not involved in the sex trade or sur-

vival sex, drag queens or transgender) although each group

accounted for no more than 2% of the total sample. Twelve per-

cent identiﬁed with some other group not listed as a response

option—taggers, squatters, musicians, ravers, or rockers; each of

these groups accounted for no more than one to two youth. Thus,

22% of the sample were included in an “other” afﬁliation category.

PEER-GROUP AFFILIATION AND HIV RISK BEHAVIORS

Between-group comparisons revealed that punks or skinheads

were signiﬁcantly more likely to be Caucasian (70%) than were

gang members or loners (Table 1). Gang members were signiﬁ-

cantly more likely than all other groups to be African American

(44%), and druggies were signiﬁcantly more likely to be male than

were hustlers and youth in the “other” category (56%) (Table 1).

With respect to age, hustlers were signiﬁcantly older than all of

the other groups (mean, 19.2 years), and gang members were the

youngest of the groups (mean, 17.7 years); the mean ages for the

other groups were 19.1 years for the loners, 18.5 years for the

punks or skinheads, and 18.4 years for the druggies.

RUG

-U

SING

ATTERNS

Rates of alcohol and other drug use were remarkably high among

the youth in this sample (Table 2). Speciﬁcally, 75% reported ever

having used a substance in the HRHD drug category: 66%

reported ever having used speed, 52% ever having used cocaine,

41% crack cocaine, and 41% alcohol at least once a week. Thirty-

seven percent reported having used HRLD drugs (32% reported

ever having used ecstasy, 17% reported ever having used mesca-

line) and 88% reported having used an LRLD drug (65% reported

ever having used LSD, 50% ever having used mushrooms, 22%

ever having used peyote, and 45% reported ever having used mari-

juana at least once per week). Of the sample, 37% reported ever

having injected drugs; of those, 58% reported having injected

within the past 30 days, and 45% reported having shared their nee-

dle or equipment at their most recent injection; 82% reported hav-

ing cleaned their needle with bleach at their most recent injection.

Analyses further revealed signiﬁcant differences between the peer

afﬁliation groups with respect to alcohol and other drug use (Table

2). Speciﬁcally, youth afﬁliated with the punks or skinheads,

druggies, and hustlers were signiﬁcantly more likely than all other

groups to report having used a greater number of different drugs

in all three of the drug risk categories. Odds ratios further

revealed that punks or skinheads, as compared with all other

groups, were nearly three times more likely than the other groups

to have used cocaine and speedball, and four times more likely to

have used opium. Both punks or skinheads and druggies, com-

pared with all other groups, were three times more likely to report

AESOP

the use of heroin and mushrooms, four and two times (respec-

tively) more likely to have used speed, two times more likely to

report the use of crack cocaine, and four times more likely to use

alcohol at least once per week. In contrast, gang members and

loners were groups least likely to report use of HRHD drugs, par-

ticularly cocaine, speed, speedball, and heroin. Gang members

were, however, four times more likely to have used marijuana at

least once per week compared with all other groups; hustlers and

loners were the least likely to use marijuana with this frequency.

Punks or skinheads were also most likely to report ever having

injected drugs, and gang members were the least likely to report

ever having injected drugs. There were no signiﬁcant differences

among the groups with respect to needle sharing and cleaning

practices (gang members were not included in this analysis given

the low prevalence of injection drug use).

EXUAL

ISK

EHAVIORS

The study youth had also engaged in a number of HIV risk-related

sexual behaviors, including survival sex (32%), sex with multiple

partners (32%), sexual intercourse while high (51%), and unpro-

tected sexual intercourse with primary (48%) or other (27%) sex

partners during most recent encounter (Table 3). Of the sample,

18% reported having been given a diagnosis of an STD, yet only

47% perceived themselves at risk for an STD; 59% perceived

themselves at risk for HIV infection. As was true for drug use,

there were distinct risk patterns among youth according to peer-

group afﬁliation, although the patterns were fewer. Speciﬁcally,

punks or skinheads were most likely to have been “high” during

their most recent sexual encounter (71%), and hustlers were sig-

niﬁcantly more likely to have engaged in survival sex (81%), to

have had multiple sex partners (72%), and to have been given a

diagnosis of an STD (31%). There were no signiﬁcant differences

between the groups with respect to use of a condom during the

most recent sexual encounter or the perceived risk for an STD or

HIV infection. Remarkably, 78% of the sample reported having

been tested for antibodies to HIV. There were, however, no signiﬁ-

cant between-group differences with respect to whether youth had

been tested.

PEER-GROUP AFFILIATION AND HIV RISK BEHAVIORS

DISCUSSION

Despite efforts to reach this very important, yet largely hidden,

population and our efforts to overcome the limitations of earlier

studies (i.e., convenience sampling at service locations), there are

some limitations to this study. First, the ﬁndings rely on clients'

self-reported behaviors, which cannot be independently veriﬁed.

The levels of use of alcohol and other drugs and the levels of sex

and drug-using behaviors (e.g., survival sex, needle sharing) may

underestimate their prevalence, given that many of these behav-

iors are illegal and socially undesirable and because the data were

collected by an interviewer who was not known to the youth before

the interviews. A second limitation is that the data are cross-

sectional and therefore do not contain information about the tem-

poral relationship between clients' introduction to the streets,

selection of, or afﬁliation with, a peer group, and involvement in

risky behaviors. Thus, no statements can be made about the

causal relationship between peer-group afﬁliation, peer norms or

perceived peer norms, and drug-using and HIV risk behaviors.

Finally, although this sample is likely to be representative of the

street youth population in the target geographic area, it is unclear

how generalizable these ﬁndings are to street youth populations in

other cities (e.g., Boston, New York, San Francisco). Future

research should continue to use street-based probability sampling

techniques to evaluate similarities and differences among street

youth populations from different geographic areas.

Despite these limitations, this study provides evidence that the

street youth population in Hollywood comprises several groups

that differ with respect to members’ involvement in alcohol and

other drug-using and HIV risk behaviors. These ﬁndings are sig-

niﬁcant for a number of reasons. First, they suggest the need to

further deﬁne the street youth population and differences with

respect to health problems and risk proﬁles according to self-

identiﬁed peer-group afﬁliation. Whereas growing evidence sug-

gests that inner-city street youth are at increased risk for the

abuse of alcohol and the use of other substances (Fullilove et al.,

1993) and HIV transmission (Kipke et al., 1995), these ﬁndings

suggest that interventions be tailored to meet the speciﬁc needs

and risk proﬁle of each segment of the larger street youth popula-

tion. Future research and service delivery efforts should therefore

AESOP

begin systematically addressing the diversity of this population.

Future research is also needed to more fully characterize behav-

ioral differences between subcultural groups, particularly with

respect to health and risk proﬁles. Attempts to replicate these

ﬁndings in other urban settings would also be of interest.

Second, these ﬁndings suggest that peers may inﬂuence street

youth both negatively and positively. For example, our ﬁndings

suggest that gang members were at less risk for the use of HRHD

drugs, for involvement in injection drug use, and for sexual inter-

course with multiple partners. Little research has examined the

social networks of street youth, the process by which youth

become afﬁliated with street peer groups, or the inﬂuence of peer-

group pressure, values, norms or perceived norms on youths’

behavior. Research is therefore needed to more fully characterize

the importance of peer relationships among these youth and the

effect of these relationships on street youths’ involvement in risky

as well as preventive behaviors.

Finally, our ﬁndings suggest that there is some urgency in the

need to intervene with this population. Designing interventions

that challenge street youth to engage in health-promoting behav-

iors is, at best, a difﬁcult task. Our ﬁndings suggest that it may

be beneﬁcial to develop interventions or intervention approaches

that match the different street youth groups. Transitioning them

off the streets or into more stable living circumstances may be the

long-term goal. More information, however, is needed—from

research and service demonstration projects—to guide the devel-

opment of intervention strategies that will identify, engage, and

change the health and risk proﬁles of these youth. Interventions

may also need to be tailored to address the unique risk proﬁle of

each social peer group.

Street outreach has recently been demonstrated to be an effective

strategy for reaching persons who are not served by traditional

health care programs and who are at risk for HIV transmission

(Wieble et al., 1996). Popular outreach approaches attempt to

engage high-risk persons through the distribution of bleach and

condoms, needle cleaning and condom demonstrations, and role-

playing of safer sex techniques. Other ﬁndings suggest that out-

reach and prevention efforts must be delivered in settings where

the target population can be found and must be staffed by people

PEER-GROUP AFFILIATION AND HIV RISK BEHAVIORS

who know the community’s values and norms, speak the language

of those whom they are seeking to attract, and are trusted by

members of the target community. A growing literature demon-

strates the effectiveness of peers, both as outreach workers (the

indigenous leader model) and behavior change specialists. Thus,

one promising intervention might use peers to conduct street out-

reach to youth, matching peers to the characteristics, values, and

norms of the different street youth subcultural groups (e.g., hiring

youth who can serve as positive role models, who are or were

homeless, punks or skinheads, formerly involved in survival sex,

former gang members). Outreach workers might be effective inter-

ventionists for changing peer norms and encouraging youth to

seek services, promoting preventive behaviors, and discouraging

risky behaviors.

ACKNOWLEDGMENTS

This study was supported by the Centers for Disease Control and

Prevention, cooperative agreement U62/CCU907198. The views

expressed are those of the authors, not necessarily the funding

agency. Special thanks go to John Anderson and Judith Green-

berg; members of the AESOP ﬁeld research team (Michael Cohen,

Marcus Kuiland-Nazario, Burke Nelson, Sara Parker, Audruin

Pittman, German Rodriguez, Lily Rodriguez); collaborating youth-

serving agencies (Angel's Flight, Covenant House California, Holly-

wood YMCA, Los Angeles Gay and Lesbian Community Services

Center, Los Angeles Free Clinic, Los Angeles Youth Network, My

Friend's Place, PROTOTYPES, Inc., Teen Canteen, The Way In);

and Eunice Villatoro.

AESOP

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Table 1. Demographic Proﬁle of Study Sample

Risk

Total

N = 750

Punks

n = 264

Druggies

n = 54

Hustlers

n = 72

Gang

n = 106

Loners

n = 89

Other

n = 165

HSD

Gender

Male 71 64 54 94 61 74 80 18

Female 29 36 44 6 39 26 20 18

Ethnicity

Caucasian 52 70 67 53 23 45 41 19

African American 19 7 20 21 43 24 19 16

Latino 15 11 7 17 22 13 23 15

Asian/Paciﬁc Islander 2 2 0 3 2 3 4 6

Other 11 10 24 7 10 15 8 9

Age (years)

13-15 9 5 9 11 22 4 8 12

16-18 41 49 43 25 40 38 39 20

19-21 39 39 41 46 32 38 41 20

22-23 11 7 7 18 7 19 12 13

HSD — honestly signiﬁcant difference. A means of comparing columns for minimal percentage difference required for signiﬁ-

cance of P < .05. For example, in the ﬁrst row, males account for 64% of the punks. The only group outside the 18% HSD

range (i.e., 64% + 18% = 82%) is the hustlers, at 94%.

Table 2. Rates of Lifetime Substance Use for Each Peer Youth Group

Risk

Total

N = 750

Punks

n = 264

Druggies

n = 54

Hustlers

n = 72

Gang

n = 106

Loners

n = 89

Others

n = 165

HSD

High risk & high dependency 75 92

1 7

Cocaine 52 70

2 0

Crack 41 46

2 0

Speed 66 85

1 9

Speedball 26 41

1 8

Heroin 28 46

1 8

Opium 25 40

1 7

Alcohol

41 59

2 0

High risk & low dependency 37 52

bcd

Mescaline 17 23

1 5

Ecstasy 32 45

bcd

Low risk & low dependency 88 96b 93b 83bc 88bc 79c 77c 14

LSD 65 84

1 9

Mushrooms 50 68

2 0

Peyote 22 32

1 7

Marijuana

45 46

2 0

Ever injected drugs 37 52

2 1

Shared needle at most

recent injection

45 41

—58

5 2

Cleaned needle at most

recent injection

——86

—61

HSD–honestly signiﬁcant difference. A means of comparing columns for minimal percentage difference required for signiﬁcance

of P < .05.

— Percentages were not calculated for cells with fewer than 10 observations.

Percentage who use at least once per week.

b, c, d

Percentages with the same letter are not signiﬁcantly different at P < .05.

Table 3. Risk Behaviors, by Peer Youth Group

Risk

Total

N = 750

Punks

n = 264

Druggies

n = 54

Hustlers

n = 72

Gang

n = 106

Loners

n = 89

Other

n = 165

HSD

Condom use, most recent sexual

encounter

Main partner 52 50

Casual partner 73 72

Sex while high, most recent encounter 51 71

Survival sex (ever) 32 19

Multiple partners, past month 40 34

Prior STD 18 17

Tested for HIV 78 76

Perceived risk for STD 47 50

Perceived risk for AIDS 59 65

HSD–honestly signiﬁcant difference. A means of comparing columns for minimal percentage difference required for signiﬁcance

of P < .05.

a,b,c

Percentages with the same letter are not signiﬁcantly different at P < .05.

ENHANCED STREET OUTREACH

AND CONDOM USE

HIGH-RISK POPULATIONS IN FIVE CITIES

John E. Anderson

, Judith Greenberg

†

and Robin MacGowan

AESOP was a 5-year, multifaceted evaluation of street outreach

interventions to injection drug users (IDUs) and high-risk youth,

which was conducted in six cities in the United States. We sum-

marize one aspect of the research project: surveys of IDUs and

youth that were conducted as part of a quasi-experimental

research design before and after enhancement of outreach activi-

ties. The objectives of the surveys were threefold: to measure

changes in HIV-related risk behavior, to measure changes in expo-

sure to street outreach workers, and to measure the association

between interaction with street outreach workers and condom use.

METHODS

TUDY

ESIGN

We used a quasi-experimental research design. Collaborating

research teams in each of six cities selected study and comparison

areas for their high-risk population. The study and comparison

areas were selected for similarity of risk-group characteristics

(age, race/ethnicity) and risk group behavior. Each area also

needed adequate numbers of the group of interest and some level

of street outreach programs in both areas. Researchers in Phila-

delphia, Chicago, and Atlanta focused on IDUs. San Francisco

*Division of HIV/AIDS Prevention - Intervention Research and Support, National

Center for HIV, STD, and TB Prevention, Centers for Disease Control and

Prevention, Atlanta, Georgia

†

Division of STD Prevention, National Center for HIV, STD, and TB Prevention,

Centers for Disease Control and Prevention, Atlanta, Georgia

AESOP

researchers focused on youth. In Los Angeles and New York, sepa-

rate teams focused on youth and on IDUs. In some cities, study

and comparison areas included multiple geographic areas, reﬂect-

ing the spread of IDUs or youth in that geographic area. Street

outreach enhancements targeting sex and drug-using behaviors

were developed and implemented in the study areas only. These

ranged from a “rubber room” in a health clinic, where youth could

obtain condoms and health information, to a mobile van for HIV

counseling and testing and other medical services for IDUs.

Enhancements differed by city (see the Results section). A series

of cross-sectional surveys were conducted both in the study and

comparison areas. Each site conducted a minimum of two pre-

enhancement rounds of interviews approximately every 3 months

from January through August 1993 and two postenhancement

rounds during 1994 and 1995, once the enhancements had been

fully implemented for at least 3 months. In this paper we compare

aggregated data from the two rounds of preenhancement surveys

with two rounds of postenhancement surveys for ﬁve sites.

ELIGIBILITY

Eligible IDU respondents were deﬁned as persons within the geo-

graphical boundaries of the intervention or comparison area who

had injected illegal drugs in the past 3 years. (In three cities—

Atlanta, Los Angeles, and Philadelphia—up to 30% of the sample

were allowed to be persons who had used crack cocaine in the

past month but who had not injected in the past 3 years). Eligible

youth respondents were deﬁned as youth aged 12 to 23 years who

had been recurrently without shelter during the past year, without

permanent shelter for 2 months, or derived their livelihood from

the street economy (drugs, prostitution, panhandling, crime). For

each research team, the goal was to complete 200 interviews in

the study area and 200 in the comparison area during each round

of the survey.

ENHANCED STREET OUTREACH AND CONDOM USE

SAMPLING

Street outreach takes place in the natural setting of the IDU and

high-risk youth populations; thus, we needed methods by which

to obtain respondents in their communities, not in clinic, shelter,

or other institutional settings. Because the behaviors that deﬁned

these risk groups (e.g., prostitution, panhandling, drug dealing or

injecting illegal drugs or smoking crack) are not common in the

general population and because many group members would not

have been located through phone or residence surveys, standard

survey sampling methods were not possible. Systematic sampling

methods were designed to reduce the sources of bias to a mini-

mum and to produce comparable repeat samples over several

waves of interviewing (Anderson et al., 1996). (See the Methods

section for a detailed description of sampling methods and Kipke,

Unger, Palmer, Iverson, and O’Connor in this monograph for how

these methods were applied at the Los Angeles youth site).

Interviewers were required to keep track of the numbers of refus-

als and eligible clients who did not complete interviews. At all

sites, clients were offered cash or food incentives to participate.

Overall response rates combining nonresponse for refusals before

screening and for noncompletion of the interview by eligible

respondents ranged from 73% to 99% (overall rate, 90%). These

response rates should be considered approximate: it is likely that

not all potential respondents were approached, because they were

not seen or were determined unapproachable (e.g., because an

illegal drug transaction was taking place).

We present data from ﬁve groups of researchers who participated

in AESOP: two groups that focused on youth (Children’s Hospital

of Los Angeles and the AIDS Ofﬁce of the San Francisco City

Health Department) and three groups that focused on IDUs (Uni-

versity of Illinois at Chicago, Los Angeles County AIDS Ofﬁce, and

Philadelphia Health Management Corporation). These groups had

collected four rounds of data—two before the enhanced interven-

tion and two after the enhancement was in place.

AESOP

STATISTICS

Dependent variables. The main dependent behavioral variables

were six measures of condom use during most recent sexual

encounter. Condom use variables were measured separately for

vaginal, anal, and oral sex, and for main and casual partners.

Note that these behaviors were not measured for the entire sam-

ple, but only for those who engaged in this particular activity (e.g.,

anal sex with casual partner). Condom use is a dichotomous mea-

sure of whether condoms were used during the most recent sexual

encounter. The two waves of pre- and postenhancement data were

aggregated to form one set of pre- and one set of postenhancement

scores.

Predictor variables. In addition to location (study area versus

comparison area) and time period (pre- versus postenhancement),

we examined the relationship between risk behavior and predictor

variables that have been associated with condom use: background

factors (age, sex, race/ethnic group, support through street econ-

omy), sex behavior variables (types of partners, number of part-

ners, exchange of sex for needs, sexual orientation, carrying

condoms), and drug-related behavior (injection history, needle

sharing, crack use, drug treatment history). We also examined

exposure to street outreach programs in the past 6 months, meas-

ured by yes-or-no variables (talked with outreach workers;

received condoms, material, or bleach from outreach workers).

Statistical signiﬁcance between the pre- and postenhancement

rounds was evaluated by using chi-square measures for percentages.

Multivariate modeling. In using the quasi-experimental design

to assess the effect of enhanced street outreach interventions on

condom use, we were looking for the effect of greater condom use

in the study area during the postenhancement period. Logistic

regression models to measure this took the following form:

condom use = study area + postenhancement period +

postenhancement study area

That is, we looked for regression effects of being in the study area,

of being in the postenhancement period, and an interaction term

measuring the effects of being in the postenhancement study area.

A positive coefﬁcient (or odds ratio of greater than 1.0) for the

ENHANCED STREET OUTREACH AND CONDOM USE

interaction term is consistent with effectiveness of the enhance-

ment under the assumptions of the quasi-experimental research

design. These three terms were included in every model. The

models were computed in two ways: including only those three

terms and including the three terms plus a series of covariates

measuring respondent characteristics, risk behaviors, and contact

with outreach programs. Stepwise modelling methods were used

to reduce the number of covariates to those that were signiﬁcant

at the .05 level in the ﬁnal models.

Some of the predictor variables can be considered intermediate

variables. For this reason, we also looked at logistic regression

analysis to determine the factors associated with getting condoms

from outreach workers and with having condoms at the time of

interview. To the extent that these factors affect condom use and

are in turn associated with enhanced programs, the programs can

be said to have indirect effects on condom use.

RESULTS

HILDREN

’

OSPITAL

NGELES

This project evaluated street outreach services provided by several

agencies in the Hollywood area. The study and comparison areas

were Hollywood and downtown San Diego. The enhanced inter-

vention centered on the opening of a storefront center (the rubber

room) for the distribution of condoms and the provision of other

services to street youth. The total enhanced outreach program

contained the following elements: (a) interagency outreach coordi-

nation, (b) peer outreach team, (c) rubber room, (d) small print

media, and (e) referral to needle exchange program.

The characteristics of survey respondents in the pre- and posten-

hancement periods were similar in the study and comparison

areas. Even the differences that were statistically signiﬁcant did

not seem to be meaningful differences. For example, in the post-

enhancement period, 100% of respondents had lived on the street

in the past year compared with 93.7 % in the preenhancement

period—a signiﬁcant difference, but probably not representative of

a substantive difference between the samples.

AESOP

For the respondents’ reported contact with AIDS-related street

outreach services, there were no statistically signiﬁcant differ-

ences between the pre- and postenhancement periods. Pre-

enhancement levels of contact were quite high in the intervention

area—64.9% of respondents had spoken with an outreach worker

in the past 6 months, and 54.6% had received condoms. In con-

trast, in the comparison area (downtown San Diego) only 20.7%

had talked with outreach workers in the past 6 months, and

12.9% had received condoms. Differences in exposure to outreach

were controlled in the logistic regression analyses.

Speciﬁc survey questions were added to measure contact with the

enhanced street outreach intervention in the study area. Of the

youth, 30% reported having visited the rubber room, and 12%

reported having received condoms there; 29% reported having

received condoms from an outreach worker from AESOP. Regard-

less of pre- or postenhancement, the percentage of respondents

who used condoms during the most recent sexual encounter dif-

fered by the pattern mention earlier: condom use was higher for

casual partners and was highest for anal sex, followed by vaginal

and oral sex.

Logistic regression results indicate that being in the postenhance-

ment study area (the quasi-experimental effect of interest) was not

statistically signiﬁcantly associated with condom use during most

recent vaginal sex for main or casual partners (Table 1). Getting

condoms from outreach workers was a strong predictor of having

condoms for youth who reported main (odds ratio [OR], 2.5; conﬁ-

dence interval [CI], 1.5–4.2) and casual (OR, 2.4; CI, 1.5–4.0)

partners. With respect to using condoms during most recent vagi-

nal sex, at postenhancement 47.6% of youth reported having used

condoms with main partner, and 71.8% reported having used con-

doms with casual partners. Having a condom at interview was

associated with higher odds of having used condoms during most

recent vaginal sex with main (OR, 2.3; CI, 1.5–3.6) and casual

partners (OR, 2.1; CI, 1.3–3.5).

Many of the high-risk youth interviewed had had contact with

street outreach workers in the pre-and postenhancement periods

in the study area. High levels of preenhancement contact in the

study area probably made large increases in exposure to outreach

in the postenhancement period difﬁcult. No statistically signiﬁ-

ENHANCED STREET OUTREACH AND CONDOM USE

cant increases in condom use were noted. However, there was a

strong link between condom use, having condoms, and getting

condoms from outreach workers, which suggests the need to

encourage the carrying of condoms, especially by high-risk youth

in the Hollywood and San Diego areas, for whom spontaneous sex

is probably the norm.

RANCISCO

ITY

EALTH

EPARTMENT

The study area was the Haight-Asbury District in San Francisco,

where high-risk youth congregate; the comparison area was a

group of outlying areas where street youth with similar character-

istics were to be found (Arcata, Berkeley, Eureka, and Santa

Cruz). The enhanced intervention was the Haight-Ashbury Youth

Center, a storefront operation that was developed especially for

AESOP. The youth center ﬁelded a street outreach team that pro-

vided (in addition to standard outreach services) referrals for med-

ical, drug treatment, and other services. (See Gleghorn et al. in

this monograph for a detailed description.) Community activities

were sponsored at the youth center: discussion groups, women's

shower times, community-designed HIV prevention posters, a

Grateful Dead prevention message video and Grateful Dead logo

condoms, and outpatient drug treatment services.

Survey data indicate that the youth interviewed in the study and

comparison areas were similar. In the study area, there were some

differences of interest between the pre- and postenhancement

periods. Respondents in the later period were less likely to be

male and more likely to inject drugs and use crack cocaine. Con-

tact with outreach programs was higher in Haight-Ashbury than

in the outlying areas for both periods. In the study area, there

were statistically signiﬁcant increases from pre- to postenhance-

ment in the percentage of high-risk youth who reported having

talked with outreach workers and received materials from them.

High-risk respondents in Haight-Ashbury reported considerable

contact with the Haight-Ashbury outreach center: 60.1% had

heard of the center, and 36.5% had received services there.

In San Francisco, there were no signiﬁcant differences pre- and

postintervention between study and comparison youth to indicate

a change to safer behavior, deﬁned as condom use during most

AESOP

recent sexual encounter by type of partner and type of sex. Multi-

variate logistic regression analysis (Table 2) indicates that being in

the postenhancement study area was not signiﬁcantly associated

with condom use for main or casual partners. Having a condom

at interview, however, was associated with higher likelihood of use

during most recent vaginal sex with main partners (OR, 2.4; CI,

1.3–4.4). For respondents with main partners, having a condom

at interview was, in turn, strongly associated with having received

condoms from outreach workers (OR, 3.4; CI, 1.8–6.4).

Survey results for San Francisco indicate increased contact with

outreach programs in the study area during the postenhancement

period. The survey also measured a substantial amount of con-

tact with the youth center by youth contacted on the street in the

Haight-Ashbury District. Although no apparent behavior change

was measured through two rounds of postenhancement surveys,

the data do indicate the importance of street outreach programs’

providing condoms to youth and encouraging youth to carry them.

NIVERSITY

LLINOIS

HICAGO

The Chicago project evaluated street outreach to IDUs in inner-

city neighborhoods. The study area was west of the Loop, and the

comparison area was near the Southside. The enhanced interven-

tion centered on services delivered from a mobile van that pro-

vided on-site HIV counseling and testing. Additional enhance-

ments included increasing the number of outreach workers,

escorting clients to referral services, improving client follow-up,

and making community presentations.

Comparisons of the pre- and postenhancement characteristics of

respondents indicate some differences between the two periods.

For example, in the postenhancement period, respondents in both

areas were less likely to exchange sex for needs, less likely to think

of themselves as at risk for HIV, and more likely to have known

someone with HIV infection or AIDS.

Contact with outreach programs increased both in the study and

comparison areas. Outreach contact was at relatively low levels in

the preenhancement period, particularly in the comparison area.

For example, in the study area, ever having talked with an out-

ENHANCED STREET OUTREACH AND CONDOM USE

reach worker increased from 32.4% to 57.3% between the pre-

and postenhancement periods; in the comparison area, it

increased from 18.6% to 47.0%. Increased contact in the compar-

ison area was related to programs unrelated to AESOP that were

being developed in this area. In the study area, the percentage

that had received condoms from outreach workers (including the

mobile van) increased from 21.4% to 39.5% and in the comparison

area, from 12.5% to 16.8%.

With regard to condom use during most recent intercourse, there

were statistically signiﬁcant increases for main partners for vagi-

nal (from 27.1% to 39.0%) and oral sex (from 10.5% to 27.3%) in

the study area. In the comparison area, these percentages

declined for vaginal (from 21.0% to 17.2% and for oral sex (from

16.1% to l1.3%).

Data provided by the outreach programs support the survey

results indicating that many respondents received services from

the mobile van. Quarterly data from the program indicate that

during 1994 (roughly corresponding to the postenhancement

period) nearly 10,000 street outreach contacts were made and

more than 66,000 condoms distributed.

Multiple logistic regression analysis (Table 3) indicates that being

in the postenhancement study area was associated with higher

use of condoms during most recent vaginal sex with main partner

(OR, 1.9; CI, 1.3–2.7). This indicates a quasi-experimental effect

for this variable, consistent with the enhanced intervention’s hav-

ing an effect on change toward safer behavior. Being in the post-

enhancement study area was also associated with a higher odds of

getting condoms from outreach workers (OR, 3.1; CI, 1.3–7.6 )

and having condoms at interview (OR, 2.0; CI, 1.0–4.0). For con-

dom use with casual partners, there were no signiﬁcant effects of

being in the postenhancement study area. Similar to condom use

for main partners, having condoms is a strong predictor of con-

dom use (OR, 3.0; CI, 1.9–5.0) and is in turn strongly related to

outreach contact (OR, 2.3; CI, 1.3–4.1), indicating a strong indi-

rect relationship between condom use and contact with outreach

programs for persons with casual partners.

AESOP

The study and comparison areas for the Chicago site had relatively

low levels of preenhancement outreach activity. Substantial

increases in interaction with outreach workers were reported in

both areas. Survey and program data show the distribution of

condoms and services by mobile van. The surveys measured

aggregate behavior change in the study area consistent with the

effectiveness of enhanced interventions on increased condom use

with main partner. As is true of data from other sites, the survey

data indicated the importance of outreach in supporting condom

use indirectly through supplying condoms.

AIDS P

ROGRAM

, L

NGELES

OUNTY

This project evaluated street outreach interventions for IDUs,

comparing enhanced street outreach in the central Los Angeles

area (Downtown, South Central, East LA, and Pico Union) with the

comparison area (San Fernando, Pasadena, San Gabriel, Harbor

South, and South LA). The enhanced intervention centered on

additional services provided by the outreach workers, including

the provision of on-the-street HIV counseling and testing, a refer-

ral tracking system, and the use of HIV prevention narratives

based on indigenous artwork on a series of cards. (See Long et al.

in this monograph for a detailed description.)

Characteristics of survey respondents indicate roughly similar

populations in the pre- and postenhancement periods, with some

differences: for example, in the study area, crack use increased;

in the comparison areas, the number of sex partners decreased. A

number of measures of contact with outreach programs increased

between the two periods in both areas. The percentage who had

talked with an outreach worker in the past month, for example,

increased from 52.7% to 59.6% in the study area and from 28.6%

to 38.2% in the comparison area. Neither area had statistically

signiﬁcant changes in the percentage who used condoms during

most recent sex, for any type of sex or type of partner.

Survey responses indicate exposure to the enhanced intervention.

Almost 16% of respondents in the postenhancement study area

who had talked with outreach workers reported having been

shown the narrative cards. A sizeable percentage reported having

talked about services and having been referred, although a

ENHANCED STREET OUTREACH AND CONDOM USE

smaller percentage reported that they went for services. Finally, of

those who talked with outreach workers, 12.9% stated that they

had received an HIV test from the worker, either on the street or in

a nearby mobile van.

Multivariate logistic regression analysis (Table 4) indicates that

having a condom at the time of interview was associated with more

frequent condom use for vaginal sex with main (OR, 2.1; CI, 1.4–

3.2) and casual (OR, 4.1; CI, 2.7–6.1) partners. Having condoms

at the time of interview was in turn strongly associated with out-

reach contact for respondents with main (OR, 2.8; CI, 2.0–3.9)

and casual partners (OR, 2.9; CI, 1.9–4.2), indicating consistent

indirect effects of outreach programs on use of condoms.

Many IDUs interviewed on the street reported contact with street

outreach interventions, including the AESOP enhanced interven-

tions. No statistically signiﬁcant change in condom use was found

from pre- to postenhancement. Consistent associations between

program contact and having condoms, and between having con-

doms and using them, indicates the importance of outreach pro-

grams in supporting condom use in this population.

HILADELPHIA

EALTH

ANAGEMENT

ORPORATION

The Philadelphia site evaluated street outreach for IDUs in two

North Philadelphia areas. The enhanced street outreach interven-

tions centered on providing specialized training to outreach work-

ers related to (a) staging clients into stage-of-change categories, (b)

improved client follow-up, (c) escorting clients to referral services,

(d) use of improved reporting forms, and (e) community presenta-

tions. Outreach workers were added. Learning the stages-of-

change concept enabled workers to stage clients in order to pro-

vide the most appropriate messages and services. Fishbein and

Rhodes (1997) have provided a discussion of how the trans-

theoretical stage model can be applied in HIV prevention.

The populations were similar. There were some differences

between rounds, for example, an increase in crack use in study

and comparison areas. A fairly high proportion of respondents in

both areas had contact with outreach programs in the pre-

enhancement period, and there were no statistically signiﬁcant

AESOP

increases. For example, 60.1% of respondents in the study area

had talked with an outreach worker in the preenhancement period

and 66.7% during the postenhancement period. In the compari-

son area, the ﬁgures were 54.2% and 60.9%.

There were no signiﬁcant increases in the percentage who had

used condoms during their most recent sexual encounter. In the

comparison area, the percentage who had used condoms during

most recent vaginal sex with casual partners decreased from

81.3% to 60.0%. Program data indicate that the enhanced pro-

gram had 4,823 outreach contacts during a 6-month period

corresponding to the postenhancement phase and that 8,715 con-

doms were distributed.

Multivariate analysis did not indicate any effects of being in the

postenhancement study area on condom use with main partners.

For casual partners, being in the postenhancement study area

had a statistically signiﬁcant effect on condom use (OR, 3.7; CI,

1.4–9.6; Table 5). However, condom use with casual partners

decreased in the comparison area (from 81.3% to 60.0%), and con-

dom use remained the same in the study area (68.0% to 64.5%).

This decrease suggests that the enhancement was effective in

maintaining condom use with casual partners. As was true at

other sites, having a condom at interview was a strong predictor of

condom use with main (OR, 1.8; CI, 1.2–2.6) and casual (OR, 2.2;

CI, 1.3–3.6) partners. Contact with street outreach programs was

a consistent predictor of having condoms at interview for respon-

dents who had main (OR, 3.0; CI, 2.0–4.6) and casual partners

(OR, 2.0; CI, 1.3–3.4).

Outreach contact was relatively high in the preenhancement

period, and the surveys did not indicate signiﬁcant increases in

outreach contact with IDUs. No increases in condom use with

main partners were observed, but condom use declined for casual

partners in the comparison area. Being in the postenhancement

study area was associated with maintaining condom use for

casual partners. As at other sites, there was consistent associa-

tion between having condoms and using them, and between out-

reach contact and having condoms, indicating the indirect effect of

the programs on condom use.

ENHANCED STREET OUTREACH AND CONDOM USE

DISCUSSION

The quasi-experimental design of AESOP—study and comparison

areas and pre- and postenhancement periods—did not identify

many areas in which there was a change in condom use behaviors

associated with enhanced programs. If we deﬁne a quasi-experi-

mental effect as a signiﬁcant association between condom use and

being in the postenhancement study area, these effects were seen

only in Chicago and Los Angeles.

The relative lack of ﬁndings indicating behavior change are in part

due to the inherent weaknesses of the quasi-experimental design

(Coyle, Boruch & Turner, 1991). These weaknesses include the

inability to control other factors affecting the behavior of risk

group members, both in the study and comparison areas, and the

difﬁculty of acquiring equivalent samples over time from the shift-

ing street populations. Further, data collected as part of AESOP

indicated that other changes were occurring in addition to the

AESOP enhancements. These changes included program stafﬁng

changes, environmental changes due to weather and other causes,

and changes in the location of street populations (Kay, 1995). The

relative lack of ﬁndings indicating behavior change may be due in

part to lack of contact with outreach workers who delivered the

AESOP enhancement. Although the respondents reported a high

level of contact with outreach workers, many linked their outreach

workers to other outreach programs or could not identify the

agencies of these workers. Because AESOP interventions were not

comparable, data could not be aggregated to examine whether the

respondents exposed to the study intervention changed behavior.

Despite these limitations of the quasi-experimental approach,

other, more powerful evaluation methods such as cohort studies

with random assignment to speciﬁc treatments may not be appro-

priate for evaluating street outreach programs. Street outreach

interventions take place in the natural environment of high-risk

groups and necessarily involve interactions with transient clients,

many of whom are not willing or able to participate in ongoing

studies.

AESOP

Apart from the quasi-experimental aspects of AESOP, the data

have great value as observational data for evaluating street out-

reach programs. Because street outreach takes place in public

places and sensitive topics are discussed, it is very difﬁcult to col-

lect information on the process. The AESOP data provide some of

the ﬁrst systematically collected data on street populations that

measure the services received from HIV prevention street outreach

programs, a major component of HIV prevention.

The AESOP survey data also provide information on the preva-

lence of risk behaviors and condom use in the high-risk popula-

tions studied. For example, the percentage who used condoms

during most recent vaginal sex ranged from 21.7% to 47.6% for

main partners and from 57.9% to 71.8% for casual partners.

These percentages can be compared with national HIV prevention

objectives that by the year 2000 the rate of condom use during

most recent intercourse should increase to 50% for unmarried

sexually active persons; and the rate should be 60% among sexu-

ally active women aged 15 to 19 years, 75% among sexually active

men aged 15 to19 years, and 60% among IDUs (U.S. Department

of Health and Human Services, 1990). Higher rates of condom use

with casual or paying partners constitute a pattern that has been

found consistently, including general population surveys (Kost &

Forrest, 1992; Tanfer, Grady, Klepinger & Billy, 1993), studies of

IDUs and their partners (CDC, 1991, 1992; Pivnick, 1993; Rhodes

et al., 1990; Singh et al., 1993), and sexually transmitted disease

clinic patients (CDC, 1990, 1993). In spite of the levels of condom

use reported by AESOP respondents, the data document the

extent to which these populations engage in high-risk behavior in

spite of public health efforts.

Street outreach is designed to reach some of the persons at high-

est risk and some of those most difﬁcult to reach with prevention

messages and services. As such, it is a very important part of HIV

prevention, but at the same time is one of the most difﬁcult. The

collection of data on outreach and for the evaluation of programs

is difﬁcult and costly. The AESOP survey data have shown the

extent to which high-risk populations have contact with outreach

programs and use their services and the extent to which outreach

workers play an important role in dispensing condoms to these

high-risk groups. The AESOP data speak very consistently of the

role of outreach programs in supporting the carrying of condoms

ENHANCED STREET OUTREACH AND CONDOM USE

and, indirectly, in condom use by these populations who typically

have spontaneous sex. At every site, having a condom at interview

was associated with higher odds of using condoms. Further, hav-

ing a condom at interview was consistently associated with having

received condoms from outreach workers. At every site, the extent

to which respondents had contact with speciﬁc enhanced inter-

ventions was measured. Contact with some enhancements, such

as the van or storefront outreach, were perhaps more easily mea-

sured by interviews with on-the-street populations.

Given that a wide array of customized enhancements to these

established programs had very limited effect on increasing behav-

ioral change over a 6-month period, our data suggest that a cre-

ative focus on condom distribution should be a major goal of

street outreach programs. This focus might include economical

distribution plans to increase availability, such as containers

accessible during evenings and weekends, when outreach workers

are typically not available. Moreover, such containers would be

accessible to the harder-to-reach persons who do not come into

contact with outreach workers. Increasing distribution could be

complemented with an ongoing, community condom promotion

aimed at youth or IDUs, such as Switzerland’s successful STOP

AIDS campaign strategies, in which sexual transmission risks

have taken top billing (Hausser, Zimmerman, Dubois-Arber &

Paccaud, 1991). An increased focus on condoms should also

reduce the acquisition of sexually transmitted diseases, which

have been linked to an increased risk for HIV transmission

(Wasserheit, 1992).

AESOP

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universitaire de medecine sociale et preventive.

Kay, L. (1995, November). Possible confounders for interpreting

data from street outreach studies. Paper presented at the

annual meeting of the American Public Health Association,

San Diego.

ENHANCED STREET OUTREACH AND CONDOM USE

Kost K., & Forrest, J.D. (1992). American women's sexual behav-

ior and exposure to risk of sexually transmitted diseases.

Family Planning Perspectives, 24, 244-254.

Pivnick, A. (1993). HIV infection and the meaning of condoms.

Culture, Medicine and Psychiatry, 17, 431-453.

Rhodes, F., Corby, N.H., Wolitski, R.J., Tashima, N., Crain, C., &

Yankovich, D.R. (1990). Risk behaviors and perceptions of

AIDS among street injection drug users. Journal of Drug Edu-

cation, 20, 271-288.

Singh, B.K., Koman, J.J., Catan, V.M., Souply, L.L., Birkel, R.C.,

& Golazewski, T.J. (1993). Sexual risk behavior among injec-

tion drug-using human immunodeﬁciency virus positive

clients. International Journal of the Addictions, 28, 735-747.

Tanfer, K., Grady, W.R., Klepinger, D.H., & Billy, J.O.G. (1993).

Condom use among men. Family Planning Perspectives, 25,

61-66.

U.S. Department of Health and Human Services. (1990). Healthy

people 2000: National health promotion and disease preven-

tion objectives (DHHS Publication No. [PHS] 91-50213). Wash-

ington, DC: U.S. Government Printing Ofﬁce.

Wasserheit, J.N. (1992). Epidemiological synergy: Interrelation-

ships between human immunodeﬁciency virus infection and

other sexually transmitted diseases. Sexually Transmitted

Diseases, 19, 61-77.

AESOP

100

Table 1. Logistic Regression Analysis: Comparison of Two

Pre- and Two Postenhancement Rounds of AESOP Data from

Children’s Hospital, Los Angeles

Vaginal Sex with Main Partners, Past Month

(466 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

African American

STD, ever

Condoms from outreach worker, ever

Have condom now

1.7

0.7

1.2

1.0–2.9

0.4–1.2

0.6–2.5

1.1

0.7

1.3

1.9

0.6

1.9

2.3

0.6– 2.1

0.4– 1.2

0.6– 2.9

1.1– 3.1

0.3– 1.0

1.2– 3.0

1.5– 3.6

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Male

Living on the street

Talked with outreach worker, past 6 mos.

3.6

3.0

0.4

1.5–8.6

1.3–7.1

0.1–1.2

1.2

3.1

0.4

2.2

2.3

7.0

0.5– 3.2

1.3– 7.7

0.1– 1.3

1.3– 4.0

1.2– 4.3

3.6–13.5

Have condoms now

Study area

Postenhancement

Postenhancement study area

Condoms from outreach worker, past mo.

3.4

1.3

0.7

1.8–6.5

0.7–2.5

0.3–1.7

3.1

1.1

0.8

2.5

1.6– 5.9

0.6– 2.2

0.3– 1.9

1.5– 4.2

ENHANCED STREET OUTREACH AND CONDOM USE

101

Vaginal Sex with Casual Partners, Past Month

(424 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

3 or more partners, past mo.

Condoms from outreach worker, ever

Have condom now

1.6

0.8

1.2

0.9– 2.9

0.5– 1.4

0.5– 2.6

1.1

0.8

1.0

1.7

2.2

2.1

0.6– 2.1

0.5– 1.4

0.4– 2.4

1.1– 2.6

1.3– 3.8

1.3– 3.5

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Hispanic

Talked with outreach worker, past 6 mos.

6.8

3.9

0.4

2.8–16.5

1.6– 9.8

0.1– 1.2

4.5

3.8

0.5

2.2

3.7

1.7–11.6

1.5– 9.7

0.1– 1.4

1.1– 4.1

2.1– 6.4

Have condoms now

Study area

Postenhancement

Postenhancement study area

Condoms from outreach worker, past mo.

1.9

1.2

1.5

1.1– 3.4

0.6– 2.2

0.7– 3.5

1.5

1.0

1.6

2.4

0.8– 2.8

0.6– 2.0

0.7– 3.8

1.5– 4.0

AESOP

102

Table 2. Logistic Regression Analysis: Comparison of Two

Pre- and Two Postenhancement Rounds of AESOP Data from

San Francisco

Vaginal Sex with Main Partners, Past Month

(318 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

African American

Living on the street

Have condom now

Condoms from outreach worker, past mo.

1.7

1.1

0.6

0.9– 3.4

0.5– 2.3

0.2– 1.6

1.7

1.4

0.6

6.8

0.4

2.4

2.0

0.8– 3.6

0.6– 3.0

0.2– 1.6

1.2–38.8

0.2– 0.8

1.3– 4.4

1.1– 3.6

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Talked with outreach worker, past 6 mos.

5.4

2.4

0.5

2.1–14.0

0.8– 6.7

0.1– 1.6

5.2

3.2

0.3

4.9

1.9–14.0

1.1– 9.6

0.1– 1.1

2.7– 8.8

Have condoms now

Study area

Postenhancement

Postenhancement study area

STD, ever

Condoms from outreach worker, past mo.

0.1

0.6

1.7

0.5– 2.0

0.3– 1.5

0.6– 5.1

0.7

0.6

1.8

2.4

3.4

0.3– 1.5

0.2– 1.4

0.6– 5.8

1.3– 4.6

1.8– 6.4

ENHANCED STREET OUTREACH AND CONDOM USE

103

Vaginal Sex with Casual Partners, Past Month

(278 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

Somewhat to very likely to get HIV

Have condom now

1.2

0.7

1.7

0.6–2.4

0.3–1.5

0.6–4.5

1.2

0.7

1.7

0.5

1.7

0.6–2.6

0.3–1.5

0.6–4.6

0.3–0.8

1.0–2.9

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Used crack, past mo.

Talked with outreach worker, past 6 mos.

3.4

0.8

1.2

1.5–7.7

0.3–2.1

0.4–3.5

2.7

0.7

0.9

2.7

4.4

1.2–6.3

0.3–1.8

0.3–2.9

1.4–5.4

2.4–8.1

Have condoms now

Study area

Postenhancement

Postenhancement study area

Condoms from outreach worker, past mo.

0.8

1.0

2.0

0.4–1.6

0.5–2.2

0.7–5.4

0.6

1.0

2.0

2.5

0.3–1.3

0.5–2.3

0.7–5.6

1.4–4.2

AESOP

104

Table 3. Logistic Regression Analysis: Comparison of Two

Pre- and Two Postenhancement Rounds of AESOP Data from

Chicago

Vaginal Sex with Main Partners, Past Month

(740 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

STD, ever

Have condom now

Condoms from outreach worker, past mo.

1.4

0.8

2.1

0.9–2.3

0.5–1.3

1.2–4.2

1.3

0.8

1.9

0.6

1.8

1.9

0.8– 2.1

0.5– 1.3

1.0– 3.8

0.4– 0.9

1.2– 2.6

1.3– 2.7

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Talked with outreach worker, past 6 mos.

Tested for HIV, ever

1.6

1.1

2.2

0.9–2.7

0.6–1.8

1.1–4.5

1.0

0.5

3.1

21.9

3.5

0.5– 2.0

0.2– 0.9

1.3– 7.6

13.7–35.2

1.8– 6.7

Have condoms now

Study area

Postenhancement

Postenhancement study area

STD, ever

Injected, past mo.

Condoms from outreach worker, past mo.

Tested for HIV, since 1993

1.1

0.8

2.4

0.7–1.9

0.5–1.4

1.2–4.7

1.1

0.6

2.0

1.7

1.8

2.4

1.9

0.7– 1.9

0.4– 1.1

1.0– 4.0

1.2– 2.4

1.0– 3.2

1.7– 3.5

1.1– 3.0

ENHANCED STREET OUTREACH AND CONDOM USE

105

Vaginal Sex with Casual Partners, Past Month

(377 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

Male

Have condom now

Condoms from outreach worker, past mo.

1.1

0.7

1.6

0.7-2.0

0.4–1.3

0.7–3.8

1.1

0.7

1.2

0.3

3.0

2.3

0.6– 2.0

0.3– 1.3

0.5– 3.1

0.2– 0.5

1.9– 5.0

1.3– 4.1

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Talked with outreach worker, past 6 mos.

1.7

2.0

1.5

0.8–3.6

0.9–4.6

0.5–4.1

1.8

0.8

1.4

25.7

0.7– 4.5

0.3– 2.3

0.4– 5.1

13.3–49.7

Have condoms now

Study area

Postenhancement

Postenhancement study area

STD, ever

Condoms from outreach worker, past mo.

Tested for HIV, since 1993

0.8

1.0

2.3

0.4–1.4

0.5–1.9

0.9–5.7

0.7

0.6

2.3

1.7

2.1

0.4– 1.2

0.3– 1.3

0.9– 5.8

1.1– 2.8

1.3– 3.5

1.1– 4.1

AESOP

106

Table 4. Logistic Regression Analysis: Comparison of Two

Pre- and Two Postenhancement Rounds of AESOP Data from

Los Angeles County

Vaginal Sex with Main Partners, Past Month

(811 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

African American

Exchange sex for needs, ever

Condoms from outreach worker, ever

Have condom now

1.2

1.0

1.2

0.7– 2.1

0.6– 1.7

0.6– 2.4

0.7

0.8

1.3

1.6

0.4

2.2

2.1

0.4–1.3

0.4–1.4

0.6–2.8

1.0–2.3

0.3–0.7

1.5–3.3

1.4–3.2

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

African American

Homeless, past year

Somewhat to very likely to get HIV

Drug treatment, past 6 mos.

Bleach from outreach worker

6.3

2.0

0.5

3.9–10.3

1.2– 3.3

0.3– 0.9

5.6

2.2

0.3

1.6

1.7

1.4

0.6

6.6

3.2–9.8

1.2–3.8

0.2–0.7

1.1–2.3

1.2–2.4

1.0–2.0

0.4–1.0

4.6–9.3

Have condoms now

Study area

Postenhancement

Postenhancement study area

Exchange sex for need, ever

3 or more partners, past mo.

Used crack, past mo.

Condoms from outreach worker, past mo.

2.1

1.0

0.9

1.3– 3.2

0.7– 1.7

0.5– 1.6

1.5

0.9

1.5

2.3

1.4

2.8

0.9–2.5

0.6–1.5

0.5–1.7

1.0–2.1

1.5–3.6

1.0–1.9

2.0–3.9

ENHANCED STREET OUTREACH AND CONDOM USE

107

Vaginal Sex with Casual Partners, Past Month

(526 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

Male

Tested for HIV, ever

Have condom now

1.4

0.8

0.9– 2.3

0.4– 1.5

1.2

1.1

0.8

0.2

2.1

4.1

0.7– 2.1

0.6– 2.0

0.4– 1.8

0.2– 0.4

1.2– 3.7

2.7– 6.1

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Bleach from outreach worker

Talked with outreach worker, past 6 mos.

6.2

2.6

0.3

3.6–10.9

1.5– 4.7

0.2– 0.7

5.6

2.4

0.3

4.4

2.8

2.9–10.6

1.2– 4.6

0.1– 0.6

1.8–10.8

1.1– 6.8

Have condoms now

Study area

Postenhancement

Postenhancement study area

Male

3 or more partners, past mo.

Talked with outreach worker, past 6 mos.

1.7

1.2

1.0

1.0– 2.7

0.8– 2.1

0.5– 1.9

1.2

0.9

1.3

0.5

1.6

2.9

0.7– 2.0

0.6– 1.6

0.6– 2.8

0.3– 0.7

1.1– 2.3

1.9– 4.2

AESOP

108

Table 5. Logistic Regression Analysis: Comparison of Two

Pre- and Two Postenhancement Rounds of AESOP Data from

Philadelphia

Vaginal Sex with Main Partners, Past Month

(692 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

Have condom now

Talked with outreach worker, past 6 mos.

0.9

1.1

1.2

0.5–1.4

0.7–1.7

0.6–2.3

0.8

1.3

1.1

1.8

1.7

0.5–1.3

0.8–2.1

0.6–2.3

1.2–2.6

1.2–2.4

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Talked with outreach worker, past 6 mos.

1.0

0.5

1.7

0.6–1.7

0.3–0.9

0.8–3.5

1.0

0.6

1.5

3.5

0.6–1.6

0.3–1.0

0.7–3.2

2.3–5.2

Have condoms now

Study area

Postenhancement

Postenhancement study area

3 or more partners, past mo.

Condoms from outreach worker, ever

Condoms from outreach worker, past mo.

1.3

0.3

1.7

0.8–2.1

0.2–0.5

0.8–3.5

1.3

0.3

1.4

3.9

2.3

3.0

0.8–2.2

0.2–0.5

0.6–3.0

2.5–6.3

1.5–3.4

2.0–4.6

ENHANCED STREET OUTREACH AND CONDOM USE

109

Vaginal Sex with Casual Partners, Past Month

(423 Observations)

Basic Model

Basic Model +

Covariates

Predictors OR 95% CI OR 95% CI

Condom use, most recent vaginal sex

Study area

Postenhancement

Postenhancement study area

Male

Somewhat to very likely to get HIV

Know someone with HIV

Talked with outreach worker, past 6 mos.

Have condom now

0.4

0.3

2.8

0.2–0.9

0.2–0.7

1.2–6.9

0.3

3.7

0.5

1.8

1.9

2.2

0.1–0.7

1.4–9.6

0.3–0.8

1.1–2.9

1.2–3.0

1.3–3.6

Condoms from outreach worker, past mo.

Study area

Postenhancement

Postenhancement study area

Talked with outreach worker, past 6 mos.

1.2

0.9

1.2

0.6–2.6

0.5–1.9

0.5–3.1

1.1

1.0

1.1

2.5

0.5–2.5

0.5–2.2

0.4–3.1

1.5–4.0

Have condoms now

Study area

Postenhancement

Postenhancement study area

Homeless, past year

Tested for HIV, ever

Condoms from outreach worker, past mo.

1.2

0.4

0.8

0.7–2.3

0.2–0.8

0.3–1.8

1.2

0.4

0.7

1.7

2.0

0.6–2.3

0.2–0.7

0.3–1.7

1.0–2.6

0.9–3.2

1.3–3.4

111

PRODUCTS AND CONTACTS

FOR

INTERVENTION REPLICATION

ASSOCIATION FOR DRUG ABUSE PREVENTION

AND TREATMENT

Title: Doing Street Outreach in the Community:

Helpful Hints to Do a Good Job and Document It

Description: The product is a monograph for administrators and

staff of community-based organizations conducting

or contemplating street outreach. The 50-page

monograph addresses documentation forms, meth-

ods, and procedures to be used in process evalua-

tion, quality assurance, and identifying and meeting

the needs of the target population. Sample forms

are included in the appendix.

Contact: Ms. Naomi Fatt

ADAPT

2230 First Avenue

New York, NY 10029

(212) 289-1957

CHILDREN’S HOSPITAL OF LOS ANGELES

Title: Facing the Challenge: Building Peer Programs for

Street Youth

Description: The product is a study aid and accompanying video

for service providers, educators, community pro-

gram organizers, and policymakers from agencies

that target high-risk youth. The 30-page study aid

addresses how to plan and conduct a peer model

program, recruit participants, and manage the pro-

gram. The 22-minute video presents illustrations of

issues that are key to successful programs.

AESOP

112

Contact: Ms. Ellen Iverson

Division of Adolescent Medicine

Children’s Hospital of Los Angeles

P.O. Box 54700, Mail Stop 2

Los Angeles, CA 90054-0700

(213) 660-2450 ext. 3110

Title: Straight Dope Productions: The Making of a

Community-Level Intervention

Description: The product is a workbook for community-based

organizations that provide HIV-related services to

youth or that would like to extend their current

activities to include services for youth.

Contact: Ms. Ellen Iverson

Division of Adolescent Medicine

Children’s Hospital of Los Angeles

P.O. Box 54700, Mail Stop 2

Los Angeles, CA 90054-0700

(213) 660-2450 ext. 3110

COUNTY OF LOS ANGELES, DEPARTMENT OF

EALTH SERVICES, AIDS PROGRAMS

Title: Conﬁdential HIV Antibody Finger Stick

Testing Manual

Description: The product is a manual for administrators and

program coordinators of agencies and organizations

that provide street outreach to injection drug users

and users of other illicit substances. The 35-page

manual contains the development and implementa-

tion of an HIV antibody testing program in which the

ﬁnger-stick method is used in a street outreach

setting. The technique is illustrated in the video L.A.

County AIDS Evaluation of Street Outreach Programs.

PRODUCTS AND CONTACTS

113

Contact: Dr. Anna Long, Chief of Staff

Public Health Programs and Services

Los Angeles County Department of Health

313 N. Figueroa Street

Los Angeles, CA 90012

(213) 240-8036

Title: Developing Culture-Speciﬁc Media for HIV Risk

Reduction for Injection Drug and Other Substance

Abusers: Lessons from the AIDS Evaluation of Street

Outreach Program

Description: The product is a monograph for agencies and

organizations that have or are contemplating HIV

risk-reduction intervention programs for injection

drug users and users of other illicit substances. The

25-page monograph describes how to develop edu-

cational materials, including determining the need

for such materials and selecting the appropriate

messages, media, and visuals to use.

Contact: Dr. Anna Long, Chief of Staff

Public Health Programs and Services

Los Angeles County Department of Health

313 N. Figueroa Street

Los Angeles, CA 90012

(213) 240-8036

AESOP

114

Title: A Guide to Determining Stages of Change for HIV

Risk Reduction Behaviors: Cessation of Needle

Sharing, Needle Bleaching, and Condom Use

Description: The product is a manual for agencies and organiza-

tions that provide street outreach to injection drug

users and users of other illicit substances. The 50-

page manual covers a method outreach workers can

use to screen clients quickly for speciﬁc risk behav-

iors, assess the relative risk of those behaviors, and

determine the clients’ intention to change their

behaviors. The technique is illustrated in the video

L.A. County AIDS Evaluation of Street Outreach Pro-

grams.

Contact: Dr. Anna Long, Chief of Staff

Public Health Programs and Services

Los Angeles County Department of Health

313 N. Figueroa Street

Los Angeles, CA 90012

(213) 240-8036

Title: L.A. County AIDS Evaluation of Street Outreach

Programs

Description: The product is a video for program coordinators and

outreach staff of agencies and organizations that

provide street outreach to injection drug users and

users of other illicit substances. The 45-minute

video covers the background of the program and

illustrates the use of four techniques for street

outreach: stages of change, artwork to engage

clients, ﬁnger-stick HIV testing, and referral track-

ing system.

Contact: Dr. Anna Long, Chief of Staff

Public Health Programs and Services

Los Angeles County Department of Health

313 N. Figueroa Street

Los Angeles, CA 90012

(213) 240-8036

PRODUCTS AND CONTACTS

115

Title: Narratives from Illustrations: Development and Use

in the Field

Description: The product is a manual for administrators, pro-

gram coordinators, and outreach staff of agencies

and organizations that provide street outreach to

injection drug users and users of other illicit sub-

stances. The 20-page manual describes an inter-

vention in which narratives and illustrations are

used to engage clients in street outreach settings

and discusses steps for developing and implement-

ing the technique. This technique is illustrated in

the video L.A. County AIDS Evaluation of Street Out-

reach Programs.

Contact: Dr. Anna Long, Chief of Staff

Public Health Programs and Services

Los Angeles County Department of Health

313 N. Figueroa Street

Los Angeles, CA 90012

(213) 240-8036

Title: Outreach Referral Tracking System Manual

Description: The product is a manual for program coordinators

and outreach staff of agencies and organizations

that provide street outreach to injection drug users

and users of other illicit substances. The 30-page

manual covers establishing personal contact with

referral service staff, assessing client readiness to

seek services, and following up client referrals to

services. The technique is illustrated in the video

L.A. County AIDS Evaluation of Street Outreach Pro-

grams.

Contact: Dr. Anna Long, Chief of Staff

Public Health Programs and Services

Los Angeles County Department of Health

313 N. Figueroa Street

Los Angeles, CA 90012

(213) 240-8036

AESOP

116

EMORY UNIVERSITY, THE ROLLINS SCHOOL OF

UBLIC HEALTH

Title: Formative Research as Foundation of Intervention

Development: Community Assessment Process (CAP)

Description: The product is a manual for administrators involved

in HIV prevention program development. The 35-

page manual addresses the need for formative

research, the systematic process of conducting it,

and the utilization of ﬁndings in the development

and implementation of intervention programs. The

process is illustrated with examples and sample

recording forms.

Contact: Dr. Claire Sterk

The Rollins School of Public Health

Emory University

1518 Clifton Road, NE

Atlanta, GA 30322

(404) 727-9124

Title: Outreach Interventions Based on the Stages of

Change Model

Description: The product is a manual for public health ofﬁcials,

researchers, and community-based organizations

dealing with HIV who use or plan to use outreach as

a means of providing an intervention. The 20-page

manual covers general training needs for outreach

workers and training needs speciﬁc to the stages-of-

change intervention; training exercises are included.

Contact: Dr. Claire Sterk

The Rollins School of Public Health

Emory University

1518 Clifton Road, NE

Atlanta, GA 30322

(404) 727-9124

PRODUCTS AND CONTACTS

117

PHILADELPHIA HEALTH MANAGEMENT CORP.

Title: Hittin’ the Streets: A Handbook for Street

Interviewers and

Hittin’ the Streets: Trainer’s Notes

Description: The product is a handbook and trainer’s notes for

street outreach. The 40-page handbook describes

preparations for conducting street interviews, how

to handle oneself on the street, establishing rapport

in the outreach area, and debrieﬁng. The 10-page

trainer’s notes contain role plays and other exercises

to help outreach workers practice what they learn

from the handbook.

Contact: Philadelphia Health Management Corp.

c/o “Hittin’ the Streets”

260 South Broad Street, 20th Floor

Philadelphia, PA 19102

(215) 985-2524

Title: Making the Change: Helping Your Clients to Help

Themselves

Description: The product is a video with trainer and student

manuals and a video for social service providers,

such as street outreach workers and social workers.

The 55-page manual addresses the stages-of-

change approach and strategies for motivating

clients. It includes tips on how to conduct training

with these materials. The 27-minute video demon–

strates interacting with clients and helping to lead

them to changing their behavior.

Contact: Philadelphia Health Management Corp.

c/o “Making the Change”

260 South Broad Street, 20th Floor

Philadelphia, PA 19102

(215) 985-2524

AESOP

118

UNIVERSITY OF ILLINOIS AT CHICAGO

Title: Evaluation – How to Use an Agency’s Own Data to

Guide Program

Description: The product is a manual for small service-delivery

organizations that have limited resources for evalu-

ation. The 15-page manual covers what evaluation

is, why it should be done, and how to do it. The ap-

pendix contains sample recording forms.

Contact: Dr. Wayne Wiebel

University of Illinois at Chicago

School of Public Health

2121 West Taylor, Room 556

Chicago, IL 60612

(312) 996-4870

Title: Indigenous Leader Outreach Model

Description: The product is a training curriculum for project

leaders and outreach staff interested in applying

peer-based street-outreach techniques. The 100-

page curriculum has two parts: one for trainers and

one for students. The document contains an outline

of the programmatic needs, techniques, and pro-

cesses involved with street outreach.

Contact: Dr. Wayne Wiebel

University of Illinois at Chicago

School of Public Health

2121 West Taylor, Room 556

Chicago, IL 60612

(312) 996-4870

PRODUCTS AND CONTACTS

119

VICTIM SERVICES AGENCY

Title: Coordination of AIDS Outreach and Prevention

Services for Homeless and Runaway Youth

Description: The product is a case study for project directors and

others interested in building service-delivery coali-

tions. The 20-page case study addresses the co-

ordination of street outreach activities among New

York City agencies that serve homeless and runaway

youth. The study discusses why coordination was

attempted, how it was accomplished, and the result-

ing beneﬁts.

Contact: Ms. Helene Lauffer

Victim Services Agency

2 Lafayette Street

New York, NY 10007

(212) 577-3806

Title: Development of Computerized Documentation

Systems for Street Outreach Programs: Case Study

Description: The product is a case study for directors of pro-

grams interested in developing computerized inter-

agency information systems. The 30-page case

study covers the basic idea of creating a wide-area

network and its application to documenting services

and community planning. Some knowledge of com-

puter software would be useful.

Contact: Ms. Helene Lauffer

Victim Services Agency

2 Lafayette Street

New York, NY 10007

(212) 577-3806

AESOP

120

Title: Innovations in AIDS Outreach and Prevention for

Homeless and Runaway Youth: A Training &

Resource Guide for Applications of the Harm

Reduction Model

Description: The product is a manual for service providers who

are interested in integrating this model into their

programs. The 145-page manual covers informa-

tion on homeless and runaway youth and the con-

ceptual foundations and clinical implications of

using the Harm Reduction Model in a client-

centered approach for this population.

Contact: Ms. Helene Lauffer

Victim Services Agency

2 Lafayette Street

New York, NY 10007

(212) 577-3806