Community-Based HIV Prevention in Presumably Underserved Populations -- Colorado Springs, Colorado, July-September 1995

Persons whose behaviors may increase their risk for infection with human immunodeficiency virus (HIV) but who may be underserved by existing HIV prevention and testing programs (in part because of limited access) include those who are homeless (1,2), chemically dependent but not in treatment (3,4), and mentally ill (5). To assess the prevalence of high-risk behaviors for HIV infection, the acceptance of HIV counseling and testing, and HIV seropositivity in such populations in Colorado Springs, Colorado (1995 population: 465,885), the El Paso County Department of Health and Environment (EPCDHE) conducted a study during July-September 1995. This report summarizes the results of the study, which indicate that such presumably underserved persons are accessible, commonly report high-risk behaviors, and previously have been tested for HIV infection and that social isolation, in part, accounted for the low seroprevalence of HIV in this study population.

During July-September 1995, two sexually transmitted diseases/HIV public health nurses, working as a team to ensure safety, visited seven community organizations, public parks, and street intersections to identify homeless persons, illicit drug users not in treatment, and persons who may have been mentally ill and to offer them confidential HIV counseling and testing. These services were offered on Mondays and Tuesdays during July-September. After obtaining signed, informed consent for the test and survey, participants were administered a questionnaire to obtain information about demographics, HIV-risk behaviors and testing history, illicit drug use, and sociosexual connections (i.e., composition of family and number of drug and sex partners).

A total of 224 persons agreed to participate, including 60 (27%) who were recruited at two homeless shelters, 53 (24%) at a soup kitchen, 56 (25%) at two outpatient mental-health centers, 12 (5%) at a community center, 19 (8%) at a detoxification center, and 24 (11%) at outdoor sites frequented by homeless persons. The average age of participants was 34.7 years (range: 14-69 years); most (67%) were men, white (67%), unemployed (58%), or marginally employed (38%). Nearly half (44%) reported being homeless, and 74% had lived in the Colorado Springs area for at least the preceding 12 months. Most (85%) were single, and 44% had never had a spouse or children; of 124 who had a spouse or children, 90 (73%) were not living with either at the time of the survey. Participants recruited at health-care facilities (i.e., mental health and detoxification centers) were less likely than those recruited elsewhere to be male (56% versus 71%; pless than 0.05), homeless (15% versus 58%; pless than 0.01), and to report ever having injected drugs (14% versus 30%; pless than 0.05).

Overall, 114 (51%) participants were classified as having high-risk behavior for HIV infection (defined as having ever injected drugs, engaged in receptive anal intercourse, or having had more than two sex partners during the preceding 6 months). A total of 53 (24%) reported a history of injecting-drug use; 37 (17%), receptive anal sex; and 55 (25%), multiple sex partners. Receptive anal intercourse was reported more commonly by women (25 {33%}) than by men (12 {8%}) (pless than 0.01).

Of the 53 participants who reported injecting-drug use, a review of EPCDHE records indicated that nine (17%) had ever been patients at the EPCDHE substance-abuse clinic (the only such facility in the region), including two who were in treatment at the time of the survey. Of 219 persons who responded to questions regarding sexual activity during the 6 months preceding the study, 64 (29%) reported no sex partners; of 117 who reported using illegal drugs, 51 (44%) reported doing so alone. Approximately one fourth (58 {26%}) reported condom use at last sexual intercourse.

Of the 224 participants, 212 (95%) consented to and completed HIV counseling and testing; two (1%) were newly tested and identified as seropositive, and one requested and received confirmation of a previously positive HIV test. Of the 212 persons tested, 147 (69%) reported having been tested for HIV since 1985 (63% as either plasma or blood donors), and 61 (29%) reported the current test as their first (data were missing for four). The likelihood of reporting previous testing was higher for participants reporting high-risk behavior (77%) than for those reporting low-risk behaviors (63%; pless than 0.05).

Reported by: NE Brace, MA, HP Zimmerman, JJ Potterat, SQ Muth, JB Muth, MD, TS Maldonado, El Paso County Dept of Health and Environment, Colorado Springs, Colorado. RB Rothenberg, MD, Family and Preventive Medicine Dept, Emory Univ School of Medicine, Atlanta. Div of HIV/AIDS Prevention-Intervention, Research, and Support, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that, among high-risk populations in Colorado Springs that would traditionally be characterized as underserved, most had been tested previously for HIV. The EPCDHE strategy of using community organizations that provide medical and/or social services to and outdoor locations frequented by these populations was successful in locating such persons. The sampling process used for this study involved geographic targeting and onsite recruitment of available participants and is commonly used to survey elusive populations (6). The strong associations between homelessness, substance abuse, social isolation, and mental illness (5,7,8) indicate that, using this method, EPCDHE successfully contacted socially marginalized persons.

The high proportion of persons who reported no recent sex partners, using drugs alone, homelessness, unemployment, and single marital status indicates the prevalence of relative social isolation among participants. A previous assessment of the social networks of heterosexuals at high risk for HIV infection in Colorado Springs suggested that network structure may be a determinant for HIV seroprevalence (9): specifically, low HIV seroprevalence was documented by social network analysis to be associated with social marginalization of HIV-infected persons within their social networks. The findings in this report underscore the belief that, despite their risk factors, persons who are socially isolated may not often come in contact with persons who are infected with HIV.

The findings in this report are subject to at least three limitations. First, restriction of recruitment to daytime hours and to summer months and the inability to determine the total number of socially marginalized persons in Colorado Springs may have resulted in an undersampling of this population. Second, persons who may have been tested elsewhere for HIV or who knew or suspected that they were HIV-infected may have been less likely to participate. Finally, participants in this study may have been likely to misperceive questions or misreport answers (5).

The findings in this report indicate that high proportions of socially marginalized persons in Colorado Springs reported HIV high-risk behaviors and previous HIV testing and were willing to use HIV outreach services; despite the presence of high-risk behaviors, the prevalence of HIV infection was low. Groups such as those in Colorado Springs can be reached using targeted sampling methods in settings where strict random selection is not possible (10). Although random sampling was not possible in this study setting, the approach used by EPCDHE was inexpensive and efficient. While these findings may not be generalizable to groups in other locations, assessments based on this approach can be used to track endemic and possibly epidemic HIV transmission and serve as an evaluation tool for community intervention programs.

References

1. CDC. Assessment of street outreach for HIV prevention -- selected sites, 1991-1993. MMWR 1993;42:873,879-80.

2. Siegal HA, Carlson RG, Falck R, et al. HIV infection and risk behaviors among intravenous drug users in low seroprevalence areas in the Midwest. Am J Public Health 1991;81:1642-4.

3. CDC. Risk behaviors for HIV transmission among intravenous-drug users not in drug treatment -- United States, 1987-1989. MMWR 1990;39:273-6.

4. Metzger DS, Woody GE, McLellan AT, et al. Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr 1993;6:1049-56.

5. Stewart DL, Zuckerman CL, Inge JM. HIV seroprevalence in a chronically mentally ill population. J Natl Med Assoc 1994;86:519-23.

6. Watters JK, Biernacki P. Targeted sampling: options for the study of hidden populations. Soc Probl 1989;36:416-30.

7. Empfield M, Cournos F, Meyer I, et al. HIV seroprevalence among homeless patients admitted to a psychiatric inpatient unit. Am J Psychiatry 1993;150:47-52.

8. Susser E, Valencia E, Conover S. Prevalence of HIV infection among psychiatric patients in a New York City men's shelter. Am J Public Health 1993;83:568-70.

9. Woodhouse DE, Rothenberg RB, Potterat JJ, et al. Mapping a social network of heterosexuals at high risk for HIV infection. AIDS 1994;8:1331-6.

10. Rothenberg RB. Commentary: sampling in social networks. Connections 1995;18:105-11.

    
    

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