- Email: [email protected]
HIV-Risk Behaviors in Adolescent Substance Abusers
Journal of Substance Abuse Treatment, Vol. 16, No. 2, pp. 169–172, 1999 Copyright © 1999 Elsevier Science Inc. All rights reserved. 0740-5472/99 $–see front matter
PII S0740-5472(98)00040-3
ARTICLE
HIV-Risk Behaviors in Adolescent Substance Abusers Deborah Deas-Nesmith, md, mph, Kathleen T. Brady, md, phd, Roxane White, bs, and Sallie Campbell, msw Medical University of South Carolina, Center for Drug and Alcohol Programs, Institute of Psychiatry, Charleston, SC
Abstract – Thirty adolescents aged 12–18 years from each group (substance use disorders, psychiatric disorders, and controls) were assessed to explore HIV-risk behaviors and knowledge about HIV/AIDS. Semi-structured instruments for psychiatric and substance use disorders were also administered. There were no significant differences between groups in knowledge of HIV/AIDS. However, chi-square analysis of risk behaviors revealed significant differences between the substance use disorders group and the controls. The knowledge–behavior gap was greater for the substance users than all other groups, in that while they knew an equal amount about HIV/AIDS, they actually engaged in more risky sexual behaviors than the other two groups. It may be that the impulsivity associated with substance use disorders accounts for this difference. It is recommended that HIV/AIDS prevention education and impulse control strategies are included in the treatment of adolescents with substance use disorders. © 1999 Elsevier Science Inc. All rights reserved. Keywords – adolescents; HIV; risk behaviors; substance abuse.
INTRODUCTION
to take risks and often feel a sense of immortality and invulnerability to dangers, they are apt to engage impulsively in high-risk behaviors such as unprotected sex with multiple partners and substance abuse. Lack of impulse control is characteristic of adult substance abusers. Some studies reveal that while many adolescents have adequate knowledge about HIV/AIDS, they continue to engage in risky behaviors (Hingson, Strunin, & Berlin, 1990; Slonim-Nevo, Ozawa, & Auslander, 1991). It is unclear what factors influence whether an adolescent will engage in risky behaviors. The knowledge–behavior gap remains a perplexing phenomena to many clinicians working with adolescents. Although the reason for the knowledge–behavior gap has not been definitively determined, the presence of mental illness(s) or other life stressors and impulsivity may be contributing factors. There is a dearth of studies investigating the relationships between risky behavior and mental health problems. Stiffman and colleagues found that risky behaviors are related to mental health problems as well as substance use (Stiffman, Dore, Earls, & Cunningham,
HIV infection has become a serious threat to many adolescents. This is reflected in the increased number of AIDS cases among adolescents and young adults, as well as the rising rates of HIV infection in this age group. The number of AIDS cases in adolescents doubles every 4 months (Kerr, 1989). Moreover, the World Health Organization estimates that half of the 14 million people infected with HIV worldwide were infected between the ages of 15 and 24 years (Goldsmith, 1993). In 1989, AIDS became the sixth leading cause of death for persons aged 15–24 years (NCHS, 1992). While this statistic illustrates the increased risk of an adolescent becoming infected with HIV, participation in high-risk behavior accelerates the odds. Since adolescents have the propensity
Requests for reprints should be addressed to Deborah Deas-Nesmith, MD, MPH, Medical University of South Carolina, Center for Drug and Alcohol Programs, Institute of Psychiatry, 171 Ashley Avenue, Charleston, SC 29425. E-mail: [email protected]
Received March 16, 1998; Accepted April 28, 1998.
169
170
D. Deas-Nesmith et al.
1992). When under the influence of a psychoactive substance, there is a reduced likelihood of assessing situations for risk, and therefore, more risks are taken than in the absence of psychoactive substances. It is also possible that impulsivity is a predisposing factor for both substance use and other high-risk behaviors. The purpose of this study was to compare the knowledge, attitudes, beliefs, and behaviors about HIV and AIDS in an adolescent psychiatric population, an adolescent substance abuse population, and a control group. This general hypothesis being tested was that substance abusers would have a greater difference between their HIV/AIDS knowledge and their actual sexual behavior. METHODS Ninety subjects, aged 12–18, were recruited; 30 from a pool of consecutively admitted adolescents to a psychiatric inpatient unit at the Institute of Psychiatry Youth Division, Medical University of South Carolina (psychiatric group), 30 from a licensed psychiatric hospital that specializes in treatment of chemical dependency (substance use group), and 30 controls from local schools and/or children of employees at the Medical University of South Carolina. Controls were matched for age, gender, and socioeconomic status. Parents and subjects were informed of the risks and benefits of the study. Parents and subjects were asked to sign informed consents and assents, respectively. Upon admission to the inpatient psychiatric or chemical dependency facility, patients received a self-report survey assessing knowledge and beliefs about HIV infection and AIDS, and the associated high-risk behaviors. The survey was adapted from HIV/ AIDS surveys by DiClemente, Zorn, and Temoshok (1986) and Slonim-Nevo et al. (1991). All subjects were assessed for psychiatric disorders using the revised Child Schedule for Affective Disorders and Schizophrenia (KSADS) (Chambers et al., 1985) and substance use disorder assessments were made using the Structured Clinical
Interview for DSM-III-R (SCID-R) (Spitzer & Williams, 1985). The control population received a brief psychiatric and substance use evaluation to rule out any past or current mental disorders. The control population had neither a substance use nor psychiatric diagnosis. The psychiatric group did not have a substance use diagnosis. Ninety-percent of the substance use group had both a substance use and a psychiatric diagnosis. Patients in the psychiatric and substance groups received intake assessments that were corroborated by parents or guardians. Data on demographics, diagnoses, family history, past hospitalizations, past diagnosis(es), and trauma were ascertained from the intake assessments. Inpatients adolescents received education in the areas of knowledge deficit about HIV/AIDS prior to discharge. RESULTS Table 1 displays the demographics of the subjects. The average age of all subjects was 14.8 (61.28). There were significantly (x2a 5 9.87, p # .005; x2b 5 13.86, p # .001) more Caucasians in the substance use group as compared to the psychiatric group and the control group. Significant gender differences were not seen between the groups. Adolescents within the substance use group abused alcohol and a variety of illicit substances (Table 2). Alcohol and marijuana were the most common substances of abuse. Overwhelmingly, in cases where the adolescents abused alcohol, they also abused marijuana. While abuse of other illicit substances occurred at a lower rate, almost a quarter (23%) of the adolescents met criteria for abuse or dependence of three or more substances. Knowledge of HIV Infection and AIDS— Response Frequency Overall, there were no group differences in knowledge about HIV/AIDS. All groups averaged 80% correct re-
TABLE 1 Demographics
Age M 6 SD Race African American Caucasian Gender Male Female NS 5 not significant. Substance vs. psychiatric. Substance vs. controls.
a b
Psychiatric (n 5 30)
Substance Use (n 5 30)
Controls (n 5 30)
Statistics
15 6 .964
15 6 1.24
14 6 1.63
NS
12 (40%)
2 (7%)
18 (60%)
17 (57%)
28 (93%)
12 (40%)
χ2 5 9.87a p # .005 χ2 5 13.86b p # .001
11 (37%) 19 (63%)
20 (67%) 10 (33%)
13 (43%) 17 (57%)
NS
HIV-Risk Behaviors in Adolescents
171
TABLE 2 Type of Substance Use Disorders in Substance Abuse Group (n 5 30)
No. (%)
Alcohol Cannabinoid Cocaine Inhalants Hallucinogens Sedative/hypnotics
19 (63) 18 (60) 8 (27) 5 (17) 3 (10) 2 (7)
sponses. However, three areas of basic information about HIV/AIDS were recorded as “don’t know” at high frequency in the three groups. More specifically, an average of 39% of the sample answered that they did not know if women were more likely to get AIDS during their period. Over 43% of the sample indicated that they did not know if AIDS is caused by the same virus that causes venereal disease (VD). Finally 26% of the sample answered that they did not know if people with AIDS usually have lots of other diseases as a result of AIDS. These responses indicate lack of knowledge of some important information related to AIDS and indicate places to target educational efforts to adolescents, in general. HIV/AIDS-Risk Behavior Assessment Behavioral differences were apparent between the three groups in the areas of vaginal intercourse without a condom, anal intercourse without a condom, intercourse with a prostitute, and intercourse with a stranger. The groups did not differ in areas of oral sex without a condom and sexual intercourse with a person that they knew very well. As can be seen in Figure 1, the percentage of substance users that engaged in vaginal intercourse without a condom was significantly higher than controls (x2 5 20.27; p # .00001). There was no significant difference between controls and the psychiatric group. Substance
FIGURE 1. HIV/AIDS-risk behavior assessment: Endorsed activities.
users engaged in anal intercourse without a condom significantly more than controls (x2 5 6.67, p # .01). None of the controls endorsed engaging in anal intercourse without a condom. Also illustrated by Figure 1, significantly more substance users had experienced intercourse with a prostitute than controls (x2 5 6.67; p # .01), and had intercourse with a stranger (x2 5 10.75; p # .00001). Taken together, substance suers engaged in risky behaviors significantly more than controls. There were no significant differences for risky behaviors between the controls and the psychiatric group. Collapsing across groups comparing younger (12–14year-olds) to older (15–17-year-olds) adolescents who engaged in high-risk behaviors yields some important information. Across groups, the younger and older adolescents did not differ in shooting up drugs, sharing needles, anal intercourse without a condom, and intercourse with a prostitute. They differed in three sexual behaviors. Older adolescents engaged significantly more in sexual intercourse with a stranger (p # .05), vaginal intercourse without a condom (p # .005), and oral intercourse with a male who did not wear a condom (Figure 2). DISCUSSION Few studies have assessed knowledge and risk behaviors about HIV/AIDS among special adolescent populations. Stiffman found a correlation between alcohol and drug problems in adolescence, and high-risk behaviors during young adulthood. The high-risk behaviors were predominately: choice of a high-risk sex partner, intravenous drug use, and engaging in prostitution (Stiffman et al., 1992). In our study of substance-using adolescents, psychiatric inpatient adolescents and age/gender-matched controls, we found a high prevalence of risk behaviors for HIV infection among substance-abusing adolescents, despite the fact that they were knowledgeable about the transmission of the virus and methods of prevention. Ninety-three percent of the substance abusers answered
FIGURE 2. Risk behaviors endorsed by age group.
172
true to the statement “using a condom during sex can lower the risk of getting AIDS”; however, significantly more substance users engaged in vaginal intercourse without a condom than controls. There were also significant differences between substance users and controls for engaging in intercourse with a person they did not know well, intercourse with a prostitute, and anal intercourse without a condom. This represents a profound gap between knowledge and behavior. Despite having accurate knowledge of transmission of HIV, substance-abusing adolescents in our population continued to engage in high-risk behaviors. The gap may, in part, be explained by the tendency for adolescents to have a sense of immortality and feelings of lack of vulnerability. The increase in high-risk sexual behaviors in the substance use group may be due to sexual contact while under the influence of substances. In a disinhibited state, these adolescents, like adults, tend to exhibit little insight and have poor judgment. It is also possible that lack of impulse control commonly seen in substance users predisposes to both substance use and high-risk sexual behaviors. Rolf reported that 24.8% of adolescent males in his study of HIV/AIDS risks among incarcerated delinquents, reported using alcohol or other drugs before engaging in sexual activity the majority of times, and 46.3% reported that alcohol was available a majority of the times at social gatherings (Rolf, Nanda, Baldwin, Chandra, & Thompson, 1990). In many cases, adolescents come in contact with unfamiliar peers at social gatherings, and while under the influence of substances, engage in highrisk sexual behaviors. Hingson and colleagues reported that a random dial telephone survey of 1,773 adolescents aged 16–19 revealed that those adolescents who drank more than five drinks a day were 2.8 times less likely to use condoms than abstaining adolescents (Hingson et al., 1990). Based on the findings in our study, adolescent substance users are at risk for engaging in high-risk behaviors, and should be considered an at-risk group for HIV infection as well as a targeted group for HIV/AIDS prevention education during the treatment course of their substance use disorders. Although the adolescents exhibited satisfactory knowledge on the subject of HIV/AIDS, there were three important deficits in knowledge. Nearly 39% of all subjects did not know that women are not more likely to get AIDS during their period and 50% of the normal controls were deficient in this area of knowledge. A large proportion (47.8%) of the subjects did not know that AIDS is not caused by the same virus that causes VD. The knowledge deficits across the three groups further support HIV/AIDS education in adolescents, in general. When the data were collapsed and analyzed based on age, significantly more of the older adolescents (15–17year-olds) experienced sexual intercourse with a stranger and vaginal intercourse without a condom, and/or had sex with a male who did not put on a condom, than their
D. Deas-Nesmith et al.
younger cohort (12–14-year-olds). It appears that as the adolescents get older, they are more apt to engage in risky behaviors. Older adolescents may be more vulnerable to negative peer pressure. Our data indicate that early interventions and prevention strategies with the younger (12–14-year-olds) age group may lead to an increased level of knowledge of HIV/AIDS and a reduction in risky behaviors. Targeting the 12–14-year age group of adolescents may be a prudent preventive measure. In conclusion, the adolescents in our sample had adequate knowledge about HIV/AIDS; however, the gap between knowledge of HIV/AIDS and risk behavior was significantly wider for adolescent substance abusers than the psychiatric or normal control group. The substances most commonly abused were alcohol and marijuana, which in most cases were used prior to engaging in highrisk behaviors. Development of AIDS prevention, educational and therapeutic programs for these at-risk adolescents is critical. Impulse control strategies should be tested as one way to bridge the gap between knowledge and behavior. Such programs may not only play a role in HIV/AIDS reduction, but also substance abuse treatment.
REFERENCES Chambers, W.J., Puig-Antich, J., Hirsch, M., Paez, P., Ambrosini, P.J., Tabrizi, M.A., & Davies, M. (1985). The assessment of affective disorders in children and adolescents by semistructured interview. Test-retest reliability of the schedule for affective disorders and schizophrenia for school-age children, present episode version. Archives of General Psychiatry, 42, 696–702. Di Clemente, R.J., Zorn, J., & Temoshok, L. (1986). Adolescents and AIDS: A survey of knowledge, attitudes and beliefs about AIDS in San Francisco. American Journal of Public Health, 76, 1443–1445. Goldsmith, M. (1993). Invisible epidemic now becoming visible as HIV/AIDS pandemic reaches adolescents [news]. Journal of the American Medical Association, 270, 16–19. Hingson, R., Strunin, L., & Berlin, B. (1990). Acquired immunodeficiency syndrome transmission: Changes in knowledge and behaviors among teenagers, Massachusetts statewide surveys, 1986 to 1988. Pediatrics, 85, 24–29. Kerr, K.L. (1989). Adolescents, AIDS, and HIV: The future starts now. Journal of School Health, 59, 277–278. NCHS. (1992). Advance report of final mortality statistics, 1989 40 (Suppl.). U.S. Department of Health and Human Services, Public Health Service, CDC. Rolf, J., Nanda, J., Baldwin, J., Chandra, A., & Thompson, L. (1990). Substance misuse and HIV/AIDS risks among delinquents: a prevention challenge. International Journal of Addiction, 25, 533–559. Slonim-Nevo, V., Ozawa, M.N., & Auslander, W.F. (1991). Knowledge, attitudes and behaviors related to AIDS among youth in residential centers: Results from an exploratory study. Journal of Adolescence, 14, 17–33. Spitzer, R., & Williams, J. (1985). Structured Clinical Interview for DSM-III-R. New York: New York State Psychiatric Institute, Biometric Research Department. Stiffman, A.R., Dore, P., Earls, F., & Cunningham, R. (1992). The influence of mental health problems on AIDS-related risk behaviors in young adults. Journal of Nervous and Mental Disorders, 180, 314–320.
PII S0740-5472(98)00040-3
ARTICLE
HIV-Risk Behaviors in Adolescent Substance Abusers Deborah Deas-Nesmith, md, mph, Kathleen T. Brady, md, phd, Roxane White, bs, and Sallie Campbell, msw Medical University of South Carolina, Center for Drug and Alcohol Programs, Institute of Psychiatry, Charleston, SC
Abstract – Thirty adolescents aged 12–18 years from each group (substance use disorders, psychiatric disorders, and controls) were assessed to explore HIV-risk behaviors and knowledge about HIV/AIDS. Semi-structured instruments for psychiatric and substance use disorders were also administered. There were no significant differences between groups in knowledge of HIV/AIDS. However, chi-square analysis of risk behaviors revealed significant differences between the substance use disorders group and the controls. The knowledge–behavior gap was greater for the substance users than all other groups, in that while they knew an equal amount about HIV/AIDS, they actually engaged in more risky sexual behaviors than the other two groups. It may be that the impulsivity associated with substance use disorders accounts for this difference. It is recommended that HIV/AIDS prevention education and impulse control strategies are included in the treatment of adolescents with substance use disorders. © 1999 Elsevier Science Inc. All rights reserved. Keywords – adolescents; HIV; risk behaviors; substance abuse.
INTRODUCTION
to take risks and often feel a sense of immortality and invulnerability to dangers, they are apt to engage impulsively in high-risk behaviors such as unprotected sex with multiple partners and substance abuse. Lack of impulse control is characteristic of adult substance abusers. Some studies reveal that while many adolescents have adequate knowledge about HIV/AIDS, they continue to engage in risky behaviors (Hingson, Strunin, & Berlin, 1990; Slonim-Nevo, Ozawa, & Auslander, 1991). It is unclear what factors influence whether an adolescent will engage in risky behaviors. The knowledge–behavior gap remains a perplexing phenomena to many clinicians working with adolescents. Although the reason for the knowledge–behavior gap has not been definitively determined, the presence of mental illness(s) or other life stressors and impulsivity may be contributing factors. There is a dearth of studies investigating the relationships between risky behavior and mental health problems. Stiffman and colleagues found that risky behaviors are related to mental health problems as well as substance use (Stiffman, Dore, Earls, & Cunningham,
HIV infection has become a serious threat to many adolescents. This is reflected in the increased number of AIDS cases among adolescents and young adults, as well as the rising rates of HIV infection in this age group. The number of AIDS cases in adolescents doubles every 4 months (Kerr, 1989). Moreover, the World Health Organization estimates that half of the 14 million people infected with HIV worldwide were infected between the ages of 15 and 24 years (Goldsmith, 1993). In 1989, AIDS became the sixth leading cause of death for persons aged 15–24 years (NCHS, 1992). While this statistic illustrates the increased risk of an adolescent becoming infected with HIV, participation in high-risk behavior accelerates the odds. Since adolescents have the propensity
Requests for reprints should be addressed to Deborah Deas-Nesmith, MD, MPH, Medical University of South Carolina, Center for Drug and Alcohol Programs, Institute of Psychiatry, 171 Ashley Avenue, Charleston, SC 29425. E-mail: [email protected]
Received March 16, 1998; Accepted April 28, 1998.
169
170
D. Deas-Nesmith et al.
1992). When under the influence of a psychoactive substance, there is a reduced likelihood of assessing situations for risk, and therefore, more risks are taken than in the absence of psychoactive substances. It is also possible that impulsivity is a predisposing factor for both substance use and other high-risk behaviors. The purpose of this study was to compare the knowledge, attitudes, beliefs, and behaviors about HIV and AIDS in an adolescent psychiatric population, an adolescent substance abuse population, and a control group. This general hypothesis being tested was that substance abusers would have a greater difference between their HIV/AIDS knowledge and their actual sexual behavior. METHODS Ninety subjects, aged 12–18, were recruited; 30 from a pool of consecutively admitted adolescents to a psychiatric inpatient unit at the Institute of Psychiatry Youth Division, Medical University of South Carolina (psychiatric group), 30 from a licensed psychiatric hospital that specializes in treatment of chemical dependency (substance use group), and 30 controls from local schools and/or children of employees at the Medical University of South Carolina. Controls were matched for age, gender, and socioeconomic status. Parents and subjects were informed of the risks and benefits of the study. Parents and subjects were asked to sign informed consents and assents, respectively. Upon admission to the inpatient psychiatric or chemical dependency facility, patients received a self-report survey assessing knowledge and beliefs about HIV infection and AIDS, and the associated high-risk behaviors. The survey was adapted from HIV/ AIDS surveys by DiClemente, Zorn, and Temoshok (1986) and Slonim-Nevo et al. (1991). All subjects were assessed for psychiatric disorders using the revised Child Schedule for Affective Disorders and Schizophrenia (KSADS) (Chambers et al., 1985) and substance use disorder assessments were made using the Structured Clinical
Interview for DSM-III-R (SCID-R) (Spitzer & Williams, 1985). The control population received a brief psychiatric and substance use evaluation to rule out any past or current mental disorders. The control population had neither a substance use nor psychiatric diagnosis. The psychiatric group did not have a substance use diagnosis. Ninety-percent of the substance use group had both a substance use and a psychiatric diagnosis. Patients in the psychiatric and substance groups received intake assessments that were corroborated by parents or guardians. Data on demographics, diagnoses, family history, past hospitalizations, past diagnosis(es), and trauma were ascertained from the intake assessments. Inpatients adolescents received education in the areas of knowledge deficit about HIV/AIDS prior to discharge. RESULTS Table 1 displays the demographics of the subjects. The average age of all subjects was 14.8 (61.28). There were significantly (x2a 5 9.87, p # .005; x2b 5 13.86, p # .001) more Caucasians in the substance use group as compared to the psychiatric group and the control group. Significant gender differences were not seen between the groups. Adolescents within the substance use group abused alcohol and a variety of illicit substances (Table 2). Alcohol and marijuana were the most common substances of abuse. Overwhelmingly, in cases where the adolescents abused alcohol, they also abused marijuana. While abuse of other illicit substances occurred at a lower rate, almost a quarter (23%) of the adolescents met criteria for abuse or dependence of three or more substances. Knowledge of HIV Infection and AIDS— Response Frequency Overall, there were no group differences in knowledge about HIV/AIDS. All groups averaged 80% correct re-
TABLE 1 Demographics
Age M 6 SD Race African American Caucasian Gender Male Female NS 5 not significant. Substance vs. psychiatric. Substance vs. controls.
a b
Psychiatric (n 5 30)
Substance Use (n 5 30)
Controls (n 5 30)
Statistics
15 6 .964
15 6 1.24
14 6 1.63
NS
12 (40%)
2 (7%)
18 (60%)
17 (57%)
28 (93%)
12 (40%)
χ2 5 9.87a p # .005 χ2 5 13.86b p # .001
11 (37%) 19 (63%)
20 (67%) 10 (33%)
13 (43%) 17 (57%)
NS
HIV-Risk Behaviors in Adolescents
171
TABLE 2 Type of Substance Use Disorders in Substance Abuse Group (n 5 30)
No. (%)
Alcohol Cannabinoid Cocaine Inhalants Hallucinogens Sedative/hypnotics
19 (63) 18 (60) 8 (27) 5 (17) 3 (10) 2 (7)
sponses. However, three areas of basic information about HIV/AIDS were recorded as “don’t know” at high frequency in the three groups. More specifically, an average of 39% of the sample answered that they did not know if women were more likely to get AIDS during their period. Over 43% of the sample indicated that they did not know if AIDS is caused by the same virus that causes venereal disease (VD). Finally 26% of the sample answered that they did not know if people with AIDS usually have lots of other diseases as a result of AIDS. These responses indicate lack of knowledge of some important information related to AIDS and indicate places to target educational efforts to adolescents, in general. HIV/AIDS-Risk Behavior Assessment Behavioral differences were apparent between the three groups in the areas of vaginal intercourse without a condom, anal intercourse without a condom, intercourse with a prostitute, and intercourse with a stranger. The groups did not differ in areas of oral sex without a condom and sexual intercourse with a person that they knew very well. As can be seen in Figure 1, the percentage of substance users that engaged in vaginal intercourse without a condom was significantly higher than controls (x2 5 20.27; p # .00001). There was no significant difference between controls and the psychiatric group. Substance
FIGURE 1. HIV/AIDS-risk behavior assessment: Endorsed activities.
users engaged in anal intercourse without a condom significantly more than controls (x2 5 6.67, p # .01). None of the controls endorsed engaging in anal intercourse without a condom. Also illustrated by Figure 1, significantly more substance users had experienced intercourse with a prostitute than controls (x2 5 6.67; p # .01), and had intercourse with a stranger (x2 5 10.75; p # .00001). Taken together, substance suers engaged in risky behaviors significantly more than controls. There were no significant differences for risky behaviors between the controls and the psychiatric group. Collapsing across groups comparing younger (12–14year-olds) to older (15–17-year-olds) adolescents who engaged in high-risk behaviors yields some important information. Across groups, the younger and older adolescents did not differ in shooting up drugs, sharing needles, anal intercourse without a condom, and intercourse with a prostitute. They differed in three sexual behaviors. Older adolescents engaged significantly more in sexual intercourse with a stranger (p # .05), vaginal intercourse without a condom (p # .005), and oral intercourse with a male who did not wear a condom (Figure 2). DISCUSSION Few studies have assessed knowledge and risk behaviors about HIV/AIDS among special adolescent populations. Stiffman found a correlation between alcohol and drug problems in adolescence, and high-risk behaviors during young adulthood. The high-risk behaviors were predominately: choice of a high-risk sex partner, intravenous drug use, and engaging in prostitution (Stiffman et al., 1992). In our study of substance-using adolescents, psychiatric inpatient adolescents and age/gender-matched controls, we found a high prevalence of risk behaviors for HIV infection among substance-abusing adolescents, despite the fact that they were knowledgeable about the transmission of the virus and methods of prevention. Ninety-three percent of the substance abusers answered
FIGURE 2. Risk behaviors endorsed by age group.
172
true to the statement “using a condom during sex can lower the risk of getting AIDS”; however, significantly more substance users engaged in vaginal intercourse without a condom than controls. There were also significant differences between substance users and controls for engaging in intercourse with a person they did not know well, intercourse with a prostitute, and anal intercourse without a condom. This represents a profound gap between knowledge and behavior. Despite having accurate knowledge of transmission of HIV, substance-abusing adolescents in our population continued to engage in high-risk behaviors. The gap may, in part, be explained by the tendency for adolescents to have a sense of immortality and feelings of lack of vulnerability. The increase in high-risk sexual behaviors in the substance use group may be due to sexual contact while under the influence of substances. In a disinhibited state, these adolescents, like adults, tend to exhibit little insight and have poor judgment. It is also possible that lack of impulse control commonly seen in substance users predisposes to both substance use and high-risk sexual behaviors. Rolf reported that 24.8% of adolescent males in his study of HIV/AIDS risks among incarcerated delinquents, reported using alcohol or other drugs before engaging in sexual activity the majority of times, and 46.3% reported that alcohol was available a majority of the times at social gatherings (Rolf, Nanda, Baldwin, Chandra, & Thompson, 1990). In many cases, adolescents come in contact with unfamiliar peers at social gatherings, and while under the influence of substances, engage in highrisk sexual behaviors. Hingson and colleagues reported that a random dial telephone survey of 1,773 adolescents aged 16–19 revealed that those adolescents who drank more than five drinks a day were 2.8 times less likely to use condoms than abstaining adolescents (Hingson et al., 1990). Based on the findings in our study, adolescent substance users are at risk for engaging in high-risk behaviors, and should be considered an at-risk group for HIV infection as well as a targeted group for HIV/AIDS prevention education during the treatment course of their substance use disorders. Although the adolescents exhibited satisfactory knowledge on the subject of HIV/AIDS, there were three important deficits in knowledge. Nearly 39% of all subjects did not know that women are not more likely to get AIDS during their period and 50% of the normal controls were deficient in this area of knowledge. A large proportion (47.8%) of the subjects did not know that AIDS is not caused by the same virus that causes VD. The knowledge deficits across the three groups further support HIV/AIDS education in adolescents, in general. When the data were collapsed and analyzed based on age, significantly more of the older adolescents (15–17year-olds) experienced sexual intercourse with a stranger and vaginal intercourse without a condom, and/or had sex with a male who did not put on a condom, than their
D. Deas-Nesmith et al.
younger cohort (12–14-year-olds). It appears that as the adolescents get older, they are more apt to engage in risky behaviors. Older adolescents may be more vulnerable to negative peer pressure. Our data indicate that early interventions and prevention strategies with the younger (12–14-year-olds) age group may lead to an increased level of knowledge of HIV/AIDS and a reduction in risky behaviors. Targeting the 12–14-year age group of adolescents may be a prudent preventive measure. In conclusion, the adolescents in our sample had adequate knowledge about HIV/AIDS; however, the gap between knowledge of HIV/AIDS and risk behavior was significantly wider for adolescent substance abusers than the psychiatric or normal control group. The substances most commonly abused were alcohol and marijuana, which in most cases were used prior to engaging in highrisk behaviors. Development of AIDS prevention, educational and therapeutic programs for these at-risk adolescents is critical. Impulse control strategies should be tested as one way to bridge the gap between knowledge and behavior. Such programs may not only play a role in HIV/AIDS reduction, but also substance abuse treatment.
REFERENCES Chambers, W.J., Puig-Antich, J., Hirsch, M., Paez, P., Ambrosini, P.J., Tabrizi, M.A., & Davies, M. (1985). The assessment of affective disorders in children and adolescents by semistructured interview. Test-retest reliability of the schedule for affective disorders and schizophrenia for school-age children, present episode version. Archives of General Psychiatry, 42, 696–702. Di Clemente, R.J., Zorn, J., & Temoshok, L. (1986). Adolescents and AIDS: A survey of knowledge, attitudes and beliefs about AIDS in San Francisco. American Journal of Public Health, 76, 1443–1445. Goldsmith, M. (1993). Invisible epidemic now becoming visible as HIV/AIDS pandemic reaches adolescents [news]. Journal of the American Medical Association, 270, 16–19. Hingson, R., Strunin, L., & Berlin, B. (1990). Acquired immunodeficiency syndrome transmission: Changes in knowledge and behaviors among teenagers, Massachusetts statewide surveys, 1986 to 1988. Pediatrics, 85, 24–29. Kerr, K.L. (1989). Adolescents, AIDS, and HIV: The future starts now. Journal of School Health, 59, 277–278. NCHS. (1992). Advance report of final mortality statistics, 1989 40 (Suppl.). U.S. Department of Health and Human Services, Public Health Service, CDC. Rolf, J., Nanda, J., Baldwin, J., Chandra, A., & Thompson, L. (1990). Substance misuse and HIV/AIDS risks among delinquents: a prevention challenge. International Journal of Addiction, 25, 533–559. Slonim-Nevo, V., Ozawa, M.N., & Auslander, W.F. (1991). Knowledge, attitudes and behaviors related to AIDS among youth in residential centers: Results from an exploratory study. Journal of Adolescence, 14, 17–33. Spitzer, R., & Williams, J. (1985). Structured Clinical Interview for DSM-III-R. New York: New York State Psychiatric Institute, Biometric Research Department. Stiffman, A.R., Dore, P., Earls, F., & Cunningham, R. (1992). The influence of mental health problems on AIDS-related risk behaviors in young adults. Journal of Nervous and Mental Disorders, 180, 314–320.