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Methodological Issues in AIDS Surveys To supplement our discussion of evaluation measurement in Chapter 2, this appendix presents an excerpt on measurement issues in AIDS research from AIDS, The Second Decade (Miller, Turner, and Moses, 1990:3594711. Readers my also wish to consult the discussion of sampling and related issues in the prior report, AIDS, Sexual Behavior, and Intravenous Drug Use (Turner, Miller, arm Moses, 1989:147-157, 214-225J. INTRODUCTION Surveys or, more generally, He memos of asking questions and recording answers, continue to be one of the most important methods for obtaining essential information about Be epidemiology of AIDS and ~V, He be- haviors Hat spread ~V, and the effectiveness of AIDS prevention efforts. Previous reports of our committee have included numerous examples of surveys and obsenabons about the methodological difficulties that often attend these measurements. Because of the central role surveys play in research on AIDS and ~V, this appendix focuses on methodological aspects of this data- gather~;ng method Hat have important consequences for He usefulness of survey data. This appendix contains much technical material and methodological detail. Our aim in presenting this material is to provide researchers conducting AIDS surveys or analyzing data collected In such surveys win a detailed review of the current state of methodological re- search In this area. Readers who seek only a synopsis of our conclusions and recommendations may wish to consult pages 27-34 of the summary chapter of the report AIDS: The Second Decade (Miller, Turner, and Moses, 19901. 207

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208 ~ APPENDIX C Before honing to specifics, it may be useful to consider data gathering in general and the types of problems that may compromise the collection of accurate and informative data. One may usefully distinguish five aspects of survey data collection: (~) the definition of the population to be studied and the drawing of a target sample from that population; (2) the execution of the sample design, that is, finding the persons in the target sample and enlisting their cooperation in the survey; (3) the posing of questions to elicit Me desired information; (4) the answering of those questions by the respondent; and (5) the recording of those answers (~d subsequent data processing and analysis). To examine these elements, let us consider a hypothetical survey (much like the decennial census) that targeted all households in a par- ticular junsdiction of the state of Texas. Let us suppose further that the information to be obtained concerned automobile ownership (e.g., how many automobiles were owned by each household, the make and year of the autos, etc.~. This survey, although not simple to conduct, would nev- er~eless be considerably less difficult to conduct than a survey seeking to assess behaviors that transmit REV; In particular, the survey involves matters of fact that are both open to direct observation and matters of public record (e.g., make and year of automobiles owned by household); We topic is unlikely to be regarded as sensitive or "nri- vate" by respondents, although as in any surveysome respondents may not wish to take the time to respond; developing questions about this topic can draw on a widely shared vocabulary (i.e., there is little ambiguity about what constitutes a "car" or "ownership"; respondents who are not wed informed can consult win other household members or check records (e.g., registration certificates); checks of survey accuracy can be made at Me group leve] (by comparing the rates of auto ownership found In Me survey and in registration records) and at the individual level (by checking individual regis~ationsi); and census data on income and statewide auto reg~s~ation data are available to target Me survey efficiently toward seg- ments of Me population of particular interest (e.g., current or "potential" owners of Belchfire 500s). Ache survey may, however, produce detailed information Bat cannot be verified from public records for example, die proportion of Belchfire 500s owned by persons with 16+ years of education.

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METHODOLOGICAL ISSUES ~ 209 Surveys that inquire about sexual behaviors or IV Mug use differ in several ways from He foregoing example, and these differences pro- vide a much greater challenge to the survey (or question-and-answer) method. First, many of the logical "target populations" for drug use and sexual behavior surveys cannot be identified reliably from officio] statistics. There are few reliable data on the distnbution across the na- tion of persons who engage In behaviors that risk HIV transmission. Furthermore, the behaviors in question occur In private and cannot be verified by direct observation or public records. Many of the behaviors are actively concealed because they are considered illicit (IV drug use is illegal throughout the nation, and many sexual behaviors of interest in preventing HIV transmission are illegal in some states). Thus, the topics these surveys cover are likely to be highly sensitive, which may create difficulties in enlisting the cooperation of persons ~ a target sample and in obtaining permission from "gatekeepers" (e.g., high school authorities) who control access to particular populations (e.g., high school students). This appendix considers these problems and reviews the available empirical evidence gathered from surveys of sexual and drug use behav- iors. Before beginning this review, however, some cautionary words are in order. The evidence presented here regarding errors In data about sen- sitive behaviors might lead some readers to unwarranted and wholesale rejection of survey findings on these important topics.2 Indeed, consid- er~ng the litany of difficulties presented In this appendix, some readers may ask whether anything at all can be learned from surveys or whether surveys have a useful role to play in research on AIDS and REV trans- mission. The following considerations prompt the committee to answer "yes" to these questions. The most important consideration arises directly from the nature of the disease. HIV infection occurs through the joint operation of the biology of this particular infectious virus and the human behaviors that transmit it. In the absence of vaccines, all interventions that seek to retard the spread of HIV infection focus on changing human behaviors to diminish the probability that the virus will be transmitted. Data on these behaviors are needed for a number of important purposes for example, to understand the factors that motivate and shape the behaviors and to determine whether behaviors that transmit HIV are becoming less frequent in the population. It might, of course, be argued that merely mo~to~g changes in He prevalence of HIV would be sufficient to determine whether behaviors 2The following pages borrow heavily from He discussion of errors in survey measurements in linger and Martin (1984:Vol. 1, 1016) and Tumer (1989).

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210 ~ APPENDIX C change was occulting. Although this argument is true to some extent, there are important deficiencies in any strategy that eschews direct mea- surement of the behaviors themselves. Reliable data on HIV prevalence and incidence, although of great value for many purposes, are only a final accounting of the number of infected and uninfected persons in He population. From the viewpoint of prevention, such statistics serve best as a catalog of failures. Yet, those who are uninfected are not necessary successes. For example, the very low rate of HIV infection in states like Wyoming does not necessarily imply that the population has adopted protective behaviors. Instead, the low rate of HIV prevalence could be attnbutable to an epidemiological happenstance (e.g., isolationin teens of sexual contacts and injection equipment sharing from populations with high HIV prevalence.) Determining whether protective behavioral changes have occurred fin Wyoming or anywhere else) requires asking questions about these risky behaviors. This activity, In tum, raises a host of methodological issues that are germane to survey research of aU types plus some questions Hat are specific to surveys of drug use and sexual behavior. The questions may be quite basic: Are the respondents telling the truth? Do Hey understand the meaning of the survey questions In He same way the investigator does? Simple or complex, such questions inevitably introduce a degree of uncertainty into the interpretation of aD survey data. Grappling with these issues forces an appreciation of the human interac cons that produce survey measurements. process Elsewhere it has been argued that fundamental aspects of the survey are quintessentially social psychological in character. They arise from a complex interpersonal exchange, they embody the subjectivities of both interviewer and interviewee, and they present their interpreter with an analytical challenge that requires a multitude of assumptions concerning, among other things, how respondents experience the reality of the interview situation, decode the "meaning" of survey questions, and respond to the social presence of the interviewer and the demand characteristics of the interview. (Tu~ner, 1984:202) Although this "analytical challenge" may be substantial, researchers are aided in their task by several decades of methodological research (see, for example, Sudman and Bradbunn [1974], Bradburn and Sudman [1979], Rossi, Wright, and Anderson [1983], Turner and Martin [1984], and Catania et al. [199Oa,bl). A further reason for not abandoning behavioral measurement is that many of the problems encountered in this arena are not unique. Useful lessons may thus be learned from other disciplines that also confront such challenges.

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METHODOLOGICAL ISSUES ~ 21t Fallibility of Measurement in Other Sciences Fallibility and error are not confined to behaviors measurements, as evidenced by the decade-Ion" controversy suuTounding the population statistics produced by the decennial censuses.3 Furthermore, just as falli- bility of measurement is not limited to behavioral measurements, neither is it I:m~ted to surveys or social statistics. For example, Hunter (1977) and Lide (1981) have noted the variability among measurements of such elementary physical phenomena as the thermal conductivity of copper (Figure C-1~. As Hunter observed, "although each analyst measured a physical quality that did not vary with location or time, it is clear that a remarkable vanability attended He measurements" (1977:2~. He concluded: "The variation in attempting to evaluate the same physi- cal constant is obvious. This example is not unusual. Similar plots of thermal conductivity as a function of temperature for approximately 400 common metals and materials can be found in a supplement to the lour- nal (Ho, Powell, and Liley, 1974~. Nor is the observed variation in the measurement of 'thermal conductivity' unique among physical paramet- ers ... ." Common biological measurements have shown similar fallibility. Examples include data collected by CDC Hat show substantial variation in the est~rnates made by different laboratories of the amount of lead in identical samples of blood. For a sample of blood with a putative lead concentration of 41 milligrams per deciliter (mg/Dl), 100 cooperating laboratories produced measurements that ranged from 33 to 55 mg/Dl; this result prompted He reviewer to observe: "Clearly, whatever He true amount of lead in a sample, the variability demonstrated [in these measurements] guarantees numerous false alanns Perhaps more ~m- portant when the true level is high nonalanns" (Hunter, 1980:870~. Another category of fallibility in the physical sciences involves "dis- coveries" that are later shown to be experimental artifacts. For example, between 1963 and 1974 more than 500 journal articles (including some ~ Science and Nature ~ discussed a supposed new substance: anomalous water, or polywater. Although it resembled ordinary water, polywater allegedly had a greater density, a reduced freezing point, and an elevated boiling point, among over anomalous properties. In He end, however, it was discovered Hat this "new substance" was nothing more than an impure solution of ordinary water (Franks, 1981; Eisenberg, 19811. 3By October 1981, more than 50 lawsuits had been filed challenging die accuracy of the 1980 Cen- sus results and their use in legislative apportionment and fund allocation decisions (Citro and Cohen, 1985:9).

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212 Q Q o , C) < a: L'J I . ~ _ ~ O _ ' ~ .D ' D co - ~ ~ C) _ _ ~ ~ ' ~ (L) - OF ~ ~ g C) ~ ~ o Ct ~ ~ C) it_ 0 04 .= O ;^ - I ~ _ o ~ {_ ,_> ,_~ M =l~lOnO NO: l~WB3H1 o ~ ~ ;` _1 . ~ ~ G vie 3 A O ~ ~ ~ ~ D ~ , ~ i` Z ~ I ~ ~ 1 ;-, .; .: ;

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METHODOLOGICAL ISSUES ~ 2~3 Such examples indicate that the problems AIDS researchers confront when they seek to assess sexual and drug-us~ng behavior are not unique in the annals of scientific measurement. As Quinn McNemar observed more than 40 years ago, "bat! measurement is befuddled with error. About this the scientist can and does do something; he ascertains the possible extent of the error, determines whether it is constant (biasing) or vanable, or both, and ever strives to improve his instruments and techniques" (1946:294~. ~ the following pages the committee reviews what is currently known about the errors that afflict measures of sexual and drug-us~ng be- havior and offers some prescriptions for how future measurements might be improved. The first section of the appendix- reviews the experience to date In mounting surveys and obtaining responses from We public. The second section considers the reliability and validity of responses obtained In surveys of sexual and drug use behaviors. The final section reviews the use of anthropological research strategies that may provide important complementary information to that obtained In surveys and that may also be crucial in questionnaire development to improve the accuracy and completeness of responses. RECRUITMENT OF RESPONDENTS IN SEX AND SEROPREVALENCE SURVEYS Much of what is now known about the epidemiology of AIDS has come from smaR-scale, local studies among subgroups thought to be at high risk for infection. Participants In these studies were recruited through venous sources and means from He clientele of local clinics or treat- ment facilities or the membership rosters of local organizations, Trough newspaper advertisements and physician referrals, and occasionally from "sweet sampling." The yield from this research has been remarkably rich. From these studies, researchers have identified the principal mecha- nisms of REV infection (i.e., transmission Trough sexual contact, sharing injection equipment In {V drug use, transfusion of contaminated blood products); verified sexual transmission of HIV from male to male, female to male, and male to female; measured the efficiency of transmission In specific kinds of sexual contacts; and discovered some of the basic fea- tures of the long natural history of this devastating disease. As valuable as these studies are, however, the data drawn from them cannot address many over important public health questions that arise because of AIDS, such as: How large is He epidemic? What is the potential for general spread of HIV infection? Can an HIV epidemic be sustained Trough het- erosexual contact alone? To answer questions like these, the knowledge

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214 ~ APPENDIX C gained from measurements and observations cattier out in local studies of special subgroups must be applied in large-scale investigations of pop- ulations chosen not because of convenient or ready access but because of their importance in understanding the genera] course of the epidemic. This section considers the feasibility of sex and seroprevalence sur- veys as a means of measuring the distribution of sexual behaviors that risk HIV transmission and the distnbution of HIV itself in general pop- ulations. Although such surveys may be designed in a variety of ways, all of the studies discussed here employ the same general procedures for participant selection: an unambiguous definition of the population to be studied and a form of sampling from this population that allows the probabilities of selection to be known. The potential advantages of a probability sampling program for selecting survey participants are well known. In principle, probability sampling permits the use of a large body of statistical theory to make inferences from the sample to the larger pop- ulation and avoids the possible biases inherent in recruitment by other means. The suggestion to use probability sampling for surveys of sexual behavior was made more than three decades ago in connection with a review of the statistical methods used In Kinsey, Pomeroy, and Mar- tin's Sexual Behavior in the Human Male (1948) (Cochran, Mosteller, and Tukey, 19531. The authors of this suggestion were a committee of the Commission on Statistical Standards of the American Statistical Association. At the invitation of Dr. Kinsey and the National Research Council's Committee for Research on Problems of Sex, they were asked to provide course! on ways to improve the statistical methods used In the Kinsey research. They recommended a step-by-step program of prob- ability sampling, beginning with a small pilot effort. They argued that research of this kind would provide a check on the results obtained with Kinsey's large, nonprobability sample. The committee was aware that problems of cost and potentially high rates of nonparticipation in such surveys would present special challenges. Their comments about the limits of this approach are worth quoting at length because the issues they raised more Han 30 years ago In relation to Kinsey's work remain germane in evaluating He potential value of contemporary surveys of sexual behavior. In our opinion, no sex study of a broad human population can expect to present incidence data for reported behavior that are known to be correct to within a few percentage points. Even with the best available sampling techniques, there will be a certain percentage of the population who refuse to give histories. If the percentage of refusals is 10 percent or more, then however large the sample, there are no statistical principles which guarantee

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METHODOLOGICAL ISSUES ~ 215 Mat Me results are correct to within 2 or 3 percent, . . . but any claim that this is Cue must be based on the undocumented opinion that the behavior of those who refuse to be interviewed is not very different from that of those who are interviewed. These comments, which are not a criticism of [Kinsey, Pomeroy, and Mariin's] research, emphasize the difficulty of answering the question: "How accurate are Me results?", which is naturally of great interest to any user of the results of a sex study. (Cochran, Mosteller, and Pokey, 1953:675) The rationale for using response rates as a "yardstick" to assess the accuracy of survey estimates is twofold: (~) high response rates reduce the influence of selective participation in surveys and hence the potential for bias in the estimates, and (2) for a given target sample size and sample design, the higher the response rate, Me larger the actual sample and the smaller the standard error of estimate. In other words, high response rates are better than low rates, provided the procedures used to achieve high response rates do not increase the degree of selectivity or inaccuracy of the responses. Few contemporary surveys on any topic achieve response rates higher than the 90 percent figure cited in Cochran, Mosteller, and Tukey's review of Me Kinsey report; indeed, response rates in most surveys are considerably below that mark. In principle, then, questions about selective participation (i.e., about differences between respondents and nonrespondents) are of concern in judging the accuracy of most survey estimates, not only those that derive from surveys of sexual behavior. Such concerns have generated a substantial literature on the character of nonresponse in surveys and what to do about possibly biased estimation resulting from nonresponse (see, for example, Goyder's 1987 synthesis of nonresponse research and Me series of volumes on incomplete data in sample surveys edited by Madow, Nisselson, and OLkin [198311. Surveys with response rates that are much lower than 90 percent may still provide useful estimates of population charactenshcs if it can be established that participation or nonparticipation is unrelated to Me characteristic for which an estimate is sought. Furtherrhore, response rates higher Man 90 percent do not guarantee accurate estimation if survey participation is highly selective. Thus, in most cases, Me value of the response rate by itself is insufficient justification for claims of accuracy or "representativeness" of survey estimates or for counterclaims that estimates fail in this respect. Such claims should be based on careful study, documentation, and possibly adjustment for bias as a result of refusals and other sources of nonresponse. In Me following review, the committee examines recent efforts to survey sexual behavior and related HIV risk factors Mat use probability

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216 ~ APPENDIX C samples from general populations. The review focuses on participation in such surveys and is motivated by the same concerns about nonresponse in probability samples that were expressed in the review of the Kinsey report. It attempts to answer three main questions: (1) What response rates have been achieved In recent surveys of sexual behavior? (2) What survey designs and procedures appear to be associated with higher versus lower levels of participation? and (3) What can be said, at present, about differences between sample persons who participate in sex surveys and sample persons who refuse to participate or do not participate for other reasons? (There is as yet too little information to hazard general statements about differences between participants and nonparticipants in seroprevalence surveys.) Questions about the validity and reliability of survey responses about sexual behavior, which were also noted in reviews of the Kinsey report, will be discussed in the later sections in this appendix. Scope of the Review The committee chose 15 surveys for its review, including some that are national in scope and some that target local populations. Most of these studies were initiated after We AIDS epidemic began in response to the need for population-based arsenates of sexual behaviors known to be associated with HIV transmission. Both telephone and face-to-face interviewing me~ods are represented, along with data collection through self-a~Tninistered questionnaires. There are wide vanations among the surveys In the proportion of questions they devote to measuring sexual practices and other risk behaviors. Four surveys were included because of their potential importance for monitoring the prevalence of HIV infection; these surveys attempted to collect a blood specimen for REV serologic testing from each sample person. The committee used four criteria for including studies in its review: (~) there was at least a minimal attempt to collect data on personal sexual behavior and, In some cases, other HIV risk factors as well; (2) some form of probability sampling was employed; (3) a response rate of He form (number of survey participants)/(number of sample persons) could be calculated; and (4) enough documentation was available to identify the pnncipal characteristics of the survey design and sampling procedures. Information about the designs, sampling procedures, and participation rates of these surveys appears in Table C-~. For the most part, the committee collected information about these surveys from published accounts In books, journal articles, and survey field reports. (The source documents are cited In Table C-~.) Occasion- ally, it was necessary to rely on conversations win survey field managers,

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METHODOLOGICAL ISSUES | 217 especially for surveys that had been completed at the time of this writing. ~ several other cases, documentation is partial because of incomplete reporting or recor~keep~ng, or both. For these reasons, and because the total number of surveys is small, the committee has not attempted a statistical analysis of participation rates in relation to survey characteris- tics. Nevertheless, the review does identify differences in response rates In sex surveys that appear to be associated with procedural and design variations. It also reveals several opportunities for learning more about patterns of participation and nonparticipation. Participation in Sex Surveys Data Collection Procedures and Response Rates Each of the surveys listed in Table C-1 asked respondents to report on certain aspects of their past and present sexual behavior. For the most part, the questions used in recent surveys (i.e., those initiated after the AIDS epidemic began) attempt to measure the occurrence of sexual behaviors associated with HIV infection and transmission and fall into three general categories: sexual orientation (with a focus on homosexuality), selection of sexual partners (number and characteristics of partners, presence of same-sex partnerships), and manner of sexual intercourse (e.g., anal, vaginal, oral). Because of the sensitive and highly personal nature of these questions, virtually all of the surveys made some provision to permit respondents to reveal the details of their sexual behavior without undue embarrassment or fear of disclosure to third parties. Most of the surveys included one or more of the following: special guarantees that responses would be kept confidential; assurance of anonymity that is, that the person viewing the results would not know the identity of the respondent; privacy during the interview; and placement of the sensitive questions near the end of the interview. Apart from these similanties, the 15 surveys differ widely with respect to basic methods of data collection and number of questions about sexual behavior. Interviewing was conducted by telephone in four of the surveys (nos. 3, 4, 9, and 10 In Table C-1), by face-to-face interview in five cases (nos. 7, 8, 12, 13, and 14), and by a combination of face-to-face interview and self-administered questionnaire (SAQ) in six (nos. I, 2, 5, 6, Il. and 151. Virtually all of the surveys that contained long, detailed inventories of sexual questions were conducted through face-to-face or telephone interviews. When SAQs were used, the length of the self-a~ninistered forms vaned considerably (some did not exceed 1 or 2 pages whereas others [e.g., survey no. 1] were more than 10 pages long).

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306 APPENDIX C Ho, C. Y., Powell, R. W., and Liley, P. E. (1974) Thermal conductivity of the elements: A comprehensive review. Journal of Physical and Chemical Reference Data 3: 1-244. Hochhauser, M. (1987) Readability of AIDS educational materials. Presented at the Annual Meeting of the American Psychological Association, New York, August. Hofferth, S. L., Kahn, J. R., and Baldwin, W. (1987) Premarital sexual activity among U.S. teenage women over the past three decades. Family Planning Perspectives 19:46-53. Hoon, E. F., Hoon P. W., and Wincze, J. P. (1976) An inventory for the measurement of female sexual arousability: The SAI. Archives of Sexual Behavior 5:291-300. Huang, K. H. C., Watters, J. K., and Case, P. (1988) Psychological assessment and AIDS research with intravenous drug users: Challenges in measurement. Journal of Psychoactive Drugs 20:191-195. Huang, K. H. C., Watters, J., and Case, P. (1989) Compliance with AIDS prevention measures among intravenous drug users: Health beliefs or sociaVenvironmental factors? Presented at the Fifth International Conference on AIDS, Montreal, June =9. Hubbard, R. L, Marsden, M. E., and Allison, M. (1984) Reliability and Validity of TOPS Data. Research Triangle Park, N.C.: Research Tnangle Institute. Hubbard, R. L., Eckennan, W. C., Rachal, J. V. and Williams, J. R. (1977) Factors affecting the validity of self-reports of drug use: An overview. Proceedings of the American Statistical Association (Social Statistics Section) 1977:36~365. Chicago, Ill., August 15-18. Hunter, J. S. (1977) Quality assessment of measurement methods. In National Research Council, Environmental Monitoring, Vol. 4a. Washington, D.C.: National Academy of Sciences. Hunter, J. S. (1980) The national system of scientific measurement. Science 210:869- 874. Hyman, H. H., Cobb, W. J., Feldman, J. J., Hart, C. W., and Stember, C. H. (1954) Interviewing in Social Research. Chicago: University of Chicago Press. Jabine, T. B., Straf, M. L., Tanur, J. M., Tourangeau, R., eds. (1985) Cognitive Aspects of Survey Methodology. Washington, D.C.: National Academy Press. Jackson, D. D., Lee, W. B., and Liu, C. (1980) Aseismic uplift in southern California: An alternative interpretation. Science 210:53~536. Jacobson, N. S., and Moore, D. (1981) Spouses as observers of the events in their relationship. Consulting and Clinical Psychology 49:269-277. Johnson, A., Wadsworth, J., Elliot, P., PIior, L., Wallace, P., et al. (1989) A pilot study of sexual lifestyle in a random sample of the population of Great Britain. AIDS 3:135-141. Johnston, L. D., and O'Malley, P. M. (1985) Issues of validity and population coverage in student surveys of drug use. In B. A. Rouse, N. J. Kozel, and L. G. Richards, eds., Self-report methods of estimating drug use: Meeting current challenges to validity. DHHS Publication No. (ADM) 85-1402. National Institute on Drug Abuse Research Monograph No. 57. Washington, D.C.: U.S. GoveInment Printing Office. Josephson, E. (1970) Resistance to community surveys. Social Problems 18:117-129. Kahn, J. R., Kalsbeek, W. D., and Hofferth, S. L. (1988) National estimates of teenage sexual activity: Evaluating the comparability of three national surveys. Demography 25:189-204.

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METHODOLOGICAL ISSUES ~ 307 Kahn, R. L., and Cannell, C. F. (1957) The Dynamics of Interviewing. New York: Wiley. Kane, S. (1989a) Heterosexuals, AIDS and the heroin subculture. Unpublished manu- script. Kane Agency, New York, N.Y. Kane, S. (1989b) Interviews with two women: AIDS, addiction and hetero-sex on Chicago's south side. Unpublished manuscnpt. Kane Agency, New York, N.Y. Kann, L., Nelson, G. D., Jones, J. T., and Kolbe, L. J. (1989) Establishing a system of complementary school-based surveys to annually assess HIV-related knowledge, beliefs, and behaviors among adolescents. Journal of School Health 59:55-58. Kann, L., Nelson, G., Jones, J., and Kolbe, L. (1989) HIV-related knowledge, beliefs and behaviors among high school students in the United States. Presented at the Fifth International Conference on AIDS, Montreal, June 09. Kaplan, H. B. (1989) Methodological problems in the study of psychosocial influences in the AIDS process. Social Science and Medicine 29:277-292. Kaplan, H. B., Johnson, R. J., Bailey, C. A., and Simon, W. (1987) The sociological study of AIDS: A critical review of the literature and suggested research agenda. Journal of Health and Social Behavior 28:14~157. Keeter, S., and Bradford, J. B. (1988) Knowledge of AIDS and related behavior change among unmarried adults in a low-prevalence city. American Journal of Preventive Medicine 4:14~152. Kelly, J. A., St. Lawrence, J. S., Hood, H. V., and Brasfield, T. L. (1989) Behavioral intervention to reduce AIDS risk activities. Journal of Consulting and Clinical Psychology 57:6~67. King, F. W. (1970) Psychology in action: Anonymous versus identifiable questionnaires in drug usage surveys. American Psychologist 25:982-985. Kinsey, A. C., Pomeroy, W. B., and Martin, C. E. (1948) Sexual Behavior in the Human Male. Philadelphia: W. B. Saunders. Kinsey, A. C., Pomeroy, W. B., Martin, C. E., and Gebhard, P. H. (1953) Sexual Behavior in the Human Female. Philadelphia: W. B. Saunders. Kipke, M. D., and Drucker, E. (1988) A method for assessing needle-shanng behavior in intravenous drug users. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Klassen, A. D., Williams, C. J., and Levitt, E. E. (1989) Sex and Morality in the U.S., edited by H. J. O'Gorman. Middletown, Conn.: Wesleyan University Press. Klassen, A. D., Williams, C. J., Levitt, E. E., Rudkin-Miniot L., Miller H., and Gunjal, S. (1989) Trends in premarital sexual behavior. In C. F. Turner, H. G. Miller, and L. E. Moses, eds., AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, D.C.: National Academy Press. Koblin, B., McCusker, J., Lewis, B., Sullivan, J., Birch, F., and Hagen, H. (1988) Racial differences in HIV infection in IVDUs. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Koester, S. (1989a) The risk of HIV transmission from sharing water, drug-mixing con- tainers and cotton filters among intravenous drug users. Unpublished manuscript. University of Colorado School of Medicine, Boulder, Colo. Koester, S. (1989b) When push comes to shove: Poverty, law enforcement and high risk behavior. Unpublished manuscript. University of Colorado School of Medicine, Boulder, Colo. Koss, M. P., and Gidycz, C. A. (1985) Sexual experiences survey: Reliability and validity. Journal of Consulting and Clinical Psychology 53:422~23.

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308 ~ APPENDIX C Lange, W. R., Snyder, F. R., Lozovsky, E., Kaistha, V., Jaffe' J. H., et al. (1988) Geographic distribution of human immunodeficiency virus markers in parenteral drug abusers. American Journal of Public Health 78:443- 446. Leach, C., Milker, S., Kuhls, T., Pams, N., Cherry, J., and Christenson, P. (1989) Changes in sexual behavior of a cohort of female health care workers during the AIDS era. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Leonard, T. L. (1990) Male clients of female street prostitutes: Unseen partners in sexual disease transmission. Medical Anthropology Quarterly 4:41-55. Lessler, J., Tourangeau, R., and Salter, W. (1989) Questionnaire design in the cognitive research laboratory. Vital and Health Statistics Series 6, Whole No. 1. Lever, J., Rogers, W. H., Carson, S., Hertz, R., and Kanouse, D. E. (1989) Behavioral patterns of bisexual males in the U.S., 1982. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Levinger, G. (1966) Systematic distortion in spouses' reports of preferred and actual sexual behavior. Sociometry 29:291-299. Lide, D. R., Jr. (1981) Critical data for critical needs. Science 212:1343-1349. Lofts E. F. (1975) Leading nIle.ctinn~ ~nr1 the Inch -~_ I::._ D_.~L_~___ 7:56~572. C ~ a~O lo. ~U8I~~~V~ <~yC~10~ Loftus, E. F., and Marburger, W. (1983) Since the eruption of Mt. St. Helens, has anyone beaten you up? Improving the accuracy of retrospective reports win landmark events. Memory and Cognition 11:11~120. Loftus, E. F., and Palmer, J. C. (1974) Reconstruction of automobile destruction: An example of the interaction between language and memory. Journal of Verbal Learning and VerbalBehavior 13:585-589. LoPiccolo. J. and ~~;~es~rr ~ ~ (] C)7~N Tl~^ ~.,^~ ;~ :_ : ~ =,_., _. _. ~^,,~, 4~- o-~ ult~la~ul1 ulv~n[~; A new Instrument for assessment of sexual dysfunction. Archives of Sexual Behavior 3:585-595. Luetgert, M. J., and Armstrong, A. H. (1973) Methodological issues in drug usage sur- veys: Anonymity, recency, and frequency. International Journal of the Addictions 8:683~89. MacKuen, M. B. (1981) Social communication and He mass policy agenda. ~ M. B. MacKuen and S. L. Coombs, eds., More than News: Media Power in Public Affairs. Beverly Hills, Calif.: Sage. MacKuen, M. B. (1984) Reality, the press, and citizens' political agendas. En C. F. Turner and E. Martin, eds., Surveying Subjective Phenomena. VoL 2. New York: Russell Sage. MacKuen, M. B. and Turner, C. F. (1984) The popularity of presidents: 1963 80. C. F. Turner and E. Martin, eds., Surveying Subjective Phenomena. Vol. 2. New York: Russell Sage.. Maddox, J., and Desmond, D. (1975) Reliability and validity of information from chronic heroin users. Journal of Psychiatric Research 12:87-95. Madow, W. G., Nisselson, H., and Ollcin, I., eds. (1983) Incomplete Data in Sample Surveys. Vol. 1, Report and Case Studies; Vol. 2, Theory and Bibliographies; Vol. 3, Proceedings of the Symposium. New York: Academic Press. Magura, S., Goldsmith, D., Casriel, C., Goldstein, P. J., and Lipton, D. S. (1987) The validity of methadone clients' self-reported drug use. International Journal of the Addictions 22:727-749.

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METHODOLOGICAL ISSUES ~ 309 Maisto, S. A., and O'Farrell, T. J. (1985) Comment on the validity of Watson et al.'s "Do alcoholics give valid self-reports?" Journal of Studies on Alcohol 46:447-453. Maisto, S. A., Sobell, L. C., and Sobell, M. B. (1982-83) Corroboration of drug abusers' self-reports through the use of multiple data sources. American Journal of Drug and Alcohol Abuse 9:301-308. Marasca, G., D'Arcangelo, E., De Candido, D., Della Giusta, G., Liseo, B., et al. (1989) Sexual behaviour and HIV related knowledge among a random sample of young population of Italy. Presented at the Fifth International Conference on AIDS, Montreal, June 4-9. Marks, I. M., and Sartorius, N. H. (1968) A contribution to the measurement of sexual attitude. Journal of Nervous and Mental Disease 145:441-451. Marshall, P., O'Keefe, J. P., Fisher, S. G., Caruso, A. J., and Surdukowski, J. (1990) Patients' fear of contracting the acquired immune deficiency syndrome from physicians. Archives of Internal Medicine 150:1501-1506. Martin, J. L., and Vance, C. S. (1984) Behavioral and psychosocial factors in AIDS: Methodological and substantive issues. American Psychologist 39:1303-1308. Mason, T. (1988) AIDS prevention among black IV drug users and their sexual partners in a Baltimore public housing project. Presented at the First International Symposium on Infonnation and Education on AIDS, Ixtapa, Mexico, October 18. Mason, T. (1989) The politics of culture: Drug users, professionals, and the meaning of needle sharing. Presented at the Annual Meeting of the Society for Applied Anthropology, Santa Fe, April. Mason, T. (1989) A preliminary look at social and economic dynamics influencing drug markets, drug use patterns, and HIV risk behaviors among injecting drug users in two Baltimore networks. In Proceedings of the Community Epidemiology Work Group: Chicago, Illinois, June 1989. National Institute on Mug Abuse, Division of Epidemiology and Statistical Analysis, Rockville, Md. May, R. M., and Anderson, R. M. (1987) Transmission dynamics of HIV infection. Nature 326:137-142. May, R. M., Anderson, R. M., and Blower, S. M. (1989) The epidemiology and transmission dynamics of HlV-AlOS. Daedalus 118:163-201. McCombie, S. C. (1986) The cultural impact of the AIDS test: The American experience. Social Science and Medicine 23:455~59. McCombie, S. C. (1989) Rituals of infection control among health care workers. Unpublished manuscnpt. Annenberg School of Communications, University of Pennsylvania. McCombie, S. C. (1990) Patterns of condom use in Trinidad and Tobago. Unpublished manuscript. Annenberg School of Communications, University of Pennsylvania. McGlothlin, W. H., Anglin, M. D., and Wilson, B. D. (1977) An Evaluation of the California Civil Addict Program. Rockville, Md.: National Institute on Drug Abuse. McLaws, M. L., McGirr, J., Croker, W., and Cooper, D. A. (1988) Risk factors for HIV and HBV infections in intravenous drug users. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. McNemar, Q. (1946) Opinion-athtude methodology. Psychological Bulletin 43:289-374. Means, B., Nigam, A. Zarrow, M., Loftus, E. F., and Donaldson, M. S. (1989) Autobiographical memory for heals related events. Vital and Health Statistics Series 6, Whole No. 1.

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310 ~ APPENDIX C Michael, R. T., Laumann, E. O., Gagnon, J. H., and Smith, T. W. (1988) Number of sex partners and potential risk of sexual exposure to human immunodeficiency virus. Mortality and Morbidity Weekly Report 37:565-568. Miller, H. G., Turner, C. F., and Moses, L. E. (1990) AIDS: The Second Decade. Washington, D.C.: National Academy Press. Millstein, S., and Irwin, C. (1983) Acceptability of computer-acquired sexual histories in adolescent girls. Journal of Pediatrics 103:815~19. Minkoff, H., McCalla, S., Delke, I., Feldman, J., Stevens, R., and Salwen, M. (1989) Cocaine use and sexually transmitted diseases including HIV. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Moatti, J. P., Tavares, J., Durbec, J. P., Bajos, N., Menard, C., and Seward, C. (1989) Modifications of sexual behavior due to AIDS in French heterosexual "at risk" population. Presented at the Fifth International Conference on AIDS, Montreal June =9. Mooney, H. W., Pollack, B. R., and Corsa, L. (1968) Use of telephone interviewing to study human reproduction. Public Health Reports 83:1049-1060. Moser, C. A., and Kalton, G. (1972) Survey Methods in Social Investigation. 2d ed. New York: Basic. Moss, A. R., Bacchetti, P., Osmond, D., Meakin, R., Keffelew, A., and Gorter, R. (1989) Seroconversion for HIV in intravenous drug users in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Mukherjee, B. N. (1975) Reliability estimates of some survey data on family planning. Population Studies 29:127-142. Myers, V. (1977a) Survey methods for minority populations. The Journal of Social Issues 33: 11-19. Myers, V. (1977b) Toward a synthesis of ethnographic and survey methods. Human Organization 36:244 251. National Research Council (NRC) (1979) Privacy and Confidentiality as Factors in Survey Response. Washington, D.C.: National Academy of Sciences. Needle, R. H., Jou, S., and Su, S. S. (1989) The impact of changing methods of data collection on the reliability of self-reported drug use of adolescents. American Journal of Drug and Alcohol Abuse 15:275-289. Needle, R., McCubbin, H., Lorence, J., and Hochhauser, M. (1983) Reliability and valid- ity of adolescent self-reported drug use in a family-based study: A methodological report. International Journal of the Addictions 18:901-912. Neisser, U. (1981) John Dean's memory: A case study. Cognition 9:1-22. Newcomer, S., and Udder, J. R. (1988) Adolescents' honesty in a survey of sexual behavior. Journal of Adolescent Research 3:419~23. Newman, R. G., Cates, M., Noun A., and Werbell, B. (1976) Reliability of self- reported age of first drug use: Analysis of New York City narcotics register data. International Journal of the Addictions 11:611-618. Newmeyer, J. A. (1988) Why bleach? Development of a strategy to combat HIV contagion among San Francisco intravenous drug users. In R. J. Battjes, and R. W. Pickens, eds., Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. DHHS Publication No. (ADM) 88-1567. National Institute on Drug Abuse Research Monograph 80. Washington, D.C.: U.S. Government Printing Office. Nisbett, R. E., and Wilson, T. D. (1977) Telling more than we can know: Verbal reports on mental processes. Psychological Review 84:231-259.

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METHODOLOGICAL ISSUES | 311 Novick, D. M., Tngg, H. L., Des Jarlais, D. C., Fnedman, S. R., Vlahov, D., et al. (1989) Drug abuse patterns and ethnicity in IVDA during the early years of the REV epidemic. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Nurco, D. N. (1985) A discussion of validity. In B. A. Rouse, N. J. Kozel, and L. G. Richards, eds., Self-report Methods of Estimating Drug Use: Meeting Current Challenges to Validity. DHHS Publication No. (ADM) 8~1402. National Lnstitute on Drug Abuse Research Monograph No. 57. Washington, D.C.: U.S. Government Printing Office. Getting, E. R., Edwards, R., and Beauvais, F. (1985) Reliability and discriminant validity of the children's drug-use survey. Psychological Reports 56:751-756. O'Reilly, K. R. (1989) Risk behaviors and their determinants. In R. Kulstad, ea., AIDS 1988: American Association for the Advancement of Science Symposia Papers. Washington, D. C.: American Association for the Advancement of Science. Page, B. P., Chitwood, D. D., Smith, P. C., Kane, N., and McBride, D. C. (1990) Intravenous drug use and HIV infection in Miami. Medical Anthropology Quarterly 4:5~71. Page, W. F., Davies, J. E., Ladner, R. A., Alfassa, J., and Tennis, H. (1977) Urinalysis screened versus verbally reported drug use: The identification of discrepant groups. International Journal of the Addictions 12:439~50. Parker, R. (1987) Acquired immunodeficiency syndrome in urban Brazil. Medical Anthropology Quarterly 1:15~175. Parker, R. (1989) Bodies and pleasures in the construction of erotic meaning in contemporary Brazil. Anthropology and Humanism Quarterly 14:504. Pearson, R. W., Ross, M., and Dawes, R. (1989) A theory of personal recall and the limits of retrospection in surveys. Unpublished manuscript. Social Science Research Council, August 1, 1989. Pelto, P., and Pelto, G. (1978) Anthropological Research: The Structure of Enquiry. London: Cambridge University Press. Peterson, J. L., and Bakeman, R. (19~9) AIDS and IV drug use among ethnic minorities. Journal of Drug Issues 19:27-37. Petzel, T. P., Johnson, J. E., and McKillip, J. (1973) Response bias in drug surveys. Journal of Consulting and Clinical Psychology 40:437~39. Podell, L., and Perkins, J. C. (1957) A Guttman scale for sexual experience A methodological note. Journal of Abnormal and Social Psychology 54:420~22. Poti, S. J., Chakraborti, B., and Malaker, C. R. (1960) Reliability of data relating to contraceptive practices. In C. V. Kiser, ea., Research In Family Planning. Princeton: Princeton University Press. Public Heals Service (PHS). (1988) Report of the Second Public Heals Service AIDS Prevention and Control Conference. Public Health Reports 103, Supplement No. Quart, A. M., Small, C. B., and Klein, R. S. (1989) Local destruction of labial surface of mandibular teeth by direct application of cocaine in drug users with AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Reining, P. (1989) Male circumcision status in relationship to seroprevalence data in Africa: A review of method. Unpublished manuscript. Department of Anthropol- ogy Catholic University. Research Tnangle Institute (RTI). (1989) National Household Seroprevalence Survey: Pilot Study Report. Research Triangle Park, N.C.: Research Triangle Institute.

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312 ~ APPENDIX C Robertson, 3. R., Skidmore, C. A., and Roberts, J. J. K. (1988) HIV infection in intravenous drug users: A follow-up study indicating changes in risk-taking behaviour. British Journal of Addiction 83:387-391. Robinson, T. W., Davies, P., and Beveridge, S. (1989) Sexual practices and condom use amongst male prostitutes in London: Differences between streetworking and non-streetworking prostitutes. Presented at the Fifth International Conference on AII)S, Montreal, June =9. Rodgers, J. L., Billy, J. O. G., and Udry, J. R. (1982) The rescission of behaviors: Inconsistent responses in adolescent sexuality data. Social Science Research 11:28~296 Rolnick, S. J., Gross, C. R., Garrard, J., and Gibson, R. W. (1989) A comparison of response rate, data quality, and cost in the collection of data on sexual history and personal behaviors. American Journal of Epidemiology 129:1052-1061. Rossi, P. H., Wright, J. D., and Anderson, A. B., eds. (1983) Handbook of Survey Research. New York: Academic Press. Rounsaville, B., Kleber, H. D., Wilber, C., Rosenberger, D., and Rosenberger, P. (1981) Comparisons of opiate addicts' reports of psychiatric history with reports of significant-other informants'. American Journal of Drug and Alcohol Abuse 8:51~9. Rouse, B. A., Kozel, N. J., and Richards, L. G., eds. (1985) Self-report Methods of Estimating Drug Use: Meeting Current Challenges to Validity. National Institute on Drug Abuse Research Monograph No. 57. Washington, D.C.: U.S. Government Printing Office. Saltzman, S. P., Stoddard, A. M., McCusker, J., Moon, M. W., and Mayer, K. H. (1987) Reliability of self-reported sexual behavior risk factors for HIV infection in homosexual men. Public Health Reports 102:692-697. Schaeffer, N. C. and Thomson, E. (1989) The discovery of grounded uncertainty: Developing standardized questions about strength of fertility motivation. Center for Demography and Ecology Working paper No. 8~19. Madison, Wisc.: Center for Demography and Ecology, University of Wisconsin. Schiavi, R. C., Derogatis, L. R., Kuriansky, J., O'Connor, D., and Sharpe, L. (1979) The assessment of sexual function and marital interaction. Journal of Sex and Marital Therapy 5:169-224. Schilling, R. F., Schinke, S. P., Nichols, S. E., Zayas, L. lI., Miller, S. O., et al. (1989) Developing strategies for AIDS prevention research with black and Hispanic drug users. Public Health Reports 104:2-11. Schmidt, K. W., Krasnik, A., Brends~up, E., Zof~nan, H., and Larsen, S. O. (1988) Occurrence of sexual behaviour related to the risk of HIV-infection. Danish Medical Bulletin 36:8W38. Schoepf, B. G., Walu, E., Rukarangira, Wn., Payanzo, N.' and Schoepf, C. (In press) Action research on AIDS with women in Central Africa. Social Science and Medicine. Schofield, M. (1965) The Sexual Behavior of Young People. Boston: Little, Brown, and Co. Schurnan, H. and Presser, S. (1981) Questions and Answers in Attitude Surveys: Experiments in Question Form, Wording, and Context. New York: Academic Press.

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METHODOLOGICAL ISSUES ~ 313 Seage, G. R., m, Mayer, K. H., Horsburgh, C. R., Cal, B., and Lamb, G. A. (1989) Validation of sexual histories of homosexual male couples. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Siegel, K., and Bauman, L. J. (1986) Methodological issues in AIDS-related research. In D. A. Feldman and T. M. Johnson, eds., The Social Dimensions of AIDS: Method and Theory. New York: Praeger. Single, E., Kandel, D. B., and Johnson, B. D. (1975) The reliability and validity of drug use responses in a large scale longitudinal survey. Journal of Drug Issues 5:426~43. Skinner, H. A., and Allen, B. A. (1983) Does the computer make a difference? Computerized versus face-to-face self-report assessment of alcohol, drug, and tobacco use. Journal of Consulting and Clinical Psychology 51:267-275. Smith, A. F., Jobe, J. B., and Mingay, D. J. (In press) Retrieval from memory of dietary information. Applied Cognitive Psychology. Smith, T. W. (1988) A Methodological Review of the Sexual Behavior Questions on the 1988 General Social Survey (GSS). GSS Methodological Report No. 58, National Opinion Research Center: University of Chicago. Sorensen, J. L., and Leder, D. (1978) Measuring the readability of written information for clients. In G. Landsberg, W. D. Neigher, R. J. Hammer, C. Kindle, and J. R. Way, eds., Evaluation in Practice: A Sourcebook of Program Evaluation Studies from Mental Health Care Systems in the United States. DHEW Publication No. (ADM) 7~763. Washington, D.C.: U.S. Government Printing Office. Sorensen, J. L., Gibson, D., Heitzmann, C., Calvillo, A., Dumontet, R., et al. (1988) Pilot trial of small group AIDS education with IV drug abusers (abstract). In L. S. Harris, ea., Problems of Drug Dependence 1988: Proceedings of the 50th Annual Scientific Meeting, Committee on the Problems of Drug Dependence. National Institute on Drug Abuse, Research Monograph 90. Washington, D.C.: U.S. Government Printing Office. Sorensen, J. L., Gibson, D. R., Heitzmann, C., Dumontet, R., London, J., et al. (1989a) AIDS prevention: Behavioral outcomes with outpatient drug abusers. Presented at the Annual Meeting of the American Psychological Association, New Orleans, La. Sorensen, J. L., Guydish, J., Costantini, M., and Batki, S. L. (1989b) Changes in needle sharing and syringe cleaning among San Francisco Drug Abusers. New England Journal of Medicine 320:807. Sorensen, J. L., Batki, S. L., Gibson, D. R., Dumontet, R., and Purnell, S. (1989c) Methadone maintenance and behavior change in seropositive drug abusers: The San Francisco General Hospital Program for AIDS Counseling and Education (PACE). Presented at the Fifth International Conference on AIDS, Montreal, June =9. Spencer, B. D. (1989) On the accuracy of current estimates of the numbers of intravenous drug users. In C. F. Turner, H. G. Miller, and L. E. Moses, eds., AIDS, Sexual Behavior,ar~Intravenous Drug Use. Washington,D.C.: NationalAcademy Press. Spencer, L., Faulkner, A., and Keegan, J. (1988) Talking About Sex. (Publication P. 5997) London: Social and Community Planning Research. Steger, K., Comella, B., Forbes, J., McLaughlin, R., Hoff, R. A., and Craven, D. E. (1989) Use of a fingerstick paper-absorbed blood sample for HIV serosurveys in intravenous drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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