zyxwvutsrqp zyxwvutsr zyxwvutsrq Public Health Nursing Vol. 13 No. 3, pp. 209-216 0737- 1209/96/$10.50 0 Blackwell Science. Inc. Effectiveness of Counseling in the Health Promotion of HIVPositive Clients in the Community Sally DiScenza, M.S.N., R.N., Mary Nies, Ph.D., R.N., FAAN, and Cynthia Jordan, Ed.D. ~~ ~ INTRODUCTION ~ Abstract The purpose of this study was to examine the effects of a nurse’s counseling intervention on high-risk sexual behaviors The problem of Human Immunodeficiency Virus (HIV) of HIV-positive patients and to explore the relationship of gender, infection has reached pandemic proportions. Heterosexual race, age, and education to high-risk sexual behaviors. A conve- transmission is escalating globally and may account for nience sample of 20 adults who were newly diagnosed with HIV 80% of HIV infection by the end of the decade, The World and were being treated at an inner-city out-patient clinic was Health Organization (WHO) projects that the total number used. Subjects were administered a questionnaire to determine of HIV-infected adults will reach 30 million by the year their precounseling AIDS knowledge and precounseling sexual 2000, and that another 10 million pediatric cases are probehaviors. A registered nurse then counseled them about safejected. Not only are infants experiencing high rates of sex practices. After 2-3 months the questionnaire was readminismorbidity, but by the year 2000 10 million uninfected tered to determine the effects of counseling on AIDS knowledge and high-risk sexual behaviors. Although statistical analysis indi- children are predicted to be orphaned (Holmes, 1991). The most common mode for HIV transmission in the cated a significant main effect for change in high-risk sexual behaviors after counseling, there were no significant relationships United States is sexual contact, followed by exposure to among change and the individual demographic variables of age, contaminated blood or blood products by intravenous drug gender, race, and education. Pretest knowledge was not found use or blood transfusion, and, lastly, transmission from to influence pretest behavior, nor was posttest knowledge found mother to fetus (Roper, 1991). Several high-risk behaviors to affect posttest behavior. Paired t tests indicated a significant have been identified that promote the transmission of HIV change in high-risk sexual behavior scores after counseling but receptive anorectal or (to a lesser extent) vaginal interno significant change in knowledge scores. course; numerous sexual partners or high-risk partners; zyxwvutsrq zyxwvuts Sally DiScenza is Nurse Practitioner, Adult Special Care Clinic, the Regional Medical Center, Memphis, Tennessee. Mary Nies (formerly Albrecht) is Associate Professor, College of Nursing, College of Medicine, and Cynthia Jordan is Assistant Professor, Academic Support Services, University of Tennessee, Memphis. Address correspondence to Mary Nies, Ph.D., R.N., FAAN, College of Nursing, College of Medicine, University of Tennessee, Memphis, 327 Angelus Street, Memphis, TN 38112. prostitution; intravenous drug use; sex exchange for crack cocaine; presence of other sexually transmitted diseases; and absence of circumcision (Holmes, 1991). Changes in behavior are needed to prevent the further transmission of HIV. A counseling component that focuses on promoting, reinforcing, and maintaining behavior changes in HIV-positive individuals is needed to prevent the spread of the disease (Hobfoll, Jackson, Lavin, Britton, & Shepard, 1994). It is crucial to follow safe-sex guidelines to prevent the spread of this disease. One role of nursing is to counsel the HIV-positive patient on safe- 209 210 Public Health Nursing zy zyxwvutsr Volume 13 Number 3 June 1996 sex behaviors to prevent the transmission of this disease. To assess the effectiveness of counseling programs in promoting, reinforcing, and maintaining behavior changes, more research is needed that looks at the relationship among counseling, patient knowledge, and risk behaviors. The purpose of this study was to examine the effects of a counseling intervention by a nurse in changing high-risk sexual behaviors of HIV-positive patients and to explore the relationships of gender, race, age, and education to high-risk sexual behaviors. Hypotheses There will be no statistically significant difference between change in high-risk sexual behaviors after counseling and age, gender, race, or education. There will be no statistically significant relationship between knowledge score and high-risk behavior scores in the HIV patient in an inner-city out-patient clinic. There will be no statistically significant difference between precounseling knowledge scores and postcounseling knowledge scores. There will be no statistically significant difference between precounseling high-risk sexual behaviors and postcounseling high-risk sexual behaviors. RELATED LITERATURE High-Risk Behaviors As health professionals struggle with understanding and tracking the transmission of HIV, it is important to be aware of certain environmental components of lifestyle that may prove predictive of the transmission of HIV (Flaskerud, 1992). Research has led to a compilation of high-risk behaviors associated with the transmission of the AIDS virus. By understanding these factors, it is believed that health care professionals will be better equipped to develop more effective education and treatment plans for those at risk for AIDS. Chiasson et al. (1990) sought to identify high-risk factors for HIV patients in a sexually transmitted-disease clinic in New York City. They interviewed 1,201 volunteers. The interview consisted of 34 questions about homosexual contact, intravenous drug use, transfusions, occurrences of exposure to blood, sexual activity, and sexual behaviors. Chiasson et al. reported that significant high-risk behaviors for men included sex with men, history of intravenous drug use, history of sexual activity with women who were intravenous drug users, and evidence of syphilis. Significant high-risk behaviors for women included sexual contact with male intravenous drug users or bisexuals, prostitution, and rectal intercourse. These findings are consistent with other studies of high-risk behaviors (Cohen, Alexander, & Wolsy, 1988, 1988; DesJarlais & Friedman, 1988; Flaskerud, 1992; Holmes, Karon, & Kreiss, 1990). Similarly, Stall, McKusick, Wiley, Coates, and Ostrow (1986) sought to identify the relationship between drug and alcohol use and high-risk behaviors. They administered a questionnaire to four groups of sexually active gay men in San Francisco. The questionnaire measured the use of alcoholic beverages, amyl or butyl nitrates “poppers,” smoking marijuana or hashish, or using other drugs while having sex. Behaviors were noted as safe, probably safe, probably risky, or risky, as measured against standards published through health education campaigns in the San Francisco area. Stall et al. report that men who did not drink alcohol during sex were three times more likely to be in the safe group. Men who drank (even rarely) prior to sex were two times as likely to participate in high-risk behavior. There was a significant correlation between high-risk behaviors and combining drinking with sexual activity. Stall et al. also found a high correlation between drug use and highrisk behaviors. There was a greater incidence of highrisk behavior if the drug was illegal, rather than legal and readily available. This was also true of subjects who used a variety of drugs over time. Flaskerud’s (1992) analysis of high-risk-factor studies indicates that if both partners are seronegative and have monogamous relationships there is no risk of sexual transmission. For populations for whom this is not true, Flaskerud reports that certain high-risk behaviors are highly correlated with the transmission of HIV. These behaviors can be described as any activity involving a potential exchange of blood or body fluids from one person to another. High-risk behaviors include numerous sexual partners, vaginal intercourse, anal intercourse, oral genital contact, prostitution, intravenous drug use, and sex exchange for crack cocaine. High-Risk Groups In the United States, approximately 80%-90% of HIV transmission results from homosexual contact or intravenous drug use (DesJarlais & Friedman, 1988; Holmes, 1991). Research indicates that HIV is currently most prevalent among homosexual and bisexual men (Holmes, 1991). The practice of anogenital intercourse has been documented as the primary risk factor for the transmission of HIV in homosexual and bisexual men (Guinan & Hardy, 1987; Hahn et al., 1989; Schoenbaum et al., 1989). The United States is now seeing a change in the trend of AIDS diagnoses. There is no longer a rise in incidence of AIDS in homosexual and bisexual men but rather a zy zyxwvu zy DiScenza et al.: Counseling HIV Clients leveling. This is especially true in large cities such as New York, San Francisco, and Los Angeles. Heterosexual transmission of HIV has increased from less than 1% of all cases in 1983 to more than 6% by 1991 (Holmes, 1991). The most rapidly growing segments of the AIDS population are composed of blacks and Hispanics (American Public Health Association [APHA], 1996; Holmes, 1991; Kelly & Holman, 1992). There are several possible explanations for this trend. First, safe-sex campaigns have been more successful with white homosexual and bisexual men. This may be due to cultural biases that exist in the campaigns themselves or to the inability of other groups to avail themselves of the services offered. Second, blacks and Hispanics do not have equal access to health care because of financial constraints, they use fewer antiviral drugs, they have problems with transportation to acquire treatment, and they suffer a degree of discrimination in the white-dominated health care system. Third, blacks and Hispanics have a higher percentage of multiple risk factors. There is greater incidence of homosexual or bisexual men who share intravenous needles, who have other sexually transmitted diseases, and who engage in prostitution among blacks and Hispanics (Holmes, 1991). Chiasson et al. (1990) in their study of 1,201 volunteers in a sexually transmitted disease clinic in New York City found that seroprevalence is significantly higher among Hispanics (17%) and blacks (11%) than among whites (5%). Williams, D’Aquila, and Williams (1987) conducted a study to determine the seroprevalence of HIV infection among intravenous drug abusers seeking treatment in New Haven, Connecticut between May 1, 1986 and February 1, 1987. The age of the group ranged from 19 to 62 years. Seventy-three percent were men and 27% were women. Of the 180 volunteer clients, 74% were white, 22% were black, and 4% were Hispanic. All had used intravenous drugs at least once during the previous year. Williams et al. (1987) found that 24% tested positive for HIV. Race was the greatest predictor of seropositivity in this group. Of the 133 white participants, 12% were positive for HIV. Of the 39 blacks tested, 62% were positive for HIV, and of the eight Hispanics, 37% were positive for HIV. There was no difference between sexes for seroprevalence; those who were seropositive, however, tended to be older than those who were seronegative. The mean age for those who were seropositive was 33 years whereas the mean age for those who were seronegative was 30 years. A surprising finding was that 74% of those responding to a question about “sharing works” reported sharing works at least once in the past, while 26% denied ever sharing their drug equipment. 2 11 The HIV infection rates are increasing among women (Hobfoll et al., 1994; Kelly & Holman, 1993). Although most AIDS cases in women occur among injecting drug abusers, cases attributed to heterosexual contact have the highest rate of increase. Heterosexual transmission has been documented both from men to women and from women to men and occurs mainly through vaginal intercourse. Holmes et al. (1990) analyzed 88,510 adult AIDS cases diagnosed in the United States between January 1, 1983 and December 31, 1988 and found that the overall percentage of cases attributed to reported heterosexual contact is 20 times higher for woman than men. Effects of Counseling Strategies Because AIDS is a disease for which there is currently no known cure or treatment, it is essential that nursing professionals be prepared to counsel HIV-positive individuals as a tool in controlling the spread and effects of this disease. Literature supporting the effects of counseling on changing high-risk behaviors is inconsistent (Cates & Handsfield, 1988; Stall, Coates, & Hoff, 1988). In the federally funded Multicenter AIDS Cohort Study (MACS), Emmons, Joseph, Kessler, Montgomery, and Astrow (1986) used cross-sectional data from a large convenience sample of self-identified gay men in Pittsburgh, Chicago, Baltimore, and Los Angeles. They found that of the five psychosocial variables considered (knowledge, perceived risk of AIDS, perceived efficacy of behavior change, barriers to behavior change, and social network characteristics), counseling patients to increase their knowledge of AIDS risk was the most strongly associated with apparent reduction in risk behaviors. Joseph et al. (1987), using data from the same sample, replicated the Emmons et al. crosssectional study but found that a longitudinal analysis of the data indicated that knowledge of AIDS risk was not significantly related to any 1 of 6 measures of risk behaviors change over time. Ginzburg et al. (1986) surveyed more than 1,000 intravenous drug users (IVDUs) from 10 drug treatment programs in New Jersey. Eighty-nine percent correctly identified IVDU as a risk group, and 87% knew that the virus was spread by sharing needles. Eighty-one percent correctly identified that never sharing needles or syringes would lower the risk of AIDS. It is disturbing, however, that approximately one-third did not recognize the potential for transmission of HIV from the intravenous drug user to his or her heterosexual partner. Perhaps more worrisome is the finding that 43% failed to recognize that infants born to women who use intravenous drugs (or whose partners do) are at risk for AIDS. AIDS is a growing and alarming problem in the United States. Without individual counseling targeted to the specific needs of high-risk populations it is likely that zyxwvutsrq 212 Public Health Nursing Volume 13 Number 3 June 1996 AIDS awareness programs will continue to have little impact. While broad-scale awareness and education programs are certainly important, it is essential that counseling be individualized to the specific needs of the patient for any significant or long-term changes to be realized. METHOD Sample The convenience sample consisted of 20 adults (18 years old and older) who were newly diagnosed with HIV and being treated in an inner-city out-patient clinic in a large city. A volunteer convenience sample was used because of the limited availability of HIV-positive patients seen in the out-patient clinic and the poor rate of compliance with return appointments (approximately 50% no show). Patients were English speakers and had the ability to comprehend the questionnaires. zyxwvu to assess one’s level of knowledge regarding general information on sexual practices recommended by the Centers for Disease Control and Prevention and the Surgeon General. The selection of items for the instrument evolved from a literature review on safer-sex practices. The KSSBQ is composed of 23 items: 14 are safe-sex practices and 9 are not safer-sex practices. Respondents indicate that an item is either a “safe-sex practice” or “not a safer-sex practice.” Total scores are found by summing the correct responses. Content validity of the KSSBQ was assessed by three content experts who rated each item on its relevancy to the domain of knowledge of safer-sex behaviors. Procedure Data were collected during the HIV-positive patients’ scheduled clinic appointments. On the first clinic visit the study was explained thoroughly to newly diagnosed HIV-positive patients in a private room by the researcher. Questions were encouraged and confidentiality and anonymity were stressed by the researcher. Upon agreement to participate in the research study, a signed consent was obtained. The participant was then given the demographic sheet, the MKAQ, the KSSBQ, and the SSBQ to complete. The researcher offered the option of having the questions read verbally by the researcher. All but one participant chose to have the questions read verbally. No time limit was imposed for completing the questionnaire, but 30 min was the usual time needed. The patients then participated in the counseling intervention session conducted by 1 of 3 nurses employed by the clinic who counseled all new HIV-positive patients. The counseling included information on HIV transmission and high-risk behaviors. Each nurse followed the same format for the counseling intervention. Two-three months later, during the participant’s regular scheduled appointment, the MKAQ, KSSBQ, and the SSBQ were readministered to participants under the same conditions. These data were used to assess the patients’ acquired knowledge of HIV transmission, knowledge of high-risk behaviors, and behavior changes after the counseling intervention from the clinic nurse. zyxwvutsr zyxwvuts zyxwvut zyxwvutsr Instruments The Safe-Sex Behavior Questionnaire (SSBQ) (DiIorio, Parson, Lehr, Adame, & Carlone, 1992) is a 27-item, self-report questionnaire used to assess sexual behaviors. The instrument is a reliable and valid measure of safesex practices for empirical data collection. The purpose of the tool is to measure safe-sex behaviors in adolescents and adults. DiIorio et al. report Crombach’s alpha reliability of 3 2 . The tool is criterion-referenced using questions created from a pamphlet entitled “Understanding AIDS” developed by the Surgeon Generals Office (U.S. Department of Health and Human Services, 1986). The criteria were divided into four categories: 1) protection during intercourse; 2) avoidance of risky behaviors such as anal sex; 3) avoidance of the spread of bodily fluids; and 4) interpersonal skills to elicit history and to negotiate the use of safe-sex practices (DiIorio et al., 1992) Modified Knowledge of AIDS Questionnaire The modified DiClemente AIDS Knowledge Questionnaire (MKAQ) is a 34-item, self-report questionnaire that measures knowledge of, misconception about, and perceived susceptibility to AIDS (DiClemente, Boyer, & Morales, 1988). Reliabilities for the three subscales are: knowledge, consisting of 26 items (.72); misconceptions, containing 5 items (.75); and perceived susceptibility, containing 3 items (.55) (DiClemente et al., 1988). The instrument has been used in several studies that have evaluated the sexual behaviors in adolescents, young adults, and minorities. Knowledge of Safer-Sex Behavior Questionnaire The Knowledge of Safer-Sex Behavior Questionnaire (KSSBQ) developed by DiIorio et al. (1992) is designed RESULTS Sample Demographics The sample population consisted of 14 blacks (70%) and 6 whites (30%). There were 14 males (70%) and 6 females (30%) in the sample population. It is also interesting to note that 100% of the females in the study were black. Again, this is probably due to the demographics of the area in which the study was conducted. The subjects’ ranged in age from 22 to 45 years zyxwvutsrqp zyxw zyxwvutsrq zyx zyxwvuts zyxwvu zyxwvuts zyxwvuts DiScenza et al.: Counseling HIV Clients 213 with a mean of 34 years. Demographics indicated that TABLE 1. Repeated Measures ANOVA Summav Comparing the majority (80%)of subjects were single; lo%, however, Changes in High-Risk Behaviors Between Age Groups and Within were divorced, 5% were married, and 5% were separated. Age Groups to Between Gender Groups and Within Gender Fifty percent of the subjects had a junior high or high Groups According to the SSBP school education, and the other 50% had completed 1-4 Sources of Variation SS df MS F years of college. Subjects responded with a variety of answers concern- Age Between groups ing how they felt they had been infected with HIV. 53.325 2 26.6625 0.09 Age Several subjects listed several high-risk factors for modes Error 5241.950 17 308.350 Subtotal 5295.275 19 of transmission. The most common responses were: sex Within groups with a homosexual (38%), sex with a heterosexual (34%), Behavior change 1010.0250 1 1010.025 7.43* sharing needles (8%), prostitution (8%), sex with an Behavior change X age 215.2583 2 107.6291 0.79 HIV-positive drug user (8%), and does not know (4%). 2310.2166 17 135.895 Error Effect of Counseling on High-Risk Sexual Behaviors A repeated measure ANOVA was performed to determine differences between change in high-risk sexual behaviors after counseling according to the demographic variables of age, gender, race, and education using the SSBQ. Although statistical analysis indicates a significant main effect for change in high-risk behaviors 0, c .05), there were no significant relationships between change and the individual demographic variables of age, gender, race, and education. The comparison of age to change in high-risk behaviors yielded no significant relationship ( F = 0.09, p = .9176). Similarly, the comparison of males to females yielded no significant differences ( F = 1.12, p = .3034) (Table 1). No significant relationship was found between races ( F = .01,p = .9352). There was also no significant difference between education level and behavior change ( F = 2.38, p = .1081) (Table 2). Relationship Between Knowledge and High-Risk Behaviors To test the hypothesis that there would be no statistically significant relationship between knowledge and behavior scores a Pearsons Product Moment Correlation was performed. Knowledge was broken down into two areas: general knowledge about HIV using the MKAQ and knowledge about safe-sex practices using the KSSBQ. The pre- and posttest scores for each were compared with pre- and posttest high-risk-behavior scores (according to the SSBQ). Pearsons Product Moment Correlation yielded no positive significant relationship between pretest knowledge scores (general and safe sex) and pretest highrisk-behavior scores. In addition, no significant positive relationship was found between posttest knowledge scores (general and safe sex) and posttest high-risk-behavior scores (Table 3). Effect of Counseling on Knowledge A paired t test was performed to determine if there was a significant difference between pre- and posttest general Subtotal Total Gender Between groups Gender Error Subtotal Within groups Behavior change Behavior change gender Error Subtotal Total X 3535.4999 8830.7749 36 310.858 4984.417 5295.275 1 18 19 310.858 276.912 1.12 1010.025 24.344 1 1 1010.025 24.344 7.27* 0.18 2401.13 1 3535.50 8830.775 18 20 39 138.952 “n = 20. * p < .05. AIDS knowledge using the MKAQ. No significant difference was found in the pre- and posttest knowledge scores (t (19) = - 1.04, p > .05) (Table 4). A separate analysis was performed to see if there was a significant difference between pre- and posttest safe-sex knowledge using the KSSBQ. No significant difference was found between the scores (t (19) = 1.12, p > .05) An analysis of individual questions in the knowledge questionnaire revealed the most frequently missed questions on the pretest questionnaire were: AIDS is caused by the same virus that causes herpes (30%), lesbians are at high risk for getting AIDS (25%), people with AIDS usually have other diseases as a result of AIDS (20%), and you can get AIDS when you give blood (20%). Of interest, on the posttest knowledge questionnaire several scores decreased or stayed the same as indicated by the following responses: lesbians are at high risk for getting AIDS (25%), AIDS is caused by the same virus that causes herpes (30%), people with AIDS usually have other diseases as a result of AIDS (25%), and you can get AIDS when you give blood (20%). Using similar analysis for the KSSBQ the most fre- zyxwvutsrqp zyxwvutsrqpon zyxwvutsrqp 214 Public Health Nursing Volume 13 Number 3 June 1996 TABLE 2. Repeated Measures ANOVA Summary Comparing Changes in High-Risk Behaviors Between Race Groups and Within Race Groups to Between Education Levels and Within Education Levels According to the SSBQ" Sources of Variation Race Between groups Age Error Subtotal Within groups Behavior change Behavior change Error Subtotal Total SS quently missed questions on the pretest questionnaire included: using a diaphragm during sexual intercourse (55%), taking birth control pills (50%), urinating after sex (40%), and using a spermicide containing nonoxynol9 (40%). zyxwvutsrqp MS df F Effect of Counseling on High-Risk Behaviors zyxwvutsrqpo zyxwvutsrqpo 2.001 1 2.00119 0.01 5293.273 18 294.0707 5295.274 19 X 1010.025 160.344 2365.1309 3535.4999 8830.7739 race 1 1010.025 7.69* 1 160.3440 1.22 18 131.3961 20 39 Education Between groups Education 1632.6845 3 544.228 Error 3662.5904 16 Within groups Behavior change 1010.025 Behavior change X education 156.846 Error 2368.6285 2.38 6.82* an = 20. * p < .05. A paired t test was used to determine if a significant difference existed between precounseling high-risk behaviors and postcounseling high-risk behaviors using the SSBQ. The results indicate that the posttest scores were significantly higher than the pretest high-risk-behavior scores (t (19) = 2.76, p < .05) (Table 5 ) . Based on the data analysis the researcher rejects the null hypothesis that there is no significant difference between pre- and posttest behaviors. Although a significant change in high-risk behaviors was found, this indicates changes in frequency of behavior rather than cessation of high-risk behaviors altogether. It is important to note that many subjects continued to practice high-risk behaviors, particularly ones that allowed direct exposure to the HIV virus. Specific highrisk behaviors include: oral sex without a protective barrier, sexual intercourse without a condom, and anal intercourse without a condom. DISCUSSION TABLE 3. Pearsons Product Moment Correlation Summary Correlating Precounseling Knowledge (MKAQ and KSSBQ) with Precounseling High-Risk Behaviors (SSBQ) and Correlating Postcounseling Knowledge (MKAQ and KSSBQj with Postcounseling High-Risk Behaviors (SSBQ)" Precounseling scores Knowledge (MKAQ) Safe-sex knowledge (KSSBQ) Postcounseling scores Knowledge (MKAQ) Safe-sex knowledge (KSSBQ) an = 20. High-Risk Behavior (SSBQ) p - .033 ,135 .89 .57 .I42 ,184 .55 .44 The results of this study suggest that a counseling intervention might be a useful tool in changing the highrisk sexual practices of persons with HIV. Results indicate that counseling might be more effective in producing changes in behavior than it is in producing change in knowledge. The results suggest that it is possible that persons with HIV already have substantial knowledge regarding safe-sex practices and that knowledge has little impact on the practices themselves. Therefore, it is imperative that counseling be directed toward changes in behavior rather than providing patients with information alone. Although results indicate a statistically significant change in the frequency of high-risk sexual behaviors, there was no significant difference that could be attributed zyxwvutsr zyxwvuts TABLE 4. t-Test Comparison Summary of Precounseling Knowledge as Indicated by the MKAQ and KSSBQ to Postcounseling Knowledge as Indicated by the MKAQ and KSSBP TABLE 5. t Test Comparison Summary of Precounseling HighRisk Behaviors as Indicated by the SSBQ to Postcounseling HighRisk Behaviors as Indicated by the SSBQ" Variable df Mean Difference SE t P Sexual behaviors (SSBQ) 19 10.05 3.646 2.76* ,012 Mean Variable df Difference SE General knowledge (MKAQ) Safe-sex knowledge (KSSBQ) 19 ,531 ,358 =n = 20. 19 -0.55 .055 1 p - 1.04 ,313 1.42 ,171 an = 20. * p < .05. DiScenza et al.: Counseling HIV Clients 215 to age, race, gender, or education. It might be that although there was diversity in age, race, gender, and education level, the critical factor affecting counseling outcomes was the presence of HIV. The common diagnosis of HIV may have been of such significance that it neutralized any differences that may have occurred due to demographic variables. Therefore it may be inferred that counseling should focus on the immediate problem of HIV and the universal problems associated with it rather than on the needs of any particular subgroup. Caution should be used in interpreting these results as the age was limited to the 22-45-year span, thereby omitting adolescents, which is one of the fastest growing populations to be affected by HIV (APHA, 1996). In addition, it may be that the impact of the diagnosis itself or that news media reports, rather than the intervention, decreased the frequency of high-risk sexual behaviors. A study of a larger, randomly selected racially diverse population using a control group may yield different results. In general these results provide impetus for further research regarding the relationships among nursing, counseling interventions, patient knowledge, and high-risk behaviors. The findings suggest an important link between counseling and change in high-risk sexual behaviors. Although there are limitations to the generalizability of the study, certain conclusions can be drawn. These are that knowledge, behaviors, and the effects of counseling can be empirically determined and that there is the possibility of a strong relationship between counseling outcomes and high-risk behaviors. The results of this study have several implications for nursing practice. Because of the relationship between counseling and posttest high-risk sexual behaviors, it is important that nurses direct their counseling efforts toward change in behaviors. This may be more easily done by determining through a questionnaire such as the SSBQ which high-risk sexual behaviors patients are involved. This information equips nurses to determine a baseline and overview of their patients from which to develop education and counseling efforts specific to individual needs. In addition this study suggests that the focus of patient education and counseling, as well as public education, may need to shift from emphasizing knowledge about AIDS to direct and specific information about high-risk behavior. Furthermore it might be concluded that nurses need to provide patients with alternatives (emotional or physical) for changing these high-risk sexual behaviors. In addition it appears that knowledge is not the primary catalyst for change but that other motivating factors are involved. It would appear that in providing successful counseling intervention it is important that the nurse determine what those motivating factors are and how they may be used to promote change. It is not sufficient to provide a “lecture” on general information about AIDS. If nurses want to bring about change, they must target both high-risk sexual behaviors and the patient’s own motivation and efficacy for change. A discouraging implication of the study is that although a significant change occurred in high-risk sexual practices, 50% of the patients continued to engage in some kind of direct contact with semen or vaginal secretions. Therefore, it is imperative that nurses provide aggressive counseling that is directed toward changing specific highrisk behaviors. zyxwv zyxw zyxwv REFERENCES American Public Health Association. (1996). AIDS education campaign aimed at nation’s youth. The Nation’s Health, 24. Cates, W., & Handsfield, H. H. (1988). HIV counseling and testing: Does it work? 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