ASSESSMENT OF SUBSTANCE ABUSE: HIV RISK ASSESSMENT BATTERY (RAB)

The Risk Assessment Battery (RAB) is a self-administered questionnaire designed for use with substance-using populations. It was developed to provide a rapid (less than 15 minutes) and confidential, non interview method of assessing both needle use practices and sexual activity associated with HIV transmission.

The forty-five questions of the RAB are simply worded and use discrete response categories. Respondents are asked to "check off" the answer that best describes their behavior. There are no open-ended questions, minimizing the need for writing skills. A brief set of instructions is included on the first page of the RAB. However, as with all self-administered questionnaires, it is particularly important to provide the respondent with a proper introduction and explanation of the form, its purpose, and how it is to be completed. A staff member should be available during administration of the test to screen for reading difficulties, answer questions as they arise, and ensure that the form is being filled out properly. Given the very sensitive nature of the information collected, it is also important that individuals administering the RAB address the issue of confidentiality. Although the more private approach of the self-administered questionnaire should reinforce the confidential nature of the assessment, it is very important that respondents understand the confidentiality of their responses will be protected.

There are two global sections within the RAB: 1) drug and alcohol use during the past 30 days, and 2) needle use and sexual behavior during the previous 6 months. Questions have been constructed to provide maximum coverage and sensitivity to potential risk behaviors within these categories. Since self-reports may be expected to provide underestimates of behaviors that are socially unaccepted, items have been assembled that assess a wider range of behaviors associated with HIV infection. Thus, questions ask not only about the behaviors directly responsible for viral transmission such as needle sharing and unprotected sexual activity, but also those associated with such activities (e.g., needle acquisition, shooting gallery attendance, exchange of money or drugs for sex). The inclusion of these items is intended to identify individuals at increased risk of HIV exposure even if transmission behaviors are not directly reported. However, endorsement of these "peripheral behaviors" does not prove that transmission behaviors have actually occurred. For example, an individual who indicates that he or she has visited a shooting gallery on numerous occasions during the assessment interval may not have shared a needle or had unprotected sex even though these behaviors are common in shooting galleries. Instead, these peripheral behaviors may be more readily reported by some respondents despite their reluctance to report primary transmission events such as sharing a syringe or unprotected sexual activity.

Scoring.

Sixteen items from the RAB are used in the computation of three scores: a drug-risk score, a sex risk score, and a total score. These scores are calculated by adding responses to selected items. For individual questions, the values range from zero to a maximum of 4. Higher values for items reflect greater frequency of occurrence for the behavior. The eight-item drug-risk score has a range of 0 to 22. The range of the sex-risk score, comprised of nine items, is 0 to 18. This simple scoring system was designed to capture frequency of engaging in each of the reported risk behaviors. Scores for the various items are not differentially weighted. This scoring strategy serves to guard against underestimates of risk resulting from the tendency to under report participation in behaviors known to be most likely to transmit the AIDS virus.

As a self-administered questionnaire, the RAB offers an efficient tool for screening individuals who may be at risk for HIV infection. The RAB provides a measure of HIV-risk behaviors, which is broken down into subscales for drug risk and sex risk and combined to yield a measure of total risk. A number of studies conducted by the authors and others suggest that when properly administered, the RAB responses are equivalent to those collected via a personal interview. Test-retest reliability has also been found to be relatively high. Most importantly, the RAB has demonstrated discriminant validity in differentiating between respondents engaging in different drug-use patterns and predictive validity in identifying seroconverters on the basis of higher-risk scores.

As the AIDS epidemic enters its third decade, it has become increasingly important to have valid, reliable, and cost-effective tools to monitor behaviors associated with the transmission of HIV. It is no longer sufficient to direct prevention resources toward populations at risk in a "shotgun" approach to risk reduction. Such a strategy is costly and inefficient since many individuals within risk groups have instituted safer behaviors. Targeting risk-reduction interventions to specific segments of the population at risk and evaluating their efficacy are necessary components in a well-planned approach to HIV prevention. Measures of risk behavior, such as the RAB, are needed to target and evaluate interventions in a more precise manner.

BIBLIOGRAPHY

Metzger D., De Philippis, D., Druley, P., O' Brien, C., Mc Lellan, A. T., Williams, J., Navaline, H., and Dyanick, S., Woody, G. (1992). The impact of HIV testing on risk for AIDS behaviors. In L. Harris (Eds.), problems of drug dependence : nida research monograph 119, Washington, D.C.: National Institute on Drug Abuse. 297-298.

Metzger, D., Woody, G., Mc Lellan, A., O' Brien, C., Druley, P., Navaline, H., De Philippis, D., Stolley, P., and Abrutyn, E. (1993). Human immunodeficiency virus seroconversion among in- and out-of-treatment intravenous drug users: An 18-month prospective follow-up. Journal of Acquired Immune Deficiency Syndromes, 6, 1049-1056.

David S. Metzger

Helen A. Navaline

George E. Woody