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HIV vaccine acceptability among high-risk drug users in Appalachia: a cross-sectional study



A vaccine could substantially impact the HIV epidemic, but inadequate uptake is a serious concern. Unfortunately, people who use drugs, particularly those residing in rural communities, have been underrepresented in previous research on HIV vaccine acceptability. This study examined HIV vaccine acceptability among high-risk drug users in a rural community in the United States.


Interviewer-administered questionnaires included questions about risk behavior and attitudes toward HIV vaccination from 433 HIV-negative drug users (76% with history of injection) enrolled in a cohort study in Central Appalachia. HIV vaccine acceptability was measured on a 4-point Likert scale. Generalized linear mixed models were used to determine correlates to self-report of being “very likely” to receive a 90% effective HIV vaccine (i.e. “maximum vaccine acceptability”, or MVA). Adjusted odds ratios (AORs) and corresponding 95% confidence intervals (CIs) are reported.


Most (91%) reported that they would accept a preventive HIV vaccine, but concerns about cost, dosing, transportation constraints, vaccine-induced seropositivity, and confidentiality were expressed. Cash incentives, oral-administration, and peer/partner encouragement were anticipated facilitators of uptake. In multivariate analysis, men were significantly less likely to report MVA (AOR: 0.33, CI: 0.21 – 0.52). MVA was more common among participants who believed that they were susceptible to HIV (AOR: 2.31, CI: 1.28 – 4.07), that an HIV vaccine would benefit them (AOR: 2.80, CI: 1.70 – 4.64), and who had positive experiential attitudes toward HIV vaccination (AOR: 1.85, CI: 1.08 – 3.17). MVA was also more common among participants who believed that others would encourage them to get vaccinated and anticipated that their behavior would be influenced by others' encouragement (AOR: 1.81, 95% 1.09 – 3.01).


To our knowledge, this study was among the first to explore and provide evidence for feasibility of HIV vaccination in a rural, high-risk population in the United States. This study provides preliminary evidence that gender-specific targeting in vaccine promotion may be necessary to promoting vaccine uptake in this setting, particularly among men. The data also underscore the importance of addressing perceived risks and benefits, social norms, and logistical constraints in efforts to achieve widespread vaccine coverage in this high-risk population.

Peer Review reports


Since 1987, the scientific community has been in pursuit of an effective HIV vaccine [1]. In response to the possibility that an HIV vaccine is on the horizon, researchers have mobilized to examine the feasibility of disseminating the vaccine. In high-risk populations around the world, numerous studies on HIV vaccine acceptability have been conducted, but people who use drugs have been underrepresented. Recent research investigating attitudes toward compulsory HIV vaccination among high-risk individuals in Los Angeles found that that people who inject drugs (PWID) were significantly less likely to endorse universal vaccination or vaccination of all children or adults compared to their non-injecting counterparts [2]. The authors point out that the strong opposition to compulsory vaccination policies among PWID may be indicate future challenges in HIV vaccine acceptance and dissemination [2], thus reinforcing the need for additional research. Of the 15 quantitative studies from the US included in a recent review [3], only three included drug users [46]; none of which reported results stratified by drug use. Qualitative studies on HIV vaccine acceptability are equally limited, as nearly all of those involving people who use drugs have been conducted in one setting (i.e. Los Angeles) [611]. There are no studies to date evaluating HIV vaccine acceptability in a high-risk, rural drug-using population in the US. National surveillance data indicate that while the prevalence of AIDS has gradually declined in most urban areas since the mid 1980's, the number of cases continues to slowly increase in many rural communities, particularly in the South [12, 13]. Given the historically low prevalence of HIV in rural areas and the common misconception that HIV is an “urban problem”, many rural communities are unequipped to deal with the social, economic, and healthcare burden posed by an increase in HIV.

Central Appalachia, which encompasses some of the most economically distressed counties in the US [14], would face many of the challenges posed by an increase in HIV and AIDS. The Appalachian region is characterized by marked health disparities [15], an under-resourced health infrastructure [15], and prevalent misuse of prescription drugs [1618]. While HIV prevalence is currently low in this population [19], recent evidence from Eastern Kentucky, in Central Appalachia, suggested that many nonmedical prescription drug users were infected with hepatitis C [20], had engaged in injection drug use (IDU) [21] and frequent unprotected sex [22], and were embedded in a highly cohesive and centralized risk network that could facilitate HIV transmission [23]. Given these risk factors, stigma surrounding HIV [24], and myriad cultural and socioeconomic complexities, Central Appalachia is a setting in which greater knowledge of potential barriers and facilitators to HIV vaccine acceptability will be essential in achieving adequate coverage. The purpose of this study was to examine demographic, behavioral, and psychosocial correlates to HIV vaccine acceptability among a sample of HIV negative, high-risk drug users in Central Appalachia.



The data used for this analysis were collected during the 24-month assessment of the longitudinal Social Networks among Appalachian People (SNAP) study. Recruitment and assessment are described in detail elsewhere [20, 23, 25]. To be eligible, participants were required to be age 18 or older, reside in Appalachian Kentucky, and to have used prescription opioids, heroin, crack/cocaine, or methamphetamine to get high in the prior 30 days. Participants (n = 503) were recruited from rural Appalachian Kentucky using respondent-driven sampling and data were collected using questionnaires administered by trained community-based staff. Participants completed follow-up interviews and HIV testing at 6-month intervals. The 24-month interview was completed by 435 participants between March 2012 and May 2013.


Following their 24-month interview, participants (n = 433) were invited to complete an interviewer-administered questionnaire on their attitudes toward HIV vaccination (two who were interviewed in jail were not invited due to time-constraints). All invited participants consented and were compensated $35 for participation. Before the questionnaire, interviewers read a script reminding them that HIV can be transmitted through sharing drug equipment and having unprotected sex, that HIV is the cause of AIDS, and that there is currently no cure. The script informed participants that the vaccine referred to throughout the questionnaire would not cure HIV, but would prevent acquisition. A 90% efficacy level was specified for the questions presented in these analyses. The University of Kentucky's Institutional Review Board approved the protocol.

HIV vaccine acceptability

HIV vaccine acceptability was assessed with: “Imagine that an affordable HIV vaccine was approved and made available to you in the next 12 months. This vaccine would prevent you from getting HIV almost all of the time (90% effective). How likely would you be to get this vaccine?” followed by a 4-point Likert scale ranging from ‘very unlikely’ to ‘very likely’. Due to skewness, the responses were dichotomized for analysis (0 = Very unlikely/Unlikely/Likely; 1 = Very likely). Given the debatable association between these intentions and actual behavior [26], this conservative dichotomization may provide a better indication of future uptake. Hereafter, those who were 'very likely' to accept the vaccine are referred to as reporting “maximum vaccine acceptability” (MVA).

Vaccine characteristics

Participants were also asked about vaccine characteristics identified in previous research as factors relevant to acceptability [3, 5, 6, 27, 28]. Items assessed willingness to pay (continuous), minimum acceptable vaccine efficacy (ordinal in increments of 10%), and whether cash incentives, dosing (multiple vs. single), administration (oral vs. injected), and/or vaccine-induced positive results on future HIV tests would affect vaccine acceptability.

Demographic, behavioral, and psychosocial measures

Basic demographic and behavioral data were also collected (listed in Table 1). The psychosocial measures were based on a modified version [29] of the Integrative Model (IM) [30], which posits that behavior is directly affected by intention. Intention is influenced by attitudes, perceived norms, and personal agency, which are in turn influenced by background factors (e.g., demographic, behavioral, and other contextual characteristics). Table 2 describes the items and coding scheme used to assess the following: attitudes (instrumental and experiential), subjective norms (descriptive and injunctive), and personal agency (perceived behavioral control and self-efficacy). Due to skew in the response distribution of the four-point Likert-scale and semantic differential scale measures, items were dichotomized at the mid-point of the ‘forced choice’ style response options such that a value of 1 indicated a positive response and a value of 0 indicated a negative response. Experiential and instrumental attitudes refers to emotional and cognitive responses, respectively, to performing a behavior [31]. Experiential attitudes were examined with semantic differential scale items used in a similar study [32]. The instrumental attitude measures were adapted from the Health Belief Model [33]; these include perceived severity of and susceptibility to HIV, and perceived benefits of and barriers to HIV vaccination.

Table 1 Demographic and behavioral characteristics of the sample (n = 433)
Table 2 Psychosocial attitudes about HIV vaccination in sample of rural drug users

Injunctive norms are a person's beliefs about and motivation to comply with what others think he/she should do. Descriptive norms refer to a person's perceptions about others' behavior and his/her motivation to comply with (i.e. imitate) their actions [34, 35]. Descriptive and injunctive norms are each comprised of two sub-constructs: normative beliefs and motivation to comply. Self-efficacy and perceived behavioral control were also examined. Self-efficacy is the belief in one's general capabilities to exercise control over his/her behavior [36], while perceived behavioral control focuses on one's abilities to perform a behavior in light of various barriers [37].

Statistical analyses

Given potential autocorrelation among responses, generalized linear mixed models were used. Models were estimated using the PROC GLIMMIX [38] procedure (SAS software, version 9.3) with a random effect for subject and Laplace approximation [39]. To adjust for potential biases presented by respondent-driven sampling [40, 41], individualized weights computed in RDSAT 7.1 (Ithaca, NY) [42] were used in all analyses. The weights were based on individual network size and partition analysis on the dependent variable using enhanced data smoothing and 25,000 bootstrap iterations. Odds ratios (ORs), adjusted odds ratios (AORs), and 95% confidence intervals (CIs) were reported. Each demographic and behavioral variable was assessed independently for its association with the outcome, and those reaching significance (p < 0.05) were entered into multivariate analyses. Due to the a priori nature of the IM, all psychosocial variables were entered into multivariate analyses regardless of bivariate significance, as suggested in previous research [43].


Descriptive demographic and behavioral data are presented in Table 1. Briefly, the median age was 34 years (range: 21–68), 55% were male, and most respondents were White (94%); the latter is reflective of the demographic profile of Central Appalachia [44]. Most (76%) reported a lifetime history of IDU and 34% reported recent IDU (past 6 months). Receptive and distributive needle sharing were uncommon, but 13% had shared other injection paraphernalia. Approximately 24% reported multiple sex partners in the past 6 months and 71% had unprotected sex, including 20% who had done so with PWID.

Attitudes toward HIV and HIV vaccination

Most reported that they would be very likely (59%) or likely (32%) to receive an HIV vaccine. Psychosocial attitudes are shown in Table 2 and anticipated barriers, stratified by gender, are displayed in Figure 1. Of note, men were significantly more likely to report cost, requirement for multiple doses, and time as barriers to vaccine acceptability; women were more likely to report that there were no barriers to vaccine acceptability. Overall, 76% were unsure or only somewhat sure that they could get vaccinated if they had to pay out-of-pocket, travel out of town to get it (58%), or if their friends/partner were unsupportive (39%). Most (83%) reported that most people they knew would accept the vaccine, but only 51% would be more likely to accept the vaccine if most people did so. Similarly, 94% believed that most people would be supportive of their vaccination and 60% would be more likely to be vaccinated if most people encouraged them.

Figure 1
figure 1

Anticipated barriers to HIV vaccine acceptability among men and women (n = 433). An asterisk (*) indicates a statistically significant difference (p < 0.05) between men and women based on chi-square analysis.

Table 3 describes attitudes toward specific vaccine characteristics. Most reported that requirement for multiple doses would not influence vaccine acceptability; however, 44% reported that they would be more likely to accept an orally-administered vaccine. Most (62%) reported that they would be more likely to get vaccinated if there was a cash incentive to do so; the median incentive amount necessary to motivate vaccination was $50. The majority (56%) reported that the vaccine would need to be 90% effective before they would agree to be vaccinated and 18% reported that the vaccine would need to provide complete protection. Nearly all (93%) were willing to pay for a 90% effective vaccine; the median price participants were willing to pay was $100.

Table 3 Characteristics of HIV vaccination that could facilitate or hinder vaccine acceptability

Bivariate and multivariate results

Bivariate results are presented in Table 4. Men and older participants were significantly less likely to report MVA. Injection drug use, use of an unclean needle, and unprotected sex with PWID in the past 6 months was positively associated with MVA. Perceived susceptibility to HIV, perceived benefit of the vaccine, positive experiential attitudes, and perceived behavioral control were also positively associated with MVA. Respondents reporting that people important to them would accept an HIV vaccine and that they would be more likely to accept the vaccine if others did so were more likely to report MVA. Similarly, those who believed that people would encourage them to receive the vaccine and who reported being more likely to accept the vaccine if others encouraged them were nearly twice as likely to report MVA.

Table 4 Bivariate correlates to vaccine acceptability (n = 433)

Multivariate results are described in Table 5. Controlling for other variables in the model, men were less likely to report MVA (AOR: 0.33, CI: 0.21 - 0.52). Participants who believed they were susceptible to HIV (AOR: 2.31, CI: 1.28 - 4.17), perceived that the vaccine would benefit them (AOR: 2.80, CI: 1.70 - 4.64), and reported positive experiential attitudes (AOR: 1.85, CI: 1.09 - 3.01) were significantly more likely to report MVA. Injunctive norms were also positively associated with vaccine acceptability (AOR: 1.81, CI: 1.09 – 3.01).

Table 5 Multivariate correlates to being “very likely” to receive an HIV vaccine (n = 432) a


In this sample of rural drug users, 91% were likely or very likely to accept a 90% effective, preventive HIV vaccine. This percentage is comparable to that found in other urban and suburban populations in the US [4547]. Men were significantly less likely to indicate that they were very likely to receive an HIV vaccine, after adjustment for behavioral characteristics and psychosocial constructs. Previous research on the association between gender and HIV vaccine acceptability is mixed, with one study finding that acceptability was higher among women [27] and another finding that it was higher among men [48]. Research conducted among high-risk adults in Los Angeles identified gender differences in concerns and motivations surrounding HIV vaccination (e.g., women were more likely to be influenced by factors related to their intimate relationships and experiences with healthcare providers, while men were more influenced by peer perceptions and risk of vaccine-induced seropositivity), but no significant association between gender and vaccine acceptability [49]. In the present study, differences in vaccination concerns, specifically those related to perceived barriers, may play an important role in the observed gender difference in vaccine acceptability. Men were significantly more likely to report that cost, requirement for multiple doses (vs. a single dose), and time to visit the clinic would be barriers to vaccine acceptability. Post-hoc analysis to investigate these patterns revealed no significant gender differences in unemployment or total monthly income; however, men reported significantly more monthly income from employment and women reported significantly more income from partners, peers, family, and child support. Men were also more likely to report being uninsured. Interestingly, there was no gender difference in the amount participants were willing to pay for the vaccine. These patterns may indicate that while men and women have similar total gross incomes and willingness to pay, men have less net income to use for purchasing an HIV vaccine and the insurance coverage to reduce out-of-pocket costs.

Findings regarding the association between gender and barriers posed by dosing and time constraints would seem to indicate that men anticipate experiencing other logistical obstacles to accessing vaccination. Unavailability of time to visit the clinic for one or multiple doses may be related to a number of factors, including employment. Post-hoc analyses revealed no association between gender and past 6-month unemployment or full-time employment, but men were more likely to report part-time, irregular day work. The location, hours, and nature of this work is largely unknown, as are details about additional obligations that could compete with time available to seek vaccination. Although gender differences in psychosocial constructs aside from perceived barriers (e.g., perceived susceptibility to HIV, perceived severity of HIV) were not observed, it is important to note that perceived and/or actual barriers to vaccination are likely only part of the confluence of factors that could contribute to gender differences in HIV vaccine acceptability in this and other settings. In this setting, a “one-size-fits-all” [50] approach to mitigating barriers to HIV vaccination may not be appropriate. Strategies that consider possible gender differences in constraints on HIV vaccine acceptance and, in turn, “meet men and women where they are” psychologically, socially, and geographically should be developed. These approaches may include strategic location of vaccine dissemination sites (e.g., at worksites, clinics, mobile units), varied hours of availability, and payment structures that limit out-of-pocket costs to those with and without insurance.

Given their low income and high rate of unemployment, it is unsurprising that most participants reported that cost would be a barrier to vaccine acceptability. Cost has been identified as an important influence in HIV vaccine acceptability in many [3, 27, 28], but not all [5, 51] previous studies. Interestingly, participants in one study believed that the vaccine should be given at some cost, as free services were often perceived as inferior to those that were purchased [52]. Nearly all participants in the present study were willing to pay for a 90% effective HIV vaccine, but only one-third would be able to afford out-of-pocket costs exceeding $100. Though some research has suggested that cost may not be as strongly associated with acceptability as are other vaccine characteristics [5], in this setting, minimization of out-of-pocket costs would be critical to achieving adequate coverage.

The majority (60%) reported that a modest cash incentive (less than $50) would improve their likelihood of accepting the vaccine. Previous research among PWID demonstrated that monetary incentives can improve compliance with a three-dose hepatitis B vaccine regimen [47]; the cost-effectiveness of a similar approach to HIV vaccination should be considered. Monetary incentives may assist in offsetting logistical costs, such as transportation, which was reported as a barrier to acceptability by a sizable minority of participants. This finding underscores, as has previous research [3], the importance of minimizing logistical constraints on accessing vaccination. However, this must be coupled with interventions which address concerns regarding confidentiality; nearly one in eight were concerned that providers would disclose their vaccination status to others. Participants in several previous studies have reported concern about peers’ negative social reactions to HIV vaccination [7, 49, 5255], though less is known about participants’ confidentiality concerns related to healthcare providers administering the vaccine. Participants in a qualitative study in Los Angeles reported concern about being seen at vaccine dissemination sites [7] and one study in Thailand found that PWID were concerned about being seen at vaccine dissemination locations due to fear of legal consequences (e.g., arrest) [55]. In this and other settings, appropriate selection of vaccine dissemination sites as well as intensive training of providers about confidentiality will be critical to ensuring adequate vaccine coverage among high-risk populations.

Findings regarding the importance of perceived social norms may also inform appropriate and effective strategies for HIV vaccine promotion. Descriptive data revealed that nearly 40% were not sure or only somewhat sure that they would be able to get the HIV vaccine if a friend/partner was unsupportive. Several previous studies have indicated that peer support and positive social norms will be important for facilitating vaccine acceptability. Participants in previous studies have reported fear of negative reactions by family members [7, 49] and intimate partners [7, 9, 49, 56] and concern that others will perceive their vaccination as an indication of ‘promiscuous’ behavior [9, 52, 55]. In the present study, participants who believed that most people would encourage them to receive an HIV vaccine and who reported they would be motivated to comply with those recommendations were significantly more likely to report MVA. Interestingly, additional research in this sample has indicated that the overwhelming majority of respondents (94%) would be willing to encourage someone to get vaccinated, particularly in circumstances in which the partner was perceived to be at risk or pose a risk for HIV [57]. This finding may serve as preliminary evidence that peer-promotion of HIV vaccination could be a successful strategy for reaching those most at risk for HIV in this population. In this context, the lack of a multivariate association between descriptive norms and vaccine acceptability deserves comment. These data suggest that passive diffusion of vaccine uptake through the social network (i.e. via imitation of others’ behavior) is unlikely, and underscore the importance of an active approach to peer-based promotion.

The findings from this study have several theoretical and methodological implications. This study demonstrates the importance of assessing both the injunctive and descriptive dimensions of social norms and of coupling measures of normative beliefs with assessments of individuals' motivation to comply. Most participants reported that other people would accept an HIV vaccine, but far fewer reported that they would be influenced by others' behavior. Although individuals may underestimate their susceptibility to peer influence, data on compliance with norms may provide preliminary insight into who may be most responsive to strategies such as social marketing.

The research focused on intent to receive an HIV vaccine and, until an HIV vaccine is approved, the correspondence between intentions and actual vaccine uptake remains unknown. Furthermore, there are limitations of querying respondents about the specific characteristics of a hypothetical vaccine; research employing conjoint analysis [5, 6, 49, 51, 58, 59] and discrete choice experiments [60] may yield better insight into relative valuations of various vaccine characteristics, project their impact on future acceptability, and inform targeted social marketing campaigns. Though the survey included assessment of several relevant vaccine-related characteristics (e.g., route of administration, dosing, vaccine-induced seropositivity) and included an open-ended item that allowed free-listing of additional barriers to vaccination, the survey did not include direct measures of two vaccine characteristics determined in previous research to be important to acceptability: duration of protection and side effects. Also, while one item measures of theoretical constructs can be problematic to establishing psychometric validity and reliability, the use of scales was not feasible given respondent burden and time constraints for conducting interviews. Similarly, time constraints limited our ability to assess psychosocial correlates to vaccine acceptability by varying levels of vaccine efficacy. The efficacy of future HIV vaccines is currently unknown; however, it is important to specify an efficacy level in measures of vaccine acceptability in order to standardize the context of participants' responses. In the current study, a 90% efficacy level was chosen as it presented a near ‘best case scenario’ for evaluating acceptability given that the ‘most realistic scenario’ is difficult to determine at this stage of vaccine development and subject to change. Nevertheless, more research is needed to explore the generalizability of the findings to vaccines of lower efficacy. Similarly, generalization of findings from this study to other regions of Appalachia and other rural areas in the US also should be made with caution, as sociocultural influences across settings are likely to vary.


In this rural community, despite low perceived vulnerability to HIV, most drug users were readily willing to accept an HIV vaccine. Minimization of out-of-pocket costs will be essential. Social norms could play a major role in influencing HIV vaccine uptake in this community, and leveraged appropriately, could present an effective mechanism for promoting the vaccine. To plan for effective promotion and dissemination strategies among populations at high risk for HIV, continued research is needed to explore influences on HIV vaccine acceptability among people who use drugs.


  1. Girard M, Osmanov S, Assossou O, Kieny M: Human immunodeficiency virus (HIV) immunopathogenesis and vaccine development: a review. Vaccine. 2011, 29: 6191-6218. 10.1016/j.vaccine.2011.06.085.

    CAS  Article  PubMed  Google Scholar 

  2. Newman P, Lee S-J, Rudy E, Diamant A, Duan N, Nakazano T, Cunningham W: Endorsement of Compulsory HIV Vaccination Policy Among Populations at High Risk of HIV Exposure (LA VOICES). Prev Sci. 2014, 15 (3): 428-435. 10.1007/s11121-014-0463-5.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Newman P, Logie C: HIV vaccine acceptability: a systematic review and meta-analysis. AIDS. 2010, 24 (11): 1749-1756. 10.1097/QAD.0b013e32833adbe8.

    Article  PubMed  Google Scholar 

  4. Crosby R, Holtgrave DR, Bryant L, Frew PM: Correlates of negative intent to receive an AIDS vaccine: an exploratory study. Int J STD AIDS. 2004, 15 (8): 552-557. 10.1258/0956462041558177.

    Article  PubMed  Google Scholar 

  5. Newman P, Duan N, Lee S-J, Rudy ET, Seiden DS, Kakinami L, Cunningham WE: HIV vaccine acceptability among communities at risk: the impact of vaccine characteristics. Vaccine. 2006, 24 (12): 2094-2101. 10.1016/j.vaccine.2005.11.013.

    Article  PubMed  Google Scholar 

  6. Newman P, Lee SJ, Duan N, Rudy E, Nakazono TK, Boscardin J, Kakinami L, Shoptaw S, Diamant A, Cunningham WE: Preventive HIV vaccine acceptability and behavioral risk compensation among a random sample of high-risk adults in Los Angeles (LA VOICES). Health Serv Res. 2009, 44 (6): 2167-2179. 10.1111/j.1475-6773.2009.01039.x.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Newman P, Duan N, Rudy ET, Roberts KJ, Swendeman D: Posttrial HIV vaccine adoption: concerns, motivators, and intentions among persons at risk for HIV. J Acquir Immune Defic Syndr. 2004, 37 (3): 1393-1403. 10.1097/

    Article  PubMed  Google Scholar 

  8. Newman P, Seiden DS, Roberts KJ, Kakinami L, Duan N: A small dose of HIV? HIV vaccine mental models and risk communication. Health Educ Behav. 2009, 36 (2): 321-333.

    Article  PubMed  Google Scholar 

  9. Rudy ET, Newman P, Duan N, Kelly EM, Roberts KJ, Seiden DS: HIV vaccine acceptability among women at risk: perceived barriers and facilitators to future HIV vaccine uptake. AIDS Educ Prev. 2005, 17 (3): 253-267. 10.1521/aeap.

    Article  PubMed  Google Scholar 

  10. Roberts KJ, Newman P, Duan N, Rudy ET: HIV vaccine knowledge and beliefs among communities at elevated risk: conspiracies, questions and confusion. J Natl Med Assoc. 2005, 97 (12): 1662-1671.

    PubMed  PubMed Central  Google Scholar 

  11. Newman P, Duan N, Kakinami L, Roberts K: What can HIV vaccine trials teach us about future HIV vaccine dissemination?. Vaccine. 2008, 26 (20): 2528-2536. 10.1016/j.vaccine.2008.03.004.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Centers for Disease Control and Prevention: Cases of HIV infection and AIDS in urban and rural areas of the United States, 2006. HIV/AIDS surveillance supplemental report. 2008, 13 (2): 1-25.

    Google Scholar 

  13. HIV surveillance in urban and nonurban areas (through 2011).,

  14. Economic overview of Appalachia 2011.,

  15. Halverson J: An analysis of disparities in health status and access to health care in the Appalachian Region. Office of Social Environment and Health Research (OSEAHR)/Prevention Research Center. 2004

    Google Scholar 

  16. An analysis of mental health and substance abuse disparities and access to treatment services in the Appalachian region.,

  17. Cicero TJ, Inciardi JA, Munoz A: Trends in abuse of OxyContin® and other analgesics in the United States: 2002–2004. J Pain. 2005, 6 (10): 11-

    Article  Google Scholar 

  18. Havens J, Oser CB, Leukefeld C, Webster JM, Martin SS, O'Connell DJ, Surratt HL, Inciardi JA: Differences in prevalence of presctiption opiate misuse among rural and urban probationers. Am J Drug Alcohol Abuse. 2007, 33 (2): 309-317. 10.1080/00952990601175078.

    Article  PubMed  Google Scholar 

  19. Kentucky Cabinet for Health and Human Services: An integrated epidemiologic profile for HIV/AIDS prevention and care planning for Kentucky - 2010. Department for Public Health, HIV/AIDS Branch. Edited by: Frankfort KY. 2012

    Google Scholar 

  20. Havens J, Lofwall MR, Frost SD, Oser CB, Leukefeld CG, Crosby RA: Individual and network factors associated with prevalent hepatitis C infection among rural Appalachian injection drug users. Am J Public Health. 2013, 103 (1): e44-e52. 10.2105/AJPH.2012.300874.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Young A, Havens J: Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: a cross-sectional comparison and retrospective survival analysis. Addiction. 2012, 107 (3): 587-596. 10.1111/j.1360-0443.2011.03635.x.

    Article  PubMed  Google Scholar 

  22. Crosby R, Oser CB, Leukefeld CG, Havens J, Young A: Prevalence of HIV and risky sexual behaviors among rural drug users: does age matter?. Ann Epidemiol. 2012, 22 (11): 778-782. 10.1016/j.annepidem.2012.07.006.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Young A, Jonas A, Mullins U, Halgin D, Havens J: Network structure and the risk for HIV transmission among rural drug users. AIDS Behav. 2013, 17 (7): 2341-2351. 10.1007/s10461-012-0371-2.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  24. Basta T: HIV-related stigma and knowledge among individuals living in rural Appalachian Ohio. Paper presented at: AIDS. 2010, Vienna, Austria, - XVIII International AIDS Conference; July 20, 2010

    Google Scholar 

  25. Young AM, Rudolph AE, Quillen D, Havens JR: Spatial, temporal and relational patterns in respondent-driven sampling: evidence from a social network study of rural drug users. J Epidemiol Community Health. [Published Online First: 1 April, 2014]. doi:10.1136/jech-2014-203935

  26. Poole G: Using psychological principles to narrow the intention-behavior gap and increase participation in HIV vaccine trials. Curr HIV Res. 2012, 10 (6): 552-556. 10.2174/157016212802429811.

    CAS  Article  PubMed  Google Scholar 

  27. Suraratdecha C, Ainsworth M, Tangcharoensathien V, Whittington D: The private demand for an AIDS vaccine in Thailand. Health Policy. 2005, 71 (3): 271-287. 10.1016/j.healthpol.2004.05.005.

    Article  PubMed  Google Scholar 

  28. Newman P, Roungprakhon S, Tepjan S, Yim S: Preventive HIV vaccine acceptability and behavioral risk compensation among high-risk men who have sex with men and transgenders in Thailand. Vaccine. 2010, 28: 958-964. 10.1016/j.vaccine.2009.10.142.

    CAS  Article  PubMed  Google Scholar 

  29. Montaño DE, Kaspryzyk D: Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. Health Behavior and Health Education: Theory, Research, and Practice. Edited by: Glanz K, Rimer BK, Viswanath K. 2008, San Francisco: John Wiley & Sons, 4

    Google Scholar 

  30. Fishbein M: A reasoned action approach to health promotion. Med Decis Making. 2008, 28 (6): 834-844. 10.1177/0272989X08326092.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Fishbein M: A reasoned action approach: some issues, questions, and clarifications. Prediction and change of health behavior: applying the reasoned action approach. Edited by: Azjen I, Albarracin D, Hornick R. 2007, Hillsdale, NJ: Erlbaum

    Google Scholar 

  32. Gagnon M, Godin G: Young adults and HIV vaccine: determinants of the intention of getting immunized. Can J Public Health. 2000, 91 (6): 432-434.

    CAS  PubMed  Google Scholar 

  33. Rosenstock I: What research in motivation suggests for public health. Am J Public Health. 1960, 50: 295-302. 10.2105/AJPH.50.3_Pt_1.295.

    CAS  Article  Google Scholar 

  34. Fishbein M: An integrative model for behavioral prediction and its application to health promotion. Emerging theories in health promotion practice and research. Edited by: DiClemente RJ, Crosby RA, Kegler MC. 2009, San Francisco: John Wiley & Sons

    Google Scholar 

  35. Cialdini RB, Reno RR, Kallgren CA: A focus theory of normative conduct: Recycling the concept of norms to reduce littering in public places. J Pers Soc Psychol. 1990, 58 (6): 1015-1026.

    Article  Google Scholar 

  36. Bandura A: Social cognitive theory of self-regulation. Organ Behav Hum Decis Process. 1991, 50 (2): 248-287. 10.1016/0749-5978(91)90022-L.

    Article  Google Scholar 

  37. Ajzen I: The theory of planned behaviour: Reactions and reflections. Psychol Health. 2011, 26 (9): 1113-1127. 10.1080/08870446.2011.613995.

    Article  PubMed  Google Scholar 

  38. SAS Institute: The GLIMMIX Procedure. SAS/STAT 93 User's Guide. 2011, Cary, NC: SAS Institute

    Google Scholar 

  39. Wolfinger R: Laplace's approximation for nonlinear mixed models. Biometrika. 1993, 80 (4): 791-795. 10.1093/biomet/80.4.791.

    Article  Google Scholar 

  40. Heckathorn D: Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl. 1997, 44 (2): 174-199. 10.2307/3096941.

    Article  Google Scholar 

  41. Heckathorn D: Respondent-driven sampling II: deriving valid population estimates from chain-referral samples of hidden populations. Soc Probl. 2002, 49 (1): 11-34. 10.1525/sp.2002.49.1.11.

    Article  Google Scholar 

  42. Volz E, Wejnert C, Cameron C, Spiller M, Barash V, Degani I, Heckathorn D: Respondent-driven Sampling Analysis Tool (RDSAT) Version 7.1. 2012, Ithaca, NY: Cornell University

    Google Scholar 

  43. Hennessy M, Bleakley A, Fishbein M, Brown L, DiClemente R, Romer D, Valois R, Vanable PA, Carey MP, Salazar L: Differentiating between precursor and control variables when analyzing reasoned action theories. AIDS Behav. 2010, 14 (1): 225-236. 10.1007/s10461-009-9560-z.

    Article  PubMed  Google Scholar 

  44. The Appalachian Region: A data overview from the 2007–2011 American Community Survey.,

  45. Webb PM, Zimet GD, Mays R, Fortenberry JD: HIV immunization: Acceptability and anticipated effects on sexual behavior among adolescents. J Adolesc Health. 1999, 25 (5): 320-322. 10.1016/S1054-139X(99)00066-X.

    CAS  Article  PubMed  Google Scholar 

  46. Lally MA, Gaitanis M, Vallabhaneni S, Reinert S, Mayer K, Zimet G, Rich J: Willingness to receive an HIV vaccine among incarcerated persons. Prev Med. 2006, 43 (5): 402-405. 10.1016/j.ypmed.2006.06.012.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Seal KH, Kral AH, Lorvick J, McNees A, Gee Lm Edlin BR: A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users. Drug Alcohol Depend. 2003, 71 (2): 127-131. 10.1016/S0376-8716(03)00074-7.

    Article  PubMed  Google Scholar 

  48. Bishai D, Pariyo G, Ainsworth M, Hill K: Determinants of personal demand for an AIDS vaccine in Uganda: contingent valuation survey. Bull WHO. 2004, 82 (9): 652-660.

    PubMed  PubMed Central  Google Scholar 

  49. Kakinami L, Newman P, Lee SJ, Duan N: Differences in HIV vaccine acceptability between genders. AIDS Care. 2008, 20 (5): 542-546. 10.1080/09540120701867180.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Newman P, Duan N, Rudy ET, Anton PA: Challenges for HIV vaccine dissemination and clinical trial recruitment: if we build it, will they come?. Aids Patient Care STDS. 2004, 18 (12): 691-701. 10.1089/apc.2004.18.691.

    Article  PubMed  Google Scholar 

  51. Liau A, Zimet GD, Fortenberry JD: Attitudes about human immunodeficiency virus immunization: the influence of health beliefs and vaccine characteristics. Sex Transm Dis. 1998, 25 (2): 76-81. 10.1097/00007435-199802000-00004.

    CAS  Article  PubMed  Google Scholar 

  52. Sayles JN, Macphail CL, Newman P, Cunningham WE: Future HIV vaccine acceptability among young adults in South Africa. Health Educ Behav. 2010, 37 (2): 193-210. 10.1177/1090198109335654.

    Article  PubMed  Google Scholar 

  53. Barrington C, Moreno L, Kerrigan D: Local understanding of an HIV vaccine and its relationship with HIV-related stigma in the Dominican Republic. AIDS Care. 2007, 19 (7): 871-877. 10.1080/09540120701203295.

    CAS  Article  PubMed  Google Scholar 

  54. Newman P, Woodford MR, Logie C: HIV vaccine acceptability and culturally appropriate dissemination among sexually diverse Aboriginal peoples in Canada. Glob Public Health. 2012, 7 (1): 87-100. 10.1080/17441692.2010.549139.

    CAS  Article  PubMed  Google Scholar 

  55. Newman P, Roungprakhon S, Tepjan S, Yim S, Walisser R: A social vaccine? Social and structural contexts of HIV vaccine acceptability among most-at-risk populations in Thailand. Glob Public Health. 2012, 7 (9): 1009-1024. 10.1080/17441692.2012.692388.

    Article  PubMed  Google Scholar 

  56. Mills E, Cooper C, Guyatt G, Gilchrist A, Rachlis B, Sulway C, Wilson K: Barriers to participating in an HIV vaccine trial: a systematic review. AIDS. 2004, 18 (17): 2235-2242. 10.1097/00002030-200411190-00003.

    Article  PubMed  Google Scholar 

  57. Young AM, DiClemente RJ, Halgin D, Sterk C, Havens JR: Drug users' willingness to encourage social, sexual, and drug network members to receive an HIV vaccine: A social network analysis. AIDS Behav. In press

  58. Lee SJ, Brooks RA, Newman P, Seiden D, Sangthong R, Duan N: HIV vaccine acceptability among immigrant Thai residents in Los Angeles: a mixed-method approach. AIDS Care. 2008, 20 (10): 1161-1168. 10.1080/09540120701855375.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Lee S, Newman P, Comulada W, Cunningham W, Duan N: Use of conjoint analysis to assess HIV vaccine acceptability: feasibility of an innovation in the assessment of consumer health-care preferences. Int J STD AIDS. 2012, 23 (4): 235-241. 10.1258/ijsa.2011.011189.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  60. Cameron MP, Newman PA, Roungprakhon S, Scarpa R: The marginal willingness-to-pay for attributes of a hypothetical HIV vaccine. Vaccine. 2013, 31 (36): 3712-3717. 10.1016/j.vaccine.2013.05.089.

    Article  PubMed  Google Scholar 

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The Social Networks among Appalachian People (SNAP) Study is funded by the National Institute on Drug Abuse (R01DA024598 and R01DA033862 to J.R.H). Data collection on attitudes surrounding HIV vaccination was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health (UL1TR000117 to J.R.H). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The sponsors had no role in the study design, collection, analysis and interpretation of data, report preparation, or in the decision to submit the article for publication. The authors would like to acknowledge Dr. Hannah Cooper for her input during the conceptualization of the study and her thoughtful review of manuscript drafts. The authors would also like to thank the reviewers for their thoughtful review of the manuscript and suggestions for its improvement.

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Correspondence to April M Young.

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The authors declare that they have no competing interests.

Authors’ contributions

AMY and JRH designed the study and wrote the protocol. AMY conducted the statistical analyses and drafted the complete manuscript. DSH, RJD, and CES provided feedback throughout the conduct of the study and assisted with editing the final manuscript. All authors contributed to and approved the final manuscript.

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Young, A.M., DiClemente, R.J., Halgin, D.S. et al. HIV vaccine acceptability among high-risk drug users in Appalachia: a cross-sectional study. BMC Public Health 14, 537 (2014).

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  • HIV
  • Vaccination
  • AIDS vaccines
  • HIV vaccines
  • Attitude
  • Drug users
  • Psychological theory
  • Rural health