       Document 1003
 DOCN  FOCS1003
 TI    FOCUS: A Guide to AIDS Research and Counseling, Volume 10,
       Number 3 - February 1995
 DT    950221

       ***********************
       Editorial: Then and Now
       Robert Marks, Editor

       It came as no surprise to me-or, I dare say, to others in the
audience-when Ron Gold declared at the International Conference on
Biopsychosocial Aspects of HIV Infection that HIV prevention efforts
were failing many gay men. The paradigm that had once been so
effective in alerting the gay community to HIV-related risk has
endured many criticisms during the past five years, but few have been
expressed as forcefully as Gold's.

       The articles in this month's issue of FOCUS derive themselves
from Gold's speech, notable for its persuasive reconsideration of
prevention ideals that many of us have taken for granted: the
existence of a safe sex culture, the importance of links to the
community, and the efficacy of information campaigns. When Michael
Helquist, the Founding Editor of FOCUS and our Editorial Advisor,
reviewed Gold's manuscript, however, he was concerned that the article
insufficiently acknowledged the complexity of the population targeted
by prevention efforts.

       Helquist questioned two assumptions that he saw underlying
Gold's thesis. First, he said, the urban gay community is not
monolithic and the response to prevention efforts is not uniform.
Second, he suggested that, if this is true, one cannot assume that
there has been an evolution in this response from "then"-the early
days of the epidemic-to "now." Helquist observed that there had been
many "generations" of gay men who had passed through the
epidemic-evolving from neophytes to veterans-and that the "information
and exhortation" approaches that Gold condemned, when well-designed,
continue to raise consciousness and yield behavior change among those
who are new to the urban community or were newly out as gay.

       Helquist's words reminded me that this epidemic is amazing in
its ability to regenerate itself. Just when you think everyone from
here to eternity must know about safer sex, you realize that most of
us listen with only half an ear to public health warnings. It is not
until a person becomes a member of "a high-risk group"-an
appropriately discredited concept that nonetheless retains a powerful
cachet-that risk begins to mean something. "Then" and "now" are not
1985 and 1995; they are "my coming out" and "attending my fifth
memorial service."

       Most frightening among Gold's observations-based on admittedly
preliminary data-is that many gay men participate in unprotected sex
because of the social pressures and potential rejection inherent in
being part of the urban gay community. His conclusion that gay men are
no nicer to each other than are heterosexual men and women is no
surprise. But its connection to unsafe sex does suggest a way of
exploring relapse, developing new prevention strategies, and
structuring therapy.

       ************************************************
       Rethinking HIV Prevention Strategies for Gay Men
       Ron S. Gold, D Phil

       At the 1993 National Gay and Lesbian Health Conference in Houston, California
psychologist Walt Odets questioned the very essence of HIV prevention
efforts. While I do not want to go as far as he did, I find myself in
sympathy with much of what he said. It seems to me that we are probably
deluding ourselves about our HIV education efforts for gay men and that the
result is a level of complacency that could prove very costly.

       Contrary to what we would like to believe, for many gay men there is not a
"safe sex" culture. In fact, the incidence of unsafe behavior remains
disturbingly high. This raises questions about the effectiveness of our
current approach to behavior change interventions. This article uses several
Australian studies to define the limits of our presumptions about the "safe
sex culture" and to outline alternative interventions that might extend
beyond these limits.

       The Failure of Safe Sex

       Three studies were designed to investigate factors that may contribute to gay
men's decisions to have unprotected anal intercourse. The studies looked at
young gay men in Melbourne (up to 21 years old),1 older gay men in Melbourne
(most of whom were between 20 and 39 years old),2 and two samples* of older
gay men in Sydney (most of whom were between 20 and 39 years old).3
Researchers recruited subjects at gay venues, most notably bars, discos, and
sex clubs, but also at medical practices and gay organizations. Each of the
samples represented a well-educated population: among the older participants,
more than half had some post-secondary education and a large proportion were
managers, professionals, or paraprofessionals.

       Researchers collected data from the younger men through interviews and from
the older men through self-administered questionnaires. In the main part of
each study, subjects were asked to recall in great detail one occasion during
which they had engaged in unprotected anal intercourse in the previous year
or previous six months. It proved astonishingly easy to find men who had
engaged in unprotected anal intercourse: over the three studies, 734 men
acknowledged the practice. Of these men, 40 percent had had unprotected sex
within the preceding month.

       Could these men just have been practicing what has been called "negotiated"
safety? That is, might they have engaged in unprotected anal intercourse only
with men with whom they were in a monogamous relationship-or at least
monogamous with respect to unprotected anal intercourse-and whom they knew
had the same antibody status as they did? The data suggests that negotiated
safety was not a factor.

       Subjects reported three categories of partner: lover, casual but not
anonymous partner, and anonymous partner [see table on page 3]. In each
study, the majority-and in two samples, almost two-thirds-of these encounters
had been with a casual partner. Indeed, in three of the samples, one-quarter
of the encounters had been with a completely anonymous partner. Among the
subsample of infected men in the Sydney study, the proportion with an
anonymous partner was more than one-third. Even where the partner was a
lover, the relationship was often not a long-standing one. And regardless of
partner type, many men did not know their partners' serostatus. For example,
only 12 percent of the young gay men in the Melbourne sample had known that
they and their partner were seroconcordant.

       During 1993, a 16-week study sought to compare two intervention approaches.4
The recruitment criterion for this study was more specific than it had been
in the earlier studies: in order to eliminate men who were practicing
negotiated safety, subjects were men who had engaged in unprotected anal
intercourse in the preceding six months and in doing so had broken their own
safe sex rules.

       Of the 700 men approached during recruitment, more than one-quarter said that
they met the criteria for the study and 138 agreed to participate. One-third
had engaged in unprotected anal intercourse with only one partner in the last
six months; one-third had done so with two partners; and one-third with more
than two. At the end of the 16 weeks, 109 men remained in the study. Of the
138 men who participated for even a short period, 64 percent "slipped up"
again at least once during the study period.

       All these studies targetted men who had engaged in unprotected anal
intercourse. Currently, we are conducting some studies in which any gay man
can participate. The aim of this work is to investigate whether it will be
possible to adapt some of the techniques used in cognitive psychology to
study gay men's thinking about HIV infection. In the first sample, we
recruited 79 men from a popular gay bar in Melbourne. Half had engaged in
unprotected anal intercourse in the preceding six months; one-quarter had
done so with more than one partner in that period. The second sample
comprised 96 men, recruited from the same and another gay bar: 46 percent had
engaged in unprotected anal intercourse during the preceding six months, and
18 percent had done so with more than one partner.

       The Dangers of Mythology

       Educational materials for the gay community often claim that there is a safe
sex culture. These findings suggest that, while many gay men may successfully
maintain safe sex regimens or practice negotiated safety, in a substantial
proportion of the gay community, there is not a safe sex culture. At best,
there may be an "occasional slip-up culture."

       For example, one of the most visually attractive sets of posters produced for
gay men in Australia has captions such as "Some of us are in love, some of us
are in lust. All of us fuck with condoms-every time!" and "Some of us have
HIV, some of us don't. All of us fuck with condoms-every time!" We put out
this sort of message because we assume that if people believe there is a
strong peer norm for safe sex, they will comply with that norm.

 ------------------------------------------------------------------
       Partners with Whom Unprotected Anal Intercourse Occurred

       Number:              % Whose Partner Was:
                                Lover      Casual,      Anonymous
                                             not
                                          Anonymous

 Young gay men	219		31		41		24
 in Melbourne

 Older gay men	219		37		30		26
 in Melbourne

 Uninfected gay 	207		37		36		23
 men in Sydney

 Infected gay         88		28		28		35
 men in Sydney
 ________________________________________________________________

       But asserting that we have a safe sex culture may make it very
difficult for gay men who slip up to admit this and discuss it with
friends who might provide emotional support and guidance. There was
evidence of this when we recruited for our studies. Time and again I
would present my spiel to a group of friends in a bar, to be solemnly
told by each of them that, no, they had not engaged in unprotected
anal sex. And time and again these same men would later seek me out
privately, to tell me that, yes, they had slipped up, but couldn't
admit it in front of their friends. As Walt Odets noted: AIDS
education has had the effect of putting the gay man who does not
maintain safe sex back into the closet.

       I am even more concerned about the conclusions gay men who slip
up may draw about themselves. For if everyone else is practicing safe
sex, but I am slipping up, then there must be something wrong with me;
I must be bad or deficient in some way. Social psychological research
suggests that people find it much harder to recover from a lapse into
undesirable behavior if they explain their lapse in this sort of way.
The message that all gay men are maintaining safe sex may lead a gay
man who does not do so to explain his behavior precisely in the way
that is least likely to help him change that behavior.

       Most important of all, I fear the effect of the claim that gay
men have a safe sex culture on those who are responsible for devising,
funding, and implementing HIV education for gay men. Educators and
planners face a strong temptation to accept this claim
unquestioningly, as a sort of received truth. The result has been an
unjustified and worrying complacency.

       Efficacy of HIV Education

       The assertion that there is a safe sex culture among gay men
has quite naturally led to the further claim that current HIV
education for gay men is effective. The trouble is, no one actually
bothers to test whether this is true. Over the past decade of HIV
education in Australia, no study has investigated, for example,
whether the posters, pamphlets, and videos used do what they are
supposed to do, that is, help gay men to adopt and maintain safe sex.
There is "evaluation" of educational campaigns, but it covers merely
superficial factors-how many gay men have seen the posters, how many
can recognize them later, how many like them. While these are crucial
factors, they do not tell us whether the materials work to change
behavior. As far as I know, Australia is not alone in this failing;
there is a similar dearth of fundamental evaluation research
throughout the world.

       Indeed, there are grounds for doubting the efficacy of current
HIV education materials. The content of these materials-combining
information about risk behaviors and exhortations to have safe sex-has
remained largely unchanged since the start of the epidemic. This
"information and exhortation" approach was probably successful in the
early days of the epidemic, and this success may have been due to the
fact that it provided new information and brought home the magnitude
of the threat. By now, however, knowledge about which behaviors are
high-risk is very common among gay men. Further, it seems quite
possible that gay men have become habituated to exhortations to have
safe sex.

       Our intervention study was designed to investigate an
alternative approach to HIV education. Earlier we had found that at
the time gay men make the decision to engage in unprotected anal
intercourse, they generally try to justify this decision to
themselves, using various arguments to "give themselves permission" to
have unsafe sex. How might HIV education target these
self-justifications? The study hypothesized that many of the
self-justifications represent thinking that only occurs during "the
heat of the moment," thinking that is unique to actual sexual
encounters.5 It posited that it might be possible to counter such
self-justifications by getting gay men to reflect on and evaluate, in
the cold light of day, the thinking that they employ when they are
having sex.

       Study participants kept a sexual diary for 16 weeks, filling
out a standardized diary page as soon as possible after each sexual
encounter and sending in completed pages at the end of each week.
After four weeks, researchers assigned each man to one of three
groups: the control, standard, or self-justifications groups. The
control group received no educational intervention at all throughout
the study.

       At the end of Week 4 and Week 8, researchers sent participants
in the standard group a set of HIV education posters designed for gay
men and unfamiliar to this study population. Researchers asked the men
to consider the posters in detail-rating each in terms of how
eye-catching it was, and how effective it was at getting across the
safe sex message to them-and justifying their judgments.

       At the end of Week 4 and Week 8, researchers sent participants
in the self-justifications group a questionnaire asking them to
recall, as vividly as possible, a sexual encounter in which they had
engaged in unprotected anal intercourse. The questionnaire included a
list of possible self-justifications. It asked participants to
indicate: the extent to which they had considered each of these at the
moment they decided to have unprotected anal intercourse, the
self-justifications that had been most strongly present in their
minds, how reasonable each of these justifications seemed to them now,
and explanations for these responses. Thus the process required the
men to recall the thinking they had employed in the heat of the
encounter and to reflect upon it in the cold light of day.

       The three groups did not differ in the percentage who slipped
up at least once during the post-intervention period. They did differ,
however, in the percentage who slipped up more than once: 42 percent
for the control group; 41 percent for the standard group; and 17
percent for the self-justifications group. Yet the groups did not
differ in terms of the average number of sexual encounters during this
period.

       The comparison between the control group and the standard group
is consistent with the hypothesis that "information and exhortation"
materials, no matter how well-designed, are no longer effective. The
comparison between the control group and the self-justifications group
was more encouraging. It appears that, while getting gay men to
reflect on and evaluate the thinking that they employ during sexual
encounters does not eliminate all slip-ups, it does help to prevent
repeated slip-ups. It seems that while this type of education is
effective, its effect is delayed until the next slip-up has occurred.
Presumably, their first post-intervention slip-up provoked and
disturbed the men; their perception that they had "done it yet again"
focused their minds on the problem. At that point, they began to
absorb the lessons of the intervention.

       Conclusion

       This article presents some unpalatable findings: among large
numbers of gay men, there is no safe sex culture; and the "information
and exhortation" approach to HIV education is ineffective at changing
behavior. Despite our discomfort with these facts, we must acknowledge
them. If we do not, we will pay for it with the lives of gay men.


       *The Sydney study was analyzed as two samples-"infected" and
        "uninfected"-because an appreciable minority of the men had
        known themselves to be HIV-infected at the time they had
        engaged in unprotected anal intercourse.

       References

       1. Gold RS, Skinner MJ. Situational factors and thought
processes associated with unprotected intercourse in young gay men.
AIDS. 1992; 6(9): 1021-1030.

       2. Gold RS, Skinner MJ, Grant PJ, Plummer DC. Situational
factors and thought processes associated with unprotected intercourse
in gay men. Psychology and Health. 1991; 5(4): 259-278.

       3. Gold RS, Skinner MJ, Ross MW. Unprotected anal intercourse
in HIV- infected and non-HIV-infected gay men. Journal of Sex
Research. 1994; 31(1): 59-77.

       4. Gold RS, Rosenthal DA. Preventing unprotected anal
intercourse in gay men: A comparison of two intervention techniques.
International Journal of STD & AIDS. In press.

       5. Gold RS. On the need to mind the gap: On-line versus
off-line cognitions underlying sexual risk-taking. In Terry D, Gallois
C, McCamish M, eds. The Theory of Reasoned Action: Its Application to
AIDS Preventive Behavior. Oxford: Pergamon Press, 1993.

       Author

       Ron S. Gold, D Phil is a Senior Lecturer in the School of
       Psychology at Deakin University in Victoria, Australia.
       ********************************
       Clearinghouse: Prevent - Gay Men

       References

       Adib SM, Joseph JG, Ostrow DG. Predictors of relapse in sexual
practices among homosexual men. AIDS Education & Prevention. 1991;
3(4): 293-304.

       Ekstrand ML, Coates TJ. Maintenance of safer sexual behaviors
and predictors of risky sex: The San Francisco Men's Health Study.
American Journal of Public Health. 1990; 80(8): 973-977.

       Hart G, Fitzpatrick R, McLean J, et al. Gay men, social support
and HIV disease: A study of social integration in the gay community.
AIDS Care. 1990; 2(2): 163-170.

       Joseph JG, Adib SM, Koopman JS, et al. Behavioral change in
longitudinal studies: Adoption of condom use by homosexual/bisexual
men. American Journal of Public Health. 1990; 80(12): 1513-1514.

       Kelaher M, Ross MW, Rohrsheim R, et al. Dominant situational
determinants of sexual risk behaviour in gay men. AIDS. 1994; 8(1):
101-105.

       Kelly JA, St. Lawrence JS, Brasfield TL. Predictors of
vulnerability to AIDS risk behavior relapse. Journal of Consulting
Clinical Psychology. 1991; 59(1); 163-166.

       Kippax S, Crawford J, Connell RW, et al. The importance of gay
community in the prevention of HIV transmission: A study of Australian
men who have sex with men. In Aggleton P, Davies P, Hart G, eds. AIDS:
Rights, Risk and Reason. London: Falmer Press, 1992.

       McLaws M, Oldenburg B, Ross MW. Application of the theory of
reasoned action to the measurement of condom use among gay men. In
Terry DJ, Gallois C, McCamish, eds. The Theory of Reasoned Action: Its
Application to AIDS-Preventive Behaviour. Oxford: Pergamon Press,
1993.

       Stall R, Ekstrand M, Pollack L, et al. Relapse from safer sex:
The next challenge for AIDS prevention efforts. Journal of Acquired
Immune Deficiency Syndromes. 1990; 3(12): 1181-1187.

       Wiktor SZ, Biggar RJ, Melbye M, et al. Effect of knowledge of
human immunodeficiency virus infection status on sexual activity among
homosexual men. Journal of Acquired Immune Deficiency Syndromes. 1990;
3(1): 62-68.

       Contacts

       Robert Remien, MD, HIV Center for Clinical and Behavioral
Studies, 722 West 168th Street, New York, NY 10032, 212-960-2375.

       Walt Odets, PhD, 2714 Telegraph Avenue, Berkeley, CA 94705,
510-845-4628.

       Ron Gold, D Phil, Faculty of Health and Behavioural Sciences,
School of Psychology, Burwood Campus, Deakin University, 221 Burwood
Highway, Burwood Victoria 3125, Australia, 61-3-244-6843 (telephone);
61-3-244-6858 (fax).

       See also references cited in articles in this issue.



       ******************************
       Gay Community Links and Safety
       Ron S. Gold, D Phil

       There are good reasons for hypothesizing that having contact
with the gay community should assist gay men to maintain safe sex.
First, proximity to the community equals proximity to peer norms for
safe sex. Second, gay community publications present what is perhaps
the most accurate information about HIV disease to non-specialists.
Third, support from gay social networks should help in dealing with
the negative mood states or lack of self-esteem that may lead to
unsafe practices. Finally, having first-hand experience of the
epidemic should make the threat of the epidemic more vivid. But, while
it is clear that links with the gay community can often be beneficial,
overstating these benefits without acknowledging potential limitations
can add to the complacency regarding HIV prevention among gay men.

       Australian Studies

       Four Australian studies highlight the problem [see "Rethinking
HIV Education for Gay Men," page 1, for a fuller description of these
studies].1,2,3,4 The samples from these studies consisted of men who
had engaged in widespread unprotected anal intercourse, but who were
in no way isolated from the gay community. For example, in an
intervention study of 138 men [see page 2 for a fuller description],
46 percent were, or had once been, members of organized gay groups; 67
percent said that of their four closest friends, at least three were
gay; and 57 percent reported that they read the gay press at least
once a week. Participants in this study had considerable experience of
the epidemic: 83 percent had at least one friend or acquaintance who
was HIV-infected, 63 percent knew someone with full-blown AIDS, and 51
percent had known someone who had died. While these men had strong
links with the community, they had all broken their safe sex rules by
having unprotected anal intercourse within the six months prior to the
study.

       Furthermore, in two of the studies, researchers found low, but
statistically significant, positive correlations between unprotected
anal intercourse and links to the gay community.5 In a study of young
gay men, the number of different partners with whom participants had
had unprotected anal intercourse over the preceding year was
positively related to the proportion of the men's closest friends who
were gay; the frequency with which the men read the gay press; and the
number of men they knew who were living with HIV disease or had died.
The results for the intervention study mentioned above followed a
similar pattern.

       These results may differ from those obtained by other
researchers because there were some notable differences in the
samples. In the Australian studies, researchers targeted gay men who
still engaged in unprotected anal intercourse. Most other studies, by
contrast, have recruited gay men without restriction, presumably
including many men who found it easier to stick to safe sex practices.

       These findings suggest that contact with the gay community
probably plays a different role for different men. For those who
already have a strong orientation towards safe sex, links with the gay
community may help to strengthen this orientation. By contrast, for
those who have difficulty maintaining safe sex, the opposite holds
true. It may be that these men distort, discount, or even actively
reject the information they receive via the gay community. Or it may
be that contact with the community simply serves to present these men
with more temptations and opportunities to engage in unsafe sex. What
is common to the two groups is that contact with the community acts as
a multiplier, heightening the effects of existing tendencies.

       Awkward Questions

       Over-optimism about the effect of community links has been
helped along by a natural desire to portray the gay community in the
most positive light. The understandable wish to avoid providing
ammunition to the community's enemies has predisposed us to avoid
asking awkward questions. It is worth mentioning two further areas
where we have skirted around some uncomfortable truths relating to the
community, both concerning the dynamics of how gay men act towards one
another.

       First, there has been an implicit assumption that men who are
HIV-infected will feel a strong sense of responsibility towards their
partners. In a Sydney study, however, of the 88 men who had known
themselves to be HIV-infected at the time they engaged in unprotected
anal intercourse, 31 percent reported thinking, "I may be infected
already, but if this guy is willing to fuck without a condom that's
his affair. I'm not responsible for him."3

       It is neither intelligent nor fair to blame these men for
having had this thought. Western culture is strongly individualistic,
and, particularly in the last 15 years, we have seen selfishness
extolled as a virtue. It is unrealistic to demand from HIV-infected
men an altruism that is less than evident in the rest of society.

       At the same time, we do the cause of HIV education no good by
ignoring the fact that some HIV-infected men believe in caveat emptor.
Of the uninfected men in the Sydney study, for example, 17 percent
reported thinking, "If this guy was really infected, he'd be a lot
more careful about taking a risk than he's being now. The fact that
he's willing to fuck without a condom means he can't be infected."
Uninfected men need to be delicately but firmly told that many
antibody positive men are not prepared to take responsibility for the
health of their sexual partners.

       The starting point for a discussion of the second area is an
analysis, undertaken in three of the Australian studies, that examined
the growth of desire specifically for unprotected anal intercourse
during an unsafe encounter.6 In general, the more distant the personal
relationship between the two sexual partners-the further from being a
lover and the closer to being an anonymous partner-the earlier there
had been a desire specifically for unprotected anal intercourse. (This
pattern was broken by young gay men having sex with anonymous
partners: in this group, the desire for unprotected anal intercourse
was almost as common as it was among young gay men having sex with
lovers.)

       What was the source of this anomaly? The analysis eliminated
some obvious possibilities: these men had not been particularly
intoxicated or stoned, nor had they been unusually sexually aroused.
What distinguished this group was more complex: at the start of the
evening, these men had been in a particularly bad mood-for example,
depressed, bored, or stressed. Unsafe sex had been what is often
referred to as "angry fucking."

       The results did not reveal why these men had been in a bad
mood. But later, while I was recruiting for other studies, I
occasionally asked young gay men what sorts of things put them in a
really bad mood. I did this in a very informal, unsystematic way, but
the results were disturbing. The men complained about a variety of
issues (difficulties with parents, homophobia, unemployment), but
dismissed most as routine hassles, handled, if necessary, simply by
ignoring them.

       By contrast, they reserved their real vehemence for
descriptions of their treatment at the hands of other gay men. If one
did not have the right "look"-the cuteness, the straight white teeth,
the firm, gym-toned body, even the right clothes-the consequences
could be awful.

       Conclusion

       This is a side of the story that we usually do not hear. The
official version is that the gay world is full of caring and emotional
support. It is unpleasant to think that in many cases some of the
dynamics of the gay world may contribute to the depression and
desperation that provoke unsafe sex. We need to face up to the
possibility that our view of the gay community is too benign and
simplistic, that how gay men relate to one another may often be part
of the problem, rather than part of the solution.

       References

       1. Gold RS, Skinner MJ. Situational factors and thought
processes associated with unpro-tected intercourse in young gay men.
AIDS. 1992; 6(9): 1021-1030.

       2. Gold RS, Skinner MJ, Grant PJ, Plummer DC. Situational
factors and thought processes associated with unpro-tected intercourse
in gay men. Psychology and Health. 1991; 5(4): 259-278.

       3. Gold RS, Skinner MJ, Ross MW. Unprotected anal intercourse
in HIV- infected and non-HIV-infected gay men. Journal of Sex
Research. 1994; 31(1): 59-77.

       4. Gold RS, Rosenthal DA. Preventing unprotected anal
intercourse in gay men: A comparison of two intervention techniques.
International Journal of STD & AIDS. In press.

       5. Gold RS, Skinner MJ,  Rosenthal DA. Links with the gay
community and the maintenance of safe sex. Medical Journal of
Australia. 1994; 160(9): 591-592.

       6. Gold RS, Skinner MJ.  Desire for unprotected intercourse
preceding its occurrence: The case of young gay men with an anonymous
partner. International Journal of STD & AIDS. 1993; 4(6): 326-329.
Author Ron S. Gold, D Phil is a Senior Lecturer in the School of
Psychology at Deakin University in Victoria, Australia.

       **************
       Recent Reports

       Maintaining Safe Sex

       Kippax S, Crawford J, Davis M, et al. Sustaining safe sex: A
       longitudinal study of a sample of homosexual men. AIDS. 1993;
       7(2): 279-282. (Macquarie University, Australia.)

       Davies PM. Safer sex maintenance among gay men: Are we moving
       in the right direction? AIDS. 1993; 7(2): 279-280. (University
       of Essex, United Kingdom.)

       Ekstrand M, Stall R, Kegeles S, et al. Safer sex among gay men:
       What is the ultimate goal? AIDS. 1993; 7(2): 281-282.
       (University of California San Francisco.)

       Three recent reports, all published in the journal AIDS, debate
whether absolute safety is a reasonable prevention goal and an
effective prevention message. According to an Australian study, which
sets the parameters of the debate, the practice of "negotiated
safety," in which sexual partners with the same serostatus engage in
intercourse without a condom, has gained popularity. As a result,
unprotected anal intercourse need not constitute a relapse into unsafe
sex.

       A 1986-1987 survey of men who have sex with men revealed that
several safe sex strategies-including using condoms, avoiding anal
intercourse, foregoing intercourse with casual partners, and remaining
monogamous-were taking hold within the community. In 1991, 31 percent
of the original sample of 535 responded to a follow-up telephone
survey that showed an overall maintenance of safe sexual practice and
an increase in behaviors associated with negotiated safety,
particularly among couples in which both partners were seronegative.
The proportion of men who engaged in anal intercourse without condoms
decreased, particularly with casual partners, and 79 percent of the
men in the 1991 sample reported a "clear agreement" on sexual practice
within their regular relationships.

       In response to this article, Peter M. Davies states that the
unreasonable standards of risk elimination strategies are inevitably
self-defeating and emphasizes the need for reasonable HIV prevention
goals. The implication of the Australian study-that negotiated safety
constitutes "safer" behavior in most cases-supports the theory that
human behavior will tend toward risk minimization rather than risk
elimination. Defining safer sex in more attainable and sustainable
terms like negotiated safety-rather than as absolutes of "safe" and
"unsafe"-is a more realistic way to approach HIV risk.

       A second response to the Australian study by Maria Ekstrand and
her colleagues states that the ultimate goal of safer sex strategies
should be nothing less than elimination of future infection.
Negotiated safety is inherently flawed because it relies on accurate
knowledge and truthful communication of serostatus, and is therefore
inherently risky; "negotiated danger" defines this approach more
precisely. While relapse to unsafe behavior may be part of a normal
human learning process, it should not be excused by HIV prevention
efforts that aim at mere minimization of risk. In the long run, while
risk elimination may be impossible, it is the only acceptable goal.

       Prevention for Seronegative Men

       Odets W. Why we stopped doing primary prevention for gay men in
       1985. AIDS and Public Policy Journal. 1995, In press.

       Undifferentiated AIDS education programs-ostensibly serving
both infected and uninfected gay men-alienate seronegative gay men and
because of their generality, undermine primary prevention efforts,
according to this critique of HIV prevention strategies.

       The goal of primary prevention is to stop the spread of HIV to
currently uninfected men. Existing education programs, however,
combine primary prevention with secondary and tertiary prevention,
which seek to control the clinical progression of HIV disease. These
undifferentiated programs confuse identities between uninfected and
infected men, exacerbating feelings that it is inevitable, even
desirable, to contract HIV; overlook the distinct psychosocial issues
of uninfected men; and disenfranchise uninfected men from the gay
community that would otherwise serve to enforce safer sex through peer
norms. This situation is particularly ironic because, while
seronegative men are the only ones at risk for primary infection, they
are left with the belief that their prevention needs are
insignificant.

       Prevention strategies designed in 1985 before the advent of
effective HIV testing had to assume that all men were HIV infected.
But the development of antibody testing did not deliver effective
primary prevention; after 1985, prevention switched to secondary and
tertiary modes, focusing on those who were already HIV infected.
Current prevention strategies include seronegative men only by
implication and adopt seropositive men as spokespeople. A true primary
prevention plan would single out seronegative men, advertise its
efforts to keep men uninfected, and explicitly state the benefits of
remaining uninfected.

       Predicting Preventive Behavior

       Fisher JD, Fisher WA, Williams SS, et al. Empirical tests of an
       information-motivation-behavioral skills model of
       AIDS-preventive behavior with gay men and heterosexual
       university students. Health Psychology. 1994; 13(3): 238-250.
       (University of Connecticut; University of Western Ontario;
       State University of New York at Buffalo; and Rhode Island
       College.)

       A comparative test of the information-motivation-behavioral
skills (IMB) model shows that it successfully represents the
determining factors of healthy behavior. The IMB model draws upon the
strengths of several previous models-social-cognitive theory, the
theory of reasoned action, the health belief model, and the
AIDS-risk-reduction model-and specifies HIV-related behavioral
determinants applicable to a variety of populations.

       According to the IMB model, HIV prevention knowledge and
motivation are the primary variables, factors that are translated
through behavioral skills to action regarding sexual activity. These
primary variables can act independently of behavioral skills. For
example, when one is sufficiently motivated to avoid sexual activity,
communication and negotiation skills need not enter the equation. The
basis of the model, however, is that individuals possessing sufficient
information, motivation, and behavior skills will behave predictably
to prevent HIV transmission.

       The IMB model was tested in two surveyed populations: gay men
and heterosexual university students. The results confirmed the
generalizability of the model across diverse risk populations.

       Perception and Inconsistency

       Offir JT, Fisher JD, Williams SS, et al. Reasons for
       inconsistent AIDS-preventive behaviors among gay men. The
       Journal of Sex Research. 1993; 30(1): 62-69. (University of
       Connecticut; State University of New York at Buffalo; and
       University of Western Ontario.)

       Despite intermittent condom use or reliance on
monogamy as their only preventive measures, gay men in a small study
perceived their behavior to be sufficient to eliminate HIV-related
risk. These inaccurate perceptions appeared to result from
dissonance-reducing techniques, which alter perceptions in response to
psychological tension caused by the disparity between risk and
behavior.

       Forty-one self-identified homosexual men participated in one
two-hour focus discussion group consisting of two to six participants.
The majority of participants were middle-class Whites between the ages
of 25 and 45.

       Thirty-nine of the 41 men reported at least one instance of
unprotected, risky sex since initiating condom use for the purpose of
HIV risk reduction. More than half of these men offered explanations
for why a particular instance of unsafe sex was not unsafe. Many were
able to justify any unsafe behaviors after the fact. Of those involved
in monogamous relationships, there was a tendency to rely on monogamy
as the sole means of protection. In only one of these eight couples,
however, had both partners been tested for HIV antibody. Twenty-six
participants perceived risky behavior as consistent with their "safe"
self-image, because it was not normal for them.

       Participants also reported unreliable means of risk reduction.
For example, 11 men used non-verbal clues to determine a partner's
risk level, five men relied on a single negative antibody test result
as "proof" of their immunity to infection, and a few men reported
adopting improved nutrition and positive attitude-rather than
condoms-to prevent infection.

       **********
       Next Month

       Communities of color present particularly difficult prevention
challenges to a culture whose strategies are often based on parochial
experience. This is no truer than among the Latino and Hispanic
subcultures of the United States. In the March issue of FOCUS,
Francisco J. Gonzalez, MD, a resident in psychiatry at the University
of California San Francisco, looks at the cultural ambiguity
experienced by Latino men who have sex with men and the counseling
issues that this raises.

       Also in the March issue, Cynthia A. Gomez, PhD, a researcher at
the UCSF Center for AIDS Prevention Studies, reports on a study of the
factors that affect sexual relationships between Latino men and women.
She explores sexual socialization, interpersonal power, and cultural
gender norms.


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