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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV/AIDS and sexual behaviour S. Quinn
a
a
Clinical Psychologist and District AIDS Counsellor , Worthing District Health Authority , West Sussex, UK Published online: 25 Sep 2007.
To cite this article: S. Quinn (1990) HIV/AIDS and sexual behaviour, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 389-393, DOI: 10.1080/09540129008257760 To link to this article: http://dx.doi.org/10.1080/09540129008257760
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
389
AIDS CARE, VOL. 2, NO.4,1990
HIWAIDS and sexual behaviour S. QUI”
Downloaded by [McGill University Library] at 07:41 11 February 2015
Clinical Psychologist and Dism‘ct AIDS Counsellor, W d i n g District Health Aurhm‘ry, West Susses UK
‘The single most effective strategy for the prevention of HIV infection is the adoption of safer sexual behaviour’. This remains, in 1990, a resounding message from the International Conference on AIDS. It was heard not only in the Epidemiology/Prevention and Social Science presentations but also from the Basic and Clinical Science tracks, wherein it was reported that, despite numerous and complex developments in understanding of the virus, we are s t d l “10 years from a vaccine”. At the 6th International Conference there were 35 Papers presented and 175 posters relating to sexual behaviour. A selection is presented here to give a global perspective on the variety of work covered and the common themes. Surveys of knowledge and sexual
behaviour Following the worldwide health education campaigns promoting safer sexual behaviour and in particular condom use, numerous studies measured levels of knowledge, attitudes and sexual behaviour. Common findings were that: (i) knowledge levels do not correlate well with condom use, e.g. Wells (ThC106) reporting a survey of almost 6,000 heterosexual and homosexual respondents across France, UK and USA found no direct correlation and Musagara (ThC109) reported a
Ugandan household survey indicating much risky behaviour persisting despite high levels of knowledge. (ii) Correct knowledge of transmission routes frequently co-exists with erroneous beliefs, e.g. Ordonana (SC46) found that only specific messages from educational campaigns reached students involved and many misconceptions persisted. Faldsey (SC690), examining levels of knowledge and awareness at a US sexually transmitted disease clinic, found a high degree of knowledge about HIV transmission and prevention co-existing with varying levels of misinformation. (iii) Although safer sex behaviours, including condom use, have been initiated, practice is not consistent, e.g. De Vincenzi (ThClOO) found that 48% of HIV discordant sexually active couples did not use condoms consistently despite knowledge of risk and safer sex counselling. This pattern of findings emerged both in heterogenous samples and across different ‘risk’ populations which were studied. Amongst Mexican prostitutes Loo (ThDSl) reported that whereas 61% stated having used condoms most of the time during the previous 4 months, 80% continued to have unprotected vaginal intercourse at times, despite knowledge of risks. In Burkino Faso where 47% of prostitutes were HIV positive, Bakouan (ThD52) repons that HIV knowledge was low although 89% of the women
Downloaded by [McGill University Library] at 07:41 11 February 2015
390 SAN FRANCISCO SUMMARIES:S. QUINN claimed to use condoms. However, 56% reported that the condom had been refused by their clients. Numerous studies examined adolescent groups, many finding high levels of risky behaviours. Fullilove (Plenary address on Primary Prevention) commented that the typical US female did not commence the use of prophylaxis until 1 year after starting sexual intercourse and that young people in the 10-19 years age range were more likely to develop genital infections than older people, suggesting a higher level of unprotected sexual intercourse and numerous partners. Whilst 50% of these adolescents reported occasional condom use only 15% used condoms consistently. Ku (SC43) in a survey of teenage American men reported that although condom use is high, having increased from 21% to 58% over 9 years, it was least common amongst those at highest risk of HIV transmission. He reported that overall 34% of sexual acts amongst youths are protected with a condom. Antunes (SC42) reported a survey of Brazil’s street youth indicating that 80% were sexually active and, despite 60% reporting knowledge of HIV, only 7.3% using condoms. Over the past few years, changes to safer sexual practice amongst homosexual men have been widely reported. A disturbing finding, in countries where health education programmes, both general and targeted, are well established is the level of risk behaviour amongst younger gay men. Hays (FC722) reported that in San Francisco younger gay men, age range 18-25 years, 43% were engaging in unprotected anal intercourse. Similarly, in the UK, McManus (FC723) surveying gay young men under the age of 21 years, found that only 48% consistently used condoms for anal intercourse. Clearly, the reported rate of condom use needs to be seen in context in order to make meaningful predictions as to future behaviour. In Mexico, Izazola (ThC107) reports 30% condom use amongst gay men engaging in anal intercourse on average. However, he finds higher rates in cities
where AIDS prevention programmes have run longer, thus predicting that condom use is still increasing. Although the notion of high risk groups continues to be utilized as a convenience in survey research and is valuable in targeting of education, the importance of investigating hgh risk behaviours was once again emphasized in Doll’s (ThD49) finding that 24% of seropositive men who sometimes have sex with other men d d not self-identify as homosexual but heterosexual and that thls group are those most likely to consider themselves at low risk from AIDS and to have unprotected sexual intercourse.
Predictors of safer sexual practice As a number of studes found only a weak relation between correct knowledge of transmission/prevention and safer sexual practice, such knowledge may perhaps be regarded as a necessary but not sufficient condition for adoption of safer sexual behaviour. A number of studies looked for factors associated with safer sexual practice which might be used as predictors. Gallois (ThD54) examined the relationslup between intention and actual sexual behaviour in Australian men and women. This was mostly concordant, particularly when intention and past practice were congruent. The strongest predictive factor for actual behaviour was past behaviour. ‘Personalization’ is associated with safer sexual practice in some groups. Wells (ThC106) found that knowing someone with AIDS correlated with increased safe practice amongst US gay males although not amongst other groups. Rotheram-Borus (SC47) utilized personalized AIDS knowledge, coping skills and access to resources in a programme for changing sexual risk behaviours of gay male and runaway adolescents which was effective at 6 month follow-up in increasing condom use. Wilson (ThD53) reported that amongst Zimbabwean school pupils of whom 58% of
Downloaded by [McGill University Library] at 07:41 11 February 2015
HIV AND SEXUAL BEHAVIOUR
males and 45% of females reported sexual experience, belief in the efficacy of HIV prevention together with social support for this behaviour are factors predicting intended condom use. Drawing on the established efficacy of peer and social norms, Kelly (SC40) utilized natural opinion leaders trained in risk reduction to reach gay men engaging in hgh risk sexual behaviours. Having identified a subset of most popular persons in gay social networks in small cities, these were trained and contracted to act as change endorsers to friends. Si@cant population-wide reductions in unprotected anal intercourse and significant increases in safer sex practices were found. This was corroborated by increased rates of condom taking in gay clubs. The authors conclude the model appears very promising for other peer-sensitive populations. Fear, often used in health education and health advertising, has in the past been shown to be unrelated to change to safer practice. Some studies in this Conference reported a limited relationship of fear of AIDS to the use of condoms or other safer behaviours. Wells (ThC106) reported that fear of AIDS was related to the use of condoms during vaginal intercourse and to initiating the use of condoms; the strongest association being found in the US and in France. Moore (ThC105) in a survey of 1,480, mainly Catholic, students in Zaire found that the fear of STDs was a major determinant in avoiding partners with multiple partners. Sherr (SC688) reported that fear arousal as a model faired less well than humour in modifying sexual and risky behaviour and that risk behaviour was reduced, although not eliminated by either. Talking about safer sex with one’s partner may also predict safer practice. Choi (SC761) found that couples who discussed using condoms were almost four times more likely to use condoms than those who had no such discussion. Amongst adolescents a similar finding was reported by Rasmussen (SC727); where sexual subjects were dis-
39 1
cussed in the home, adolescents were more likely to d~scusscontraception before intercourse. Sarna Seppo (SC702) followed a cohort of homosexually active men for 6 years in Finland to determine the effect of repeated personal c o u n s e b g on the use of condoms. Whilst other influences on behaviour over such a period cannot be ignored, this longterm follow-up shows dramatic changes in sexual behaviour. A decrease from 90% to 62% practising anal intercourse, and a decrease from 87% to 8% of men never using condoms was reported to occur over 6 years. Ferreros (SC697) reported the success of a social marketing programme for condoms utilizing the technologies of mass consumer research. Total sales in Zaire increased by 443% over one year. Helquist (SC693) examined the effect of both a descriptive brochure and structured modelling of correct condom use on condom use skills. Whilst both interventions produced improved skills, significantly greater improvement was found with the modelling intervention. T h s study of male STD clinic patients in the Eastern Caribbean demonstrated that although time consuming, the modelling of correct condom use may be a valuable component in educational interventions. Barchi (SC714) reported that counselling and HIV testing together with the rehearsal of correct condom use was associated with an increase of condom use during vaginal intercourse amongst sex workers in California.
Barriers to safer sexual behaviour and factors correlated with risk A variety of factors have been examined and identified as relating to risky behaviour. Correlating psychological factors, Kelly (ThB26) reported that a sense of helplessness and hopelessness was associated with an increased likelihood of unprotected anal intercourse and Philips (FC734) examining stress and coping found that subjects who engaged in unprotected anal intercourse
Downloaded by [McGill University Library] at 07:41 11 February 2015
392
SAN
FRANCISCOSUMMARIES:s. QUINN
(USAI) use more self-controlling coping, more distancing and more escape avoidance coping than subjects who did not engage in UAI, amongst a sample of gay men. Capell (ThC111) found that amongst the general Californian population unmarried status together with increased age was associated with increased likelihood of risky behaviour. A report from the 5th population-based survey of the San Francisco AIDS Foundation found that more than one-third of gay and bi-sexual men combined alcohol and drugs use with sex. This combination is frequently associated with an increased likelihood of unsafe sex. Pollack (FC721) examining reasons for having unsafe sex amongst gay men in San Francisco found that those not in a primary relationship are more susceptible to situational factors such as drinking and drug use, also non-avadability of condoms, stress and sexual arousal are relevant factors in making a decision about whether or not to have unprotected intercourse. Those in monogamous relationships having unprotected anal intercourse are more likely to quote reasons such as being ‘in love’ or ‘having the same antibody status’. Whatever the relationship status being sexually ‘turned-on’ was quoted as a major factor in deciding to have unprotected sexual intercourse and the authors conclude, in common with several other studies t h ~ syear that there is a need to eroticize safer sex practices to make them more attractive. The need to improve sexual communication skills was also highlighted in &IS study as those not in longterm monogamous relationships were less likely to communicate effectively about HIV sero status and condom use. Wilson (ThD53) reporting on intention to use condoms amongst Zimbabwean school pupils also suggests the need to develop communication skills to reduce barriers to condom use, e.g. diminishing embarrassment about procurement and negotiation with the partner. Wilson suggests that one such barrier is the fear of upsetting the partner with the implication of AIDS. Poon (FC751) examined risk behav-
iours in partners of sero-positive haemophiLacs who have previously been counselled. They conclude that despite continual bombardment of safer sex counselling since 1982 risky sexual behaviour continues with a high pregnancy rate and suggest that an approach which takes into account more complex issues of sex, safer sex and procreation in this population is needed.
Return to unsafe practice
BU
from safer sexual
A number of authors raised the issue of ‘relapse’. Stall (ThClOS) reported from the AIDS Behavioural Research project in San Francisco that although there had been profound reduction in risk behaviours recorded in the study since 1984 a return from low risk to high risk behaviours of 19% was found. Predictors for return to unsafe sexual behaviour include an initial report of unprotected anal intercourse as a favourite activity and peer support for risk taking. The importance of maintenance interventions is stressed. St Lawrence (FC725) reported that factors predicting return to unsafe sex include the strength, frequency and reinforcement value of past unsafe behaviour and suggested the teachmg of skills to anticipate and successfully handle relapse temptations whilst developing community-based methods to assure environmental and social support for sustained behaviour change. Terms such as ‘relapse’ and ‘recidivism’ attracted considerable attention at this year’s Conference. However, these concepts are not yet clearly defined and agreed across studies. Such definitions must also take account of the reported inconsistency in safer sexual practice. Discussion Whilst the term ‘relapse’ may be useful in alerting us to the need for maintenance efforts it is nonetheless a medical term suggesting return to pathology. It is important that such terminology does not prevent us
Downloaded by [McGill University Library] at 07:41 11 February 2015
HI” AND SEXUAL BEHAVIOUR 393
examining the barriers to safe practice and exploring the motivators and decision-making processes around safer sex. We must also remain aware of the dissonant experience of reporting correct knowledge of transmission routes and prevention and at the same time discordant unsafe behaviour. Depending on the design of the study the subject may well give post hoc rationalisations such as unavailability of condoms. Some intriguing findings indicate that, whilst not following official health education guidelines, many individuals may consider themselves to be reducing their risk of HIV transmission through what they consider to be safer sexual practice. For example Sawazaki (ThDSO) found that in Japan, where reported sero-prevalence amongst gay men is low, the most common practice of ‘safer sex’ was to exclude ‘foreigners’ from bath houses. Interestingly this practice, which is preferred to that of condom use, is in a social setting where condoms are readily available through slot machines. In other cases the conclusion that sex is safer is based on erroneous beliefs, e.g. washing the anus after unprotected anal intercourse (Messiah
(SC686). At other times the issue may not be risk versus no risk but calculated risk. Hays (FC722) reports that the likelihood of acquiring HIV from young gay men was perceived as being significantly lower than -from older gay men. Amongst sexual partners of HIV haemophiliacs the desire to procreate may be stronger than the fear of AIDS, Poon (FC751). Studies of sexual behaviour look for evidence of the acceptance of well reasoned logical safer sex guidelines into the individual’s life style yet the evidence suggests that sexual behaviour is the result of a multitude of factors beyond rationahy, including emotions, situational variables, social norms, individual values, arousal, expectation. In the opening ‘Science to Policy’ Plenary Gloria Hall reminded us that provision of information is not enough. Prevention must affect the individual at the visceral level including values, experience and prior learning. With the elegant image of the attempt to pour the contents of a jug into an already full vessel Hall illustrated the fallacy of so many attempts to alter sexual behaviour.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV/AIDS and sexual behaviour S. Quinn
a
a
Clinical Psychologist and District AIDS Counsellor , Worthing District Health Authority , West Sussex, UK Published online: 25 Sep 2007.
To cite this article: S. Quinn (1990) HIV/AIDS and sexual behaviour, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 389-393, DOI: 10.1080/09540129008257760 To link to this article: http://dx.doi.org/10.1080/09540129008257760
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
389
AIDS CARE, VOL. 2, NO.4,1990
HIWAIDS and sexual behaviour S. QUI”
Downloaded by [McGill University Library] at 07:41 11 February 2015
Clinical Psychologist and Dism‘ct AIDS Counsellor, W d i n g District Health Aurhm‘ry, West Susses UK
‘The single most effective strategy for the prevention of HIV infection is the adoption of safer sexual behaviour’. This remains, in 1990, a resounding message from the International Conference on AIDS. It was heard not only in the Epidemiology/Prevention and Social Science presentations but also from the Basic and Clinical Science tracks, wherein it was reported that, despite numerous and complex developments in understanding of the virus, we are s t d l “10 years from a vaccine”. At the 6th International Conference there were 35 Papers presented and 175 posters relating to sexual behaviour. A selection is presented here to give a global perspective on the variety of work covered and the common themes. Surveys of knowledge and sexual
behaviour Following the worldwide health education campaigns promoting safer sexual behaviour and in particular condom use, numerous studies measured levels of knowledge, attitudes and sexual behaviour. Common findings were that: (i) knowledge levels do not correlate well with condom use, e.g. Wells (ThC106) reporting a survey of almost 6,000 heterosexual and homosexual respondents across France, UK and USA found no direct correlation and Musagara (ThC109) reported a
Ugandan household survey indicating much risky behaviour persisting despite high levels of knowledge. (ii) Correct knowledge of transmission routes frequently co-exists with erroneous beliefs, e.g. Ordonana (SC46) found that only specific messages from educational campaigns reached students involved and many misconceptions persisted. Faldsey (SC690), examining levels of knowledge and awareness at a US sexually transmitted disease clinic, found a high degree of knowledge about HIV transmission and prevention co-existing with varying levels of misinformation. (iii) Although safer sex behaviours, including condom use, have been initiated, practice is not consistent, e.g. De Vincenzi (ThClOO) found that 48% of HIV discordant sexually active couples did not use condoms consistently despite knowledge of risk and safer sex counselling. This pattern of findings emerged both in heterogenous samples and across different ‘risk’ populations which were studied. Amongst Mexican prostitutes Loo (ThDSl) reported that whereas 61% stated having used condoms most of the time during the previous 4 months, 80% continued to have unprotected vaginal intercourse at times, despite knowledge of risks. In Burkino Faso where 47% of prostitutes were HIV positive, Bakouan (ThD52) repons that HIV knowledge was low although 89% of the women
Downloaded by [McGill University Library] at 07:41 11 February 2015
390 SAN FRANCISCO SUMMARIES:S. QUINN claimed to use condoms. However, 56% reported that the condom had been refused by their clients. Numerous studies examined adolescent groups, many finding high levels of risky behaviours. Fullilove (Plenary address on Primary Prevention) commented that the typical US female did not commence the use of prophylaxis until 1 year after starting sexual intercourse and that young people in the 10-19 years age range were more likely to develop genital infections than older people, suggesting a higher level of unprotected sexual intercourse and numerous partners. Whilst 50% of these adolescents reported occasional condom use only 15% used condoms consistently. Ku (SC43) in a survey of teenage American men reported that although condom use is high, having increased from 21% to 58% over 9 years, it was least common amongst those at highest risk of HIV transmission. He reported that overall 34% of sexual acts amongst youths are protected with a condom. Antunes (SC42) reported a survey of Brazil’s street youth indicating that 80% were sexually active and, despite 60% reporting knowledge of HIV, only 7.3% using condoms. Over the past few years, changes to safer sexual practice amongst homosexual men have been widely reported. A disturbing finding, in countries where health education programmes, both general and targeted, are well established is the level of risk behaviour amongst younger gay men. Hays (FC722) reported that in San Francisco younger gay men, age range 18-25 years, 43% were engaging in unprotected anal intercourse. Similarly, in the UK, McManus (FC723) surveying gay young men under the age of 21 years, found that only 48% consistently used condoms for anal intercourse. Clearly, the reported rate of condom use needs to be seen in context in order to make meaningful predictions as to future behaviour. In Mexico, Izazola (ThC107) reports 30% condom use amongst gay men engaging in anal intercourse on average. However, he finds higher rates in cities
where AIDS prevention programmes have run longer, thus predicting that condom use is still increasing. Although the notion of high risk groups continues to be utilized as a convenience in survey research and is valuable in targeting of education, the importance of investigating hgh risk behaviours was once again emphasized in Doll’s (ThD49) finding that 24% of seropositive men who sometimes have sex with other men d d not self-identify as homosexual but heterosexual and that thls group are those most likely to consider themselves at low risk from AIDS and to have unprotected sexual intercourse.
Predictors of safer sexual practice As a number of studes found only a weak relation between correct knowledge of transmission/prevention and safer sexual practice, such knowledge may perhaps be regarded as a necessary but not sufficient condition for adoption of safer sexual behaviour. A number of studies looked for factors associated with safer sexual practice which might be used as predictors. Gallois (ThD54) examined the relationslup between intention and actual sexual behaviour in Australian men and women. This was mostly concordant, particularly when intention and past practice were congruent. The strongest predictive factor for actual behaviour was past behaviour. ‘Personalization’ is associated with safer sexual practice in some groups. Wells (ThC106) found that knowing someone with AIDS correlated with increased safe practice amongst US gay males although not amongst other groups. Rotheram-Borus (SC47) utilized personalized AIDS knowledge, coping skills and access to resources in a programme for changing sexual risk behaviours of gay male and runaway adolescents which was effective at 6 month follow-up in increasing condom use. Wilson (ThD53) reported that amongst Zimbabwean school pupils of whom 58% of
Downloaded by [McGill University Library] at 07:41 11 February 2015
HIV AND SEXUAL BEHAVIOUR
males and 45% of females reported sexual experience, belief in the efficacy of HIV prevention together with social support for this behaviour are factors predicting intended condom use. Drawing on the established efficacy of peer and social norms, Kelly (SC40) utilized natural opinion leaders trained in risk reduction to reach gay men engaging in hgh risk sexual behaviours. Having identified a subset of most popular persons in gay social networks in small cities, these were trained and contracted to act as change endorsers to friends. Si@cant population-wide reductions in unprotected anal intercourse and significant increases in safer sex practices were found. This was corroborated by increased rates of condom taking in gay clubs. The authors conclude the model appears very promising for other peer-sensitive populations. Fear, often used in health education and health advertising, has in the past been shown to be unrelated to change to safer practice. Some studies in this Conference reported a limited relationship of fear of AIDS to the use of condoms or other safer behaviours. Wells (ThC106) reported that fear of AIDS was related to the use of condoms during vaginal intercourse and to initiating the use of condoms; the strongest association being found in the US and in France. Moore (ThC105) in a survey of 1,480, mainly Catholic, students in Zaire found that the fear of STDs was a major determinant in avoiding partners with multiple partners. Sherr (SC688) reported that fear arousal as a model faired less well than humour in modifying sexual and risky behaviour and that risk behaviour was reduced, although not eliminated by either. Talking about safer sex with one’s partner may also predict safer practice. Choi (SC761) found that couples who discussed using condoms were almost four times more likely to use condoms than those who had no such discussion. Amongst adolescents a similar finding was reported by Rasmussen (SC727); where sexual subjects were dis-
39 1
cussed in the home, adolescents were more likely to d~scusscontraception before intercourse. Sarna Seppo (SC702) followed a cohort of homosexually active men for 6 years in Finland to determine the effect of repeated personal c o u n s e b g on the use of condoms. Whilst other influences on behaviour over such a period cannot be ignored, this longterm follow-up shows dramatic changes in sexual behaviour. A decrease from 90% to 62% practising anal intercourse, and a decrease from 87% to 8% of men never using condoms was reported to occur over 6 years. Ferreros (SC697) reported the success of a social marketing programme for condoms utilizing the technologies of mass consumer research. Total sales in Zaire increased by 443% over one year. Helquist (SC693) examined the effect of both a descriptive brochure and structured modelling of correct condom use on condom use skills. Whilst both interventions produced improved skills, significantly greater improvement was found with the modelling intervention. T h s study of male STD clinic patients in the Eastern Caribbean demonstrated that although time consuming, the modelling of correct condom use may be a valuable component in educational interventions. Barchi (SC714) reported that counselling and HIV testing together with the rehearsal of correct condom use was associated with an increase of condom use during vaginal intercourse amongst sex workers in California.
Barriers to safer sexual behaviour and factors correlated with risk A variety of factors have been examined and identified as relating to risky behaviour. Correlating psychological factors, Kelly (ThB26) reported that a sense of helplessness and hopelessness was associated with an increased likelihood of unprotected anal intercourse and Philips (FC734) examining stress and coping found that subjects who engaged in unprotected anal intercourse
Downloaded by [McGill University Library] at 07:41 11 February 2015
392
SAN
FRANCISCOSUMMARIES:s. QUINN
(USAI) use more self-controlling coping, more distancing and more escape avoidance coping than subjects who did not engage in UAI, amongst a sample of gay men. Capell (ThC111) found that amongst the general Californian population unmarried status together with increased age was associated with increased likelihood of risky behaviour. A report from the 5th population-based survey of the San Francisco AIDS Foundation found that more than one-third of gay and bi-sexual men combined alcohol and drugs use with sex. This combination is frequently associated with an increased likelihood of unsafe sex. Pollack (FC721) examining reasons for having unsafe sex amongst gay men in San Francisco found that those not in a primary relationship are more susceptible to situational factors such as drinking and drug use, also non-avadability of condoms, stress and sexual arousal are relevant factors in making a decision about whether or not to have unprotected intercourse. Those in monogamous relationships having unprotected anal intercourse are more likely to quote reasons such as being ‘in love’ or ‘having the same antibody status’. Whatever the relationship status being sexually ‘turned-on’ was quoted as a major factor in deciding to have unprotected sexual intercourse and the authors conclude, in common with several other studies t h ~ syear that there is a need to eroticize safer sex practices to make them more attractive. The need to improve sexual communication skills was also highlighted in &IS study as those not in longterm monogamous relationships were less likely to communicate effectively about HIV sero status and condom use. Wilson (ThD53) reporting on intention to use condoms amongst Zimbabwean school pupils also suggests the need to develop communication skills to reduce barriers to condom use, e.g. diminishing embarrassment about procurement and negotiation with the partner. Wilson suggests that one such barrier is the fear of upsetting the partner with the implication of AIDS. Poon (FC751) examined risk behav-
iours in partners of sero-positive haemophiLacs who have previously been counselled. They conclude that despite continual bombardment of safer sex counselling since 1982 risky sexual behaviour continues with a high pregnancy rate and suggest that an approach which takes into account more complex issues of sex, safer sex and procreation in this population is needed.
Return to unsafe practice
BU
from safer sexual
A number of authors raised the issue of ‘relapse’. Stall (ThClOS) reported from the AIDS Behavioural Research project in San Francisco that although there had been profound reduction in risk behaviours recorded in the study since 1984 a return from low risk to high risk behaviours of 19% was found. Predictors for return to unsafe sexual behaviour include an initial report of unprotected anal intercourse as a favourite activity and peer support for risk taking. The importance of maintenance interventions is stressed. St Lawrence (FC725) reported that factors predicting return to unsafe sex include the strength, frequency and reinforcement value of past unsafe behaviour and suggested the teachmg of skills to anticipate and successfully handle relapse temptations whilst developing community-based methods to assure environmental and social support for sustained behaviour change. Terms such as ‘relapse’ and ‘recidivism’ attracted considerable attention at this year’s Conference. However, these concepts are not yet clearly defined and agreed across studies. Such definitions must also take account of the reported inconsistency in safer sexual practice. Discussion Whilst the term ‘relapse’ may be useful in alerting us to the need for maintenance efforts it is nonetheless a medical term suggesting return to pathology. It is important that such terminology does not prevent us
Downloaded by [McGill University Library] at 07:41 11 February 2015
HI” AND SEXUAL BEHAVIOUR 393
examining the barriers to safe practice and exploring the motivators and decision-making processes around safer sex. We must also remain aware of the dissonant experience of reporting correct knowledge of transmission routes and prevention and at the same time discordant unsafe behaviour. Depending on the design of the study the subject may well give post hoc rationalisations such as unavailability of condoms. Some intriguing findings indicate that, whilst not following official health education guidelines, many individuals may consider themselves to be reducing their risk of HIV transmission through what they consider to be safer sexual practice. For example Sawazaki (ThDSO) found that in Japan, where reported sero-prevalence amongst gay men is low, the most common practice of ‘safer sex’ was to exclude ‘foreigners’ from bath houses. Interestingly this practice, which is preferred to that of condom use, is in a social setting where condoms are readily available through slot machines. In other cases the conclusion that sex is safer is based on erroneous beliefs, e.g. washing the anus after unprotected anal intercourse (Messiah
(SC686). At other times the issue may not be risk versus no risk but calculated risk. Hays (FC722) reports that the likelihood of acquiring HIV from young gay men was perceived as being significantly lower than -from older gay men. Amongst sexual partners of HIV haemophiliacs the desire to procreate may be stronger than the fear of AIDS, Poon (FC751). Studies of sexual behaviour look for evidence of the acceptance of well reasoned logical safer sex guidelines into the individual’s life style yet the evidence suggests that sexual behaviour is the result of a multitude of factors beyond rationahy, including emotions, situational variables, social norms, individual values, arousal, expectation. In the opening ‘Science to Policy’ Plenary Gloria Hall reminded us that provision of information is not enough. Prevention must affect the individual at the visceral level including values, experience and prior learning. With the elegant image of the attempt to pour the contents of a jug into an already full vessel Hall illustrated the fallacy of so many attempts to alter sexual behaviour.
