A Guide to AIDS Research and Counseling
Volume 8, Number 2, January 1993
In this issue
Editorial: Right Behavior
Robert Marks, Editor
In the HIV community, the word "relapse" has taken on almost mythic
proportions. In the wake of dramatic changes in sexual behavior among gay
men, HIV prevention efforts were held up to the world as a model. Relapse
was the David that tarnished this Goliath achievement, proving that our
declarations of victory were premature.
Both beliefs--that behavior change succeeds or fails--are
oversimplifications. Behavior change is a process, not an attribute that one
acquires, not a vaccine that once injected protects for life. In this issue
of FOCUS, David Silven's examination of four behavior change theories
demonstrates the complexity of this process and the variety of factors called
into play each time an individual makes a decision about behavior. Wayne
Blankenship's survey of relapse programs shows how educators have begun to
respond to this complexity.
As much as we hope that the behavior process can be facilitated by the
programs Blankenship covers, it is clear that the central arena in which the
struggle plays out is in the minds of individuals. And these minds are not
as easily manipulated to change sexual practices as they seem to be to change
breakfast cereal or soft drink.
Defined more by individual than by cultural or societal perceptions
about sex, intimacy, risk, and the value and struggle of life, the response
to behavior change interventions is far more complicated than it might first
appear. "Relapse" is an indication not of the failure of HIV prevention, but
of the importance of counseling approaches that respond to these individual
Mental health practitioners are faced with the crucial task of framing
HIV prevention in this context and helping people work toward understanding
their attitudes and feeling about these issues. Silven's article will help
counselors identify theoretical approaches, and Blankenship's will help
practitioners appreciate the range of prevention programs.
To succeed in their efforts, however, counselors might consider
tempering ultimate therapeutic goals and redefining success. If lapses are
a normal part of behavior change, and if it is in acknowledging our beliefs
that we can recognize the motivations that determine the behaviors we choose,
then the counselor's goal is first and foremost to get clients to confront
the thoughts and feelings that induce risky behaviors.
Given the complexity of these factors, the hardest part of the
counseling effort is that it must go beyond the assumption that everyone
will, or should, embrace life. Success for the therapist is not in deterring
relapse but in enabling clients to consider these issues so that they may
come to their own prevention-positive conclusions.
Behavioral Theories and Relapse
by David Silven, Ph.D.
At a recent discussion of health educators about relapse into unsafe
sex among gay and bisexual men, a participant suggested that theory-based
principles of behavior change be used as guides to develop relapse prevention
interventions. Other participants responded with skepticism; the majority
seemed to agree that theory should remain in the classroom.
What use, if any, does theory have in the critical area of sexual
relapse prevention? To address this question, this article summarizes four
basic behavior theories--The Health Belief Model, Social Cognitive Theory,
Stages of Change, and Marlatt's Relapse Prevention Model--and examines the
applicability of these theories in planning prevention interventions.
The Health Belief Model
The Health Belief Model grew out of research in the 1950s and 1960s--by
Irving Rosenstock and colleagues at the United States Public Health Service--
that investigated the widespread failure of people to take preventive health
measures such as annual physical checkups, and screening tests for
tuberculosis and dental disease. The model postulates that individuals will
take preventative actions when they:
- believe that they are susceptible to a disease that would
have at least moderately severe negative consequences;
- believe that taking such actions will be beneficial in reducing
the threat of the disease and that this benefit will sufficiently
outweigh the costs, such as the inconvenience and effort required,
embarrassment, and financial expense;
- perceive a stimulus or "cue to action": either internal, for
example, the perception of an uncomfortable bodily state; or
external, for example, mass media campaigns, newspaper articles,
or personal knowledge of someone affected by the disease.
The perception of threat and the occurrence of a cue to action, which
raises awareness of feelings of threat, lead to the decision to act. The
direction that action takes is influenced by beliefs about the relative
availability and effectiveness of alternatives for reducing the threat,
which, in turn, are influenced by social norms.
Social Cognitive Theory
Albert Bandura's Social Cognitive Theory suggests that in order to take
a particular course of action, individuals must not only possess the required
skills but must also believe that the action will lead to a desired outcome
and that they are personally capable of performing the action. This belief
in personal capability, known as "self-efficacy," is a pivotal concept in
Bandura's theory: it influences how much effort a person invests in an action
and how long he or she will persevere in the face of difficulties or
As individual develops self-efficacy by accumulating feedback from four
primary sources: personal experience of successfully performing the behavior;
vicarious experience through observing others perform the behavior
("modeling"); persuasion by others who convey that the individual is capable
of performing the behavior; and physiological states.
Of these four sources of information, successful performance of
"mastery" experiences are considered the most potent in raising levels of
self-efficacy. Proficiency with new behaviors requires extensive practice.
Ideally, this practice occurs with considerable external guidance,
encouragement, and feedback; it progresses gradually to more challenging
situations, the removal of external support, and increased opportunities for
self-guided practice. Failure and difficulty during the learning process
help build a resilient sense of self-efficacy by providing experience in
Through modeling, people learn skills and judge their capabilities in
comparision to others. It is crucial that individuals perceive themselves as
similar to the models they observe, articularly in terms of the degree of
hesitancy and fear they feel in challenging situations.
Persuasion by others provides encouragement that can lead people to
believe they are capable of performing a desired behavior. The impact of
persuasion varies according to the perceived credibility of the persuader.
Finally, individuals rely partly on their physiological state to judge
their abilities to perform target behaviors. Self-efficacy is strengthened
when people possess skills to reduce uncomfortable physiological reactions,
such as agitation, and insight to interpret these reactions as normal rather
than as a sign of inefficacy.
States of Change
In the early 1980's, James Prochaska and Carlo DiClemente outlined
several fundamental stages through which individuals typically progress when
making behavioral changes precontemplation, contemplation, action, and
maintenance of change. During the precontemplation stage, people are
unaware--because they are uninformed or in denial--of having a problem in
need of change, even though others may perceive the problem.
In the next stage, contemplators are seriously thinking about but not
committed to changing their behavior. They tend to be relatively open to
feedback and education about the problem behavior. The contemplation stage
ends at the point that a commitment to change is made.
Progression through the stages is cyclical rather than linear. People
will often revert to an earlier stage, which is then repeated. Relapse is
seen as leading back to either the contemplation stage, from which the
individual may again attempt to change, or to the precontemplation stage,
during which the individual succeeds in avoiding, at least temporarily,
having to think about the behavior as a problem.
People utilize different processes of change during the various stages.
In the contemplation stage, for example, the processes include information
seeking and evaluation of one's behavior. In the action and maintenance
stages, processes include changing the environment to build in supports for
new behaviors and to minimize risk-associated stimuli, and developing new
responses to these stimuli.
Marlatt's Relapse Prevention Model
Alan Marlatt and his colleagues developed in the mid-1980s a
cognitive-behavioral model that focuses on coping during "high-risk
situations," situations that pose a threat to the individual's sense of
control and increase the risk of relapse. According to the theory, lapses--or
single incidents of slipping into the avoided behavior--are considered
important and expected components of the behavior change process. Through
trial-and-error, new response patterns in high-risk situations are gradually
acquired, corrected, and strengthened.
Whether lapses are followed by a total relapse, that is, a return to
baseline levels of the behavior, is largely determined by how the individual
reacts to the lapse: this is called the "Abstinence Violation Effect." If he
or she perceives the slip as a response to a particularly difficult situation
or as a sign that he or she needs more practice with the new behavior, the
lapse is unlikely to lead to relapse. On the other hand, if the individual
attributes the slip to personal weakness or failure, the risk of relapse is
Another aspect of the Abstinence Violation Effect is the experience of
cognitive dissonance resulting from the contradiction between the
individual's self-perception as an abstainer and the occurrence of the
prohibited behavior. This dissonance creates conflict or guilt and motivates
efforts to eliminate these unpleasant feelings. Thus, people may engage
further in the prohibited behaviors in an attempt to produce positive
feelings to replace these unpleasant ones. Alternately, there may be a change
in self-image as lapsers begin to think of themselves as non-abstainers. In
either of these cases, the stage is set for relapse.
Additional factors contributing to the risk of relapse include the use
of denial to mask the potential negative consequences of slipping, and
rationalization to justify the prohibited behavior based, for example, on the
extreme demands of everyday life. Finally, relapse may be seen as the result
of a chain of decisions leading to a high-risk situation.
Applying the Theories
These theories suggest several reasons why sexual relapse might occur
and guidelines for how to minimize the risk of its occurrence. First, as
suggested by the Health Belief Model, people may relapse because they no
longer perceive unsafe sex as a significant problem. As suggested by the
Stages of Change theory, behavior change may naturally involve back-and-forth
movement among stages, including repeated reentry into the precontemplation
stage of unawareness. Alternately, people may initially change behavior from
unsafe to safer sex as a result of external pressure, and prior to a firm
internal commitment to safer sex; once the external pressure diminishes, the
behavior change breaks down. A third explanation, using Marlatt's model, is
that people fail to perceive unsafe sex as a problem because of the
psychological denial they employ to avoid anxiety.
HIV-infected people, in particular, may relapse because they question
the legitimacy of warnings against the dangers of "reinfection" by HIV.
Others may be unaware of the seriousness of the risk to their immune systems
of other diseases that can be contracted through unsafe sex.
Successful prevention efforts should first establish whether the target
audience is fully aware of the dangers of unsafe sex before proceeding with
information about prevention strategies. For those who are not yet committed
to avoiding unsafe sex, educators might direct efforts at mobilizing interest
in exploring whether a problem really exists. For those who are misinformed
or uninformed, providing information about risk is critical.
Second, as suggested by the Health Belief Model and Social Cognitive
Theory, people may relapse because they are not convinced that safer sex
adequately reduces the chances of infection. Specifically, they may question
whether condoms are truly effective barriers against transmission. They may
have heard stories about condoms breaking, or about people becoming infected
presumably without having participated in unsafe sex or other high-risk
activities. Again, supplying clear and credible information--in this case,
about the effectiveness of condoms--would seem critical.
Third, people may relapse because, as the Health Belief Model further
suggests, they do not feel convinced that the health benefits of safer sex
outweigh the effort required to avoid unsafe sex. As Marlatt points out,
those who experience day-today life as full of demands may reach a point
where they no longer feel motivated to pursue long-term goals--in this case,
health and longevity--that involve depriving themselves of short-term
pleasure or relief. Or, they may not feel they have the internal strength and
resources needed for prolonged efforts avoiding unsafe sex. This may be
particularly true of many who are feeling the effects of loss and grief. Help
in coping with extreme stress, depression, and loss may be necessary before
these individuals can feel renewed commitment to safer sex.
Fourth, according to Social Cognitive Theory and Marlatt, people may
relapse because they do not have, or do not feel they have, the necessary
skills to avoid unsafe sex in all situations. This may result from
insufficient trial-and-error learning. People may lack skill or confidence in
using condoms or in having satisfying forms of safer sex that do not require
condoms. They may also lack the skill or confidence required to effectively
deal with various situations that can easily lead to unsafe sex. These
include negotiating or talking about safer sex with partners; insisting on
safer sex; coping with stress related to social anxiety; and responding to
social or internal pressures to drink or use drugs in conjunction with sex.
Finally, according to Marlatt, people who relapse may lack the
awareness or resolve to break the chain of events that tends to lead to
high-risk situations. For example, a man may be unable to stop himself from
going to a bar to find a sex partner, despite the fact that he knows that
this will lead to the pressure to drink heavily, the likelihood that he will
become intoxicated, and the heightened risk that he will engage in unsafe sex
as a result. Furthermore, they may lack the ability to see failures or
setbacks as normal parts of the learning process, leaving them unable to
rebound when slips do occur.
These theories suggest that behavior change interventions must go
beyond providing prevention information and limited practice with condoms.
Educators must make efforts to identify additional areas in which target
audiences lack skills, including negotiating safer sex and avoiding
situations in which sex and mind-altering substances are mixed. They must
help people acquire skills and achieve mastery, provide practice in coping
with mistakes, and prepare individuals for the possibility that lapses may
occur. Finally, for those not ready to commit to avoiding unsafe sex,
supplying basic information may be ineffective without efforts to address the
reluctance to change.
Bandura A. "Self-efficacy; Toward a unifying theory of behavior change,"
Psychological Review 1977;84:191-215.
Bandura A. "Social foundations of thought and action: A social cognitive
theory." Englewood Cliffs, NJ: Prentice Hall, 1986
Clearinghouse: Preventing Relapse
Marlatt A. Gordon Jr. Relapse Prevention: Maintenance Strategies
in Addictive Behavior Change. New York: Guilford Press, 1985.
Prochaska JO. DiClemente CC. Transtheoretical therapy: Toward a
more integrated model of change. Psychotherapy Theory, Research,
and Practice. 1982;19(3):176-288.
Prochaska JO. DiClemente CC. Stages and processes of self-change
of smoking: Toward an integrative model of change. Journal of
Consulting and Clinical Psychology. 1983;51:390-395.
Rosestock IM. Historical origins of the health belief model. Health
Education Monographs. 1974;2(4):328-335.
David Silven, PhD is a clinical psychologist in private practice
in San Francisco and Clinical Consultant to Community and Client
Services at the UCSF AIDS Health Project.
Relapse Prevention Interventions
The unprecedented success of safe sex programs for gay and bisexual men
has led to the recent focus on relapse prevention programs aimed at men who
have made a commitment to safe sexual behavior but have experienced lapses
into unsafe sex. This article examines current gay and bisexual men's relapse
prevention programs ranging from peer education and professional
counseling-which seek on a personal level to encourage consistency--to social
marketing strategies--which are designed to solidify community norms
supporting safe behaviors.
It is important to note that designing relapse programs is complicated
by the difficulty of identifying and recruiting participants. Even the best
programs will fail if those targeted do not participate.
Peer Education Models
Peer education models have sought to create a safe and nonjudgmental
environment in which men can discuss the complexities of long-term behavior
change while learning from others. One such program at Gay Men's Health
Crisis (GMHC) in New York--the "Keep It Up" workshops--began in 1989, before
the terminology of "relapse" had been used to describe what GMHC had
identified as inconsistencies" in safe sex behavior.
"Keep It Up" workshops were designed as follow-up support for men who
had attended a safe sex forum. The day-long workshop, facilitated by small
group discussion leaders, focused on eroticizing safe sex, developing
negotiating skills, and resolving other challenges related to behavioral
inconsistencies. Also, some men described relapse in terms of compulsive or
out-of-control situations while others described it as a conscious decision
to have unsafe sex.
Among the peer education programs that first focused specifically on
relapse were the STOP AIDS Project in San Francisco and LIFEGUARD in Los
Angeles. In the past few years, relapse-related workshops have become more
targeted and specific, for example, focusing on mixed serostatus couples.
City agencies collectively produce San Francisco's annual "Carnal Carnival,"
which includes live demonstrations and games geared to sustain an interest in
safe sex in a city where some men have become numbed to the usual educational
messages. Other programs around the country have found that workshops using
dating and relationships as a primary focus--"How to Meet a Man" is the title
of one--are successful in breaking through the resistance to attend yet
another safe sex workshop.
Another innovative strategy coordinated by Jeffrey Kelly at the
University of Wisconsin trains popular gay men to serve as "key opinion
leaders" in the gay male community.2 By instructing them in developing a new
vocabulary--for example, "I am learning to..." rather than "You
should..."--the program enables them to influence their friends and community
norms around safe behaviors.
Counseling models have sought to provide therapeutic behavior
modification or structured referral and prevention for men experiencing
relapse. The ARIES Project from the University of Washington in Seattle uses
a group phone counseling format in a cognitive-behavioral approach.3 Men
either participate in 14 half-hour anonymous phone sessions or as members of
a control group. Initial results indicate that men from rural areas and men
who are less identified with the gay community access this type of service at
higher rates than they access other types of services.
Two San Francisco programs--the UCSF AIDS Health Project's Safer Sex
Counseling Program and 18th Street Services, which targets gay men in
recovery--offer relapse-specific counseling interventions.
Also in San Francisco, the Gay Men of Color Consortium, Japanese
Community Health Center, Stop AIDS Project, and San Francisco AIDS Foundation
are beginning to provide city-wide referral and individual case management
concerning behavior maintenance. Men who have identified relapse as a concern
will get help developing a prevention plan with realistic goals and
individualized completion criteria.
Several agencies have been successful in using high-profile,
environmental ad campaigns to encourage change in peer norms for safe
behaviors. The Northwest AIDS Foundation in Seattle designed an ad campaign
using the "Keep It Up, Seattle" slogan to send a congratulatory message
encouraging consistency and a sense of personal and gay community pride.
The San Francisco AIDS Foundation ran a relapse-specific ad campaign
including two full-page ads on consecutive pages--one titled "Relapse" and
one titled "Maintain." The first ad articulated a clear definition of
relapse, and the second acknowledged and encouraged safe behavior
Many of the recent high-profile ad campaigns from "first wave" cities,
like the foundation's 1992 "Moral Majority, Family Values, Right to Life"
subway and bus shelter posters are designed to support behavior maintenance
by asserting that safe sex is an accepted norm for gay men. These public
programs seem to be most effective when other interventions are in place to
provide further information and support.
This short history of gay men's relapse prevention programs raises as
many questions about the future of relapse prevention as it answers about the
current state of safe sex education. Do we adopt the terminology of "relapse"
or "behavior maintenance" in our education strategies? Do we follow the model
of substance abuse prevention, and if so, do we employ strategies that stress
abstinence or gradual and systematic risk reduction?
How do we rethink our primary messages to gay and bisexual men who may
have believed that safe sex was a temporary concession in the mid-1980s
rather than a lifetime commitment? What message are we offering seropositive
men about the need for continued safe sex? How do we discourage some
behaviors without the financial support from government to "promote" less
How do we counter media stories that characterize our efforts as
failures in headlines like "Gay Men Still Engaging in Unsafe Sex?"
These questions cannot be answered without additional funding for
research regarding such issues as gay male sexuality and the relative risk of
behaviors like oral sex, and how behavior is affected by grief and other
responses to surviving the epidemic. They also cannot be answered without
comprehensive and scientific evaluation of prevention approaches.
Ironically, the goals of current relapse prevention strategies--to
encourage confidence and self esteem--are often in conflict with cultural
messages about gay men. As we struggle to create images of confident and
successful gay men--supported by their peers to engage in healthy
behaviors-continued underfunding of prevention programs affirms the
frightening idea that the lives of gay men are expendable sacrifices to the
first decade of the epidemic.
One study suggests that overestimating risk of unprotected oral
sex may, in fact, contribute to relapse into unprotected anal
- DeMayo M. The future of AIDS prevention programs. SIECUS
- Kelly J. Lawrence JS. Diaz YE. et al. HIV-risk behavior
reduction following intervention with key opinion leasers of
population: An experimental analysis. American Journal of Public
- Roffman RA. Beadnall BA. Gordon Jr. et al. Relapse prevention
counseling by telephone as a means of reducing AIDS risk in men who
have sex with other men. Presentation from the 99th Annual Meeting
of the American Psychological Association, San Francisco, August
- Marlatt GA. Tapert SF. Harm reduction: Reducing the risks of
addictive behaviors. In: Baer JS, ed. Addictive Behaviors Across
the Lifespan: Prevention, Treatment and Policy Issues. Newbury
park, Calif: Safe Publications.
- De Vroome E. Sandfort T. Tidman R. Overestimating the risk of
orogenital sex may increase unsafe anogenital sex. Presentation
from the VIII International Conference on AIDS, Amsterdam,
Netherlands, July 1992.
Wayne Blankenship is a Campaign Development Coordinator at the San
Francisco AIDS Foundaton and Coordinator of the National Relapse
A Critique of the Concept of Relapse
Hart G, Boulton M, Fitzpatrick R, et al. 'Relapse' to unsafe
sexual behaviour among gay men: A critique of recent behavioural
HIV/AIDS research. Sociology of Health & Illness. 1991; 14(2):
216-232. (University College and Middlesex School of Medicine,
St. Mary's Hospital Medical School, and University of Oxford .)
The concept of relapse confuses efforts to understand why some gay men
engage in unprotected anal intercourse after periods of not doing so.
According to a methodological and empirical critique of the term relapse,
this concept fails to convey the contexts and decision-making processes
within which sexual behaviors occur.
Use of an absolute category obscures the nature of relationships within
which risks are taken and overlooks how knowledge of antibody status affects
choices. For example, the risk of engaging in unsafe sex is lower between
antibody negative gay men in monogamous relationships. In this context, a
decision to engage in risky sex is best described not as a "relapse" but as
a decision made after an analysis of relative risks. The design of some
relapse studies also obscures the facts that some gay men may be better
described as "chronic high-risk takers" and that younger gay men may be
commencing a particular sexual activity rather than relapsing.
"Relapse," borrowed from medical science specifically in terms of
alcohol and drug addiction, imparts a negative moral judgment to sexual
behavior. The concept also implies that unsafe sex is addictive, whereas
research demonstrates that gay men who engage in unprotected anal intercourse
cannot be distinguished in any way from other gay men. Further, the model of
human sexual response that underlies the concept of relapse portrays gay male
sexuality as governed by powerful penetrative needs that require long-term
policing. This portrait plays into societal prejudices and stereotypes about
To accurately understand gay male sexual behavior and HIV transmission,
future studies should be more process-oriented, that is, focused on how the
nature of each relationship affects decisions to take sexual risks. Analysis
of other situational factors, such as the antibody status of partners, the
emotional dimensions of relationships, and prevalent local and social
realities would reveal the true complexity of gay male sexuality.
Interventions That Reduce Risk Behaviors
Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychological
Bulletin. 1992; 111(3): 455-474. (University of Connecticut and
University of Western Ontario.)
A comprehensive review and analysis of the research on AIDS
interventions published from 1980 to 1990 found that a combination of AIDS
information, motivation, and behavioral skills can reduce risk behaviors. A
suggested model features interventions targeted at populations whose needs
must be clarified through research to determine levels of AIDS knowledge,
motivation, and behavioral skills. The resulting population-specific
interventions must then be evaluated in terms of specific outcomes.
The reviewers analyzed 48 published and unpublished reports of interventions
directed at gay and bisexual men, injection drug users, prostitutes, college
students, adolescents, STD clinic attendees, and the general public. They
described the nature of the intervention, the numbers of people affected, and
the intervention's impact. Most interventions were based on an informal mix
of logic and practical experience, rather than on social psychological
theory, and rarely included research to identify the specific needs of the
target populations. Interventions with a broader focus conveying HIV-related
information, motivation, and behavioral skills tended to have a greater
impact, although most of these interventions had methodological problems that
undercut their usefulness and applicability.
In the proposed intervention model, information is necessary but not
sufficient to produce change. Motivation to change AIDS-risk behavior must
also be present. Using the theory of reasoned action developed by Fishbein
and Ajzen, individual and societal attitudes towards preventive behavior are
the key elements affecting motivation. Identifying these attitudes and
designing interventions to change them is the focal point of prevention
efforts. Finally, the intervention model asserts that behavioral skills must
be taught, rehearsed, and modeled. Among these skills are communicating and
being assertive with sexual partners about specific safer sex practices and
self-efficacy, that is, a belief in one's ability to behave in certain ways.
Long-Term Risk Reduction by Drug Users
Des Jarlais DC, Abdul-Quader A, Tross S. The next problem:
Maintenance of AIDS risk reduction among intravenous drug users.
International Journal of the Addictions. 1991; 26(12): 1279-1292.
(Beth Israel Medical Center, Narcotic and Drug Research Inc., and
Memorial Sloan-Kettering Cancer Institute.)
Factors that influence initial HIV risk reduction do not affect
maintenance, according to a study of injection drug users in New York City.
Initiating risk reduction was associated with having fewer sex partners and
with having friends who practiced risk reduction. But maintaining risk
reduction was linked to ethnicity--specifically, Latino/Hispanic-and to a
belief that risk reduction protects against HIV infection.
Following a face-to-face HIV prevention intervention focusing on sexual
and drug-using behaviors, researchers recruited and questioned 399 injection
drug users in New York City about their sexual practices, drug use, beliefs
about AIDS, and demographic characteristics. Subjects were primarily White
men (45 percent), most were male (71 percent), and 44 percent had less than
12 years of education. The mean age was 35 years. Although 80 percent had
initiated risk reduction, a significant minority (36 percent) reported some
degree of relapse to pre-intervention risky behaviors. Most instances of
relapse, however, were episodic.
Because the factors affecting initiation and maintenance were
different, risk reduction is best understood as a process accomplished in
stages. To be successful, interventions must address the motivational demands
appropriate to each stage.
Predicting Relapse among Gay Men
Adib SM, Joseph JG, Ostrow DG, et al. Predictors of relapse in
sexual practices among homosexual men. AIDS Education and
Prevention. 1991; 3(4): 293-304. (University of Michigan.)
Being in monogamous relationships, receiving minimal peer support for
safer sex, and lacking assertiveness in negotiating about sex were among the
interpersonal factors that predicted relapse among subjects in a large study
of gay men in Chicago. Personality factors, such as self-esteem and mastery,
and sociodemographic factors were not predictive. Researchers analyzed
questionnaires submitted by 910 participants in the Chicago component of the
Multicenter AIDS Cohort Study (MACS). A majority of respondents were White
(92 percent); the mean age of the group was 35, mean income was $26,000, and
mean educational attainment was 16.3 years.
From 1986 to 1987, of those practicing receptive anal intercourse, 53
percent maintained safer sexual practices and 31 percent relapsed; of those
practicing insertive anal intercourse, 47 percent maintained safer sex
practices and 35 percent relapsed. For both groups, relapse occurred among
those who were less motivated to reduce transmission risk, had lower
limit-setting skills, were less assertive in negotiating safer sex, and had
a lower tolerance of safer sex. Men who practiced receptive anal sex were
also less likely to be satisfied with condom use.
The results of this study may be biased by study design and data
collection techniques, including self-selection and self-report biases, and
a dropout effect. It is best applied to individuals similar to the
Additional Reading: Preventing Relapse
Aspinwall LG, Kemeny ME, Taylor SE, et al. Psychosocial predictors
of gay men's AIDS risk-reduction behavior. Health PsYcholoay. 1991;
Dorfman LE, Derish PA, Cohen JB. Hey girlfriend: An evaluation of
AIDS prevention among women in the sex industry. Health Education
Quarterly. 1992; 19(1): 25-40.
Dublin S, Rosenberg PS, Goedert JJ. Patterns and predictors of
high-risk sexual behavior in female partners of HIV-infected men
with hemophilia. AIDS. 1992; 6(5): 475-482.
Ekstrand ML. Safer sex maintenance among gay men: Are we making any
progress? AIDS. 1992; 6(8): 875-877.
Jemmott JB 3rd, Jemmott LS, Fong GT. Reductions in HIV risk-
associated sexual behaviors among black male adolescents: Effects
of an AIDS prevention intervention. American Journal of Public
Health. 1992; 82(3): 372-377.
Kalichman SC, Hunter TL. The disclosure of celebrity HIV infection:
Its effects on public attitudes. American Journal of Public Health.
1992; 82(10): 1374- 1376.
Kelly JA, St. Lawrence JS, Brasfield TL. Predictors of
vulnerability to AIDS risk behavior relapse. Journal of Consulting
and Clinical Psychology. 1991; 59(1):163-166.
Mays VM, Cochran SD, Belinger G. The language of black gay men's
sexual behavior: Implications for AIDS risk reduction. Journal of
Sex Research. 1992; 29(3): 425-434.
McCusker J, Stoddard AM, McDonald M, et al. Maintenance of
behavioral change in a cohort of homosexually active men. AIDS.
1992: 6(8): 861-868.
McKusick L, Hoff CC, Stall R, et al. Tailoring AIDS prevention:
Differences in behavioral strategies among heterosexual and gay bar
patrons in San Francisco. AIDS Education and Prevention. 1991;
O'Reilly KR, Higgins DL. AIDS community demonstration projects for
HIV prevention among hard-to-reach groups. Public Health Reports.
1991; 106(6): 714-720.
Schilling RF, el-Bassel N, Schinke SP, et al. Building skills of
recovering women drug users to reduce heterosexual AIDS
transmission. Public Health Reports 1991; 106(3): 297-304.
Sufian M, Friedman SR, Curtis R, et al. Organizing as a new
approach to AIDS risk reduction for intravenous drug users. Journal
of Addictive Diseases. 1991; 10(4): 89-98.
Wenger NS, Linn LS, Epstein M, et al. Reduction of high-risk sexual
behavior among heterosexuals undergoing HIV antibody testing: A
randomized clinical trial. American Journal of Public Health. 1991;
Wayne Blankenship, San Francisco AIDS Foundation, 25 Van Ness Avenue, San
Francisco, CA 94101, (415) 864-4376.
Martin McCombs, PhD, Gay and Lesbian Community Services Center, 1625 North
Hudson Avenue, Hollywood, CA 90028-9998, (213) 993-7643.
David Silven, PhD, UCSF AIDS Health Project, Box 0884, San Francisco, CA
94143, (415) 476-6441.
Ronald O. Stall, PhD, UCSF Center for AIDS Prevention Studies, Box 0886, San
Francisco, CA 94143, (415) 597-9155.
FOCUS is a monthly publication of the AIDS Health Project,
affiliated with the University of California San Francisco.
Twelve issues of FOCUS are $36 for U.S. residents, $24 for those
with limited incomes, $48 for individuals in other countries, $90
for U.S. institutions, and $110 for intitutions in other countries.
Make checks payable to "UC Regents." Address subscription requests
and correspondence to: FOUCS, UCSF AIDS Health Project, Box 0884,
San Francisco, CA 94143-0884. Back issues are $3 each; for a list,
write to the above address or call (415) 476-6430.
To ensure uninterrupted delivery, send your new address four weeks
before you move.
Comments and Submissions
We invite readers to send letters responding to articles
published in FOCUS or dealing with current AIDS research and
counseling issues. We also encourage readers to submit article
proposals, including a summary of the idea and a detailed outline
of the article. Send correspondence to:
UCSF AIDS Health Project, Box 0884
San Francisco, CA 94143-0884
(Sat Feb 11 02:16:09 1995)