Sexual RelapseHIV Counselor PERSPECTIVESV1, N1, January 1991 Research UpdateFrom the early 1980s when it was first learned that HIV could be transmitted during certain sexual practices, and continuing for several years after that, the prevalence of those risk behaviors declined. This behavior change was noted most dramatically within gay communities in large cities such as Los Angeles and San Francisco, where behaviors were studied. Little research has been done in smaller communities or among heterosexuals. A survey in San Francisco found that the percentage of subjects who reported engaging in unsafe sexual activities during a 30-day period dropped from 59% in 1984 to 25% in 1987 (San Francisco AIDS Foundation, 1990). Reports of reduced rates of unsafe sex were supported for several years by cohort studies that showed declining rates of sexually transmitted disease (STD) and HIV seroconversion. An increase in unsafe sexual activities was first noted in 1988. A survey conducted by the San Francisco AIDS Foundation in 1989 documented an increase in high risk behavior, including a significant number of individuals who acknowledged a return to unsafe activities. Thirty percent of the 401 subjects in the survey defined unsafe sex as unprotected anal intercourse, oral-anal contact, fisting or oral sex with ejaculation. Eighty-five percent of the survey's subjects said they had made a commitment to avoid unsafe sexual behaviors. Sixteen percent of those who made the commitment failed to keep it and had "relapsed" into unprotected sex sometime in the previous year. Relapse rates were highest among young men, people of color, and those with lower incomes. These individuals also were among the most likely to report engaging in unsafe sex. Subjects were an average of 38.6 years of age, and 83% of all subjects were white. In a study of 389 gay men in San Francisco, 19% of the subjects reported they sometimes reverted to risky practices (Stall et al., 1990). Researchers estimated that in San Francisco as much as 75% of all unsafe sex could be attributed to relapse, with only 25% of the unsafe sex attributed to those who have never adopted safer-sex practices. Cause of RelapsesStudies show that many factors can lead a person to relapse into unsafe behavior, including some that involve emotional issues. The factors are:
Recent FactorsAs the risk of infection through certain behaviors has continued, and individuals have started to realize that they might never be able to safely resume some behaviors that were once popular, other factors have made individuals increasingly vulnerable to relapse. These are:
While rates of HIV infection among gay men are declining in many regions, the rate of new infections in many cities is still increasing among substance abusers and their sexual partners. Differences for Single MenReasons cited for relapse are different for men in a relationship compared to those who are single. Single men most often state their reasons for relapse as drunkenness, an absence of condoms or a request from a partner that condoms not be used. Men in relationships respond that they have relapsed into unsafe activities because they are "in love", or because they believe that their partner has the same antibody status. Men more likely to relapse are those who state that they "run in a fast crowd" in which risk-taking is met with social support, and those who cited anal sex as their favorite activity. Relapsers who have seroconverted tend to be young, frequent drinkers and those who believe that insertive anal sex is safe. Knowledge of HIV antibody status may not have a significant effect on deterring unsafe behavior. And, some individuals may be more susceptible to sexual relapse after learning their antibody status. In the case of a positive antibody result, individuals may believe their attempts to prevent infection may have been unsuccessful and there is no reason to continue to practice safer forms of sex. Individuals who test negative may feel that because they have been given what they consider a "healthy" report, they may be more lenient in their adherence to safer-sex guidelines. Methods of Reducing RelapseResearchers have suggested that relapse to unsafe sex can best be understood when unsafe sex is studied as a permanent behavior change, similar to the way other unhealthy behaviors such as smoking, alcohol use, diet and a sedentary lifestyle, are examined (Stall et al., 1988). Research suggests it is relatively easy to halt a behavior for a limited time, but quite difficult to permanently eradicate that behavior. At the start of the epidemic, individuals resolved to alter their practices but believed they needed to do so only temporarily rather than make long-term changes. Many individuals still expect that they will soon be able to safely engage in any sexual practice. And some do not fully understand or believe that, unlike a person who occasionally slips into other unhealthful behaviors, a slip into even one episode of unsafe sex can mean infection with HIV. Continuing education and reinforcement are also important to preventing relapse. When not continually presented with safer sex messages, some individuals lose their awareness of the importance of safer sex or believe that practicing safer sex is no longer necessary. Health educators have also suggested that discussion of the relapse issue should be a primary role of education efforts. REFERENCESFullilove RE. Fullilove MT. Bowser BP. et al. Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, Calif. Center for AIDS Prevention Studies. Journal of the American Medical Association. 1989;263(6):851-55. St. Lawrence JT. Brasfield TL. Kelly JA. Factors which predict relapse to unsafe sex by gay men. Poster presentation from the Sixth Internatinal Conference on AIDS. June 19-24, 1990, San Francisco. San Francisco AIDS Foundation, Communication Technologies. HIV- Related Knowledge, Attitudes, and Behaviors among San Francisco Gay and Bisexual Men: Results from the Fifth Population-Based Survey. Unpublished report, 1990. Stall R. Coates TJ. Hoff C. Behavior risk reduction for HIV infection among gay and bisexual men: A review of results from the United States. American Psychologist. 1988;43(11):978-85. Traux SR. Ramirez A. Fraziear T. Annual Evaluation of the Anonymous Human Immunodeficiency Virus Testing Program. Sacramento: Office of AIDS, Department of Health Services, State of California, 1989.
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