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Patterns of Sexual Behavior Change Among Homosexual / Bisexual Men -- Selected U.S. Sites, 1987-1990

In the United States, human immunodeficiency virus (HIV) transmission has been associated with anal sex without use of condoms (1,2). However, surveys of sexual behavior among homosexual/bisexual men (i.e., men who have had sex with men) (3) and evaluation results from intervention studies have consistently shown that such risks can be reduced (4). Despite such reductions in risk, relapse from safer sex to riskier practices has been documented among homosexual/bisexual men (5). Because the serostatus or HIV risk behaviors of any sex partner can be difficult to ascertain, especially for anonymous partners, anal sex with nonsteady partners without using a condom remains a high-risk behavior. This report summarizes an evaluation by CDC of behavior changes among homosexual/bisexual men involving anal sex with nonsteady partners without use of a condom (1,2). The evaluation examined community demonstration projects, funded by CDC in 1986, to assess methods of preventing the spread of HIV infection primarily among homosexual/bisexual men.

In four communities (Dallas, Texas; Denver, Colorado; Long Beach, California; and Seattle, Washington) cohorts of men were recruited to be followed prospectively. By August 1990, approximately 3800 cohort participants were recruited through announcements on posters, newspaper advertisements, referrals from health-care providers and community-based organizations, and by word of mouth. Once enrolled, cohort participants at all sites received HIV-antibody testing and pretest/posttest counseling. Follow-up visits were scheduled every 6 months. At each visit, detailed information on sexual activity, attitudes, and drug use was obtained by a self-administered questionnaire.

Based on self-reported information, men were classified at each visit into one of four behavioral stage categories:* precontemplation (PC) (i.e., lacking intention to change relevant sexual behavior); contemplation (C) (i.e., expressing an intention to adopt safer sexual behavior); action (A) (i.e., refraining from anal sex without a condom with nonsteady partners but unsure about maintaining this behavior change); and maintenance (M) (i.e., refraining from the behavior and expressing confidence that they will not engage in this risk behavior under any circumstances).

*All standard errors were less than 3%.

As of August 1990, data from initial visit through third follow-up visit were available for 303 men (75 (25%) from Dallas, 107 (35%) from Denver, 23 (8%) from Long Beach, and 98 (32%) from Seattle). These men were primarily white (91%) and 26-40 years of age (50%) (median age: 31 years). Of the 303 men, 29 (10%) were seropositive for HIV antibody at their initial visit. Three initially seronegative men were seropositive at a subsequent visit.

The patterns of behavioral change within the categories were statistically similar for cohorts in each of the cities. On average, at any given visit, 8% of the men were classified into stage PC (range: 6%-10%); 11%, stage C (range: 7%-19%); 16%, stage A (range: 14%-20%); and 65%, stage M (range: 55%-70%). From any given visit to the next visit, some men remained in the same behavioral category while others were classified in a different category (Table 1). For example, on average, of men in stage M at a previous visit, 11% (range: 8%-14%) were in the PC or C stages at the next visit, indicating relapse to the risky behavior; of men in stage C at a previous visit, 30% remained in stage C at the next visit.

Positive behavior change (i.e., positive transition through the stages of behavior change) was associated with positive change in three psychosocial factors: 1) perceived self-efficacy (i.e., confidence that one can practice safer sexual behavior even in difficult circumstances, such as when under the influence of drugs or alcohol or in the company of a new sex partner) (odds ratio (OR)=1.5; 95% confidence interval (CI)=1.1-2.0), 2) safer sex skills (i.e., ability to use condoms and ability to talk to sex partners about sex and using condoms) (OR=1.5; 95% CI=1.1-2.1), and 3) perceived peer support for safer sex (i.e., among other homosexual/bisexual men known by the respondent) (OR=1.4; 95% CI=1.0-2.0). Four other variables were not associated with positive change: age, HIV serostatus, a steady sex partner, and belief that safer sex reduces the chance for HIV transmission. Reported by: A Freeman, MPH, Dallas County Health Dept, Texas. D Cohn, MD, Denver County Health Dept, Colorado. N Corby, PhD, Long Beach Health Dept, California. R Wood, MD, Seattle-King County Dept of Public Health, Washington. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The findings in this report underscore that, among men included in the four-city evaluation, positive changes in behavior may be associated with training in safer sex skills, enhancing a person's self-confidence in practicing those skills, and identifying and promoting peer support for HIV-risk reduction. Although not associated with positive change, the belief that safer sex reduces the risk for HIV transmission was prevalent; this belief is considered an important element of intervention to induce HIV-risk reduction (7). The findings also indicate that intention to reduce sexual behavior risk sometimes may not lead to immediate or complete behavior change, and the factors important for inducing positive change may differ from those necessary to maintain that change. Therefore, interventions to promote change may differ from interventions required to maintain positive behavior change. For example, maintenance intervention should include reinforcing the self-confidence of men who have made positive behavior change.

Although the evaluation in the four cities indicated the occurrence of relapse to riskier sexual behavior, these findings are subject to at least two potential constraints: 1) the study did not incorporate an experimental design, and 2) the analysis is specific to one behavior and to a select population and therefore cannot be generalized. Nonetheless, the findings underscore the dynamic nature of sexual behavior change among homosexual/bisexual men--in particular, relative to anal intercourse without a condom with nonsteady partners. Because of continuing potential for HIV transmission associated with this behavior, public health agencies should continue to both monitor and target intervention efforts toward sexual health behaviors among homosexual/bisexual men.


  1. Kingsley LA, Kaslow R, Rinaldo CR Jr, et al. Risk factors for seroconversion to human immunodeficiency virus among male homosexuals. Lancet 1987;1:345-9.

  2. Darrow WW, Echenberg DF, Jaffe HW, et al. Risk factors for human immunodeficiency virus infections in homosexual men. Am J Public Health 1987;77:479-83.

  3. Winkelstein W Jr, Samuel M, Padian NS, et al. The San Francisco Men's Health Study: III. Reduction in human immunodeficiency virus transmission among homosexual/bisexual men, 1982-86. Am J Public Health 1987;76:685-9.

  4. Becker MH, Joseph JG. AIDS and behavioral change to reduce risk: a review. Am J Public Health 1988;78:394-410.

  5. Stall R, Ekstrand M, Pollack L, McKusick L, Coates TJ. Relapse from safer sex: the next challenge for AIDS prevention efforts. J Acquir Immune Defic Syndr 1990;3:1181-7.

  6. DiClemente CC, Prochaska JO, Gibertini M. Self-efficacy and the stages of self-change of smoking. Cognitive Therapy and Research 1985;9:181-200.

  7. Bandura A. Reflection on self-efficacy. In: Franks CM, Wilson GT, eds. Annual review of behavior therapy: theory and practice. New York: Brunner/Mazel, 1979.

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