Human immunodeficiency virus (HIV) prevention programs are directed to persons at risk for acquiring and transmitting HIV because of their sexual behaviors or drug use. Effective HIV prevention requires monitoring risk behaviors among persons who are infected, persons who are at highest risk for infection, and the general population (1). The Behavioral Risk Factor Surveillance System (BRFSS) provides behavioral data at the state level. Because sexual behavior questions are not part of the BRFSS core instrument, in 1997, an optional module was developed and used by 23 states and Puerto Rico. This report summarizes the analysis of these data, which indicates that 11% of respondents had multiple sex partners and 4.2% reported other high-risk behaviors. These findings underscore the continued need for education about behaviors that place persons at risk for HIV infection, promotion of HIV testing among those who engage in these behaviors, and counseling to reduce risk.

BRFSS is a state-based, random-digit--dialed telephone survey of the civilian, noninstitutionalized U.S. population aged >18 years (2). In the 1997 survey, an optional module on sexual behavior was administered to 23 of 50 states, the District of Columbia, and Puerto Rico. For this module, the upper age limit for respondents was 49 years. The sexual behavior module included questions on the number of sex partners, condom use during most recent intercourse, and other HIV risk behaviors. To determine sexual activity, respondents were asked, "During the past 12 months, with how many people have you had sexual intercourse?" Those who reported one or more sex partners during the preceding 12 months were considered sexually active. Risk behaviors were measured by two questions: 1) having multiple (i.e., two or more) sex partners during the preceding year and 2) a composite measure of risk that included use of intravenous drugs, treatment for sexually transmitted disease, and anal sex without a condom during the preceding year or a positive test for HIV; specific risks were not assessed individually. Condom use was determined by the question, "Was a condom used the last time you had sexual intercourse?"

Data were weighted by demographic characteristics and selection probabilities and are representative of the adult population aged 18--49 years in each state. SUDAAN was used to account for the complex survey design. Because BRFSS data are state-specific, median values, rather than average values for the selected states, are reported. Data from the District of Columbia were not included in this analysis because it is more comparable to urban areas than to states.

A total of 33,913 respondents were included in this analysis. The median response rate was 61.7% (range: 44.2%--88.9%). A median of 3.6% of respondents (range: 0.7% [Puerto Rico]--13% [Massachusetts]) refused to answer the question about the number of sex partners during the preceding year and were not asked further questions from the sexual behavior module. The median prevalence of sexual activity among adults aged 18--49 years was 85% (Table 1); state-specific prevalences ranged from 69% (Tennessee) to 89% (Nevada and Wisconsin).

Among respondents who were sexually active, the median prevalence of having multiple sex partners was 11% (range: 5% [Montana]--18% [Nevada]). Among respondents with multiple sex partners, the median prevalence of condom use at last sex was 65%; state-specific prevalences ranged from 53% (Rhode Island) to 79% (New Jersey).

The median proportion of sexually active respondents answering "yes" to the composite question on risk was 4.2% (range: 1.9% [Montana]--5.9% [New Mexico]). The median prevalence of condom use in this group was 26.6% (range: 12.2% [Rhode Island]--43.7% [New Jersey]) compared with 23.2% (range: 15.6% [Puerto Rico]--33.8% [New Jersey]) among those who answered "no" to the question.

Reported by the following BRFSS coordinators: P Owen, Alaska; F Breukelman, Delaware; S Hoecherl, Florida; B Steiner, MS, Illinois; J Davia, Iowa; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; N Salem, PhD, Minnesota; D Johnson, MS, Mississippi; P Feigley, PhD, Montana; L Andelt, PhD, Nebraska; E DeJan, MPH, Nevada; J Taylor, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; C Baker, New York; L Shireley, MPH, North Dakota; P Cross, Ohio; J Hesser, PhD, Rhode Island; D Ridings, Tennessee; C Roe, MS, Vermont; K Pearson, Wisconsin; Y Cintron, MPH, Puerto Rico. Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion and Surveillance Br, Div of HIV/AIDS Prevention---Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note: 

The findings in this report indicate that among persons aged 18--49 years in the areas surveyed, a small proportion were at risk for HIV on the basis of the composite question and a larger proportion on the basis of having multiple sex partners. The proportion of sexually active adults with multiple partners in the BRFSS data is similar to that found in other surveys of the general population (3--5). Responses to a question on the 1995 National Health Interview Survey that was similar to the BRFSS composite measure resulted in a prevalence of 3.4%, compared with 4.2% in BRFSS (3). These data indicate an ongoing need for prevention efforts focusing on HIV and other sexually transmitted diseases, including efforts to promote healthy sexual behaviors.

The findings in this report are subject to at least five limitations. First, small sample sizes, including small numbers of respondents with risk behaviors, precluded categorical analyses of sexual behaviors with other relevant variables (e.g., sex or marital status). Second, because BRFSS excludes persons without telephones and those living in institutional settings, this study may have underestimated the prevalence of sexual risk behaviors in the U.S. population. Third, the measure used to assess high risk for HIV may not accurately describe all persons who may be exposed to HIV. Fourth, BRFSS data are self-reported data (6). Finally, because not all 50 states used the sexual behavior module and the sample was limited to those aged 18--49 years, the findings in this report may not be generalizable to the U.S. adult population. Assessments of the prevalence of risk behavior for HIV infection among youth in the U.S. population are available from the Youth Risk Behavior Survey (7).

General population surveys such as the BRFSS can contribute to the description and monitoring of HIV risk behaviors. BRFSS provides state-based estimates of the prevalence of sexual and other risk behaviors and enables states to project the need for HIV prevention messages to promote risk reduction in the general population.

References

1. Fichtner RR, Rietmeijer CA, Brackbill RM, and the Behavioral Surveillance Workgroup. Toward an integrated surveillance system for HIV/STD risk behaviors. In: Programs and abstracts of the XII International Conference on AIDS. Geneva, Switzerland, June 1998.
2. Holtzman D, Powell-Griner E, Bolen JC, et al. State- and sex-specific prevalence of selected characteristics---Behavioral Risk Factor Surveillance System, 1996 and 1997. MMWR 2000;49(no. SS-6).
3. Anderson JE, Wilson RW, Barker P, et al. Prevalence of sexual and drug-related HIV risk behaviors in the U.S. adult population: results of the 1996 National Household Survey on Drug Abuse. J Acquire Immune Defic Syndr 1999;21:148--56.
4. Catania JA, Coates TJ, Stall R, et al. Prevalence of AIDS-related risk factors and condom use in the United States. Science 1992;258:1101--6.
5. Leigh BC, Temple MT, Trocki KF. The sexual behavior of U.S. adults: results from a national survey. Am J Public Health 1993;83:1400--8.
6. Catania JA, Gibson DR, Chitwood DD, Coates TJ. Methodological problems in AIDS behavioral research: influences on measurement error and participation bias in studies of sexual behavior. Psychol Bull 1990;108:339--62.
7. CDC. Youth risk behavior surveillance---United States, 1997. MMWR 1998;47(no. SS-3).

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