From January 1978 through April 1980, approximately 6,700 homosexual and bisexual men attending a clinic for sexually transmitted diseases in San Francisco were enrolled in studies of the prevalence and incidence of hepatitis B virus infection (1). Approximately 1,300 participants answered standardized questions regarding their sexual practices. From December 1983 through December 1985, a random sample from this study group was asked to participate in studies of the acquired immunodeficiency syndrome (AIDS) by providing further information about their sexual behaviors (2,3). Study results show that homosexual and bisexual men in San Francisco have considerably reduced both their number of nonsteady sexual partners and their participation in specific sexual practices associated with increased risk of human immunodeficiency virus (HIV) infection, especially receptive anal intercourse.

Questionnaires administered to a subset of 126 members of this random sample in 1978, 1984, and 1985 provided data on their number of steady and nonsteady male partners in the 4 months preceding each interview. The numbers of steady partners (individuals with whom the participant had had sexual contact on three or more occasions during the 4-month period) rose from a mean of 1.6 per person in 1978 to 2.5 per person in 1984, then decreased to 1.5 in 1985. Numbers of nonsteady partners (defined as individuals with whom the participant had had sexual contact only once or twice) decreased from a median of 16 per person (mean = 29.3) during the 4-month period in 1978 to 3 (mean = 14.5) in 1984. By 1985 the median was 1 (mean = 5.5).

Participants also reported the percentage of time in the preceding 4 months that their sexual contacts with male partners included penetration or exchange of body fluids. To estimate a risk index of sexual activities that may have resulted in exposure to HIV in the previous 4 months, the percentage of time the participant engaged in each of several types of sexual behaviors was multiplied by the number of steady and nonsteady male partners during the same period.

The risk index for receptive anal intercourse with nonsteady partners decreased 90% between the two interview periods in 1978 and 1985. The risk index for receptive anal intercourse with a steady partner remained close to zero for each of the three 4-month periods in 1978, 1984, and 1985.

Although the risk index for receptive orogenital contact with nonsteady partners declined by 68% from 1978 to 1985, the decrease was not as striking as the decline in receptive anal intercourse. The risk index for receptive orogenital contact with steady partners remained low and relatively constant during this 7-year period.

Indices of exposure risk for insertive sexual contacts were also estimated. The risk index for insertive anal intercourse with nonsteady partners decreased 93% from 1978 to 1985, while the risk index for insertive orogenital contact with nonsteady partners declined 83% during the same period. Exposure risk for both insertive anal and orogenital contact with steady partners remained low and relatively constant between 1978 and 1985.

Information on condom use among these 126 men is unavailable; however, data collected during a pilot study in 1983 suggested that

95% of the men in the cohort did not use condoms during anal intercourse at that time (CDC, unpublished data). Preliminary data collected since November 1986 on a group of 104 cohort members indicate that approximately 33% of this group had anal intercourse at least once in the previous 4 months without using a condom (CDC, unpublished data). The majority (73%) of these unprotected sexual contacts were with steady partners. Reported by: D Werdegar, MD, P O'Malley, T Bodecker, N Hessol, D Echenberg, MD, PhD, San Francisco Dept of Public Health. AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Examination of trends in self-reported behavioral change provides an opportunity to indirectly evaluate educational efforts aimed at reducing high-risk behaviors. Within the time frame of this study (1983-1985), the Public Health Service recommended that members of high risk groups reduce their number of partners and avoid sexual contact with anyone known or suspected of having AIDS (4). In addition, the San Francisco Department of Public Health, in cooperation with the San Francisco AIDS Foundation, has implemented an extensive risk reduction program aimed at reducing high-risk sexual behavior in homosexual and bisexual men during this time period (5). Participants from this and other studies report significant reductions in certain high-risk behaviors (6-8). Ninety percent of the sample from this study reduced their number of nonsteady partners. The median number of partners declined from 16 in 1978 to 1 in 1985. Thirty-four percent of the men reported having only one or no partners during the preceding 4 months in 1985.

However, in 1985, some of the men in this survey still reported having sexual contact with multiple partners or engaging in high-risk behaviors. The results from this study suggest that the major source of exposure to HIV in 1978, 1984, and 1985 may have been unprotected sexual contacts with nonsteady partners. However, unless steady partners are known to be seronegative for HIV infection, the potential for exposure through sexual contacts with steady partners cannot be discounted either. Because of the high prevalence of HIV infection in homosexual men (9), the Public Health Service recommendations presently state that high-risk individuals should abstain or limit their sexual contact to one steady partner. Furthermore, those at risk should protect themselves during sexual activity with any possibly infected person by taking precautions against contact with the person's blood, semen, urine, feces, saliva, or cervical or vaginal secretions (10).

Although homosexual and bisexual men in San Francisco are generally aware of the guidelines for avoiding transmission of HIV, there is, for some men, a discrepancy between their knowledge of these guidelines and their behavior (6,7). These individuals need to be studied more intensively so that educational programs appropriate for this subgroup may be developed. Additional study of those who have already changed their behavior may also be helpful in identifying key factors motivating reductions in high-risk sexual behaviors.

References

1. Schreeder MT, Thompson SD, Hadler SC, et al. Hepatitis B in homosexual men: prevalence of infection and factors related to transmission. J Infect Dis 1982;146:7-15.

2. Jaffe HW, Darrow WW, Echenberg DF, et al. The acquired immunodeficiency syndrome in a cohort of homosexual men: a six-year follow-up study. Ann Intern Med 1985;103:210-4.

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

4. CDC. Prevention of acquired immune deficiency syndrome (AIDS): report of inter-agency recommendations. MMWR 1983;32:101-3.

5. San Francisco Department of Public Health. AIDS in San Francisco: status report and plan for 1987-88. San Francisco: San Francisco Department of Public Health, 1987.

6. Research and Decisions Corporation. Designing an effective AIDS prevention campaign strategy for San Francisco: results from the third probability sample of an urban gay male community. San Francisco: Research and Decisions Corporation, 1986.

7. McKusick L, Wiley JA, Coates TJ, et al. Reported changes in the sexual behavior of men at risk for AIDS, San Francisco, 1982-84--the AIDS Behavioral Research Project. Pub Health Rep 1985;100:622-9.

8. CDC. Self-reported behavioral change among gay and bisexual men--San Francisco. MMWR 1985;34:613-5.

9. Winkelstein W Jr, Lyman DM, Padian N, et al. Sexual practices and risk of infection by the human immunodeficiency virus: the San Francisco men's health study. JAMA 1987;257:321-5.

10. CDC. Additional recommendations to reduce sexual and drug abuse-related transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus. MMWR 1986;35:152-5.

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