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Monitoring unsafe sexual behavior among gay and bisexual men over time

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Title:
Monitoring unsafe sexual behavior among gay and bisexual men over time
Creator:
Dice, Brent A
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English
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ix, 76 leaves : forms ; 29 cm

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Subjects / Keywords:
Gay men -- Sexual behavior -- Colorado ( lcsh )
Bisexual men -- Sexual behavior -- Colorado ( lcsh )
AIDS (Disease) -- Social aspects ( lcsh )
Safe sex in AIDS prevention ( lcsh )
AIDS (Disease) -- Social aspects ( fast )
Bisexual men -- Sexual behavior ( fast )
Gay men -- Sexual behavior ( fast )
Safe sex in AIDS prevention ( fast )
Colorado ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 68-76).
General Note:
Submitted in partial fulfillment of the requirements for the degree, Master of Arts, Sociology.
General Note:
Department of Sociology
Statement of Responsibility:
by Brent A. Dice.

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|University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
37887173 ( OCLC )
ocm37887173
Classification:
LD1190.L66 1997m .D53 ( lcc )

Full Text
MONITORING UNSAFE SEXUAL BEHAVIOR AMONG
GAY AND BISEXUAL MEN OVER TIME
BA,
by
Brent A. Dice
Metropolitan State College of Denver, 1995
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Sociology
1997


1997 by Brent A. Dice
All rights reserved


This thesis for the Master of Arts
degree by
Brent A. Dice
has been approved
by
A. Leigh Ingram
Date


Dice, Brent A. (M.A., Sociology)
Monitoring Unsafe Sexual Behavior Among Gay and
Bisexual Men Over Time
Thesis directed by Assistant Professor Candan Duran-Aydintug
Abstract
This study examines trends in sexual behavior among men
who have sex with men (MSM). Its main purpose is to search for
evidence of relapse behavior among populations of MSM and to
identify changes in unsafe sexual behavior. This is accomplished
by examining self-reported high risk sexual behavior among
specific populations of MSM and making comparisons to the same
populations in the past. Data from the Knowledge, Attitudes,
Beliefs, and Behaviors (KABB) study conducted by the Colorado
Department of Public Health and Environment are used. Samples
taken in 1991 (N=225) and 1995 (N=464) consist of respondents
who reside in the state of Colorado and who report having at least
one male sexual partner in the past 12 months. Targeted
sampling techniques are used for data collection.
IV


The instrument used for measurement in the KABB study is
an anonymous, self-administered questionnaire. All
questionnaires were distributed and collected in person, and
respondents were instructed not to include their names on the
questionnaire. The questionnaires surveyed the knowledge,
attitudes, and beliefs, as well as sexual behavior of the
respondents. It included questions concerning the number of
reported male and female sexual partners of the respondents in
the previous twelve months, as well as their current relationship
status. It also included questions relating to the respondents
level of reported unsafe sexual behavior and their concerns about
risk for HIV infection. Other questions included: amount of
perceived social support, attitudes toward using condoms, and
demographical information such as race, age, and place of
residence.
Results indicate that MSM are not relapsing into unsafe
sexual behavior as suggested in recent literature. Results do
indicate, however, that certain populations of MSM, including
young and minority MSM, are at increased risk for HIV infection.
v


This study also indicates that MSM who adopt negotiated safety
strategies in their sexual practice are at higher risk for HIV
infection than those who do not. Furthermore, MSM who receive
little or no social support from their friends and sexual
partner(s) are more likely to be at greater risk for HIV infection.
This abstract accurately represents the content of the
candidates thesis. I recommend its publication.
Signed
VI


ACKNOWLEDGEMENTS
I wish to thank my mentor and friend, Dr. Candan Duran-Aydintug,
for her endless hours of support and encouragement. In addition,
special thanks to Dr. Tamara Hoxworth at the Colorado
Department of Public Health and Environment for being so
generous in sharing her time and data, and to Terry Stewart and
the staff and volunteers at the Colorado AIDS Project. Thanks
also to Ricky Weimer whose support and friendship made this all
possible.


CONTENTS
CHAPTER
1. INTRODUCTION ................................. 1
2. LITERATURE REVIEW............................ 5
Relapse Defined ......................... 6
Evidence of Relapse ..................... 9
Factors of Relapse ..................... 11
Young MSM and HIV ................. 12
Older MSM ......................... 17
Minority MSM ...................... 21
African-American MSM ... 22
Latino MSM ................... 25
Asian MSM .................... 27
Determinants of Relapse ................ 28
Social Support .................... 29
Homophobia.................... 30
Family Support................ 31
HIV+ MSM...................... 32
Perceived Risk .................... 34
Rationale for the Present Study .... 35
3. METHODS ..................................... 37
Sample ................................. 37
Instrument ............................. 40
Measures ............................... 41
4. RESULTS ..................................... 43
5. DISCUSSION .................................. 51
VIII


< CO
APPENDIX
REFERENCES
58
63
68
IX


CHAPTER 1
INTRODUCTION
According to the World Health Organization (WHO), there are
estimated to be 19.5 million people living with Human
Immunodeficiency Virus (HIV) and 4.5 million people living with
Acquired Immune Deficiency Syndrome (AIDS) worldwide. By the
year 2,000, it is projected that between 30 and 40 million people
will be infected with HIV. The HIV epidemic, now in its second
decade, continues to grow throughout the world at an estimated
rate of 6,000 new infections each day (World Health Organization,
1996).
AIDS was first discovered in the United States in 1981 and
was initially called the gay cancer by physicians who began
documenting unexplained illnesses that were largely effecting
men who have sex with men (MSM).i MSM were not only the group
most affected by HIV and AIDS in the U.S. early in the epidemic,
iFor the purpose of this study, the term men who have sex with other men
(MSM) will be used, regardless of whether they identify themselves as being gay or
bisexual or not.
1


but they continue to make up the largest group affected by AIDS
in the U.S. today (CDC, 1996a; Coates, 1995).
HIV, the virus that causes AIDS, is found in the blood,
semen, and vaginal secretions of an infected person. The primary
modes for HIV infection in the United States is through the
practice of unprotected sex and sharing of needles by I.V. drug
users (CDC, 1996a; CDC 1996b). Since there is currently no
vaccination or cure for AIDS, much effort has been given towards
HIV education and prevention strategies.
Because of the impact AIDS has had on MSM, particular
focus has been on education and encouragement of MSM to adopt
AIDS risk reduction strategies (Bernstein, 1991; Connell, 1990;
De Wit, 1994). Such strategies include behavioral changes
through the adoption of safer sex practices, which involve
avoiding the exchange of bodily fluids, either by substituting for
different methods of sexual activity (such as massage), or by
using a condom to decrease the risk of HIV infection. This has
lead to the existence of what has been labeled the safe sex
culture among MSM.
2


Since the beginning of the AIDS epidemic, studies have
shown that MSM have made many changes in their sexual practices
and have adopted prevention strategies in the fight against the
spread of AIDS (CDC, 1995b; Connell, 1990; De Wit, 1994).
However, recent research indicates that some MSM have gone into
relapse, a term used to describe persons who have adopted
safer sex practices in the past, but have returned to practicing
unsafe sexual behavior. Recent evidence (Bartos, 1994; Gold,
1995a, 1995b; Odets, 1994) suggests that safer sex prevention
strategies are failing, particularly within certain subgroups of
MSM, such as minorities and young MSM. This has even led to the
suggestion that a safe sex culture does not really exist.
Although many determinants can be associated with risk for HIV
infection, the issue of relapse has recently become a factor of
concern toward monitoring the epidemic. Therefore, in the
interest of applied sociology, it is necessary to determine the
extent of unsafe sexual behavior among MSM and whether or not
relapse is occurring among this group. Emphasis in determining
change of sexual behavior among MSM will be the scope of this
3


study. Such research is important in assisting health care
professionals to design more effective educational strategies
toward AIDS prevention.
Because few longitudinal studies involving recent changes
in sexual behavior of MSM have been conducted, the aim of this
study is not only to determine the existence of relapse, but to
investigate factors associated with any changes in such behavior.
The objective of this study, therefore, is to answer the main
question, Is there evidence of relapse into unsafe sexual
behavior among MSM? Furthermore, hypotheses will be tested
concerning the significance of factors associated with any
change, so that determinants can be identified. Particular
emphasis will be placed on age, with a comparison of young,
middle aged, and older MSM. Other factors will include:
race/ethnicity, amount of perceived social support, and the
perception of risk. Prior to describing the methodology used in
the present study, the relevant literature will be reviewed.
4


CHAPTER 2
LITERATURE REVIEW
It has been well established since the beginning of the AIDS
epidemic that MSM in the United States have made significant
changes in their sexual behaviors to prevent the spread of HIV
infection (Hart, 1992). This change has been evident in the
overall reduction of sexually transmitted diseases found among
this group, and confirmed through the use of longitudinal studies
aimed at cohorts of MSM. Such longitudinal studies have
determined an increase in self-reported condom use among MSM in
anogenital insertive and receptive intercourse (Van Griensven,
1993). However, although changes have been made among the
population overall, some MSM have not incorporated these changes
into their lives to prevent risk for HIV infection. Furthermore,
indications are that some MSM who previously made changes
regarding safer sex behavior have gone back to practicing unsafe
sexual behavior. If this is true, what are the characteristics of
MSM who fail to adopt long term safer sex prevention measures?
5


Relapse Defined
Ron Stall, Ph.D., an assistant adjunct professor of
epidemiology at the Center for AIDS Prevention Studies at the
University of California, San Francisco, describes relapse among
MSM as men who ...adopted safer sexual habits to avoid
contracting HIV but were unable to maintain those new practices
(cited in Staver, 1992, p:10). This generally agreed upon
description is acceptable for purposes of defining relapse, but
fails to fully explain the specifics involved. Hart, et al. (1992),
in a critique of recent behavioral HIV/AIDS research, argue that
studies involving sexual behaviors of MSM continually define
relapse in a number of different ways. It is therefore necessary
for researchers involved in studying relapse to identify what
constitutes relapse.
Many studies claiming evidence of relapse among MSM
include men who are in mutually monogamous relationships. Hart
(1992), reports that in one study it was determined:
...men engaging in unprotected anal receptive sex were more
likely to be in long-term primary relationships, to have
6


lovers with known negative serostatus, and to be in
relationships closed by agreement to outside sex. Men in
open relationships or men who suspected their partners
were unfaithful were more likely to use condoms...
(p:122)
This has led some studies to make a distinction between high-
risk relapse and stable-risk relapse depending upon the
relationship status of the sexual partners. Some label
unprotected sex within a monogamous relationship as no
relapse or low risk (Connell, 1990; Hart, 1992).
Precaution should be taken not to identify relapse in terms
of rates for HIV incidence the number of new infections within
a group. This particular method has been used in making
comparisons between young MSM and older MSM, and many studies
using this method have concluded young MSM to be at higher risk
as a result. Even though HIV incidence rates have been found to be
higher among young MSM, this is not a strong indicator that young
MSM are practicing more unprotected sex than older MSM. During
the early period of the AIDS epidemic there was a large range of
populations at risk, both young and old. It is to be expected that
new entrants into a high risk sex group leading to HIV incidence
7


would tend to be young, because they are just beginning to become
sexually active (Rosenberg, 1995; Stall, 1992). This does not
mean HIV incidence should not be used as an indicator in
determining where HIV prevention is most needed after all it is
HIV infection that is trying to be prevented. Nonetheless, it
should be stated that HIV incidence alone is not an accurate
measurement in determining relapse.
How should relapse pertain to young MSM? It has been
suggested (Hart, 1992) that relapse should not apply to young MSM
at all. For many young MSM, failure to practice safer sex may not
necessarily indicate individual relapse. Some young MSM may not
have adopted safer sex prevention methods at all, or they may
begin engaging in unsafe sexual behavior for the first time. For
purposes of epidemic monitoring, it has been suggested that
incidence of high risk sexual behavior among young MSM should be
compared to persons of the same age in the past (Rosenberg,
1995). Taking this into account, specific subgroups of MSM,
including youth, will be examined by comparing high risk sexual
behavior among certain subgroups over time. Thus relapse will be
8


defined in this study as the failure to maintain long term safer
sex behavior among populations of MSM over time.
Evidence of Relapse
Just because safer sex is effective at preventing HIV,
doesnt mean its easy. Continuing safer sex behavior
over a long time is difficult; we all know that its
easier to start a diet than to stay on one. For many
men in the gay community, the challenge is not to
start having safer sex, but to do so consistently and
for the long haul.
(Coates, 1995, p:1)
HIV prevention intervention programs proved to be very
effective and drastically decreased the rate of HIV incidence
among MSM in the 1980s. In San Francisco, the annual HIV
infection rate in 1985 was 18% by 1997 it was down to 1%
(cited in Bernstein, 1991, p:23). Studies have shown that
knowledge concerning HIV infection is very high among MSM
(Hays, 1995; Hunter, 1994; Kelly, 1990; Remafedi, 1994). This
led some HIV intervention programs to believe they effectively
dealt with prevention issues and were no longer necessary. This
misconception led to the shut-down of a Stop AIDS project in San
Francisco, and organizers have since learned a valuable lesson:
9


The battle is never over. You cant do something once and expect
the results to stick forever (Bernstein, 1991, p: 23). AIDS
organizations have found that new generations of gay men are
constantly coming out and many of them are not practicing
safer sex.
In one San Francisco study (Staver, 1992), about 20% of MSM
surveyed had adopted safer sex practices, but later resumed
unsafe sexual practices. About 30% reported maintaining
behavioral change; 48% reported engaging in low risk sexual
behaviors; and 2% reported practicing risky behavior all along.
Another report indicated 30% of MSM visiting a Los Angeles
health clinic were diagnosed with some form of gonorrhea. In
Seattle the incidence of gonorrhea among MSM tripled from 1988
to 1989. Similar increases in other sexually transmitted
diseases such as syphilis, herpes, genital warts, and chlamydia
have been seen in MSM (Chase, 1990).
In the second decade of the epidemic, MSM are frustrated
with the fact that AIDS will probably be around for a long time.
Although scientists feel they are coming close to finding a
10


vaccine for AIDS, there is no indication of a cure in sight. In the
meantime, it is imperative for HIV prevention measures to
continue. Because few recent studies have indicated an
occurrence of relapse among MSM, more research must be done. In
continuing to monitor the epidemic, social scientists should
determine if, in fact, relapse is occurring, and should identify
factors associated with any changes in sexual behavior.
Factors of Relapse
Two groups indicating failure to maintain long term safer
sex practices among MSM are youth and ethnic minorities.
Studies conducted in New York, Pittsburgh, and San Francisco
showed young MSM to be at very high risk for HIV infection. In
these studies 60-80% of young MSM reported having engaged in
anal intercourse, with 40% claiming to have done so while using
no safe sex practices (CDC, 1995a).
MSM who are of an ethnic minority in the U.S. are
disproportionately effected by the HIV epidemic. In a report
collaborated by the Center for AIDS Prevention Studies in San
11


Francisco, it is stated that:
By March 1993, Latinos comprised 17% of all diagnosed
AIDS cases in the US, yet represented only 9% of the general
population. In Washington, DC, White MSM showed a 16%
decrease in AIDS incidence between 1988 and 1993, while
African-American MSM showed a 63% increase.
(Coates, 1995, p:2)
Especially from an applied sociology perspective, it is necessary
for social research to identify groups most commonly associated
with high risk sexual behavior. This will enable health care
professionals to implement effective prevention programs that
take into account the social and cultural differences of specific
groups.
Young MSM and HIV
Studies show that young MSM, as a group, show a significant
risk for HIV infection (Dean, 1995; Lemp, 1994; Rotheram-Borus,
1994; Stall, 1992). In a survey conducted in San Francisco and
Berkeley (n=474) approximately one third of MSM between the
ages of 17-22 reported having unprotected anal intercourse in the
previous six months (Lemp, 1994). The Centers for Disease
Control (CDC) reported that, cumulatively, young MSM account
12


for 35% of all reported AIDS cases. Overall, incidence of HIV
infection has decreased over the last five years for young MSM,
but evidence suggests this group still remains at very high risk.
(CDC, 1996a; CDC1995b; Lemp, 1994)). For example, according to
the Centers for Disease Control and Prevention (1995b):
During 1992-1993, HIV seroprevalence was 4.8% among MSM
aged 18-23 years in San Francisco and, during 1990-1991,
9% among MSM aged 18-24 years in New York City. During
the same periods, the overall rates of new HIV infections
among MSM in San Francisco and New York City were 1.2%
and 2% respectively.
(p:403)
As previously stated, studies show that many MSM have
made changes in their sexual practices and have adopted
prevention strategies in the fight against the spread of AIDS
(CDC, 1995b; Connell, 1990; De Wit, 1994). Many of these studies
documented changes in sexual behavior among cohorts of MSM in
the early years of the epidemic. However, little has been done to
determine the actual prevalence of unprotected sexual activity
(namely unprotected anal intercourse) of young MSM since these
earlier longitudinal studies have been conducted (Dean, 1995).
13


Cross-sectional surveys of schools, clinics, and households
indicate that young MSM are more knowledgeable now about HIV
than they were in the past (Hunter, 1994; Remafedi, 1994). Much
of this has to do with the fact that the current generation of
young MSM began their sex lives having knowledge of HIV
infection available (Dean, 1995). According to Hunter (1994),
Gay male adolescents tend to be fairly knowledgeable about HIV
infection. For example, males readily identify unprotected anal
intercourse as a high risk behavior for transmission of the virus
(p:347). However, although young MSM are aware of HIV
prevention methods, research suggests such prevention methods
are not always being used. According to Hays (1995):
In contrast to studies with older gay men which
demonstrate dramatic reductions in HIV risk-taking
behaviors, a variety of studies show that young gay men are
engaging in high rates of unsafe sex. In a survey of gay men
aged 18-25 in three medium-sized West Coast communities,
43% of the sample reported having engaged in unprotected
anal intercourse during the previous 6 months. A study of
gay and bisexual adolescent males in Minnesota found that
63% were at extreme risk due to unprotected anal
intercourse or intravenous drug use. A San Francisco
telephone survey showed that 44% of gay men under the age
of 30 had engaged in unprotected anal intercourse during the
previous year, compared to 18% of the men over age 30.
(pci)
14


These findings bring into question whether HIV prevention
efforts, originally designed for MSM who are now in their 30s and
40s, are effective for young MSM in their teens or early twenties.
There has also been a lack of research aimed at defining
specific determinants to unprotected sex among young MSM,
which could hold the key for designing effective prevention
methods targeted to this group (Lemp, 1994; Rotheram-Borus,
1991). According to a report released by the Centers for Disease
Control (1995a), the following summary of risk factors are
associated with unprotected anal intercourse among young MSM:
Many young MSM may think their sexual partners are not HIV
infected because they look healthy, clean and/or
attractive.
Many young MSM have labeled AIDS as an older gay mans
disease. Even though young MSM are knowledgeable about
AIDS, the reality of the disease has not been personalized to
their group. They havent had the experience like that of
older MSM who have seen many of their friends suffer in the
advanced stages of AIDS.
There is a lack of peer or social support in encouragement
toward practicing safer sex. The pressure of trying to fit
into what I think my friends are doing has an impact on
behavioral choices. This plays a significant role for young
men trying to explore their sexual identities.
15


Even when young MSM wish to practice safer sex they may
not have the skills to be assertive and effectively
communicate this to their partners.
Another factor leading to unprotected sex among young MSM
is homophobia. According to Grossman (1994), by the time MSM
reach an age where they begin to acknowledge their sexuality,
they have learned societys homophobia lesson well to dislike,
disapprove, and despise anything that can be labeled homosexual,
including themselves (p:39). Many young MSM do not come out
as having a gay or bisexual identity out of fear of rejection by
family, friends, religious institutions, and the fear of physical
assault. Barriers to acknowledging their sexuality and failure to
internalize this knowledge may keep young MSM from seeking
effective prevention methods, including condoms and safer sex
information. Young MSM are clearly lacking in social support and
often times do not seek support out of fear that their sexuality
will be discovered. Having knowledge about AIDS is simply not
enough to be an effective prevention method for young MSM.
Knowledge about HIV risk reduction is most likely to have an
effect on behavioral change when it is built on social support,
16


peer approval, self-esteem, and positive identity (Grossman,
1994; Hunter, 1994; Morris, 1995; Nader 1989).
There are multiple factors contributing to high risk sexual
behaviors among young MSM. Multi-level prevention programs are
needed that acknowledge the interpersonal and social needs of
young MSM. One of the greatest barriers of HIV prevention for
young MSM is the lack of resources directed toward this group.
For example, when adolescents receive information about safer
sex prevention methods it is usually based on a heterosexual
model. Young MSM need to receive personalized information of
HIV prevention methods designed for same sex partners in order
to internalize AIDS as a perceived threat. Adolescents in general
have a difficult enough time personalizing knowledge of AIDS
without having the added societal heterosexual barriers to
overcome (Hunter, 1994; Nader, 1989).
Older MSM
Even just for a little while I want to get
back the feeling of what it was like in the
time before AIDS, when it was great to be
gay and you could do what you liked
17


sexually, and I was younger/more
attractive/a great fuck. For a little while
I want to try to feel like I did then.
(Gold, 1991, p:269)
Data from the 1989 Communication Technologies cross-
sectional survey of gay men in San Francisco indicate that the
reasons for failing to practice safer sex behavior among older
MSM are different than those of younger MSM. For MSM over the
age of thirty the following reasons were given for high risk
sexual behavior: impact of the AIDS epidemic on ones lifestyle,
having a primary partner, frequency of gay bar attendance,
concern about AIDS, and social support for unprotected anal
intercourse (p:684-685). Many of the same reasons were given
for young MSM, but in addition to these reasons, level of
knowledge of unprotected anal intercourse and length of
residency were also factors (Stall, 1992).
Although there have been several studies indicating young
MSM are at greater risk (Dean, 1995; Lemp, 1994; Rotheram-
Borus, 1994; Stall, 1992), one study reported otherwise. In a
Survey conducted by the Los Angeles County Department of Health
and Services (n=1,182), MSM between the ages of 30-44 were
18


reported as generally more likely to engage in unprotected anal
intercourse in comparison to other age groups (Kanouse, 1991).
However, this relationship was not considered statistically
significantly and was reported in 1991, whereas much of the
research supporting failure to maintain safer sexual behavior
among young MSM compared to older MSM has been more recent. In
one report, Dan Wohlfeiler, education director of STOP AIDS
Project San Francisco, states that evidence indicates that some
MSM view the current advances of new drug therapies, which
make AIDS appear as a chronic, manageable disease by lowering
the incidence of HIV in the bloodstream, as a cure for HIV
infection (cited in Gallagher, 1997). Some MSM who are already
HIV positive have leapt to the conclusion that a low viral load in
the blood correlates to a low viral load in semen. This has lead
some HIV positive men to believe they can dispense with the
condoms even if their partner is HIV negative (Gallagher, 1997,
p: 39).
One segment of the population that has often been
overlooked in assessing HIV prevention needs is among those over
19


the age of 50. This group comprises of 10% of all diagnosed AIDS
cases in the United States (Stall, 1994). One recent study
(Kooperman, 1994), reported unprotected anal sex among this
group to be low, with a higher frequency of low-risk sexual
activities such as mutual masturbation. It was also reported that
respondents who did practice unprotected anal sex were most
likely to be in a mutually monogamous relationship. Unlike young
MSM who may not internalize their high risk behavior as a
problem, older MSM have personalized the AIDS epidemic which
has led to changes toward practicing safer sex behavior.
In another report, however, Arnold H. Grossman (1995), a
professor in the Department of Health Studies at New York
University, states that a certain segment of the population of
MSM over the age of 50 may be at particular risk. Many MSM over
50 have lived their entire lives in the closet and are not able to
reveal their sexual orientation in their later years. Internalized
homophobia plays a role for HIV infection among these men and as
a result they are not likely to reach out or respond to available
HIV/AIDS intervention programs. Denial not only plays a role in
20


accepting their sexual orientation, but also in their perception of
risk. Grossman reports that many older gay men deny they are at
risk for HIV/AIDS because they see it as a young gay mans
disease (p:15). Ironically, the opposite is perceived by many
young MSM.
Minority MSM
Although widespread HIV prevention efforts have had a
significant effect in reducing high risk sexual behavior among
MSM, most of this change has occurred among White MSM.
According to the Centers for Disease Control (1996a; and 1995b),
the incidence of AIDS has been higher among ethnic minority MSM
than among White MSM in the U.S. Factors associated with
increased risk among ethnic minorities in the U.S. include less
access to HIV intervention agencies and culturally inappropriate
HIV-prevention activities (CDC, 1995b). Other factors consist of
a lack of HIV/AIDS prevention knowledge, particularly among
Black and Hispanic MSM, and a high amount of substance abuse
among Blacks, Hispanics, and Asians (Choi, 1995; Thomas, 1991).
21


Although substance abuse is a significant determinant of high
risk sexual behavior among all ethnic groups, it has been
\
suggested that this may play a more significant role among
minority MSM. This indicates a need for prevention programs
which focus on the hazards of combining substance use with sex,
especially among the ethnic minority MSM (Choi, 1995; and Icard,
1992). An examination of factors associated with high risk
sexual behavior, as well as implementation of culturally
appropriate HIV intervention methods targeted toward ethnic
minorities should be given high priority.
African-American MSM
A recent study in San Francisco found that 52% of African-
American MSM report engaging in unprotected anal intercourse
(Peterson, 1995). Compared to White MSM, African-American MSM
report lower levels of knowledge concerning HIV prevention
compared to their White counterparts. Recent findings show that
cultural perceptions regarding HIV/AIDS, and of sex in general,
may play a distinctive role in these differences (Icard, 1992;
22


Peterson, 1995; Thomas, 1991).
It has been suggested that homophobia is greater among the
African-American culture than what is seen in mainstream
American culture (Icard, 1992; and Thomas, 1991). African-
American MSM are faced with the double burden of being a part of
two minority groups, both facing issues of prejudice and
discrimination. In addition to this, African-American MSM feel
they have to make a choice between identifying with the African-
American community or the Gay community. These men feel
pressures of not being accepted in either community:
On one hand, they are subject to negative attitudes about
homosexuality and the gay community from the black
community, and the other they are subjected to the
attitudes and values, including racism and sexual racism,
from the gay community (Icard, 1992, p:441).
Additionally, the African-American gay community is not as
organized as the White gay community in the U.S. and there has
been a lack of prevention efforts specifically targeted toward
this group.
A study (Thomas, 1991) assessing AIDS knowledge,
attitudes and risk behaviors among African-American and Latino
23


MSM indicates a lack of knowledge concerning HIV infection
among both populations. The results of this study were
astonishing:
20% answered incorrectly or dont know to
questions stating that AIDS could be transmitted in
everyday contact at work or at play, such as drinking
from the same glass as an infected person.
6% answered incorrectly or dont know to a
statement that AIDS could not be transmitted
through the air.
47.4% incorrectly answered true or dont know in
response to the statement a person could get AIDS
from a mosquito bite.
91.1% of respondents incorrectly answered false
and 3.3% answered dont know to the statement, a
person can get AIDS from having sex just one time
with someone.
90% reported knowing that correct use of condoms
provides protection against HIV infection. However,
36% did not know natural skin condoms offer less
protection for HIV protection as compared to latex
condoms, while 20% thought that natural skin condoms
provide more protection.
21% responded that being the insertive partner
during anal intercourse offered protection from HIV
infection, while 10% answered dont know.
In the same report, 50% of respondents reported always using
24


condoms during anal sex, while 9.2% reported using them often.
28.9% of respondents reported never using condoms or using
condoms not too often. These findings clearly point out a high
need for prevention efforts targeted to this population.
Latino MSM
Studies focused on Latino MSM in the U.S. are virtually
nonexistent. There is some evidence that Latino MSM are having
more unsafe sex than any other ethnic group in the U.S. and they
are not changing to safer sex practices as reported among White
MSM. It is also believed that estimated cases of AIDS among this
group are vastly under reported in the U.S. Homosexual
discrimination is not really an issue for this population, because
most Latino MSM do not identity as being gay and therefore are
not subject to this type of discrimination. What has been
described as being the greatest barrier to HIV prevention among
Latino MSM is that much of their heritage has been based on a
culture of denial (Bardach, 1995; Ramirez, 1994).
25


Many Latino MSM do not adopt the American liberated gay
model by acknowledging their homosexual orientation. A telling
factor in this has to do with the imported cultures coming from
Mexico and many Latin American countries. Instead they are more
likely to identify as being bisexual. Freddie Rodriguez, from the
Health Crisis Network in Miami, Florida, says, To be bisexual is a
code.Jt means, I sleep with men but I still have power (cited in
Bardach, 1995, p:28). The power he speaks of is represented in
the machismo ethic which plays a central role in the lives of
Latino men. Rodriguez explains, Part of the Machismo ethic...is
not wearing a condom. Furthermore, there are many self-
identified heterosexual men who dont regard sex with other men
as a homosexual act If youre a top, el bugaron youre not a
faggot. By not identifying with what is commonly perceived as a
high risk group, many Latino MSM feel why worry about AIDS if
only gay men get AIDS? It has been predicted that an increase
will occur in HIV incidence among Latino women the wives and
girlfriends of Latino MSM. This stems from the refusal of Latino
MSM to acknowledge their behavior as risky and thereby may
26


transmit the virus to their heterosexual partners (Bardach, 1995).
Ramirez, et al. (1994), reported in a study that older Latino
MSM engage in higher risk behaviors than younger Latino MSM.
They argue that one reason may be that older MSM may have more
difficulty in changing their sexual habits. However, other
evidence contradicts these findings and suggest that young Latino
MSM practice a higher level of unprotected sex (Ramirez, 1994;
Rotheram-Borus, 1991). More research needs to be conducted to
determine exactly where prevention efforts are most needed.
Asian MSM
Little is known about HIV risk behaviors among Asian-
American MSM. One factor associated with high risk, which is
common among other ethnic groups, is social stigma concerning
homosexuality in their own communities. A study conducted in
San Francisco (Choi, 1995) reported that Asian-American MSM
report a high level of AIDS knowledge. However, the reported
number of Asian-American MSM who practice unprotected anal
intercourse is higher than what is reported for White MSM.
27


Similar to other minorities, Asian-American MSM are less likely
to perceive themselves as being at risk for HIV, believing that
AIDS is a White gay male disease (Choi, 1995; Greene, 1995).
In examining minority MSM, there is no conclusive evidence
indicating relapse. What is prevalent, however, is that minority
MSM are at a higher risk for HIV infection than White MSM. Rather
than relapse, what may be of more concern are findings that
indicate minority MSM may have failed to adopt safer sex
behavior in the first place. An examination of determinants
associated with high risk sexual behavior is necessary in order to
implement effective intervention programs that identify and
understand the diverse sociocultural needs present among all
populations of MSM.
Determinants of Relapse
In a presentation made in Houston at the 1996 annual
conference for the Society for the Scientific Study of Sexuality,
William Elwood emphasized that risk groups are not as
important as risk behavior. Some MSM do not internalize
28


membership into what has been considered a high risk group (gay
males) and therefore do not identify themselves as being at risk,
although their behavior may prove otherwise. For example,
Elwood (1996) reported that 20% of MSM in one study who
reported having recent sex with a woman did not consider
themselves to be part of a risk group.
Two determinants commonly found in literature concerning
failure to maintain safer sex practices among MSM are lack of
social support, and perceived risk.
Social Support
Social support networks can convey information and help to
establish social norms regarding safer sex behavior. MSM who are
at greater risk for contracting HIV exhibit a particular need for
better social support. Research suggests that lack of social
support may contribute to unsafe sexual behavior among MSM and
increase their likelihood of relapse. (Coates, 1995; Hunter, 1994;
Morris, 1995). Being part of a group associated with increased
risk for contracting AIDS can have many social implications for
29


MSM, including the reinforcement of negative attitudes toward
homosexuals (Nisbet, 1993).
Homophobia. Studies have shown a great amount of social
stigma directed toward people at risk for AIDS; this particularly
applies to MSM (Baker, 1993; Greene, 1995; Lackner, 1993;
Turner, 1993; Vincke, 1994). Homophobia, the fear and hatred of
homosexuals, is seen at the interpersonal level, societal level,
and in laws governing our nation. For example, the following
congressional record was passed on October 14, 1987, which
established guidelines for funding of AIDS education materials
distributed by the Centers for Disease Control:
To prohibit the use of any funds provided under this ACT to
the Centers for Disease Control from being used to provide
AIDS education information, or prevention materials and
activities that promote, encourage, or condone homosexual
sexual activities... (Congressional Record, 1987, SI 4215)
Evidence indicates that many MSM respond positively to erotic
safe sex literature. This provision may impede development of
effective safer sex literature directly targeted to MSM (Thomas,
1991). Furthermore, it sends a clear message to MSM that they
30


are not valid members of society and not worth recognizing. This
type of homophobia and the message that it carries can be
projected through many segments of our society such as the
family.
Family Support. Perhaps the most desired source of
support by MSM is that of family support. MSM often withdraw
from their families of origin out of reluctance to disclose their
homosexual orientation. By doing so, MSM often do not discuss
their concerns about AIDS with family members and as a result
they lack the social support many heterosexuals receive from
their families. Instead, many MSM try to replace this type of
social support by creating what is perceived as an extended
family comprised of friends (Berger, 1993; Eichberg, 1990;
Griffin, 1986; Martelli, 1987; Turner, 1993; Weston, 1991). This
leads to a special concern for MSM who do not integrate into the
gay community and are lacking any source of perceived family
support. Furthermore, some MSM may not receive social support
from their families of origin until after being diagnosed with
31


AIDS or becoming ill with HIV-related symptoms.
Social Support for HIV+ MSM. A vast amount of
literature has determined that social support plays a vital role in
the ability of MSM to cope with AIDS (Hays, 1990; Kadushin,
Nicholson, 1990; 1996; Rodgers, 1995; Sandstrom, 1996a, 1996b).
According to Kadushin (1996), among HIV+ MSM, there are many
reasons for the lack of social support received from their
families of origin, such as:
...the familys lack of acceptance of homosexuality and the
relationship with a male partner; the stigma associated
with AIDS; the inability of family members to communicate
openly about homosexuality and AIDS; the lack of
competence among family members in dealing with HIV
issues; and overprotective, infantilizing behavior by
parents.
(p:141)
As a result, many HIV+ MSM report their greatest support coming
from networks of friends. While some HIV+ MSM report an
increase in social support after diagnosis of AIDS, there are also
some who report a decrease in support and alienation from their
peer groups (Hays, 1990; Sandstrom, 1996a; Stewart, 1996).
32


Some HIV+ MSM who report feeling alienated from
traditional support structures attend formalized community
support groups designed for them. This type of support can be
very positive for many HIV+ MSM. In a study by Sandstrom
(1996a), one HIV+ MSM said about the support group he attended
that, It was great, we all became friends and had someone to
talk with ... that was important, especially for me because after I
got HIV, my old friends never went out with me again (p:58).
Support groups not only provide an outlet for emotional support,
but also provide cognitive support through the exchange of
information relating to the conditions of their illness. In
addition, support groups can provide an outlet for discussing how
being HIV+ has effected changes in their sexual and intimate
relationships. One HIV+ MSM stated in his support group:
Ive said to myself, Oh yes, I know all there is to know
about setting boundaries [on sex] and feel okay with it. But
then, what if you get in a situation where you feel
extremely passionate, does it all go out the window?
Wheres the boundary, you know? And what if someone -
what if you meet someone who doesnt give a shit about
safe sex? And he tells you, I dont care, lets do
everything!
(Sandstrom, 1996b, p:248)
33


Social support networks which promote discussion of such issues
among MSM, whether HIV+ or not, can be very important in helping
to maintain safer sex practices and prevent relapse.
Perceived Risk
In one recent study (Bosga, 1995), factors associated with
MSM who relapsed are described as, not having sex with a partner
known to have HIV or AIDS, and not having friends or relatives
who are HIV+ or have AIDS. Some MSM may think their sexual
partners are not HIV infected because they look healthy, clean,
and/or attractive (CDC, 1995a; Gold, 1991). Another factor of
relapse is the status of the relationship between MSM and their
sexual partners.
Studies indicate that MSM currently report having fewer
partners than at the beginning of the AIDS epidemic. Some MSM
believe they are at little or no risk for HIV infection because they
have established a monogamous relationship or have minimized
their sexual partners to people they know (Bosga, 1995; Buchanan,
1996; Dawson, 1994; Kelly, 1991; Van Griensven, 1989). This
34


method of perceived risk is commonly referred to as negotiated
safety. Davies (1993) reported that, ...a very high proportion of
the increase in unsafe sex is due to strategies of negotiated
safety (p:280). By adopting such strategies, many MSM find it
difficult to maintain safer sex guidelines over a long period of
time and instead adopt a process of risk minimization, rather
than risk elimination.
Rationale for the Present Study
As stated earlier, very few studies have suggested the
existence of relapse behavior or its determinants. The purpose of
this study is to search for evidence of relapse behavior among
populations of MSM and to identify changes in unsafe sexual
behavior. Data from the Knowledge, Attitudes, Beliefs, and
Behaviors (KABB) study conducted by the Colorado Department of
Public Health and Environment will be used. By assuming that
recent reports are correct, based on the discussed literature, the
following hypotheses will be tested by conducting a longitudinal
analysis of data collected in the years 1991 and 1995.
35


1) MSM are more likely to slip into unsafe sexual behavior in
1995 than in 1991.
2) Young MSM are more likely to be at higher risk for HIV
infection than older MSM.
3) MSM who are of an ethnic minority are more likely to be at
higher risk for HIV infection than White MSM.
4) MSM who adopt negotiated safety strategies in determining
when to practice safer sex are more likely to be at higher
risk than those who dont.
5) MSM who report a low amount of social support are more
likely to be at higher risk for HIV infection than men who
report receiving high amounts of social support.
Analyses performed in this study will focus on determining the
existence and extent of relapse behavior. This will be done by
examining self-reported high risk sexual behavior among specific
populations of MSM and making comparisons to the same
populations in the past.2
2The KABB study is a longitudinal trend study. Samples taken in 1991 and
1995 are two distinct samples and do not involve the same cohort of respondents.
36


CHAPTER 3
METHODS
Sample
In this study, data from the Knowledge, Attitudes,
Beliefs and Behaviors (KABB) study conducted by the Colorado
Department of Public Health and Environment for the years 1991
(N=225) and 1995 (N=464) will be used. The population examined
consists of MSM who reside in the state of Colorado and who
report having at least one male sexual partner in the past 12
months.
The KABB study surveyed subjects from a variety of public
places and events including the Peoples Fair, Taste of Colorado,
AIDS Walk, Gay Pride events, gay bars, Colorado AIDS Projects
(CAPS), local health departments, and other venues. The study
used purposive/targeted sampling techniques. Non-probability
sampling, specifically targeted and snowball sampling methods,
are the most widely accepted methods of sampling among this
population. Random sampling techniques are virtually impossible
37


because not only is this group considered to be a partially hidden
minority, but there is a lack of consensus on defining this
segment of the population. For example, some studies define this
population as self-identified gay and bisexual men, while others
define this population as men who report having sex with other
men regardless of whether or not they identify as being gay or
bisexual.
Sample Characteristics
Because there are some respondents in the study who report
not having sex or only having sex with female partners, the
samples have been reduced to include only those respondents who
reported having sex with a male partner in the previous 12
months (1991 n=200; 1995 n=433). For most of the analysis in
this study, the sample sizes have been further reduced to include
only those respondents who report not being in a relationship
(1991 n= 100; 1995 n= 270). These samples are are the ones of
main interest to this study, because it is hard to determine what
constitutes unsafe sex among those who report being in a
38


relationship, particularly those who claim to be in a monogamous
relationship and are aware of their partners HIV status. MSM who
are in a relationship are briefly mentioned in the analysis where
appropriate, but are treated as a separate sample.
In the 1991 sample, 50% of respondents report not being in
a relationship. Of those not in a relationship, respondents are
between the ages of 18 and 64 with a mean age of 33. The
respondents are mainly White, where Whites consisted of 78% of
the sample, African-Americans 5%, Latinos 11 %, Asian-
Americans 2%, Native-Americans 2%, and Other as 2%. The
number of male partners within the previous 12 months range
from 1 to 99 with a mean of 10.52 partners. The number of
female partners range from 0 to 6, with 93.9% reporting no
female partners in the previous 12 months. The majority of
respondents are HIV negative, with 61.6% negative, 20.2%
positive, and 18.2% unaware of their status.
In the 1995 sample, 62.4% of respondents report not being
in a relationship. Of this population, respondents are between the
ages of 16 to 56 with a mean age of 33. Respondents are also
39


mainly White, with Whites consisting of 83.1%, African-
Americans 3.4%, Latinos 10.3%, Asian-Americans 0.8%, Native-
Americans 1.1%, and Other as 1.1%. Respondents report having
between 1 and 250 partners within the previous 12 months with a
mean of 10.17 partners. Number of female partners ranged from 0
to 8, with 90.4% reporting no female partners. The majority of
respondents are also HIV negative, with 84% negative, 11.2%
positive, and 4.8% not knowing their HIV status.
Instrument
The instrument used for measurement in the KABB study is
an anonymous, self-administered questionnaire (see Appendix A
and B). The questionnaires were administered between the
months of May through September of the years 1991 and 1995.
All questionnaires were distributed and collected in person, and
respondents were instructed not to include their names on the
questionnaire.
The questionnaire, as indicated in the title of the study,
surveyed the knowledge, attitudes, and beliefs, as well as sexual
40


behavior of the respondents. It included questions relating to the
respondents level of reported unsafe sexual behavior, as well as
their concerns about risk for HIV infection. Other questions
measured: amount of perceived social support, attitudes toward
using condoms, and demographical information such as race, age,
and place of residence.
Measures
Independent variables used in the analyses are age,
ethnicity, and relationship status. Age is recoded into the
variable Agel, where value 1 signifies respondents who are 24
years of age and younger, value 2 indicates respondents between
the ages 25 through 45, and value 3 denotes respondents 46 years
of age and older. Race is recoded into the variable Ethnic,
where value 1 indicates that the respondent is White and 2
indicates that the respondent is Non-White.3 The original
variable Re 1st at is recoded to Relstatl, where value 1
symbolizes respondents who are in a relationship and 0
3For purposes of easier identification, some of the original variable names
have been changed.
41


symbolizes respondents who are not in a relationship.
Dependent variables used in the analyses are slip, insertive
anal sex, and receptive anal sex. Slip is recoded into the variable
SI i p 1, where value 1 includes respondents who slip into
participating in unsafe (unprotected) sex, and 0 indicates
respondents who never slip into unsafe sex. The variable Insert
is recoded into the variable Insert"!, where value 1 pertains to
respondents who report rarely to always practicing insertive
anal sex (being the insertive partner) without a condom during
sexual encounters, while 0 consists of respondents who never
have insertive anal sex without the use of a condom. The variable
Recept is recoded into the variable Receptl, which refers to
respondents likelihood to practice unprotected receptive anal
intercourse. The value labels of Receptl were coded in the same
manner as Insert 1 (value 1 indicates rarely to always and 0
indicates never).
42


CHAPTER 4
RESULTS
To determine whether or not relapse is occurring,
difference of proportions tests have been performed on high risk
variables, comparing 1995 respondents with 1991. Results from
these tests do not give an indication toward relapse and thus do
not support hypothesis 1 (see chapter 2). Among all MSM who
report not being in a relationship, there is no significant change
(Z = 1.45, p > .05) in percentages of men claiming to slip into
unprotected sexual behavior and those who do not slip.
Furthermore, there is some indication that single MSM are
actually practicing more safer sex now than they were previously.
When asked about condom use during insertive (Z = -1.73, p < .05)
or receptive (Z = -1.65, p < .05) anal sex, significantly fewer
respondents claimed to practice unprotected anal sex in 1995
than in 1991.
When comparing different age groups to determine
existence of relapse, young MSM do not show any change in slip
43


behavior. Among the variables determining slip (Z = 1.16, p > .05)
and unprotected insertive (Z = -0.36 > .05) and receptive (Z = 0.71,
p > .05) anal intercourse, young MSM show no change. Among
middle aged MSM, there is no change in those reporting to slip (Z =
0.50, p > .05). However, when asked about insertive (Z = -2.16, p <
.05) and receptive (Z = -2.00, p < .05) anal intercourse, middle
aged MSM show a significant change, with a decrease in the
number of men claiming to practice unprotected anal intercourse.
The only age group showing an increase toward slip is among
older MSM (Z = 1.76, p < .05). However, when asked about
unprotected insertive (Z = 0.34, p > .05) and receptive (Z = -0.05, p
> .05) anal intercourse, older MSM show no significant change. It
should be noted that it may be more difficult to determine slip
among older MSM, because of the small number of older
respondents present in the samples (1991, n = 14; 1995, n = 25).
In comparing White with Non-White respondents, neither
group shows any indication of relapse. Among variables
determining slip (Z = 1.43, p > .05), unprotected insertive (Z = -
1.53, p > .05) and receptive (Z = -1.26, p > .05) anal intercourse,
44


White MSM show no significant change. For Non-White MSM there
is no significant change in slip (Z = 0.40, p > .05), unprotected
insertive (Z = -0.76, p > .05) or receptive (Z = -1.13, p > .05)
intercourse either.
Although results do not support hypothesis 1, by failing to
provide evidence of relapse behavior, percentages attached to
high risk sexual behavior are still of great concern. Of all men in
1995 who are not in a relationship, a majority (61.5%) report
slipping into unsafe sexual behavior within the previous 12
months. In the same sample, 28.5% report engaging in
unprotected insertive anal intercourse, while 21.5% report
engaging in unprotected receptive anal intercourse in the previous
12 months.
To calculate for any significant difference between age
groups and reported high risk sexual behavior, measurements of
association have been performed on the 1995 sample. Results
comparing age and reported slip are significant (X2=.016, p<
.05)), where a lower percentage of middle aged MSM (55.9%)
report slipping in the previous 12 months than do young (73.7%)
45


and older (80%) MSM. Difference between age groups is
particularly significant (X2 = .022, p < .05) among those who
report practicing unprotected receptive anal intercourse; results
indicate young MSM (39.5%) are about twice as likely as middle
aged (19%) and older (20%) MSM to practice unprotected receptive
anal intercourse. Although not statistically significant,
percentages show that young MSM (36.8%) are also more likely
than middle aged (27.2%) and older (32%) MSM to practice
unprotected anal intercourse when they are the insertive partner.
The above results, therefore, are in support of hypothesis 2 (see
chapter 2).
Measuring for a possible relationship between respondents
ethnicity with reported slip behavior in the 1995 sample, results
are also found to be significant (X2 = .047, p < .05). More Non-
White (73.6%) respondents reported slipping than did White
(58.5%) respondents, thus supporting hypothesis 3 (see chapter 2).
Although not statistically significant, more Non-White
respondents also reported practicing unprotected insertive
(35.8%) and receptive (28.3%) anal intercourse than White
46


respondents (26.7% and 19.8% respectively).
In the 1995 survey, respondents were asked about their
concerns over HIV infection and their reasons for slipping into
unsafe sexual behavior. Several reasons were given. Some
respondents mentioned alcohol as playing a role in their decision
to practice unsafe sex. Another determinant mentioned by
respondents was getting caught up in the heat of the moment,
or letting passion influence their decision making. Other
factors included, lack of self-esteem, pressure from their sexual
partner(s), not caring anymore, believing they will eventually
become infected anyway, as well as one respondent who admitted
to wanting to be HIV positive. Perhaps of most interest to this
study are respondents who indicate practicing less risky sex,
and having unsafe sex only with partners they know and trust.
These last factors are of concern in terms of investigating
negotiated safety.
Of all single MSM in 1995 who are either HIV negative or do
not know their HIV status (n=238), 89.1% say it is somewhat to
extremely important to know the HIV status of their sexual
47


partner(s). When measurements of association are performed to
compare those who report importance in knowing their partner(s)
HIV status to those who place little or no importance on this
knowledge, a significant relationship is found in support of
hypothesis 4 (see chapter 2). Of those who place importance on
knowing their partner(s) HIV status, 21.5% (compared to 4% of
those who do not place importance on this factor) report
practicing unprotected receptive anal intercourse in the previous
12 months. Likewise, 31.1% of those who place importance,
compared to 12% of those who do not, report practicing
unprotected insertive anal intercourse.
Perhaps the most difficult group to determine existence of
negotiated safety in this study is of those in a relationship. In
1995, 35.6% (n=154) of respondents claim to be in a relationship.
Of those in a relationship, 38.3% report having engaged in
unprotected receptive anal intercourse within the previous 12
months, while 44.2% report engaging in unprotected insertive anal
intercourse. Although unprotected sex within a monogamous
relationship where both partners are HIV negative is not
48


considered unsafe sex, what may be of greatest relevance is
that 61.7% of respondents in a relationship claim to have had sex
with someone other than their primary partner in the previous 12
months (overall mean number of male partners = 5.0)
What is unclear and cannot be determined from this study is
what type of negotiated safety those claiming to be in a
relationship may be practicing. It is possible that these
respondents have unprotected sex with their primary partner
while practicing safer sex with partners outside of the
relationship, or it is also possible they practice protected sex
with their primary partner while occasionally slipping into
unsafe sex outside of the relationship. What is of great
importance is that 90.2% of respondents in a relationship state
that knowing their partners status is important, with the
majority (55.2%) claiming it is extremely important.
To determine if there is any relationship between amount of
perceived social support and high risk sexual behavior,
measurements of association have been performed on MSM who
report not being in a relationship in the 1995 survey. Results
49


comparing amount of support received from friends and slip
behavior are significant (X2 = .002, p < .05), where 91% of those
who receive little or no support from their friends report slipping
in the previous 12 months. Amount of support received from a
sexual partner(s) is also significant (X2 = .003, p < .05) when
compared to slip behavior. Of those who report receiving little or
no support from their sexual partner(s) to practice safer sex, 85%
report slipping. Given these results, hypothesis 5 is clearly
supported (see chapter 2).
50


CHAPTER 5
DISCUSSION
Hypothesis 1 of the present study, which supposes MSM are
relapsing into unsafe sexual behavior, is not supported. These
results do not confirm evidence, as stated in the literature,
which indicates an occurrence of relapse (Bernstein, 1991; Chase,
1990; Staver, 1992). There are a number of reasons why results
differ from what has recently been found in the literature.
According to Hart (1992), in an empirical critique on
behavioral research reporting relapse, studies differ on what
constitutes safe or unsafe sexual practice. For example,
some may include MSM who are in mutually monogamous
relationships. In reading the literature, it is often not reported
who was included or excluded in the samples. In this study, MSM
who defined themselves as being in a relationship were treated
as a separate sample. It is possible that many studies claiming
the occurrence of relapse include men in mutually monogamous
relationships among those failing to maintain safer sex practices.
51


MSM, who are in fact, in a mutually monogamous relationship and
are aware of their own and their partners HIV status should not
be included among those practicing unsafe sex. What should
perhaps be done is to classify differences between no relapse
or low risk (MSM who have unprotected anal sex within a
mutually monogamous relationship) and those considered at high
risk (MSM who have unprotected anal sex outside of a mutually
monogamous relationship) (Connel, 1990; Hart, 1992).
Another reason the present study may have produced
different results than found in recent literature may be due to a
difference in study design. This study, designed by the Colorado
Department of Public Health and Environment, was designed as a
longitudinal trend study and collected separate samples used in
the analysis. Other research has involved the use of cohort
studies where the behavior of the same respondents were
followed over a period of time. Although there may be some
advantages to targeting relapse behavior among a cohort of MSM,
there are also some disadvantages. For example, cohort studies
run the risk of incomplete information due to the drop out rate of
52


respondents over a period of time. Also, cohort studies have been
successful in recruiting mainly White MSM who have in fact
shown the greatest sexual behavior change throughout the AIDS
epidemic.
Hypothesis 2, which supposes that young MSM are more
likely to be at higher risk than older age groups, is clearly
supported. Results may indicate that HIV prevention efforts,
originally designed for MSM now in their 30s and 40s, may not be
effective for the new generation of young MSM who are just
beginning to explore their sexuality. There has been vast
discussion in the literature (Lemp, 1994; Rotheram-Borus, 1991)
affirming a lack of research targeted to young MSM. Research
specifically aimed at defining determinants of unsafe sexual
behavior among young MSM is in great need. It should also be
noted that research targeting older MSM is almost non-existent.
Little is known about this group and they are under represented in
this study.
Hypothesis 3, which supposes ethnic minority MSM are more
likely to be at greater risk for HIV infection than White MSM, is
53


also supported. This concures with what is currently being
reported in the literature (Bardach, 1995; CDC 1996a and 1995b;
Choi, 1995; Icard, 1992; Peterson, 1995; Ramirez, 1994; Thomas,
1991). Although there is no indication of relapse, what may be of
more concern is that some minority MSM may not have adopted
safer sex practices to begin with. Further research is needed in
an effort to identify determinants associated with unsafe sexual
behavior among minority populations. It should also be noted that
in the present study, minority populations are under represented.
Future studies are needed that target minority populations, in an
effort to establish culturally appropriate intervention strategies.
Another issue that should be investigated, which is not
included in this study, is the role economic status has upon ethnic
minorities. It is difficult to determine whether an increase
toward HIV infection among minorites is based more on cultural
differences or on differences in class status within society.
Results indicate that single MSM who adopt negotiated
safety strategies are more likely to be at higher risk for HIV
infection than those who dont, thus supporting hypothesis 4.
54


What is unclear, however, is the magnitude of negotiated safety
that may exist among respondents who claim to be in a primary
relationship. Findings in the current study suggest that
negotiated safety may play a significant role for MSM in a
relationship, especially when considering that 61.7% of these men
report having sex with someone outside of their relationship in
the previous 12 months. Research is needed which focuses on
sexual behavior and negotiated safety strategies found among
MSM in a relationship.
Hypothesis 5 is supported with results showing that MSM
who receive little or no support from their friends or sexual
partners are likely to place themselves at higher risk for HIV
infection. As mentioned in the literature (Berger, 1993; Eichberg,
1990; Griffin, 1986; Martelli, 1987; Turner, 1993; Weston, 1991)
many MSM do not receive acceptance for their sexual identity
from their families of origin. Instead, many MSM rely on support
received from friends and partner(s). This type of support is
important in helping to adopt and maintain safer sex practices.
Partner support, or lack of, may play a particular role in helping
55


to maintain safer sex behavior. Not mentioned under results in
Chapter 4, but worth mentioning here, is that 43% of single MSM
report its sometimes to always difficult to find a safer sex
partner. This brings into question the so called safe sex
culture that is said to exist (see Gold, 1995a, and 1995b).
In summary, a question that must be asked is, what role
should sociologists play in studying the impact of AIDS among
MSM? Since the early 1980s, when AIDS was first discovered, a
vast amount of data has been collected on MSM. There are many
implications for further research; many questions are in need of
answers, such as: Why do MSM continue to practice unsafe sex?
Under what settings does unsafe sex occur? What types of
prevention strategies have shown to be effective? What types
are not effective? Answers to these questions are possible
through continued research and the collection of data. From a
sociological standpoint however, there is a great need for data to
be explained from a theoretical perspective.
Thus far, theories concerning HIV have been used more
informally; which are based upon what prevention planners have
56


found to be most effective in changing individual behavior. More
formal theory, such as, the theory of reasoned action, social
cognitive theory, and the health belief model are occasionally
mentioned in the literature. However, such theories are in need
of further testing. Through the help of sociologists, theoretical
constructs should be further developed and applied, with hopes of
establishing better and more effective prevention strategies.
57


Appendix A
KABB 1995 Annual Survey
Please complete the following questions as honestly and carefully as possible. Do not
put your name on the survey. Your answers are completely anonymous.
Thank you!
1. In the last 12 months, how many different male partners have you had sex
with? (WRITE NUMBER IN BLANK)____________________
2. In the last 12 months, how many different female partners have you had sex
with? (WRITE NUMBER IN BLANK)____________________
3. How easy is it to find a safer sex partner? (CIRCLE ONLY ONE)
a. always easy
b. usually easy
c. sometimes easy/sometimes difficult
d. usually difficult
e. always difficult
4. What is your HIV antibody status? (CIRCLE ONLY ONE)
a. negative
b. positive > (skip to #8)
c. dont know
5. How concerned are you about becoming HIV infected
a. extremely
b. very
c. somewhat
d. not very
e. not at all
f. I am HIV positive
6. If you circled 5a or 5 b, why do you think you are likely to become infected?
(If you did not, please skip to question #8)
58


7. How important is it for you to know the HIV status of your sexual
partner(s)? (CIRCLE ONLY ONE)
a. extremely important
b. very important
c. somewhat important
d. not very important
e. not important at all
8. How often do you slip into unsafe (unprotected) sex?
(CIRCLE YOUR RESPONSE)
9.
Always Often Sometimes Rarely Never
III II
1 2 3 4 5 > (skip to #11)
Why do you slip into unsafe sex?
10. How much support for safer sex do you get from (PLEASE CIRCLE A
RESPONSE FOR EACH ITEM BELOW)
a. your friends alot quite a bit some not much none
b. your partner(s) alot quite a bit some not much none
c. Gay community alot quite a bit some not much none
d. media alot quite a bit some not much none
e. other communities alot quite a bit some not much none
What type of educational workshops would you like to see offered? (CIRCLE
AS MANY AS YOU WISH)
a. Sex and Dating in the 90s
b. SEXCESS!: For couples of Mixed Antibody Status
c. SEXCESS!: Getting started with Safer Sex
d. S.E.A. (Self Esteem and Attitudes)
e. H.E.A.T. (HIV Education and Treatment)
f. S.A.N.D. (Sex and Nintys Dating)
g. S.H.A.D.E.S. (Safe, Hot, and Damn Erotic Sex)
h. Men, Intimacy, and Sex
i. Other (please specify)________________________
59


12. How do you describe your injection (needles) drug use?
(CIRCLE ONLY ONE)
a. I currently use injection drugs
b. I used to but no longer use injection drugs (specify year you
stopped__________)
c. I have never used injection drugs > (SKIP TO QUESTION 16)
13. In the last 12 months, how many times have you shared needles and/or
syringes (works) with other users?________________(WRITE NUMBER IN
BLANK)
14. In the last 12 months, how many times have you cleaned your works with
bleach/Clorox BEFORE using them when you shared?________________
(WRITE NUMBER IN BLANK)
15. How much do these opinions affect whether or not you use condoms? (CIRCLE
RESPONSE FOR EACH OPTION)

a. oral sex without condoms is low risk extremely very somewhat not very not at all
b. condoms reduce sensation extremely very somewhat not very not at all
c. sex is better without condoms extremely very somewhat not very not at all
d. condoms are not romantic extremely very somewhat not very not at all
e. partner and 1 are HIV negative extremely very somewhat not very not at all
16. How often do you engage in the following when you have sex? (CIRCLE ONE
RESPONSE FOR EACH OPTION)
a. Rimming or always usually sometimes rarely never
oral anal contact b. Give a blow job always usually sometimes rarely never
without a condom c. Get a blow job always usually sometimes rarely never
without a condom
60


d. Fuck someone without a condom always usually sometimes rarely never
e. Get fucked without a condom always usually sometimes rarely never
17. Current relationship status:
a. not in a relationship
b. in a relationship with an HIV negative partner
c. in a relationship with an HIV positive partner
d. in a relationship with a partner who doesnt know their HIV status
18. How old are you?____________
19. What is your racial/ethnic identity?
a. Caucasian
b. African American
c. Latino
d. Asian American
e. Native American
f. Other (please specify)____________________________
20. Where did you get accurate information on AIDS/Safer Sex/HIV testing etc.?
(CIRCLE THE BEST ANSWER)
a. Rocky Mountain News
b. Denver Post
c. Television (channel_____)
d. Radio (station number or call letters_________)
e. Out Front
f. Preferred Stock
g. HOMO
h. Quest
i. Advocate
j. AIDS information hotlines (please specify_____________________)
k. Physician or other health provider
l. Local health department
m. Community-based Organizations (ie. Colorado AIDS Project,\
GLBCSCC, PWA Coalition, B A PAL/CARE, P.O.C.C.A., Latino AIDS
Community Network)
n. Other (Please specify_________________________)
61


21. How satisfied are you with the AIDS education programs in your area?
a. extremely satisfied
b. very satisfied
c. somewhat satisfied
d. not very satisfied
e. not at ail satisfied
22. What is your zip code?_______________________
Thank you very much!
If you have questions regarding this survey or HIV/AIDS please contact Bill Hogan at
the Colorado AIDS Project (303) 837-0166 or the Colorado Department of Health
STD/AIDS Education and Training Program (303) 692-2720.
62


Appendix B
1991 ANNUAL SURVEY
A COOPERATIVE EFFORT BETWEEN
THE COLORADO AIDS PROJECT AND
THE COLORADO DEPARTMENT OF HEALTH
Directions: We ask that you complete the following questions as honestly and
carefully as possible. Do not put your name on the survey. Your answers are
COMPLETELY ANONYMOUS. Thank you!
1. In the last 12 months, how many different male partners have you had sex
with?
a. only one partner
b. more than one partner (specify number__________)
c. none
2. In the last 12 months, how many different female partners have you had sex
with? (CIRCLE ONLY ONE)
a. only one partner
b. more than one partner (specify number__________)
c. none
3. What is your HIV antibody status? (CIRCLE ONLY ONE)
a. negative
b. positive
c. dont know
4. How concerned are you about the confidentiality of you HIV antibody test
results? (CIRCLE ONLY ONE)
a. extremely
b. very
c. somewhat
d. not very
e. not at all
63


5. How easy is it to find a safer sex partner? (CIRCLE ONLY ONE)
a. always easy
b. usually easy
c. sometimes easy/sometimes difficult
d. usually difficult
e. always difficult
6. How likely are you to participate in a social group for men who practice safer
sex?
a. extremely
b. very
c. somewhat
d. not very
e. not at all
7. If you are HIV negative or do not know your antibody status, how likely are
you to become infected? (CIRCLE ONLY ONE)
a. extremely
b. very
c. somewhat
d. not very
e. not at all
f. I am HIV positive
8. How important is it for you to know the HIV status of your sexual
partner(s)? (CIRCLE ONLY ONE)
a. extremely important
b. very important
c. somewhat important
d. not very important
e. not important at all
9. If you practice safer sex, do you occasionally slip into unsafe sex?
a. yes
b. no
c. I dont practice safer sex
d. I dont have sex
64


10. How much support for safer sex do you get from:
(PLEASE CIRCLE A RESPONSE FOR EACH OPTION)
a. Your friends extremely very somewhat not very not at all
b. Your partners extremely very somewhat not very not at all
c. Knowing HIV extremely very somewhat not very not at all
status
d. Not knowing HiV extremely very somewhat not very not at all
status
e. Gay communities extremely very somewhat not very not at all
f. Media extremely very somewhat not very not at all
11. What type of educational workshops would you like to see offered? (CIRCLE
ONLY ONE)
a. SEXCESSI: and the single man (a safer sex workshop)
b. SEXCESSI: Condoms for couples
c. SEXCESSI: Getting started
d. HIV testing: What it is and why its important
e. Keep it Up!: Staying safe
f. SEXCESSI: for couples of mixed antibody status
g. Other_________________________________________
12. How do you describe your IV (needles) drug use? (CIRCLE ONLY ONE)
a. I currently use IV drugs
b. I used to but no longer use IV drugs (specify year you stopped_)
c. I have never used IV drugs
13. In the last twelve months, how many times have you shared needles and/or
syringes (works) with other users?_________________________
14. In the last twelve months, how many times have you cleaned your works
BEFORE using them when you share?__________________________
15. How much do these opinions affect whether or not you use condoms? (CIRCLE
ONE RESPONSE FOR EACH OPTION)
a. oral sex without condoms is low risk extremely very somewhat not very not at all
b. condoms reduce sensation extremely very somewhat not very not at all
c. sex is better extremely very somewhat not very not at all
without condoms
65


d. condoms are not romantic extremely very somewhat not very not at all
e. partner and 1 are HIV negative extremely very somewhat not very not at all
16. How often do you engage in the following when you have sex? (CIRCLE A
RESPONSE FOR EACH OPTION)
a. Rimming or oral anal contact always usually sometimes rarely never
b. Give a blow job without a condom always usually sometimes rarely never
c. Get a blow job without a condom always usually sometimes rarely never
d. Fuck someone without a condom always usually sometimes rarely never
e. Get fucked without a condom always usually sometimes rarely never
f. Get fisted without a glove always usually sometimes rarely never
d. Fist someone without a glove always usually sometimes rarely never
e. Get pissed on (golden showers) always usually sometimes rarely never
17. Current relationship status:
a. Not in a relationship
b. In a relationship with an HIV negative partner
c. In a relationship with an HIV positive partner
d. In a relationship with a partner who doesnt know HIV status
18. How old are you?______________
66


19. What is your race/ethnic origin?
a. White
b. African American
c. Latino
d. Asian American
e. American Indian
f. Other (please specify)___________;___________________
20. Where do you get good, accurate information on AIDS/Safe Sex/HIV testing etc.,?
(CIRCLE THE BEST ANSWER)
a. Rocky Mountain News
b. Denver Post
c. Television (channel________)
d. Quest
e. Outfront
f. Advocate
g. Community-based organizations (ie. CAP, GLCCC, PWA Coalition,
MAC)
h. Local health department
i. AIDS information hotlines (specify____________)
j. Physicians or other health providers
k. Other (please specify)________________;_______
21. How satisfied are you with the AIDS education programs in your area?
a. extremely satisfied
b. very satisfied
c. somewhat satisfied
d. not very satisfied
e. not at ail satisfied
22. What is your zip code?____________________
THANK YOU VERY MUCH!
If you have any questions regarding this survey or HIV/AIDS education please call
Bill Hogan (303) 937-0166 or Jesus M. Gonzalez (303) 331-8675.
67


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