Changes in Sexual Behavior and Condom Use Associated with a Risk-Reduction Program -- Denver, 1988-1991

Human immunodeficiency virus (HIV) risk-reduction programs have been developed to discourage homosexual / bisexual men (i.e., men who have sex with men) from engaging in anal and oral sexual intercourse with partners who are infected with HIV or whose infection status is unknown (1). The consistent and proper use of latex condoms with adequate lubrication may reduce the risk for HIV transmission during intercourse (2). To assist these men in understanding and following "safer" sexual behaviors, the Denver Disease Control Service conducted a longitudinal cohort study as part of CDC's Demonstration Projects for HIV Prevention and Risk Reduction. This report describes the effects of individual counseling sessions -- including a basic introduction to the availability and proper use of condoms and lubricants -- on short- and long-term behavior change among a group of homosexual / bisexual men in Denver during 1988-1991.

Participants were recruited from June 1, 1988, through January 31, 1991, through referrals from community-based organizations, public clinics, and other health-care providers; advertising campaigns; and word-of-mouth communication. Study participants made two visits at study entry, then made follow-up visits every 6 months. During initial visits, participants 1) completed self-administered questionnaires regarding knowledge, attitudes, beliefs, and sexual behaviors (including condom use); 2) underwent HIV-antibody testing; 3) received extensive counseling on the natural history of HIV infection, modes of HIV transmission, and ways to prevent infection; and 4) received skills-provision training, which included placing and removing condoms on and off a rubber phallus with lubricant and reviewing a poster about condoms and lubricants. The poster reemphasized the risk for transmission of HIV associated with anal intercourse; encouraged the use of latex condoms and water-based lubricants, including those with nonoxynol-9 spermicide; and discouraged anal intercourse without condoms, rectal douching before and after anal intercourse, and the use of "natural membrane" condoms and petroleum-based lubricants. At each follow-up visit, participants completed questionnaires and received HIV-antibody testing and reinforcement of educational messages. Skills-provision training was not systematically repeated unless requested by the participant or the project staff identified a need for repeat training during risk assessment.

From 1988 through 1991, 298 men completed questionnaires at both initial and 12-month visits. Of the participants, 268 (90%) were white; 18 (6%), Hispanic; 9 (3%), black; and 3 (1%), unknown. Ninety-five (32%) were HIV seropositive. Respondents reported on sexual behaviors in the previous 90 days with primary, occasional, and one-time partners. * Completed questionnaires from both initial and 12-month visits were available for 180 (60%) to 216 (72%) study participants (Table 1).

Because there were no substantial differences in sexual behavior or condom use between HIV-seropositive and HIV-seronegative men at either initial or 12-month visits, the data for these two groups were combined. Paired analysis indicated significantly higher rates of discontinuation than relapse for insertive and receptive anal intercourse with one-time and occasional partners (Table 1). A decrease was observed among men who engaged in insertive anal intercourse with primary partners (p=0.11); the percentage of men engaging in receptive anal intercourse with a primary partner remained the same.

Among 252 (85%) men who reported condom use, any condom use in the previous 90 days increased significantly, from 63% at initial visits to 71% after 12 months (p less than 0.05). Based on a 5-point Likert scale, changes in frequency of condom use were analyzed for the small proportions of participants who reported insertive or receptive anal intercourse at both initial and 12-month visits (Table 2). Paired analysis indicated a trend toward increased condom use for men engaging in insertive anal intercourse with one-time partners (p=0.07). At both initial and 12-month visits, participants reported using condoms more frequently with one-time and occasional partners than with primary partners (p less than 0.01).

To evaluate the possibility of early changes followed by relapse, interim data for 6-month visits were also analyzed. For men who engaged in insertive anal intercourse with primary partners, condom use increased from 2.6 at the initial visit to 3.2 at 6 months (p less than 0.05), followed by a decrease to 3.0 after 12 months. The pattern was similar for men having receptive anal intercourse with primary partners: an increase from 2.8 to 3.5 at 6 months (pless than or equal to 0.05), followed by a decrease to 3.0 at 12 months (p less than 0.05).

Reported by: DL Cohn, MD, CAM Rietmeijer, MD, MS Kane, SG Cooper, CJ Martindale, FN Judson, MD, Denver Disease Control Svc. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that, among study participants in Denver, it was possible to achieve a substantial decrease in anal intercourse with one-time and occasional partners; these findings may be attributable to the emphasis the intervention program placed on the high risks associated with unprotected anal intercourse in transmitting HIV (3). In addition, factors outside the risk-reduction program may have accounted for some of the reported changes in behavior. For example, sexual behavior changes in this group of self-selected men may have been influenced by changes in community norms or by an increasing awareness of the modes of HIV transmission through sources other than the intervention project (e.g., national campaigns or other AIDS intervention activities in the community) (4).

Findings in this study also documented an increase in overall condom use between the initial and 12-month visits. However, no significant changes occurred in condom use by partner types for the small group of men who reported continuing insertive or receptive anal intercourse. Consequently, the relatively small change in prevalence of reported condom use for anal intercourse may reflect either limited statistical power or selection of a subgroup of less motivated men who persisted in these activities.

The finding that participants were more likely to discontinue anal sex or to use condoms with one-time and occasional rather than primary partners may reflect decisions in primary partnerships based on knowledge of HIV serologic status (5,6). Although this possibility was not evaluated in the current study, other studies among HIV-infected patients seeking health care in the same public clinics in Denver have documented lower condom use with sero-identical partners (C.A.M. Rietmeijer, Denver Disease Control Service, unpublished data, 1992). The initial increase in condom use for both insertive and receptive anal intercourse with primary partners at 6 months followed by a decrease at 12 months may also have been the result of the absence of standardized reinforcement of skills-provision training for all study participants at the 6-month visit. The increasing use of condoms for insertive anal intercourse for one-time partners may be a result of the relative effectiveness of interventions in changing active (insertive) behavior compared with an insufficient provision of skills in men who engage in receptive intercourse.

The effects of HIV counseling and testing on sexual behavior of men who have sex with men have varied; knowledge of seropositivity has often been associated with subsequent decreases in risk behaviors (7). Skills-provision training increases condom use for insertive anal intercourse (8) and is important in teaching basic skills for condom use and proper choice of lubricants (9). Condom use is a relatively complex behavior that involves personality types (e.g., men who have assertive communication styles may be more successful in changing condom-use behavior with partners) and psychological adjustment that may be facilitated by reinforced skills-provision training (10). In addition, learning how to negotiate safer sex skills is especially important for men who continue to have sex with occasional and one-time partners; counseling and skills-provision training assists men who have sex with men to discontinue or decrease anal intercourse and increase condom use. These findings suggest the need for HIV prevention counseling and skills-provision training in programs providing HIV-prevention intervention for men who have sex with men.

References

1. Stall RD, Coates TJ, Hoff C. Behavioral risk reduction for HIV infection among gay and bisexual men. Am Psychol 1988;43:878-85.

2. CDC. Condoms for prevention of sexually transmitted diseases. MMWR 1988;37:133-7.

3. Detels R, English P, Visscher BR, et al. Seroconversion, sexual activity, and condom use among 2915 HIV seronegative men followed for up to 2 years. J Acquir Immune Defic Syndr 1989;2:77-83.

4. Kelly JA, Saint Lawrence JS, Diaz YE, et al. HIV risk behavior reduction following intervention with key opinion leaders of population: an experiment analysis. Am J Public Health 1991;81:168-71.

5. Van Griensven GJ, de Vroome EM, Tielman RA, et al. Effect of human immunodeficiency virus (HIV) antibody knowledge on high-risk sexual behavior with steady and nonsteady sexual partners among homosexual men. Am J Epidemiol 1989;129:596-603.

6. Valdiserri RO, Lyter DW, Leviton LC, Callahan CM, Kingsley LA, Rinaldo CR. Variables influencing condom use in a cohort of gay and bisexual men. Am J Public Health 1988;78:801-5.

7. Higgins DL, Galavotti C, O'Reilly KR, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA 1991;266:2419-29.

8. Valdiserri RO, Lyter DW, Leviton LC, Callahan CM, Kingsley LA, Rinaldo CR. AIDS prevention in homosexual and bisexual men: results of a randomized trial evaluating two risk reduction interventions. AIDS 1989;3:21-6.

9. Cohn DL, Gourley PJ, Cole VJ, Judson FN. Condom usage for anal intercourse in a longitudinal cohort of gay and bisexual men (Abstract). Vol 1. IV International Conference on AIDS. Stockholm, June 12-16, 1988;281.

10. Ross MW. Psychological determinants of increased condom use and safer sex in homosexual men: a longitudinal study. International Journal of STD and AIDS 1990;1:98-101.

• Respondents were allowed to indicate whether they considered any particular sex partner a primary, occasional, or one-time sex partner.

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