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                           AIDS NEWS SERVICE
                      Michael Howe, MSLS, Editor
                        AIDS Information Center
                   VA Medical Center, San Francisco
                        [phone] ext 3305
                           January 20, 1995

                 Safer Sex: Information for Counselors
                              (Part XVI)

FOCUS - A Guide to AIDS Research and Counseling
Volume 8, Number 2, January 1993

                       EDITORIAL: RIGHT BEHAVIOR
                         Robert Marks, Editor

      In the HIV community, the word "relapse" has taken on almost
mythic proportions.  In the wake of dramatic changes in sexual
behavior among gay men, HIV prevention efforts were held up to the
world as a model.  Relapse was the David that tarnished this
Goliath achievement, proving that our declarations of victory were
premature.
      Both beliefs--that behavior change succeeds or fails--are
oversimplifications.  Behavior change is a process, not an
attribute that one acquires, not a vaccine that once injected
protects for life.  In this issue of FOCUS, David Silven's
examination of four behavior change theories demonstrates the
complexity of this process and the variety of factors called into
play each time an individual makes a decision about behavior.
Wayne Blankenship's survey of relapse programs shows how educators
have begun to respond to this complexity.
      As much as we hope that the behavior process can be
facilitated by the programs Blankenship covers, it is clear that
the central arena in which the struggle plays out is in the minds
of individuals.  And these minds are not as easily manipulated to
change sexual practices as they seem to be to change breakfast
cereal or soft drink.
      Defined more by individual than by cultural or societal
perceptions about sex, intimacy, risk, and the value and struggle
of life, the response to behavior change interventions is far more
complicated than it might first appear.  "Relapse" is an indication
not of the failure of HIV prevention, but of the importance of
counseling approaches that respond to these individual perceptions.
      Mental health practitioners are faced with the crucial task
of framing HIV prevention in this context and helping people work
toward understanding their attitudes and feeling about these
issues.  Silven's article will help counselors identify theoretical
approaches, and Blankenship's will help practitioners appreciate
the range of prevention programs.
      To succeed in their efforts, however, counselors might
consider tempering ultimate therapeutic goals and redefining
success.  If lapses are a normal part of behavior change, and if
it is in acknowledging our beliefs that we can recognize the
motivations that determine the behaviors we choose, then the
counselor's goal is first and foremost to get clients to confront
the thoughts and feelings that induce risky behaviors.
      Given the complexity of these factors, the hardest part of the
counseling effort is that it must go beyond the assumption that
everyone will, or should, embrace life.  Success for the therapist
is not in deterring relapse but in enabling clients to consider
these issues so that they may come to their own prevention-positive
conclusions.

                    BEHAVIORAL THEORIES AND RELAPSE
                        by David Silven, Ph.D.

      At a recent discussion of health educators about relapse into
unsafe sex among gay and bisexual men, a participant suggested that
theory-based principles of behavior change be used as guides to
develop relapse prevention interventions.  Other participants
responded with skepticism; the majority seemed to agree that theory
should remain in the classroom.
      What use, if any, does theory have in the critical area of
sexual relapse prevention?  To address this question, this article
summarizes four basic behavior theories--The Health Belief Model,
Social Cognitive Theory, Stages of Change, and Marlatt's Relapse
Prevention Model--and examines the applicability of these theories
in planning prevention interventions.

The Health Belief Model

      The Health Belief Model grew out of research in the 1950s and
1960s--by Irving Rosenstock and colleagues at the United States
Public Health Service--that investigated the widespread failure of
people to take preventive health measures such as annual physical
checkups, and screening tests for tuberculosis and dental disease.
The model postulates that individuals will take preventative
actions when they:

      o    believe that they are susceptible to a disease that would
           have at least moderately severe negative consequences;

      o    believe that taking such actions will be beneficial in
           reducing the threat of the disease and that this benefit
           will sufficiently outweigh the costs, such as the
           inconvenience and effort required, embarrassment, and
           financial expense;

      o    perceive a stimulus or "cue to action": either internal,
           for example, the perception of an uncomfortable bodily
           state; or external, for example, mass media campaigns,
           newspaper articles, or personal knowledge of someone
           affected by the disease.

      The perception of threat and the occurrence of a cue to
action, which raises awareness of feelings of threat, lead to the
decision to act.  The direction that action takes is influenced by
beliefs about the relative availability and effectiveness of
alternatives for reducing the threat, which, in turn, are
influenced by social norms.

Social Cognitive Theory

      Albert Bandura's Social Cognitive Theory suggests that in
order to take a particular course of action, individuals must not
only possess the required skills but must also believe that the
action will lead to a desired outcome and that they are personally
capable of performing the action.  This belief in personal
capability, known as "self-efficacy," is a pivotal concept in
Bandura's theory: it influences how much effort a person invests
in an action and how long he or she will persevere in the face of
difficulties or disappointing results.
      As individual develops self-efficacy by accumulating feedback
from four primary sources: personal experience of successfully
performing the behavior; vicarious experience through observing
others perform the behavior ("modeling"); persuasion by others who
convey that the individual is capable of performing the behavior;
and physiological states.
      Of these four sources of information, successful performance
of "mastery" experiences are considered the most potent in raising
levels of self-efficacy.  Proficiency with new behaviors requires
extensive practice.  Ideally, this practice occurs with
considerable external guidance, encouragement, and feedback; it
progresses gradually to more challenging situations, the removal
of external support, and increased opportunities for self-guided
practice.  Failure and difficulty during the learning  process help
build a resilient sense of self-efficacy by providing experience
in overcoming setbacks.
      Through modeling, people learn skills and judge their
capabilities in comparision to others.  It is crucial that
individuals perceive themselves as similar to the models they
observe, articularly in terms of the degree of hesitancy and fear
they feel in challenging situations.
      Persuasion by others provides encouragement that can lead
people to believe they are capable of performing a desired
behavior.  The impact of persuasion varies according to the
perceived credibility of the persuader.
      Finally, individuals rely partly on their physiological state
to judge their abilities to perform target behaviors.
Self-efficacy is strengthened when people possess skills to reduce
uncomfortable physiological reactions, such as agitation, and
insight to interpret these reactions as normal rather than as a
sign of inefficacy.

States of Change

      In the early 1980's, James Prochaska and Carlo DiClemente
outlined several fundamental stages through which individuals
typically progress when making behavioral changes precontemplation,
contemplation, action, and maintenance of change.  During the
precontemplation stage, people are unaware--because they are
uninformed or in denial--of having a problem in need of change,
even though others may perceive the problem.
      In the next stage, contemplators are seriously thinking about
but not committed to changing their behavior. They tend to be
relatively open to feedback and education about the problem
behavior.  The contemplation stage ends at the point that a
commitment to change is made.
      Progression through the stages is cyclical rather than linear.
People will often revert to an earlier stage, which is then
repeated. Relapse is seen as leading back to either the
contemplation stage, from which the individual may again attempt
to change, or to the precontemplation stage, during which the
individual succeeds in avoiding, at least temporarily, having to
think about the behavior as a problem.
      People utilize different processes of change during the
various stages. In the contemplation stage, for example, the
processes include information seeking and evaluation of one's
behavior. In the action and maintenance stages, processes include
changing the environment to build in supports for new behaviors and
to minimize risk-associated stimuli, and developing new responses
to these stimuli.

Marlatt's Relapse Prevention Model

      Alan Marlatt and his colleagues developed in the mid-1980s a
cognitive-behavioral model that focuses on coping during "high-risk
situations," situations that pose a threat to the individual's
sense of control and increase the risk of relapse. According to the
theory, lapses--or single incidents of slipping into the avoided
behavior--are considered important and expected components of the
behavior change process. Through trial-and-error, new response
patterns in high-risk situations are gradually acquired, corrected,
and strengthened.
      Whether lapses are followed by a total relapse, that is, a
return to baseline levels of the behavior, is largely determined
by how the individual reacts to the lapse: this is called the
"Abstinence Violation Effect." If he or she perceives the slip as
a response to a particularly difficult situation or as a sign that
he or she needs more practice with the new behavior, the lapse is
unlikely to lead to relapse. On the other hand, if the individual
attributes the slip to personal weakness or failure, the risk of
relapse is greatly increased.
      Another aspect of the Abstinence Violation Effect is the
experience of cognitive dissonance resulting from the contradiction
between the individual's self-perception as an abstainer and the
occurrence of the prohibited behavior. This dissonance creates
conflict or guilt and motivates efforts to eliminate these
unpleasant feelings. Thus, people may engage further in the
prohibited behaviors in an attempt to produce positive feelings to
replace these unpleasant ones. Alternately, there may be a change
in self-image as lapsers begin to think of themselves as
non-abstainers. In either of these cases, the stage is set for
relapse.
      Additional factors contributing to the risk of relapse include
the use of denial to mask the potential negative consequences of
slipping, and rationalization to justify the prohibited behavior
based, for example, on the extreme demands of everyday life.
Finally, relapse may be seen as the result of a chain of decisions
leading to a high-risk situation.

Applying the Theories

      These theories suggest several reasons why sexual relapse
might occur and guidelines for how to minimize the risk of its
occurrence. First, as suggested by the Health Belief Model, people
may relapse because they no longer perceive unsafe sex as a
significant problem. As suggested by the Stages of Change theory,
behavior change may naturally involve back-and-forth movement among
stages, including repeated reentry into the precontemplation stage
of unawareness. Alternately, people may initially change behavior
from unsafe to safer sex as a result of external pressure, and
prior to a firm internal commitment to safer sex; once the external
pressure diminishes, the behavior change breaks down. A third
explanation, using Marlatt's model, is that people fail to perceive
unsafe sex as a problem because of the psychological denial they
employ to avoid anxiety.
      HIV-infected people, in particular, may relapse because they
question the legitimacy of warnings against the dangers of
"reinfection" by HIV. Others may be unaware of the seriousness of
the risk to their immune systems of other diseases that can be
contracted through unsafe sex.
      Successful prevention efforts should first establish whether
the target audience is fully aware of the dangers of unsafe sex
before proceeding with information about prevention strategies. For
those who are not yet committed to avoiding unsafe sex, educators
might direct efforts at mobilizing interest in exploring whether
a problem really exists. For those who are misinformed or
uninformed, providing information about risk is critical.
      Second, as suggested by the Health Belief Model and Social
Cognitive Theory, people may relapse because they are not convinced
that safer sex adequately reduces the chances of infection.
Specifically, they may question whether condoms are truly effective
barriers against transmission. They may have heard stories about
condoms breaking, or about people becoming infected presumably
without having participated in unsafe sex or other high-risk
activities. Again, supplying clear and credible information--in
this case, about the effectiveness of condoms--would seem critical.
      Third, people may relapse because, as the Health Belief Model
further suggests, they do not feel convinced that the health
benefits of safer sex outweigh the effort required to avoid unsafe
sex. As Marlatt points out, those who experience day-today life as
full of demands may reach a point where they no longer feel
motivated to pursue long-term goals--in this case, health and
longevity--that involve depriving themselves of short-term pleasure
or relief. Or, they may not feel they have the internal strength
and resources needed for prolonged efforts avoiding unsafe sex.
This may be particularly true of many who are feeling the effects
of loss and grief. Help in coping with extreme stress, depression,
and loss may be necessary before these individuals can feel renewed
commitment to safer sex.
      Fourth, according to Social Cognitive Theory and Marlatt,
people may relapse because they do not have, or do not feel they
have, the necessary skills to avoid unsafe sex in all situations.
This may result from insufficient trial-and-error learning. People
may lack skill or confidence in using condoms or in having
satisfying forms of safer sex that do not require condoms. They may
also lack the skill or confidence required to effectively deal with
various situations that can easily lead to unsafe sex. These
include negotiating or talking about safer sex with partners;
insisting on safer sex; coping with stress related to social
anxiety; and responding to social or internal pressures to drink
or use drugs in conjunction with sex.
      Finally, according to Marlatt, people who relapse may lack the
awareness or resolve to break the chain of events that tends to
lead to high-risk situations. For example, a man may be unable to
stop himself from  going to a bar to find a sex partner, despite
the fact that he knows that this will lead to the pressure to drink
heavily, the likelihood that he will become intoxicated, and the
heightened risk that he will engage in unsafe sex as a result.
Furthermore, they may lack the ability to see failures or setbacks
as normal parts of the learning process, leaving them unable to
rebound when slips do occur.

Conclusion

      These theories suggest that behavior change interventions must
go beyond providing prevention information and limited practice
with condoms. Educators must make efforts to identify additional
areas in which target audiences lack skills, including negotiating
safer sex and avoiding situations in which sex and mind-altering
substances are mixed. They must help people acquire skills and
achieve mastery, provide practice in coping with mistakes, and
prepare individuals for the possibility that lapses may occur.
Finally, for those not ready to commit to avoiding unsafe sex,
supplying basic information may be ineffective without efforts to
address the reluctance to change.

References

Bandura A. "Self-efficacy: Toward a unifying theory of behavior
change," Psychological Review 1977;84:191-215.

Bandura A. "Social Foundations of Thought and Action: A Social
Cognitive Theory."  Englewood Cliffs, NJ: Prentice Hall, 1986.

Marlatt A. Gordon Jr. Relapse Prevention: Maintenance Strategies
in Addictive Behavior Change. New York: Guilford Press, 1985.

Prochaska JO. DiClemente CC. Transtheoretical therapy: Toward a
more integrated model of change. Psychotherapy Theory, Research,
and Practice. 1982;19(3):176-288.

Prochaska JO. DiClemente CC. Stages and processes of self-change
of smoking: Toward an integrative model of change. Journal of
Consulting and Clinical Psychology. 1983;51:390-395.

Rosestock IM. Historical origins of the health belief model. Health
Education Monographs. 1974;2(4):328-335.

Authors

David Silven, PhD is a clinical psychologist in private practice
in San Francisco and Clinical Consultant to Community and Client
Services at the UCSF AIDS Health Project.

                   RELAPSE PREVENTION INTERVENTIONS
                           Wayne Blankenship

      The unprecedented success of safe sex programs for gay and
bisexual men has led to the recent focus on relapse prevention
programs aimed at men who have made a commitment to safe sexual
behavior but have experienced lapses into unsafe sex. This article
examines current gay and bisexual men's relapse prevention programs
ranging from peer education and professional counseling-which seek
on a personal level to encourage consistency--to social marketing
strategies--which are designed to solidify community norms
supporting safe behaviors.
      It is important to note that designing relapse programs is
complicated by the difficulty of identifying and recruiting
participants. Even the best programs will fail if those targeted
do not participate.

Peer Education Models

      Peer education models have sought to create a safe and
nonjudgmental environment in which men can discuss the complexities
of long-term behavior change while learning from others. One such
program at Gay Men's Health Crisis (GMHC) in New York--the "Keep
It Up" workshops--began in 1989, before the terminology of
"relapse" had been used to describe what GMHC had identified as
inconsistencies" in safe sex behavior.[1]
      "Keep It Up" workshops were designed as follow-up support for
men who had attended a safe sex forum. The day-long workshop,
facilitated by small group discussion leaders, focused on
eroticizing safe sex, developing negotiating skills, and resolving
other challenges related to behavioral inconsistencies. Also, some
men described relapse in terms of compulsive or out-of-control
situations while others described it as a conscious decision to
have unsafe sex.
      Among the peer education programs that first focused
specifically on relapse were the STOP AIDS Project in San Francisco
and LIFEGUARD in Los Angeles. In the past few years,
relapse-related workshops have become more targeted and specific,
for example, focusing on mixed serostatus couples. City agencies
collectively produce San Francisco's annual "Carnal Carnival,"
which includes live demonstrations and games geared to sustain an
interest in safe sex in a city where some men have become numbed
to the usual educational messages. Other programs around the
country have found that workshops using dating and relationships
as a primary focus--"How to Meet a Man" is the title of one--are
successful in breaking through the resistance to attend yet another
safe sex workshop.
      Another innovative strategy coordinated by Jeffrey Kelly at
the University of Wisconsin trains popular gay men to serve as "key
opinion leaders" in the gay male community.[2] By instructing them
in developing a new vocabulary--for example, "I am learning to..."
rather than "You should..."--the program enables them to influence
their friends and community norms around safe behaviors.

Counseling Models

Counseling models have sought to provide therapeutic behavior
modification or structured referral and prevention for men
experiencing relapse. The ARIES Project from the University of
Washington in Seattle uses a group phone counseling format in a
cognitive-behavioral approach.[3] Men either participate in 14
half-hour anonymous phone sessions or as members of a control
group. Initial results indicate that men from rural areas and men
who are less identified with the gay community access this type of
service at higher rates than they access other types of services.
      Two San Francisco programs--the UCSF AIDS Health Project's
Safer Sex Counseling Program and 18th Street Services, which
targets gay men in recovery--offer relapse-specific counseling
interventions.
      Also in San Francisco, the Gay Men of Color Consortium,
Japanese Community Health Center, Stop AIDS Project, and San
Francisco AIDS Foundation are beginning to provide city-wide
referral and individual case management concerning behavior
maintenance. Men who have identified relapse as a concern will get
help developing a prevention plan with realistic goals and
individualized completion criteria.

Social Marketing

      Several agencies have been successful in using high-profile,
environmental ad campaigns to encourage change in peer norms for
safe behaviors. The Northwest AIDS Foundation in Seattle designed
an ad campaign using the "Keep It Up, Seattle" slogan to send a
congratulatory message encouraging consistency and a sense of
personal and gay community pride.
      The San Francisco AIDS Foundation ran a relapse-specific ad
campaign including two full-page ads on consecutive pages--one
titled "Relapse" and one titled "Maintain." The first ad
articulated a clear definition of relapse, and the second
acknowledged and encouraged safe behavior maintenance.
      Many of the recent high-profile ad campaigns from "first wave"
cities, like the foundation's 1992 "Moral Majority, Family Values,
Right to Life" subway and bus shelter posters are designed to
support behavior maintenance by asserting that safe sex is an
accepted norm for gay men. These public programs seem to be most
effective when other interventions are in place to provide further
information and support.

Future Applications

      This short history of gay men's relapse prevention programs
raises as many questions about the future of relapse prevention as
it answers about the current state of safe sex education. Do we
adopt the terminology of "relapse" or "behavior maintenance" in our
education strategies? Do we follow the model of substance abuse
prevention, and if so, do we employ strategies that stress
abstinence or gradual and systematic risk reduction?[4]
      How do we rethink our primary messages to gay and bisexual men
who may have believed that safe sex was a temporary concession in
the mid-1980s rather than a lifetime commitment? What message are
we offering seropositive men about the need for continued safe sex?
How do we discourage some behaviors without the financial support
from government to "promote" less risky ones?* How do we counter
media stories that characterize our efforts as failures in
headlines like "Gay Men Still Engaging in Unsafe Sex?"
      These questions cannot be answered without additional funding
for research regarding such issues as gay male sexuality and the
relative risk of behaviors like oral sex, and how behavior is
affected by grief and other responses to surviving the epidemic.
They also cannot be answered without comprehensive and scientific
evaluation of prevention approaches.
      Ironically, the goals of current relapse prevention
strategies--to encourage confidence and self esteem--are often in
conflict with cultural messages about gay men. As we struggle to
create images of confident and successful gay men--supported by
their peers to engage in healthy behaviors-continued underfunding
of prevention programs affirms the frightening idea that the lives
of gay men are expendable sacrifices to the first decade of the
epidemic.

*One study suggests that overestimating risk of unprotected oral
sex may, in fact, contribute to relapse into unprotected anal
sex.[5]

References

1.  DeMayo M. The future of AIDS prevention programs. SIECUS
Report. 1991;20(1):1-7.

2.  Kelly J. Lawrence JS. Diaz YE. et al. HIV-risk behavior
reduction following intervention with key opinion leasers of
population: An experimental analysis. American Journal of Public
Health. 1991;81(20:168-171.

3.  Roffman RA. Beadnall BA. Gordon Jr. et al. Relapse prevention
counseling by telephone as a means of reducing AIDS risk in men who
have sex with other men. Presentation from the 99th Annual Meeting
of the American Psychological Association, San Francisco, August
1991.4.  Marlatt GA. Tapert SF. Harm reduction: Reducing the risks of
addictive behaviors. In: Baer JS, ed. Addictive Behaviors Across
the Lifespan: Prevention, Treatment and Policy Issues. Newbury
park, Calif: Safe Publications.

5.  De Vroome E. Sandfort T. Tidman R. Overestimating the risk of
orogenital sex may increase unsafe anogenital sex. Presentation
from the VIII International Conference on AIDS, Amsterdam,
Netherlands, July 1992.

Authors

Wayne Blankenship is a Campaign Development Coordinator at the San
Francisco AIDS Foundaton and Coordinator of the National Relapse
Prevention Network.

                            RECENT REPORTS

A Critique of the Concept of Relapse

Hart G, Boulton M, Fitzpatrick R, et al. 'Relapse' to unsafe sexual
behaviour among gay men: A critique of recent behavioural HIV/AIDS
research. Sociology of Health & Illness. 1991; 14(2):216-232.
(University College and Middlesex School of Medicine, St. Mary's
Hospital Medical School, and University of Oxford.)

      The concept of relapse confuses efforts to understand why some
gay men engage in unprotected anal intercourse after periods of not
doing so. According to a methodological and empirical critique of
the term relapse, this concept fails to convey the contexts and
decision-making processes within which sexual behaviors occur.
Use of an absolute category obscures the nature of relationships
within which risks are taken and overlooks how knowledge of
antibody status affects choices. For example, the risk of engaging
in unsafe sex is lower between antibody negative gay men in
monogamous relationships. In this context, a decision to engage in
risky sex is best described not as a "relapse" but as a decision
made after an analysis of relative risks. The design of some
relapse studies also obscures the facts that some gay men may be
better described as "chronic high-risk takers" and that younger gay
men may be commencing a particular sexual activity rather than
relapsing.
      "Relapse," borrowed from medical science specifically in terms
of alcohol and drug addiction, imparts a negative moral judgment
to sexual behavior. The concept also implies that unsafe sex is
addictive, whereas research demonstrates that gay men who engage
in unprotected anal intercourse cannot be distinguished in any way
from other gay men. Further, the model of human sexual response
that underlies the concept of relapse portrays gay male sexuality
as governed by powerful penetrative needs that require long-term
policing. This portrait plays into societal prejudices and
stereotypes about gay men.
      To accurately understand gay male sexual behavior and HIV
transmission, future studies should be more process-oriented, that
is, focused on how the nature of each relationship affects
decisions to take sexual risks. Analysis of other situational
factors, such as the antibody status of partners, the emotional
dimensions of relationships, and prevalent local and social
realities would reveal the true complexity of gay male sexuality.


Interventions That Reduce Risk Behaviors

Gisher JD, Fisher WA. Changing AIDS-risk behavior. Psychological
Bulletin. 1992; 111(3): 455-474. (University of Connecticut and
University of Western Ontario.)

      A comprehensive review and analysis of the research on AIDS
interventions published from 1980 to 1990 found that a combination
of AIDS information, motivation, and behavioral skills can reduce
risk behaviors. A suggested model features interventions targeted
at populations whose needs must be clarified through research to
determine levels of AIDS knowledge, motivation, and behavioral
skills. The resulting population-specific interventions must then
be evaluated in terms of specific outcomes. The reviewers analyzed
48 published and unpublished reports of interventions directed at
gay and bisexual men, injection drug users, prostitutes, college
students, adolescents, STD clinic attendees, and the general
public. They described the nature of the intervention, the numbers
of people affected, and the intervention's impact. Most
interventions were based on an informal mix of logic and practical
experience, rather than on social psychological theory, and rarely
included research to identify the specific needs of the target
populations. Interventions with a broader focus conveying
HIV-related information, motivation, and behavioral skills tended
to have a greater impact, although most of these interventions had
methodological problems that undercut their usefulness and
applicability.
      In the proposed intervention model, information is necessary
but not sufficient to produce change. Motivation to change
AIDS-risk behavior must also be present. Using the theory of
reasoned action developed by Fishbein and Ajzen, individual and
societal attitudes towards preventive behavior are the key elements
affecting motivation. Identifying these attitudes and designing
interventions to change them is the focal point of prevention
efforts. Finally, the intervention model asserts that behavioral
skills must be taught, rehearsed, and modeled. Among these skills
are communicating and being assertive with sexual partners about
specific safer sex practices and self-efficacy, that is, a belief
in one's ability to behave in certain ways.


Long-Term Risk Reduction by Drug Users

Des Jarlais DC, Abdul-Quader A, Tross S. The next problem:
Maintenance of AIDS risk reduction among intravenous drug users.
International Journal of the Addictions. 1991; 26(12): 1279-1292.
(Beth Israel Medical Center, Narcotic and Drug Research Inc., and
Memorial Sloan-Kettering Cancer Institute.)

      Factors that influence initial HIV risk reduction do not
affect maintenance, according to a study of injection drug users
in New York City. Initiating risk reduction was associated with
having fewer sex partners and with having friends who practiced
risk reduction. But maintaining risk reduction was linked to
ethnicity--specifically, Latino/Hispanic-and to a belief that risk
reduction protects against HIV infection.
      Following a face-to-face HIV prevention intervention focusing
on sexual and drug-using behaviors, researchers recruited and
questioned 399 injection drug users in New York City about their
sexual practices, drug use, beliefs about AIDS, and demographic
characteristics. Subjects were primarily White men (45 percent),
most were male (71 percent), and 44 percent had less than 12 years
of education. The mean age was 35 years. Although 80 percent had
initiated risk reduction, a significant minority (36 percent)
reported some degree of relapse to pre-intervention risky
behaviors. Most instances of relapse, however, were episodic.
      Because the factors affecting initiation and maintenance were
different, risk reduction is best understood as a process
accomplished in stages. To be successful, interventions must
address the motivational demands appropriate to each stage.


Predicting Relapse among Gay Men

Adib SM, Joseph JG, Ostrow DG, et al. Predictors of relapse in
sexual practices among homosexual men. AIDS Education and
Prevention. 1991; 3(4): 293-304. (University of Michigan.)

      Being in monogamous relationships, receiving minimal peer
support for safer sex, and lacking assertiveness in negotiating
about sex were among the interpersonal factors that predicted
relapse among subjects in a large study of gay men in Chicago.
Personality factors, such as self-esteem and mastery, and
sociodemographic factors were not predictive.  Researchers analyzed
questionnaires submitted by 910 participants in the Chicago
component of the Multicenter AIDS Cohort Study (MACS). A majority
of respondents were White (92 percent); the mean age of the group
was 35, mean income was $26,000, and mean educational attainment
was 16.3 years.
      From 1986 to 1987, of those practicing receptive anal
intercourse, 53 percent maintained safer sexual practices and 31
percent relapsed; of those practicing insertive anal intercourse,
47 percent maintained safer sex practices and 35 percent relapsed.
For both groups, relapse occurred among those who were less
motivated to reduce transmission risk, had lower limit-setting
skills, were less assertive in negotiating safer sex, and had a
lower tolerance of safer sex. Men who practiced receptive anal sex
were also less likely to be satisfied with condom use.
      The results of this study may be biased by study design and
data collection techniques, including self-selection and
self-report biases, and a dropout effect. It is best applied to
individuals similar to the

                ADDITIONAL READING: PREVENTING RELAPSE

Aspinwall LG, Kemeny ME, Taylor SE, et al. Psychosocial predictors
of gay men's AIDS risk-reduction behavior. Health PsYcholoay. 1991;
10(6): 432-444.

Dorfman LE, Derish PA, Cohen JB. Hey girlfriend: An evaluation of
AIDS prevention among women in the sex industry. Health Education
Quarterly. 1992; 19(1): 25-40.

Dublin S, Rosenberg PS, Goedert JJ. Patterns and predictors of
high-risk sexual behavior in female partners of HIV-infected men
with hemophilia. AIDS. 1992; 6(5): 475-482.

Ekstrand ML. Safer sex maintenance among gay men: Are we making any
progress? AIDS. 1992; 6(8): 875-877.

Jemmott JB 3rd, Jemmott LS, Fong GT. Reductions in HIV risk-
associated sexual behaviors among black male adolescents: Effects
of an AIDS prevention intervention. American Journal of Public
Health. 1992; 82(3): 372-377.

Kalichman SC, Hunter TL. The disclosure of celebrity HIV infection:
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**********

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