Maintenance of Safer Sexual Behaviors and Predictors of Risky Sex: The San Francisco Men's Health Study MARIA L. EKSTRAND, PHD,

AND

THOMAS J. COATES, PHD

Abstract: This paper describes the sexual behavior changes made by 686 gay and bisexual men in San Francisco between 1984 and 1988, focusing on the individual maintenance of this behavior change over time. There were drastic reductions in insertive and receptive unprotective anal intercourse over time and the vast majority of subjects were able to maintain these changes for at least 12 months prior to the last interview. A total of 12 percent of participants admitted to relapsing to unprotected receptive anal

intercourse following initial behavior change; 10 percent reported engaging in unprotected receptive anal sex during every year of the study period. Men were more likely to practice unprotected anal intercourse in 1988 if at baseline they were younger, practiced unprotected anal intercourse, reported more sex partners, did not have a close friend or lover with AIDS, and engaged in fewer other health-related behaviors. (Am J Public Health 1990; 80:973-977.)

Introduction This study seeks to document the stability of change and psychosocial predictors of unprotected anal intercourse in a probability sample of San Francisco gay and bisexual men. Gay men account for 95.7 percent of all AIDS (acquired immunodeficiency syndrome) cases in San Francisco to date' and 68 percent of the cases in the United States to date.2 San Francisco gay and bisexual men have been particularly hard hit by this epidemic with infection rates estimated at 52 percent.3 Earlier studies ', *' ** have documented drastic sexual behavior changes in volunteer samples of gay and bisexual men in San Francisco. Although these findings are encouraging, it is crucial that the changes are maintained over time. There have been few studies examining the long term stability of this behavior change. Joseph, Montgomery, Kessler, et al,*** reported that between 25 and 35 percent of their sample of Chicago gay men resumed high-risk behavior at least once following initial risk reduction. In Boston, 13 percent of the gay men who reported practicing safe sex in year one relapsed during the following year.t The present study examines both the prevalence and decline of high-risk

behavior among all gay and bisexual subjects as well as the stability of this change and the relation between high-risk behavior and demographic and psychosocial variables, HIV (human immunodeficiency virus) antibody status, HIV-related symptoms, and other health-related behaviors.

Address reprint requests to Maria L. Ekstrand, PhD, Center.for AIDS Prevention Studies, University of California at San Francisco, S-600, 74 New Montgomery, San Francisco, CA 94105. Dr. Ekstrand is also with the Department of Epidemiology and Biostatistics, UCSF School of Medicine, and is a Scholar with the American Foundation for AIDS Research. Dr. Coates is with the Department of Epidemiology and Biostatistics, the Division of General Internal Medicine, and the Center for AIDS Prevention Studies, UCSF School of Medicine. This paper, submitted to the Journal May 22, 1989, was revised and accepted for publication February 6, 1990.

*Bye L, Capell F, Anderson R, et al: Prevalence of AIDS risk factors in the population of the State of California. Presented at the IV International Conference on AIDS, Stockholm, 1988.

"*Doll L, Damon W, Jaffee H, et al: Self-reported changes in sexual behaviors in gay and bisexual men from the San Francisco City Cohort. Presented at the III International Conference on AIDS, Washington, DC, 1987. ***Joseph J, Montgomery S, Kessler R, et al: Determinants of high risk behavior and recidivism among gay men. Paper presented at the IV International Conference on AIDS, Stockholm, June 1988.

tSaltzman S, Stoddard A, McCusker J, Mayer K: Factors associated with recurrence of unsafe sex practices in a cohort of gay men previously engaging in 'safer sex'. Poster presented at the V International Conference on AIDS, Montreal, Canada, June 1989. Editor's Note: See also related paper p 978 this issue. © 1990 American Journal of Public Health 0090-0036/90$1.50

AJPH August 1990, Vol. 80, No. 8

Methods Subjects The San Francisco Men's Health Study is a prospective study of single, predominately White, well-educated males between the ages of 25 and 54 recruited by multistage probability sampling from the six kilometer square area in San Francisco with the highest cumulative incidence of AIDS in 1984. Sampling methods, as well as statistical, and data collection procedures have been described previously.3,5 6 The analyses in the present study include data on 686 gay and bisexual men who participated in the first year (July 1984-June 1985) of data collection, 633 who participated in the second year (July 1985-June 1986), 627 from year three (July 1986-June 1987), and 592 from year four (July 1987-June 1988). At least 57 subjects died between July 1984 and June 1988 and an additional 25 subjects had died from 1988 to 1989. Demographic subject characteristics for this subsample, obtained in July 1984, show that this area is populated mostly by White, employed, and well-educated gay males. Analysis of Attrition Bias

We compared those subjects who remained in the study to those who dropped out between 1984 and 1988. The scores of these two groups on all predictor and outcome variables in year one did not differ appreciably with regard to sexual behaviors (Table 1). Dropout subjects were more likely to be HIV positive in year one, and to report HIV-related symptoms at that time; they were more depressed, drank less alcohol, and thought of themselves as gay at an earlier age than subjects who remained in the study. These differences probably reflect the differing percentages of HIV positive subjects in the two groups. Measures

Sexual Behavior-Self-report data on high-risk sexual behavior were obtained eight times from July 1984 to June 1988. Subjects were asked whether they had engaged in any sexual activity during the previous six months. Those who answered "yes" were then asked whether they had engaged in any of 22 specific behaviors. For each of these activities, the subjects were asked to report the number of partners with whom they had engaged in that behavior since the last clinic 973

EKSTRAND AND COATES TABLE 1-Comparison of Panel Members and Dropout Subjects at Year One (1984-85)

Stayed (n = 592)

Variables

(95% Cl of differences)

36.5 18.9

1. proportions .76 (-.10,.06) .94 (-.06,.04) .46 (-.03,.19) (-.07,.15) .54 .74 (-.16,.02) .47 (-.01,.21) .72 (.14,.34) .58 (.07,.29) .50 (-.02,.20) 2. means 36.5 (-1.5,1.4) 17.4 (-3.0,-i1)

21.4

20.6

(-1.7,.2)

4.3 4.3 8.7 81.2 32.1

3.8 4.0 11.1 89.9 32.3

(-.8,-.1) (-.1,.7)

.78 .95 .37 .50 .82 .37 .48 .40 .40

Any unprotected anal intercourse Oral sex Oral-anal contact Anonymous partners Multiple partners Smoked regularly Antibody positive HIV-related symptoms Friend, lover with AIDS Age (years) Age (years) at which first thought of self as gay Age (years) at which first socialized as gay Alcohol consumption (mean) Loneliness (mean) Depression (mean) Amount of social support (mean) Social support satisfaction (mean)

Dropped (n = 94)

(.5,4.3) (-1.0,.6) (-7.4,24.6)

visit. Although unprotected insertive and receptive anal intercourse and multiple sexual partners are the only firmly established major risk factors for seroconversion in maleto-male relationships,7 we also examined the prevalence of anal-oral contact, genital-oral contact, fist-anal contact, and whether the respondent had engaged in sex with anonymous partners. To facilitate presentation, we combined these eight six-month segments into four one-year intervals. Since all of the sexual behaviors have been dichotomized, an affirmative response during either six-month segment in a given year resulted in an individual being classified as having engaged in the behavior during that year. To examine correlates of risky sex, two multiple logistic analyses were conducted, predicting unprotected receptive and insertive anal intercourse in waves two (January to June 1985) and eight (January to June 1988). The predictor variables in these analyses (Tables 2 and 3) also included items developed for the psychosocial component of the project and were administered to the subjects in wave 2 (January to June 1985); they are defined in detail in the Appendix. Procedure

We examined yearly prevalence rates of sexual behav-

-

All receptive '°- All insertive

70% 5,

*-- Receptive with

6 0% 50% 40% 30% -

°3-

70% 60% 50% 40% * 30% 20% * 10%0% 1 984-5

Multiple Partners

0- Anonymous Partners

0

1 985-6

1 986-7

1 987-8

FIGURE 2-Percent Men Who Reported Having Sex with Multiple and Anonymous Partners Each Year

iors for the entire gay and bisexual sample. Group changes in sexual behaviors from 1984 to 1988 were then analyzed using McNemar tests.8 We also examined fluctuations in individual behavior patterns. In order to do this, the study period was divided into four 12-month segments consisting of: 1) July 1984 to July 1985; 2) July 1985 to July 1986; 3) July 1986 to July 1987; and 4) July 1987 to July 1988. A subject was considered "high risk" for a given period if he reported engaging in any unprotected receptive or insertive anal intercourse with or without ejaculation during that time. This yielded 16 behavior patterns which were combined into four groups; stable low risk, stable high risk, change from high to low risk, and relapse. The relation between the predictor variables and unprotected anal sex was examined using multiple logistic regression.9 A dichotomous score was created classifying subjects as high risk if they reported having engaged in either insertive or receptive unprotected anal intercourse during January to June 1985 and 1988. Results Behavior Change

Figures 1, 2, and 3 present data showing the percent of men who reported engaging in each of the sexual behaviors in years one through four (i.e., 1984-5, 1985-6, 1986-7, and 1987-8). The most dramatic changes have occurred in unprotected insertive (37 percent to 2 percent) and receptive (34 percent to 4 percent) anal intercourse with ejaculation. Significant changes were also reported in insertive and

70% * 60%

ejaculation

40%. 30% 20% 10%

1 985-6

1 986-7

1987-8

I-------

.0-

80% j

50%

FIGURE 1-Percent Men Who Reported Engaging in Unprotected Anal Intercourse Each Year

90%

ejaculation Insertive with

-

0% v 1984-5

974

*

1 00% iT

100% 90% 80%

10%

90%

Oral-Genital Oral-Anal Fist-Anal

.--

I

I 0 1 987-8 1 984-5 1 985-6 1986-7 FIGURE 3-Percent Men Who Reported Engging in Oral-genital, Oral-anal, and Flst-anal Sex Each Year

A9JPH August 1990, Vol. 80, No. 8

MAINTENANCE OF SAFER SEXUAL BEHAVIOR TABLE 2-Cross-sectional Predictors of Unprotected Anal Intercourse In 1985

Predictors

Adjusted Odds Ratio

Age (20 year difference) Age at which first thought of self as gay Age at which first socialized as gay Number of sex partners Antibody status (positive) HIV-related symptoms Smoking Alcohol consumption Friends, lover with AIDS Loneliness Amount of social support Social support satisfaction Depression

0.6 1.0 1.1 1.4 1.3 1.1 1.1 1.3 0.9 1.0 1.0 1.0 0.9

(95% Cl)

(0.5,0.8) (0.9,1.2) (0.8,1.3) (1.2,1.6) (1.1,1.5) (0.9,1.3) (0.9,1.3) (1.1,1.6) (0.8,1.1) (0.9,1.1) (1.0,1.0)

(0.9,1.2) (0.8,1.0)

receptive anal practices with and without ejaculation, which decreased from 42 percent and 63 percent to 17 and 17 percent respectively. All behaviors changed significantly from year one to year two. After June 1986, most behavior changes leveled off. Unprotected insertive and receptive anal intercourse and insertive oral-genital contact continued to decrease significantly from 1985-6 to 1986-7. The percent of subjects reporting unprotected insertive and receptive anal sex, insertive and receptive oral-genital contact, sex with anonymous partners, and multiple sexual partners continued to decline until 1987-8. Maintenance of Behavior Change

Behaviors were remarkably stable: 25 percent and 31 percent of the subjects were classified as stable low risk, and an additional 50 percent and 47 percent fell into the change to low risk category. Only 16 percent and 12 percent of the subjects admitted to relapsing to unprotected insertive and receptive anal sex, respectively, while an additional 10 percent were stable high risk. Younger men were more likely to engage in unprotected anal intercourse than older men in the sample in both 1985 and 1988. Subjects who reported in 1985 that they had friends or lovers with AIDS were less likely to engage in unprotected TABLE 3-Longitudinal Predictors of Unprotected Anal Intercourse In 1988

Predictors

Adjusted Odds Ratio

Age (20 year difference) Baseline sexual behavior Age at which first thought of self as gay Age at which first socialized as gay Number of sex partners HIV positive, knowing results HIV negative, knowing results HIV positive, not knowing results HIV-related symptoms Smoking Alcohol Friend, lover with AIDS Loneliness Amount of social support Social support satisfaction Depression

0.6 3.4 1.0 1.0 1.2 0.7 0.9 0.7 0.9 1.3 0.8 0.8 1.1 1.0 1.1 1.1

See appendix for a description of measures

AJPH August 1990, Vol. 80, No. 8

(95% Cl)

(0.3,0.9) (2.1,5.4) (0.8,1.4) (0.7,1.6) (1.1,1.4) (0.5,1.1) (0.6,1.3) (0.4,1.1) (0.7,1.2) (1.0,1.6) (0.6,1.2) (0.6,1.0) (0.8,1.2) (1.0,1.0)

(0.9,1.4) (0.9,1.3)

anal sex in 1988 than were men who did not have this experience (Table 3). Men who reported engaging in unprotected anal intercourse in 1985 were likely to report doing so in 1988 than were men who had been practicing safer sex only in 1985. Participants who were HIV positive in 1985 were more likely to engage in unprotected anal sex at that time. However, knowledge of HIV antibody status in 1987 did not predict sexual behavior in 1988. The presence of HIV-related symptoms did not predict report of high-risk behavior. Men who reported a greater number of partners in 1985 were far more likely to practice unprotected anal sex in 1988 than were men who had been practicing safer sex only in 1985. Subjects who reported consuming a greater volume of alcohol were more likely to report engaging in high-risk sexual behavior than those who reported less alcohol consumption. This relation held for the cross-sectional analysis in 1985, but did not predict risk behavior longitudinally. Subjects who reported smoking regularly in 1985 were somewhat more likely to engage in unprotected anal sex in 1988. Men who reported greater levels of depression in 1985 were less likely to report having engaged in unprotected anal sex in that year than subjects who reported fewer depressive symptoms. Participants who reported having a large number of people on whom they could rely for social support were less likely to report practicing risky sex. Loneliness and satisfaction with social support were unrelated to sexual behaviors. Discussion The results on individual and group behavior change show that San Francisco gay men have greatly reduced their levels of almost all high-risk sexual behaviors from 1985 to 1988. The differences between all anal sex and anal sex with ejaculation may be due to a misconception that anal sex is "safe" as long as one withdraws before ejaculating.tt This fits with our finding that there has been very little change in oral sex practices, which is another behavior considered "safe" by many in the San Francisco gay community.

Approximately three-fourths of the subjects reported that they were in either the stable low or change to low categories. The data further show that occasional relapse is now more prevalent than stable high-risk practices in this community. Prevention efforts need to shift from focusing on the initial adoption of safe sex, to a relapse prevention format, emphasizing the long-term maintenance of safer sex. Overall, these changes may represent the most profound behavior changes ever observed in the literature on health behavior change.10 Studies on smoking cessation, alcohol abstinence and dieting show that it is extremely difficult to maintain healthy behaviors over time. The results on prevalence replicate findings from other San Francisco studies using volunteer populations,"'112 thus providing a consistent picture of gay sexual behavior in San Francisco. Although results from similar studies in other parts of the country also show a reduction in high-risk behavior in this population, the degree of stability of change observed in this study may be unique to this cohort or to San Francisco. Although this is good news, it is important to place it in context. It has been estimated that more than half of the ftEkstrand ML, Stall RD, Coates TJ, McKusick L, Morin S: Risky sex relapse: The next challenge for AIDS prevention: The AIDS Behavioral Research Project. Paper presented at the V International Conference on AIDS, Montreal, Canada, 1989. 975

EKSTRAND AND COATES

mainstream gay community in San Francisco has been infected by HIV; any instance of risky sex with a partner of unknown serostatus thus carries an unacceptable risk. It is important to identify characteristics of relapsers and to obtain a better understanding of the reasons for relapse in order to design effective prevention programs focusing on both the acquisition and maintenance of safe sex in this population. The most consistent predictors of high-risk behavior included demographic and behavioral variables. Younger men were more likely to engage in unprotected anal sex and those who had friends or lovers with AIDS in 1985 were less likely to practice risky sex in 1988. These findings have been replicated both in other samples of gay and bisexual men'2-'4 and among heterosexual men. ttt The finding that younger gay men seem to be having more difficulty changing their behaviors could be due to a variety of factors, such as greater impulsivity, having less social support for safe sex practices, feeling uncomfortable obtaining or using condoms, perceptions of invulnerability, or having poor "safe sex negotiating skills." Results from a recent study of HIV risk-taking among young gay men'4 showed that those who practiced unprotected anal intercourse reported enjoying it more, perceiving it as less risky, and had poorer communication skills than those men who did not engage in this practice. The finding that men who practice risky sex report having less social support might be related to this issue, since it is possible that younger gay men may be less involved in the network of gay organizations than are older gay men in San Francisco. This may pose a challenge to future campaigns, since it would imply that the men who need to be targeted may be the hardest to reach. Past sexual behavior appears to be a strong predictor of future sexual behavior. However, by targeting only those who report current unsafe behaviors we run the risk of missing many men at risk for future unsafe sex, since relapse is even more common than stable high-risk practices in this population. We may thus have to develop different targeting and intervention strategies for men who relapse than for men who have never adopted safer sexual practices. The finding that antibody positive subjects were more likely to practice unprotected anal sex in 1985 may be due to a variety of factors. This was the year the HIV antibody test first became available and it is therefore possible that the subjects had not received the results of their antibody test when engaging in risky sexual practices. It is also possible that some of these people only engaged in unprotected anal sex with other seropositive partners. However, we have no data on partner serostatus. A recent study of the impact of antibody testing on sexual behaviors in this cohort showed that knowledge of being seropositive was associated with a lower prevalence of insertive anal intercourse in 1987.t No differences were found in the prevalence of receptive anal intercourse, suggesting that seropositive men perceive insertive practices as the most likely way of infecting others.t This distinction was not made in the present study and may explain why knowledge of serostatus failed to predict overall rates of unprotected anal intercourse. In addition, the Coates, et al, study followed subjects until 1987, while the present study examined behavior in 1988. tttGuydish J, Coates T, Ekstrand M: Changes in AIDS-related high-risk behavior among heterosexual men. Presented at the IV International Conference on AIDS, Stockholm, Sweden, 1988. WCoates T, Ekstrand M, Kegeles S, Stall R: Knowledge of HIV antibody status, behavior change, and psychological distress in two cohorts of gay men in San Francisco. Manuscript under review.

976

In summary, the data from this study suggest that we need to target younger gay men, and possibly men who are less involved in the social networks of the gay community. The prevailing norm needs to be that any unprotected anal sex, including occasional relapse, is risky and thus unacceptable.

APPENDIX

Selected Measures HIV Status Although HIV status has been measured at each wave of this study, only subjects who have requested knowledge of their results have received them. In wave six (January to June 1987) we asked subjects whether they had received these results and, if so, from whom they had received them. The results showed that 33.1 percent and 31.4 percent knew that they were antibody positive and negative, respectively. An additional 17.3 percent and 18.1 percent were antibody positive and negative, but denied having received their test results. In our 1985 cross-sectional analyses, we were thus only able to use HIV status alone as a predictor of sexual behavior. In the longitudinal analyses, we combined actual HIV status with reported knowledge into three predictor variables (HIV positive, knowing results; HIV negative, knowing results; and HIV positive, not knowing results). For each of the three comparisons, the target group was compared to all other subjects. * HIV-Related Symptoms We used a clinical index that was developed in a previous study of this sample and which was found to predict HIV infection, diminished skin test reactivity, and reduction in Leu 3a T cells.'6 It includes self-report of the following symptoms: new rash, diarrhea, night sweats, weight loss, persistent fever, herpes, shingles, or bullous impetigo. In addition, it was noted whether the subjects had been diagnosed with oral hairy leukoplakia or oral candidiasis during their physical examination. A subject was considered to have HIVrelated symptoms if he had any two or more of these symptoms or infections. * Health-Related Behaviors Quantity and frequency of alcohol consumption were measured during the interview by asking subjects both how often they had consumed an alcoholic drink during the past six months, and how many drinks they typically consumed on these occasions. Amount was scored on a 4-point scale ranging from "I or 2 drinks" to "7 or more drinks," while frequency was measured on a 9-point scale, ranging from "every day" to "not at all." Information on amount and frequency of alcohol consumption was then combined into a single 7-point scale, where 1 = abstinent, 2 = occasional-light, 3 = occasional-heavy, 4 = infrequent-light, 5 = infrequent-heavy, 6 = frequent-light, and 7 = frequent-heavy consumption. Cigarette smoking was assessed by asking subjects if they had been smoking during the past month (scored dichotomously). * Number of Sexual Partners Number of male sexual partners during the previous six months was used as a continuous measure to examine whether men who engage in unprotected anal sex are more likely to have fewer or more sex partners than men who do not engage in this practice. * Psychosocial Measures Loneliness was measured using the short form of the Revised UCLA Loneliness Scale. 17 This includes those four scale items, which, using optimal subset regression techniques, best predicted scores in the self-labeling loneliness index. (Chronbach's alpha = .75.) Depression was assessed with the Center of Epidemiological Studies Depression Scale (CESD). The CESD'" was developed for use in studies examining the epidemiology of depression in general populations. The scale has high reliability (.77-.92) and correlates highly with other measures of depression (.55-.74). Social Support-The instrument contains 12 questions (four tangible support items, four emotional support items, and four informational support items). Structural support was expressed in the number of people providing each type of support. Perceived support is the tabulation of satisfaction ratings of that support. Satisfaction scores range from 3 (very satisfied) to 0 (not at all satisfied) for each type of support. The present study used an instrument partly derived from the Social Support Questionnaire by Sarason, et al,'9 chosen because of its high stability and internal consistency. The framework used to separate the items into distinct categories of emotional, tangible, and informational support comes from the research on the health-related functions of social support provided by Schaefer, Coyne, and Lazarus.20 *

AJPH August 1990, Vol. 80, No. 8

MAINTENANCE OF SAFER SEXUAL BEHAVIOR ACKNOWLEDGMENTS

We would like to thank Jim Wiley, PhD, Warren Winkelstein, MD, MPH, Stephen Hulley, MD, MPH, and Norman Hearst, MD, MPH for their helpful comments on earlier drafts of this paper. We are also grateful to Walter Hauck, PhD, for statistical consultation. Preparation of this manuscript was supported in part by Contract NIH-NOI-A1-82515, CAPS center grant MH 42459, and a scholarship grant to Dr. Ekstrand from the American Foundation for AIDS Research.

REFERENCES I. San Francisco Department of Public Health, 8/31/89. 2. Centers for Disease Control: HIV/AIDS Surveillance Report, July 1989; 1-16. 3. Winkelstein W, Lyman D, Padian N, et al: Sexual practices and the risk of infection with the human immunodeficiency virus. JAMA 1987; 257:321-325. 4. McKusick L, Wiley J, Coates T, et al: Reported changes in the sexual behavior of men at risk for AIDS. San Francisco, 1982-84 the AIDS Behavioral Research Project. Public Health Rep 1985; 100:622-629. 5. Winkelstein W, Samuel M, Padian N, et al: The San Francisco Men's Health Study: III. Reduction in human immunodeficiency virus transmission among homosexual/bisexual men, 1982-86. Am J Public Health 1987;

77:685689. 6. Piazza T: Sampling methods and wave 1 field results of the San Francisco Men's Health Study. A report to the National Institutes of Allergy and Infectious Disease, April 1986. 7. Friedland G, Klein R: Transmission ofthe human immunodeficiency virus. N Engl J Med 1987; 371:1125-1135. 8. Fleiss JL: Statistical Methods for Rates and Proportions, 2nd Ed. New York: J. Wiley and Sons, 1981.

I

9. Hosmer, DW, Lemeshow S: Applied Logistic Regression. New York: J. Wiley and Sons, 1989. 10. Coates T: Strategies for modifying sexual behavior for primary and secondary prevention of HIV Disease. J Consult Clin Psychol 1990; (in press). 11. Bye LA: Report on designing an effective AIDS prevention campaign strategy for San Francisco, CA: Communication Technologies, 1987. 12. McKusick L, Coates T, Morin S, Pollack L, Hoff C: Longitudinal predictors of reductions in unprotected anal intercourse among gay men in San Francisco: The AIDS Behavioral Research Project. Am J Public Health 1990; 80:978-983. 13. Catania J, Coates T, Kegeles S, Ekstrand M, Guydish J, Bye L: Implications of the AIDS Risk Reduction Model for the gay community: The importance of perceived sexual enjoyment and help-seeking behavior. In: Mays V, Albee G, Jones J, Schneider J (eds): Psychological Approaches to the Prevention of AIDS. Beverly Hills, CA: Sage Publications, 1989. 14. Hays R, Kegeles S, Coates T: High HIV risk-taking among young gay men. AIDS (in press). 15. Stall R, McKusick L, Wiley J, Coates T, Ostrow D: Alcohol and drug use during sexual activities and compliance with safe sex guidelines for AIDS: The AIDS Behavioral Research Project. Health Educ Q 1986; 13:359-371. 16. Lang W, Anderson R, Perkins H, et al: Clinical, immunologic, and serologic findings in men at risk for acquired immunodeficiency syndrome. The San Francisco Men's Health Study, JAMA 1987; 257:326-330. 17. Russell D: The revised loneliness scale: Concurrent and discriminant validity evidence. J Pers Soc Psychol 1980; 39:472-480. 18. Radloff C: The CES-D Scale: A self-report depression scale in the general population. AppI Psychol Measurement 1977; 1:385401. 19. Sarason I, et al: Assessing social support: The social support questionnaire. J Pers Soc Psychol 1983; 44:127-139. 20. Schaefer C, Coyne J, Lazarus R: The health-related functions of social support. J Behav Med 1981; 4:381401.

NIH Consensus Panel Issues Report on Sunlight and UVR

The National Institutes of Health convened a Consensus Development Conference on Sunlight, Ultraviolet Radiation, and the Skin last year, and has now issued a report containing conclusions and recommendations concerning the effects of sunlight and UVR on the skin. The report was prepared by a panel of experts who considered scientific evidence presented at the conference. A two-page summary of the document is also available. To obtain a free copy of the consensus statement on the effects of sunlight and UVR on the skin, contact: William H. Hall Director of Communications Office of Medical Applications of Research National Institutes of Health Building 1, Room 260 9000 Rockville Pike Bethesda, MD 20892 Tel: (301) 496-1143

AJPH August 1990, Vol. 80, No. 8

977