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Letters to the Editor are welcomed and will be published, iffound suitable, as space permits. Submission of a Letter to the Editor constitutes permission for its publication in the Journal. Letters should not duplicate similar material being submitted or published elsewhere. Letters refering to a recent Journal article should be received within three months of the article's publication. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and should not exceed 400 words.
Local Survey of HIV+ Individuals Investigators have found that despite a reduction in new HIV (human immunodeficiency virus) infections among gays, HIV infected males still exhibit high-risk behaviors. Schechter, for example, found that 36 percent of infected gay men who have anal sex with steady partners never or infrequently use condoms.' In the process of developing computer systems to support HIV-infected people2 we conducted focus groups to understand their needs. We noticed a phenomenon that may explain the continued level of apparent risk taking along with reduced incidence of new infections, and later conducted a small survey. A convenience sample of 25 HIVinfected males was given a 60-item questionnaire addressing health service use, social support, cognition, health status, and risk behavior. The target group was contacted by the staff of an AIDS support network, operators of a gay bar, and the director of an STD (sexually transmitted disease) clinic. Two of the questions are listed below, along with response summaries. * What proportion of your current sex partners are HIV-infected? Not Sexually All Most Some None Active 7 1 3 0 3 * Is your steady partner HIV-infected? 1000
Letters to the Editor Yes No Unsure N/A 8 1 0 5 These results need to be validated with larger samples. They suggest, however, that risk behaviors of infected people may be less serious than previously thought. Amidst the calls for behavior changes that are difficult to implement and maintain, the HIV population by consciously or otherwise limiting sex to people already infected may have found a way to maintain their life-style and fulfill societal obligations to prevent infection. There is another explanation for our observation. One partner could have infected the other because they did not practice safer sex even after realizing they were carrying the virus. Moreover, we realize unprotected anal intercourse may speed the progress of the infection and that other STDs may be contracted. Neither of these obviates the need to study unprotected anal sex between already infected people. The implications for research are: 1) HIV infected people should be surveyed about their partner's infection status; and 2) surveys used to collect data about risk behaviors of infected people need to distinguish between sex (and needle sharing) practices of people who are and those who are not already infected. Such information is relevant to an assessment of the extent to which appropriate protective behaviors have been adopted. REFERENCES 1. Schecter M, Kevin J, Math M, et al: Sexual behavior and condom use in homosexual men. Am J Public Health 1988; 79:1535-1538. 2. Gustafson D, Bosworth K: The Comprehensive Health Enhancement Support System. Proceedings of the 1989 International Conference on Human Computer Interaction, Boston, September 19-21, 1989. David H. Gustafson, PhD Professor of Industrial Engineering and Preventive Medicine, University of Wisconsin-Madison Tim Tillotson Director, Blue Bus Clinic, HIV testing site, U-
WI-Madison Kris Bosworth, PhD Director, Center for Adolescent Studies, Indiana University
X 1990 American Journal of Public Health
Risk Factors and Non-Differential Misclassification In a previous letter to the editor,' I challenged the claims of Irwin, et al, that restaurant inspections can predict outbreaks of foodborne illness.2 My major concern was that most foodborne illnesses are neither reported nor confirmed. The authors responded that my concern were a "non-differential misclassification." They argued that removing these biases would only strengthen their reported associations.3 I believe the authors missed my point. The conclusion of their article explains they would use their risk estimates as a "simple instructional tool." In their example, sanitarians would explain that improper food temperatures raised the risk of foodborne illness by a factor of 10. However, non-differential misclassification is a serious bias in low risk estimates.4 The Irwin study shows a relatively low odds ratio of 1.4 for item 5 (improperly cooled foods). This "simple instructional tool" suggests we should virtually ignore cooling procedures! Apparently, we should focus on inexplicably high-risk estimates such as item 22 of their list (improper storage of equipment). In a more representative sample, the odds ratio for item 5 could increase, perhaps even more than item 22. Thus, their suggested instructional tool is misleading and not as predictive as they suggest. I must also challenge the definition of an outbreak as used in the Irwin study. Over half of their cases (16 out of 28) involved only one or two individuals. It is unclear if cases with two individuals were independent reports. The authors defended their study by citing the "internationally recognized" IAMFES definition of an outbreak. However, this same document recognizes that when one or two persons report a foodborne illness, then determining if ". . . consumption and the onset ofthe illness was only coincidental, is often difficult. "5 I doubt that the IAMFES ever intended their definition of an outbreak for developing quantitative risk factors. AJPH August 1990, Vol. 80, No. 8
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Letters to the Editor are welcomed and will be published, iffound suitable, as space permits. Submission of a Letter to the Editor constitutes permission for its publication in the Journal. Letters should not duplicate similar material being submitted or published elsewhere. Letters refering to a recent Journal article should be received within three months of the article's publication. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and should not exceed 400 words.
Local Survey of HIV+ Individuals Investigators have found that despite a reduction in new HIV (human immunodeficiency virus) infections among gays, HIV infected males still exhibit high-risk behaviors. Schechter, for example, found that 36 percent of infected gay men who have anal sex with steady partners never or infrequently use condoms.' In the process of developing computer systems to support HIV-infected people2 we conducted focus groups to understand their needs. We noticed a phenomenon that may explain the continued level of apparent risk taking along with reduced incidence of new infections, and later conducted a small survey. A convenience sample of 25 HIVinfected males was given a 60-item questionnaire addressing health service use, social support, cognition, health status, and risk behavior. The target group was contacted by the staff of an AIDS support network, operators of a gay bar, and the director of an STD (sexually transmitted disease) clinic. Two of the questions are listed below, along with response summaries. * What proportion of your current sex partners are HIV-infected? Not Sexually All Most Some None Active 7 1 3 0 3 * Is your steady partner HIV-infected? 1000
Letters to the Editor Yes No Unsure N/A 8 1 0 5 These results need to be validated with larger samples. They suggest, however, that risk behaviors of infected people may be less serious than previously thought. Amidst the calls for behavior changes that are difficult to implement and maintain, the HIV population by consciously or otherwise limiting sex to people already infected may have found a way to maintain their life-style and fulfill societal obligations to prevent infection. There is another explanation for our observation. One partner could have infected the other because they did not practice safer sex even after realizing they were carrying the virus. Moreover, we realize unprotected anal intercourse may speed the progress of the infection and that other STDs may be contracted. Neither of these obviates the need to study unprotected anal sex between already infected people. The implications for research are: 1) HIV infected people should be surveyed about their partner's infection status; and 2) surveys used to collect data about risk behaviors of infected people need to distinguish between sex (and needle sharing) practices of people who are and those who are not already infected. Such information is relevant to an assessment of the extent to which appropriate protective behaviors have been adopted. REFERENCES 1. Schecter M, Kevin J, Math M, et al: Sexual behavior and condom use in homosexual men. Am J Public Health 1988; 79:1535-1538. 2. Gustafson D, Bosworth K: The Comprehensive Health Enhancement Support System. Proceedings of the 1989 International Conference on Human Computer Interaction, Boston, September 19-21, 1989. David H. Gustafson, PhD Professor of Industrial Engineering and Preventive Medicine, University of Wisconsin-Madison Tim Tillotson Director, Blue Bus Clinic, HIV testing site, U-
WI-Madison Kris Bosworth, PhD Director, Center for Adolescent Studies, Indiana University
X 1990 American Journal of Public Health
Risk Factors and Non-Differential Misclassification In a previous letter to the editor,' I challenged the claims of Irwin, et al, that restaurant inspections can predict outbreaks of foodborne illness.2 My major concern was that most foodborne illnesses are neither reported nor confirmed. The authors responded that my concern were a "non-differential misclassification." They argued that removing these biases would only strengthen their reported associations.3 I believe the authors missed my point. The conclusion of their article explains they would use their risk estimates as a "simple instructional tool." In their example, sanitarians would explain that improper food temperatures raised the risk of foodborne illness by a factor of 10. However, non-differential misclassification is a serious bias in low risk estimates.4 The Irwin study shows a relatively low odds ratio of 1.4 for item 5 (improperly cooled foods). This "simple instructional tool" suggests we should virtually ignore cooling procedures! Apparently, we should focus on inexplicably high-risk estimates such as item 22 of their list (improper storage of equipment). In a more representative sample, the odds ratio for item 5 could increase, perhaps even more than item 22. Thus, their suggested instructional tool is misleading and not as predictive as they suggest. I must also challenge the definition of an outbreak as used in the Irwin study. Over half of their cases (16 out of 28) involved only one or two individuals. It is unclear if cases with two individuals were independent reports. The authors defended their study by citing the "internationally recognized" IAMFES definition of an outbreak. However, this same document recognizes that when one or two persons report a foodborne illness, then determining if ". . . consumption and the onset ofthe illness was only coincidental, is often difficult. "5 I doubt that the IAMFES ever intended their definition of an outbreak for developing quantitative risk factors. AJPH August 1990, Vol. 80, No. 8
