Self-disclosure of HJV Infection to Sexual Partners Gary Marks, PhD, Jean L. Richardson, DrPH, and Nonna Maldonado, BA
Infroduion Individuals who are aware they are infected with the human immunodeficiencyvirus (HIV) and who engage in sexual relations have a social and legal responsibility to disclose their infection to their partners.'-3 Withholding this information increases the potential for HIV transmission because it creates a situation in which unsafe sexual activity is more likely to occur. Should a partner become infected, he or she may unknowingly infect others. This chain of events suggests that nondisclosure of HIV infection to sexual partners may be an important cause of the continuing HIV epidemic. Little is known about the prevalence of this behavior. Studies have examined intentions to inform partners among individuals who had not been tested for HIV4 or had not yet received test results.5 Two studies have focused on HIV-infected individuals. Of 25 seropositive women, only 52% had disclosed their infection to all sexual partners since diagnosis.6 One hundred and seven homosexual men informed only 31% of their new sexual partners.7 We report findings of an ongoing study of self-disclosure in relation to the specific sexual activities performed.
Methods Adult men who have tested seropositive for HIV in the previous 18 months were recruited for study at a public HIV clinic located in a predominantly Hispanic section of Los Angeles. Study candidates were from any ethnic group, spoke English or Spanish, and were 18 years of age or older. Recruitment was conducted in the waiting area of the clinic by a bilingual Hispanicwoman. Of the men approached, 96% agreed to participate. Each subject completed a self-administered confidential questionnaire in a private section of the waiting area. A four-digit numerical code, uniquely derived by each subject, was used as identification. Sexual activity and disclosure were measured with a matrix checklist thoroughly explained to each subject. Instructions requested subjects to think of all partners since testing seropositive, includ-
ing intimate lovers, casual partners, and spouse if married. For each partner, subjects checked the activities that occurred8,9 and indicated whether they had revealed their HIV infection before the activity (yes = 1; no = 0) and whether the partner was known to be infected with HIV (yes = 1; no or don't know = 0). Subjects who had not had any sexual relations during this time period checked a box at the top of the checklist.
Resuts The sample consisted of 138 men (104 Hispanics, 83% of whom used a Spanish language questionnaire; 21 non-Hispanic Whites; 11 Blacks; and 2 Asians). Ninetyone percent identified themselves as homosexual or bisexual. Overall, 13% reported ever injecting a nonprescription drug and 2% reported injecting drugs since they tested seropositive. Seventy percent had an annual income under $10 000. Sixty-one percent were asymptomatic or had minimal symptoms short of AIDS-Related Complex (ARC), 16% had ARC, and 23% had AIDS.1O Seventy-five percent had tested HIV seropositive within the previous 8 months. Sixty-two of the 138 men (45%) had been sexually active (other than kissing) since learning their serostatus. Of these 62, 4 were deleted from the disclosure analysis due to missing data on relevant questionnaire items. Thirty out of 58 men (52%) kept their infection secret from one or more partners. Disclosure did not differ significantly by ethnicity (i.e., Hispanicvs non-Hispanic). Of the men who had only 1 sexual partner since diagnosis (n = 36), 69%/o disclosed their serostatus to that partner. Among those with 2 to 4 partners (n = 11), The research for this paper was conducted at the Department of Preventive Medicine, University of Southern California. Requests for reprints should be sent to Gary Marks, PhD, Department of Preventive Medicine, University of Southern California, Parkview Medical Building, A-301, 1420 San Pablo Street, Los Angeles, CA 90033. This paper was submitted to the journal September 7, 1990, and accepted with revisions February 20, 1991.
American Journal of Public Health 1321
Public Health Briefs
CS s- --2s- ss s ss}x- ss- }l-ssyss}}--:s-}} } --
s-s -ssssX ss s ix}8ss g sy S-lS a .} f~ ~ ~~~~~~~~~~~~~~~~~~.........
}sx-sfe
.: : : : :E: :S.: :. .::S :S : : : : :S :S :S':S' S: S: :.Y.'S. .:":R 5
SZ S :fSS 5
:=:
..; :Sf: .-: .: s: :S :::::
s s5 s ::::: rS f::
S S:S:::::::
.-:s.:::::.::::.:.:-S.: :g.:: :. ..: ::Y: S.::::: fS:: s:s '':s ': :':'S:':.S:'..'.S':::.f::.::....:::::.::::: S:: ::::-:: ::S:::S::S:: S::::::::::::::S::S :S ::S:::::::::::::::: :S::S:::S::::R::::::S::::S: :S:::S::. S:: :::::::::::S::::S:........::::.:::::::: SStS, -e ,-,-,
'sS't'S':'-''''-''
''s'''' 't'''Sf'''S''''S' 'S' '' 'S
Sf t-St
"'""'
S' 'tS'S'"'"G"'
::......
S'' f''Sf S
::.:. 5
:S.::::::::.:.....'..S. S.
promoting nondisclosure would be immensely valuable for counseling and educational purposes. El
:........................
.' -.' .......... :-:: ...... .. ........:- -.:.t::.::::::......:: ....::::::: ...:: ::y ::::: -::::: s:: :. ............. ::.-.s-.s.:--s-:::.--ss-...:.::.:.S.S.:S.:::::::.:::.'E ::S:.....:.::::::::S ::::e 'S :S-:S: S...}: S:
::: :::s::::-:s:::::-::::::::::-:S ::::: :::: : :_.1.'c-;:-:. .::.-;.--;;;'i ' .'-''. . '. . ' .'l l' .'.'.':.''''''''''*''.' e...S..::: :::..S...5 :: :} .- :ss:::::-::::::::::::::::::::::::s: f,. .:.,,,, ', ............... ,,X,:'.,f., .-.f,:::s:-:::::::-:::::::S: --,,, .-..,,.,.,. ..':'.:':::':'...:::: ::'.::'.'::'.S:::: S. 'tS'S2 s'
S
SSS
tSt S
X
'
2
'
S
~
ssS...............':'...''::':'...
'''-S
.................,,., .. .t :.:-:}
..........'...........': :: :s :'
:' 'Si:S:5:
.S: S; ;- ::s :S-:S: S:::S:f :: :S :i f S :.;.:.:: :::f.::S.:.S:.S::S.S :.S.:..-.-..::....SS RRS.::::..-§:S -x:ffS'5 '-':S'':.'-:.:.-..:s§:.:':SS5:.'.:.'............ ...............::: S:: 5: :>:f:: -: :e:: 'St:S 'S2 S:: :::::'S} '::R:fR::S::S:::: :}:: S ':SS' :::::S:i :;::: .'S .'.S:'t:S' ..........::::..... :t:S'. ::........... :-:...':.. :S:. ex ::: S: R::X:::.:::: '' yS:SS:S'f':S:::'' ,': S'':':s':': s:: :' ''':S'S ::S:'::'S':' f'' f :':':' ..........'.f' .':':.S':S'' :S S::: a:sf;s:ss f: :S S:::::: :S:ff:} '::: '} ':: ': ':f'S:':' SS' :::: :::::: s: :.... ......................................':y.':S:.:'::.:':'::.:::
Ss.5:S:.:.x. :!Sfl4 ^,S,:S :-:S,fS,:S,S,' s:~~~... :S:.t:S-.:S..-... ..........--..:S.-:SS...... xy s : '.S.3 1 :S SS SS S f: :SS S : : 5:SS :SX ::: : S: S: :S::::: : S:........ S: ..:.. S::S::........ ..S:.S: ..................}. ''S'S ''5: ::::'::s 5S': :'5: '-'s::S S 2 fs :: :: -'S ::'' ' ....:2f:
'"g:'::'< '' f-S SfS
'x;-
::':.. ':'
1. Gostin L, Curran WJ. Legal control for AIDS: reporting requirements, surveillance, quarantine, and regulation of public meeting places. Am J Public Health. 1987;77:214-218. 2. Dicken BM. Legal rights and duties in the
>' ': §:S': f>S:'ff9< S :': ::-:: -: x -:Z:f f:S 5:s::: '':' ' :S: S:::::::: :'::: :S::sX S: :SS::::':':'.:S::S:.
f:f ':':':':':: :S S:SS: ::.2 z f S fs':.: :':':': :s '.:':S fSf S:: :z::::: :S:' ' 'X' 'sx :S S§:S f :S:::::: ' ' ':: :':S ':ss:: :4:::::: :S s::~~............. if S':'5:':'-.. :":S,S,:-:S,f,: :,.f:: ::: BS}: :-: rSS: ::: #:w: ::: ::: :S5: :S:: :S:: :R:::: :Ss:s:s :S:: ::::: :'^:9S:g: :}S: :::......::S ............ *- ..:fff: ..-:.. s:s::-:s:sfsss-: ...s::::: :S:S
'-.'..'.,..''...'.'s' S'''''''''
f'
' ,
s~~~~~~~~~~............. sS
..........."
36% disclosed to at least 1 partner. Among those with 5 or more partners (n = 11), only 18% disclosed to at least 1 partner. This highly significant trend (x2) = 9.50, P < .01) indicates that the likelihood of disclosure decreased in direct proportion to the number of partners. Table 1 displays, for each sexual activity, the total number of subjects, total number of partners, and number of partners presumed to be seronegative at the time of the activity. Information is provided separately for partners to whom subjects disclosed and those to whom subjects did not disclose. Ten subjects (17% of the sexually active) engaged in insertive anal intercourse without using a condom and without disclosing to 13 seronegative partners. Seventeen men (29% of the sexually active) engaged in unprotected receptive anal intercourse without disclosing to 41 seronegative partners. The higher prevalence of receptive than insertive anal intercourse is consistent with a study of HIV-infected homosexual White men from Boston.'1 Both activities are risk factors for transmitting the virus.12 In Table 1, the difference between the total number of partners and the number of seronegative partners represents the number of seropositive partners. This difference was larger for informed than uninformed partners, indicating that subjects tended to reveal their infection to those known to be seropositive. When the activity involved insertive or receptive anal intercourse, disclosure to seropositive partners generally occurred in combination with unprotected contact, whereas disclosure to seronegative 1322 American Journal of Public Health
This research was supported by National Institute of Mental Health grant R01-MH42023. We thank Malcolm C. Pike, PhD, Fred R. Sattler, MD, and Ms. Monica Ruiz for their helpful comments on an earlier version of this paper.
References
'.S''.S.' .'t'
S ss. ...: .:.:: :. . :: .......:s ,: :,. s
.
Acknowledgments
...........................''
partners generally occurred in combination with protected contact. Finally, we examined whether the gender of the partner was associated with disclosure among the bisexual men. Because the activity checklist did not explicitly ask subjects to indicate partner gender, we compared nondisclosure rates for vaginal intercourse (female partners) with nondisclosure rates for receptive anal intercourse (male partners). No significant differences were found.
Discusion In a sample consisting primarily of lower socioeconomic homosexual/ bisexual Hispanic men, we found a relatively high prevalence of nondisclosure of HIV infection to current sexual partners in combination with unsafe sexual activity. For this sample, nondisclosure was not due entirely to lack of knowledge about sexual transmission of HIV. Ninety-four percent of the subjects were aware that they could infect others through unprotected sexual intercourse. Use of alcohol or other nonintravenous drugs before sexual relations, as well as attitudes about social responsibility, may have been factors, although we do not have confirmatory information. The restricted nature of our sample precludes any wide generalization of the results. Additional studies of Whites, Blacks, Hispanics, and other minority groups of varying socioeconomic levels are needed before a more refined picture can be obtained. Investigation of factors
AIDS epidemic. Science. 1988;239:580586. 3. Gostin L). Public health strategies forconfronting AIDS. JAMA. 1989;261:16211630. 4. Temoshok L, Ellmer RM, Moulton JM, Baxter M, Shalwitz J. Youth at high risk for HIV: knowledge, sexual practices, and intentions to inform sexual partners of HIV status. Presented at the 5th International Conference on AIDS, Montreal, Quebec, Canada, June 1989. Abstract T.D.O.29. 5. Kegeles SM, Catania JA, Coates TJ. Intentions to communicate positive HIV-antibody status to sex partners. JAMA. 1988;259:216-217. 6. Chervenak JL, Weiss SH. Sexual partner notification: attitudes and actions of HIVinfected women. Presented at the 5th International Conference on AIDS, Montreal, Quebec, Canada, June 1989. Abstract Th.D.P.4. 7. Stempel R, Moulton J, Bacchetti P, Moss AR. Disclosure of HIV-antibody test results and reactions of sexual partners, friends, family, and health professionals. Presented at the 5th International Conference on AIDS, Montreal, Quebec, Canada, June 1989. Abstract E.729. 8. Saltzman SP, Stoddard AM, McCusker J, Moon NW, Mayer KH. Reliability of selfreported sexual behavior risk-factors for HIV infection in homosexual men. Public Health Rep. 1987;102:692-697. 9. Coates RA, Calzavara LM, Soskolne CL, et al. Validity of sexual histories in a prospective study of male sexual contacts of men with AIDS or an AIDS-related condition. Am J Epidemiol. 1988;128:719728. 10. Centers for Disease Control. Revision of the CDC surveillance case definition of acquired immunodeficiency syndrome. MMWR 1987;36:3S-14S. 11. McCusker J, Stoddard AM, Mayer KH, Zapka J, Morrison C, Saltman SP. Effects of HIV antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men. Am J Public Health. 1988;78:462-467. 12. Coates RA, Calzavara LM, Read SE, et al. Risk factors for HIV infection in male sexual contacts ofmen with AIDS oran AIDSrelated condition. Am I Epidemiol.
1988;128:729-739.
October 1991, Vol. 81, No. 10
Infroduion Individuals who are aware they are infected with the human immunodeficiencyvirus (HIV) and who engage in sexual relations have a social and legal responsibility to disclose their infection to their partners.'-3 Withholding this information increases the potential for HIV transmission because it creates a situation in which unsafe sexual activity is more likely to occur. Should a partner become infected, he or she may unknowingly infect others. This chain of events suggests that nondisclosure of HIV infection to sexual partners may be an important cause of the continuing HIV epidemic. Little is known about the prevalence of this behavior. Studies have examined intentions to inform partners among individuals who had not been tested for HIV4 or had not yet received test results.5 Two studies have focused on HIV-infected individuals. Of 25 seropositive women, only 52% had disclosed their infection to all sexual partners since diagnosis.6 One hundred and seven homosexual men informed only 31% of their new sexual partners.7 We report findings of an ongoing study of self-disclosure in relation to the specific sexual activities performed.
Methods Adult men who have tested seropositive for HIV in the previous 18 months were recruited for study at a public HIV clinic located in a predominantly Hispanic section of Los Angeles. Study candidates were from any ethnic group, spoke English or Spanish, and were 18 years of age or older. Recruitment was conducted in the waiting area of the clinic by a bilingual Hispanicwoman. Of the men approached, 96% agreed to participate. Each subject completed a self-administered confidential questionnaire in a private section of the waiting area. A four-digit numerical code, uniquely derived by each subject, was used as identification. Sexual activity and disclosure were measured with a matrix checklist thoroughly explained to each subject. Instructions requested subjects to think of all partners since testing seropositive, includ-
ing intimate lovers, casual partners, and spouse if married. For each partner, subjects checked the activities that occurred8,9 and indicated whether they had revealed their HIV infection before the activity (yes = 1; no = 0) and whether the partner was known to be infected with HIV (yes = 1; no or don't know = 0). Subjects who had not had any sexual relations during this time period checked a box at the top of the checklist.
Resuts The sample consisted of 138 men (104 Hispanics, 83% of whom used a Spanish language questionnaire; 21 non-Hispanic Whites; 11 Blacks; and 2 Asians). Ninetyone percent identified themselves as homosexual or bisexual. Overall, 13% reported ever injecting a nonprescription drug and 2% reported injecting drugs since they tested seropositive. Seventy percent had an annual income under $10 000. Sixty-one percent were asymptomatic or had minimal symptoms short of AIDS-Related Complex (ARC), 16% had ARC, and 23% had AIDS.1O Seventy-five percent had tested HIV seropositive within the previous 8 months. Sixty-two of the 138 men (45%) had been sexually active (other than kissing) since learning their serostatus. Of these 62, 4 were deleted from the disclosure analysis due to missing data on relevant questionnaire items. Thirty out of 58 men (52%) kept their infection secret from one or more partners. Disclosure did not differ significantly by ethnicity (i.e., Hispanicvs non-Hispanic). Of the men who had only 1 sexual partner since diagnosis (n = 36), 69%/o disclosed their serostatus to that partner. Among those with 2 to 4 partners (n = 11), The research for this paper was conducted at the Department of Preventive Medicine, University of Southern California. Requests for reprints should be sent to Gary Marks, PhD, Department of Preventive Medicine, University of Southern California, Parkview Medical Building, A-301, 1420 San Pablo Street, Los Angeles, CA 90033. This paper was submitted to the journal September 7, 1990, and accepted with revisions February 20, 1991.
American Journal of Public Health 1321
Public Health Briefs
CS s- --2s- ss s ss}x- ss- }l-ssyss}}--:s-}} } --
s-s -ssssX ss s ix}8ss g sy S-lS a .} f~ ~ ~~~~~~~~~~~~~~~~~~.........
}sx-sfe
.: : : : :E: :S.: :. .::S :S : : : : :S :S :S':S' S: S: :.Y.'S. .:":R 5
SZ S :fSS 5
:=:
..; :Sf: .-: .: s: :S :::::
s s5 s ::::: rS f::
S S:S:::::::
.-:s.:::::.::::.:.:-S.: :g.:: :. ..: ::Y: S.::::: fS:: s:s '':s ': :':'S:':.S:'..'.S':::.f::.::....:::::.::::: S:: ::::-:: ::S:::S::S:: S::::::::::::::S::S :S ::S:::::::::::::::: :S::S:::S::::R::::::S::::S: :S:::S::. S:: :::::::::::S::::S:........::::.:::::::: SStS, -e ,-,-,
'sS't'S':'-''''-''
''s'''' 't'''Sf'''S''''S' 'S' '' 'S
Sf t-St
"'""'
S' 'tS'S'"'"G"'
::......
S'' f''Sf S
::.:. 5
:S.::::::::.:.....'..S. S.
promoting nondisclosure would be immensely valuable for counseling and educational purposes. El
:........................
.' -.' .......... :-:: ...... .. ........:- -.:.t::.::::::......:: ....::::::: ...:: ::y ::::: -::::: s:: :. ............. ::.-.s-.s.:--s-:::.--ss-...:.::.:.S.S.:S.:::::::.:::.'E ::S:.....:.::::::::S ::::e 'S :S-:S: S...}: S:
::: :::s::::-:s:::::-::::::::::-:S ::::: :::: : :_.1.'c-;:-:. .::.-;.--;;;'i ' .'-''. . '. . ' .'l l' .'.'.':.''''''''''*''.' e...S..::: :::..S...5 :: :} .- :ss:::::-::::::::::::::::::::::::s: f,. .:.,,,, ', ............... ,,X,:'.,f., .-.f,:::s:-:::::::-:::::::S: --,,, .-..,,.,.,. ..':'.:':::':'...:::: ::'.::'.'::'.S:::: S. 'tS'S2 s'
S
SSS
tSt S
X
'
2
'
S
~
ssS...............':'...''::':'...
'''-S
.................,,., .. .t :.:-:}
..........'...........': :: :s :'
:' 'Si:S:5:
.S: S; ;- ::s :S-:S: S:::S:f :: :S :i f S :.;.:.:: :::f.::S.:.S:.S::S.S :.S.:..-.-..::....SS RRS.::::..-§:S -x:ffS'5 '-':S'':.'-:.:.-..:s§:.:':SS5:.'.:.'............ ...............::: S:: 5: :>:f:: -: :e:: 'St:S 'S2 S:: :::::'S} '::R:fR::S::S:::: :}:: S ':SS' :::::S:i :;::: .'S .'.S:'t:S' ..........::::..... :t:S'. ::........... :-:...':.. :S:. ex ::: S: R::X:::.:::: '' yS:SS:S'f':S:::'' ,': S'':':s':': s:: :' ''':S'S ::S:'::'S':' f'' f :':':' ..........'.f' .':':.S':S'' :S S::: a:sf;s:ss f: :S S:::::: :S:ff:} '::: '} ':: ': ':f'S:':' SS' :::: :::::: s: :.... ......................................':y.':S:.:'::.:':'::.:::
Ss.5:S:.:.x. :!Sfl4 ^,S,:S :-:S,fS,:S,S,' s:~~~... :S:.t:S-.:S..-... ..........--..:S.-:SS...... xy s : '.S.3 1 :S SS SS S f: :SS S : : 5:SS :SX ::: : S: S: :S::::: : S:........ S: ..:.. S::S::........ ..S:.S: ..................}. ''S'S ''5: ::::'::s 5S': :'5: '-'s::S S 2 fs :: :: -'S ::'' ' ....:2f:
'"g:'::'< '' f-S SfS
'x;-
::':.. ':'
1. Gostin L, Curran WJ. Legal control for AIDS: reporting requirements, surveillance, quarantine, and regulation of public meeting places. Am J Public Health. 1987;77:214-218. 2. Dicken BM. Legal rights and duties in the
>' ': §:S': f>S:'ff9< S :': ::-:: -: x -:Z:f f:S 5:s::: '':' ' :S: S:::::::: :'::: :S::sX S: :SS::::':':'.:S::S:.
f:f ':':':':':: :S S:SS: ::.2 z f S fs':.: :':':': :s '.:':S fSf S:: :z::::: :S:' ' 'X' 'sx :S S§:S f :S:::::: ' ' ':: :':S ':ss:: :4:::::: :S s::~~............. if S':'5:':'-.. :":S,S,:-:S,f,: :,.f:: ::: BS}: :-: rSS: ::: #:w: ::: ::: :S5: :S:: :S:: :R:::: :Ss:s:s :S:: ::::: :'^:9S:g: :}S: :::......::S ............ *- ..:fff: ..-:.. s:s::-:s:sfsss-: ...s::::: :S:S
'-.'..'.,..''...'.'s' S'''''''''
f'
' ,
s~~~~~~~~~~............. sS
..........."
36% disclosed to at least 1 partner. Among those with 5 or more partners (n = 11), only 18% disclosed to at least 1 partner. This highly significant trend (x2) = 9.50, P < .01) indicates that the likelihood of disclosure decreased in direct proportion to the number of partners. Table 1 displays, for each sexual activity, the total number of subjects, total number of partners, and number of partners presumed to be seronegative at the time of the activity. Information is provided separately for partners to whom subjects disclosed and those to whom subjects did not disclose. Ten subjects (17% of the sexually active) engaged in insertive anal intercourse without using a condom and without disclosing to 13 seronegative partners. Seventeen men (29% of the sexually active) engaged in unprotected receptive anal intercourse without disclosing to 41 seronegative partners. The higher prevalence of receptive than insertive anal intercourse is consistent with a study of HIV-infected homosexual White men from Boston.'1 Both activities are risk factors for transmitting the virus.12 In Table 1, the difference between the total number of partners and the number of seronegative partners represents the number of seropositive partners. This difference was larger for informed than uninformed partners, indicating that subjects tended to reveal their infection to those known to be seropositive. When the activity involved insertive or receptive anal intercourse, disclosure to seropositive partners generally occurred in combination with unprotected contact, whereas disclosure to seronegative 1322 American Journal of Public Health
This research was supported by National Institute of Mental Health grant R01-MH42023. We thank Malcolm C. Pike, PhD, Fred R. Sattler, MD, and Ms. Monica Ruiz for their helpful comments on an earlier version of this paper.
References
'.S''.S.' .'t'
S ss. ...: .:.:: :. . :: .......:s ,: :,. s
.
Acknowledgments
...........................''
partners generally occurred in combination with protected contact. Finally, we examined whether the gender of the partner was associated with disclosure among the bisexual men. Because the activity checklist did not explicitly ask subjects to indicate partner gender, we compared nondisclosure rates for vaginal intercourse (female partners) with nondisclosure rates for receptive anal intercourse (male partners). No significant differences were found.
Discusion In a sample consisting primarily of lower socioeconomic homosexual/ bisexual Hispanic men, we found a relatively high prevalence of nondisclosure of HIV infection to current sexual partners in combination with unsafe sexual activity. For this sample, nondisclosure was not due entirely to lack of knowledge about sexual transmission of HIV. Ninety-four percent of the subjects were aware that they could infect others through unprotected sexual intercourse. Use of alcohol or other nonintravenous drugs before sexual relations, as well as attitudes about social responsibility, may have been factors, although we do not have confirmatory information. The restricted nature of our sample precludes any wide generalization of the results. Additional studies of Whites, Blacks, Hispanics, and other minority groups of varying socioeconomic levels are needed before a more refined picture can be obtained. Investigation of factors
AIDS epidemic. Science. 1988;239:580586. 3. Gostin L). Public health strategies forconfronting AIDS. JAMA. 1989;261:16211630. 4. Temoshok L, Ellmer RM, Moulton JM, Baxter M, Shalwitz J. Youth at high risk for HIV: knowledge, sexual practices, and intentions to inform sexual partners of HIV status. Presented at the 5th International Conference on AIDS, Montreal, Quebec, Canada, June 1989. Abstract T.D.O.29. 5. Kegeles SM, Catania JA, Coates TJ. Intentions to communicate positive HIV-antibody status to sex partners. JAMA. 1988;259:216-217. 6. Chervenak JL, Weiss SH. Sexual partner notification: attitudes and actions of HIVinfected women. Presented at the 5th International Conference on AIDS, Montreal, Quebec, Canada, June 1989. Abstract Th.D.P.4. 7. Stempel R, Moulton J, Bacchetti P, Moss AR. Disclosure of HIV-antibody test results and reactions of sexual partners, friends, family, and health professionals. Presented at the 5th International Conference on AIDS, Montreal, Quebec, Canada, June 1989. Abstract E.729. 8. Saltzman SP, Stoddard AM, McCusker J, Moon NW, Mayer KH. Reliability of selfreported sexual behavior risk-factors for HIV infection in homosexual men. Public Health Rep. 1987;102:692-697. 9. Coates RA, Calzavara LM, Soskolne CL, et al. Validity of sexual histories in a prospective study of male sexual contacts of men with AIDS or an AIDS-related condition. Am J Epidemiol. 1988;128:719728. 10. Centers for Disease Control. Revision of the CDC surveillance case definition of acquired immunodeficiency syndrome. MMWR 1987;36:3S-14S. 11. McCusker J, Stoddard AM, Mayer KH, Zapka J, Morrison C, Saltman SP. Effects of HIV antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men. Am J Public Health. 1988;78:462-467. 12. Coates RA, Calzavara LM, Read SE, et al. Risk factors for HIV infection in male sexual contacts ofmen with AIDS oran AIDSrelated condition. Am I Epidemiol.
1988;128:729-739.
October 1991, Vol. 81, No. 10
