All that time before is made less ambiguous
         by getting tested together before having sex
         for sexually transmitted infections.

         The same strategy is used for our blood supply.

         Here's a blog and a wiki about the strategy
         http://NotB4WeKnow.EditThisPage.com
         http://www.seedwiki.com/wiki/not_b4_we_know

"Big Gay Al" <al@felcher.net> wrote in message

Epidemiology
April 2001

Auerbach, J. D. and Coates, T. J. (2000). HIV Prevention Research: Accomplishments and
Challenges for the Third Decade of AIDS. American Journal of Public Health 90(7): 1029-32.

The past 2 decades have taught us that HIV prevention can work. We now have evidence from
places as diverse as Senegal, Thailand, Uganda, and Australia that concerted HIV prevention
efforts at the national level have resulted in the maintenance of low seroprevalence rates
where they otherwise would have been expected to rise. We are beginning to observe declining
rates of HIV prevalence and incidence in places and populations with historically high
rates--for example, injection drug users in New York City. This trend points to the long-term
impact of prevention efforts in those communities. The best of these efforts have been based on
sound scientific research. As we move into the third decade of the AIDS epidemic, it is
important to restate principles, acknowledge advances, and identify challenges and future
directions in HIV prevention research.

Barrett, D. C., Hudes, E. S. and Paul, J. P. (1997). Reexamination of Intergenerational Linkage
of HIV Infection [Letter; Comment]. Journal of Acquired Immune Deficiency Syndromes and Human
Retrovirology 15(4): 318-9.

Binson, D., Michaels, S., Stall, R., Coates, T. J., Gagnon, J. and Catania, J. (1995).
Prevalence and Social Distribution of Men Who Have Sex with Men: United States and Its Urban
Centers. Journal of Sex Research 32(3): 245-254.

Examined the prevalence data on the social distribution, and AIDS-related behavior of
homosexual men, from 2 national probability surveys (the General Social Survey [GSS] and the
National Health and Social Life Survey [NHSLS]), and a probability survey of urban centers in
the US (the National AIDS Behavioral Surveys [NABS]). Six waves of the GSS were combined with
the NHSLS into a single data set (1988-1994). A large number of Subjects (aged 18-49 yrs) were
interviewed regarding their sexual behavior. Results show that Subjects residing in larger
cities, the highly educated, and Whites were more likely to report sex with men. In the urban
sample, one-third of Subjects reported sex with women. Minority men were more likely to report
sex with men and women. More than half of the men with an HIV risk factor reported consistent
condom use. ((c) 1999 APA/PsycINFO, all rights reserved)

Binson, D. and Catania, J. A. (1998). Respondents' Understanding of the Words Used in Sexual
Behavior Questions. Public Opinion Quarterly 62(2): 190-208.

Assessed the difficulty 4,790 respondents (aged 18-49 yrs) have in understanding the vocabulary
used in sexual behavior questions. We embedded several questions related to respondents'
self-reported difficulty in understanding the terms "vaginal intercourse" and "anal
intercourse" in a telephone survey of the general population. National AIDS Behavioral Survey
II was administered. Most Subjects reported that these terms were easy to understand. However,
men were more likely than women to report difficulty, and minority Subjects were more likely
than white Subjects to indicate that "vaginal intercourse" and "anal intercourse" were
difficult to understand. Most striking was the finding that 25% of those with less than 12 yrs
of education reported comprehension difficulty with these terms. In addition, in the High Risk
Cities sample, respondents who found the terms difficult to understand were more likely to
report "zero" when asked the number of people they had vaginal or anal intercourse with. This
has implications for STD/HIV prevention policy in that some demographic groups may appear less
sexually active than they really are. Hence, they may be ignored as likely candidates for
intervention programs. More research is needed to assess the various dimensions to this
problem. ((c) 1999 APA/PsycINFO, all rights reserved)

Catania, J. A., Gibson, D. R., Chitwood, D. D. and Coates, T. J. (1990). Methodological
Problems in AIDS Behavioral Research: Influences on Measurement Error and Participation Bias in
Studies of Sexual Behavior. Psychological Bulletin 108(3): 339-62.

An unprecedented number of human sexuality studies have been initiated in response to the
acquired immune deficiency syndrome (AIDS) epidemic. Unfortunately, methodological developments
in the field of sex research have been slow in meeting the demands of AIDS investigations
focusing on the diverse populations at risk for infection with the human immunodeficiency virus
(e.g., adolescents, gay men, intravenous-drug users, ethnic minorities, elderly transfusees).
In this article, we review and integrate current literature on measurement error and
participation bias in sex research, with an emphasis on collecting sexual information in the
context of AIDS. The relevance of these findings for AIDS-related sex research is discussed,
and recommendations are made to guide future investigations.

Catania, J. A., Binson, D., Van Der Straten, A. and Stone, V. (1995). Methodological Research
on Sexual Behavior in the AIDS Era. Annual Review of Sex Research(VI): 77-125.

Reviews recent methodological studies on the use of methods currently employed to assess adult
sexual behavior, particularly AIDS-relevant sexual behaviors (P. Blumstein et al., 1990; J. A.
Catania et al, 1993; Catania et al., 1990; Catania et al., 1990). The authors provide a brief
overview of the recent surveys that have been conducted using probability sampling techniques,
along with a discussion of sexual behavior issues endemic to AIDS-related surveys; reliability
and validity of self-reported sexual behavior; validity of self-reported changes in sexual
behavior; pretesting of survey instruments; indices of measurement error; and major influences
on measurement error of sexual behaviors, including respondent factors, instrument and mode
effects, and interviewer variables. It is concluded that although some excellent methodological
studies have been conducted, much of this work is in need of replication across various ethnic,
age, and AIDS-risk groups. ((c) 2000 APA/PsycINFO, all rights reserved)

Catania, J. A., Moskowitz, J. T., Ruiz, M. and Cleland, J. (1996). A Review of National
AIDS-Related Behavioral Surveys. AIDS 10 Suppl A: S183-90.

Catania, J. A., Canchola, J. and Pollack, L. (1996). They Said It Couldn't Be Done - the
National Health and Social Life Survey - Response. Public Opinion Quarterly V60(N4): 620-627.

Catania, J., Binson, D., Peterson, J. and Canchola, J. (1997). The Effects of Question Wording.
Researching Sexual Behavior : Methodological Issues. Jenkins, A. C. and Bancroft, J.
Bloomington :, Indiana University Press.

Catania, J. (1998). The Sexual Self-Disclosure Scale. Handbook of Sexuality-Related Measures.
Davis, C. M. Thousand Oaks, Calif. :, Sage Publications.

Catania, J. (1998). The Dyadic Sexual Communication Scale. Handbook of Sexuality-Related
Measures. Davis, C. M. Thousand Oaks, Calif. :, Sage Publications.

Catania, J. (1998). The Dyadic Sexual Regulation Scale. Handbook of Sexuality-Related Measures.
Davis, C. M. Thousand Oaks, Calif. :, Sage Publications.

Catania, J. A. (1999). A Framework for Conceptualizing Reporting Bias and Its Antecedents in
Interviews Assessing Human Sexuality. Journal of Sex Research 36(1): 25-38.

journal abstract The present paper reviews conceptual models of self-presentation bias in
interview situations that focus on assessments of human sexuality. An heuristic framework is
developed that synthesizes these models to focus on self-presentation/self-disclosure bias as a
function of emotional distress and threat to self-esteem, both intermediate outcomes that are
influenced by four general factors: Respondent, Interviewer, Task, and Contextual. Empirical
research within each of these four general factors is discussed, and areas for further research
are outlined. ((c) 1999 APA/PsycINFO, all rights reserved)

Catania, J. A. (1999). A Comment on Advancing the Frontiers of Sexological Methods. Journal of
Sex Research V36(N1): 1-2.

Catania, J., Binson, D., Dolcini, M. M., Moskowitz, J. T. and van der Straten, A. (2001).
Frontiers in the Behavioral Epidemiology of HIV/STDs. Handbook of Health Psychology. Baum, A.,
Revenson, T. A. and Singer, J. E. Mahwah, N.J. :, Lawrence Erlbaum Associates.

Cates, W., Jr., Chesney, M. A. and Cohen, M. S. (1997). Primary HIV Infection--a Public Health
Opportunity? American Journal of Public Health 87(12): 1928-30.

Primary human immunodeficiency virus (HIV) infection should be considered a key target for HIV
prevention activities. Mathematical models suggest that the primary HIV infection interval
makes a disproportionate contribution to the HIV epidemic, perhaps accounting for as many as
half of the existing infections at any point in time. If this is true, primary infection
presents a special window of opportunity within which to exert a maximum impact on the spread
of HIV. A combination of biological, behavioral, and social factors may account for the
influence of primary infection on the HIV epidemic. HIV prevention measures can be focused on
each of these factors. Biologically, detecting individuals early in the course of infection and
offering treatment can reduce viral load and possibly an individual's infectiousness.
Behaviorally, counseling newly infected persons about the importance of adopting safer
practices may instill prevention behaviors at a critical time. Socially, using a network
approach to notify persons exposed to those with primary infections can dampen the
amplification effect of rapid HIV spread through high-risk environments. By focusing prevention
efforts on the primary HIV infection interval, public health officials could increase their
leverage in slowing the HIV epidemic.

Coates, T. J., Aggleton, P., Gutzwiller, F., Des Jarlais, D., Kihara, M., Kippax, S.,
Schechter, M. and van den Hoek, J. A. (1996). HIV Prevention in Developed Countries. Lancet
348(9035): 1143-8.

HIV prevention in developed countries is marked by impressive successes and dismal failures.
The successes point the way to what works; the failures highlight obstacles that must be
overcome. Successes include important behavioural changes among gay and bisexual men, antiviral
use to prevent vertical transmission, and securing the safety of the blood supply. New
strategies are needed to reach the residual of individuals continuing with unsafe practices (a
special hazard in high-prevalence areas); to reach young people who are beginning to engage in
sexual relations and injection drug use; and to overcome political opposition to prevention
strategies.

Coates, T. J. and Feldman, M. D. (1997). An Overview of HIV Prevention in the United States.
Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 14 Suppl 2: S13-6.

Despite recent promising results with protease inhibitors and combinations of drugs in treating
HIV-infected persons, a cure or vaccine for AIDS is unlikely within the next several years.
Therefore, prevention remains the most realistic strategy for dealing with the HIV epidemic.
However, HIV prevention efforts in the United States face enormous challenges. Translating
knowledge about effective HIV prevention strategies into sound HIV prevention policy must be a
priority. For example, AIDS prevention experts must dispel the myth that needle exchange
programs for injection drug users encourage drug use. Such programs may, however, decrease the
risk for HIV transmission. Another challenge is to implement effective sex education programs.
It is well established that early sex education does not lead to promiscuity among young
people; in fact, it may actually decrease overall sexual activity and decrease high-risk sexual
activities. Finally, prevention programs must reach those most at risk. Surveillance data
indicate that these include young gay men, Hispanic and African Americans, and the economically
disadvantaged. Prevention policy too often is formed on the basis of opinion or anecdote rather
than on the basis of science. Sound and strong science is needed to ensure that the best
programs and policies can be put into place.

Colford, J. M., Jr., Ngo, L. and Tager, I. (1994). Factors Associated with Survival in Human
Immunodeficiency Virus-Infected Patients with Very Low Cd4 Counts [See Comments]. American
Journal of Epidemiology 139(2): 206-18.

The authors examined the survival experience of 289 human immunodeficiency virus (HIV)-infected
men to identify factors independently associated with survival in patients with very low CD4
counts (< or = 100/mm3). All subjects were HIV-infected men cared for at the San Francisco
Veterans' Affairs Medical Center between January 1988 and November 1991. Survival was measured
from the date on which a patient was first known to have a CD4 count < or = 100/mm3 until death
or censoring. Factors potentially associated with survival were examined initially using the
product limit (Kaplan-Meier) method; a multivariate model of survival was constructed using a
proportional hazards (Cox) regression. Four variables were identified as independently
associated with survival (p < 0.05) in the Cox proportional hazards model: CD4 count,
hematocrit, azidothymidine use, and clinical stage (prior history of acquired immunodeficiency
syndrome vs. no prior history). All 16 possible combinations of these four (dichotomized)
variables were examined; eight different patterns of survival were detected. Identification of
survival patterns that can be described by data obtained as part of routine clinical care has
implications for patient care, the design of clinical trials, the study of mechanisms of
progression of HIV-related immunosuppression, and planning of health care resource needs for
populations of patients with very low CD4 counts.

Collins, C. (1997). Dangerous Inhibitions: How American Is Letting AIDS Become an Epidemic of
the Young. San Francisco, CA, Center for AIDS Prevention Studies.

Daley, C., Caceres, C. F., Choi, K. H., Hearst, N., Hironaka, K. and Osmond, D. H. (1999).
International Epidemiology of HIV/AIDS. The AIDS Knowledge Base : A Textbook on HIV Disease
from the University of California, San Francisco and San Francisco General Hospital. Sande, M.
A., Volberding, P. and Cohen, P. T. Philadelphia, PA :, Lippincott, Williams and Wilkins:
23-41.

DeCarlo, P. and Grinstead, O. (1999). The 'Post-AIDS' Era and the Effect of Treatment Advances.
Focus 14(11): 1-4.

DeCarlo, P. (1999). HIV among Women in Developing Countries. Harvard AIDS Review(Spring): 2-6.

Grandi, J. L., Goihman, S., Ueda, M. and Rutherford, G. W. (2000). HIV Infection, Syphilis, and
Behavioral Risks in Brazilian Male Sex Workers. AIDS & Behavior 4(1): 129-135.

To describe the epidemiology of HIV and syphilis infection and sexual practices among male sex
workers, the authors studied 434 transvestites and 96 "hustlers" (mean age 22 yrs) recruited by
peers in the metropolitan area of Sao Paulo, Brazil, from 1992-1998. Participants were young
adults with low education levels who had recently immigrated to Sao Paulo and supported
themselves primarily through sex work. The prevalence of HIV infection among transvestites and
hustlers was 40% and 22% respectively, and the prevalence of current or past syphilis was 43%
and 27%, respectively. Infection was associated more with gender performance and duration of
sex work than to recent unsafe sexual practices or recent condom use. As opposed to hustlers
whose clients came primarily from Sao Paulo and were homosexual, transvestites were more likely
to have foreign and heterosexual clients. HIV and syphilis among sex workers are urgent public
health problems that require continuous prevention programs for male sex workers and their
clients. (PsycINFO Database Record (c) 2000 APA, all rights reserved)

Hearst, N., Mandel, J. S. and Coates, T. J. (1995). Collaborative AIDS Prevention Research in
the Developing World: The Caps Experience. AIDS 9(Suppl 1): S1-5.

BACKGROUND: Prevention through behavior change is the only way to control the spread of HIV
infection in the developing world. Success in prevention requires consistent and persistent
intervention over time, a clear understanding of the realities of target populations and
involvement of members of these populations in prevention efforts. Applied local research is
urgently needed, especially in the developing world, to design interventions that meet these
criteria and to test their effectiveness. CENTER FOR AIDS PREVENTION STUDIES (CAPS) MODEL OF
INTERNATIONAL COLLABORATIVE RESEARCH: Each year, eight to 10 scientists from developing
countries visit CAPS in San Francisco for 10 weeks of intensive learning and collaboration. The
main emphasis is on designing a protocol for a research project related to AIDS prevention in
the visiting scientist's home country. CAPS provides pilot study funding and technical
assistance to implement the project. RESULTS: The quality of the resulting collaborative
research is represented by the articles published in this volume and by the many alumni of the
program who have undertaken additional research projects and/or assumed leadership positions in
AIDS control efforts in their countries.

Kahn, J. G., Gurvey, J., Pollack, L. M., Binson, D. and Catania, J. A. (1997). How Many HIV
Infections Cross the Bisexual Bridge? An Estimate from the United States. AIDS 11(8): 1031-7.

OBJECTIVE: Most heterosexual women with AIDS have been infected by male sex partners who
acquired HIV via injecting drug use or sex with men. The contribution of bisexuality to
heterosexual HIV however, has been poorly quantified. In this paper, we estimate the number of
HIV infections that spread from the homosexual community to women who have sex with bisexual
men. METHODS: We developed an HIV transmission model and assigned values to the model's
parameters using data from a probability survey of US cities with a high risk of HIV. RESULTS:
We estimated that these are about 400 HIV infections transmitted annually from HIV-infected
bisexual men in high-risk cities to their female sex partners; two-thirds of these infections
are transmitted to main female partners and one-third to casual partners. Uncertainties in the
value of model parameters lead to variation in expected HIV infections mostly within the range
200 to 600, and for one parameter up to nearly 800. CONCLUSION: We conclude that transmission
via bisexuality is a relatively minor component of the estimated 40,000 annual HIV infections
in the USA.

Lacerda, R., Gravato, N., McFarland, W., Rutherford, G., Iskrant, K., Stall, R. and Hearst, N.
(1997). Truck Drivers in Brazil: Prevalence of HIV and Other Sexually Transmitted Diseases,
Risk Behavior and Potential for Spread of Infection. AIDS 11 Suppl 1: S15-9.

OBJECTIVES: To determine the prevalence of HIV and syphilis and related risk behavior in a
sample of truck drivers in Santos, Brazil. SUBJECTS AND METHODS: A cross-sectional study was
performed of 300 male truck drivers recruited in the port of Santos, Brazil, including a
face-to-face interview and blood sampling for HIV and syphilis serology. RESULTS: Of 300
subjects, 4 (1.3%) were positive for HIV, 25 (8.3%) for syphilis by the Venereal Disease
Research Laboratory (VDRL) test and 38 (13%) were positive for syphilis by the fluorescent
treponemal antibody (absorbed) test (FTA-Abs). Seventy-one per cent had been employed as truck
drivers for more than 10 years and 93% lived outside of Santos. Most participants were married
(72%); 40% reported having more than one sex partner; 21% reported sex with commercial sex
workers; 14% reported sex with girls that they met on the road; 16% had sex with other men's
wives; and 3.3% reported sex with men during the past year. The use of rebite, an oral
stimulant, was reported by 43% and was associated with being FTA-Abs-positive (P = 0.04). Being
HIV-positive was associated with having sex with friends (P = 0.04), partners usually
considered 'safe' by truck drivers. Being syphilis-positive (VDRL) was significantly associated
with sex with partners also considered as 'safe', namely primary sex partners, steady partners
and other men's wives. DISCUSSION: This is the first study to determine HIV and syphilis
seroprevalence among truck drivers in South America. Findings confirm that this group has a
high potential risk for HIV infection and other sexually transmitted diseases, and thus
currently presents an opportunity for prevention.

Lifson, A. R., Allen, S., Wolf, W., Serufilira, A., Kantarama, G., Lindan, C. P., Hudes, E. S.,
Nsengumuremyi, F., Taelman, H. and Batungwanayo, J. (1995). Classification of HIV Infection and
Disease in Women from Rwanda. Evaluation of the World Health Organization HIV Staging System
and Recommended Modifications. Annals of Internal Medicine 122(4): 262-70.

OBJECTIVE: To develop a human immunodeficiency virus (HIV) staging system for sub-Saharan
Africa on the basis of an evaluation of the World Health Organization (WHO) system and
predictors of mortality. DESIGN: Prospective cohort study with 4 years of follow-up. SETTING:
Kigali, Rwanda. PATIENTS: 412 HIV-infected women recruited from prenatal and pediatric clinics.
MEASUREMENTS: Clinical signs and symptoms of HIV disease, laboratory assays (including complete
blood count and erythrocyte sedimentation rate), and cumulative mortality. RESULTS: The WHO
staging system includes a clinical and a laboratory axis. The clinical axis was revised by
inclusion of oral candidiasis, chronic oral or genital ulcers, and pulmonary tuberculosis as
"severe" disease (clinical stage IV); in addition, body mass index was substituted for weight
loss in the definition for the wasting syndrome. The 36-month cumulative mortality was 7% for
women in modified clinical stage I ("asymptomatic"), 15% for those in stage II, 19% for those
in stage III, and 36% for those in stage IV (P < 0.001). The laboratory axis was revised by
replacing lymphocyte count with hematocrit and erythrocyte sedimentation rate. The 36-month
mortality was 10% for women in modified stage A ("normal" laboratory results) and 33% for those
in stage B (erythrocyte sedimentation rate > 65 mm/h or hematocrit < 0.38) (P < 0.001). A
single staging system combining clinical and laboratory criteria is proposed, with a 36-month
mortality of 7% for women in combined stage I, 10% for those in stage II, 29% for those in
stage III, and 62% for those in stage IV (P < 0.001). CONCLUSIONS: On the basis of this
analysis, a staging system relevant for sub-Saharan Africa is proposed that reflects the range
of HIV-related outcomes, has strong prognostic significance, includes inexpensive and available
laboratory tests, and can be used by both clinicians and researchers.

Lindan, C. P., Lieu, T. X., Giang, L. T., Lap, V. D., Thuc, N. V., Thinh, T., Lurie, P. and
Mandel, J. S. (1997). Rising HIV Infection Rates in Ho Chi Minh City Herald Emerging AIDS
Epidemic in Vietnam. AIDS 11 Suppl 1: S5-13.

OBJECTIVE: To describe the epidemiology of HIV in Ho Chi Minh City in the context of current
surveillance data from Vietnam. METHODS: Since the late 1980s, HIV surveillance data have been
collected in Ho Chi Minh City from centers for the treatment of venereal disease and
tuberculosis, centers for the rehabilitation of injecting drug users and sex workers, prenatal
clinics, blood banks and other sites. RESULTS: The first case of HIV infection in Vietnam was
identified in 1990 in Ho Chi Minh City. The cumulative number of reported HIV infections in
this city at the end of 1996 was 2774, about half of the number of cases in the country; 86% of
infections were among men, 86% among injecting drug users, 2.5% among patients with sexually
transmitted diseases and 2.5% among sex workers. The first HIV infection among antenatal women
was detected in 1994. The prevalence of HIV among injecting drug users rose dramatically from
1% in 1992 to 39% in 1996, compared with 1.2% among sex workers, 0.3% among blood donors and
1.3% among tuberculosis patients in 1996. The populations of injecting drug users and sex
workers in Ho Chi Minh City are estimated to be 30000 and 80000, respectively, and rates of
sexually transmitted diseases are 2-3 per 1000 persons per year. By the end of December 1996,
42 out of 53 provinces had reported HIV infections, and border areas near China and Cambodia
began identifying large numbers of HIV-seropositive people. CONCLUSIONS: Ho Chi Minh City is at
the forefront of a new HIV epidemic in Vietnam. This epidemic shows similarities to that in
Thailand nearly a decade ago, with rapidly rising HIV rates among injecting drug users and
infection already established among sex workers. Prevention efforts should include the
targeting of injecting drug users and sex workers outside rehabilitation centers, the
availability of sterile needles and condoms, the establishment of anonymous testing sites, the
control of sexually transmitted diseases and the coordination of programs within southeast
Asia.

Lurie, P., Lowe, R. A., Avins, A. L., Phillips, K. A., Kahn, J. G., Franks, P. E. and
Ciccarone, D. H. (1992). Undiagnosed HIV Infection in Acute Care Hospitals [Letter; Comment]
[See Comments]. New England Journal of Medicine 327(25): 1815-6.

Martin, J. N., Ganem, D. E., Osmond, D. H., Page-Shafer, K. A., Macrae, D. and Kedes, D. H.
(1998). Sexual Transmission and the Natural History of Human Herpesvirus 8 Infection. New
England Journal of Medicine 338(14): 948-54.

BACKGROUND: Although human herpesvirus 8 (HHV-8) has been suspected to be the etiologic agent
of Kaposi's sarcoma, little is known about its seroprevalence in the population, its modes of
transmission, and its natural history. METHODS: The San Francisco Men's Health Study, begun in
1984, is a study of a population-based sample of men in an area with a high incidence of human
immunodeficiency virus (HIV) infection. We studied all 400 men infected at base line with HIV
and a sample of 400 uninfected men. Base-line serum samples were assayed for antibodies to
HHV-8 latency-associated nuclear antigen (anti-LANA). In addition to the seroprevalence and
risk factors for anti-LANA seropositivity, we analyzed the time to the development of Kaposi's
sarcoma. RESULTS: Anti-LANA antibodies were found in 223 of 593 men (37.6 percent) who reported
any homosexual activity in the previous five years and in none of 195 exclusively heterosexual
men. Anti-LANA seropositivity correlated with a history of sexually transmitted diseases and
had a linear association with the number of male sexual-intercourse partners. Among the men who
were infected with both HIV and HHV-8 at base line, the 10-year probability of Kaposi's sarcoma
was 49.6 percent. Base-line anti-LANA seropositivity preceded and was independently associated
with subsequent Kaposi's sarcoma, even after adjustment for CD4 cell counts and the number of
homosexual partners. CONCLUSIONS: The prevalence of HHV-8 infection is high among homosexual
men, correlates with the number of homosexual partners, and is temporally and independently
associated with Kaposi's sarcoma. These observations are further evidence that HHV-8 has an
etiologic role in Kaposi's sarcoma and is sexually transmitted among men.

Martin, J. N., Rose, D. A., Hadley, W. K., Perdreau-Remington, F., Lam, P. K. and Gerberding,
J. L. (1999). Emergence of Trimethoprim-Sulfamethoxazole Resistance in the AIDS Era. Journal of
Infectious Diseases 180(6): 1809-18.

Trimethoprim-sulfamethoxazole (TMP-SMX) is widely used for Pneumocystis carinii pneumonia
prophylaxis in human immunodeficiency virus (HIV)-infected patients, but little is known about
the effects of this practice on the emergence of TMP-SMX-resistant bacteria. A serial
cross-sectional study of resistance to TMP-SMX among all clinical isolates of Staphylococcus
aureus and 7 genera of Enterobacteriaceae was performed at San Francisco General Hospital.
Resistance among all isolates was <5.5% from 1979 to 1986 but then markedly increased, reaching
20.4% in 1995. This was most prominent in HIV-infected patients: resistance increased from 6.3%
in 1988 to 53% in 1995. The largest increases in resistance were in Escherichia coli (24% in
1988 to 74% in 1995) and S. aureus (0% to 48%) obtained from HIV-infected patients. A rapid
increase in the use of prophylactic TMP-SMX in HIV disease was also observed during this time
in San Francisco and is likely responsible for the increase in TMP-SMX resistance.

Martin, J. N. and Osmond, D. H. (2000). Determining Specific Sexual Practices Associated with
Human Herpesvirus 8 Transmission [Invited Commentary]. American Journal of Epidemiology 151(3):
225-9; discussion 230.

Laboratory and epidemiologic studies have established human herpesvirus 8 (HHV8) as an
etiologic agent of Kaposi's sarcoma. With strong evidence linking HHV8 infection with the
number of sexual partners among homosexual men, the challenge now is to determine the specific
sexual acts associated with HHV8 transmission. Initial studies of specific practices, however,
have differed in their conclusions; the paper by Dukers et al. in this issue of the Journal is
the first to associate penile-oral intercourse with HHV8 transmission. Many sources of bias may
contribute to the conflicting findings of studies reported to date: HHV8 research still lacks
an adequately specific and sensitive serologic assay; identification of relevant exposure
periods and measurement of sexual practices are imperfect; and sufficient adjustment for
confounding is problematic. These numerous potential biases may be particularly important when
trying to detect underlying associations that may be of low-order magnitude. The study by
Dukers et al. (Am J Epidemiol 2000;151:213-24) is an important contribution to research on HHV8
transmission, but we do not yet know enough about the possible sexual routes of transmission to
recommend avoiding any single behavior. For now, the best prevention advice is to reinforce the
more general safe sex practices that have been promoted to prevent human immunodeficiency virus
and other sexually transmitted diseases.

Martin, J. N., Amad, Z., Cossen, C., Lam, P. K., Kedes, D. H., Page-Shafer, K. A., Osmond, D.
H. and Forghani, B. (2000). Use of Epidemiologically Well-Defined Subjects and Existing
Immunofluorescence Assays to Calibrate a New Enzyme Immunoassay for Human Herpesvirus 8
Antibodies. Journal of Clinical Microbiology 38(2): 696-701.

Agreement between assays for the detection of human herpesvirus 8 (HHV-8) antibodies has been
limited. In part, this disagreement has been because assay calibration (i.e., differentiating
positive from negative results) has not been done in a standardized fashion with reference to a
wide spectrum of HHV-8-infected (true-positive) and HHV-8-uninfected (true-negative) persons.
To describe the performance of an assay for HHV-8 antibodies more accurately, we used
epidemiologically well-characterized subjects in conjunction with testing on two existing
immunofluorescence assays for HHV-8 antibodies to define two groups: a group of 135
HHV-8-infected individuals (true positives), including Kaposi's sarcoma patients and those
asymptomatically infected, and a group of 234 individuals with a high likelihood of being HHV-8
uninfected (true negatives). A new enzyme immunoassay (EIA), using lysed HHV-8 virion as the
antigen target, was then developed. With the above true positives and true negatives as
references, the sensitivity and specificity of the EIA associated with different cutoff values
were determined. At the cutoff that maximized both sensitivity and specificity, sensitivity was
94% and specificity was 93%. When the EIA was used to test a separate validation group, a
distribution of seropositivity that matched that predicted for the agent of Kaposi's sarcoma
was observed: 55% of homosexual men were seropositive, versus 6% seropositivity in a group of
children, women, and heterosexual men. It is proposed that the EIA has utility for large-scale
use in a number of settings and that the calibration method described can be used for other
assays, both to more accurately describe the performance of these assays and to permit
more-valid interassay comparison.

Mbugua, G. G., Muthami, L. N., Mutura, C. W., Oogo, S. A., Waiyaki, P. G., Lindan, C. P. and
Hearst, N. (1995). Epidemiology of HIV Infection among Long Distance Truck Drivers in Kenya.
East African Medical Journal 72(8): 515-8.

A total number of two hundred eighty three long distance truck drivers and their assistants
(loaders) who ferry goods between Kenya and Zaire were included in a cross-sectional study
between September 1991 and April 1992. Twenty six percent of the study subjects were
seropositive for HIV-1 and none were HIV-2 seropositive. Countries of birth and residence were
significantly associated with HIV infection (X2 = 23.6, P = 0.0006). Significant associations
were also found between HIV seropositivity and level of education from secondary school and
above (OR = 3.4, 95% C.I. = 1.01-11.55); being circumcised was more protective, (OR = 0.38; 95%
C.I. = 0.19-0.76), history of many years of driving (X2 = 9.3, p = 0.0254) and income (OR =
11.13, 95% C.I. = 1.35-91.95). When a stepwise multiple logistic regression model was fitted to
all the variables observed to be significant in the univariate analysis, the following risk
factors attained statistical significance: lack of circumcision (OR = 3.75); income greater
than Ksh. 2000 (OR = 7.24); being employed in long distance driving more than 11 years (OR =
3.98); and secondary school education and above (OR = 4.06, 95% C.I. = 1.18-13.98). Reference
for all the above Odds Ratios was 1.

McFarland, W., Mvere, D., Shandera, W. and Reingold, A. (1997). Epidemiology and Prevention of
Transfusion-Associated Human Immunodeficiency Virus Transmission in Sub-Saharan Africa. Vox
Sanguinis 72(2): 85-92.

BACKGROUND AND OBJECTIVES: Compared to industrialised nations, countries in sub-Saharan Africa
experience a greater amount of transfusion-associated HIV transmission due to high rates of
transfusion in some groups of patients, a higher incidence and prevalence of HIV infection in
donor populations, a lack of HIV antibody screening in some areas, and a higher residual risk
of contamination in blood supplies despite antibody screening. MATERIALS AND METHODS:
Epidemiologic review. RESULTS: Epidemiologic evidence supports the effectiveness of three
relatively inexpensive strategies to prevent transfusion-associated HIV transmission in
sub-Saharan Africa: HIV antibody screening, avoidance of unnecessary use of blood products, and
exclusion of donors at high risk of infection. Such prevention strategies have not been
universally implemented. CONCLUSIONS: International aid to establish and maintain HIV antibody
screening programmes, implementation of sound criteria for transfusion, and the search for HIV
risk factors to use as donor exclusion criteria must be expanded in the region.

McFarland, W. and DeCarlo, P. (1998). New Epidemics: The Global Status of HIV. Focus 13(11):
5-7.

McFarland, W., Kellogg, T. A., Louie, B., Murrill, C. and Katz, M. H. (2000). Low Estimates of
HIV Seroconversions among Clients of a Drug Treatment Clinic in San Francisco, 1995 to 1998.
Journal of Acquired Immune Deficiency Syndromes 23(5): 426-9.

We estimated HIV incidence among injection drug users attending a drug treatment clinic in San
Francisco from 1995 to 1998 using two methods. An anonymous sequential testing method
identified no seroconversions among clients seen more than once during the period (one-sided
upper 95% confidence limit 1.02 per 100 person-years). A sensitive/less sensitive immunoassay
testing strategy detected no early infections (one-sided upper 95% confidence limit 1.90% per
year). Methods were concordant and feasible in the setting. Although detection of no new HIV
infections in this population of injection drug users (IDUs) is encouraging, epidemiologic
studies among IDUs not in treatment are needed to monitor the HIV epidemic effectively.

McQuitty, M., McFarland, W., Kellogg, T. A., White, E. and Katz, M. H. (1999). Home Collection
Versus Publicly Funded HIV Testing in San Francisco: Who Tests Where? Journal of Acquired
Immune Deficiency Syndromes 21(5): 417-22.

We examined records of all HIV antibody tests performed at anonymous publicly funded (PF) sites
and by home collection (HC) testing for residents of San Francisco from August 1996 to December
1997. Although far fewer tests were performed by HC testing than at PF sites (715 versus 8712,
respectively), a higher proportion of HC testers reported no prior history of HIV testing
(33.1% versus 17.9%). HIV seroprevalence was higher among PF tests (1.8%) than among HC tests
(0.9%). Compared with PF testers, HC testers were less likely to be gay men, lesbian or
bisexual women, heterosexual women, African American, or Latino. HC testers were more likely to
report sex with a known HIV-positive partner. HC testers were also more likely to reside in
affluent neighborhoods. HC testing reaches some high-risk persons who may not otherwise seek PF
testing, although, overall, the risk profile of HC testers appeared lower than that of PF
testers. HC testing reaches some individuals who can financially afford HC testing, thus saving
public prevention resources for hard-to-reach, high-risk populations.

Mills, T. C., Stall, R., Catania, J. A. and Coates, T. J. (1997). Interpreting HIV Prevalence
and Incidence among Americans: Bridging Data and Public Policy. American Journal of Public
Health 87(5): 864-6.

Page-Shafer, K., Delorenze, G. N., Satariano, W. A. and Winkelstein, W., Jr. (1996).
Comorbidity and Survival in HIV-Infected Men in the San Francisco Men's Health Survey. Annals
of Epidemiology 6(5): 420-30.

The course of disease associated with infection with the human immunodeficiency virus varies
widely. Some patients deteriorate rapidly, while others live for years, even after an illness
that defines the acquired immunodeficiency syndrome (AIDS). In this study, comorbidity, or the
presence of concurrent health problems, was investigated prospectively as a possible co-factor
for different rates of decline in 395 homosexual/bisexual men in the San Francisco Men's Health
Study (SFMHS) who were infected with the human immunodeficiency virus (HIV). Comorbidity data
obtained from baseline interviews included both chronic and infectious diseases as well as
depression. Smoking, alcohol, and drug use were also examined. The most prevalent comorbid
conditions were sexually transmitted diseases (90%) and hepatitis B infection (76%). Most
chronic and acute concurrent health conditions were not significant discrete predictors of
survival to AIDS or death after controlling for immune status and markers of disease
progression. Significantly, other risk factors (e.g., depression and smoking) were found to be
associated with more rapid progression. Men with symptoms of depression had a higher risk of
progression of AIDS diagnosis; the relative hazard (RH) was 1.4 (95% confidence interval [CI],
1.00-2.08); smoking was associated with higher risk of death (RH, 1.6; 95% CI, 1.20-2.17).
Older age was marginally associated with poorer survival to death. No associations were found
between survival and alcohol and drug use.

Page-Shafer, K. A., McFarland, W. and Katz, M. (1997). 1997 HIV Consensus Report on HIV
Prevalence and Incidence in San Francisco. Dept. of Public Health, AIDS Office, Epidemiology
Unit,

Paul, J. P., Stall, R. and Bloomfield, K. A. (1991). Gay and Alcoholic: Epidemiologic and
Clinical Issues. Alcohol Health & Research World 15(2): 151-160.

Examines whether elevated rates of alcoholism exist in the gay community (GC), whether the
rates of alcohol abuse (ALA) are changing, and what are the risk factors for ALA in the GC. The
authors also examine whether there is a need for gay-sensitive alcoholism treatment programs,
how the existing treatment programs respond to the needs of gay alcoholics, and how gay
alcoholics obtain the social support necessary to maintain sobriety. Early studies estimated
that 1 out of every 3 gay men and lesbians was an abuser of alcohol or illegal drugs. Later
work found lower rates of ALA among gay men. There is evidence of a decline of alcoholism among
lesbians also. ((c) 1999 APA/PsycINFO, all rights reserved)

Paul, J., Hays, R. B. and Coates, T. J. (1995). The Impact of the HIV Epidemic on U.S. Gay Male
Communities. Lesbian, Gay, and Bisexual Identities over the Lifespan : Psychological
Perspectives. D'Augelli, A. R. and Patterson, C. New York :, Oxford University Press: 347-397.

Peterson, J. and DiClemente, R. (1994). Lessons Learned from Behavioral Interventions: Caveats,
Gaps and Implications. Preventing AIDS : Theories and Methods of Behavioral Interventions.
DiClemente, R. J. and Peterson, J. L. New York :, Plenum Press.

Ruiz, J. D., Molitor, F., McFarland, W., Klausner, J., Lemp, G., Page-Shafer, K., Parikh-Patel,
A., Morrow, S. and Sun, R. K. (2000). Prevalence of HIV Infection, Sexually Transmitted
Diseases, and Hepatitis and Related Risk Behavior in Young Women Living in Low-Income
Neighborhoods of Northern California. Western Journal of Medicine 172(6): 368-73.

OBJECTIVE: To estimate the prevalence of human immunodeficiency virus (HIV) infection, sexually
transmitted diseases, and hepatitis and the associated sexual and drug-using behavior among
women residing in low-income neighborhoods in 5 northern California counties. METHODS: From
April 4, 1996, to January 6, 1998, women aged 18 to 29 years were recruited door-to-door from
randomly selected street blocks within 1990 census block groups below the 10th percentile for
median household income for each county. RESULTS: Of 24,223 dwellings enumerated, contact was
made with residents from 19,546 (80.7%). Within contacted dwellings, 3,560 eligible women were
identified and 2,545 enrolled (71.5%). Weighted estimates for disease prevalence were HIV
infection, 0.3% (95% confidence interval, 0.1%-0.4%); syphilis, 0.7% (0.3%-1.1%); gonorrhea,
0.8% (0.3%-1.3%); chlamydia, 3.3% (2.4%-4.8%); herpes simplex virus, type 1, 73.7%
(71.6%-76.9%); herpes simplex virus, type 2, 34.4% (29.9%-39.0%); hepatitis A, 33.5%
(28.3%-38.7%); chronic hepatitis B, 0.8% (0.3%-1.2%); and hepatitis C, 2.5% (1.4%-3. 6%).
Condom use at last sexual intercourse with a new partner was reported by 44.0% (33.9%-54.1%).
Injection drug use in the last 6 months was reported by 1.8% (1.0%-2.7%). CONCLUSIONS: The
Young Women's Survey provided population-based estimates of the prevalence of 8 infectious
diseases and related risk behavior within a population for whom data are often difficult to
collect. Population-based data are needed for appropriate targeting and planning of primary and
secondary disease prevention.

Seed, J., Allen, S., Mertens, T., Hudes, E., Serufilira, A., Carael, M., Karita, E., Van de
Perre, P. and Nsengumuremyi, F. (1995). Male Circumcision, Sexually Transmitted Disease, and
Risk of HIV. AIDS 8: 83-90.

Ssali, F. N., Kamya, M. R., Wabwire-Mangen, F., Kasasa, S., Joloba, M., Williams, D., Mugerwa,
R. D., Ellner, J. J. and Johnson, J. L. (1998). A Prospective Study of Community-Acquired
Bloodstream Infections among Febrile Adults Admitted to Mulago Hospital in Kampala, Uganda.
Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 19(5): 484-9.

Septicemia is a frequent cause of death in HIV-infected adults in developing countries.
Additional prospective studies are needed to determine the etiology of bloodstream infections
(BSI) in febrile HIV-infected adults and guide initial evaluation and treatment in this
setting. We assessed the prevalence and etiology of community-acquired BSI among 299
consecutive febrile adult medical admissions to Mulago Hospital, Kampala, Uganda, over a
4-month period in 1997. The median age of our patients was 30 years, 159 (53%) were male, and
227 (76%) HIV-1-seropositive. Overall, prevalence of bacteremia or fungemia (1 patient) was
24%. Bacteremia was more frequent in HIV-infected than in uninfected patients (27% versus 15%,
respectively; p = .04). Mycobacterium tuberculosis (n = 28), Streptococcus pneumoniae (n = 15)
and Salmonella species (n = 13) were the most frequent isolates. All Salmonella and
mycobacterial isolates were recovered from HIV-infected patients. Pneumococcal bacteremia was
not associated with HIV seropositivity. M. avium complex and M. simiae were isolated from two
HIV-infected patients. The rate of mycobacteremia among febrile HIV-infected adults presenting
for hospitalization was 13%. Bacteremia and disseminated tuberculosis are frequent causes of
morbidity in febrile HIV-infected Ugandan adults. Initial empiric antibiotic coverage in this
setting should be targeted toward the pneumococcus and gram-negative enteric bacilli,
especially nontyphi Salmonella species. All patients presenting with chronic cough should be
evaluated for tuberculosis.

Stall, R. D., Greenwood, G. L., Acree, M., Paul, J. and Coates, T. J. (1999). Cigarette Smoking
among Gay and Bisexual Men. American Journal of Public Health 89(12): 1875-8.

OBJECTIVES: This study measured the prevalence of cigarette smoking among gay men and
identified associations with smoking. METHODS: Household-based (n = 696) and bar-based (n =
1897) sampling procedures yielded 2593 gay male participants from Portland, Ore, and Tucson,
Ariz, in the spring of 1992. RESULTS: Forty-eight percent of the combined sample reported
current smoking, a rate far above prevalence estimates for men in Arizona (z = 14.11, P < .001)
or Oregon (z = 24.24, P < .001). Significant associations with smoking included heavy drinking,
frequent gay bar attendance, greater AIDS-related losses, HIV seropositivity, lower health
rating than members of same age cohort, lower educational attainment, and lower income.
CONCLUSIONS: Rates of cigarette smoking are very high among gay men. Tobacco prevention and
cessation campaigns should be designed to reach the gay male community.

Strathdee, S. A., Veugelers, P. J., Page-Shafer, K. A., McNulty, A., Moss, A. R., Schechter, M.
T., van Griensven, G. J. and Coutinho, R. A. (1996). Lack of Consistency between Five
Definitions of Nonprogression in Cohorts of HIV-Infected Seroconverters. AIDS 10(9): 959-65.

OBJECTIVE: To identify appropriate criteria for characterizing HIV-infected nonprogressors.
DESIGN: Five definitions were compared as follows: (1) last CD4 count > 500 x 10(6)/l; (2) two
most recent CD4 counts > 500 x 10(6)/l; (3) calculated CD4 count based on linear regression >
500 x 10(6)/l; (4) CD4 slope > or = 0 with no antiretroviral use; (5) all CD4 counts > 500 x
10(6)/l, decline in CD4 slope < 5 cells per year, no antiretroviral use. PARTICIPANTS: Five
prospective cohorts of homosexual men with documented dates of HIV-1 seroconversion. MAIN
OUTCOME MEASURES: Proportions of nonprogressors were calculated 7, 8, 9 and 10 years following
seroconversion (n = 285). Definitions were evaluated with respect to consistency over time and
across sites. Subjects lacking CD4 counts within 3 years preceding end of follow-up were
excluded. RESULTS: Across sites, proportions of nonprogressors ranged from 1% (definition 5) to
17.5% (definition 1) 10 years after seroconversion. Definitions based on absolute CD4 counts
(definitions 1-3) had higher proportions and were less consistent than those based on stable
slopes (definitions 4 and 5). For each definition, proportions decreased as follow-up
increased, but were most stable for definition 4 (3%). Site differences decreased as follow-up
increased, but remained nearly threefold for definitions 1-3. None of the definitions
classified the same subjects as nonprogressors at any timepoint. CONCLUSIONS: Observations
regarding nonprogression are highly dependent on the definition and the duration of follow-up.
Our findings highlight methodological challenges which will need to be overcome in natural
history studies of nonprogression.

van Benthem, B. H., Veugelers, P. J., Cornelisse, P. G., Strathdee, S. A., Kaldor, J. M.,
Shafer, K. A., Coutinho, R. A. and van Griensven, G. J. (1998). Is AIDS a Floating Point
between HIV Seroconversion and Death? Insights from the Tricontinental Seroconverter Study.
AIDS 12(9): 1039-45.

OBJECTIVE: To investigate the significance of the time from seroconversion to AIDS (incubation
time) and other covariates for survival from AIDS to death. METHODS: In survival analysis,
survival from AIDS to death was compared for different categories of length of incubation time
adjusted and unadjusted for other covariates, and significant predictors for survival from AIDS
to death were investigated. RESULTS: Survival after AIDS was not affected by the incubation
time in univariate as well as in multivariate analyses. Predictive factors for progression from
AIDS to death were age at seroconversion, type of AIDS diagnosis, and CD4 cell count at AIDS.
The relative hazard for age at seroconversion increased 1.38-fold over 10 years. Men with a CD4
cell count at AIDS of <130 x 10(6)/l had a twofold higher risk in progression to death than men
with higher CD4 cell counts. Persons diagnosed with lymphoma had a sixfold higher risk of
progression to death than persons with Kaposi's sarcoma or opportunistic infections.
CONCLUSIONS: The incubation time as well as other factors before AIDS did not affect survival
after AIDS. Survival from AIDS to death can be predicted by data obtained at the time of AIDS
diagnosis, such as type of diagnosis, age and CD4 cell count. AIDS seems to be a significant
point in progression to death, and not just a floating point between infection and death
affected by prior factors for persons who did not receive effective therapy and did not have
long incubation times.

Waldo, C. R. and Coates, T. (2000). Acquired Immune Deficiency Syndrome. Encyclopedia of
Psychology. Kazdin, A. E. Washington, D.C. : Oxford [Oxfordshire] ; New York :, American
Psychological Association ; Oxford University Press.

Waldo, C. R. and Coates, T. (2000). HIV/AIDS Prevention: Successes and Challenges. Promoting
Human Wellness : New Frontiers for Research, Practice, and Policy. Jamner, M. S. and Stokols,
D. Berkeley :, University of California Press.

Waldo, C. R., McFarland, W., Katz, M. H., MacKellar, D. and Valleroy, L. A. (2000). Very Young
Gay and Bisexual Men Are at Risk for HIV Infection: The San Francisco Bay Area Young Men's
Survey Ii. Journal of Acquired Immune Deficiency Syndromes 24(2): 168-74.

OBJECTIVES: To compare HIV seroprevalence and sexual risk behavior among very young gay and
bisexual men (aged 15-17 years) and their older counterparts (aged 18-22 years). To examine
drug-use patterns and correlates of sexual risk behavior in both of these age groups. DESIGN
AND METHODS: An interviewer-administered cross-sectional survey of 719 gay and bisexual males
between 15 and 22 years old was conducted through a venue-based sampling design. Blood
specimens were collected and tested for HIV antibodies, hepatitis B, and syphilis. Interviews
assessed sexual and drug-use behavior as well as psychosocial variables believed to be related
to sexual risk-taking, including self-acceptance of gay or bisexual identity, perceptions of
peer norms concerning safer sex, and perceptions of the ability to practice safer sex (safer
sex self-efficacy). RESULTS: Of the 719 participants, 100 (16.2%) were aged between 15 and 17
years. HIV seroprevalence was somewhat lower among those aged 15 to 17 years (2.0%) compared
with those aged 18 to 22 years (6.8%). Overall, the prevalence of hepatitis-B core antibody was
significantly lower in the younger age group (5.0%) than in the older group (14.1%). The men
aged 15 to 17 years used alcohol, ecstasy, and heroin less frequently than those aged 18 to 22
years. The age groups did not differ in the proportion of men who reported any unprotected anal
intercourse in the previous 6 months (31.2%). In both age groups, use of amphetamines, ecstasy,
and amyl nitrate was associated with unprotected anal intercourse. Self-acceptance of gay or
bisexual identity was related to less sexual risk for those aged 15 to 17 years. In both age
groups, greater safer sex self-efficacy was linked to less HIV sexual risk-taking. In the
younger group, perceptions of peer norms that support safer sex were related to less risk
behavior. CONCLUSIONS: Very young gay and bisexual men engage in unprotected anal sex at rates
comparable with those for their somewhat older counterparts, raising serious concern over their
risk of acquiring HIV infection. To prevent seroconversions, interventions must target those
<18 years of age, and prevention programs should address the use of certain drugs in relation
to sex and sexual risk-taking. To be most effective, programs should develop innovative
communication strategies to take into account lack of self-acceptance of gay or bisexual
identity and low self-efficacy for practicing safer sex.

Waldo, C. R. and Coates, T. J. (2000). Multiple Levels of Analysis and Intervention in HIV
Prevention Science: Examplars and Directions for New Research. AIDS 14(Supplement 2): 500.

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