Letter to the Editor
To the Editors:
The excellent article by Collins and Diallo1 highlighted the important role that structural interventions could play in HIV prevention. We wholeheartedly concur with their assessment. Nevertheless, we feel obliged to clarify the incomplete representation of the results of our study2 cited in support of an example of a structural intervention, which might lead readers to mistakenly conclude that the data from our study supported the “no-door policy” that requires removing the doors to private rooms in bathhouses.
As Collins and Diallo1 reported, our study found that men in San Francisco (which had a no-door policy) were significantly less likely to report unprotected anal intercourse (UAI) in bathhouses than men in 3 other cities with different bathhouse policies (which allowed doors). However, as we acknowledged in the discussion section, the results were more complex. First, the no-door policy was only 1 component of the San Francisco policy and that component may not have had anything to do with the results obtained. Moreover, there was a measurement problem that made it likely that the one result we found regarding where UAI occurred biased the result in favor of San Francisco (ie, the wording of the question may have led San Francisco respondents to exclude UAI in some settings that should have been included in that response). Finally, the larger pattern of findings presented a consistent picture that, like the other cities, the San Francisco policy appeared to move risk behavior to other locations rather than to reduce overall risk behavior. For these reasons, the results did not provide strong support for the efficacy of the no-door policy.
Furthermore, exit surveys using probability sampling at a bathhouse in a neighboring jurisdiction whose policy allows doors indicated that fully a third of patrons of that business reside in San Francisco.3 That much larger, neighboring bathhouse attracted on a weekly basis nearly as many or more San Francisco residents as all the sex clubs in San Francisco combined. If something in the San Francisco policy were having an effect, it would have to have been due to components of the policy shared with policies in the neighboring jurisdiction, and therefore not likely to be due to the no-door policy in San Francisco. A qualitative study of bathhouse HIV prevention policies in 12 health jurisdictions found that, when evaluated on a wider range of prevention activities, San Francisco's no-door policy does not compare favorably to other less regimented approaches.4
It is also worth noting that exit survey data from the neighboring bathhouse show that, despite the lack of a no-door policy, the overall rate of UAI during the bathhouse visit was only 11.1% (5.5% for receptive UAI),3 and the modal partnering pattern was a single UAI partner.5 These findings suggest that bathhouses are not epicenters of risky sexual behavior or HIV transmission risk. However, because bathhouses are patronized by men who, as a group, report higher rates of sexual risk behavior,5 they are likely to be important sites for conducting HIV prevention interventions, such as HIV testing, with this high risk group.3,5-8
In sum, although the no-door policy has been promoted as a successful structural intervention in bathhouses,9 available data suggest that the no-door policy is ineffective at best and, in a worst case scenario, may distract from identifying and engaging in more effective structural prevention efforts. More importantly, a no-door policy may lend a false sense of security. Although it targets a risky population, it intervenes where, relatively speaking, risky behavior is not occurring but has no effect on risky behavior taking place outside the venue.
William J. Woods, PhD
Diane Binson, PhD
Lance M. Pollack, PhD
Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
1. Collins C, Diallo DD. A prevention response that fits America's epidemic: community perspectives on the status of HIV prevention in the United States. J Acquir Immune Defic Syndr
2. Woods WJ, Binson D, Pollack L, et al. Public policy regulating private & public space in gay bathhouses. J Acquir Immune Defic Syndr
3. Woods WJ, Binson D, Blair J, et al. Probability sample estimates of bathhouse sexual risk behavior. J Acquir Immune Defic Syndr
4. Woods WJ, Binson D, Pollack LM, et al. Dynamic prevention programs in gay bathhouse more likely under non-regulatory policies. Presented at: XVIII International AIDS Conference, July 18-23, 2010; Vienna, Austria (Poster Presentation Abstract: 7842).
5. Binson D, Pollack LM, Blair J, et al. HIV risk at a gay bathhouse. J Sex Research
6. Binson D, Woods WJ, Pollack L, et al. Differential HIV risk in bathhouses and public cruising areas. Am J Public Health
7. Bingham TA, Secura GM, Behel SK, et al. HIV risk factors reported by two samples of male bathhouse attendees in Los Angeles, California, 2001-2002. Sex Transm Dis
8. Reidy WJ, Spielberg F, Wood R, et al. How risky are gay bathhouses and sex clubs? Findings from two Seattle surveys of HIV/STI-related factors. Am J Public Health
9. Wohlfeiler D, Ellen JM. The limits of behavioral interventions for HIV prevention. In: Cohen L, Chavez V. Chemini S, eds. Prevention Is Primary: Strategies for Community Well-Being
. San Francisco, CA: Jossey-Bass and the American Public Health Association; 2007.