Fifteen years after the identification of HIV, approximately two-thirds of those in the United States who are infected with the virus are aware of their seropositive status . People who are aware of their infection can decrease the risk of developing AIDS by taking antiretroviral therapy. It is less clear, however, whether awareness has decreased the risk of transmitting the virus through unsafe sex. As more people are tested for HIV, a larger proportion of all transmission will be from people who know they are infected. Reducing this transmission is an immensely important public health concern, compounded by the long period in which many seropositive people remain asymptomatic and by new medical advances that enable infected people to live longer, healthier lives [2-5]. However, there are few programs for helping these people reduce sexual risk in the ensuing years.
HIV counseling and testing remain the primary means for delivering behavioral intervention to seropositive persons tested at publicly funded testing sites [6,7]. Although counseling and testing are valuable for establishing awareness of serostatus and for providing medical referrals, they are limited in their capacity to help infected people change their sexual risk behaviors and maintain those changes. Post-test counseling is usually delivered in a single brief session shortly after test results are conveyed. This is a time when many people who have tested positive may be unprepared psychologically or limited in their motivation or ability to assimilate prevention messages. For the most part, people who test positive for HIV must draw on their own internal resources (e.g., felt responsibility to protect others) in their attempts to change their behaviors. Seropositive people are asked to behave in ways that minimize the likelihood of transmitting the virus and to be accountable for their actions. Prevention efforts must also provide the social conditions that encourage and reinforce safe behavior.
In this review, we examine sexual risk-taking of seropositive persons and discuss the roles of personal and collective responsibility for reducing transmission of HIV. First, we describe findings of studies that have examined sexual risk behaviors of seropositive adults. Second, we consider some of the psychological factors associated with risky sex in this group and whether and how interventions aimed at increasing a sense of personal responsibility to avoid transmitting HIV may enhance prevention efforts. Although some commentators have suggested that the normalization of HIV infection has substantially reduced the social barriers to responsibility-based messages , others have more cautiously pointed to the need for more research and reflection . Third, we discuss the role of collective responsibility in HIV prevention efforts. Policymakers, researchers, and citizens alike have an obligation to help combat the HIV/AIDS epidemic. Social attitudes, norms, and practices, both within risk populations and in the broader society, influence behavior that spreads disease. Insufficient attention to the ecology of HIV prevention limits the effectiveness of individual-level interventions and hinders the development of interventions to address directly the social forces that provide too many incentives for risk and too few rewards for safety.
Prevalence of unsafe sex
Most adults are sexually active. If anything, people who have contracted HIV have been more sexually active than people who remain uninfected. Many of those with HIV infection do change their sexual practices after testing positive . Nevertheless, studies indicate that more than 70% of seropositive men and women engage in oral, vaginal, or anal sex after they become aware they have HIV [11-15] and that the probability of sexual activity increases with the length of time since they tested seropositive (unpublished data).
Some infected people do not reveal their serostatus to their sex partners. Of HIV-positive adults (mostly men), 30% had not informed any past partners, and 29% had not informed any current partners even after an average of 6h of counseling over 2 years . Another study found that 52% of sexually active HIV-positive men kept their infection status secret from one or more sex partners . The prevalence of disclosure is somewhat higher among seropositive women than men , stemming in part from the fact that women have fewer sex partners [18,19]. As the number of partners increases, the likelihood of informing any of them decreases [16,20]. Most seropositive men and women disclose their status to primary sex partners [21-26], but disclosure to other partners is less likely [19,26]. The HIV serostatus of the partner also influences disclosure: seropositive men who have sex with men (MSM) who engaged in anal intercourse informed 86% of HIV-positive partners, 46% of HIV-negative partners, and 18% of partners whose serostatus they did not know . Disclosure is associated with an increased likelihood of protected sex with uninfected partners .
Table 1 presents findings of studies that have examined the prevalence of unprotected anal or vaginal intercourse amongst HIV-positive adults. Although the varying recall periods for the self-reports make comparisons difficult, a sizable percentage of seropositive men and women engage in unprotected sexual intercourse after they learn they are infected. The studies would overestimate transmission risk if unprotected sex occurred primarily with other infected persons. HIV-positive MSM have been found to be three times more likely to have engaged in unprotected insertive anal intercourse with HIV-positive partners than with other partners . The results of other studies are similar [11,13,14,32,33,37-39]. In these partner-specific analyses, only 35-45% of the partners were seropositive; thus, many of the other partners may have been placed at risk.
Undoubtedly, most seropositive people feel a unique sense of responsibility to protect sex partners . They know that it is wrong to endanger others by exposing them to HIV without their knowledge. This is most evident when there is emotional involvement with a partner and commitment to an ongoing relationship. Indeed, disclosure of seropositive status and protected sexual activity are most likely to occur when there is commitment to partners at risk for infection, and least likely to occur with casual partners of unknown serostatus . The desire for intimacy and sexual pleasure may, at times, overcome motivation of serodiscordant couples to use condoms during sexual intercourse . Nevertheless, just as committed relationships and reduction in the number of sex partners protect against contracting HIV, they protect against transmitting the virus. Sexual partnerships of two seropositive persons also protect against infecting others.
In sexual encounters with casual partners, good intentions may not always be translated into protective behavior. Some infected persons may want to disclose and feel that it is the right thing to do but may reason that their physical appearance, preferred sex activities, or nonverbal cues (e.g., leaving medication or printed materials in plain sight) constitute disclosure. Direct disclosure is often difficult; it may stigmatize a person and precipitate other negative outcomes (e.g., refusal to have any type of sex). Some infected persons who withhold disclosure may attempt to protect partners by using a condom or by restricting the range of sexual activities. Nevertheless, keeping one‚s seropositive status secret keeps the partner from making an informed decision about risk and deters honest communication and negotiated behavior.
The responsibility to protect others can become psychologically and behaviorally challenging. Some infected people may question why they are the ones who must shoulder the responsibility for protecting others and may cognitively shift the responsibility to the partner. This cognitive shift may be initiated and reinforced by general prevention messages such as, ‚everyone who is sexually active should use a condom.‚ It may serve to rationalize high-risk acts and alleviate feelings of guilt or anxiety. Some infected persons may reason that partners who are willing to forego condoms have accepted the risk that they may be exposed to the virus and so do not need to be notified or protected.
Shifts in responsibility to protect may be influenced by the psychological states of infected persons. Anger, anxiety and tension may promote psychological overload that may trigger motivation to escape the aversive psychological state as well as the burden to protect partners [39,41]. Motivation to escape may induce a person to make external attributions of responsibility for protection (i.e., more responsibility attributed to sex partners than to self) or to use drugs before sex. These escape mechanisms may increase the likelihood of unprotected sexual intercourse . Importantly, negative affect and motivation to escape are not conducive to processing, assimilating, or acting on prevention messages. Receptiveness to those messages may be increased by interventions that help seropositive people maintain positive affective states. When people feel good about themselves and feel respected, they may be more likely to accept responsibility for their actions, more likely to orient themselves to the future, and more likely to consider the consequences of their behaviors [42-44].
The importance of responsible behavior has been a major feature of post-test counseling, and its underlying value of preventing further HIV transmission may be widely accepted by most seropositive people. But messages about personal responsibility to protect others can easily be perceived as victim blaming that only enhances the stigma of the disease and lessens the motivation to protect others. Such messages and the perceptions of social hostility they may engender can also have the broader effect of polarizing the political climate in which prevention messages are offered. We strongly believe that all infected people should receive a dual-theme message that emphasizes protecting their own health as well as that of their partners. This type of message has been featured in some brochures and literature for HIV-positive persons [45-47]. The issue of self-protection has surfaced strongly in the context of combination antiretroviral therapies. It is important that infected people gain access to these therapies and adhere strictly to prescribed treatment regimens. Adherence can lower viral load, help prevent drug resistance, and significantly improve health and prolong life [2-5]. Similarly, seropositive people who adhere to safer-sex guidelines protect themselves. Unsafe sex can lead to secondary infections (e.g., syphilis, gonorrhea, herpesvirus associated with Kaposi‚s sarcoma) that may accelerate disease progression [48-52] and heighten the infectiousness of HIV [53,54]. This type of self-protective message may be quite powerful when communicated to HIV patients by their health-care providers.
Individual-level approaches to prevention
Messages about self-protection and social responsibility to protect others are needed now more than ever, because the success of medical treatments may have unintended behavioral consequences for HIV prevention. Lowering viral load and keeping it low may reduce the likelihood that a seropositive person may infect a partner during sexual contact [55-57]. However, as treatment options enable people with HIV infection to live longer and feel healthier, those people may become more sexually active. Those who believe that low viral load renders them non-infectious may stop using condoms. Furthermore, as therapeutic successes are publicized, people‚s perceptions of HIV disease may change. What was once viewed as an acute and fatal disease may now be viewed as a chronic, manageable and survivable disease . These perceptions may increase sexual risk behaviors among infected and uninfected people. Recent studies suggest that optimism about the new HIV therapies is associated with sexual risk-taking in MSM [58-60]. Moreover, people at risk for infection may increasingly turn to HIV therapy as a perceived prophylaxis after possible sexual exposures to the virus .
Prevention messages for seropositive people and interventions for reducing sexual risk behaviors can be implemented in public clinic settings and managed care facilities. The HIV outpatient clinic is an ideal, yet underused, setting for delivering prevention messages and addressing individual behavior change. The setting provides an opportunity to reach a large number of seropositive people, to integrate behavioral intervention into routine medical care, to provide ongoing counseling and support, and to involve clinic staff (e.g., nurses, physicians, social workers) in prevention activities. Sexually transmitted disease (STD) and tuberculosis clinics afford the same opportunities. Recently published findings are encouraging. HIV-positive patients who reported that clinic staff had discussed the issue of disclosure with them were more likely than other HIV patients to have informed uninfected sex partners of their risk . These intervention opportunities hinge on seropositive people‚s access to care and on the capacity and ability of health-care workers to provide such messages.
Clinics provide an environment for developing and reinforcing attitudinal and behavioral norms for safer sex. The use of peer leaders in gay bars has promoted shifts in sexual attitudes and behaviors [62-64]. Safer sex norms can be promoted in clinics through visual cues (posters in waiting rooms and medical examining rooms), printed information, communication from providers, and a more open discussion with patients about disclosure and sexual risk. Complementary approaches can be instituted at community-based organizations (e.g., AIDS service organizations).
Finally, client-centered approaches to counseling also show much promise. Brief client-centered counseling has reduced the risk for new infections in people attending STD clinics  and may be effective in HIV clinics as well. The counseling involves working with patients to establish achievable steps they can take to reduce their risk behavior. Social workers, nurses, and physicians can easily conduct this type of intervention after proper training. At the very least, health-care providers must be able to recognize the need for, and believe in the value of, behavioral intervention and appropriate referrals.
Social aspects of individual choice
So far we have focused on some of the ways in which seropositive persons may cope with their infection. This focus posits the HIV-seropositive diagnosis as a profound event in a person‚s life. Learning one‚s seropositive status no doubt has powerful psychological and behavioral consequences. However, no matter how well we understand a person‚s cognitive and affective processes, the effectiveness of individual-level interventions is limited by the social forces impinging on a person.
The environmental factors that encourage sexual risk-taking remain largely unchanged for infected people and may foster unsafe sex after the seropositive diagnosis. This is a familiar problem in public health: interventions aimed at using diagnostic information to influence an individual‚s behavior have the advantages of salience and motivation but often call upon the individual to make changes in behavior that may be inappropriate to and unsupported in his or her social setting . Rotello, in his account of gay sexual ecology, argued just this point . He described how communities exhibit a powerful system of social rewards for practicing risky sex and having multiple partners, despite strong efforts by some within those communities to encourage risk reduction. The same may be said for heterosexuals infected with HIV. Their decisions about using condoms, about substance use, and about the responsibility of partners to each other are heavily mediated by complicated community norms . We know even less about this sexual ecology than we do about the ecology of gay men [69,70].
Gay and heterosexual communities are nested within the larger society. Their norms of sex and partnering reflect the culture as a whole and the social policies that sustain it . To point to the protective value of long-term stable relationships is to highlight the fact that American social policy has prevented such relationships among gay men. Gay sexual behavior has been shaped by social hostility toward homosexuality and by the use of law and other forms of social control to express that hostility . Gay men can still be prosecuted in some states for having sex and, in all but 10 states and the District of Columbia, a person living openly in a gay relationship has no protection from discrimination [73,74]. The stigma of homosexuality has been linked to risky behavior [75,76]. Acculturation into the gay community may reduce risky sex , but stigma and social hostility keep many MSM closeted and cut off from social support networks.
Social attitudes toward and policies concerning homosexuality have also influenced gay sexual behavior by omission. A huge array of legal rules and social practices provide incentives to most heterosexuals to form relationships that are intended to be permanent and monogamous. Through the civil status of marriage, heterosexual couples acquire tangible economic benefits ranging from favorable rules of property ownership and inheritance, to insurance benefits, to parental rights. Virtually all of these are denied to gay men and lesbians .
Heterosexual behavior is also influenced by social attitudes and policies. Heterosexuals with HIV infection tend to be poor and are disproportionately members of minority groups . In these communities, a complex set of economic and social policies may discourage marriage and endanger stable family groups [79,80]. Not the least of these are law enforcement policies that incarcerate poor black men at a staggering rate , shrinking the pool of available partners for women in communities at risk . The epidemic among heterosexuals has also been shaped powerfully by policies creating a shortage of safe injection equipment  and more broadly by a preference for interdiction and imprisonment over treatment for the nation‚s drug abuse problem [84,85]. Furthermore, the absence of a strong campaign to promote a norm of condom use [86,87] in the face of evidence that condom use protects men and women from HIV infection is yet another instance of the public health effect of society‚s difficulty addressing issues of sexuality . In broadest perspective, gender, poverty, race, and homophobia represent ‚fundamental social causes of disease‚, which should be recognized and addressed in public health work .
Taking collective responsibility for HIV prevention
The concept of collective responsibility emphasizes that all of us, infected or not, low risk or high, bear a responsibility to change our attitudes and behaviors that may promote HIV infection. Without this balance, calls for personal responsibility become almost indistinguishable from that of blaming the victim and are likely to be counterproductive to prevention efforts. Thus, it is important to distinguish between two general HIV prevention strategies: (i) individual strategies that support infected persons coping with their disease and social circumstances, and (ii) ecological or population strategies that try to modify the group norms, social practices, and laws that influence a person‚s attitudes and behaviors [66,71,90,91]. These strategies are complementary, in that changes in individuals contribute to changes in populations and vice versa. Furthermore, each approach provides useful insights to the other . They are distinct, however, in their primary focus (individual versus population) and in the sort of social science theory they rely upon.
Individual approaches to HIV prevention have become steadily better at identifying the social forces that beset people with HIV infection and helping them reduce risk behaviors in spite of those forces . Tools such as social cognitive theory  and the theory of planned behavior  can effectively model how people respond to social stimuli, and have made a tremendous contribution to HIV prevention. In these models, however, social and community factors (e.g., norms, economic conditions, laws) are seen as inputs in the cognitive processes of individuals . These theories do not undertake to explain the nature and development of social factors themselves. For that we need to look to a different body of social science work [71,90].
Ecological strategies address the social conditions in which individuals make their choices. Research and intervention at the population level complement individual strategies, both by improving the conditions with which individuals must cope and by equipping behavioral strategies with sophisticated accounts of the social forces affecting individuals. Ecological interventions seek to change structural factors inhibiting health, such as laws, public policies and institutional practices [96,97]. They also address less tangible but equally powerful cultural factors (norms, attitudes, values) through ‚the regulation of social meaning‚ [98,99], the use of law, social marketing and other tools of state power to change how people think. Thus, for example, a law protecting gay people from discrimination not only changes the structure of legal rights and protections in a community, but also expresses the idea that discrimination based on sexual orientation is ‚bad‚.
Of course, the importance of social factors in health is frequently noted [96,100]. Prevention research and programs that focus on altering community norms and practices cover a range of health threats, including smoking , diet , binge drinking , and lack of sunscreen use . We see similar approaches in HIV control , including the Community Demonstration Projects  sponsored by the US Centers for Disease Control and Prevention, efforts to change norms of sexual behavior in gay bars [62-64], and the Thai condom campaign . However, integrating interventions and research aimed at community and particularly social-level change into HIV prevention continues to be difficult and continues to happen all too rarely . The problem for prevention professionals lies not in recognizing in a general way that social conditions heavily influence health and behavior, although this claim can be politically controversial , but in finding ways to directly intervene at the population level in ways that are both effective and acceptable. Preventing HIV transmission by people who are infected is an important occasion for addressing this problem.
The conditions that impede wider use of population strategies are widely recognized. Those strategies frequently bring to the forefront deeply rooted social disputes over matters such as sexuality, drug use, race and poverty [88,109]. Attempts to change the social meaning of unhealthy behavior (i.e., making smoking seem ‚uncool‚, or condom use more ‚cool‚) are often perceived as paternalism or a government endorsement of deviance [99,110]. Furthermore, it is extremely difficult to study ‚meaning‚ as it emerges from and feeds back into the dynamics of social interaction . Given these complications, ecological strategies can easily seem to falter before the key public health question of whether they will be effective in preventing HIV given the resources available.
Although they are useful to think about, none of these objections is sufficient to overcome the factors militating towards a more widespread and effective deployment of ecological strategies to prevent HIV infection. It must be recognized that individuals and groups influence the environment all the time. Government, the private sector, and communities have created the conditions that have facilitated the spread of HIV infection. Moreover, deliberate efforts to change the ecology of HIV transmission have been part of the campaign against HIV from early in the epidemic. Closing or regulating bathhouses was intended to change the environment fostering unsafe sex and HIV transmission, and at least some of the controversy it occasioned was perceived as expressing collective disapproval of homosexuality . In some instances, state governments have used their power to try to regulate the social meaning of HIV-related behavior. For example, they have tried to encourage people to get tested for HIV by establishing privacy and anti-discrimination laws that attempt to protect people who test HIV-positive . Communities have tried to disassociate condom use from either the confession or accusation of an STD by propagating what has been called the ‚code of the condom‚ . Communities have also tried to reduce the political opposition to increasing the supply of sterile injection equipment by transforming needle exchange from paraphernalia delivery to harm reduction. Criminal transmission statutes have been enacted that supposedly ‚send a message‚ that unsafe sex is wrong. Some of the efforts, such as criminalizing sexual behavior, are bad ideas , but even the good ones have probably been pursued with less rigor than is possible. One of us (S.B.) has argued, for example, that the effort to use privacy and anti-discrimination law to reduce the social risks of HIV testing has not been sufficiently supported by research on the social concerns that deter testing and how law can be used to address those concerns . Clearly, the question is not whether to deploy interventions that aim directly at changing structural and cultural factors promoting HIV, but how to do so effectively.
In our view, the status of ecological approaches to preventing HIV infection today is analogous to the status of behavioral approaches a decade ago. There is a well-developed and diverse literature on structural causes of disease , on social epidemiology [116,117], on the social construction of disease and health [88,100], and on ways in which social norms, practices and conditions emerge to shape the individual and society [90,118]. Ecological strategies have been applied in public health generally and in HIV, but not systematically and not within a well-supported, deliberate effort to put theory to immediate public health use. Such a project would, amongst other things, study how interventions aimed at changing the social meaning of behavior have worked in other health campaigns, such as those against smoking or drunken driving, as well as major social changes such as the effort to eliminate racial discrimination. It would build stronger collaborative links on at least two axes: (i) within the research community, between people in different disciplines that focus on different levels of analysis; and (ii) between researchers and ‚consumers‚ of research (policymakers, advocates, communities) to ensure that the things consumers know and are concerned about appropriately influences research. It would examine and find ways to support health-promoting leaders and institutions in communities at risk. It would take as a major task enhancing public health‚s capacity to practically foster structural and cultural changes through law, policy and social marketing. Better methods could go a long way towards eliminating what might be referred to as the ‚social nihilism‚ that regards any effort to deliberately address community and social factors as hopelessly impractical.
Table 2 presents a number of individual and population-level measures that can plausibly be predicted to help prevent HIV transmission. We cannot prove that they will do so, nor do we mean to imply that changing the social ecology is simple or even fully within our capacity to accomplish. On the contrary, the problem posed for public health by ecological interventions is the necessity of acting without having full information. Public health as a scientific discipline requires the use of theory and research methodologies to constantly assess our premises. Public health as a source of leadership in social change requires us to bring that technical expertise and analytic rigor to bear on decisions that cannot await better data, and so ultimately depend upon intuition and political compromise .
People who have HIV infection bear both a practical and an ethical responsibility to help control the spread of HIV through their sexual behavior. Behavioral interventions are making a significant contribution to lasting behavior change among people with HIV, and may be enhanced with the integration of messages of personal responsibility. However, this personal responsibility is inseparable from the collective responsibility to create the conditions in which both seropositive and seronegative people can make healthy choices. Fulfilling this collective responsibility for individual health depends in part on material factors such as full access to high-quality health care. It depends on changes to environmental and policy conditions such as lack of access to safe injection equipment, insufficient availability of drug abuse treatment, and legal barriers to stable emotional relationships. Fulfilling society‚s responsibilities will also require changes in what all of us do: both the uninfected and the infected must model and support each other in safer behavior. Among researchers and policymakers, a major, concerted effort to develop a better understanding of social forces is necessary to develop interventions that will address HIV at the individual, social, and community levels in a way that is both effective and acceptable.
1. Sweeny PA, Fleming PL, Karon JM, Ward JW: A minimum estimate of the number of living HIV
infected persons confidentially tested in the United States. 37th Interscience Conference on Antimicrobial Agents and Chemotherapy.
Toronto, September-October 1997 [abstract I-16].
2. Hammer SM, Katzenstein DA, Hughes MD, et al.
: A trial comparing nucleoside monotherapy with combination therapy in HIV
-infected adults with CD4 cell counts from 200 to 500 per cubic millimeter. N Engl J Med
3. Hammer SM, Squires KE, Hughes MD, et al.
: A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. N Engl J Med
4. Gulick RM, Mellors JW, Havlir D, et al.
: Treatment with indinavir, zidovudine and lamivudine in adults with human immunodeficiency virus infection and prior antiretroviral therapy. N Engl J Med
5. Hogg RS, Heath KV, Yip B, et al.
: Improved survival among HIV
-infected individuals following initiation of antiretroviral therapy. JAMA
6. Centers for Disease Control and Prevention: HIV Counseling, Testing, and Referral Standards and Guidelines.
Atlanta: US Department of Health and Human Services; May 1994.
7. Valdiserri RO, Weber JT, Frey R: Trends in HIV
seropositivity in publicly funded HIV
counseling and testing programs: implications for prevention policy. Am J Prev Med
8. Danziger R: An epidemic like any other? Rights and responsibilities in HIV
9. Bayer R: AIDS
prevention: sexual ethics and responsibility
. N Engl J Med
10. Kilmarx PH, Hamers FF, Peterman TA: Living with HIV
: experiences and perspectives of HIV
-infected sexually transmitted disease clinic patients after posttest counseling. Sex Transm Dis
11. Kline A, VanLandingham M: HIV
-infected women and sexual risk reduction: the relevance of existing models of behavior change. AIDS Educ Prev
12. Perry SW, Card CAL, Moffatt M, Ashman T, Fishman B, Jacobsberg LB: Self-disclosure of HIV
infection to sexual partners after repeated counseling. AIDS Educ Prev
13. Wenger NS, Kusseling FS, Beck K, Shapiro MF: Sexual behavior of individuals infected with the human immunodeficiency virus. Arch Intern Med
14. Wiktor SZ, Biggar RJ, Melbye M, et al.
: Effect of knowledge of human immunodeficiency virus infection status on sexual activity among homosexual men. J Acquir Immune Defic Syndr
15. Thompson SC, Nanni C, Levine A: The stressors and stress of being HIV
-positive. AIDS Care
16. Marks G, Richardson JL, Maldonado N: Self-disclosure of HIV
infection to sexual partners. Am J Public Health
17. Stein MD, Freedberg A, Sullivan LM, et al.
: Sexual ethics: disclosure of HIV
-positive status to partners. Arch Intern Med
18. Simoni JM, Mason HRC, Marks G, Ruiz MS, Richardson JL: Women living with HIV
: sexual behaviors and counseling experiences. Women Health
19. Marks G, Ruiz MS, Richardson JL, et al
.: Anal intercourse and disclosure of HIV
infection among seropositive gay and bisexual men. J Acquir Immune Defic Syndr
20. DeRosa CJ, Marks G: Preventive counseling of HIV
-positive men and self-disclosure of serostatus to sex partners: new opportunities for prevention. Health Psychol
21. Schnell DJ, Higgins DL, Wilson RM, Goldbaum G, Cohn DL, Wolitski RJ: Men‚s disclosure of HIV
test results to male primary sex partners. Am J Public Health
22. Marks G, Bundek NI, Richardson JL, Ruiz MS, Maldonado N, Mason HRC: Self-disclosure of HIV
infection: preliminary results from a sample of Hispanic men. Health Psychol
23. Hays RB, McKusick L, Pollack L, Hilliard R, Hoff C, Coates TJ: Disclosing HIV
seropositivity to significant others. AIDS
24. Mason HRC, Marks G, Simoni JM, Richardson JL: Culturally sanctioned secrets? Latino men‚s nondisclosure of HIV
infection to family, friends, and lovers. Health Psychol
25. Simoni JM, Mason HRC, Marks G, Ruiz MS, Reed D, Richardson JL: Women‚s self-disclosure of HIV
infection: rates, reasons, and reactions. J Consult Clin Psychol
26. Stempel RR, Moulton JM, Moss AR: Self-disclosure of HIV
-1 antibody test results: the San Francisco general hospital cohort. AIDS Educ Prev
27. McCusker J, Stoddard AM, Mayer KH, Zapka J, Morrison C, Saltzman SP: Effects of HIV
antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men. Am J Public Health
28. Cleary PD, Van Devanter N, Rogers TF, et al
.: Behavior changes after notification of HIV
infection. Am J Public Health
29. Zenilman JM, Erickson B, Fox R, Reichart CA, Hook EW: Effect of HIV
posttest counseling on STD incidence. JAMA
30. Otten MW, Zaidi AA, Wroten JE, Witte JJ, Peterman TA: Changes in sexually transmitted disease rates after HIV
testing and posttest counseling, Miami, 1988 to 1989. Am J Public Health
31. Hays RB, Paul J, Ekstrand M, Kegeles SM, Stall R, Coates TJ: Actual versus perceived HIV
status, sexual behaviors and predictors of unprotected sex among young gay and bisexual men who identify as HIV
-positive and untested. AIDS
32. Van de Ven P, Campbell D, Kippax S, et al.
: Factors associated with unprotected anal intercourse in gay men‚s casual partnerships in Sydney, Australia. AIDS Care
33. Hoff CC, Stall R, Paul J: Differences in sexual behavior among HIV
discordant and concordant gay men in primary relationships. J Acquir Immune Defic Syndr Hum Retrovirol
34. Kalichman SC, Kelly JA, Rompa D: Continued high-risk sex among HIV
seropositive gay and bisexual men seeking HIV
prevention services. Health Psychol
35. Kalichman SC, Greenberg J, Abel GG: HIV
-seropositive men who engage in high-risk sexual behaviour: psychological characteristics and implications for prevention. AIDS Care
36. Wolitski RJ, Gomez C, Parsons J, Ambrose T, Remien R: HIV
-seropositive men‚s perceived responsibility
for preventing the transmission of HIV
to others. 12th World AIDS Conference.
Geneva, June 1998 [abstract 23361].
37. Posner SJ, Marks G: Prevalence of high-risk sex among HIV
-positive gay and bisexual men: a longitudinal analysis. Am J Prev Med
38. Marks G, Cantero PJ, Simoni JM: Is acculturation associated with sexual risk behaviors? An investigation of HIV
-positive Latino men and women. AIDS Care
39. Marks G, Bingman CR, Duval TS: Negative effect and unsafe sex in HIV
-positive men. AIDS Behav
40. Remien RH, Carballo-Dieguez, Wagner G: Intimacy and sexual risk behaviour in serodiscordant male couples. AIDS Care
41. McKirnan DJ, Ostrow DG, Hope B: Sex, drugs, and escape: a psychological model of HIV
-risk behaviours. AIDS Care
42. Bond MJ, Feather NT: Some correlates of structure and purpose in the use of time. J Pers Soc Psychol
43. Perkins DO, Leserman J, Murphy C, Evans DL: Psychosocial predictors of high-risk sexual behavior among HIV
-negative homosexual men. AIDS Educ Prev
44. Leary MR, Schreindorfer LS, Haupt AL: The role of low self-esteem in emotional and behavioral problems: why is low self-esteem dysfunctional? J Soc Clin Psychol
45. Living with HIV: Positively Sexual.
Columbus, Ohio: Columbus Health Department AIDS
46. HIV Positive Handbook
. Seattle: Seattle-King County Department of Public Health.
47. HIV: What If I‚m Positive?
Santa Cruz, California: ETR Associates.
48. Phair J, Jacobson L, Detels R, et al.
: Acquired immune deficiency syndrome occurring within 5 years of infection with human immunodeficiency virus type-1: The Multicenter AIDS
Cohort Study. J Acquir Immune Defic Syndr
49. Wiley DJ, Visscher B, Detels R, Murphy R: Gonorrhea and syphilis infection as risk factors for short-term rapid CD4+ decline in a cohort of HIV
-infected men who have sex with men. First National Conference on Human Retroviruses and Related Infections.
Washington, DC, December 1993.
50. Balzquez MV, Madueno JA, Jurado R, Fernandez-Arcas N, Munoz E: Human herpesvirus-6 and the course of human immunodeficiency virus infection. J Acquir Immune Defic Syndr Hum Retrovirol
51. Knox KK, Carrigan DR: Active human herpesvirus (HHV-6) infection of the central nervous system in patients with AIDS
. J Acquir Immune Defic Syndr Hum Retrovirol
52. Gao SJ, Kingsley L, Hoover DR, et al.
: Seroconversion to antibodies against Kaposi‚s sarcoma-associated herpesvirus-related latent nuclear antigens before the development of Kaposi‚s sarcoma. N Engl J Med
53. Wasserheit JN: Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis
54. Cohen MS, Hoffman IF, Royce RA, et al.
: Reduction of concentration of HIV
-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV
55. Musicco M, Lazzarin A, Nicolosi A, et al.
: Antiretroviral treatment of men infected with human immunodeficiency virus type 1 reduces the incidence of heterosexual transmission: Italian Study Group on HIV
Heterosexual Transmission. Arch Intern Med
56. Royce RA, Sena A, Cates W, Cohen MS: Sexual transmission of HIV
. N Engl J Med
57. Ragni MV, Faruki H, Kingsley LA: Heterosexual HIV
-1 transmission and viral load in hemophilic patients. J Acquir Immune Defic Syndr Hum Retrovirol
58. Kelly JA, Hoffmann RG, Rompa D, Gray M: Protease inhibitor combination therapies and perceptions of gay men regarding AIDS
severity and the need to maintain safer sex. AIDS
59. Murphy S, Miller L, Appleby PR, Marks G, Mansergh G: Antiretroviral drugs and sexual behavior in gay and bisexual men: when optimism enhances risk. 12th World AIDS Conference.
Geneva, June 1998 [abstract 14137].
60. Kalichman SC, Tannenbaum L, Nachimson D: Post-exposure prophylaxis for HIV
infection in gay and bisexual men: implications for the future of HIV
prevention. Am J Prev Med
61. Katz MH, Gergerding JL: Postexposure treatment of people exposed to the human immunodeficiency virus through sexual contact or injection-drug use. N Engl J Med
62. Kelly JA, St Lawrence JS, Diaz YE, et al.
risk behavior reduction following intervention by key opinion leaders of a population: an experimental analysis. Am J Public Health
63. Kelly JA, St Lawrence JS, Stevenson LY, Hauth AC: Community AIDS
risk reduction: the effects of endorsements by popular people in three cities. Am J Public Health
64. Kelly JA, Murphy DA, Sikkema KJ, et al.
: Randomised, controlled, community-level HIV
-prevention intervention for sexual-risk behaviour among homosexual men in US cities. Lancet
65. Kamb ML, Fishbein M,Douglas JM, et al.
: Efficacy of risk-reduction counseling to prevent human immuno-deficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA
66. Rose G: Sick individuals and sick populations. Int J Epidemiol
67. Rotello G: Sexual Ecology: AIDS and The Destiny of Gay Men.
New York: Dutton; 1997.
68. Muller RB, Boyle JS: ‚You don‚t ask for trouble‚: women who do sex and drugs, attitudes toward HIV
infection. Fam Community Health
69. Wortley PM, Fleming PL: AIDS
in women in the United States: recent trends. JAMA
70. Lehner T, Chiasson MA: Seroprevalence of human immunodeficiency virus type 1 and sexual behaviors in bisexual African-American and Hispanic men visiting a sexually transmitted disease clinic in New York City. Am J Epidemiol
71. Waterston A: Anthropological research and the politics of HIV
prevention: towards a critique of policy and priorities in the age of AIDS
. Soc Sci Med
72. Chauncey G: Gay New York: Gender, Urban Culture and the Making of the Gay Male World, 1890-1940.
New York: Basic Books; 1994.
73. Eskridge W Jr: Privacy jurisprudence and the apartheid of the closet, 1946-1961. Florida State University Law Rev
74. Eskridge W Jr: Challenging the apartheid of the closet: establishing conditions for lesbian and gay intimacy, nomos, and citizenship, 1961-1981. Hofstra Law Rev
75. Herek GM: Illness, stigma and AIDS
. In Psychological Aspects of Serious Illness: Chronic Conditions, Fatal Diseases and Clinical Care
. Edited by Herek GM, Levy SM, Maddi SR, Taylor SE, Wertlieb DL. Washington, DC: American Psychological Association; 1990:107-149.
76. Rotheram-Borus MJ, Rosario M, Reid H, Koopman C: Predicting patterns of sexual acts among homosexual and bisexual youths. Am J Psychiatry
77. Seibt AC, Ross MW, Freeman A, et al
.: Relationship between safe sex and acculturation into the gay culture. AIDS Care
1995, 7 (suppl 1):85-88.
78. Burris S: Gay marriage as a public health issue. Temple Political Civil Rights Law Rev
79. Handler JF: Women, families, work, and poverty: a cloudy future. UCLA Women‚s Law J
80. Wallace R, Fullilove MT, Flisher AJ: AIDS
, violence and behavioral coding: information theory, risk behavior and dynamic process on core-group sociogeographic networks. Soc Sci Med
81. Miller JG: Search and Destroy: African-American Males in the Criminal Justice System.
New York: Cambridge University Press; 1996.
82. Wilson WJ: The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy
. Chicago: University of Chicago Press; 1987.
83. Gostin L, Lazzarini Z: Prevention of HIV
among injection drug users: the theory and science of public health and criminal justice approaches to disease prevention. Emory Law J
84. Gilmore N: Drug use and human rights: privacy, vulnerability, disability, and human rights infringements. J Contemp Health Law Policy
85. Gostin L: Drug dependency and HIV
. In AIDS Law Today
. Edited by Burris S, Dalton H, Miller J. New Haven: Yale University Press; 1993:150-176.
86. Stein ZA: Editorial: more on women and the prevention of HIV
infection. Am J Public Health
87. Cohen DA, Farley TA, Bugg S: Why the US needs a national policy on condoms. AIDS Policy Law
88. Brandt AM: No Magic Bullet: A Social History of Venereal Disease in the United States since 1880.
New York: Oxford University Press; 1987.
89. Link B, Phelan MJ: Social conditions as fundamental causes of disease. J Health Soc Behav
1995, Special issue:80-94.
90. Bourdieu P: Outline of a Theory of Practice.
Cambridge: Cambridge University Press; 1990.
91. Aral SO, Holmes KK, Padian NS, Cates W Jr: Individual and population approaches to the epidemiology and prevention of sexually transmitted diseases and human immunodeficiency virus infection. J Infect Dis
1996, 174 (suppl 2):S127-S133.
92. Susser M, Susser E: Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology. Am J Public Health
93. Fishbein M, Guinan M: Behavioral science and public health: a necessary partnership for HIV
prevention. Public Health Rep
1996, 111 (suppl 1):5-10.
94. Bandura A: Social Foundations of Thought and Action: A Social Cognitive Theory
. Englewood Cliffs, NJ: Prentice Hall; 1986.
95. Ajzen I: From intentions to actions: a theory of planned behavior. In Action-Control: From Cognition to Behavior
. Edited by Kuhl J, Beckmann J. Heidelberg: Springer; 1985.
96. Heimer R, Bluthenthal RN, Singer M, Kroshmood K: Structural impediments to occupational syringe-exchange programs. AIDS Public Policy J
97. Turshen M: The Politics of Public Health
. New Brunswick: Rutgers University Press; 1989.
98. Lessig L: The regulation of social meaning. University Chicago Law Rev
99. Sunstein CR: Social norms and social roles. Columbia Law Rev
100. Fee E, Krieger N: Thinking and rethinking AIDS
: implications for health policy. Int J Health Policy
101. Kagan RA, Skolnick JA: Banning smoking: compliance without enforcement. In Smoking Policy: Law, Politics, and Culture
. Edited by Rabin RL, Sugarman SD. New York: Oxford University Press; 1993:69-91.
102. Schmid TL, Pratt M, Howze E: Policy as intervention: environmental and policy approaches to the prevention of cardiovascular disease. Am J Public Health
103. Haines M, Spear SF: Changing the perception of the norm: a strategy to decrease binge drinking among college students. J Am Coll Health
104. Boutwell WB: The Under Cover Skin Cancer Prevention Project. A community-based program in four Texas cities. Cancer
1995, 75 (suppl 2):657-660.
105. Person B, Cotton D: A model of community mobilization for the prevention of HIV
in women and infants. Public Health Rep
1996, 111 (suppl 1):89-98.
106. Leviton LC, O‚Reilly K: Adaptation of behavioral theory to CDC‚s HIV
prevention research: experience at the Centers for Disease Control and Prevention. Public Health Rep
1996, 111 (suppl 1):11-17.
107. Nelson KE, Celentano DD, Eiumtrakol S, et al
: Changes in sexual behavior and a decline in HIV
infection among young men in Thailand. N Engl J Med
108. Burris S: The invisibility of public health: population-level measures in a politics of market individualism. Am J Public Health
109. Powell JH: Bring Out Your Dead: The Great Plague of Yellow Fever in Philadelphia in 1793.
Philadelphia: University of Pennsylvania Press; 1949.
110. Gostin LO, Burris S, Lazzarini Z: The law and the public‚s health: a study of infectious disease law in the United States. Columbia Law Rev
1999 (in press).
111. Bruner J: Acts of Meaning
. Cambridge, MA: Harvard University Press; 1990.
112. Bayer R: Private Acts, Social Consequences: AIDS and the Politics of Public Health
. New York: The Free Press; 1989.
113. Burris S: Driving the epidemic underground? A new look at law and the social risk of HIV
testing. AIDS Public Policy J
114. Chambers DL: Gay men, AIDS
and the codes of the condom. Harvard Civil Rights Civil Liberties Law Rev
115. Dalton HL: Criminal law. In AIDS Law Today
. Edited by Burris S, Dalton HL, Miller J. New Haven: Yale University Press; 1993:242-260.
116. Pierce N: Traditional epidemiology, modern epidemiology, and public health. Am J Public Health
117. Susser M, Susser E: Choosing a future for epidemiology: I. Eras and paradigms. Am J Public Health
118. Geertz C: The Interpretation of Cultures
. New York: Basic Books; 1973.
119. Institute of Medicine, National Academy of Sciences: The Future of Public Health
. Washington, DC: National Academy Press; 1988.