Health care policy. U.S. priorities-HIV prevention.

One of the scientific anomalies of the AIDS epidemic is the large difference in infection rates across populations. Given limited resources and segregated epidemics, prevention funding should be directed to population segments with high HIV prevalence and incidence. However, recent surveys of U.S. populations indicate that the allocation of prevention dollars is not consistent with the distribution of HIV in the population.

Obtaining HIV test results with a home collection test kit in a community telephone sample.

OBJECTIVES: To test the feasibility of obtaining HIV test results by home collection kit from a probability telephone sample of men who have sex with men (MSM). METHODS: A quota sample of 615 MSM previously interviewed by the Urban Men's Health Study phone survey in Chicago, Los Angeles, New York City, and San Francisco were re-contacted and offered an HIV test using an oral specimen (Orasure) home collection kit. RESULTS: Eighty percent consented to be mailed a kit, and 84% returned a specimen, for a 67% participation rate. All self-reported HIV-positive persons tested positive (77 of 77); 4 of 266 (1.5%) with a prior negative test and 2 of 69 (2.9%) with no prior positive HIV test result. Participation was associated with self-reported prior HIV test status-HIV-positive (83%), HIV-negative (68%), or no prior HIV test result (54%)-and marginally associated with New York City residence after adjustment for HIV status (odds ratio = 0.7; 95% confidence interval, 0.4-1.1; p =.08). CONCLUSIONS: These results suggest that urban MSM identified and interviewed by telephone will participate in home collection HIV testing. This methodology could be used to produce population-based estimates of HIV seroprevalence and seroincidence in MSM and could probably be extended to other populations and other viral infections.

Health-related characteristics of men who have sex with men: a comparison of those living in "gay ghettos" with those living elsewhere.

OBJECTIVES: This study investigated the limitations of probability samples of men who have sex with men (MSM), limited to single cities and to the areas of highest concentrations of MSM ("gay ghettos"). METHODS: A probability sample of 2881 MSM in 4 American cities completed interviews by telephone. RESULTS: MSM who resided in ghettos differed from other MSM, although in different ways in each city. Non-ghetto-dwelling MSM were less involved in the gay and lesbian community. They were also less likely to have only male sexual partners, to identify as gay, and to have been tested for HIV. CONCLUSIONS: These differences between MSM who live in gay ghettos and those who live elsewhere have clear implications for HIV prevention efforts and health care planning.

Risk factors for HIV and other sexually transmitted diseases and prevention practices among US heterosexual adults: changes from 1990 to 1992.

OBJECTIVES: The National AIDS Behavioral Survey (1990-1992) of heterosexual adults (18-49 years) measured human immunodeficiency virus (HIV) risk factors, condom use, and HIV antibody testing, with a focus on major "high-risk" cities. METHODS: A longitudinal survey was conducted. RESULTS: There was little reduction in the overall prevalence of HIV risk factors in the national or high-risk cities cohorts over time. Despite this picture of stability, approximately 39% of the population at risk for HIV because of multiple sexual partners turns over annually. There was little change in HIV test-seeking or in consistent condom use with primary sexual partners. Although the majority of at-risk respondents used condoms sporadically or not at all (65%), a significant increase in condom use was found among those reporting multiple sexual partners in both waves, particularly among Black heterosexuals. Data from other surveys and condom sales nationally support the findings. CONCLUSIONS: There is a need for a series of surveys in this area to assess the reliability of the present findings and to monitor the general US population's response to prevention programs.

National trends in condom use among at-risk heterosexuals in the united states.

Based on national level surveys, we examined data relevant to the United States' overall effort to prevent the spread of HIV among heterosexual adults. We examined changes in condom use among at-risk heterosexuals over the past decade. The observed increases over time in condom use across all heterosexual at-risk population segments are consistent with the observed (declines) trends in HIV and syphilis in the 1990s. These results and findings from prior studies suggest that U.S. efforts to facilitate condom use and contain HIV and related sexually transmitted disease (STD)-cofactors among adult at risk heterosexuals was succeeding over most of the 1990s. The absence of national level behavioral trend data after 1996, and the ambiguities of HIV spread suggest some caution in projecting trends into this century. National and local efforts need to be directed at sustaining behavioral change and conducting more rigorous studies on population trends in HIV/STD-related behaviors/pathogens.

The continuing HIV epidemic among men who have sex with men.

OBJECTIVES: This study characterized the AIDS epidemic among urban men who have sex with men (MSM). METHODS: A probability sample of MSM was obtained in 1997 (n = 2881; 18 years and older) from New York, Los Angeles, Chicago, and San Francisco, and HIV status was determined through self-report and biological measures. RESULTS: HIV prevalence was 17% (95% confidence interval = 15%, 19%) overall, with extremely high levels in African Americans (29%), MSM who used injection drugs (40%), "ultraheavy" noninjection drug users (32%), and less educated men (< high school, 37%). City-level HIV differences were non-significant once these other factors were controlled for. In comparing the present findings with historical data based on public records and modeling, HIV prevalence appears to have declined as a result of high mortality (69%) and stable, but high, incidence rates (1%-2%). CONCLUSIONS: Although the findings suggest that HIV prevalence has declined significantly from the mid-1980s, current levels among urban MSM in the United States approximate those of sub-Saharan countries (e.g., 14%-25%) and are extremely high in many population subsegments. Despite years of progress, the AIDS epidemic continues unabated among subsegments of the MSM community.