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This electronic representation of RAND intellectual property is provided for non-commercial use only. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. RESEARCH AND PRACTICE Sex Without Disclosure of Positive HIV Serostatus in a US Probability Sample of Persons Receiving Medical Care for HIV Infection | Daniel H. Ciccarone, MD, MPH, David E. Kanouse, PhD, Rebecca L. Collins, PhD, Angela Miu, MS, James L. Chen, MPH, Sally C. Morton, PhD, and Ron Stall, PhD It is difficult to identify a more charged Objectives. We estimated the proportion of HIV-positive adults who have any sexual issue in AIDS prevention than that of contact without disclosure and the proportion of their sexual partnerships that involve nondisclosure of positive HIV status to sex- unprotected sex without disclosure. ual partners. Seropositive individuals who Methods. We drew participants from the HIV Cost and Services Utilization Study do not disclose their status to sexual part- (n=1421). Interviews assessed disclosure and sexual activities with up to 5 recent ners are often portrayed as dangerous pari- partners. ahs.1 As of 1999, 31 states had statutes Results. Overall, 42% of the gay or bisexual men, 19% of the heterosexual men, and making sexual contact without disclosure a 17% of all the women reported any sex without disclosure, predominately within nonex- criminal offense.2 Public health researchers, clusive partnerships (P<.001). Across all groups, 13% of serodiscordant partnerships involved unprotected anal or vaginal sex without disclosure, with no significant differ- responding to data reporting sexual contact ence between groups. without disclosure by HIV-positive persons, Conclusions. Risky sex without disclosure of serostatus is not uncommon among have called for interventions to promote in- people with HIV. (Am J Public Health. 2003;93:949–954) creased sexual responsibility and to in- crease rates of consistent safer sex among HIV-positive persons.3,4 als’ behavior varies according to their part- METHODS Public discourse on this topic is heavily ners’ HIV status and condom use. influenced by a few well-publicized cases in We report data from the Risk and Pre- Sample Description which individuals who knew they were HIV vention Study subset of the nationally rep- Respondents were participants in the positive reportedly infected a series of un- resentative probability sample of the HIV HCSUS, a national probability sample of suspecting partners. The public health sig- Cost and Services Utilization Study 2864 persons aged 18 years or older with nificance of nondisclosure, however, de- (HCSUS). We describe (1) the extent to known HIV infection who made at least 1 pends on both its prevalence and the which Americans in treatment for HIV visit to a nonmilitary, nonprison medical riskiness of the behaviors that occur with- have sex without disclosure, (2) the extent provider other than an emergency depart- out disclosure—that is, the extent to which to which this population has unprotected sex ment in the contiguous United States during sex without disclosure is unprotected sex without disclosure, and (3) the extent to the first 2 months of 1996. Full details of the between serodiscordant partners. Previous which unprotected sex without disclosure HCSUS design are available elsewhere.16 ,17 studies show that not disclosing positive occurs within serodiscordant sexual part- The Risk and Prevention Study subset used HIV serostatus to at least some sexual part- nerships. To the best of our knowledge, this for our study consisted of 1421 HCSUS par- ners is common,5–7 that HIV-positive per- is the first study to report data on the ex- ticipants. Eligible members of the HCSUS sons are more likely to disclose their status tent of sex without disclosure from a proba- sample were those who were interviewed in to steady partners than to nonsteady part- bility sample of HIV-positive adults in the English at the HCSUS baseline interview, ners,8–10 and that unprotected sex without United States and the first to provide com- whose sex was unambiguous on the basis of disclosure occurs within both types of part- parative data across risk groups. Because HCSUS data, and who participated in the sec- nerships.5,9 Much of the previous research data were collected on partnerships, we can ond follow-up HCSUS interview, conducted on this topic focused on specific subpopula- examine disclosure at both the dyad and in- from August 1997 through January 1998 tions, such as gay and bisexual men,9,11 dividual levels. We hope that this analysis (n=2205). We drew 1794 individuals from men in general,12 or women.7,13,14 Studies will help inform policy and intervention de- this group, sampling randomly after stratifying that included both sexes or multiple risk bates on the best ways to encourage disclo- by primary HCSUS sampling unit, type of groups8,10,15 generally did not use suffi- sure among HIV-positive persons and safer health care provider, age, ethnicity, and self- ciently large sample sizes to support de- sex practices among the broad range of described sexual orientation. We randomly tailed group comparisons. Nor did previous Americans infected with HIV or at risk of sampled one third of eligible White gay men studies examine whether and how individu- infection. aged 40 years, 44% of eligible White gay June 2003, Vol 93, No. 6 | American Journal of Public Health Ciccarone et al. | Peer Reviewed | Research and Practice | 949 RESEARCH AND PRACTICE men aged 39 years and younger, and 100% of engaging in oral, anal, and vaginal sex; to examine the prevalence of abstinence, sex of all other groups. We conducted interviews consistency of condom use with each activity; only with disclosure, any sex without disclo- from September through December 1998. disclosure; and timing of sexual activity rela- sure, and any unprotected anal or vaginal sex The completion rate was 79%, and the re- tive to disclosure. without disclosure by risk group. To adjust sponse rate after adjustment for known mor- standard errors and statistical tests for the dif- Measures tality was 84%. ferential weighting and complex sample de- Sexually active respondents were those re- The Risk and Prevention Study subsample sign, we used linearization methods18 , 2 0 avail- porting any oral, anal, or vaginal sex in the was weighted to represent a target population able in the statistical package Stata (Stata preceding 6 months; all others were consid- of 197063 HIV-positive adults receiving Corp, College Station, Tex). ered abstinent. Aggregating across partners, medical care in the 48 contiguous states of Analyses at the partnership level focused we classified each active respondent into 1 of the United States in 1996 and surviving until on 1273 serodiscordant partnerships, exam- 2 mutually exclusive categories reflecting be- 19 9 8. The analytic weights take into account ining the prevalence of unprotected anal havior in the past 6 months: (1) had sex only differential selection probabilities, nonre- and vaginal sex within these partnerships. after disclosure, and (2) had any sex without sponse, multiplicity, and attrition.18 Men who Results for the multiple partners of a re- disclosure. Respondents who refused to an- identified themselves as “gay,” “bisexual,” or spondent might be correlated. In a sensitiv- swer whether there had been any sex before “heterosexual” and all women were included ity analysis, we adjusted for this design ef- disclosure were classified as missing data in the analysis reported in this article. Men fect by treating each individual and his or (n=7); those who said they didn’t know or who specified “other” or who did not report her associated partners as a primary sam- who were otherwise missing data were their sexual orientation were excluded pling unit and by using the same analytic treated as having had sex only after disclo- (n=24). Tables show proportions weighted to weights. Because the sensitivity analysis sure (n=45). represent the population, as well as un- yielded the same conclusions as our original Within partnerships, we first combined weighted sample sizes. analysis, which did not account for the cor- the “sex without disclosure” variable with relation among partners, and because the consistency of condom use (“always” vs any Survey Instrument and Procedures sensitivity analysis reduced our statistical other response) for anal and for vaginal sex The Risk and Prevention Study covered power owing to the design effect, we pres- and then aggregated across partners to cre- sexual activities, attitudes, and beliefs