Copyright 1990 by the American Psychological Association, Inc.

0022-006X/90/M0.75

Journal of Consulting and Clinical Psychology

1990, Vol. 58, No. 1, 117-120

BRIEF REPORTS

Psychological Factors That Predict AIDS High-Risk

Versus AIDS Precautionary Behavior
Jeffrey A. Kelly, Janet S. St. Lawrence, and Ted L. Brasfield
University of Mississippi Medical Center

Audie Lemke, Terry Amidei, and Roger E. Roffman,

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

University of Washington

Joseph E. Srnith

Harold V. Hood
Florida Department of Health and Rehabilitative Services
Tampa, Florida

University of Mississippi
Medical Center

Hilda Kilgore

Chip McNeill, Jr.

American Red Cross
Mobile, Alabama, Chapter

Tampa AIDS Network

Tampa, Florida

Men (W = 526) who patronized gay bars in three cities completed measures of sexual behavior
covering the previous 3 months and psychological measures theoretically pertinent to AIDS risk.
Thirty-seven percent of the sample reported engaging in unprotected anal intercourse, the behavior
most strongly associated with transmission of human immunodeficiency virus (HIV) infection. Perceived peer norms concerning the acceptability of safer sex practices, AIDS health locus of control
scores, risk behavior knowledge, age, and accuracy of personal risk estimation, but not personal HIV
serostatus knowledge, were associated with high-risk and precaution-taking behavior.

areas of health behavior promotion research, several psychological dimensions were expected to predict risk behavior patterns.
In relation to persons who have modified risky aspects of their
sexual behavior, those who still engage in high-risk practices
were hypothesized to be less knowledgeable about AIDS; to be
more apt to attribute personal likelihood of HIV infection to
luck, chance, and powerful-other external factors than to internal locus of control; to perceive fewer social norms that encourage safety; and to know fewer people with AIDS. Accuracy of
personal risk estimation was assessed in exploratory fashion,
because previous research has linked risky conduct with underestimation of vulnerability (Joseph et al., 1987). The relation
of HIV serostatus knowledge, age, education, and race to risk
behavior patterns was also examined.

Efforts to limit the spread of human immunodeficiency virus

(HIV) infection, the agent responsible for AIDS, require that
persons make changes in sexual and drug use behaviors that
confer risk. Given the high HIV infection prevalence among gay
men and the efficiency of viral transmission during unprotected
anal intercourse, cessation of this sexual practice is important
in AIDS primary prevention efforts among homosexual men.
Recent surveys show large reductions in high-risk behavior
among gay men in AIDS epicenters such as San Francisco and
New York (Martin, 1987; McKusick et al., 1985), although
some men in these cities continue to engage in risky practices
and a much larger proportion of gay men outside epicenters still
report high-risk behavior (St. Lawrence, Hood, Brasfield, &
Kelly, 1989). There is a need to better identify psychological and
background differences between gay men who have successfully
reduced high-risk patterns and those who have not.
The current study examined relations between the AIDS-risk
sexual practice level of gay men and a number of psychological
and behavioral variables. On the basis of findings from other

Method
Subjects in the study were men who patronized a total of eight gay
bars in three cities (Seattle, Washington; Tampa, Florida; and Mobile,
Alabama) in late 1988. The cities constitute geographically distinct major metropolitan areas with moderate AIDS prevalence representative
of much of the country outside the original AIDS epicenters. In comparison with San Francisco and New York City, which respectively report 104.5 and 65.1 diagnosed AIDS cases per 100,000 population, the
study cities have AIDS incidence rates of 8-23 cases per 100,000 population (United States Public Health Service, 1989). Subjects completed
measures individually, anonymously, and without personal identifiers at
tables near the bar entrance to prevent contamination as a result of
discussion or scale completion by persons who were intoxicated. Sub-

This research was supported by National Institute of Mental Health

Grants l-R01-MH42908and 1-R01-MH41800.
Correspondence concerning this article (and requests for a copy of
the study measures) should be addressed to Jeffrey A. Kelly, Division of
Psychology, Department of Psychiatry and Human Behavior, University
of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.
117

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

118

BRIEF REPORTS

jects were told that the research was intended to study men's health
issues and that the measures required 10 min to complete. Between 75%
and 90% of all male patrons agreed to complete the measures. Of 526
men who began the measures, 45 subjects did not complete the entire
battery. The final sample consisted of 188, 182, and 111 subjects from
Tampa, Seattle, and Mobile, respectively. Subjects' mean age was 31.8
years (SD = 7.9) and education level was 14.9 years (SD = 2.9 years);
91% of the sample were White, 5% were Black, 2% were Hispanic, and
2% were Asian-American or Native-American. (The minority proportion ranged from 5% in Seattle to 14% in Mobile.)
Respondents marked the number of times and the number of different partners for these behaviors over the past 3 months: anal intercourse
without a condom, anal intercourse using a condom, oral-genital sex to
orgasm without a condom, and sexual activities that did not involve
insertion. For each of the first three practices, subjects reported how
often they were the insertive or receptive partner.
Nine items from the Health Locus of Control Scale (HLOC; Wallston, Wallston, & Devillis, 1978) were modified to make them pertinent
to AIDS. These items reflected the three dimensions of the original
measure: internal control (sample item: "If I take the right steps I can
avoid the AIDS virus"), chance/luck external control ("If I get the AIDS
virus, it's a matter of fate"), and powerful-others external control
("Other people play a big part in whether I get the AIDS virus"). Respondents marked items using 5-point Likert scale ratings from strongly
disagree (1) to strongly agree (5).
To assess perceived peer norms concerning the social acceptability of
risk reduction changes, subjects used 5-point Likert scales to indicate
agreement or disagreement with five statements that tap beliefs about
whether peers have adopted AIDS precautionary behavior ("My friends
always use condoms during intercourse," "My friends talk about safer
sex more than they actually practice it") as well as perceived peer attitudes concerning risk precautions ("My friends believe that insisting on
safer sex implies you don't trust your partner").
To assess understanding of risk, a 23-item true/false objective measure of AIDS risk knowledge was used. This measure has been used in
several previous studies and has acceptable psychometric characteristics
(Kelly, St. Lawrence, Hood, & Brasfield, 1989, in press). The measure
taps practical knowledge about high-risk sexual practices, risk reduction steps, and misconceptions about how HIV is transmitted and yields
a single score of items answered correctly.
In addition, subjects estimated their level of risk on a 5-point scale
from no risk (1) to extremely high risk (5) on the basis of behavior over
the past 3 months and indicated the number of friends or acquaintances
known to have AIDS. Personal HIV serostatus knowledge was assessed
by asking whether the respondent had had an HIV antibody test and, if
so, whether the result was positive or negative. Data on age, education
level, and race were also requested.

Results
Eighty percent of respondents reported homosexual activity
within the past 3 months. A preliminary multivariate analysis
of variance (MANOVA) revealed no significant differences between respondents from the three cities on the total set of sexual
practice variables and number of different partners for each
practice, Hotelling's T2(\9,460) = .73, p = .88. Therefore, data
from the three cities were pooled for all subsequent analyses.
Because even low rates of unprotected anal intercourse
strongly predict HIV seroconversion among gay men, a MANOVA compared subjects who reported unprotected anal intercourse with those who reported no occurrences of this practice
on all of the dependent variables. Thirty-seven percent of the
sample reported engaging in unprotected anal intercourse in

Table 1
Means, Standard Deviations, and Analysis of Variance Results
Comparing Men Who Did or Did Not Engage in Unprotected
Anal Intercourse (UAI)

Variable
HLOC score
Internal
Chance
Powerful others
AIDS risk behavior
knowledge score
Peer norms score
Number friends with AIDS
Risk estimate score
Number sexual partners
Age (years)
Education (years)

Men who
engage in
UAI

Men who
do
not engage
in
UAI

SD

SD

13.2

2.3
3.2
3.1

13.6

2.0
2.8
3.1

2.9
3.7
9.2
1.0
6.8
7.2
2.5

21.1
17.0

5.7
6.7
20.4
15.1

5.2
2.3
4.0
32.2
14.7

5.1
6.6

4.2
1.7
1.9
32.8
15.2

2.1
3.7
5.8
.07
3.0
8.2
3.0

F(l,479)
4.81*
3.98*
0.10
9.35**
27.95****
1.97
63.36****
22.89****
12.12***
2.78

Note. HLOC = Health Locus of Control Scale.

*p<.05; **p<.01; ***p<;.001; ****p
p <.0001.

the past 3 months, whereas 63% did not. The MANOVA revealed
significant differences between the two groups, Hotelling's
r2(10, 470) = .25, p < .0001, and was followed by univariate
analyses of variance (ANOVAS) to identify differences for each
variable. As shown in Table 1, men who reported unprotected
anal intercourse obtained higher scores on the HLOC Chance
scale, reflecting belief that likelihood of infection with HIV was
largely a function of luck; scored lower on the HLOC Internal
scale, reflecting less belief that personal control influences
whether one develops HIV infection; scored lower on the AIDSrisk knowledge test; perceived fewer peer supports for lowered
risk conduct; reported having more sexual partners in the previous 3 months; were younger; and correctly estimated their
AIDS risk as higher than did men who did not engage in unprotected anal intercourse. Chi-square analyses revealed no significant differences between subjects who did or did not report
unprotected anal intercourse on the categorical variables of
race or personal serostatus knowledge.
Multiple regression analyses were then used to examine the
relations between the independent variable set and the levels of
risky or safer behavior during the past 3 months. Frequencies
of sexual practices were linearly transformed for the multiple
regression analyses using the formula logioC* + 1) to reduce
skew and preserve assumptions of distribution normality.
Level of risk for AIDS under most circumstances is a function of both how many times an individual engages in a risky
practice and the number of different sexual partners. A highrisk index was computed for each subject by multiplying number of unprotected anal intercourse occasions by number of
different intercourse partners. The nine predictor variables, entered simultaneously, yielded a significant relation with the risk
index, R = A2;R2 = A9;F(9,471)= 12.26, p<. 0001. As Table
2 shows, subjects' estimates of their risk level and number of

119

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

BRIEF REPORTS
friends with AIDS bore a significant and positive relation to
index scores. Perceived peer norms for safer conduct, AIDS
knowledge test scores, and age were significantly and negatively
related to risk index levels. Thus, men at highest risk as a result
of unprotected anal intercourse with multiple partners were less
knowledgeable about AIDS, perceived fewer peer norms favoring lowered risk conduct, were younger, had more friends diagnosed with AIDS, and regarded themselves as being at higher
AIDS risk than did those with lower risk index scores.
A condom-use safety index was then computed to reflect the
proportion of anal intercourse occasions when condoms were
used. The relation of the predictor variable set to this index was
also examined. The overall regression was significant, R = .40;
R2 = .16, F(9, 282) = 5.88, p < .0001. As Table 2 shows, the
proportion of anal intercourse occasions protected by condoms
was predicted by greater perceived peer norms for lower risk
behavior, knowledge about AIDS, correct estimate of risk, and
scoring more internally on the HLOC Internal scale.
Table 3 presents a cross tabulation of those who did or did
not report unprotected anal intercourse with the risk estimate
respondents assigned to their own behavior. Those who did not
engage in this extremely high-risk practice were more accurate
in their self-appraisal: Ninety-one percent estimated they were
at no risk or slight risk, and 8% estimated they were somewhat
at risk. However, subjects who reported engaging in unprotected anal intercourse underestimated their actual risk level.
Only 13% placed themselves at the higher end of the scale (moderate or extreme high risk). Thus, 87% of respondents who engaged in this dangerous activity greatly underestimated the degree of risk associated with their behavior.

Discussion
In contrast with well-documented changes in the sexual behavior of gay men in some original AIDS epicenters, over one
third of the men in the cities studied here had engaged in unprotected anal intercourse over the previous 3 months. This is

Table 2
Multiple Regressions to Predict High-Risk Index Scores and
Proportion of Intercourse Occasions Protected by Condoms
Risk index score

Condom use index

Predictor variable

ft

F(9,471)

&

F(9,282)

Risk estimate score

Peer norm score
AIDS risk behavior
knowledge score
Age (years)
Number friends with
AIDS
HLOC score
Internal score
Chance
Powerful others
Education (years)

.29
-.20

46.51
21.07

-.16
.29

7.29*
25.50**

-.09
-.09

4.00
4.00

.17
-.04

7.18*
0.53

.09

4.20

.05

0.73

-.02
.06
-.08
0.00

0.12
1.77
3.53
0.01

.10
.03
.04
0.03

3.28
0.18
0.50
0.25

Note. HLOC = Health Locus of Control Scale.

*p<.01. **p<.0001.

Table 3
Personal Risk Estimate by Those Who Did and Did Not
Practice Unprotected Anal Intercourse
Unprotected anal intercourse
Practiced

Never
practiced

Total

Personal risk
estimate

No risk
Slight risk
Some risk
Moderate risk
Highest risk
Total

22
44
21
9
4
37

40
79
37
16
7
179

46
45
8
1
1
63

139
135
25
1
2
302

37
44.5
13
3.5
2.0
100

179
214
62
17
9
481

cause for concern because of the prevalence of HIV infection

among homosexual men and the greatly elevated probability of
HIV seroconversion among men who engage in this practice
even at very low rates (Kingsley et al., 1987).
Our investigation identified a number of characteristics that
differentiated men who do or do not engage in high-risk practices. Gay males who did not engage in unprotected anal intercourse, in relation to those who engaged in this activity, were
more likely to consider safer behavior an accepted norm within
their social network; more likely to attribute safety to their own
precautionary behavior; and less likely to attribute AIDS risk
to external factors such as chance, luck, or fate. In addition to
higher knowledge about risk practices, these men also had fewer
sexual partners, estimated their own risk level in greater concordance with their actual behavior, and were older than men who
engaged in unprotected intercourse. In similar fashion, condom
use was predicted by perceived peer norms favoring safer sex,
by accurate estimation of personal risk, and by risk behavior
knowledge. While risk knowledge levels differentiated men who
did or did not practice unprotected intercourse, even persons
who engaged in risky activities answered most knowledge items
correctly. This indicates that factual information about AIDS
risk has been fairly well disseminated among most gay men. It
also suggests that primary prevention campaigns that convey
risk precautionary behavior as an accepted peer norm or interventions that directly modify social norms to encourage health
promotion and discourage continued high-risk practices may
now be especially important. These data also indicate the need
to address personal attributions concerning risk and to emphasize internal control and personal behavior choice, rather than
chance, as a determinant of risk.
Our study surveyed largely White, well-educated men patronizing gay bars, and it is not known whether these risk behavior findings generalize to homosexual men who do not visit
bars. The significant but modest magnitude of some variables
as risk predictors raises the possibility that other factors may
also influence risk behavior. Heavy use of intoxicants before
sex as well as low perceived self-efficacy for making behavior
changes has been particularly implicated as a risk determinant
(McKusick et al, 1985; Stall, McKusick, Wiley, Coates, & Ostrow, 1986). Research on AIDS risk behavior necessarily relies
on subject reports of privately occurring activities that may be

120

BRIEF REPORTS

susceptible to recall inaccuracy. Nonetheless, these findings

highlight the need for further research exploring process factors
that influence risk behavior decision making and for prevention
models derived from psychological research in these areas.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

References
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Received March 20,1989

Revision received July 10, 1989
Accepted July 20,1989