Experiencing release: sex environments and escapism for HIV-positive men who have sex with men.

Sexual behavior is often driven by nonsexual motivations, such as the need for socialization or to alleviate negative affect (Gagnon & Simon, 1973). A corollary of this principle is that research on sexuality should pay particular attention to the motivations that people have for seeking out sexual experiences. It also follows that there will be differences in the ways in which concrete aspects of sexual situations (e.g., type of partner, presence or absence of substances, setting) relate to each other. Thus, differences in motivations will have implications both for understanding sexuality in general and, more pragmatically, for studies seeking to understand sexual risk.

Parsons et al. (2004) recently outlined how alcohol played different roles in the sexual behavior of HIV-positive men who have sex with men. The desire to escape from stressful thoughts and feelings related to HIV was one of the principle motivators for combining alcohol use and sexual activity. Although many of these HIV-positive men reported using alcohol to facilitate escapism during sexual activity, in some situations, sexual behavior was actually an unintended outcome of using alcohol to cope with other stressors, particularly related to HIV.

Purcell, Ibanez, and Schwartz (2005) specifically examined escapism as it related to recreational drug use and risky sexual activity among HIV-positive men who have sex with men. Drugs were found to facilitate cognitive escape in some men, specifically to help them forget about their HIV status or to deny the dangers associated with unprotected sex acts. Like Parsons et al. (2004), these researchers found that personal and contextual factors often had an effect on the relationship between substance use and unsafe sex.

These previous findings provide additional support for the theoretical work of McKirnan, Ostrow, and Hope (1996), who developed the cognitive escape model in order to understand the relationship between alcohol or other substance use and sexual risk behavior. They postulated that some men who have sex with men use alcohol and other drugs to escape from HIV-related stress and subsequently may be more inclined to engage in more HIV sexual risk behavior. In terms of the cognitive escape model, substance use within sexual and social environments acts as a releasing mechanism in that it liberates men who have sex with men from sources of emotional vulnerability, such as stressful thoughts and anxiety, by means of narrowing their attention to the here-and-now, thereby increasing the impact of environmental cues and triggers (e.g., partner's desires, the behavior of other men who have sex with men, level of arousal, and routines for sexual encounters) on sexual behaviors (McKirnan et al., 1996). Thus, substance use enables men who have sex with men to achieve cognitive escape by

means of releasing mechanisms. On a broader level, the cognitive escape model outlines how people may seek experiences that heighten arousal and diminish more abstract thought to enable cognitive escape and how this can result in sexual experiences. Sex itself might play the role of a releasing mechanism, similar to alcohol and substance use. The physical and social characteristics of public and commercial sex environments (e.g., bathhouses, sex clubs, public parks where men "cruise" other men for sexual activity) frequented by men who have sex with men may provide the heightened emotional experiences that enable cognitive escape by amplifying sexual arousal (Somlai, Kalichman, & Bagnall, 2001; Tewksbury, 2002).

Broadly speaking, these "sites of male-centered sexual opportunity," as termed by Leap (1999), have been designated as such by men who have desires for each other and want to express them. According to Berube (1996), men historically sought out venues in which they could more freely express their sexual desires for other men within a homophobic society. In other words, given the cultural context of discrimination and oppression targeting same-sex desire, these venues served as safe spaces where men who have sex with men could socialize and express their sexual desires. Some of these venues were intended specifically for sex (e.g., bathhouses, sex clubs, adult movie houses, and pornography shops that allow or encourage the use of "buddy booths" for previewing movies). They provided locales where men could go for casual sex encounters. There were also more public sexual environments men appropriated for the purpose of meeting male sex partners (e.g., wooded areas in parks, bathrooms in department stores, and beaches). These locations were or contained spaces that were secluded or lightly trafficked. At these types of venues, the public nature of the location and the on-site possibilities intensify the power and pleasure of the erotic moment (Leap, 1999). These venues may also provide the heightened emotional experiences that enable cognitive escape.

The historical context provides one aspect of the cultural background and setting of sex environments informing the current role of these venues for men who have sex with men. Sexual behavior at these venues is further channeled by the physical characteristics of these venues, social norms for behavior within the spaces, and personal motivations related to more global issues.

The environmental characteristics of sex environments include, among other things, whether or not they are outdoors or indoors, the degree of openness (i.e., clearings in wooded areas and bathroom stalls or large public rooms, private rooms, and private booths), and exposure to public and/or legal scrutiny (e.g., in a public bathroom or paid admission sex club). These characteristics facilitate and constrain different types of sexual activities. Having sex with multiple partners while fully nude can take place in a paid admission sex club more readily than it can in a clearing in the woods. The physical characteristics of these venues have played important roles in structuring the sexual encounters of the men who have sex with men who frequent them (Flowers, Hart, & Marriott, 1999).

In conjunction with the physical characteristics of sexual environments, social norms within these venues impact sexual behavior. Men who have sex with men communicate sexual interest and desired sexual activities through eye contact, physical gestures, and how they position their bodies. This type of communication depends on a shared understanding between men on how to behave at these particular settings. Certainly, for this type of communication to exist, cohorts of men have had to learn codes from more experienced peers and older men (Berube, 1996). Further, this communication at a very basic level requires that the context narrow the range of possible interpretations. A glance in a sex club is not equivalent to a glance in a boardroom.

In addition to the physical characteristics and social norms of sex environments, individual motivations for attending these venues impact sexual behavior. Individual motivations may attenuate the way that social norms are negotiated during sexual encounters (Berube, 1996; Somlai et al., 2001). Further, individual motivations influence which venues are sought out and which aspects of the venues are most appealing (Tewksbury, 2002).

Individual motivations, the social or cultural contexts within which men who have sex with men and sex environments exist, the physical characteristics of these venues, and the relationships among these components all contribute to the sexual behavior of these men when they attend such sites of sexual opportunity. To some degree the analysis of these diverse components requires an environmental psychosocial approach that can provide a broad framework capable of illuminating specific instances of behavior.

In this project, our primary aim was to use the cognitive escape model to examine the role sex environments play in the sexual risk behavior of HIV-positive men who have sex with men from New York City and San Francisco, based on their sexual narratives. We outlined sources of emotional vulnerability (i.e., HIV-related stress, anxiety, and other stressful life events) that some of the men who frequent these venues may be seeking to escape and how the experiences at these venues might act as releasing mechanisms to alleviate dissonant thoughts and feelings (Parsons & Halkitis, 2002; Wolitski, Bailey, O'Leary, Gomez, & Parsons, 2003). Using the cognitive escape model as a theoretical foundation and focusing on participants' vulnerabilities and sexual experiences that act as releasing mechanisms provided a framework for understanding how some of the men in this study use sex environments for nonsexual reasons.

METHOD

Participants

We used data from the Seropositive Urban Men's Study (SUMS) funded by the Centers for Disease Control and Prevention (see Wolitski, Parsons, & Gomez, 2004; Parsons, Halkitis, Wolitski, Gomez, & the SUMS Team, 2003). A total of 250 men from New York City (NYC) and San Francisco (SF) met eligibility criteria (i.e., they self-identified as HIV-positive, reported sexual activity with another man in the past 3 months, and were age 18 or older) and completed baseline surveys and qualitative interviews. The subsample described in this paper consisted of 64 men who were selected because they mentioned sexual environments in their interviews.

Of this subsample, 70% (n = 45) were men of color, and the mean age of participants was 37.6 years (SD = 9.2). Average time since HIV diagnosis was 6.5 years (SD = 3.9), and 49% (n = 31) had been diagnosed with AIDS. With regard to recruitment venue, 30% were recruited from AIDS service organizations, 23% from a gay community venue, 29% from a sex environment, and 18% through friendship referrals.

Procedure

The participants for this study were recruited using active and passive recruitment strategies (Parsons et al., 2003; Wolitski et al., 2004) from AIDS service organizations, gay community venues, and sex environments between 1997 and 1998. Quotas were established to ensure that men from diverse racial and ethnic backgrounds as well as from different recruitment venues were represented in the study. Men were screened by telephone to determine eligibility. Anyone who was deemed eligible and was still interested in participating in the study was scheduled for a baseline interview. At the interview, the participants provided informed consent and completed the self-administered baseline measures and the qualitative interview.

Measures

The qualitative interview included a critical incident measure in which participants were asked to describe their most recent sexual encounter they felt was unprotected. Interviewers probed for information regarding when the incident occurred, where, with whom (primary or casual partner), what happened, their mental state at the time, etc. Interviewers were trained to assist participants in providing sufficient detail so that a "picture" of the risk situation emerged. Participants were also asked to describe their most recent protected sexual activity. Comparable probes and follow-up questions were used, and participants were asked to compare and contrast the two events. Such measures have been found to be useful in better understanding the contextual nature of HIV transmission (Leonard & Ross, 1997; Parsons et al., 2004).

Data Analyses

Participants' narratives were coded as individual cases of sexual activities. Transcripts were entered into QSR*Nudist, a qualitative data analysis software program. Patterns and interrelationships among the data were extrapolated into recurring themes for coding (Glaser & Strauss, 1967). Interrater reliability was relatively high ([kappa] [greater than or equal to] 70). Once coding was complete, we used the cognitive escape model to situate the emerging themes within a systematic theoretical framework.

RESULTS

Throughout their sexual narratives, men discussed sources of emotional vulnerability such as HIV-related stress and anxiety and other stressful life events. In addition, many of these men discussed seeking cognitive escape at sex environments when they felt anxious or stressed. Certain aspects of sex environments enabled men to escape because they elicited high levels of arousal and excitement, designating these venues as releasing mechanisms for these men. These aspects included physical characteristics (e.g., being in a wooded area of a public park, being in a private room at a sex club), social norms about silence during these encounters, and anonymity and nonverbal communication, as well as partner variables, such as availability, variety, nudity, and the presence of recreational drugs. The age, race-ethnicity, and city of residence of the participant follow each quote, although the data did not support differences by these factors.

Vulnerabilities

Some participants discussed how they struggled with the impact of HIV on their lives. They sought to escape from "thinking about" having the virus, yet at the same time they needed to express their feelings about being HIV-positive.

   Oh, I've been very depressed about it. Because we didn't understand
   it back then because it was just all for AIDS and we didn't
   understand what it was. So, I became depressed, suicidal, started
   using drags and alcohol to cover up the fact that I had this thing
   in my body and I didn't want to think about it. And I started having
   more sex to make myself feel better and to also get revenge
   because I was angry. (32, African American, NYC)

A few men indicated that HIV fatalism was an impetus to maximize pleasure in the present given their uncertain future. Participants who maintained these fatalistic attitudes about HIV sought out venues where they could disregard concerns about their partner's status and/or cope with stress by using sex.

   If the guy is in the park you don't ask. You don't care. You should
   care but you don't care. You know it's that fatalistic attitude from
   the 80s. You knew you were going to die no matter what you did,
   so why not do it anyway and enjoy your life whatever you were
   going to have with it. And I guess I still kind of have that attitude
   but I'm more conscious of it now. (36, White, SF)

   Like I said in the beginning I was ready for death so I went to
   Florida--lived with my aunt. I figured, "Well let me die. I'll have
   some fun." I slutted it up and down in the beaches [sex environment]
   in Florida. (34, White, NYC)

Most of the participants discussed visiting sex environments to seek relief from emotions such as anger and flustration over the events of the day. These stressors may or may not have been necessarily related to or even compounded by serostatus.

   The need to release frustration was definitely a better part of our
   sex. If I got stressed out or angered by something or other, I could
   just go to the [sex] club and just release it, totally. No doubt
   about it. (32, Latino, NYC)

When asked about his feelings at the time of going to a sex club, one participant talked about how his stressful week resulted in his need to escape:

   I'd been having a hard week or a hard time with my recovery--with
   feeling, you know, serene and comfortable with my surroundings.
   So, that's why I think that a lot of times I go looking
   for intimacy, or looking for love in a sense, and always leaving
   disappointed. So, I believe that I was feeling very uncomfortable.
   Because I think sometimes I kind of go to sex as a way to get
   away from what I'm feeling at the moment - an escape, like drugs
   used to be, you know? (32, White, SF)

For these participants, emotional needs (i.e., intimacy, solace, and comfort) and psychological distress often motivated them to seek out sexual environments. These sources of emotional and psychological distress acted as sources of vulnerability. And within the cognitive escape model, the very experience of being in a sex environment acted as a releasing mechanism.

Releasing Mechanisms

Most participants described sex environments as places in which verbal communication was brief or nonexistent. Naturally, this silence would proscribe discussion around stress, difficult experiences, and HIV. There were many participants who felt that at these venues, HIV in particular was not spoken about.

   See it's like I told you. I go to the bathhouse. That is one issue
   [HIV status] that men don't talk about there. And plus, l would
   assume that there's a high percentage of infected people who go
   to the bathhouses in the first place. (31, mixed race, SF)

As this participant illustrates, HIV-positive men who have sex with men often assume that their sex partners at sex environments are also positive. The lack of communication about HIV was commonly described as part of the social norms at these venues.

   In those places, people, they know what they are doing. They
   don't talk about HIV. They don't talk about HIV. Some of them,
   they don't want--they get offended if you ask for a condom or if
   you ask them to, to behave. They get offended. So in general,
   sometimes I don't use protection. Sometimes--I don't know. I
   don't know. I lose my control and I don't use protection. (39,
   Latino, NYC)

This participant felt that discussing HIV and safer sex offended other men at the venue so he generally did not use condoms. Furthermore, not using condoms or not being able to discuss safer sex was tied to feeling out of control.

Another effect of silence described by a few participants was to maintain greater anonymity. One participant, in responding to questions about sex and frequenting bathhouses and public parks, discussed seeking out sex as a form of serf-medication and being desired by anonymous partners as a form of validation:

   Well, you know how some people, when they get depressed, eat
   food or go to sleep or do whatever? Well, I have sex. When things
   don't go well, the first thing I want to do is have sex. So I don't
   know if that makes me an addict, but [laughs], you know, it's
   something that I use as a crutch, you know. I mean it's just--and
   I think it has to do with--in the industry that I'm in there's a lot
   of rejection, you know. You deal with a lot of, you know, oh, you
   didn't get this part, or you didn't get this gig. or whatever. So you
   deal with a lot of that. And, going and having anonymous sex with
   someone, it's like, you know, acceptance, you know. (29, African
   American. NYC)

Many participants described how the pleasure and arousal they felt at sex environments enabled or led them to forget about their own HIV status.

   When you go to the park, you cruise, at night. So I went to the
   park that evening and I met up with a guy. I forgot his name. And
   he was visiting from New Jersey or something. So at the time, I
   didn't have any condoms. I didn't really expect to get into anything
   sexually. And, and we went to a picnic table, sat down, and
   we got it on.... He came. And then that was it. I never heard from
   him. I was so nervous because I, [laughs] I was thinking that, the
   pleasure is so good. I didn't think about my HIV [laughs] status.
   (28, White, NYC)

For those participants who were motivated by a heightened desire to escape reality, substance use amplified the already intense sexual atmosphere at sex environments.

   I was not as high as I've ever been or not as high as I wanted to
   be. When I go out [to sex clubs] for myself I want to lose touch
   with reality. And that's my whole, sole purpose. To just get away.
   Although it's detrimental to my immune system it sure is; well
   you know, the same point that it's bad for your immune system, I
   think it's good for your immune system. I mean, people go and
   do, when I go out and I party and stuff I don't have a care in the
   world. And I'm really like relaxing myself. I'm really happy
   about life. (34, White, NYC)

Some participants articulated this connection more specifically. There were men who reported using drugs as an integral part of their sex environment routine, only for specific sexual activities, or to help fulfill certain fantasies with casual partners.

   I was drunk and I was horny and I wanted some dick.... That's the
   only time I would go into the park, because if I'm sober, I'm very
   quiet and shy; I don't--I wouldn't talk to you if I did not know
   you. [Once in this situation] your mind goes oft on you... You
   know? You're not thinking about--you're not bringing a condom
   or doing--you just want to get busy, you know? (40, Latino,
   NYC)

A few participants discussed how substance use contributed to the excitement surrounding unprotected anal intercourse. Drugs were part of the preparation for sexual risk behaviors.

   Oh, there is some excitement, there's some excitement about it.
   You know, like, wow, this guy's going to do this without a condom,
   you know, I'm thinking, you know. And usually also when
   I have sex in a bath then 99% of the time I'm using poppers, 80
   to 90% of the time. (32, White, NYC)

One participant exemplified this behavior in his description of the way in which he consciously used poppers at sex environments to overcome any concerns about the consequences of risky sex.

   And, me, I don't think at first, I think while I'm sucking the dick,
   I get thoughts - "Well, what if he has herpes? What if he has
   something that I can't see'? I shouldn't be doing this." And so the
   rest of it either becomes half-hearted, unless the guy's a total
   stud, and then [laughs] and then l just forget about it and I'll
   take some poppers, some poppers will get me through it. (34, Latino,
   NYC)

There were a few men for whom sex itself was a drug. These men provided the most powerful articulations of cognitive escape at sex environments.

   No one talked. They don't want to know [about HIV status]. They
   don't care and, of course I am afraid, but in, in that moment no
   one cares. I believe I was more at risk. Um, when this guy, ah,
   came inside me, I don't know what happened ... It's like blocking
   your, your mind. I don't - at that moment I don't think. I want fun.
   I want to, to have company. I want to do something. But I don't
   think in risk or anything. Because it's an escape - It's an escape.
   Some people use drugs to escape and I use that. I use that to
   escape. (Latino, 39, NYC)

A participant who had stopped using alcohol 3 years prior to the interview felt that sex at sex environments had taken the place of substance use as a coping mechanism:

   Feeling bad, feeling uncomfortable with myself, not liking
   myself, not wanting to feel. And that's weird because you think
   when you're having sex, you want to feel, you want to feel something.
   You want to at least feel the sensations of the sex, the act.
   But the biggest problem I had was I was feeling too much. So in
   not wanting to feel, you escape. How do you escape? You can't do
   drugs. You're going on 3 years drugs and alcohol free. So, you
   look for the next best thing. Go out to a park and have anonymous
   sex. (Latino, 36, SF)

The emotional experiences these men had at sex environments played a key role in enabling them to achieve cognitive escape. Often the desire for escape was explicit, and sometimes men enhanced the already sexualized and hyperstimulating atmosphere at sex environments by using drugs. For some, drugs enabled them to engage in sex, while for the participants above, sex at sex environments was itself the primary method of coping.

DISCUSSION

In this paper we used the cognitive escape model to frame one way in which men who have sex with men use sex environments. The model was originally formulated to describe how gay and bisexual men might use alcohol and other sub stances to enable them to escape distressing thoughts and feelings about HIV (McKirnan et al., 1996). The result of using substances was to locus their attention on the immediate surroundings (Steele & Josephs, 1990). Alcohol and other substances diminished their ability to self-monitor and to consider more abstract issues, such as the potential negative consequences of sexual risk behavior.

In the current study, participants' sources of vulnerability not only included HIV and HIV-related issues but also loneliness, frustrations, and daily stressors. Multiple psychosocial stressors (e.g., homophobia, depression, substance use, sexual risk behavior, HIV infection) cluster and thus amplify each other's impact on the lives of men who have sex with men. Stall et al. (2003) have recently found evidence of this synergistic effect. Therefore, HIV-related stress may be one of the more salient sources of stress within a cluster of issues ranging from drug use to alienation.

Similar to the use of alcohol and other drugs per the cognitive escape model, some of the participants in our study sought out sex environments to cognitively disengage from sources of vulnerability. The emotional experiences these men had at sex environments enabled them to cope with distressing thoughts and feelings.

As previously mentioned, sex environments, such as bathhouses, have historically served as places where men who desired to have sex with other men could, with varying degrees of success, escape from homophobia, discrimination, legal retribution, and potential physical assault due to their sexual practices (Berube, 1996). In the present study, these venues still served as places where some men sought release from distress and vulnerability through immersion in sexuality. For these sexual minority men, this way of coping may also be a way of connecting with other men like themselves who also desire sex with men.

Various aspects of sex environments contributed to the sexualized atmosphere. These included silence and anonymity, and the hypersexuality resulting from available partners, sexual activities and at times substance use. The silence meant that, among other topics, discussions of HIV status were precluded, thus enabling men who have sex with men to operate on assumptions of partner status and also facilitating the reduction of sexual inhibitions. Silence and anonymity enabled men to maintain emotional distance during their sexual encounters at sex environments. However, these men communicated their sexual attraction and their sexual desires through physical gestures.

For some men in this study, drug use amplified sexuality at these venues, which lowered their inhibitions and escalated their level of arousal. There were, in fact, men who always used recreational drugs and/or alcohol at sex environments. For these men the sex and drugs were interwoven and led to truly ecstatic experiences, quite separate from everyday life. Davis (1983) provides a useful discussion on the experiential differences between daily realities and erotic experiences.

It bears emphasizing that there is nothing unique about escapism. People plan and prepare trips to out-of-the-way locations and pay large amounts of money to be admitted to places such as movies, amusement parks, and carnivals, just to escape real life and in some cases have little adventures. As for the men in this study, it is the source and intensity of the thrill of the sexual atmosphere in sex environments that places these men at particular risk. This raises questions about the relationship between the intensity of the escape mechanism and the level of stress faced by these participants.

Finally, some participants in this study were motivated to go to sex environments because the emotional experiences that resulted from the diverse aspects of these venues created a space where they could escape various stressors. This relationship between motivation or intention and social and physical environmental factors emphasizes the importance of understanding the nonsexual reasons that at times drive sexual behavior.

This study has a number of limitations that need to be taken into account. First, we did not find racial-ethnic differences among men in this study, nor did age appear to play a role in differentiating the ways sex environments facilitate cognitive escape. This may be due to the fact that this was a qualitative analysis focused on the role of venues within the cognitive escape model or due to the small sample size. A recent study using probability samples found that men of color were more likely than White men to frequent sex venues (Binson et al., 2001). Quantitative analyses of SUMS data revealed that HIV-positive African American men were less likely to go to commercial sex venues compared to other men, but they were just as likely to frequent public sex venues (Parsons & Halkitis, 2002).

A second limitation to this study is that we cannot speak to the experiences of HIV-negative men who frequent sex environments. Future qualitative studies should explore this subgroup of men who have sex with men. In addition, even though these data were collected between 1997 and 1998, the issues presented by the men in this study remain salient in terms of HIV-related issues like safer sex fatigue, medication side effects, survivor guilt, and HIV fatalism, in addition to the ongoing legal and societal discrimination that still exist today.

Further qualitative work should also be done to investigate and describe other types of motivations that men who have sex with men who frequent sex environments have for attending these venues. These studies should continue to explore the relationship between motivations or intentions and social and physical environmental factors.

Finally, this paper was focused on men's emotional experiences at sex environments. Due to the limitations of the methodology, however, we did not systematically collect data on the actual structure of different sex environments. Work more closely linking behavior with specific aspects of sex environments has been done elsewhere (Somlai et al., 2001; Tewksbury, 2002). However, there is still a need for work that brings together richer descriptions of the environments with equally in-depth descriptions of the participants' motivations for seeking out sex environments and their emotional experiences within them. Moreover, studies should seek to understand the degree to which escape involves drugs and extreme sex for different kinds of men. Researchers and health care providers should pay close attention to the motivations and experiences of men who have sex with men in order to determine which type of interventions would suit them best.

Sex environments provided powerful releasing mechanisms for many of the men in this study. This phenomenon highlights the need to provide and make visible sources of social support these men can seek out to cope with distress. However, it also highlights the need for services and other outlets that do not involve engaging or discussing the stressors in their lives. The discussion of stressors may instill more feelings of vulnerability and anxiety. An outlet that allows men to experience more positive and pleasurable nonsexual thoughts and feelings may be necessary. In other words, there seems to exist a great need for avenues of socialization where men who have sex with men can leave behind their concerns without necessarily engaging in HIV sexual risk behavior.

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Wolitski, R. J., Bailey, C. J., O'Leary, A., Gomez, C. A., & Parsons, J. T. (2003). Self-perceived responsibility of HIV-seropositive men who have sex with men for preventing HIV transmission. AIDS and Behavior; 7, 363-372.

Wolitski, R. J., Parsons, J. T., & Gomez, C. A. (2004). Prevention with HIV-seropositive men who have sex with men: Lessons from the Seropositive Urban Men's Study (SUMS) and the Seropositive Urban Men's Intervention Trial (SUMIT). Journal of Acquired Immune Deficiency Syndrome, 37(S2), 101-109.

This research was conducted as part of the Seropositive Urban Men's Study (SUMS). It was supported by the Centers for Disease Control and Prevention through cooperative agreements with New Jersey City University (U62/CCU213605, Jeffrey T. Parsons, Principal Investigator) and University of California, San Francisco (U62/CCU913557, Cynthia A. Gomez, Principal Investigator). The following colleagues participated fully in the development, design, and implementation of SUMS: James Carey, Cynthia Gomez, Colleen Hoff, Robert Hays, Perry N. Halkitis, Ann O'Leary, Robert Remien, Michael Stirratt, and Richard Wolitski.

Address correspondence to Jeffrey T. Parsons, Ph.D., Associate Professor, Department of Psychology, Hunter College of the City University of New York, 695 Park Avenue, New York, NY 10021; e-mail: [e-mail].

Kalil J. Vicioso Center for HIV Educational Studies and Training

Jeffrey T. Parsons Hunter College and the Graduate Center of the City University of New York Center for HIV Educational Studies and Training

Jose E. Nanin Center for HIV Educational Studies and Training

David W. Purcell Centers for Disease Control and Prevention

William J. Woods University of California, San Francisco