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Objectives. We assessed differences in HIV prevalence and sexual risk behavior among men who have sex with men (MSM) between 1997 and 2002 in San Francisco. Methods. We used 2 population-based random-digit-dial telephone surveys of MSM households in San Francisco in 1997 (n=915) and 2002 (n=879). Results. Estimated HIV prevalence increased from 19.6% in 1997 to 26.8% in 2002. Measures of sexual risk also increased. Unprotected anal intercourse with a partner of different or unknown HIV serostatus increased from 9.3% to 14.6%. Mean number of male partners increased from 10.7 to 13.8. The largest reported increase was 18.9% to 26.8% for “serosorting,” or choosing unprotected anal intercourse partners believed to have the same HIV serostatus as oneself. Men aged 30 to 50 reported the largest increase in unprotected anal intercourse, whereas men aged 18 to 29 reported the largest increase in serosorting. Changes in the age distribution did not explain the increase in risky behavior. Conclusions. Both HIV prevalence and sexual risk increased substantially among MSM in San Francisco between 1997 and 2002. Serosorting is being adopted more frequently than condom use by young MSM, but its effectiveness as a harm reduction strategy is not known.

Objectives. We conducted a large, population-based study to assess tobacco use in California’s lesbian, gay, and bisexual (LGB) population. Methods. Standard measures of tobacco use from 2 separate, statewide household-based studies were used to compare basic prevalence rates in the LGB population and the general population in California. Data were derived from a 2003–2004 survey of LGB individuals living in California as well as from the 2002 version of the California Tobacco Survey, which gathered data on the state’s general population. Results. Smoking prevalence rates were higher in our sample of lesbians, bisexual women, and women who have sex with women than among women in the general California population. In the case of men, the only significant difference was that rates were higher among gay men than among men in the general population. Disparities in tobacco use between the LGB population and the general population were still evident after we controlled for key demographic variables and in comparisons with other tobacco use indicators such as average cigarette consumption. Conclusions. Tobacco control efforts targeting the LGB population are needed to reduce this group’s high rate of cigarette smoking.

Objectives. We measured the extent to which a set of psychosocial health problems have an additive effect on increasing HIV risk among men who have sex with men (MSM). Methods. We conducted a cross-sectional household probability telephone sample of MSM in Chicago, Los Angeles, New York, and San Francisco. Results. Psychosocial health problems are highly intercorrelated among urban MSM. Greater numbers of health problems are significantly and positively associated with high-risk sexual behavior and HIV infection. Conclusions. AIDS prevention among MSM has overwhelmingly focused on sexual risk alone. Other health problems among MSM not only are important in their own right, but also may interact to increase HIV risk. HIV prevention might become more effective by addressing the broader health concerns of MSM while also focusing on sexual risks.

Objectives. This report investigates differences in risk behaviors among men who have sex with men (MSM) who went to gay bathhouses, public cruising areas, or both. Methods. We used a probability sample of MSM residing in 4 US cities (n = 2881). Results. Men who used party drugs and had unprotected anal intercourse with nonprimary partners were more likely to go to sex venues than men who did not. Among attendees, MSM who went to public cruising areas only were least likely, and those who went to both public cruising areas and bathhouses were most likely to report risky sex in public settings. Conclusions. Distinguishing between sex venues previously treated as a single construct revealed a significant association between pattern of venue use and sexual risk. Targeting HIV prevention in the bathhouses would reach the segment of men at greatest risk for HIV transmission.

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.

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.

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.

We agree that disparities in health (e.g., physical, behavioral, mental) can indeed be thought of in terms of sexual orientation and gender identification as well as in terms of race/ethnicity. The data reported by Archer and colleagues are consistent with other studies showing that lesbian, gay, bisexual, and transgendered (LGBT) populations experience higher rates of smoking than others.1 Beyond measuring the prevalence of tobacco use, however, we have few data on consumption patterns and rates of tobacco cessation for LGBT populations similar to those that are available for the general population. To address such questions large-scale data sets are typically needed, particularly when they take into account the intersections of race, class, and access to health care to model smoking and cessation outcomes for LGBT populations. The addition of sexual orientation and gender identification questions to ongoing large-scale tobacco use surveys is an essential first step toward addressing LGBT disparities in tobacco use. Furthermore, as Archer and colleagues note, tobacco misuse is just one of a cluster of comorbid conditions that appear to be more prevalent in LGBT populations than in the general population: depression,2 substance abuse,3 HIV/AIDS,4 victimization,5 and childhood trauma.6 These health conditions are known not only to coexist but to interact and amplify each other’s effects in classic syndemic fashion.7 It is possible that reducing the prevalence of these co-occurring problems in LGBT populations might result in a parallel decline in prevalence of tobacco use. At a minimum, it is important that national, state, and local tobacco control efforts work in partnership with LGBT populations to take full advantage of current best-practice models of effective tobacco control programs,8 which include multilevel efforts designed to reduce tobacco-related morbidity and mortality. Finally, in addition to the influence of the tobacco industry’s targeting of LGBT populations, it is important to identify other risk and protective factors associated with smoking and quitting for LGBT smokers. For example, tobacco (and other health) disparities in the LGBT population are likely related to high levels of societal discrimination and daily stress.9 Research is needed to uncover how identity (gender, sexual, and ethnic), socioeconomic status, and other key individual, interpersonal, social, and environmental factors combine to contribute to tobacco use and cessation. In addition, we need to know more about the resilience that helps some LGBT individuals remain smoke-free.

We are gratified to note that Mathy does not have any substantive criticisms of our research. However, we would like to address 2 of Mathy’s points: first, that other population-based studies on this topic have been conducted, and second, that our analyses lacked cultural sensitivity. As our comment that prior research has been “primarily based on opportunistic samples” does not deny that some population-based research has occurred (which we cite), I am at pains to understand the contention that our “assertion” is incorrect. The implication is that there are no benefits to the publication of our article. This can be readily rebutted. Our analyses were based on data from a rigorously derived population-based sample of men who have sex with men (MSM) in 4 major US cities. The representative nature and size of this sample, along with the breadth of health issues covered in telephone interviews, have offered a unique perspective on urban MSM. Such a perspective is needed in addition to the groundbreaking work with opportunistic samples that typically preceded this research. Mathy cited Remafedi, who identified 6 “population-based and controlled studies published since 1997.”1 These publications actually represent 5 studies, as 2 articles2,3 reported on the same data set. Four2–6 were studies of school-based samples of adolescents, using the Youth Risk Behavior Survey. Variations in the operationalization of sexual orientation (e.g., self-label, sexual behavior, “romantic attractions”) not only meant variations in the comparison groups but have led to discrepant findings in other analyses.7,8 Further, we noted that adolescents who self-identify as gay, lesbian, or bisexual (GLB) by 13 to 18 years of age may not be representative of the broader GLB population, a point echoed by others. The remaining study defined a population-based sample of 750 men aged 18 to 27 years in a neighborhood in Calgary, Canada.9 However, the reported prevalence of homosexual activity, identity, or both contradicts prior demographic research and suggests the need for confirmatory research.10 As we noted, subsequent studies’ analyses using national data sets have been limited by relatively small numbers of MSM and lack of gay-specific variables. Mathy claims that our age cohort analysis lacked sensitivity to the culturally significant health-related events of this population. While the removal of homosexuality as a disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973 signaled a significant, affirmative shift in how the professional and academic world viewed homosexuality, it was embedded within larger social changes. It is unclear how immediately this action influenced the developmental experiences of gay men, lesbians, and bisexuals. The professional and academic resistance to this change was evidenced by the necessity 14 years later of removing “ego-dystonic homosexuality” from the DSM. Mathy’s critique does an injustice to the degree to which cultural context was considered in our article. We used a key watershed event—the Stonewall Riots and the birth of the modern gay liberation movement—as this marked an era of social transformation and empowerment for the GLB community. Research on GLB youth in the United States since that date (e.g., Cohen and Savin-Williams11) suggests that marked changes have occurred over time, not necessarily linked to any one event but as part of a progressive cultural shift. The reactions to these social changes are complex; evidence also suggests that GLB youth are facing greater violence today than in decades past.12 Thus we chose to compare those who reached age 25 by 1970 with cohorts that reached that age within subsequent decades, a 10-year span being not uncommon to this type of analysis. Our cohort analyses considered one marker in the growth of the GLB community, rather than other milestones suggested by Mathy. We may differ in the significance we attach to these milestones, but that is all.