      FOCUS: A Guide to AIDS Research and Counseling
      Volume 9, Number 6 - May 1994
      ----------------------------------------------

      Editorial: Seronegatives and Scarcity
      Robert Marks, Editor

      Until recently, many have viewed the concerns of
seronegative gay men with suspicion. Post-traumatic stress
syndrome, survivor guilt, and dwindling feelings of community
were seen as self-indulgent preoccupations compared to the
life-threatening challenges of HIV-infected people. 

      Studies have shown, however, that the stress of living in
the war zone of the epidemic is severe, authentic, and a natural
psychological response to multiple loss. It can lead not only to
depression and other mood disorders, but also to self-
destructive acts, and, in particular, to unsafe sex. Health
planners now recognize that services for seronegatives are a
crucial component of HIV prevention as well as a way to maintain
the integrity of the hardest hit communities and to enable
people in these communities to continue supporting their
seropositive friends and partners. 

      Outside gay, lesbian, and bisexual communities, there is
another pocket of seronegative angst, a place where being
infected is commonplace and the stresses of being uninfected are
significant and unrecognized. Seronegative children living with
seropositive parents or siblings are often swept up in the
crisis of infection as their normal developmental needs become
secondary to the demands of HIV disease. These children often
live in communities that have disproportionately high rates of
HIV infection and so experience multiple loss on the scale of
any gay community. These communities are often poor,
disenfranchised, and already occupied with the challenges of
basic survival. In this atmosphere, it is difficult to imagine
any of us being able to focus on the needs of ostensibly "well"
children. 

      In this issue of FOCUS, James Dilley and Thomas Moon
present the results of a study of seronegative men in San
Francisco and compare those who have been receiving support
services with those who have not. Phyllis Hansell, Wendy Budin,
and Phyllis Russo describe the developmental dangers faced by
seronegative children. Both articles support the necessity for
paying attention to uninfected people living in the midst of the
epidemic. 

      When the concept of seronegative services arose for the
first time--about five or six years ago--the response was
derisive. Survivor guilt!, the commentators were amazed. You're
alive--get over it, they instructed. Fear of death and grief can
blind even the best of us, but what these commentators really
seemed to be responding to was scarcity--scarcity of money and
scarcity of time. Their responses, while insensitive and
extreme, were natural in a world where social service provision
is by definition an act of triage. 

      Today, there is greater need and no greater abundance than
there was six years ago, and scarcity-related fears remain
rational. But the needs of seronegative people are demonstrably
legitimate, even for the most cynical of us: provide support for
seronegatives and they are less likely to become infected and
more likely to help in the volunteer efforts that HIV-related
care has always required. 
      
      ******************************************
      Supporting Uninfected Gay and Bisexual Men 
      James Dilley, MD and Thomas Moon, MS

      Gay and bisexual men who are not infected with HIV have
nevertheless been keenly affected by the epidemic. This is
especially true of those living in urban areas with large gay
and bisexual populations. Seronegative men watch as their
friends and lovers wither and die, and, in addition to
fulfilling significant roles as caregivers, must develop
intimate and emotionally sustaining relationships in an
environment that poses clear potential for HIV infection. The
resulting tension is exacerbated by the required strict
adherence to safer sex practices. 

      Researchers and AIDS service organizations are only
beginning to address the mental health consequences of living
with such stressors. Nevertheless, clinicians working with this
population have seen the effects of the epidemic on the
psychological and social lives of seronegative gay men: they
have witnessed the depression, the grief over lost loved ones,
the uncertainty about and loss of faith in the future, and
perhaps most ominously, the sometimes worn out commitment to
safer sexual practices. In a very few instances, programs have
attempted to address these needs. 

      This article reports on a survey of 83 gay and bisexual
seronegative men in San Francisco. It documents the effects of
the stressors these men face, and demonstrates significant
differences between men who avail themselves of
seronegative-specific support services and those who do not.
Further, it suggests several steps therapists might take in
addressing these issues with their clients. 

      Background

      Health professionals have noted throughout the epidemic
that uninfected gay and bisexual men experience major
psychological dislocations. Mindy Fullilove described the
difficulties of the "worried noninfected": "Symptoms are
anxiety-related and include panic attacks and generalized
anxiety. Similarly, symptoms of obsessive compulsive disorder
and hypochondriasis can occur... Some of these individuals
suffer from sufficient distress to severely disrupt their social
and occupational functioning."[1] 

      In 1990, Walt Odets suggested that a "psychological
epidemic" existed among uninfected gay and bisexual men.[2]  He
noted as a consequence symptoms of social isolation, depression,
anxiety disorders, adjustment disorders, post traumatic stress
disorder, hypochondriasis, sexual dysfunction, and repeated
engagement in unsafe sex. 

      Quantitative studies support his impressions. In a study
of 745 New York gay men, John L. Martin found that there was a
"direct dose-response relation between bereavement episodes and
the experience of traumatic stress response symptoms,
demoralization symptoms, and sleep disturbance symptoms."[3] The
use of licit drugs and sedatives also increased proportionally
to bereavement episodes, and men with one or more bereavements
were four to five times as likely to seek mental health
assistance to deal with concerns about their own health than
were men with no bereavements. In another New York study of 139
asymptomatic gay men and 236 AIDS and "ARC" patients,
researchers found that 39 percent of the "healthy" control group
qualified for a diagnosis of Adjustment Disorder with Depressed
or Anxious Features.[4] 

      The widely publicized concern about a "second wave" of HIV
infections among gay men has raised the question of the
relationship between HIV-related emotional stressors and
engagement in unsafe sex. A 1993 San Francisco survey examined
this question and summarized key findings from 12 focus groups
of gay men in which 133 men discussed their attitudes and
feelings about the epidemic.[5]  Participants reported a number
of stresses that led to relapse behavior including: overwhelming
grief and loss; problems with self-esteem and homophobia; a
sense of hopelessness about the future; survivor guilt; a lack
of a sense of community; and the feeling that having AIDS is an
inevitable part of the gay experience. The study called for a
"new generation" of prevention efforts that would go beyond
education and address the emotional needs of gay and bisexual
men. 

      Methods and Demographic Data

      The UCSF AIDS Health Project (AHP) adapted a survey
questionnaire developed at Columbia University* and distributed
it to two groups of seronegative gay and bisexual men. One group
included men who had received AHP services within the past year,
and the second group was a convenience sample that included
acquaintances of AHP staff and men who responded to a
street-based solicitation in San Francisco's Castro district.
The men in the first group received services through AHP's
Negatives Being Positive support group program or attended an
event sponsored by the Negatives Being Positive social program. 


      The survey concentrated on four areas personal
information; attitudes towards HIV infection status and safer
sex practices; the effect of the epidemic on individuals; and
managing these effects. Differences in responses between the
groups were tested using chi-square statistics. The survey
comprised 32 men who had received services and 51 men who had
not. Both groups were predominately White and middle-class. The
group that received services tended to be older: their mean age
was 44 compared to 38 in the non-service group. Of note is that
the mode age--the age reported most frequently--was 44 in the
services group and 30 in the non-service group. While drawing
conclusions from this small, relatively homogenous sample
requires some caution, the data confirm clinical reports about
the needs of seronegative men. 

      Attitudes Toward Relationships

      The majority of men in both groups reported not being in
primary relationships. Men who sought out services, however,
were significantly more likely than those who did not to be
single and to state that they wanted to start a relationship.
Attitudes towards relationships with people already infected did
not differ greatly between the groups: the majority of both--
roughly 60 percent--felt it was "very important" to know the HIV
infection status of prospective partners. Further, a small
number of respondents--6 percent of the services group and 14
percent of the non-service group (this difference was not
statistically significant)--reported currently being in
relationships with seropositive men. 

      Further, the two groups did not differ in their
willingness to start a relationship with a seropositive partner
or in terms of having been in relationship with a seropositive
person in the past. Two other items, while not statistically
significant, were of interest. Respondents in the services group
were somewhat more likely to have known more than 10 "people
close to you who have died of AIDS"--59 percent versus 43
percent of those who had not--and were slightly less likely to
have had a lover who had died of AIDS--24 percent compared to 19
percent. 

      These findings suggest that seronegative gay and bisexual
men who seek services are more likely to be socially isolated
and are more interested in developing a relationship than the
comparison group. These men may also make the effort to avail
themselves of services partly because they are, in fact, looking
for a relationship. Respondents from both groups have
experienced a considerable loss of friends to HIV disease. At
the same time, the survey does not support fears that
seronegative-specific services would foster "viral apartheid,"
hostility toward or social separation from HIV-infected peers. 

      Attitudes Towards HIV Status and Safer Sex


      There was no significant difference between the groups in
their assessment of why they had not become infected with HIV:
both attributed their seronegative status primarily to "changes
in their sexual behavior" and "luck." When asked to rank order
the factors responsible for their status, more than
three-quarters of respondents in both groups identified "changes
in sexual behavior" as the most important reason they have
remained seronegative. At the same time, a substantial number of
both groups--60 percent of the services group and 71 percent of
the non--services group-ranked "luck" as the first or second
most important factor in explaining their seronegative status. 

      The frequent endorsement of luck suggests that, despite
acknowledging the importance of behavior change, respondents
feel an element of wonder about having remained uninfected. The
fact that these men say they have escaped infection may suggest
that they have occasionally "slipped" into unsafe sex, or that
they have ongoing concerns that their practices, while
technically safe, may not fully protect them. 

      In fact, the survey suggests that "slipping" is a real
concern. In answer to the question, "Over the last six months,
how often have you found yourself engaging in sex that is higher
risk than you would have liked?" respondents in the services
group were significantly less likely than those not receiving
services to endorse "Never" or "Rarely." One respondent noted,
"As irrational as it may seem, it is a daily struggle to not
give in to the virus." Similarly, those who had received
services were less certain of their abilities to maintain their
seronegative status in the future. While this finding did not
quite reach statistical significance, slightly less than
one-third of the services group stated they would "Definitely"
be uninfected in the future compared to 50 percent in the
non-services group. 

      These findings suggest that men receiving services fight
an ongoing battle to remain committed to protecting themselves
and that it is likely in part because of this struggle that
these men avail themselves of services. Conversely, it may be
that men who have not availed themselves of services have been
more successful at "making peace" with the behavior changes
needed to remain safe. One factor that may be important in this
regard is age: since the services group was generally older and
thus, likely to have been more sexually active in the era before
AIDS, this group may have greater difficulty remaining committed
to the limitations of safer sex. Finally, substantial numbers of
respondents in both groups were unable to state that they would
"Definitely" be seronegative in the future, again attesting to
the difficulties seronegative men have in expressing confidence
about the future. 

      Not surprisingly, virtually all men in both groups
reported that in general the HIV epidemic had had a "moderate or
major" effect on their quality of life and had caused increased
stress in their lives In response to questions about mood,
however, those receiving services were significantly more
distressed. For example, one in four of those receiving services
stated they felt "Very or Somewhat" hopeless in the last six
months compared to one in five of those not receiving services.
Conversely, while not statistically significant, only about
one-third of the services group versus almost half of the
non-service group felt "Somewhat or Very" hopeful. These
findings further suggest a relationship between greater distress
and greater difficulty maintaining safer sex practices. 

      Implications for Therapy

      For seronegative gay and bisexual men. living in the
epidemic poses challenges that at first glance may not be
obvious, or may be overshadowed by the needs of those living
with HIV disease. Many respondents spoke to the feeling that
their needs have been neglected. One man wrote, "Being
HIV-negative should be valued, but sometimes it is not." Another
man admitted that he keeps his serostatus a secret: "I keep my
mouth shut and I know there are people who think I am positive."
Others reported that they feel out of place: "Out of sync with
the gay male community. So many people are HIV positive." These
responses suggest that therapists need to be alert to these
issues and, by asking directly, to validate the struggle of
seronegative men who must go on, caring for infected friends and
lovers while striving to maintain meaningful lives. 

      The survey also supports the need for group approaches and
services for seronegative gay and bisexual men. The results
clearly suggest that AHP's services currently attract a group of
seronegative gay and bisexual men who are at high risk for HIV
infection and who have significant mental health needs as a
consequence of the epidemic. 

      Several men echoed a wish for additional support when they
wrote about their hope that this research would lead to more
programs for seronegative men. Others expressed concern that
"people think we're just feeling sorry for ourselves" and noted
that, as a result, it was difficult to accept their own needs. 

      Two comments eloquently summarize the issues for many
seronegative men. One man wrote: "The questionnaire helps to
'break the silence' around issues HIV-negative gay men have been
reluctant to face, and hopefully this research will lead to new
prevention programs that assist men to remain HIV negative."
Another wrote: "Programs need to be developed to assist
survivors in rebuilding extended family, rebuilding community,
and having a shared sense of the future, while we live with the
reality that AIDS will be a part of us for the rest of our
lives." 

      ~ A p-value of <.003 indicates a markedly strong
statistical significance for the relationship between seeking
and being single.

      References

      1. Fullilove MT.  Anxiety and stigmatizing aspects of HIV
infection.  Journal of Clinical Psychiatry. 1989;50(N11, Supp
1):5-8.

      2. Martin J.L. Psychological consequences of AIDS-related
bereavement among gay men.  Journal of Consulting and Clinical
Psychology, 1988;56(6):856-862.

      3. Odets W. The homosexualization of AIDS, FOCUS: A Guide
to AIDS Research and Counseling, 1990;5(11):1-2.

      4. Tross S. Psychological impact of AIDS spectrum
disorders in New York City.  Presentation at the American
Psychological Association Annual Meeting.  Washington, D.C.
1986.

      5. Communication Technologies.  A Call for a New
Generation of AIDS Prevention for Gay and Bisexual Men in San
Francisco: Communication Technologies, 1993.

      Authors

      James W. Dilley, MD is Associate Clinical Professor of
Psychiatry at the University of California San Francisco,
Executive Director of the UCSF AIDS Health Project, and
Executive Director of FOCUS.

      Thomas Moon, MS is a therapist in private practice in San
Francisco and is doing doctoral research on seronegative gay
men.

      **********************************************
      Seronegative Children in HIV-Affected Families 
      Phyllis Shanley Hansell, EdD, RN, Wendy C. Budin, MSN, RN,
      and Phyllis Russo, EdD, RN 

      Seronegative children-so called because they live in
families where a parent or sibling is HIV-infected-face unique
developmental and psychosocial challenges in the context of
families in crisis. Acquired at birth, early in childhood, or
during adolescence, a seronegative status in an HIV-affected
family leads to stressors that vary with the stage of the
child's psychosocial and cognitive development. These stressors
can contribute to the development of an immature adult, burdened
with poor problem-solving skills, ineffective coping,
depression, and low self-esteem. This article describes the
psychosocial issues of uninfected children in terms of
situational and developmental stressors. 

      Families with seronegative children typically reside in
urban areas, are from under-represented minority groups, and are
likely to include members who are using or have used injection
drugs. These families are often unstable, headed by a single
parent, usually the mother and usually HIV-infected. They are
often encumbered by poverty, reliant on public assistance, and
enduring persistent unmet needs. In response, AIDS becomes a
multi-generational disease: siblings or children of HIV-infected
family members may be separated from their biological families,
and sent to live with extended family members or foster parents.

      Young Children

      All of these psychosocial factors interact with each
other, with the stresses of HIV disease, and with the emotional
response to HIV disease-anger, fear, sadness, and even violence
can become commonplace-to complicate the normal developmental
tasks for seronegative children. Seronegative children may
encounter several problems including: the deteriorating health
and death of other family members; unmet physical needs; loss of
social interaction; loss of emotional support; interruptions in
education; and fragmentation of schooling. These stresses are to
a great extent developmentally determined, and infants,
toddlers, preschool-age children, school-age children, and
adolescents will respond in different ways. 

      Very young children under the age of two are by nature
dependent, need continuous loving attention, and have limited
verbal abilities to express loss and anxiety. Their
understanding of the world and HIV-related stresses is
restricted by an inability to deal in the abstract. Major
stressors for these children are related to interruptions in
continuity of both physical and emotional care, a situation
likely to occur as a parent's HIV disease progresses. Unmet
needs can become all encompassing at this age and may result in
the complete breakdown of the child's world, affecting the
normal progression of development. A parent's deterioration may
also lead to a child being placed under the care of an extended
family member or a foster parent. Removing the child from the
biological parents is an extremely traumatic experience for the
young child, and seronegative children are at a particularly
high risk for this trauma because most come from single-parent
families. 

      Preschool children, between the ages of two and five, have
a better grasp of family membership than younger children and
are better able to express their feelings verbally. For these
children, verbal expression provides an important outlet and is
a means of effective coping. While preschool children understand
what it means to be sick, to go to the doctor, and to take
medicine, they do not comprehend the irreversible nature of HIV
disease progression. 

      Their greatest stressors are the lack of continuity of the
family--which they understand only at very concrete levels--and
illness and loss of family members. They readily perceive
changes in caregivers from biological parents to extended family
members; however, they do not easily comprehend the duration of
these changes and the underlying rationale for them. Disruptions
in the family are particularly difficult for preschool children
and may result in reversion to a less mature level of behavior,
including loss of toilet training, difficulty sleeping, and
social withdrawal. The lack of continuity may extend beyond the
family when a preschool child must deal with a new family
composition, a new home, or new preschool. 

      School-Age Children

      School-age seronegative children--between the ages of 5
and 12--are better able to understand the changes that are
taking place in their families and the irreversible progression
of HIV disease. HIV-related stressors for them are connected to
the family's functional and socioeconomic status, progression of
illness, and loss of life. Since achieving tasks, acquiring
knowledge, and forging positive social relationships are the
primary developmental tasks for school-age children, one of the
most significant stressors for them is lack of continuity in
school and the resulting disruptions in social situations.
Changing schools--because of moving--and assuming caregiving
responsibilities for ill parents may hinder achievement in
school, leaving children to lose focus on these developmental
tasks. 

      These stressors can be so substantial that normal
developmental tasks become completely subverted and the orderly
progression of life becomes totally disrupted. The outcome is
often failure in school and withdrawal from peer relationships,
leaving such children with a limited foundation to enter
adolescence. 

      Adolescence is normally an extremely difficult and
challenging stage of development. It is a time when children
struggle to achieve self-identity and to establish a sense of
intimacy and intimate relationships. They must also make
important decisions concerning schooling and vocation. In the
HIV-affected family, the seronegative adolescent often shoulders
the greatest burden of all: many take on caregiving
responsibilities as the head of the household, while others end
up dropping out of school and leaving their families. The normal
establishment of identity and intimacy are often put on hold. In
many cases, these children are completely devastated by the
effects of HIV disease and have little hope of regaining a
normal adolescence without in-depth counseling and emotional
support. 

      Conclusion

      In response to these stressors and to achieve
developmental goals, age-appropriate counseling and support is
essential.  It is important to remember that coping, like
stress, is developmentally determined, and for each stage of
development, there will be healthy and unhealthy coping. At any
age, seronegative children will lack the coping skills that
adults attain only through achieving developmental milestones:
skills that make a horrific epidemic approach able. Counselors
can support these children by helping them develop these coping
skills and complete their psychological development.

      References

      1. Butler KM, Pizzo R. HIV infection in children. In
Devita VI; Hellman S. Rosenberg SA. AIDS Etiology, Diagnosis,
Treatment and Prevention, (3rd ed.). Philadelphia: JB
Lippincott, 1992. 

      2. Center for Disease Control. HIV/AIDS Surveillance
Report 1993; 5(3):17. 

      3. Grosz J. Hopkins K. Family circumstances affecting
caregivers and brothers and sisters. In Crocker AC, Cohen HJ,
Kastner TA, eds. HIV Infection and Developmental Disabilities.
Baltimore: Paul H. Brookes Co., 1992. 

      4. Hansell P. Hughes C, Caliandro G. et al. Stress,
coping, social support and problems experienced by caregivers of
HIV-infected children: A comparison of HIV-infected caregivers
to non-HIV-infected caregivers. Presentation from the IXth
International Conference on AIDS, Berlin, Germany, I 993. 

      Authors

      Phyllis Shanley Hansell, EdD, RN is a Professor and
      Director of Nursing Research, Seton Hall University,
      College of Nursing, in South Orange, New Jersey. 
      
      Wendy Budin, MSN, RN, is Assistant Professor, Seton Hall
      University, College of Nursing. 

      Phyllis Russo, EdD, RN, is Associate Professor, Seton Hall
      University, College of Nursing. 

      **************
      Recent Reports

      Partner Preferences and Serostatus

      Colleen C, Hoff BA, McKusick L, et al. The Impact of HIV
      antibody status on gay men's partner preferences: A
      community perspective. AIDS Education and Prevention.
      1992; 4(3): 197-204. (University of California San
      Francisco.) 

      Serostatus may influence the formation of primary partner
bonds in gay male communities, according to a large San
Francisco study. Seronegative and untested men were more likely
to prefer seronegative men than seropositive men for romantic
relationships, while seropositive men were more likely to prefer
other seropositive men or to report that serostatus did not
matter. 

      In November 1988, researchers surveyed 540 gay men by
mail. The survey included measures of sexual behavior, antibody
testing status, AIDS loss and relationship status, and partner
preference. Of the respondents, 9.3 percent were White and 69
percent were college educated. Twenty-nine percent were sero-
positive, 38 percent were seronegative, and 29 percent had not
been tested. The mean age of respondents was 35 years old. 

      Eighty-three percent of seronegative men and 74 percent of
untested men preferred uninfected partners for romantic
relationships, whereas 68 percent of seropositive men indicated
that antibody status did not matter.

      Seropositive men were less likely to report antibody
status preferences for friendships: 89 percent of those who
tested antibody positive versus 76 percent of those who tested
antibody negative and 79 percent who had not taken the test did
not have preferences for friendships based on antibody status.
Of those who stated a preference, however, seronegative men were
more likely than seropositive men to prefer seronegative men for
friendship. 

      Researchers found no connection between current
relationship status and serostatus preference for romantic
relationships or friendship. The one exception was that single
men were more likely than men in relationships to base a
preference for friendship on serostatus. 


      ---------------------
      Bereavement Reactions

      Neugebauer R. Rabkin JG, Williams JBW, et al. Bereavement
      reactions among homosexual men experiencing multiple
      losses in the AIDS epidemic. American Journal of
      Psychiatry. 1992; 149(10): 1374-1379. (Columbia
      University.) 

      A New York City study of gay men found no association
between loss and depressive symptoms for either seropositive or
seronegative men. In contrast, the study found for both groups
an increase in thoughts and feelings specifically focused on the
deceased person and in preoccupation with and searching for the
deceased. 

      Researchers interviewed, in 1988 and 1989, 84 seronegative
and 123 seropositive gay and bisexual men and subjected them to
medical, psychiatric, and psychosocial examinations. Researchers
measured depression using two self-report symptom check lists,
the Hamilton Rating Scale for Depression, and the Structured
Clinical Interview for DSM-III-R. 

      Of the 207 participants, 87 percent were White, 7 percent
Hispanic, and the remainder were Black or Asian. The mean number
of years of education was 16 and the mean age was 38 years old.
Half of the group reported one or more losses since the start of
the epidemic, and more than 20 percent had experienced a loss in
the six months preceding the interview. 

      Men with greater numbers of losses reported more
subjective experiences characteristic of preoccupation with and
searching for the deceased than did men with fewer losses.
Tearfulness at the thought of the deceased, inability to accept
death, or pain and distress when thinking about the deceased
were common symptoms. 

      In contrast, neither level of depressive symptoms nor rate
of diagnosed depressive disorder was related to number of
losses. The lack of association between loss and depressive
symptoms held for seropositive and seronegative men separately,
and held on three different depression scales. 

      -----------------------
      Gay Male Survivor Guilt

      Boykin FF. The AIDS crisis and gay male survivor guilt.
      Smith College Studies in Social Work. 1991; 61 (3):
      247-259. (Smith College.) 

      A small urban study found modest yet prevalent survival
guilt among gay men. Surprisingly, seropositive men tended to
have higher survivor guilt scores than seronegative men. There
was no clear correlation between survivor guilt and the number
of friends, ex-lovers, and lovers affected by HIV disease, and
there was a high correlation between involvement in gay or AIDS
organizations and relief from survivor guilt feelings. 

      Of the 92 subjects, 77 completed a written questionnaire
and 15 responded to a face-to-face interview. The study was
based on an original survey, in which the subjects
self-identified the presence and magnitude of survivor guilt.
Participants had a mean age of 36 years; all but two were White.

      Overall there was a modest amount of survivor guilt in
both the interview and the questionnaire groups. On a scale of
1 to 10, with 10 the highest, the survivor guilt score averaged
3.1 for the interview group and 2.5 for the questionnaire group,
with seropositive men scoring slightly higher than seronegative
men. It is notable that one-third of interviewees and
one-quarter of the questionnaire group experienced survivor
guilt at an intensity of 5. Sixty percent of interviewees and 53
percent of those who completed the questionnaire reported that
involvement in AIDS organizations helped alleviate feelings of
survival guilt. 

      --------------------------------------------
      Partners of HIV-infected Men with Hemophilia

      Klimes I, Catalan J. Garrod A, et al. Partners of men with
      HIV infection and haemophilia: Controlled investigation of
      factors associated with psychological morbidity. AIDS
      Care. 1992; 4(2): 149-156. (Oxford Haemophilia Centre,
      Oxford University and Westminster Medical School, London.)
      
      No differences were found in the psychological status of
female partners of HIV seronegative and HIV seropositive men
with hemophilia according to a study that determined the
prevalence of psychosocial problems in partners of men with
hemophilia and HIV infection. However, partners of men with
hemophilia, regardless of serostatus, had twice the number of
psychological symptoms of women in a general community survey. 

      The interviews focused on psychological status, sexual
functioning, and past psychiatric history, and included the
following self-administered scales: Modified Social Adjustment
Scale; Self-Control Schedule; Hardiness Scale; and Health Locus
of Control Scale. Partners of 17 seropositive and 19
seronegative men with hemophilia were interviewed. 

      The two groups of women were comparable in terms of age,
their own and their partner's employment status, and social
class. All women in the study were tested and confirmed HIV
antibody negative. On the average, the seronegative couples had
been together for 14 years, while the couples with a
seropositive partner had been together for an average of seven
years. In both instances, the women had known about their
partner's serostatus for at least three years. More than four-
fifths of the seropositive men were asymptomatic. Despite having
to cope with their husband's psychological state, changes in
sexual relationships, and concerns about HIV transmission, 78
percent of partners of seropositive men reported their general
relationship was unchanged since their partners first took the
antibody test. The heightened level of psychological distress
among all partners suggests that living with and managing
hemophilia is more stressful and of more immediate concern than
the challenges of living with asymptomatic HIV disease. While
the men's serostatus was not an indication of psychological
distress among partners, the women's past psychiatric history
and poor social adjustment were associated with psychological
morbidity. 

      Next Month

      In the new world of health care reform and managed care,
long-term psychotherapy may become a luxury. In response, many
practitioners are considering brief psychotherapy, particularly
for issue-specific treatment- for example, to cope with
bereavement and stress response syndromes. In the June issue of
FOCUS, John Devine, MD, Director of the Psychiatric Outpatient
Service AIDS Program of the San Francisco Veterans'
Administration Hospital, compares long-term and brief
psychotherapy, describes two approaches to brief psychotherapy
and applies them to HIV-related situations. 

      Group support is central to the HIV-related
psychotherapeutic response, and group psychotherapy is also seen
as a response to shrinking resources, especially when trained
volunteers can facilitate groups without compromising quality.
Also in the June issue, Louis Piccarello, a group facilitator
with the UCSF AIDS Health Project, describes the group
facilitation experience from the perspective of a volunteer. 

      Copyright (c) 1994 - Reproduced with Permission. 
      Reproduction of FOCUS must be cleared through the Editor,
      FOCUS --UCSF AIDS Health Project, Box 0884, San Francisco,
      CA 94143-0884, (415) 476-6430.  Subscription information:
      12 monthly issues- $36 individuals; $90 institutions.