Bringing together opposites: how dialogue groups are helping to reduce HIV risk behaviour in Africa and Miami

Studies of HIV prevention interventions from remote villages in South Africa and from the ‘gay ghetto’ of Miami, presented at the Eighth AIDS Impact Conference in Marseilles last week, show that facilitating dialogue between potential transmitters and acquirers of HIV who normally don’t talk together – in one case young men and women, in the other HIV-positive and negative gay men – can produce significant reductions in risk behaviour and in HIV/STI incidence.

Stepping Stones is not a new programme. Devised in 1995 by Alice Welbourn, Chair of the International Community of Women Living with HIV (ICW), it is described as a “gender transformative programme for HIV intervention,” in other words it uses participatory learning groups to bring young women and men together to talk about issues such as sexual violence, women’s inequality, negotiating condom use and the way gossip is used to destroy reputation.

Introduced in Uganda, it was brought to South Africa in 1998, but this trial was the first proper evaluation of its biological and behavioural outcomes. Direct measurements of HIV and STI incidence are quite rare in studies of behavioural interventions, as they require large study groups in high-incidence areas. Most studies measure behavioural outcomes.

Rachel Jewkes of the South African Medical Research Council told the conference that Stepping Stones was probably the most widely-used HIV behavioural intervention in the world. Other countries that have used it include Tanzania and Mozambique, where 500,000 young people have been through the programme.

The intervention consists of 14 three-hour single-sex groups for young women and men, who are then brought together for three mixed-sex dialogue groups. This controlled trial consisted of comparing the full Stepping Stones programme with one called “Stepping Stones Short” which included the modules on HIV information, safer sex and condom use but omitted the broader discussions of gender relations.

The trial recruited 1,423 women and 1,371 men aged 15-26 years from 70 villages in a remote rural region of Eastern Cape province around the town of Umtata. Villages, rather than individual participants, were randomised to receive either the full or the short programme.

Most of the young people were recruited through schools. HIV and herpes (HSV-2) prevalence and sexual behaviour were assessed at baseline, 12 months and 24 months through blood tests and in a face to face interview. Follow-up rates at 24 months were 87% (for blood tests) and 75% (for the behavioural re-interview). All 70 villages stayed in the programme.

A small qualitative study interviewing eleven women and ten men before and after the study elicited more in-depth reactions to the programme.

At baseline 11% of the women and 2% of the men had HIV, and 27% and 10% respectively had HSV-2. Incidence of HSV-2 was measured because HSV-2 infection increases vulnerability to HIV infection due to genital herpes ulcers, and because HSV-2 infection, even without symptomatic genital herpes, may increase HIV shedding in genital fluids, particularly in women.

At follow-up there was no difference in HIV incidence amongst the men (1.38% a year in both arms) and only a non-significant difference in herpes incidence (1.42% versus 2.02%, p = 0.36), though Jewkes commented that HIV incidence was generally lower than expected. In women there was a non-significant difference in HIV incidence (5.69% versus 6.74%, p = 0.35), but a significant difference in herpes acquisition (5.1% versus 7.4%). Adding together HIV and HSV-2 incidence in both women and men yielded a ‘composite efficacy’ of 31% for the programme.

There were significant behavioural changes amongst the men. Men in the full programme reported 9% fewer sexual partners at 12 months and 14% fewer at 24 months and also reported more condom use, less transactional sex, less severe inter-partner violence, and less substance use. Forty-four per cent of men in the intervention arm decided to get an HIV test versus 34% in the control arm.

There were fewer differences in behavioural outcomes for women, which may reflect less ability to take control over behaviour. Jewkes told the conference that young men showed increased rates of carrying condoms (even though one man described doing this as “hunting with salt”, i.e. appearing over-ready for sex) and using them.

Women however showed less sense of agency in their dealings with men; one young woman described her experience of unsafe sex with an older boyfriend (a teacher) as “these things happen on their own,” and although some women were able to insist on condom use, others described not daring to for fear of jeopardising their relationship.

The intervention in Miami, in contrast to Stepping Stones, was a pilot intervention of a new concept in HIV prevention for gay men in which ‘high-risk’ HIV-positive and HIV-negative gay men were brought together to discuss HIV risk and risk behaviour.

Researcher Steven Kurtz of the University of Delaware first conducted extensive focus groups among gay men described as heavy substance users (meaning more than three instances of recreational drug use in the last 90 days, excluding alcohol) and having significant amounts of unprotected sex (meaning more than two incident in the last 90 days).

This fieldwork indicated that HIV risk was exacerbated, said Kurtz, “because of striking differences in HIV-positive and HIV-negative men’s attitudes toward the severity and meaning of HIV infection, their perceptions of responsibility for self protection and disclosure, and the lack of shared meanings of non-verbal serostatus disclosure techniques.”

He told the conference: “Safer sex behaviour and serostatus disclosure norms are different for HIV-positive and negative men.”

Because of this, he came to the conclusion that conducting discussion or support groups restricted to men of one HIV status may do more harm than good.

“Serostatus-segregated risk reduction interventions maintain social segregation,” he told the conference, “and may sustain bounded disclosure norms.”

He said that his focus groups revealed that:

• There was evidence that significant numbers of men were avoiding HIV testing in order to avoid diagnosis.
• Silence pervades sexual situations; verbal HIV status disclosure is the exception, not the rule.
• This silence is “embedded in gay and bisexual men’s lifelong patterns of secrecy,” i.e. gay men have grown up learning to be silent about their sexuality and lack terms with which to discuss it.
• Non-verbal attempts at disclosure are frequently misunderstood; as other studies have found, an offer of unprotected sex is intended by positive men as a declaration of their HIV status but is interpreted by negative men as the opposite, i.e. a declaration that they are ‘safe’.
• Open discussion is hindered by HIV-negative men’s extreme fear of infection and HIV-positive men’s equally extreme fear of being blamed or rejected; by fatalism about the inevitability of HIV; and by “wanting to be in love,” which led men to fantasise that their partner ‘must’ share their serostatus.

These qualitative findings led Kurtz to develop the MensROOM (Men Reaching Out to Other Men) intervention.

This consisted of a short (three-session) discussion group for gay men with and without HIV. The sessions covered life history; shared experiences; critical discussion and awareness of individual and group norms of risk behaviour and disclosure; and goal setting.

The study recruited gay and bisexual men aged 18 and older. Their median age was 38 and although their standard of education was good their income was generally low, with average earnings of only $18,000 a year. It was a very racially mixed group (38% Hispanic, 32% African American, and 30% white). Forty per cent had HIV and 26% had had an sexually transmitted infection (STI) in the last six months.

Participants reported high rates of current depression (75%), arrest (65%) and homelessness (52%) histories. This was a group with high rates of drug use: participants reported taking drugs two-thirds of all days in the last 90 days and an average of 22 out of the last 90 days in which they were ‘high all day’.

The intervention was popular; 84% of participants attended all three sessions and 91% at least two.

The intervention produced significant changes in behaviour (although it should be noted that this was not a controlled study, so there was no comparison group).

Unprotected anal intercourse (UAI) with casual partners in the past 90 days was reduced by over 50% from a mean 17.4 times at baseline to 8.1 times at follow-up, with 53.5% of respondents reporting no UAI at follow-up.

The number of sex partners in 90 days was reduced by almost 50% from 12.8 at baseline to 6.9 at follow-up. Drug-free days increased from 36 in 90 days at baseline to 46 at follow-up and ‘high all day’ decreased from 22 days at baseline to 11 at follow-up.

Apart from the behavioural changes, the most striking finding of the study was, Kurtz reported, the men’s surprise at finding themselves in a mixed status group.

“We did not say in the recruiting ads that this would be a mixed-status group. It was advertised as being ‘three sessions to talk about men’s health, drugs, sex and dating’. Men just assumed it would be a support group for men of their own status and it became clear during the first session that they were astonished at finding not all men shared their status.

“Discussions of who had responsibility for maintaining safer sex – the positive or negative partner – were polarised, with negative men saying that positive men had the primary responsibility, and positive men saying that negative men were responsible for their own protection. Discussion did become heated at times but this was resolved with skilled facilitation. The ground rules we established needed to overcome considerable emotional vulnerabilities and entrenched beliefs.”

HIV-positive men described multiple layers of stigma and perceived sexual and social status even within their own population: between “just HIV” and “AIDS”; between undetectable and not undetectable; and between first and subsequent drug regimens.

HIV-negative men described often feeling ‘left out’ of structures of support and understanding.

Not everyone was helped by the intervention. Statistically significant baseline predictors of non-response included the use of poppers; poor physical health; a higher-than-average number of partners; and “high levels of sexual sensation seeking,” as measured by a questionnaire. However there was no difference in response rates between HIV-positive and negative men or between men of different ages or ethnicities.

Kurtz now intends to take the MensROOM intervention forward into a larger randomised trial.