Only a quarter of gay men who had had unprotected sex
were offered and accepted a structured intervention (such as motivational
interviewing or counselling) when attending their sexual health clinic, according to an
audit published this week in the online advance edition of Sexually Transmitted Infections.
The authors recommend that the reasons why such
interventions are not offered to men at higher risk of HIV infection be
investigated and addressed. Moreover, practitioners need a better understanding
of how acceptable such interventions are to potential participants.
One of the first
pieces of public health guidance issued by the National Institute for
Health and Clinical Excellence (NICE), in 2007, was that health professionals
should offer a structured discussion on risk reduction to people who are at
high risk of having a sexually transmitted infection (STI), including men who
have sex with men. These one-to-one discussions should be structured on the basis
of behaviour change theories, and should address factors that can help reduce
risk taking and improve self-efficacy and motivation. Sessions – of which there
may be more than one - should last at least 15 to 20 minutes.
Similarly, recent safer sex guidelines from the
British Association for Sexual Health and HIV (BASHH) and the British HIV
Association (BHIVA) recommend that brief (15-20 minute) evidence-based
behaviour-change interventions focussing on skills acquisition, communication
skills and increasing motivation to adopt safer behaviours, using
techniques such as motivational interviewing, should be routinely provided to
those at elevated risk of infection. Motivational interviewing
techniques should be used as part of an intensive course of risk-reduction
counselling for gay men at high risk of HIV infection.
Compliance with the guidance was assessed by an audit
conducted at 15 of the larger sexual health clinics in England. For each, the
notes of 40 gay or bisexual male patients who attended in June 2010 were
examined, with a total of 598 sets of notes available. Men with diagnosed HIV were
The average age was 34 and three-quarters were of white
ethnicity. One third of men reported unprotected anal intercourse in the past
HIV testing was offered to almost all men (92%), in line
with guidelines, and almost all men accepted the offer (92%). In the twelve months
that followed, 43% of men tested at least one more time.
Four-in-ten patients (251) received a behavioural
intervention, but frequently this was just advice. Fewer than one-in-ten (52)
received a structured behavioural
intervention as recommended by NICE.
Interventions delivered were counselling (37 men),
motivational interviewing (14 men), cognitive behavioural therapy (2 men) and
peer education (2 men).
Although men who reported unprotected anal intercourse (UAI) in
the past six months were more likely to be offered and to accept an
intervention than men who didn’t report UAI, uptake remained low.
The notes didn’t contain much detail on refusals, but it was
recorded that 42 men were offered and refused an intervention, including
advice. Of these, three men said they didn’t have time and 17 felt that they
didn’t need the intervention (of whom six had reported unprotected sex).
The authors discuss possible reasons for the limited
number of men who are offered structured interventions. These could include limited
resources, lack of training, and guidelines only being published relatively recently.
Moreover, while such interventions may have a relatively modest impact on
infection rates, they require intensive efforts and should be offered in
The audit also has information on how clinics define
which men are at high risk of HIV infection. This is relevant as guidelines recommend that risk assessments are conducted.
Based on examination of policy at 24 clinics, there
appears to be great variability. Four clinics considered all men who have sex
with men to be, per se, at higher
risk. Two clinics had no criteria at all, while the other 18 took into account a
mix of unprotected sex (17 clinics), having an HIV-positive partner (14),
previous STI infection (13), problematic drug or alcohol use (12), partner numbers (8) and
previous use of PEP (7).
The authors comment that UK sexual health clinics need a
standardised risk assessment tool, which could be used to target intensified
interventions to men with the greatest need.