This has led to the proliferation of approaches using the internet, a medium where you can have very personal talks with a complete stranger but hide behind a nickname. Numerous studies have now confirmed that gay men use the internet as a tool for making disclosure of HIV status easier, as we reported here4.
These fall roughly into four types:
1.Notification schemes for people who have contracted a sexually transmitted infection and want an anonymous way to tell partners. In one such approach in Boston5 60% of the gay men notified through an email that they might have been in contact with an STI duly phoned up the clinic hotline.
2.Sites that use health advisors in chatrooms. Although this approach has been used for some years in both the UK and the US, such resources have tended to be under-used relative to the rather labour-intensive nature of the work and have tended, again, to succeed best with small, tightly-knit communities such as Hispanic gay men in California. No successful interventions using the approach were presented at Toronto, but a much larger intervention is being prepared for trial, using community consultation, in the US5.
3 Sites that use animated characters to guide people through an educational process around drugs, sex and HIV. Two examples presented at the project were the Dutch site www.gaycruise.nl8 and the harder-edged, New York-based www.mysexycity.com9. One intended specifically for HIV-positive youth is the site www.livepositive.ca10). ‘Gaycruise’ uses elements of the two previous approaches: it can be accessed via a ‘nick’ (online name) in gay chatrooms, and breaks from the animated characters to use live actors in photomodel stories acting out safer sex and dating dilemmas.
Gaycruise has been evaluated for efficacy: according to the results of an online questionnaire of site users, it produced statistically significant increases in the proportion of men who always take condoms on a first date and who bring up their HIV status online before meeting.
4. Sites that use role models. This is an extension of the ‘popular opinion leader’ concept into cyberspace and was pioneered by www.hivstopswithme in the USA. In Australia www.stayingnegative.net.au6 has extended the concept to using gay men who are HIV-negative as role models, getting them to relate their life stories and day-to-day decisions around sex and dating.
In an entertaining presentation, Mike Kennedy of the Victoria AIDS Council said that the site was based on the ‘information/motivation/behavioural skills’ model of behaviour change. He said that gay men need more than just information about HIV in order to change their risk behaviour; they have to have the skills and the motivation to do it.
Analysis of prevention messages since antiretroviral therapy arrived showed they were based mainly on medicalised statements about HIV risk and ways to avoid it; this did not place the risk in the context of gay men’s real thought patterns and behaviour. In other words it did not get gay men to think why they took risks in the first place. Role models taking about their daily lives could do this. In response to criticism that it might possibly portray seroconversion as a failure, Kennedy said that the site had also recently started recruiting HIV-positive spokesmodels. ‘Staying Negative’ has been running for 18 months and is currently being evaluated for effectiveness.
A similar site7, but directed at people with HIV, will soon be up and running in the UK. DIPEx (www.dipex.org) is a site using as spokesmodels patients with chronic health conditions and the HIV section has been developed as a collaboration between researchers, two HIV clinics in London, patients and two NGOs (the Terrence Higgins Trust and George House Trust). It will be up and running in November. It uses video interviews with HIV-positive spokesmodels to talk about specific aspects of living with HIV, including disclosure, coping with mental health problems, religion and stigma and discrimination, and users will be guided through the site using a carefully structured directory of topics.
DIPEx is directed at both gay men and Africans with HIV, since research showed that 75% of Africans with HIV in the UK have internet access, though it will also be available on a CD. Although most of the (largely white) gay men on the site speak as themselves, fear of stigma prevented all but one of the African spokesmodels doing so and their words are spoken by actors. A trial of DIPEx’s effectiveness in meeting the prevention needs of high-risk or newly-diagnosed patients is being planned.
All this internet-based activity surely doesn’t apply to the developing world, does it? Well, several surveys showed high levels of internet use among gay men in countries like the Philippines11 and Peru12.
The Peru survey used banner ads on www.gayperu.com, enticing some of the participants with offers of free condoms and STI tests. A total of 1,124 men responded to the survey of whom 79 (7%) said they had HIV – half the estimated prevalence according to UNAIDS. Fifty-four per cent had taken an HIV test – a higher proportion than in, for instance, Glasgow – and 70% had met a sex partner through the internet in the last year. Forty-seven per cent of those who had had and HIV test and 58% of those who had not had had unprotected receptive anal sex during the last year. Eighty-three per cent said they would be interested in HIV prevention initiatives such as email STI contact tracing and discussion groups.