Making prevention work: interventions with gay men

If there was one big story at the Toronto World AIDS Conference, it was the results of the first trial of tenofovir pre-exposure prophylaxis in human beings¹. This proved conclusively that giving people condoms and safer-sex counselling stopped them catching HIV.

Come again? Wasn’t it meant to prove that taking antiretrovirals stopped them catching HIV? In fact there was no statistically significant difference between HIV incidence in the tenofovir (Viread) and placebo arms. This was because HIV incidence was half of what was expected. And this was because the proportion of women who used condoms the last time they had sex increased hugely, from 52% at screening to 94% by the end of the study. Out of every seven women who were regularly having unsafe sex at the beginning of the trial, six stopped.

Of course, we can’t prove that it was the condoms and the safer-sex counselling that the researchers were ethically obliged to provide that made the difference, because it wasn’t a randomised controlled trial of the concept. But it makes a pretty convincing case that if you supply the tried-and-tested prevention interventions to people who are in a position to use them, they work.

Another interesting moment at the conference was during the question-and-answer session at the end of the ‘Circumcision – Time to Act?’ session. Social scientist Gary Dowsett from La Trobe University in Australia, who himself presented sessions on how men who have sex with men define themselves in different cultures², questioned the way circumcision had suddenly become the latest ‘white hope’ in prevention technology.

He said that social scientists at the conference were becoming concerned about how the social and political consequences of potential mass circumcision programmes were being ignored by its proponents.

He said: “Circumcision isn’t a ‘prevention technology’, it’s a deeply meaningful social and political act. And even if some kind of effectiveness is demonstrated there are many public health tools we don’t use in this epidemic because of their moral and political consequences, such as quarantine.”

Dowsett earned both applause and mutterings for his intervention. But even if, as reports of Swazi men queuing at clinics suggest, fear of AIDS will overcome doubts about circumcision for men in high-prevalence countries, his general point is well-made: no prevention intervention can be divorced from its context, because HIV prevention always involves questions of culture, behaviour and identity. After all, condoms are a biomechanical prevention method with 90% efficacy, but we’ve spent 20 years trying to persuade people to use them, to supply them, and to sanction their use.

There were a huge number of posters and presentations about new ways of getting people to reduce risk presented at the conference, but few interventions were actually evaluated in terms of their effect on risk behaviour. One that was evaluated was the ‘popular opinion leader’ trial among young black gay men in North Carolina, reported here³. This produced really quite significant changes in risk behaviour among its target community – a target community with among the highest HIV incidence – in one study, a record-breaking 15% a year – of any group of people on earth.

Yet trials of this approach in the United Kingdom have failed. Why? Culture again: when a similar approach was tried in London among gay gym users, the researchers had difficulty in recruiting opinion leaders, and they in turn had huge difficulty “in talking to complete strangers about sex,” to quote the researchers. This is less likely to be a US/UK cultural difference than a small town/big city one. All the trials of this approach that have been successful have taken place in small, tightly-knit gay communities. People come to big cities precisely in order to seek anonymity and change their identity and where there is no unitary ‘peer group’.

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.

Several sessions at the conference took a long-overdue look at the HIV epidemics occurring among men who have sex with men (MSM) in the developing world. In some parts of the world such as south-east Asia, there is evidence of a quite recent and sudden increase in HIV prevalence among gay and male-desiring men. For instance, Fritz van Griensven¹³ reiterated the news from a survey published last December that showed, using careful sampling in many different kinds of gay meeting place, that HIV prevalence among MSM in Bangkok had increased from 17.3% in 2003 to 28.3% in 2005.

Van Griensven was also involved in a Bangkok survey¹⁴ that showed that, despite being at higher risk of HIV, receptive gay men (‘bottoms’) had something in common with women, in that they had a harder time enforcing condom use than insertive men. Receptive men were very significantly more likely than insertive men to report not using condoms: insertive men were twice as likely as average to have safer sex and receptive men 60% less likely.

Altogether, 22% of men who identified as gay and 29% of transsexuals reported not using condoms during their last sex.

Back in Africa, however, HIV is still largely considered to be a heterosexual matter. There was one poster¹⁵ from, of all countries, Sudan, looking at the lives and HIV risks of young receptive MSM in Khartoum. This stigmatised and hard-to-reach population was contacted through ‘snowballing’, i.e. using one contact to contact friends. The 713 men surveyed were young (50% school age) and 9.3% had HIV.

Unsurprisingly, three-quarters were involved in commercial sex and although 47% had used a condom at last sex, only one in 30 did so consistently. Alarmingly, 53% - perhaps the same ones who didn’t use condoms – did not know that anal sex was an HIV risk. The researcher comments: “The study revealed that MSM are part of the Khartoum…community, though marginalised and undignified.”