Outreach work has developed in a number of settings thought to expose individuals to high risk of HIV infection. These include public sex environments (PSEs), commercial sex premises (saunas, massage parlours) and gay clubs. Outreach work has also occurred on the streets amongst injecting drug users, homeless youth and commercial sex workers.

The attraction of outreach work is that it can bring individuals into contact with services and messages they might not have received otherwise (e.g. Bleach and teach in San Francisco, see Social diffusion below). It also reaches people at earlier stages in their drug using careers, although there is no clear evidence that it is a superior method for reaching men who are just becoming homosexually active.

Outreach work is highly labour intensive when professionalised, and difficult to regulate when performed by volunteers. There is a considerable literature on outreach projects with injecting drug users (e.g. Rhodes 1991), which have been evaluated more thoroughly than work in cottages and cruising areas (PSEs). Rhodes et al found that existing outreach methods among injecting drug users had a number of limitations:

• They only reached those who were relatively easy to reach `hard to reach' drug users.
• Outreach tends to target individuals rather than the social networks in which they use drugs or have sex, despite the fact that community–wide norms influence behaviours.
• Drug users had a variety of other needs which took precedence over receiving advice about HIV risk. They wanted housing, money and treatment.

Nevertheless, Rhodes concluded that outreach had an important role to play in HIV prevention work with injecting drug users, a view endorsed by the Department of Health and NHS Executive in its 1997 guidance on purchasing effective treatment and care for drug misusers. However, the guidance also recommended that providers should collect data including statistics on `the effect of contact', without a clear discussion of how purchasers might judge when the aims and objectives of an outreach project were either realistic or being met effectively in terms of behaviour change. Specific outcome measures for assessing behaviour change and project efficacy amongst IDUs are discussed in Risk behaviour: injecting drug users below.

Outreach work with gay and bisexual men in public sex environments has been one of the preferred models of intervention with this group, based on a number of assumptions:

• A significant population of hard to reach gay and bisexual men exists who can only be reached through such settings, and who will otherwise remain uninformed about HIV risks.
• Cottages and cruising areas are a significant locus of unsafe sexual activity.

Evidence from research in the UK tends to contradict both these assumptions. Many cruising areas are heavily used by gay men who also frequent the commercial gay scene, as the SIGMA Research Pride surveys have demonstrated. Weatherburn has also shown that men who do not use the commercial gay scene with a high degree of frequency and who may not identify as gay, nevertheless have a high level of knowledge about HIV. Other researchers have shown that unprotected sex is less likely to occur in cottages than at home.

However, research by GMFA on the sexual behaviour and condom use of men using London's largest cruising area indicates that:

• A large proportion of men who use that location to meet sex partners will have sex with those partners, either on the Heath or later at home.
• Condoms distributed by GMFA were used on the Heath.
• A large proportion of men did not bring condoms to the Heath.
• A large proportion of those who did bring condoms did not bring lubricant, or brought condoms which may be unsuitable for anal sex.
• The population reached on the Heath was not disproportionately different from that identified by another GMFA survey (Kelley 1997) as regular users of the commercial gay scene.

This research suggests that outreach which concentrates on face-to-face contacts will be less cost–effective than outreach targeted at sites where a high volume of sexual contacts takes place, and where many opportunities exist to supply appropriate condoms and lubricant.

References

Kelley P, et al: How far will you go?, GMFA, 1997.

Rhodes T, et al: Hard to reach or out of reach: an evaluation of an innovative model of HIV outreach education, Tufnell Press, London, 1991.

Rhodes T, et al: Out of the agency and onto the streets: a review of HIV outreach health education in Europe and the United States, ISDD, 1991.

Rhodes T: Outreach work with drug users: principles and practice, Council of Europe, 1996.

Weatherburn P, et al: No aggregate change in homosexual HIV risk behaviour change among gay men attending the Gay Pride festivals, 1993–1996, AIDS 10: 771–774, 1996.

Weatherburn P, et al: Behaviourally bisexual men, HEA, 1996.