Single session of cognitive therapy can lead to sustained fall in risky sex in MSM

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A single session of cognitive counselling can achieve a swift and sustained decrease in HIV risk behaviour amongst gay men who present for multiple HIV tests, according to a study conducted in San Francisco and published in the April 15th edition of the Journal of Acquired Immune Deficiency Syndromes.

The study involved 305 gay men who were recruited from publicly funded HIV testing sites across San Francisco between 2002 and 2004. All the men received standard pre-test HIV counselling and were provided with their HIV test result. However, half of the men were randomised to receive personalised cognitive counselling from a certified HIV counsellor where they had the opportunity to examine their decision making processes during recent sexual encounters when they had unprotected anal sex. Six and twelve months after the counselling intervention, the men were asked to provide details of their sexual activity, and the investigators calculated if the enhanced, personalised cognitive counselling was associated with a reduction in HIV risk behaviour. Participants in the trial were asked to say how satisfied they were with their counselling experience.

Personalised cognitive counselling, delivered by trained cognitive behavioural therapists has been shown in a previous study to be an effective way of reducing HIV risk-taking. However, the cost of employing mental health specialists to deliver this service would be prohibitive. Therefore investigators from the University of California and San Francisco Public Health Department wished to see if it was possible, effective, and acceptable to provide this intervention using so-called paraprofessionals – individuals educated to bachelor degree level, with a recognised certificate in HIV pre-test counselling, who had also received specialist training and support regarding personalised cognitive counselling.


risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

randomised controlled trial (RCT)

The most reliable type of clinical trial. In a trial comparing drug A with drug B, patients are split into two groups, with one group receiving drug A and the other drug B. After a number of weeks or months, the outcomes of each group are compared.

control group

A group of participants in a trial who receive standard treatment, or no treatment at all, rather than the experimental treatment which is being tested. Also known as a control arm.

unprotected anal intercourse (UAI)

In relation to sex, a term previously used to describe sex without condoms. However, we now know that protection from HIV can be achieved by taking PrEP or the HIV-positive partner having an undetectable viral load, without condoms being required. The term has fallen out of favour due to its ambiguity.

All the men who participated in the study were aged 18 or over and had had one previous HIV-negative test in the six months before entering the study and at least one episode of unprotected anal sex with a non-primary male partner in the last year who was either HIV-positive or of unknown HIV status. The men had a mean age of 36 years, 64% were Caucasian, 76% had a graduate degree and average household income was between $30,000 and $49,999 a year.

At the time of HIV testing the men were interviewed about their sexual risk behaviours, history of sexually transmitted infections, and drug use. These interviews were repeated six and twelve months later.

Standard HIV pre-test counselling was provided to all the men. However, the men who were randomised to the personalised cognitive counselling arm of the study also received 50 minutes of time with a counsellor who used a questionnaire to explore self-justifications for risky sexual behaviour. This questionnaire included a list of 33 possible self-justifications, and the men were asked to rate how strongly the thought had occurred to them. After completing the questionnaire, the men were asked by the counsellor to narrate events before, at the beginning of, and during the latest sexual encounter when they had had risky sex. On completing this narrative, the counsellor and participant discussed any identified self-justifications, and a plan to address these in the future was developed.

Similar amounts of risky sex were reported by men in both arms of the study at baseline (mean of 4.2 episodes, personalised cognitive counselling arm, versus mean of 4.8 episodes in the control arm).

A 60% reduction in the instance of risky sex was seen after six months amongst the men who received the cognitive counselling (mean 1.9, p

The reduction in risk taking was sustained until month twelve, when, once again men who received personalised cognitive counselling reported a mean of 1.9 risky sexual encounters. However, by month twelve, there had also been a significant fall from baseline in the amount of risky sex reported by men who only received standard HIV counselling (mean, 2.2, p

Individuals who received personalised cognitive counselling were significantly more likely to rate the quality of service they received as “excellent” (69% versus 54%, p = 0.022). In additionally only 9% of individuals who received the cognitive intervention reported that the issues that led to their risky sexual behaviour remained unchanged, compared to over a quarter of men who received the standard pre-test counselling (p = 0.01). None of the men in the cognitive counselling arm reported additional stress as a result of the intervention.

“This study demonstrated that our personalised cognitive counselling approach could be taught to and successfully delivered by experienced paraprofessional HIV antibody test counselors”, conclude the investigators. They add, “when compared in a randomized controlled trial with usual client-centered risk reduction counselling, the approach had a stronger and more immediate effect at reducing the incidence of [unprotected anal intercourse] among high-risk repeat testing [men who have sex with men].


Dilley JW et al. Brief cognitive counseling with HIV testing to reduce sexual risk among men who have sex with men. J Acquir Immune Defic Syndr 44: 569 – 577, 2007.