‘Opinion leader’ campaign in young black gay men achieves significant reductions in unsafe sex

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With HIV prevalence among young African-American men who have sex with men reported as high as 46%, or over 15 times the prevalence reported among white peers, this is clearly a group in need of HIV prevention interventions. However very few interventions designed specifically for young black MSM have in fact been devised.

The XVI World AIDS Conference in Toronto heard of an apparently successful one on Monday August 14th.

Kenneth Jones of the Centres for Disease Control and Prevention, reporting on behalf of the North Carolina Men’s Health Initiative, reported on the success of ‘d-UP,’ a prevention campaign conducted among young black MSM recruited in nightclubs in the towns of Raleigh, Greensboro and Charlotte between December 2004 and December 2005.

Glossary

sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

pol

The HIV gene that encodes a group of enzymes needed for viral replication (called protease, integrase and reverse transcriptase).

receptive

Receptive anal intercourse refers to the act of being penetrated during anal intercourse. The receptive partner is the ‘bottom’.

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.

statistical significance

Statistical tests are used to judge whether the results of a study could be due to chance and would not be confirmed if the study was repeated. If result is probably not due to chance, the results are ‘statistically significant’. 

The campaign resulted in significant reductions in unprotected anal intercourse (UAI) amongst the target population by the end of the campaign and a significant reduction in unprotected receptive anal intercourse (URAI) within four months of the start of the campaign.

The d-UP campaign is based on the ‘Popular Opinion leader’ (POL) concept of HIV awareness dissemination pioneered by Jeffrey Kelly in two studies in 1991 and 1997. The idea is to recruit members of the local community who are particularly popular and influential and train them to hold discussions on risk reduction with their peers. In the USA Kelly’s trials of the concept remain amongst the most successful community-level HIV behaviour-modification initiatives, though they may not always be translatable across cultures: the same concept tried among gym users in London (Elford) and gay bar-goers in Glasgow (Flowers) produced little or no behavioural change.

The d-UP campaign recruited opinion leaders in 2004 and in conversation with them adapted Kelly’s POL scripts to include matters of relevance to young black gay men such as, to quote Kenneth Jones, “Racism, homophobia, bisexuality, poverty and religion.”

The website recruiting the POLs says:

“Few people have the opportunity to learn and pass along information that can actually save other people's lives. You will have this opportunity, and if you take it, you will have made a positive impact on your community. We will also provide you with d-UP wear: t-shirts, sweatshirts, headbands, wristbands, dog tags, book bags, pens, etc. We want you to wear your gear so that we can spread the word about reducing the rates of HIV infection for African-American men.”

The POLs also received $20 gift vouchers for attending training sessions. After the initial training-up period, quarterly surveys were then done of the local young black MSM population to assess rates of behaviour change, if any. POLs had to keep diaries of conversations held and with whom.

The group assessed numbered 1,198 men, 15% of whom were trained as POLs themselves. They were young, with a mean age of 23; a majority (57%) identified as gay; HIV prevalence was very high, at 44%; and although two-thirds had tested for HIV in the last 12 months there was a much lower rate of STI awareness and testing, with only 3.1% having had an STI checkup in the last 12 months, suggesting that over-concentrating on HIV testing may be leading to reduced awareness and monitoring of general sexual health, especially amongst those who are already HIV positive.

At baseline 42.0% of the sample reported unprotected anal sex. By 12 months this had declined by a third (32.3%) to 28.5% of the sample. This was statistically significant (p=.0009).

More dramatic was the decline in unprotected receptive anal sex (URAI). At baseline 32.4% of the sample reported URAI at baseline. By four months into the study this had declined to 24.7% and by 12 months to 18%, or a 44.5% decline (p=.0001).

Unprotected Insertive Sex (UIAI) declined too, from 29.3% at baseline to 18.6% at 12 months, a 36.5% decline (p=.0033).

The trial had no control group as the design meant that the POLs were free to choose who they talked to and how much, so a direct relationship cannot be demonstrated between the behaviour change and the POL training. Kenneth Jones also commented that other variables such as whether participants moved in and out of long-term relationships and therefore in and out of risk groups were not monitored.

Nonetheless this represents a rare success among a group at high risk of HIV infection that has hitherto been seen as ‘hard to reach’ with conventional HIV prevention messages.

References

Jones K et al. Evaluation of a community-led peer-based HIV prevention intervention adapted for young black men who have sex with men (MSM). Sixteenth International AIDS Conference, Toronto. Abstract MoAbC0103. 2006.

Elford J et al. Peer education has no significant impact on HIV risk behaviours among gay men in London. AIDS 15(4):535-8. 2001.

Flowers P et al. Does bar-based, peer-led sexual health promotion have a community-level effect amongst gay men in Scotland? Int J STD AIDS.13(2):102-8. 2002.