Successful peer-recruited project shows it is possible to do prevention work with gay men in hostile environments

A community education and HIV prevention project that took place among 626 gay men and other men who have sex with men (MSM) in St Petersburg in Russia and Budapest in Hungary produced significant falls in the proportion of men having unprotected sex, especially with casual or multiple partners. The incidence of HIV and sexually transmitted infections (STIs) also decreased in the intervention arm, though the study was too small for these falls to be statistically significant

How subjects were recruited

The study, conducted in the two cities between 2007 and 2012, randomised men into two groups.

Men were recruited initially by means of anthropological research. Researchers connected with the gay community frequented gay bars, cruising grounds or attended private parties and identified individuals who seemed to a) have a particularly large number of social contacts and/or b) were acquainted with different groups of men who otherwise did not know each other, in other words served as social links, and/or c) confirmed that they often talked about important issues.

The recruiters identified 18 such ‘seed’ individuals. They were then asked to recruit other men they know for the study, who were in turn asked to recruit more men, who were each asked to recruit more men. There were thus three ‘rings’ of friends surrounding the initial ‘seed’ individual. There were ten groups recruited in Russia and eight in Hungary. The average number of men in each group was 35, and groups ranged in size from eight to 65 men. Groups in Hungary tended to be larger (average 46 members versus 25 members in Russia). Everything was done on a first-name basis and confidentiality was elaborately assured.

The participants and the study intervention

Glossary

condomless

Having sex without condoms, which used to be called ‘unprotected’ or ‘unsafe’ sex. However, it is now recognised that PrEP and U=U are effective HIV prevention tools, without condoms being required. Nonethless, PrEP and U=U do not protect against other STIs. 

p-value

The result of a statistical test which tells us whether the results of a study are likely to be due to chance and would not be confirmed if the study was repeated. All p-values are between 0 and 1; the most reliable studies have p-values very close to 0. A p-value of 0.001 means that there is a 1 in 1000 probability that the results are due to chance and do not reflect a real difference. A p-value of 0.05 means there is a 1 in 20 probability that the results are due to chance. When a p-value is 0.05 or below, the result is considered to be ‘statistically significant’. Confidence intervals give similar information to p-values but are easier to interpret. 

safer sex

Sex in which the risk of HIV and STI transmission is reduced or is minimal. Describing this as ‘safer’ rather than ‘safe’ sex reflects the fact that some safer sex practices do not completely eliminate transmission risks. In the past, ‘safer sex’ primarily referred to the use of condoms during penetrative sex, as well as being sexual in non-penetrative ways. Modern definitions should also include the use of PrEP and the HIV-positive partner having an undetectable viral load. However, some people do continue to use the term as a synonym for condom use.

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.

syphilis

A sexually transmitted infection caused by the bacterium Treponema pallidum. Transmission can occur by direct contact with a syphilis sore during vaginal, anal, or oral sex. Sores may be found around the penis, vagina, or anus, or in the rectum, on the lips, or in the mouth, but syphilis is often asymptomatic. It can spread from an infected mother to her unborn baby.

All participants received HIV and STI testing on entry to the study plus a basic counselling/education session lasting 20 minutes covering HIV risk, how to reduce it, and strategies to try.

All participants completed questionnaires three months after the end of the study period and another twelve months afterwards. These did not just include sexual behaviour but also asked participants how easy they had found it to do things like discuss condom use and how often they had had conversations about HIV risk.

Participants received modest financial incentives to attend testing and questionnaire visits and, in the intervention arm, training sessions.

In the one half of subjects that comprised the intervention arm, 30% of the men (101 out of 314), were identified as ‘leaders’, based on the same set of criteria as those originally recruited as ‘seeds’. These leaders received training in HIV prevention, both information-based and psychological. These training sessions lasted three hours: five were conducted in the first month followed by four more at monthly intervals. The training looked at how risk knowledge, norms, attitudes, intentions, and self-efficacy (confidence) affect whether people adopt behaviour that protects them against HIV.

A lot of the training workshops was taken up, via role plays, with devising messages that the leaders could drop into conversations with friends. Leaders practised their skills on each other and at each training session gave feedback on their success in talking to group members about HIV and safer sex over the previous month and received suggestions and feedback from other leader-workshop members. While leaders were assigned to talk to their specific group of friends/contacts about the subjects they had dealt with in the workshops, there was no specific suggestion for how to do so.  All study participants were also asked how often in the past three months anyone (not just a trained leader) had talked to them about HIV and about HIV risk reduction in the past three months.

The average age of the men in the study was 28. Most had had secondary education, about 70% were in full time work and most of the others were students. About 80% had ever had an HIV test. HIV prevalence among the groups was 7.2% and altogether 15% had either HIV and/or another STI, with gonorrhoea being the most common. A minority of men (11%) were married (to a woman). Over 60% reported multiple partners in the previous three months. Alcohol use was relatively moderate, with men reporting on average drinking alcohol one out of every five days, though nearly half reported they’d got drunk at least once in the last month. Nearly half also reported using poppers or marijuana: rates of use of other drugs were low and only 2% reported recent use of injected drugs.

Results of the intervention

There were significant falls in indicators of sexual risk in the men who belonged to the intervention/peer-education group. In this group. The proportion who reported any condomless anal sex with any partner within the previous three months fell from a mean of 54% at baseline to 38% three months after the study and was at 43% a year after the end of the study. In contrast the proportion of men reporting condomless sex was the same at all three timepoints in the non-intervention group, at approximately 57%. This difference between intervention and control groups was statistically significant (p=0.036).

The median number of occasions of condomless anal sex in the past three months fell from two at baseline to zero at month three and month 12 in the intervention arm but increased from one to two in the non-intervention arm.

More striking was the fall in the proportion reporting condomless sex with casual and non-regular partners: this declined from 18% at baseline to 8% three months after the intervention and 9% twelve months after:  in contrast it remained at approximately 22% in the non-intervention group (p=0.042).

The same applied to group sex with multiple partners: this declined from14% to 2% to 5% at baseline, month three and month twelve in the intervention groups but only declined non-significantly from 19% to 17% to 13% in the non-intervention group. This was not due to any overall reduction in sexual behaviour as the number of occasions of anal sex and the number of different partners that men reported stayed the same over the study and did not differ between groups.

The reductions in condomless sex, casual sex, and group sex were not just restricted to the trained leaders: when these were removed from the analysis, the falls in sexual risk behaviour in the intervention group remained.

This study was not big enough to prove statistically whether these changes in risk behaviour translated into significant reductions in HIV and STI infections. Nonetheless, while five per cent of the non-intervention arm members became HIV positive in the year after the study, only 3% did in the intervention arm; and while 8% in the non-intervention arm had syphilis, gonorrhoea or chlamydia at one-year follow-up, only 5% on the intervention arm did.

Comparisons with other studies

This study resembles behavioural interventions that were studied in the US gay community the 1990s and 2000s, for instance in so-called “popular opinion leader” interventions in which individuals judged to be influential or popular within their communities were trained up as community communicators in safer sex. Some of these studies had positive results, others did not or were not found to offer greater benefits than individual counselling. However this is the first intervention study to combine this approach with so-called ‘snowball recruitment’, a technique often used for behavioural surveys among gay men and other groups such as sex workers in hostile environments that might be exposed to legal attention or violence if they were recruited more openly.

It does show that it is possible to recruit and work with gay men and other MSM in situations where they are criminalised and must remain anonymous although, as the researchers point out, this method of recruitment would not work with MSM who were completely isolated.

References

Amirkhanian YA et al. Effects of a social network HIV/STD prevention intervention for MSM in Russia and Hungary: a randomised controlled trial. AIDS, early online edition. Doi: 10.1097/QAD.0000000000000558. 2015.

This report is also available in Russian.