'Trickle-down' education can increase safer sex practices in hard-to-reach communities

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Hard-to-reach communities at high risk of acquiring HIV may well benefit from peer-led risk-reduction interventions, according to the results of a two-arm randomised community trial in Russia and Bulgaria. According to a paper from United States, Russian, Bulgarian and Hungarian researchers, published in the November 4th edition of the journal, AIDS, now available online, educating the leaders of small social networks of young gay and bisexual men with HIV risk-reduction information leads to a 'trickle-down' effect of this information, and increased safer sex practices.

Explosive HIV and STI epidemics are currently affecting Russia, Ukraine and neighbouring former Soviet-bloc countries, like Bulgaria. In the Russian metropolis of St Petersburg (population 4.6 million) alone, one of the two sites of this current study, HIV prevalence increased 100-fold between 1998 and 2003, disproportionally affecting injecting drug users (IDUs), sex workers and their clients, and gay and bisexual men. Although Sofia (population 1 million), Bulgaria's capital, has lower HIV incidence, STI rates are high and sexual HIV transmission is predominant.

Long after the Soviet era, many gay and bisexual men in Eastern Europe remain 'in the closet'. The long-held distrust of government agencies has resulted in few gay and bisexual men receiving information on how to avoid and reduce the risk of acquiring HIV and sexually transmitted infections (STIs). These former Soviet countries also do not yet have a network of community-based non-governmental organisations providing safer sex information, and instead, people rely on their personal social networks for trusted advice.


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.


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. 

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.


How well something works (in a research study). See also ‘effectiveness’.

For this study, cultural anthropologists, known as ethnographers, identified small groups of young gay and bisexual men who formed social circles in bars and clubs in St Petersburg and Sofia. The de-facto leaders - the individuals who appeared to be at the centre of the social circle - were asked whether they would like their group to enter the study. Half of the leaders approached agreed, resulting in a total of 52 social networks (34 in St Petersburg, 18 in Sofia) with 276 network members. Each social network had an average of five members (range 3-10) with an average age of 22.5 years.

Each network member was asked to specify who they thought was the leader of their group, using social status scoring, and the one with the highest score was designated as their leader. All the participants were asked about attitudes to safer sex, HIV and AIDS, their sexual behaviour, and how often they talked about HIV-related topics in the previous three months. They also all received individual standard HIV risk reduction education. The networks were then randomised into two groups of 26 (experimental and control groups).

The researchers found that the men in these social groups had an average of 13 male and 1.3 female partners in the past year, with more than 70% having had both male and female partners in their lifetimes, 13% in the past three months. Almost two-thirds of the men had multiple sexual partners in the previous three months, and at baseline sexual risk-taking was high in both the control and experimental groups. Around 70% of the men had unprotected anal or vaginal intercourse in the previous three months.

The leaders of the experimental groups then had nine sessions of safer sex training over three months, each lasting three to four hours. The sessions included behavioural techniques, role-playing and group exercises, that also taught them skills in communicating with their friends about how to reduce their risk of acquiring HIV. Each leader was provided with "a modest incentive" to attend the sessions.

During the three-month training period, those leaders who underwent training talked about AIDS more often with their network members than those who weren't being trained, although conversations about safer sex took place an average of eight times during the three month follow-up period in both the experimental and control groups.

After three months everyone in the study was interviewed again and their risk-taking behaviours compared to baseline. They found that members of the experimental groups became significantly less likely to engage in any unprotected intercourse (p=0.03) and unprotected anal intercourse (p=0.03) compared with control group members.

Participants who had multiple partners in the previous three months were analysed separately, and here, members of the experimental groups had an even stronger association of reduced frequency of unprotected intercourse (p=0.02) and unprotected anal intercourse (p=0.01) compared with control group members.

Follow-up interviews also took place twelve months after baseline, and although the intervention effects had diminished, there remained a significant difference between experimental and control group members when it came to HIV risk knowledge (p=0.009). In addition, after twelve months, the experimental groups in Sofia continued to practice more safer sex than the controls, but this was not the case in St Petersburg. The investigators suggest this may "reflect differences between the smaller and closer-knit community in Sofia" compared with "the large urban centre of St Petersburg."

In their discussion, the authors say that "to the best of our knowledge, this is the first report from Eastern Europe to describe outcomes of a randomized, controlled HIV prevention trial," as well as being the one of the first to use social network intervention techniques. They argue that after three months "significant and consistent reductions across almost all sexual risk indicators" took place amongst the experimental social networks, and that "'network-level change was not simply due to changes in the leaders' behaviour."

Noting the reduced efficacy after twelve months, they suggest that "additional research is needed to study ways to enhance the maintenance of long-term risk reduction," and conclude by calling for "future studies...to apply social network-based methods to HIV prevention efforts with other hard-to-reach and at-risk populations."


Amirkhanian A et al. A randomized social network HIV prevention trial with young men who have sex with men in Russia and Bulgaria. AIDS 19 (16): 1897-1905, 2005.