A Call for Change: Rethinking HIV Prevention Education Approaches in Toronto's Gay Community.
by John Maxwell
Gay Men's Health Promotion Programme
It has now been over ten years since HIV prevention education targeted to gay and bisexual men began in the city of Toronto. Over the past decade, gay and bisexual men have undertaken dramatic behaviour changes that have led to a marked decrease in the occurrence of unprotected anal intercourse.
Despite these achievements, some gay men are still engaging in unprotected anal sex. Both Men's Survey '90 (the Toronto based study of the knowledge, attitudes and behaviours of gay and bisexual men) and the national Men's Survey found that significant numbers of men reported engaging in at least one episode of unprotected anal sex over the past three months (over 20% in both studies). While we do not know how many of these men were in mutually-monogamous relationships in which both partners had tested HIV negative, we can assume that there still are numbers of gay and bisexual men who are finding it difficult to maintain safer sexual practices.
Much of the literature points to reasons why gay and bisexual men are unable to consistently practise safer sex: alcohol and drug use, resistance to using condoms, problems with negotiating sex as well as temptation and pressure from partners difficult to turn down. A San Francisco study of gay and bisexual men produced in August 1993 set out to look beyond these reasons to identify the deeper, underlying feelings, beliefs and psychological factors that have developed after the many years of the AIDS epidemic and now interfere with the ability of gay and bisexual men to maintain safer sex practices.
While San Francisco has been much harder hit by the epidemic than Toronto (estimates of sero-prevalence rates amongst gay and bisexual men are 43% in San Francisco versus 25% in Toronto), many similarities can be drawn between the two cities: both are large gay epicentres with organized gay communities and both cities have large populations of HIV infected gay and bisexual men. It follows then that many of the conclusions drawn from this San Francisco study would be relevant to Toronto. Below, I have outlined several recommendations from the San Francisco study that I believe should be adopted and used in HIV prevention education in this city. I have also added specific references to the educational needs of Toronto's gay and bisexual community.
The Need for Evolving AIDS Prevention Efforts:
AIDS prevention efforts must address continuing changes in the needs of all groups of gay and bisexual men for relevant information and for support in maintaining safe behaviour. These efforts must be culturally and linguistically relevant and address the various developmental stages in men's lives.
Here in Toronto, we must continue to produce HIV prevention materials that use language and imagery appropriate to the intended target groups. At the same time, it is important to realise that different approaches towards HIV education need to be taken given the fact that gay and bisexual men are not a homogeneous group - what works for older gay men will not necessarily work for younger gay men. To effectively reach different groups of gay and bisexual men it is thus necessary to try innovative approaches to AIDS education.
Self Esteem, Community and the Future:
An effort should be made to make use of a variety of strategies that increase resolve to survive the epidemic by recognizing and valuing the experience of gay and bisexual men dealing with the epidemic, building self-esteem, strengthening ties to the community, building a future and creating a stronger identity for the community apart from the epidemic.
Providing Greater Care and Support for Gay and Bisexual Men:
Social networks exist naturally among circles of gay and bisexual men. These peer networks have long been recognized as the most effective tool for disseminating AIDS information and advocating safer sex. Peer-based efforts can also assure sensitivity to the cultural needs of gay and bisexual men. For these reasons, the role of social networks should be expanded to address the issues facing gay and bisexual men around consistent safer sex behaviour.
In Toronto, use should be made of the many social networks that serve different populations of gay and bisexual men: Lesbian and Gay Youth Toronto, Pride and Prejudice (Central Toronto Youth Services), Metropolitan Community Church, The Out and Out Club, The Fraternity etc.
Building a Greater Sense of Responsibility for Safe Sex:
Gay men are generally well informed about what constitutes safer sex. Most intend to practice safer sex all the time, however some find that they are unable to say no unsafe sex, for emotional and social reasons.
AIDS prevention efforts must reinforce a sense of responsibility amongst all gay and bisexual men, and help them to realise that they can have control over the kind of sex they have and that others ask of them. This will lead to gay and bisexual men feeling more positively about themselves and their sexual practices.
Making Existing AIDS Prevention More Visible:
AIDS prevention agencies need to continue to widely distribute thorough messages about safer sex, including the most basic information. Agencies should find ways to present this information
using new and innovative methods that once again capture the attention of their audience.
Making Condoms More Available:
Businesses that serve the gay community should do more to assure that condoms are visible and available everywhere men meet one another for sex. Just as with other information campaigns, organizing men to hand condoms to their peers at bars, clubs, baths and community events could increase condom use.
In Toronto, gay venues could be approached and asked to make condoms available to their patrons. In bars and clubs, condoms and lubricant should become as easily obtainable as books of matches.
Expanding the Role of the Lesbian and Gay Press:
Community leaders must encourage the lesbian and gay press to expand their coverage and analysis in ways that help build the self-esteem and future of the community it serves, and provide a thoughtful dialogue on the issues that face gay and bisexual men.
Community papers include classified sections that are a resource for many sexually active men. These papers should be encouraged to display safer sex messages and information in their classified sections.
To assist in reaching the goals outlined above, I have outlined below several strategies that could be implemented in the area of Gay Men's Health Promotion::
1) Peer Education:
Peer education has long been known as an effective way of educating gay and bisexual men about HIV/AIDS. For certain groups of gay and bisexual men (notable young people) peer education works best, as young people can relate to educators who are seen as "one of us". Since many young gay men do not presently access ACT's services, and have not generally attended safer sex workshops, peer educators would assist in helping young gay men to realise that they are at risk for HIV infection and could help them to develop the skills necessary to successfully negotiate safer sex.
One such programme of peer education targeted to young gay men was used in three medium-sized west coast U.S. cities, successfully reducing the rates of unsafe sex by more than 10% in the first eight months of the project. The goals of the programme were fourfold: 1) to promote a norm that young gay men should only engage in safer sex 2) to increase peer support for safer sex 3) to increase motivation to have safer sex 4) to increase sexual communication skills among young gay men.
The project was peer-driven and involved young gay men who took safer sex messages to bars, parties and other social activities, and encouraged their friends to practice safer sex. Young gay men were also recruited to attend safer sex workshops that were led by their peers.
Currently, ACT's bar outreach project has largely been limited to the distribution of condoms in gay venues. By adapting the role of bar outreach volunteers to turn them into volunteer peer educators, a similar programme could be utilized by ACT. These volunteers would become peer educators who engage gay men in conversations about safer sex, recruit participants for workshops/ forums / discussion groups, and help broaden the ways in which safer sex messages are delivered to gay and bisexual men.
If volunteers were recruited from venues in which gay men socialize, this would help other gay men relate to them. The recruitment of key opinion leaders, has successfully been used in southern U.S. cities as a way of disseminating HIV prevention information to peers. As in the west coast U.S. programme, it would be necessary for peer educators to be involved in all aspects of the planning and implementation of outreach activities, to ensure that messages will be understood and retained by the target group. To date, I have put forward a proposal to adapt the role of bar outreach/Infoboard volunteers so that their roles would become that of peer educators. (Please see Appendix A, Volunteer Peer Educators).
The implementation of a peer education programme at ACT would assist in making existing AIDS prevention more visible, build a greater sense of responsibility for safer sex, help build self-esteem amongst gay and bisexual men (by providing positive role models) and strengthen ties to the community (by disseminating information about existing services within the gay and HIV communities).
2) Different Messages for Different Groups:
To assist in achieving the goal of addressing the continuing changes in the needs of all groups of gay and bisexual men for relevant information and support in maintaining safe behaviour, ACT needs to critically look at the types of safer sex messages we currently deliver. The new condom brochure "Get it On" and safer sex brochure "Safer sex for gay men: HIV + & -" both utilised explicit language and imagery - this as a result of focus group testing with the target group that showed us that these were things that gay and bisexual men wanted to see.
However, most of the advertising that we use is very "safe" and middle class in its appearance. While this might appeal to certain segments of gay and bisexual men, it does not work for all of these men. Anecdotal information from many young, club- oriented gay men has shown that these men often see ACT's materials as boring and unappealing. As young men, they respond to bold graphics and images; imagery that is current, "hip" and "cool".
To effectively reach the widest possible groups of gay and bisexual men, ACT needs to broaden the types of messages that we deliver. This would include the use of language appropriate to younger men as well as messages that are clever and "in your face". The use of one time, short campaigns would ensure that our materials are current and relevant to different populations of gay and bisexual men.
3) Condom Availability in Bars:
To assist in this goal of ensuring that gay community businesses make condoms visible and accessible to gay men, ACT should look into the feasibility of getting bar and club owners to have condoms available at all bars in their establishments. As part of the Volunteer Peer Educators duties, condom supplies could be restocked on a regular basis. ACT should explore the feasibility of sharing the costs associated with supplying condoms to bars, and should work with the City of Toronto, Department of Public Health to ensure that such a programme could be implemented.
4) Safer Sex Workshops: Can they be Made Relevant?
ACT has largely abandoned the use of safer sex workshops for gay and bisexual men. It is true that workshops seem to attract white, middle class gay men in their early thirties who are fairly articulate and comfortable in group settings, and thus have limited appeal, however these men are still an important group to reach. ACT in the past has used such workshops as "Hot Rap", "Hot, Horny and Healthy" and G.M.H.C.'s "Keep it Up" workshops.
Several workshops have been used in other locales to assist gay men in reducing risk behaviours for HIV infection. A University of Mississippi study recruited gay men and conducted a series of group sessions over a seven week period. Topics covered during the sessions included risk education, skills training (which involved discussions of past unsafe encounters and problem-solving to help participants develop alternatives to unsafe sex should similar situations occur again), assertiveness training as well as pride, efficacy and support issues.
Results from the sessions indicated that large increases were found for overall rated social skill in handling sexual propositions and in refusing partner pressure to engage in unsafe sexual activities. Large changes in risk behaviour over four month periods before and after intervention: the proportion of all occasions of anal sex when condoms were used increased from 72% to 90% following intervention. The study also noted that to be practical, skills-training groups must be offered in accessible settings. If ACT were to consider similar types of workshops, it might be advantageous to hold such sessions in settings that are more comfortable to gay men, rather than the ACT offices.
A research study from The University of California, San Francisco employed discussion groups for gay men that dealt specifically with inconsistent behaviour (or "relapse"). These groups were advertised in the San Francisco gay press under the title "Sex, Health and Community".
It is interesting to note that focus groups that were conducted before the discussion sessions were developed indicated that words such as "relapse" should be avoided - they were too medical sounding and not relevant to most gay men. Instead, words such as "sex", "health" and "community" were found to be effective key words that would draw men to these sessions. Group leaders were peers who were trained to facilitate all sessions. Session topic covered issues such as satisfaction with sex, talking openly about sex, sero-status, sex and love, potentially unsafe sexual situations as well as skills building exercises. The discussion groups involved both individual as well as group participation.
The use of similar discussion groups in Toronto, (perhaps under the title "Let's Talk about It!" could be useful ways of engaging gay men in discussions about such issues as safer sex in relationships, young gay men and safer sex, safer sex between mixed sero-status couples.
5) The Role of the Gay Press:
XTRA! magazine, with a circulation of over 28,000 copies every two weeks, should be utilised more often as a vehicle for disseminating HIV prevention/health promotion information.
The classified section would be an appropriate section to place safer sex maintenance messages. Moreover, if a four unit ad was purchased to run in each issue, this could be used to notify gay and bisexual men of workshops/discussion groups as well as be used to promote new campaigns and brochures. By purchasing ad space in advance, this would save considerable amounts of money. XTRA! could also be approached to give us a further discount over that which we currently receive, thus making this initiative even more cost effective.
It is interesting to note that participants of focus groups for the condom brochure, the ten year campaign and the relationships campaign were recruited largely as a result of the ads placed in XTRA! Clearly, most gay and bisexual men pick up and read XTRA! ACT should make use of this medium as a way of making existing AIDS prevention materials more visible within the community.
MYERS, T., GODIN G., CALZAVARA L., LAMBERT J., LOCKER D., The Canadian Survey of Gay and Bisexual Men and HIV Infection: Men's Survey. 1993.
SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH et al. A call for a new generation of AIDS prevention for gay and bisexual men in San Francisco. 1993.
COATES, T., HAYS, R., KEGELES S., Community-Level Risk Reduction Intervention for Young Gay and Bisexual Men. 1992 University of California, San Francisco.
ANDREW M., BRASFIELD T., DIAZ Y., HAUTH A., KALICHMAN S., KELLY J., LAWRENCE J., SMITH J., STEVENSON L., HIV Risk reduction following Intervention with Key Opinion Leaders of a Population: An experimental Analysis. American Journal of Public Health 1991: 81: 168-171.
BETTS R., BRASFIELD T., HOOD H., KELLY J., LAWRENCE J., A Skills-training Group Intervention Model to assist Persons in Reducing Risk Behaviours for HIV Infection. 1990 AIDS Education and Prevention 2(1) 24-35.
EKSTRAND M., HILLIARD R., HOFF C., McKUSICK L., Don't Call it Relapse: A report on a research project in progress designed to help gay men reduce risk of HIV infection through sex. 1992. University of California, San Francisco.
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