Gay, bisexual and other men who have sex with men
In most industrialised countries, homosexual and bisexual men have been disproportionately affected by HIV/AIDS. Unprotected anal sex is the primary mode of transmission and receptive intercourse carries the greatest risk.
The success of early safer sex promotion campaigns primarily led by gay organisations has been highlighted as one of the greatest early successes in HIV prevention with evidence of falling STI rates, stabilisation in HIV prevalence and rapid uptake of safer sex practices. Over time these changes have proved difficult to sustain. Although condom use has become a social norm within the gay community, in recent years increasing proportions of homosexual men are engaging in unprotected anal sex. This particularly involves sex between men who are known to be HIV positive, partners whose HIV status is unknown to each other and younger men (< 25 years) who are likely to have become sexually active in the era of HIV/AIDS, and were not exposed to the intensive campaigns of the mid 1980s.Factors which may contribute to increasing risk behaviour include: “boredom” with prevention messages; failures to target appropriate messages to a new generation of gay men; and perceived decreased threat of HIV in the era of highly active antiretroviral therapy (HAART).
The content of the successful interventions targeting gay men varies, but have often included motivational training, audiovisual presentations (for example, eroticising safer sex), brief safer sex negotiation skills training, stress reduction training and intensive group counselling. Interventions such as these are likely to attract individuals with particular concerns about their sexual risk behaviours and greater motivation to address them, so such interventions alone are not likely to meet all of the prevention needs of men who have sex with men. These interventions are particularly relevant to men using genitourinary medicine (GUM) clinics and HIV testing services.
Knowing that face-to-face interventions will never be able to reach all of the people at risk, community level strategies offer the potential of reaching those who do not attend services.
Broader strategies focused at the community level have been shown to be effective in reaching higher risk and vulnerable men who often do not participate in small group interventions. Prevention programmes involving outreach workers and peereducators can be used to target men using community venues (for example, bars, clubs, saunas), public sex environments (for example, cruising grounds, public toilets) and other places where homosexual men meet to have sex. These strategies often follow the principals of empowerment or community-building models of health promotion, with the intervention being developed either by gay communities themselves, or in collaboration with public health or sexual health providers. The
Figure 16.3 Face-to-face interventions may be particularly relevant for persons attending health care and other services reproduced with permission from the Terrence Higgins Trust
16.4 HIV testing has important primary prevention value with some carefully defined groups reproduced with permission from the New Zealand AIDS Foundation
content of successful community-focused interventions varies, but among the most important components are peer and opinion-leader delivery of risk reduction messages, communitybuilding activities and peer-outreach providing safer sex materials (i.e. condoms and lubricant). One of the very few rigorously evaluated and effective interventions that specifically targeted young gay men (for example, aged 18—29) was developed using these approaches.