An HIV prevention program that focuses on young gay men educating and supporting one another about safer sex has proved very effective in a major study in two West Coast communities.
Followup data showed a substantial and sustained reduction in unprotected anal intercourse--the behavior most risky for HIV transmission--among participants.
Developed by team at the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco, the program was implemented in Santa Barbara, Calif., and Eugene, Ore. Data were analyzed to determine program effectiveness and changes in patterns of high-risk behavior.
Named the "Mpowerment Project," the program is based on empowering young gay men to deal with the very real issues that they face in their daily lives--homophobia, gay bashing, discrimination, isolation, and HIV/AIDS--and then mobilizing them in a positive way to influence one another, said Susan Kegeles, PhD, an associate professor with UCSF CAPS and co-director of the project with Robert B. Hays, PhD, also with CAPS.
"Life in the U.S. for young gay men is not easy, even in the 90s. One need only look at the example of Matthew Shepard to understand that young gay men have very real fears about being openly gay in a society that does not support them. Moreover, they are trying to find their way in terms of loving and intimate relationships. Many of them have experienced sexual abuse as young people as well," she said
"The Mpowerment program gives young gay men a place to deal with personal issues about their homosexuality, about coming out, and about intimacy, and then talk about HIV safety in that context. It can't work any other way," she emphasized.
Study findings are reported in a recent issue of the journal AIDS.
The researchers found that the proportion of men who engaged in unprotected anal intercourse with non-primary partners decreased by 18 percent. The same unsafe practice with boyfriends decreased by 28 percent. These changes were maintained one year following the end of the program, a goal that is very hard to achieve, according to Kegeles.
Data analysis also showed that study participants increased their enjoyment of safe sex, were better at communicating that they wanted to have safe sex, and felt more support from their friends about having safer sex after participating in the program than they did at its inception.
"The project messages were very sex-positive and included explicit suggestions about a large variety of safer sexual practices, not just condom use," Kegeles said. "Eroticizing safer sex and encouraging men to think of new, fun and satisfying ways of having low-risk sex was particularly important in view of our knowledge from other studies that the more one believes that safe sex is associated with diminished enjoyment, the less one engages in it."
"Ongoing studies show high numbers of young gay men nationwide are continuing to engage in high-risk behavior and are contracting HIV at alarming rates, so there is an urgent need for effective prevention programs that truly reach this group," said Thomas J. Coates, PhD, project co-investigator and executive director of the UCSF AIDS Research Institute.
"A social focus was adopted as the organizing feature of this project because a sole focus on HIV and AIDS would not be very compelling to young gay men, and our findings show that in order to reach young gay men effectively, HIV prevention activities must be integrated into their social network and must be supported by that network," he added.
Various components of the program reached 500 or more gay and bisexual men aged 18-30 in each community.
The two West Coast communities were chosen for the study because they were similar in population size and about two hours drive from a large city, had a large university, attracted many young people from surrounding areas for social activities, and had no HIV prevention programs targeted at young gay men.
Sexual risk-taking behavior of young gay men is explained by factors at three main levels--individual, inter-personal, and social--and the UCSF program focuses on reaching all three simultaneously, according to Kegeles.
"Because young men engage in unsafe sexual behaviors for diverse reasons, interventions that focus solely on one level of factors will miss men who engage in high-risk sex for other reasons," she said.
At the individual level, for example, reasons for risk-taking include perceptions that safe sex is less enjoyable than unsafe sex, inaccurate beliefs about risky behaviors, and being depressed. Interpersonal reasons include poor communication skills and having a boyfriend, while social factors include a lack of support for safer sex and frequent visits to gay bars or public cruising areas that are associated with unprotected sex.
In the Mpowerment Project, the content of the HIV prevention messages was the same in each community but local young gay men, both employees and volunteers, developed outreach and social activities that would best carry the message to young men within their respective settings.
"By local young gay men having a sense of ownership of the program, there was an increased motivation to spread the message--adapting it as their own--to their peers," Kegeles said.
"Attracting as many young men as possible to the program was an important objective. Every young man who became involved by attending a social event or a small group discussion, or by volunteering in any capacity, became a potential agent for encouraging and supporting safer sex among his social network," she added.
Components of the outreach effort included both formal and informal activities:
- Outreach teams went to areas where young gay men congregated (bars, community
events, social events the project created, etc.) to communicate the message.
Fun and entertaining approaches were often used, such as performances and/or
costumes.
- A young men's center was set-up in each community with weekly events (video
parties, discussion groups, drop-in hours) and other special activities such as
dance parties, picnics, hikes, and bicycle rides where outreach was also
conducted.
- Interesting and appealing hand-out materials about safe sex were distributed
by the outreach teams at places young gay men congregate in the community,
including project-sponsored social events.
- Men were trained and encouraged to support their friends in informal
conversations about having safe sex.
- There were peer-led small group meetings that focused on eroticizing safer sex, how to use condoms, clarifying misconceptions, sexual communication, and nonverbal negotiating skills. Participants also were encouraged to become agents of change by taking the message to their friends.
"Much work remains if we are to eliminate HIV among young gays. While our results are encouraging, programs like these must be sustained. Young men come out everyday, and HIV prevention programs need to be in place so they too do not get infected," Kegeles said.
She added that future research needs to focus on determining how this prevention approach will work in larger, more complex, and more diverse communities.
The project team also included Lance M. Pollack, PhD, of UCSF CAPS. The study was supported by grants from the National Institute for Mental Health.
UCSF CAPS is a program of the UCSF AIDS Research Institute, a campuswide enterprise without walls that encompasses all UCSF AIDS programs under a single umbrella and includes close to 1,000 investigators.
Journal
AIDS