Intervention program seeks to change sexual behaviors

Message should be aimed at HIV-positive people

Health care professionals sometimes assume that once they tell a patient he or she has HIV, the patient will practice celibacy or switch to safe-sex behaviors. But surveys show this often isn’t the case.

Particularly when these patients are young, clinicians should expect that they’ll continue to have sex with multiple partners and possibly do so without using condoms or checking their partner’s serostatus.

"If you’re younger, you’re more likely to be sexually active, and if you’re younger and HIV-positive, you’re still going to be sexually active," says Rosemary Ryan, PhD, principal investigator of Project SHAPE, which targets gay and bisexual HIV-positive men for prevention interventions. Ryan also is a research associate professor at the University of Washington School of Social Work in Seattle.

Research shows that HIV-positive gay and bisexual men have even more unprotected anal sex than HIV-negative men have, Ryan says. "And more recently, with the advent of highly active antiretroviral therapies and AIDS complacency, it looks like risk reduction gains are being reversed somewhat, so I would say that nowadays HIV-positive men are engaging in more risk behavior than they were previously."

Prevention messages need to be directed toward HIV-positive people, and they should address these individuals’ common attitudes and assumptions about the risk of their infecting someone else.

Although HIV-positive men might say they had unprotected sex with a stranger or uninfected person as a result of a spur-of-the-moment decision, Ryan’s research suggests that’s not true.

Eschewing safe sex is conscious decision

"The work we’ve been doing suggests that positive men who have high-risk sex have made a decision to not use protection, and it’s very much less of a heat-of-the-moment thing and very much more of a conscious decision," Ryan says.

Project SHAPE focuses on finding out why HIV-positive men engage in unprotected sex. One answer is that these men often make an assumption that their potential sex partners are HIV-positive. Why else would they be visiting a public sex environment or having a one-night stand?

"They think it’s not their responsibility to be worrying about other people," Ryan says. "We find that once those assumptions are challenged and people confront the possibility that they may be infecting someone who is negative, that’s a whole different ball game because people are not callous, and they don’t want to infect others."

A Project SHAPE prevention intervention begins with an interviewer either meeting with an HIV-positive man or talking to him over the telephone. They spend between 60 and 90 minutes discussing the man’s sexual behaviors, including detailed descriptions of his sexual behavior with up to four anal or vaginal intercourse partners within the past four months. The man also answers a variety of questions regarding his attitudes about HIV prevention and safe sex activities. The men, all of whom have had anal intercourse with men at least once within the past four months, mostly are referred to the project from AIDS services providers.

The interviewer and other people involved with the project analyze the questionnaire and interview and design an individualized intervention for that man. Then the interviewer meets with the man in about a week, again for 60 to 90 minutes, and discusses the man’s attitudes and beliefs.

For example, one question asks the man to agree or disagree with this statement: "If a sex partner doesn’t ask you to use a condom, it probably means he’s HIV-positive." If a man agrees with that statement, then the interviewer will point out to him that research shows that if you ask that same question of a person who is HIV-negative, the HIV-negative person will say they assume that if someone doesn’t ask you to use a condom, it’s because they are HIV-negative, Ryan explains. So the interviewer challenges the man’s assumption that anyone who would have sex with him without asking his HIV status is probably HIV-positive.

Another question asks, "How responsible do you feel about protecting your partners from HIV and STDs?" Typically, the man with HIV responds that he is not very responsible. Then he’s asked how serious it would be if he got a new strain of HIV or a new sexually transmitted disease, and most men will say that is very serious.

"So we ask them to reconcile that attitude of not being responsible with their saying that it is very serious to become re-infected," Ryan says. "We hand them this conflict and say, What do you make of that?’"

The theory behind the personal interviews, both the baseline initial interview and the baseline follow-up interview, is that men will examine their own assumptions and attitudes and change some of them. Along with changing their attitudes, they’ll change their behaviors.

So far, the six-month follow-up interview data have shown that to be the case. The project is ongoing and the data now are being prepared for publication, but the preliminary results are positive, Ryan says.

After intervention, more men have safe sex

The baseline interviews involved 257 men, and so far there are 114 men included in the six-month follow-up interviews. Of the initial 257 men, 44% reported unprotected anal sex with a partner who had an unknown or negative HIV status. That compares with 26% of the 114 men at six-month follow-up.

The initial analysis also has found that the average number of one-time partners has decreased. Among the initial group, there was an average of 1.04 one-time partners per person. Among the follow-up group, there was an average of 0.59 one-time partners.

"The likelihood of HIV disclosure is lower with one-time partners than with repeat partners," Ryan says. "Often, they will not discuss what their HIV status is, and this is a prime situation for making those assumptions that if this guy’s out here he must be positive."

A 12-month follow-up is in the works, although the program’s funding only covered baseline and six-month interviews, Ryan says. "An interesting question is whether what appears to be a change can be sustained over time, and if it’s not, is it worthwhile to do this kind of intervention on an intermittent basis?"

Another step might be to take the current program, which is expensive and time-intensive, and streamline the intervention to create a model that could be used within a clinic setting as a normal part of the client visit, she adds.