Prevention works – if you ask people what they want to prevent

Prevention works – if you ask people what they want to prevent

So get this. The results of a randomised controlled trial of an HIV prevention method were presented  on Monday and they produced a 57% reduction in the risk of HIV infection.

So was this some study of circumcision in Africa or PrEP in Peru you’ve unaccountably missed? No. It was a behavior-change programme for gay men at the Boston Fenway HIV clinic and while it was too small to show differences in HIV incidence it produced dramatic cuts in the amount of risky sex guys were having.

What was even more impressive is that it was the ‘hi-risk’ gay men – the sluts, in short, and I claim that word proudly as an ex-slut – who benefited most. The guys who do several hookups a week, or several encounters a night, not the ones with a nice steady boyfriend and cat. And on both sides of the Atlantic these have proved to be the hardest-to-change group in HIV prevention.

So how come this worked? It worked because they asked people what prevention they wanted, and then set about designing a trial of a method that incorporated what they wanted.  Not the usual scenario of a bunch of scientists or psychologists deciding to test their own concept like a microbicide or a vaccine or for that matter a weekend condom workshop or a microcredit scheme, but instead the same researchers sitting down with gay men and asking:  “What do you need in HIV prevention? “ What that ended up producing was a modular course. There were 7 modules. The first one, on sex, everyone took. The others were on relationships (getting them and keeping them), disclosure, community and culture, party drugs, managing stress and triggers for unsafe sex. The most popular ones by far were relationships and disclosure, in other words getting a man and keeping him even when you tell him you have HIV.

The result? A 57% decline in the number of unsafe-sex incidents in the hi-risk guys, sustained over a year.

What does this tell us? Well, I went to The Lancet Session on prevention yesterday, which I’ll blog separately on, and the mantra I kept hearing was that ‘Magic Bullets don’t work’. Oh, we’ve always said that but we’ve tended to act as if all we’re looking for is that magic microbicide or whatever that will mean we don’t have to make hard choices over sex any more, our magic bullet will protect us.

Well, get this, sex is risky and it involves hard and not always rational choices about personal health and safety, and it always will. It involves not making choices about whether to be infected with HIV but whether  you’re going to hang on to that cute guy or blow it if you mention HIV and whether it would be simpler just to give up on relationships and slope off to the bathhouse (or equivalent).

What the gay guys at Fenway were asking for was help in making choices that were good and appropriate for them. And when they not only got that help but were involved in designing what it looked like, they responded, bigtime. And I bet that would apply if you took the same model and repeated the experiment in a tin shack in Gugulethu in South Africa too.

We have to get the community ownership back into HIV prevention.

For my full report on the Positive Prevention session see:

http://www.aidsmap.org/en/news/7CEF6ED1-0E41-483B-ACE2-5D67B0D1A786.asp