Education and Prevention: Some Hits and some Misses
Speech given by Associate Professor Susan Kippax, Associate Director, National Centre for HIV Social Research, Macquarie AIDS Research Unit, Macquarie University NSW 2109
Conference Paper: AIDS – Have we got it Right?
A conference organised by The Australian Doctors Fund Ltd.
Hosted by Professor Fred Hollows & ADF Chairman Dr. Bruce Shepherd
Sheraton Sydney Airport Hilton
May 14th and 15th, 1992
Men and women, both heterosexual and homosexuals, endorse and adopt a variety of strategies which they believe (rightly or wrongly) prevent the transmission of HIV. These prevention strategies have been taken up differentially by sections of the population. Some prevention strategies have been promoted in education and media campaigns. it is argued that the uptake of these ‘advocated’ strategies points to some successes in such campaigns. The failure of some sections of the population to adopt these strategies reflects in part the absence of appropriate campaigns and the reliance on myths and misinformation. Many of these myths have been produced, often unwittingly, by medical discourse and promulgated by the media. Data are presented which indicate that certain campaigns have been and continue to be effective for many men who have sex with men. On the other hand, the response of some sections of the heterosexual community points to a number of barriers to the adoption of safe sexual behaviour. Suggestions are made to improve the hit rate.
There has been a great deal of debate over the past months about the number of new HIV infections. There have been discussions of whether these infections have been contained within the ‘gay community’ or whether HIV has ‘taken off’ in the general heterosexual population because of the ‘wild cards of sexuality’ – as one media commentator has called bisexual’ men who ‘conceal their sexual preferences from their wives’, or whether the heterosexual transmission figures are exaggerated and ‘normal’ people need not worry about HIV or AIDS…
Mixed up in this debate has been a further debate about the efficacy of HIV-prevention education programmes – whether they have contained the appropriate information, whether they have fuelled hysteria, whether they have targeted the appropriate populations, and whether they have achieved their main purpose, that is to stop or at least reduce the spread of HIV in the Australian population.
I am going to deal with one set of issues – those which concern education programmes and their efficacy. Much of this debate has been ill-informed. Part of the problem lies in the false belief that social scientists (or anyone else for that matter) can measure the outcome, the impact of any one particular campaign in the same way as one can measure the impact of a new drug (its efficacy and side-effects). An education campaign is not like a clinical trial – give group x (drawn at random) drug a and give group y (the control) a placebo – and measure the impact of drug a. There are a number of differences:
- can’t isolate the ‘control’ group who don’t receive the information or the education .. so have no control
- can’t isolate either the experimental group, which receives the information, or the control group, which doesn’t from the other information and messages which are being broadcast, talked about written about, etcâ€¦
- people do not simply absorb the message… they interpret, shapes, modify the information; they deny, forget, remember the wrong bits, discard, refuse to believe, etcâ€¦
- people are active interpreters of educational and other messages, not simply passive ciphers. Messages about sex or drug use, for example, are received from particular positions; the sexually inexperienced will respond differently from the sexual experienced, men will respond differently from womenâ€¦
- the information doesn’t flow directly in a simple one-way fashion from educational programmes or the media to the individual – rather the information is mediated by the cultural and sub-cultural understandings and interpretations of the groups of which the individual is a member.
Education programs are thus extraordinarily complex things to evaluate. They have intended and unintended consequences. They can, however, be evaluated – but not as clinical trials are and not as single entities. Rather the cumulative impact of the education programs and other messages from media can be assessed in terms of the strength of the relationship between the changes advocated in the education programs and the changes which occur in the populations targeted by the education programs. Monitoring changes in sexual practices and injecting drug behaviour over time does allow us to draw some conclusions about the success or otherwise of educational programs. As I hope to show, behavioural data also allow give us some purchase on the processes underlying any changes that are made.
All indications from clinical data and epidemiological data point to a peaking of infections in 83/84 and a rapid drop after that date…. (from 3,000 – 4,500 in 83/84 to national estimates of 600 new infections of HIV in 1988-1990). The behavioural data available in Australia support the clinical and epidemiological data. The figures look good – at least as compared with other countries.
A number of questions remain: for example, there are new infections each year, where are these new infections occurring? men who have sex with men? amongst heterosexuals? or amongst injecting drug users? Where should future education programs and campaigns be directed?
It is fair to say, however, that Australia has got a great deal of it right. SOMETHING is working … or we would be in a much worse position than we are now. A reasonable hypothesis is that the education programs and campaigns (or some aspects of them) worked and continue to work – and that in response to the educational programs some people did and are continuing to modify their behaviour – their sexual behaviour and their drug injecting behaviour.
In this paper I explore this hypothesis with reference to behavioural data on sexual practice. I will also use the behavioural data to explore the processes underlying behavioural change by demonstrating which prevention strategies have been adopted and by whom, and which prevention strategies appear to have missed their mark.
First a very brief account of the major findings of some of the Australian behavioural studies – with reference to two populations – men who have sex with men and heterosexual men and women.
Gay and Bisexual Men
The dominant approach in HIV prevention efforts among gay and bisexual men in Australia (and elsewhere such as the US) is to encourage the adoption of safe sex practices by the widespread dissemination of AIDS risk reduction information, focused group interventions to demonstrate ways to criticise safe sex, and the use of group norms and social support to motivate behaviour changes. These efforts began, in Sydney, in 1983 and 1984 – largely by the gay community – the AIDS Action Committees – which later (in 1985) became the AIDS Councils (Ballard 1989; Dowsett et al. in press).
It is important to recognise that from the start the national response to the epidemic in Australia involved three groupings: 1) Federal and State governments; 2) the non-government sector, initially and predominantly the gay communities’ AIDS organisations, and 3) health professionals and researchers. Although the Commonwealth was responsible for the national mass media education campaigns both it and the State governments funded non-government organisations to develop educational programs for at-risk populations and groups. Such targeted programs were funded from 1984 onwards.
If we begin with the studies with which I am most familiar – the Social Aspects of the Prevention of AIDS Project (series of studies 1986/7 and again in 1991) – which analysed the sexual practices of a diverse sample of men who have sex with men in New South Wales . This sample included young and old, professional and working class men, men from the inner and outer suburbs of Sydney, from rural centres in NSW and from the ACT, and it was not simply a sample of gay community attached men. What we know about these men is that:
- their knowledge of HIV transmission is good, with most men having satisfactory knowledge of what is unsafe behaviour and with some possessing highly accurate and quite sophisticated knowledge;
- almost all of them are aware of their own risk, 70% had been tested for HIV in 1986/7 and this figure for the men followed up in 1991 is over 80%;
- almost all of them have adopted one or more of a range of prevention strategies;
- and a significant majority had changed their behaviour in the direction of safe sex.
These findings have been replicated in Melbourne – and overseas, in New York, San Francisco, Chicago, Amsterdam, Londonâ€¦ The educational efforts have been highly successful and, as the behavioural data from here and overseas demonstrate have resulted in the most profound modifications of personal health-related behaviours ever recorded. (Stall and Ekstrand, 1989; Ekstrand & Coates, 1990; Connell et al. 1989; Adib, Joseph, Ostrow & Sherman, 1991; Kippax et al. 1992). In particular they demonstrate the success of informed social support in bringing about behaviour change. More and more studies are reporting that interpersonal and social variables are among the most important in the adoption and maintenance of safe sex.
Heterosexual Men and Women
Educational programs directed at heterosexuals did not come on line until 1987. The Grim Reaper began the national mass media education program. The target of this and the following national media campaigns, the ‘general’ population, was, by definition, heterogeneous diverse and diffuse. The educational task was made wore difficult by the small number of heterosexual HIV transmissions.
The behavioural data on heterosexual sexual practice reflect the difficulties of reaching this diffuse target. Heterosexuals are alerted to HIV and AIDS but many of them believe that the problem of HIV infection is not theirs – but belongs elsewhere.
Much of the data on heterosexual men and women with regard to sexual activity in the context of HIV and AIDS is confined to tertiary students. Since 1987 data have been collected each year from random samples of students as well as from first year student intakes into certain faculties and disciplines in Universities up and down the east coast of Australia. This data collection is currently being extended to TAFE Colleges in NSW and to Australian secondary school students.
Briefly what these data indicate is:
- these young people are well informed with regard to HIV transmission, although their knowledge of the details of safe sexual practice is not as sophisticated as that possessed by gay men;
- they do not, in general, see themselves at risk of HIV infection;
- and with one exception there is very little evidence of any change to sexual practice. The exception in an increasing use of condoms for sex with casual partners.
As well as indicating whether the education programmes have worked or not – and with whom they have worked – the behavioural data indicate which prevention strategies have been endorse, adopted – and by whom.
Education Programmes/Media Messages
Major education programmes and campaigns (not only the national media campaigns but also those developed by the AIDS Councils, and community groups, â€¦ funded by the federal and state government bodies) have advocated a number of strategies. These I have called ‘education programmes’ (see overhead). As well these educational programmes there have been a number of strategies advocated (often not explicitly) by media commentators and media news reports – I refer to these as ‘media messages’. There is a third act of strategies to which I refer – I have called these ‘other strategies’.
Education programmes (national, state and local) have advocated the following:
- use of condoms for penetrative sex;
- avoidance of unsafe sexual practices, especially unprotected anal intercourse and unprotected vaginal
intercourse. (It in interesting to note that although gay men have been asked by some to forgo anal sex, the avoidance of vaginal sex, as distinct from ‘sex’ has not been explicitly recommended);
- the adoption of safe forms of sexual expression such as mutual masturbation;
- the encouragement of talk and negotiation, and honesty within relationships. Such talk and negotiation is an essential adjunct to HIV prevention strategies. An accurate knowledge of a partner’s sexual and drug using history way be a useful adjunct to safe sex, although education programmes have pointed to the pitfalls of simply relying on knowing one’s partner; and
- reduction in the number of sexual partners. This strategy is often confused with (6).
These major education programmes have been ‘supplemented’ by a number of strategies which are implicit in much media coverage of the issues around HIV and AIDS. The major prevention strategies which are advocated, either explicitly or implicitly, by much of the media are:
- monogamy or reliance on ‘regular’ partner or serial monogamy. Monogamy is advocated, both explicitly and implicitly, by the many messages which suggest that only the promiscuous get HIV/AIDS;
- selection of ‘clean’ partners. This strategy in associated with the one above. HIV is associated with promiscuity and with being a ‘slut’;
- avoidance of ‘risk groups’. This strategy is implicit in the term ‘risk group’ itself as well as talk of deviance, the ‘gay plague’, and in calls for isolation and quarantining. It is also implicit in the medical/epidemiological definitions of transmission categories – homosexual, bisexual, heterosexual, drug user. What does bisexual transmission mean? (It and (7) are the basis of HIV-related discrimination and prejudice); and
- reliance on mass testing.
There are two other important strategies – the sources of which i cannot identify:
- the reliance of HIV zero-status; and
- celibacy. The source of this was perhaps Ita Buttrose.
Problems in the Strategies
Are these strategies rational – in the sense that if individuals incorporate them into their sexual practice they will be effective in the prevention of the transmission of HIV? And what problems are people who adopt them likely to face?
Strategies from Education Programmes
- Condom use is an extremely effective strategy in preventing HIV transmission, although it is not 100% safe because of problems of breakage.There is among some groups some resistance to condom use particularly the sexually inexperienced. Introducing condom use into an ongoing monogamous or ‘regular’ relationship is extremely difficult as it may be perceived an indicating lack of fidelity and/or trust. This is especially true for heterosexuals.
- Avoidance of anal and vaginal intercourse is an effective strategy but one that may be difficult to sustain. Many heterosexuals equate sex with vaginal penetration, so for some avoidance becomes celibacy. For many men and women (both in homosexual and heterosexual partnerships) intercourse is the corner-stone of intimacy and love as well as the most physically satisfying of the sexual repertoire.
- Adoption of safe sexual practices is an effective strategy in the sense of preventing HIV transmission but one that might be difficult to sustain for the reasons given in (2) above. There is also the problem of the uncertainty of the safety of oral-genital contact.
- All of the above strategies depend for their success on talk and negotiation. This appears to be more of a problem for heterosexuals than for homosexual men because of the taken-for-granted nature of heterosexuality (it is assumed that there is nothing to discuss, it just is). For some men who have sex with men, however, it may be a problem particularly the newly homosexual, the young, and men who are not socially connected to other gay men or gay culture. For heterosexuals such talk and negotiation may be difficult because of the unequal power relations between men and women, and because there is no language (except medical or porn) to use in discussions of sex.
- Partner reduction will reduce risk of transmission particularly in populations where the incidence of HIV in high. Its adoption will not however prevent transmission.
- Reliance on monogamy (or serial monogamy) in and of itself is not a rational strategy. Restricting sex to one’s monogamous partner is safe if and only if self and partner are HIV zero-negative. (Note: this strategy is rational on a population basis but it is not rational as an individual one. If everyone were absolutely monogamous then those who were zero-positive would infect their partners and no one else – eventually HIV would disappear). In the case of serial monogamy or reliance on a regular partner a further problem is what is meant by ‘regular’. For many people, both heterosexual and homosexual, a regular partner is someone with whom one has an exclusive relationship for anything from one week to forever. There is also the problem that in some cases what women see as ‘regular’ relationship, men see as ‘casual’. This strategy is effective only if the partners know that each is zero-negative and the relationship is based on honesty (see 10)
- Selecting ‘clean’ partners is not a rational strategy; one can not tell whether someone is infected by looking at them.
- Avoidance of people assumed to belong to one of the ‘risk groups’ is also not a rational strategy. Being able to tell whether someone is an injecting drug user or not will not necessarily prevent transmission. The risk does not reside in the identity of the person but in whether one engages in safe or unsafe practices. In the case of ‘bisexual men’ when a woman has sex with a man (who also has sex with men), she has heterosexual sex – not bisexual sex. Having sex only with someone you believe is heterosexual will not protect you.
- Reliance on mass screening is an irrational strategy unless the persons so tested are marked in some way to identify them as HIV zero-positive. Further, the testing of the population would have to be continuous â€¦
- This strategy of reliance on HIV status is a rational one if both persons are zero-negative and if both partners are faithful OR if both partners are zero-negative and if both partners have safe sex outside relationship. The strategy is only effective where there is honest negotiation.
- It is a rational strategy but one perhaps that is difficult for most people.
Prevention Strategies Endorsed and Practised
Which of the above strategies have been adopted or endorsed? and by whom? which populations or groups?
- Behavioural data indicate that condom use has been adopted as a prevention strategy by many men who have sex with men, particularly gay men who have the social support of other gay men, and who have a good understanding of unsafe sexual behaviour. Data from the tertiary student studies indicate that although there is not widespread adoption of condoms, there in a very small increase in condom use among younger heterosexual students especially in casual sexual contact.
- Data indicate that some men who have sex with men are avoiding anal intercourse, at least on some occasions and in come contexts – particularly in casual sexual encounters. On present evidence, there have been no similar moves amongst the heterosexual population with regard to vaginal sex.
- Amongst men who have sex with men, the second strategy is often accompanied by the adoption and elaboration of safe sexual practices. There is no evidence that there has been an elaboration of the sexual repertoire of heterosexuals or that non-penetrative sex has replaced vaginal intercourse amongst heterosexuals.
- Data from men who have sex with men indicate that many of these men have developed understandings, arrangements, and contracts about safe sex with their partners. The talk itself has led to a change in the everyday understandings of these men, the taken-for-granted in which these men operate has changed. A ‘safe sex’ culture has developed. One has to explain why no condoms if having anal sex, not why condoms. This has not occurred amongst the heterosexual population as far as we can tell. Some sexually experienced heterosexuals find negotiation manageable, for others it appears to be extremely difficult.
- Many gay men have reduced the numbers of their sexual partners in response to HIV. There is little data on heterosexuals.
- Monogamy and/or reliance on regular partner (aerial monogamy) has been endorsed and adopted by some men who have sex with men. It has been endorsed particularly by men who are not socially supported by other gay men and/or who do not have the detailed understanding of safe sexual strategies, that is, they are unsure of what they can do safely. The strategy is also the one favoured by most of the tertiary students. There is a widespread belief that one’s regular partner is ‘safe’.
- There are data from both studies of heterosexuals, and homosexuals which show that this strategy of selecting ‘clean’ partners is endorsed and practised by some men but not women. Some gay men are changing the places where they meet or pick up men, for example. it is difficult to estimate how widespread the practice is amongst heterosexuals, but Chapman et al. showed that some young men believe that they can pick ‘clean’ women. It is also widely acknowledged that at the recent Meeting of the World Bank in Bangkok last Year a call went out for 500 clean women to service the conference participants.
- Avoidance of members of so-called ‘risk-groups’ is widespread. Recent studies examining HIV-related discrimination in the Australian Population found that social avoidance of a range of ‘risk-group’ members was endorsed a small proportion of the sample – particularly by men.
- This mass testing strategy is beyond the control of individuals. But mass screening is favoured by some tertiary students particularly women.
- This strategy, based on the knowledge of one’s sexual partner’s HIV zero-status, is one that is being practised by a large number of gay men. The strategy is being used in conjunction with contracts about fidelity or the avoidance of anal intercourse and/or condom use for anal intercourse outside the relationship. Many men in regular relationships are using their zero-negative concordant status to arrive at prevention strategies which protect them and their partners. There is no data for heterosexuals.
- I am not aware on any data on the use of this strategy.
Gay and Bisexual Men
When we compare the strategies advocated with the strategies .adopted, then it in clear that for MANY gay and bisexual men strategies (1), (2), (3), (4), (5) and (10) have been successful. The something that is working are the education programmes developed and managed in the main by the AIDS Councils and gay communities themselves, and funded by governments.
It is also fair to say that the education campaigns have not reached all men who have sex with men but from the data we have at present, it appears that those who have not been reached include those men who live in rural communities and those who do not have the informed social support necessary to enable them adopt these strategies. There is evidence to indicate that some men are still reliant on the assumed safety of their regular or monogamous partner.
More data is needed as to which men are being missed and how they may be reached. Such data is currently being collected via a national phone survey of men who have sex with men MALE-CALL.
Heterosexual Men and Women
The success of the education campaigns with regard to the heterosexual population is far less certain. Heterosexuals are knowledgeable about modes of transmission and although there seem to be some small success with regard to condom use, there is no widespread behaviour change.
Heterosexuals have been far more willing to take up the more comfortable messages from the media which in general free them from worrying about HIV transmission.
Future campaigns focused on heterosexuals will have to combat much of the information. They will also have to narrow their sights and aim their educational programmes at particular cultural and sub-cultural groups in the heterosexual population.
- The behavioural data indicate that education programmes have been successful – at least in certain instances and with certain populations;
- The Australian population is reasonably well informed although a number of myths survive.
- With regard to changing sexual practice, the big successes are amongst gay men – particularly those who have been easy to target. The changes that have occurred have occurred at the cultural level; the social norms have been changed.
- Such successes indicate the social and interpersonal processes which underlie behaviour change. These processes may well form the basis of future education campaigns focused on populations which have not been reached in the past.
Behavioural research not only provides a marker of behaviour change (alongside epidemiological and clinical data) but, at its best, it can provide an understanding of the processes underlying such behaviour change. Education is the best defence against HIV transmission and I hope that one of the outcomes of this conference is a clarification of the many complex issues surrounding prevention and education.