HIV in Canada: A primer for service providers

Behavioural Prevention Interventions

Key Points

  • Behavioural interventions for HIV prevention (health promotion) seek to influence knowledge and attitudes, influence people’s perceived risk of acquiring HIV, and provide people with the motivation and skills they need to change their behaviours.
  • Behavioural interventions need to remain a main priority for HIV prevention.
  • Behavioural prevention strategies need to be delivered with sufficient coverage, intensity and duration to be effective.
  • Behavioural prevention interventions are necessary but are not sufficient to eliminate HIV transmission — they need to be combined with structural and biomedical approaches in ways that address the needs of local epidemics.
  • Behavioural prevention interventions should be part of a comprehensive package of HIV prevention strategies.

HIV transmission is the result of human social behaviour: sexual and drug-use behaviours cause almost all HIV transmissions in Canada.

Since the beginning of the epidemic, the widespread delivery of effective strategies to change behaviour has been central to HIV prevention efforts in Canada and around the world. Behavioural HIV prevention interventions seek to influence knowledge and attitudes, to influence people’s perceived risk of acquiring HIV, and to provide the motivation and skills people need to change their sexual and drug-using behaviours that place them at risk for HIV. Behavioural strategies have various goals, including the following:

  • delaying the onset of first intercourse
  • decreasing the number of sex partners
  • increasing the correct and consistent use of effective prevention approachesand
  • providing counselling and testing for HIV

Behavioural strategies for HIV prevention can be targeted at multiple levels: individuals, couples, families, peer groups or networks, institutions and entire communities. Within households, HIV prevention programs can address the stigma of HIV and sexuality and promote open discussion. At a community level, programs can seek to increase the value associated with safer behaviours, support community members to reduce their risk and reinforce new norms.

Behavioural strategies attempt to motivate behaviour change in individuals and groups through a range of educational, motivational, peer-group, skills-building and community approaches.

However, human behaviour is complex and thus it is challenging to achieve widespread and sustained behaviour changes. Despite the challenges, behavioural interventions for HIV prevention need to remain a main priority for HIV prevention. Although behavioural interventions are necessary, they are not sufficient to eliminate HIV transmission: they need to be combined with structural and biomedical approaches.

To improve the effectiveness of our prevention efforts we need to ensure that all HIV behavioural interventions address the needs of the specific local epidemic. If they are to be effective, these efforts also need to reach a sufficiently large number of people (i.e., there must be sufficient coverage), elicit behaviour change (i.e., they must be delivered at a sufficient intensity) and sustain the change for long periods of time (i.e., they must be delivered for a sufficient length of time).

A mix of communication channels should be employed to disseminate clear and simple messages about risk-reduction and health-seeking options. People must be provided with options on how to reduce their risk, as there is no one-size-fits-all approach. Community involvement in the development and dissemination of messages is essential. Achieving the right mix of behavioural approaches depends on understanding the target population and adapting existing programs to meet the needs of the population.

It is not easy to change behaviours: there are many impediments to successful programming. The stigma and discrimination experienced by the populations at greatest risk for infection have undermined support for these programs. Addressing stigma and discrimination is important to the success of HIV prevention initiatives in Canada. Efforts to implement certain programs have met social, political and/or ideological disputes; these hamper our ability to implement effective programming. Sexual and drug-using behaviours are diverse and are usually conducted in private, making it difficult for those developing programs to fully understand these behaviours, to locate those most at risk and to motivate behaviour change. Behaviour change, while possible, is difficult to sustain over long periods of time. Our efforts must remain strong to ensure a sustained behavioural response. Finally, efforts to build effective programming are hampered by a lack of understanding of the social context and the other factors that affect whether an individual engages in risk-reduction behaviours.

Existing models of behavioural interventions are often based on cognitive-behavioural theories that assume that individuals will take steps to avoid risks if they are fully informed and sufficiently motivated — that is, that they can exercise personal “agency” when confronted with HIV-associated risk. However, individual behaviour is often heavily influenced by individual, socioeconomic, cultural and environmental factors. Employing structural approaches in combination with behavioural approaches will increase the effectiveness of behavioural interventions.

Resource

Integrating HIV Prevention with Care: Behavioural Interventions in the Clinical Setting – National Collaborating Centre for Infectious Diseases      

Sources

  1. Coates TJ, Richter L, Ceres C. Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet. 2008 August;372(9639):669–84.
  2. Global HIV Prevention Working Group. Behaviour change and HIV prevention: [re] considerations for the 21st century. 2008. Available from: http://library.catie.ca/PDF/PCatie/24892.pdf
  3. San Francisco AIDS Foundation (SFAF)]. HIV evidence report: effective behavioural interventions for reducing HIV risk and transmission. San Francisco: SFAF; 2008. Available from: http://www.sfaf.org/policy-center/policy-library/sfaf-hiv-evidence-report-may-2008-effective-behavioral-interventions.pdf