Prevention in Focus

Spring 2016 

The Resonance Project: What service providers are saying about biomedical information on HIV prevention

By San Patten

One of the biggest factors that will impact the progression of Canada’s HIV epidemic over the coming decade will be the extent to which biomedical knowledge of HIV risk, transmission and prevention is integrated into our programming, and into individual behaviours.

Why “RESONANCE”?

Resonance refers to the waves of discourse and resulting action generated by new biomedical information about HIV, and its incorporation into the community wisdom and individual decision-making of gay men.

There has been rapid advancement in the science of HIV prevention over the last 10 years, particularly around the role that antiretroviral drugs can play.

In the Resonance Project, we decided to concentrate on the knowledge that gay men and other men who have sex with men and their service providers have about these new prevention approaches. The focus was on gay men because they are the group that accounts for the largest proportion of new HIV infections in Canada, and the largest group of people living with HIV. Also, gay men tend to be early adopters1 of new information, new technologies, and new trends, and thus they have been among the first to take on new approaches to HIV prevention.

What is the Resonance project?

The Resonance Project: Emerging Biomedical Discourses and Decisions within Gay Men’s Knowledge Networks is a community-based research project led by four researchers, with representatives from four national HIV organizations and three gay men’s health organizations. The Resonance team set out to critically examine:

  • how gay men are taking up biomedical knowledge of HIV;
  • how biomedical knowledge of HIV impacts or influences their everyday lives;
  • the dialogue gay men and their service providers use to make sense of risk, and inform sexual decision-making and practices; and
  • the roles and responsibilities of institutions and service providers to shape and respond to these discourses.

We conducted focus groups in Vancouver, Toronto and Montreal with 22 service providers who provide sexual health, counselling and HIV prevention services to gay men; interviews with eight nurses and physicians working in a clinic or public health setting; and interviews with eight service providers who identify as gay men.

We also conducted focus groups and interviews with 86 gay men in Vancouver, Toronto and Montreal.

It should be noted that the focus groups and interviews were conducted over the winter of 2013-2014 and represents service provider perceptions at a certain point in time. Discussions of new biomedical technologies have developed rapidly since then in the gay community, the media and the HIV sector. A new series of focus groups and interviews would likely show a marked evolution in how these issues are now resonating with gay men and how service providers are responding to the challenges.

This article looks at some key findings from the service providers. Highlights of our findings from gay men will be covered in a future Prevention in Focus article.

Results

What are the challenges for service providers in managing new HIV prevention information?

Staying on top of it all

One of the challenges service providers face is finding the time to read, interpret and distil research findings, and translate them into simple lay terms in ways that clients understand. Some service providers noted the high expectation from clients and colleagues to have ‘all the answers’ despite their own knowledge limitations. A minority of service providers felt that the messages are relatively straight forward and not all that difficult to communicate to clients.

Service providers also felt challenged when clients asked them for their personal opinion or judgment about prevention strategies.

“I think as service providers we need to acknowledge our limitations as well…. It’s scary that they place a lot of authority on us…. It’s hard for us to admit we have that power over our clients…. If we are positioning ourselves as the experts, then we need to know what we’re talking about…. We’re not all on the same page sometimes. Not all of us have that education or have that capacity to understand all those complex issues going on with HIV.”

“There’s a bit of a paternalistic tinge to it but I think most gay men are not ready to digest this information. It’s not possible for a lot of gay guys to read the peer review papers and to draw conclusions from it. But I think it’s really important that people who work in the field try and stay on top of this stuff.”

Consensus versus multiple interpretations

The service providers expressed a contradiction in their risk counselling: on one hand wanting to have consensus and be able to provide a definitive statement about a particular biomedical intervention, while on the other hand wanting to be able to provide a variety of viewpoints and interpretations of the science. The lack of consensus leads to conflicting interpretations, messages and advice.

“People want to hear the clear-cut answer…. So many of us are still squabbling, fighting over things that should have been figured out years and years and years ago. We have some cleaning house to do as a community, as people who work in HIV prevention in gay men’s health.”

“There’s just a real lack of consensus on a lot of new biomedical reasoning. A lot of the research in the last five to ten years has thrown a lot of different potentially innovative and interesting ideas about HIV prevention but there’s very diffused and uneven uptake of those things by public health which is traditionally a very conservative institution.”

“It can feel really frustrating as an educator working with someone and trying to help them gain knowledge and make their own decisions about what risks they want to take when every answer is ‘it depends.’”

Erring on the side of caution

Some service providers tended to give the most conservative messages possible, such as condom use only, but also acknowledged that being overly simplistic, overly complex or too conservative in HIV prevention messages can frustrate or alienate clients who know of risk-reduction options other than condoms.

“We have a really disproportionately skeptical orientation towards things other than condoms and we’re really married to this idea of condoms.”

“A question that’s coming up for me is what does caution look like? Does it look like simplifying the message ‘always use a condom’ or does it look like bringing in the complexities? If you give them back complexity, does that help? If you give them back a simple answer does that help?”

Heterogeneity of the gay community

Service providers noted the wide range of awareness and openness to new prevention strategies in the gay community. The service providers talked about encountering gay men with very basic knowledge whom they perceive as not being ready for, or open to, the complexities of biomedical aspects of HIV prevention.

At the other end of the spectrum, service providers said they encounter gay men with sophisticated knowledge of HIV prevention, challenging service providers to keep up with the community. They noted that some gay men are quite self-aware, well-informed and inquisitive, and look to service providers for more information about their personal risk-reduction strategies.

“We just have to acknowledge the sheer diversity of the community and uneven distribution of information, resources, connections that facilitate or impede the uptake of different ideas or concepts or even things like safer sex.”

“There are three different situations. One, a person is completely ignorant of everything and we bring it to the table for them. Then you have the people that sought out the information and they now have more questions about it. Then you have the people that are very keen and on the ball about it. The last category of people is people who do their homework…. Definitely the largest group is the second one.”

The service provision context

Service providers explained that the risk-reduction messages they give to their clients depend on the setting, duration and frequency of their contact with gay men. If they only see a client in a brief one-time encounter such as in a bathhouse, or only have a brief exchange through online outreach on a cruising app, then some service providers will err on the side of caution in their risk-reduction message, whereas if they are able to have repeated contact with a client over time, the messages can be more nuanced.

“As opposed to a Towel Talk that can last anywhere from like 30 seconds to 10 minutes, some people you see on a regular basis…. We have a counselling session of 30 minutes, so it can go a lot more in-depth in regards to various different harm reduction strategies and helping them integrate them into their lives.”

“In an office that is truly private, it’s easier to talk. But during outreach—in the bathhouses, in the bars—interactions are a lot shorter. There, I have about 2 to 3 minutes with a person. There is often discomfort because they’re in public so they want it done as quickly as possible.”

How are service providers helping gay men navigate new HIV prevention information?  

Correcting partial information

Service providers find it challenging to help gay men correct and make sense of brief and often sensationalized snippets of information.

Some service providers had the impression that gay men approach them to confirm information gleaned from sources such as news headlines, awareness campaigns or social media posts. They described clients seeking support or reassurance about their understanding of that information.

Q: “Are you under the impression that they visit reliable sites?”

A: “No, no, no. It’s the opposite and that frustrates me a little bit. Because they come to me with things…that are sensationalist…I get the impression they’re Googling oral sex and they see a penis with cancer on it and they’re seeing the worst of the worst. They don’t know how to assess the information.”

“Sometimes all they catch is just headlines or just a comment that a friend posts and that’s enough for him to know what the article is about. I find that many guys are just being educated by one sentence or one word sentence and that’s how misinformation becomes.”

“They’re merging their basic knowledge with whatever the media just said, which is usually sensationalized ridiculously so…. That’s when you get the complicated questions because it’s a mixture of like misinformation on the basic sense and then trying to match it with what they’re hearing. Sometimes I’m like I need to have an hour conversation with you.”

Finding the right fit

Service providers discussed the scientific complexity of the multiple prevention options that are now available, the resulting complexity of prevention messages, their concerns with keeping up with the science, the underlying value systems that often guide prevention messaging, and how all of this affects their work in HIV prevention. They discussed the challenge of identifying who will benefit most from different prevention options.

“The challenge that we’re at right now given the state of the science is to identify those people, use these tools for the right people and not use them for people who don’t necessarily need them or are not going to have…the risk benefit ratio is the most in favour of their use.”

“Harm reduction and prevention methods are becoming more and more complex. It’s becoming harder and harder for campaigns to communicate the entirety of it when in the past it may have been ‘use condoms, get tested.’ Now it’s way more than that and there’s a limitation to information campaigns. They are still necessary to plant the idea. But having direct education and discussions and conversations are becoming much more important.”

Avoiding paternalism

Service providers noted that while some clients want clear directives, others resist paternalistic messages and don’t want to be told what to do. Some service providers believe that some gay men become overwhelmed with an increasing range of options and choose to avoid new strategies, and therefore avoid giving too much information to their clients. Other service providers pointed out that many gay men have been adopting different non-condom strategies for a long time, sometimes in reaction to conventional prevention messaging.

“There’s a lot of paternalism in health promotion and to some extent that’s why some segments of the population that we work with, that’s what they want. They’re craving someone to provide some kind of direction in this really complicated and messy world. But there’s a whole other segment of the population that we work with that has an intense hatred of being patronized, of being told what is the right way of doing something.”

“When we recognize that gay men have known for a long time that there’s more than one way of preventing HIV…at least I begin to appreciate the fact that there have been many cultures and communities of gay men who have adopted lots of different ways of preventing HIV that fall outside of the official way.”

Helping clients assess their own risk tolerance

Many service providers explained that an important part of their risk-counselling process is helping the client decide what level of risk they are comfortable with, as well as helping them think through risk-reduction or management strategies. 

“We tried to work a little bit on that, questions of PEP, PrEP, serosorting, all the others methods that exist to try to reduce the risk as much as possible. It was like we were putting cards on the table and they saw with their values or their level of knowledge what they were going to take from the available options…. And my second meeting with them, often it was then that they had chosen which cards they would use and they were starting to try to use those strategies. For example, if it was the number of sexual partners, to understand a bit more what was leading them to have so many partners.”

 “We have no control and it drives us crazy. What is missing from that equation is someone’s risk tolerance and then their values. That’s what makes it right or wrong. It’s not whether we’re saying it’s right or wrong. It’s if you think that having sex without a condom is the natural way to do it and that feels good for you and that makes you more intimate with your partner, then that’s the right answer. But if someone else thinks that barebacking is gross, then they’re right too. That’s all we can do really.”

Suggestions for Moving Forward

Start where he’s at

Service providers face complex challenges in providing HIV prevention information, advice and counselling to gay men. We know that condoms, PrEP (pre-exposure prophylaxis) and undetectable viral load are all highly effective at reducing the risk of sexual transmission of HIV, when used consistently and correctly. But whether an individual chooses to rely on one or more of these prevention strategies will depend on not only his understanding, but also his preferred sexual practices, his relationship with his sexual partners, his values around what it means to be a responsible person, and the extent to which he feels he can trust his sexual partners. For service providers, an important part of risk counselling and prevention education is to quickly gauge the knowledge levels, values, and types of sexual relationships of their clients, and customize the messages accordingly.

Equip him to decide for himself

Service providers often face difficult questions from clients who want a definitive answer when one doesn’t exist. Some clients want their service providers to provide advice in the form of: “you should do this….” A key role that a service provider plays is to equip a client with enough information to make a judgment call for himself, balancing what he knows about HIV risk, transmission and prevention, with what he desires and values.

Do what you can in any given context

The context in which service providers interact with gay men makes a big difference. When counselling gay men about risk reduction during a quick encounter in a bar or bathhouse, for example, a service provider may not have the time to fully explain alternative prevention strategies such as PrEP or undetectable viral load, and instead may choose to emphasize condom use. In the context of repeated or more lengthy interactions with clients, more time can be spent explaining how PrEP, PEP (post-exposure prophylaxis), undetectable viral load, or less effective strategies (such as seropositioning) work, and helping gay men think through which strategies best fit with their sexual lives.

Ground HIV prevention in the lived realities of gay men

Finally, resist the temptation to go straight to a PowerPoint presentation to explain the various prevention strategies when hosting workshops or discussion forums about HIV prevention for gay men. Actually, we’d recommend against framing your workshop as an HIV prevention workshop altogether, and in all risk-counselling interactions with gay men focus instead on situations, relationships, and encounters that gay men are likely to experience in their community. In our focus groups, we used mock hook-up and dating profiles, and dating and relationship scenarios, to trigger discussions about biomedical approaches to prevention.

Stay tuned…

In the time since the data was collected for the Resonance Project, the science has become more definitive (regarding the preventive efficacy of PrEP, for example), and the consensus in the sector is stronger, making it easier for service providers to be clear in our messaging. This data captures a transitional time when the science was changing and a consensus had not yet developed within the sector about what can be confidently said about the new prevention strategies.

The next steps for the Resonance Project are to develop knowledge transfer tools and messages that help service providers convey biomedical knowledge of HIV in ways that are sensitive to, and resonate with, the lived realities of gay and bisexual men. The Resonance Team is developing workshops for service providers and gay men, and a community report that will be released in spring 2016.

Who is behind the Resonance Project?

The Resonance Project: Emerging Biomedical Discourses and Decisions within Gay Men’s Knowledge Networks is a community-based research project.

It was conducted by:

  • Dr. Barry Adam from the Department of Sociology, Anthropology and Criminology at the University of Windsor
  • Ed Jackson, Len Tooley and James Wilton from CATIE
  • San Patten from the CIHR Social Research Centre in HIV Prevention, and a consultant
  • Marc-André LeBlanc, consultant
  • Kim Thomas from the Canadian AIDS Society
  • Shayna Buhler from the Interagency Coalition on AIDS and Development
  • Greg Penney from the Canadian Public Health Association
  • Wayne Robert and Jody Jollimore from the Health Initiative for Men (Vancouver)
  • Robert Rousseau and Gabriel Girard from REZO (Montreal)
  • Owen McEwen from the Gay Men’s Sexual Health Alliance (Ontario)

The project was funded by the Canadian Institutes for Health Research and had ethics approval from the University of Windsor.

Related article

For a discussion on the issues related to talking to gay men about new prevention strategies, see From the front lines: Gay men’s knowledge of new prevention strategies.

Reference

  • 1. Kippax S. Race K. Sustaining safe practice: Twenty years on. Social Science and Medicine. 2003;57:1–12.

About the author(s)

San Patten, the Resonance Project Coordinator, is a consultant based in Halifax who specializes in HIV policy, community-based research, facilitation, and program evaluation. San completed a master’s degree in Community Health Sciences at the University of Calgary, teaches part-time at Mount Allison University and the University of Alberta, and is a co-investigator of the Centre for HIV Prevention Social Research at the University of Toronto.