The Resonance Project

What we heard from gay men and their service providers about: Risk Counselling Challenges and Strategies 

What we heard from gay men and their service providers about:

Service providers highlighted several challenges they faced as well as some of the strategies they used to incorporate new biomedical information in their work with gay men. These challenges included: staying on top of new information; determining how to convey this information in ways that are accessible; the lack of consensus around certain topics; and their desire to offer a variety of viewpoints. Some service providers said they often erred on the side of caution in their messaging – which translated into condom use promotion – although other service providers were critical of this approach. Many service providers described how they had to develop approaches that took into account the community’s diversity, as well as the variety of contexts within which they did their work.

Challenge of staying updated

Some of the service providers reflected on the challenges of having the time to read, interpret and distil research findings, and translate them into simple lay terms in ways that clients/patients will understand. Some of the service providers noted the high expectation on them to have ‘all the answers’ despite their own knowledge limitations. Service providers also felt challenged when clients asked for their personal opinion or judgment about prevention strategies. A minority of service providers felt that the messages were relatively straight- forward and not all that difficult to communicate to patients/clients.

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.  SP, 35-49, CBO, TO

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 to try and stay on top of this stuff.  SP, <35, PSYC, VAN

Dealing with complexity

Service providers discussed the multiple prevention options that were now available, their scientific complexity, the resulting complexity of prevention messages, their concerns with keeping up with the science, and the underlying value systems that often guided prevention messaging.

It doesn’t say this is right or wrong. it just says this is new information, it’s interesting, it could be very exciting and here are some questions that we’re trying to figure out about what it means. Just get it out there right away so that we can be a part of framing what guys in the community, how they’re interpreting it. Again, we don’t have the answers and we certainly don’t want to endorse or not endorse something. SP, 35-49, CBO, TO

Service providers believed that some gay men were overwhelmed by the growing range of available options, and instead avoided these new strategies.

Now that there’s so much to consider it makes it more complex… It’s very confusing for the average guy. SP, <35, GMHO, MTL

They noted that many gay men have long adopted a diverse range of strategies beyond condoms, sometimes in reaction to conventional condom messaging.

Gay men have known for a long time that there’s more than one way of preventing HIV… 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. SP, <35, PSYC, VAN

Some service providers mentioned that they noticed more openness among young men.

I think younger guys have been more willing to adopt and embrace newer paradigms around prevention and more readily accept that you can have safer condomless sex. SP, <35, PSYC, VAN

Consensus versus multiple interpretations

The service providers expressed a contradiction: on one hand wanting to have consensus and to be able to provide a definitive statement, while on the other hand wanting to be able to provide a variety of viewpoints and interpretations of the science. The lack of consensus led to conflicting interpretations, messages and advice.

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. SP, <35, PSYC, VAN

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. SP, <35, PH, VAN

Providing a balanced answer

Service providers noted the challenge of providing advice when there was conflicting information, no definitive answer could be given, chance played a role, and the only truly correct answer about risk was “it depends”. They saw their role as building enough knowledge and skills in clients in order to instil self-efficacy, and remove a reliance on chance. Several noted that they owed clients a balanced answer about risk, and not necessarily just their own professional or organizational perspective.

When people ask for your opinion that’s where they’re trying to justify maybe an internal belief…Sometimes it’s best for people to form their own opinion first. I want to encourage them to hear about both sides of the argument and not really give my opinion. SP, <35, GMHO, VAN

It can feel really frustrating as an educator…trying to help them make their own decisions about what risks they want to take when every answer is ‘it depends.’ SP, 35-49, CBO, TO

You also have to be very cautious as a healthcare provider – what is their motivation for asking? Are they asking you for permission? Are they asking you as an expert? Are they asking you for information? Are they asking you because something might have happened? What is their subjective position that they’re coming to you with this seeking of information?  SP, 35-49, PSYC, VAN

Scepticism and erring on the side of caution

“Erring on the side of caution” was probably the phrase we heard most frequently during the service provider focus groups. Some service providers tended to give the most conservative messages possible (i.e., condom use only), but also acknowledged that being overly simplistic or conservative in HIV prevention messages could frustrate or alienate clients who knew of risk reduction options other than condoms. Some of the service providers noted that it could be difficult to express their scepticism around biomedical information without being construed as stigmatizing towards people living with HIV.

We have a really disproportionately skeptical orientation towards things other than condoms and we’re really married to this idea of condoms. SP, <35, CBO, VAN

I think erring on the side of caution; it also is kind of like dehumanizing in that you’re sort of telling someone that their desires and their decisions don’t matter based on this set of ideals and ideology. SP, <35, GMHO, VAN

I want to support new technologies, and we will get excited when we should, but I’m not changing our practices or suggesting this information when we just don’t have enough data. We have no idea what the toxicities will be over 30 years…It becomes divisive, we’re either seen as holding information back, or being irresponsible and too loose and free with promoting the meds. SP, 35-49, CBO, TO

Heterogeneity of awareness and receptivity within the gay community

Service providers noted the heterogeneity of the gay community, with some gay men having very basic knowledge and not being ready for, or open to, the complexities of biomedical aspects of HIV prevention. At the other end of the spectrum were gay men with quite sophisticated knowledge of HIV prevention, which led service providers to feel that  it was a challenge to keep up with community discourse.

I have people that know a lot and there are those that don’t know nothing. I know people that think that they can re-use condoms. Otherwise I have people who are serodiscordant and they are on PrEP. SP, <35, CBO, TO

There’s a lot of paternalism in health promotion and to some extent 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. SP, <35, PH, VAN

The service provision context

Service providers described how the context of contacts with clients had an impact on the extent to which they could do harm reduction counseling. If a risk calculation conversation were a one-off, some service providers would err on the side of caution, whereas sustained conversations over time could 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 counseling 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.  SP, <35, GMHO, MTL

Patten S, LeBlanc MA, Jackson E, Adam B (2016). The Resonance Project Community Report: Emerging biomedical discourses on HIV among gay men and their service providers.

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