Issues Paper No. 7BEHAVIOUR CHANGE IN RESPONSE TO THE HIV
EPIDEMIC: TABLE OF CONTENTS The gay community and behaviour
change 1. The gay community and behaviour change The HIV epidemic first made itself known to the world when it appeared among gay men* in the United States in 1979 and 1980: the first published account of the disease, in July 1981, described cases seen among gay men in Los Angeles, over the following three years AIDS appeared in the gay communities of all the developed countries. Although as early as 1982 cases of AIDS were seen in people other than gay men (male and female injecting drug users, recipients of HIV-contaminated blood products, heterosexual men and women including female sex workers and infants born to HIV-infected women), the great majority of diagnosed AIDS cases in most of the developed countries during the 1980s were seen in gay men. The appearance of the HIV epidemic had an enormous impact on the gay communities** of the developed countries, and organisations to respond to the epidemic were formed in most countries by 1985. One of their most urgent tasks was to advise gay men how they could avoid contracting the disease. Before the discovery of HIV as the cause of the disease in 1983/84, the reason gay men were developing AIDS was unclear. It was therefore very difficult for gay men to protect themselves from it. Since, however, it was evident that HIV was sexually transmitted, gay community organisations (and government health authorities) recommended to gay men that they reduce the number of sexual partners they had. Many gay men followed this advice, some to the extent of ceasing to have sex at all. In retrospect, though, it is evident that this advice was ineffective. Reducing the number of sexual partners does not significantly reduce the risk of contracting HIV infection in a population where infection is already widespread. It just slows the process down somewhat. In any case, men are extremely reluctant to accept advice even at the risk of their own lives. In this respect, at least, gay men are no different from man in general. The discovery of HIV and the subsequent determination of the exact mechanisms of HIV transmission during sex between men enabled gay community organisations to make more specific recommendations to gay men. It became clear that unprotected anal intercourse was responsible for virtually all HIV transmission among gay men, and the correct and consistent use of condoms and water-based lubricant during anal sex would reduce the risk of HIV infection for gay men to close to zero. These discoveries made it possible for gay community organisations to make recommendations to gay men which were both effective in preventing HIV infection and capable of being adopted in a sustained way by the majority of gay men. Few men enjoy using condoms, but the use of condoms for anal intercourse was a compromise between fear of HIV infection and fear of giving up sexual gratification which most gay men were prepared to accept and able to implement. While compliance with even this fairly minimal modification of sexual behaviour has been far from universal, it has been sufficiently widespread to reduce greatly the incidence of HIV infection among gay men in most developed countries. I have referred to gay community organisations making "recommendations" to gay men about changes in sexual behaviour. In fact, of course, the process of bringing about behaviour change among most gay men was vastly more complicated than simply issuing recommendations. The populations of gay men in the developed countries are very diverse, and include a significant group of "submerged" gay men (few of whom actually identify as gay) who are not in contact with the organised gay community. The gay communities are divided along lines of race, ethnicity, age, place of residence, educational level and social/economic status. Patterns of sexual behaviour among gay men differ considerably along these lines, and are further complicated by issues such as injecting drug use, use of alcohol and other recreational drugs, the sale of sex for money, transsexualism and other behavioural influences. These considerations made the task of bringing about sustained and appropriate behaviour change among gay men an extremely complex one, and a task made more difficult three further factors: the great urgency imposed by the rapidly expanding number of gay men acquiring HIV infection, the lack of previous research into the sexual behaviour patterns of gay men, and the lack of models of successful campaigns to bring about rapid and widespread changes in personal behaviours. When gay community organisations undertook in the early 1980s the task of bringing about rapid, radical and sustained changes in the sexual behaviours of a large and diverse population of sexually-active men, they undertook to do something which had never been done before, in a very short period of time, and bereft of the usual resources, research data and analytical tools which usually accompany such major campaigns of social engineering. 2. Factors influencing behaviour change among gay men By the late 1980s, however, these deficiencies had to some extent been addressed. A number of major research projects had been carried out among gay men to find out more about their patterns of sexual behaviour, to monitor the speed and extent of behaviour change, and to determine the social and cultural factors which facilitated or impeded the process of behaviour change. One of the most far-reaching of these projects has been carried out in Australia. This is the Social Aspects of Prevention of AIDS (SAPA) project, a joint undertaking of the AIDS Council of NSW (a gay community non-government organisation) and the School of Behavioural Sciences of Macquarie University, Sydney. In 1986 and 1987, SAPA researchers conducted extensive interviews with 535 Australian gay men, and have been analyzing the results since, issuing their findings in regular installments since 1988. Report No. 7, The Importance of Gay Community in the Prevention of HIV Transmission, appeared in April 1990. The report consists mainly of a statistical analysis of the relationship between the interviewees' attachment to the gay community (measured by several criteria) and the degree, appropriateness and speed of the changes in their sexual practices in response to the HIV epidemic. The report's conclusion is worth quoting at length.
The SAPA research demonstrates that the most important component of preventing HIV infection among gay men is their willingness to identify themselves as gay, and to become "sexually-confident, well-educated gay men, who are sexually and socially engaged with community". Other Australian research has supported this view. Sinnott and Todd (1988) found that the most important source of accurate information about HIV transmission and prevention available to men who have sex with men is the material produced by gay community organizations and distributed within the gay community. Bennett et al (1989) found that men who find male sexual partners in public places such as parks ("beats"), and who have a low rate of self-identification as gay and a low level of contact with the gay community, also have a much higher rate of unsafe sexual practice and therefore a higher risk of HIV infection. The conclusion of this research seems clear. Men who identify as gay, who are confident in that identification, who are socially, culturally or politically active in the gay community and who find their sexual partners in the gay community, are much more likely to have accurate knowledge about HIV infection, than are men who have sex with men who are not attached to the gay community. They are also much more likely to act on that knowledge by making appropriate and sustained changes to their sexual practice. It is therefore clear that bringing about appropriate and sustained behaviour change among gay men has not just been a matter of producing information about HIV and safe sex and distributing it to individuals. Behaviour change among gay men has resulted from a community-wide response to the epidemic, which has sought to use the existing communication networks and value systems of the gay community to influence the collective behaviour of that community. New community values about acceptable and unacceptable sexual behaviours have been established, and have been enforced by community opinion, a far more effective way of enforcing standards of behaviour than coercion by the state. The experience of the gay communities in the developed countries is not uniform. The Australian gay community, on which the SAPA research is based, has had certain advantages not enjoyed by some other communities: a high degree of racial and linguistic uniformity, concentration in a small number of cities, government funding, a supportive social and political environment to carry out prevention work, and access to a cadre of skilled community activists to design and carry out both the programs and the research which has guided them. But in broad terms the experience of the Australian gay community has echoed those of the other developed countries. Rapid and massive behaviour change can be brought about through community-based programs. Since 1985 or so a number of studies have been undertaken, in the United States, Australia and other developed countries, to determine the reasons why some gay men have adapted to the demands of behaviour change in response to HIV and AIDS more readily than others. The SAPA studies have cast some light on this subject, as have American studies such as the Multi-Centre AIDS Cohort Study (MACS), which has followed thousands of gay men over several years to monitor their behaviour and the factors influencing it. The findings of these studies and others like them, taken together, show that a number of identifiable groups of men are at continuing risk of HIV infection. These are:
An additional, perhaps more surprising, finding was that gay men in relationships were more likely to be at risk of infection than were men who were not in relationships. These groupings reveal distinct social co-factors for HIV infection among gay men. Age is clearly one of the most important of these factors, because it relates to several of the others. Many younger people are likely to use alcohol and "soft" drugs while having sex. Many young gay men have low incomes. Young people of all sexual orientations are prone to the opinion that nothing bad can happen to them, and this is aggravated in the case of HIV risk by the fact that, because of the eight to ten year incubation period of HIV, few gay men under 25 have many friends with diagnosed AIDS. Young men are also less likely to have formed firm sexual self-identifications or to have developed strong gay community links, which are important in building a sense of the immediacy of the HIV threat and of responsibility for one's own and one's partner's health. The issue of the relationship between social and economic status, of which educational levels and literacy skills are generally assumed to be indicators, and sexual behaviour among gay men is a complex and controversial one, and has been bedeviled by a politically-motivated preoccupation with identifying (or creating) a category of "working-class gay men". Gay men have a peculiar occupational structure, heavily weighted to white collar and service occupations, with many transient, part-time and shift workers. This blurs traditional distinctions of class. In addition, many young gay men from working-class backgrounds find that the gay community offers contacts and opportunities, and a ladder to higher-status occupations and incomes. Nevertheless, many gay men still have limited educational levels and poor literacy skills, partly because of the alienation that many gay men feel from their peers during the period of accepting a gay identity, which coincides for many with the years of higher secondary education. Low literacy cuts many gay men off from the gay print media and print-based HIV educational campaigns waged by gay community organisations, which, as Sinnott and Todd showed, have been the most important sources of information about HIV and AIDS and about safe sex, and are also an important source of positive reinforcement for gay identity and community involvement. In Australia, which does not have the deep racial divide which characterises the United States, issues of ethnicity and linguistic background are still important factors influencing the ability of gay men to adopt and sustain behaviour change. Most developed countries now have large populations of first or second-generation immigrants, many of them from developing countries, and many of them maintaining cultural and religious traditions which mark them off from the culture of the host country. Gay men in these ethnic communities, who often do not identify as gay, suffer a double crisis of identity, in that they are violating their communities' accepted standards of behaviour by being gay, while being isolated from the host countries' gay community by cultural or linguistic barriers. This cuts many men off from the behaviour change messages which the gay community organisations are producing, usually in English and usually using an imagery and a vocabulary derived from the majority culture. Alcohol and other recreational drugs have been identified as among the major villains of the HIV epidemic in the gay communities. Alcohol, it is said, lowers self-control, heightens self-delusion and makes previous decisions about safe sex harder to stick to. The fact that so many gay men find their sexual partners in places where alcohol is served make this a chronic problem. Many health educators, however, argue that the belief that alcohol makes men incapable of controlling their sexual behaviour is a myth, and a myth which serves the interests of men in many contexts. They argue that men use alcohol as an excuse to engage in sexual (and other) behaviours which they know to be socially unacceptable. It may seem contradictory to say that gay men in relationships are at higher risk than gay men who have multiple sexual partners. There are two factors operating here. The first is that most highly sexually-active gay men have been acutely aware that they at high risk for a long time. They were the first to be targeted, and many long ago adapted to the discipline of safe sex. The sex-centered, antiromantic "culture of promiscuity" that exists around the saunas and sex clubs has served as an effective agent of behaviour change for many of these men. On the other hand, many gay men who think of themselves as relationship-centered and "not promiscuous" have been slow to perceive their own risk. 3. Lessons of the gay communities' experience with behaviour change It may seem a heroic leap to try to use the experiences of gay men in affluent societies to find lessons for reducing the impact of the HIV epidemic among the majority of people at risk of HIV infection in the world: men, women, and children in the developing countries. But it is not an impossible task. Despite the enormous differences in circumstances and contexts, there are some underlying similarities in the experiences of the two populations which can be usefully studied. This is particularly so when we remember that it is the sexual behaviour of men which is the fundamental behavioural problem in preventing the further spread of HIV infection in most parts of the world. The HIV epidemic in the developing countries is increasingly being understood to be a consequence of the sexual and social subordination of women in those countries. This is evidenced by a pattern of infection in which men are the vectors of infection and women the principal subjects of infection: married men who have multiple sexual partners are infecting their wives, who are prevented by economic and social restraints from protecting themselves from infection. There are those who may feel that it is impossible to induce men to forgo sexual gratification and adopt socially responsible behaviours. The experience of behaviour change in the gay communities suggests that this is not so. The gay communities are, after all, communities of men. The gay communities offer a unique opportunity to study the sexual behaviour of men. That the behaviour change campaigns mounted by gay community organisations have succeeded to the extent that they have in bringing about rapid and sustained change in the sexual behaviours of gay men, without resort to any kind of coercive mechanism, offers hope that changing the sexual behaviours of heterosexual men is not beyond the scope of human ingenuity. It is difficult to judge how far the social and behavioural risk factors which have been identified as making some gay men more likely than others to engage in behaviours likely to expose them to HIV infection are applicable to other risk populations, and particularly to people in developing countries. Clearly HIV infection in heterosexual populations raises issues around gender and power imbalances between men and women which do not arise in the gay communities. It seems clear, too, that the sale of sex plays a greater role in the proliferation of HIV infection in these countries than it does in the gay communities. Nevertheless, it may be possible to draw some analogies from the research about the risk factors which have been identified among gay men. Among the more likely candidates for social risk factors among heterosexual populations in developing countries are drug and alcohol use and relationship status. Men in all cultures use alcohol and recreational drugs of various kinds as social disinhibitors, and drinking or drug use frequently accompanies sexual activity. The extent to which alcohol abuse by heterosexual men contributes to the subsequent HIV infection of women, both sex workers and wives, is something which can be determined only by research on the spot, but it seems a fair bet, on the analogy of the experience of the gay communities, that a link will be found. If it is, it is important to remember research in the gay communities: that the link between alcohol use and unsafe sexual behaviour is not that alcohol deprives men of the ability to control their sexual behaviour, but that it gives them an excuse to behave in ways which they know would be otherwise unacceptable. The exposure of that excuse goes a long way to ending the ability of men to use alcohol in this way. Gay community HIV organisations have run campaigns stating this explicitly, such as the "Drugs and Alcohol: No Excuse" campaign of the Victorian AIDS Council. The analogies between the transmission of HIV within gay male relationships and its transmission within marriage in developing countries is harder to develop, because of the obvious fact that a gay relationship is a voluntary and informal (in a legal sense) relationship between two men, and any power dimensions that exist within it have been largely invented by the participants, whereas a marriage is a relationship between a man and woman, contracted in law and carrying with it the legacy of centuries of accumulated tradition and assumption about gender power distribution. A marriage is usually an economic relationship as well, involving the economic dependence of the woman. Nevertheless, it may be pointed out that the belief among many gay men that participation in a monogamous relationship somehow confers immunity from HIV infection may have some parallels in heterosexual relationships. It has been pointed out that, biologically, HIV in women is a disease of fidelity, not of promiscuity, since most women who contract HIV infection sexually do so from repeated exposure to a single infected man, usually their husband, rather than from single exposures to many infected men. Behaviour change campaigns which seek to promote monogamous relationships and marital fidelity will therefore be singularly inappropriate in places where a high proportion of married men are already infected. There are a number of lessons which may be drawn from the experiences of the gay communities in designing HIV behaviour change and prevention programmes in societies which may appear to have very little in common with those of the developed countries where most gay men live. Information and motivation The first point is that the provision of information is not enough. In the early 1980s both governments and community-based organisations in the developed countries engaged in large-scale mass media and community campaigns to disseminate basic facts about HIV and AIDS and to stimulate community awareness of the disease. Some of these campaigns were restrained and confined to giving information. Others were frankly alarmist, such as the British "tombstones" campaign and the Australian "Grim Reaper" campaign. What they all had in common was their failure to bring about any significant changes in behaviour in their target populations. Research shows that people do not change deeply-entrenched behaviour, such as sexual practices, simply on the basis of unintellectual awareness that the behaviour may be dangerous to them. A study of gay men in Los Angeles showed that those who were continuing to engage in unsafe sexual practices had exactly the same level of knowledge about HIV and safe sex as those who had adopted and maintained safe practices. The differences between the two groups were those of identity with the gay community, as discussed above. This reinforces the point that behaviour change among gay men in the developed countries has been brought about by community-based campaigns which promoted safe sex practices as a community standard of behaviour. By contrast, populations at risk of HIV infection which have been subjected only to information-based mass media campaigns have failed to show any significant change in behaviour. An obvious example is sexually-active young heterosexuals, whose risk of HIV infection is substantial but who have failed to respond to media campaigns aimed at influencing their behaviour. There is an obvious and positive lesson here for developing countries: expensive and high profile media campaigns are ineffective in bringing about behaviour change. This is an important point for countries with limited resources and poorly developed mass media structures, and particularly those which do not have linguistic or cultural unity (such as Papua New Guinea, for example) which would find national media campaigns even more difficult. Individuals and communities The second lesson is that behaviour change is not so much a process of individuals absorbing information and making rational decisions about their behaviour. It is much more a process of individuals changing their behaviour as a result of their membership of a community which is changing the standards of behaviour it expects from its members, because they identify with that community and wish to remain members of it. The best example of this is condom use. Most gay men dislike using condoms, but have accepted that they should do so, not so much from a rational decision to use condoms because this is the best way to avoid HIV infection (although this is probably how the decision would be articulated), but because they are aware that the community of gay men to which they belong, from which they derive a sense of identity and of personal worth, and to which they wish to continue to belong, has now adopted condom use as its standard of behaviour, and condemns those who do not use them. The sanction for failure to use condoms is not so much HIV infection, a long-term and somewhat nebulous threat, especially for younger gay men who do not have personal experience of HIV, but disapproval and possible ostracism by their peers. It follows from this that campaigns based on mobilising loyalty to and identification with specific communities offers the best hope for influencing the sexual behaviours of heterosexual men. While the gay community is a community of men who share a sexual orientation, and thus has certain unique advantages as a vehicle for influencing the sexual behaviours of its members, there is no reason why any pattern of community identification could not be adapted to the same purpose. This is in fact precisely what has been attempted with other risk populations in the developed countries, such as female sex workers and injecting drug users. Some rudiments of community organisation and identification already existed among these populations before the advent of the epidemic. HIV organisations have sought to build on these foundations, creating a community infrastructure, and communications network to build a sense of community commitment to safe behaviours and a sense of solidarity in achieving and enforcing behaviour change in the emerging community. While the results of this strategy have been mixed, they have been at least partly successful in some places; notably in Australia, where the incidence of HIV infection among injecting drug users and female sex workers is extremely low by world standards. Once again, of course, this is a strategy of building or, if necessary, creating communities based on an identity that relates directly to the risk behaviour involved; a community of female sex workers all share the risk behaviour of exchanging sex with men for money, and a community of injecting drug users all share the risk of behaviour of injecting drugs. Whether it is possible to mobilise the identity of heterosexual men with other kinds of community, for example a religious community, a sporting community or a neighborhood community, to reinforce the need for changes to sexual behaviours is difficult to determine. But it is certainly possible to suggest that the mechanism of community identification and loyalty, and thus the need and desire to retain membership of the community by conforming to the expected pattern of behaviour of that community, still operates regardless of the nature of that community, and this mechanism is the mainspring of bringing about behaviour change through community-based programs. Greater and lesser evils The third point is that behaviour change messages must give people realistic and sustainable choices. Few people welcome large-scale changes in their lives, particularly when these changes involve sacrificing behaviours which people find gratifying and which play a large role in forming their identities and sense of worth. When gay men were advised that they should abstain from sexual activity or radically reduce their number of sexual partners, most failed to respond, because these changes were too great to absorb into their lives. When the message was refined, and concentrated on the adoption of condoms for anal sex, there was a high level of acceptance, since this was a change which most gay men could accommodate without radical disruption to their lives. The debate within gay community HIV organisations about oral sex is an instructive example of this. There have been a small number of documented cases of HIV transmission between gay men following the intake of semen during oral sex. Some gay community organisations feel that oral sex should therefore be included on the list of unsafe sexual practices which gay men should be advised to abstain from. Others have argued, however, that the risk of HIV infection through oral sex is so low, certainly many times lower than the risk of infection through unprotected anal sex, that making a recommendation against it would be counter-productive. Many men, it is argued, would look at a list of "prohibited" practices and conclude that they could not make such radical changes, and would therefore make no changes at all. It is better, in this view, to accept a continuing small risk of infection through oral sex in order to persuade the majority to abandon the really high risk activity, unprotected anal sex. The analogy for developing countries may be that, since the really radical changes in behaviour needed to completely eliminate HIV infection cannot be achieved in the necessary time, because the intensity of community-based education needed to bring them about is too resource intensive, prevention efforts must focus on changes may be less effective in preventing HIV infection but which have a relatively low level of impact on people's lives and which thus have a greater chance of being adopted quickly. Thus, in countries in which condoms are neither readily available, cheap nor culturally acceptable, that is, where men will not use them and women cannot compel them to do so, the best option may be to enable women, and particularly sex workers, to improve their level of genital health so that their risk of infection through unprotected vaginal intercourse is reduced to a level comparable to that of women in developed countries, where HIV infection among heterosexual women is spreading much more slowly than it is in developing countries. This strategy will buy time for a more comprehensive strategy, based perhaps on large-scale voluntary testing and partner notification, to be developed and implemented. Horizontal and vertical education The fourth point is that the source of information and education must always be as close as possible to the people who are the targets of the education campaign. Ideally, the source of the information and education should in fact belong to the population at risk of infection. This was a lesson which the gay communities in the developed countries learned only after some costly errors in the early years of the HIV epidemic. The initial educational campaigns mounted by gay community organisations were heavily media-based: they consisted of print materials such as posters and leaflets, and display advertisements in the gay print media. As noted earlier, these campaigns were deficient in that they failed to communicate effectively with gay men who did not speak or, more commonly, read the language in which the campaign was being conducted or who lacked the literacy skills to take in the messages being put forward. But they were deficient in a more fundamental sense as well. Even though the source of these materials were gay community organisations, set up by gay activists who lived and worked in the gay community, they were still a form of vertical education: self-appointed experts were addressing messages to their communities through the impersonal medium of print. While these campaigns achieved considerable success, they failed to influence the behaviour of a large number of gay men in a sustained way. By 1986 gay communities in some countries were evolving a more sophisticated form of HIV education, based on peer education models. While the gay activists and health professionals who worked for gay community organisations were in a sense the peers of the gay men they were seeking to educate, the techniques they were using were the same as those traditionally used by governments and other sources of authority to influence behaviour and guide opinion. Gay men, as a marginalised and in some senses oppressed group, tended to be sceptical of messages seen as deriving from sources of authority: This was particularly true of men who shared the social and behavioural characteristics discussed above which made them less likely to readily adopt appropriate behaviour changes. The peer education strategies adopted by some gay community organisations were based on a philosophy of empowerment of individuals within the context of developing a stronger gay community. "Ordinary" gay men, that is, gay men who were not already HIV activists and were not professionally qualified were recruited to organise meetings of their friends, at which HIV and safe sex were discussed in the context of their own lives and relationships. In these small group discussions, gay men could discuss freely the difficulties and challenges of adapting to safe sex, could freely admit failures and lapses, and could offer each other support in sustaining behaviour change. Men who "graduated" from these meetings were in turn recruited to organise more meetings, thus penetrating wider and wider strata of the gay community, and of the population of men who have sex with men but who do not identify as gay. Particular attention was paid to young men, to older men, to men from non-English-speaking backgrounds, to bisexual men, to men who injected drugs, to transsexuals and to male sex workers: all groups which had been identified as having particular difficulties in adapting to safe sex. More ambitious programs were developed in some places: The "Gay Now" program of the Victorian AIDS Council in Melbourne, Australia, organised large-scale meetings involving hundreds of gay men at which facilitators led discussions and activities both in small groups and for the whole meeting. Several thousand gay men participated in these meetings during this campaign. While these peer education programs were naturally uneven in their degree of sophistication and in their organisation, there is no doubt that they carried behaviour change messages to a much wider network of gay men than were being reached by more traditional behaviour change campaigns, or that these messages were being communicated more effectively in the highly personalised context of small group meetings than they could ever be through even the most sophisticated print campaigns. The key to the success of gay community peer education campaigns was that behaviour change messages carry more impact when conveyed horizontally, by peers, than when they are conveyed vertically, by sources of authority to "the masses", and that individuals who are given the power to make decisions about their own lives in the context of a supportive community are far more likely to adopt and maintain appropriate behaviours than those who are spoon-fed behaviour change messages as passive and socially-isolated consumers. In this, of course, the gay communities simply rediscovered the techniques by which all knowledge was conveyed in periods before the evolution of mass communication systems. There are models even more directly analogous, since HIV peer education campaigns have been mounted among female sex workers in some developed countries, including Australia. Their success has been less marked than that of the gay community campaigns, mainly because it is more difficult to empower female sex workers, who are usually young and economically marginalised, than it is to empower gay men, many of whom enjoy a degree of class and gender privilege. It is also much more difficult to construct a genuine community of female sex workers than it has been to construct a community of gay men. Few women positively want to be sex workers: it is harder to engender a sense of pride in being a sex worker than it is to spread a sense of pride in being a gay man. Nevertheless, HIV peer education campaigns among female sex workers have achieved some successes, and could serve as a model for campaigns among sex workers elsewhere. In summary, there are a number of important lessons that can be drawn from the response of gay communities to the HIV epidemic. The first is that people do not change their behaviour on the basis of an intellectual awareness that the behaviour may be dangerous to them. Rather, one of the most important determinants of sustained change is membership of a community organisation which actively promotes and supports such changes. Secondly, behaviour change is less a process of individuals deciding to change than one of communities changing their standards of behaviour and values. Thirdly, behaviour change messages must give people realistic and sustainable choices from amongst which individuals and couples can choose according to their preferred sexual practices and the circumstances of their lives. Finally, the source of information, advice and counselling should be as close as possible to the community, preferably within the community. Behaviour change messages carry more impact when delivered by friends and colleagues than by authorities. Further, having and being encouraged to exercise the power to make decisions about their own life within a supportive community is critical. The relevance of these experiences to people at risk of HIV infection in developing countries should be obvious. The application of these lessons is independent of access to modern communication technology. Further, in countries where governments and other authority structures are either weak and ineffectual, or authoritarian and mistrusted, it is most unlikely that government-directed behaviour change campaigns will have a great impact. A strategy which has at its centre the empowerment of oppressed and marginalised individuals and the development of strong and autonomous communities will enable women and men to protect themselves against HIV infection. _______________ * The term "gay men" is used here to mean all men who have sex with other men, regardless of whether they identify as homosexual, bisexual or heterosexual. ** The term "gay community" referred originally to the community of gay men and lesbians. Lesbians increasingly do not accept that they share a community with gay men, and the term "gay and lesbian communities" has been adopted. Accordingly, I use the term "gay community" here to refer to the community of gay men. Acknowledgements This paper was prepared in December 1991 by Adam Carr for the United Nations Development Programme series of HIV and Development Programme Issues Papers. Biographical Note Adam Carr is an Australian gay community activist, journalist and HIV consultant. He was deputy chair of the Ministerial Advisory Committee on HIV of Victoria, Australia, and past president of the Victorian AIDS Council and Gay Men's Health Centre in Melbourne. He has written and lectured extensively on many HIV issues since 1983. |
