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The ‘prevention revolution’: Implications for health promotion on the ground, with a focus on HIV testing


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John de Wit, (NCHSR) argues that strengthening HIV prevention approaches will benefit significantly from drawing on behaviour change science. This presentation was given at the AFAO/NAPWA Gay Men's HIV Health Promotion Conference in May 2012.

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The ‘prevention revolution’: Implications for health promotion on the ground, with a focus on HIV testing

  1. 1. The ‘prevention revolution’:Implications for health promotion onthe ground, with a focus on HIV testingNational Centre in HIV Social ResearchJohn de Wit & Philippe Adam
  2. 2. Main messages Much (political) momentum to strengthen HIV prevention and bring down new infections, in particular in gay men However, there are no magic solutions; it’s about making best use of approaches, including clever combinations Behaviours remain key in shaping success across the increasingly expanding spectrum of responses Strengthening HIV prevention approaches will benefit significantly from drawing on behaviour change science
  3. 3. Overview of presentation Fighting HIV by ‘revolutionising’ prevention From ‘what to achieve’ to ‘what to do to achieve’ Implementing responses to make change happen Building programs on knowledge of shaping factors Some conclusions and recommendations
  4. 4. Fighting HIV by ‘revolutionising’preventionNational Centre in HIV Social Research
  5. 5. Getting to zero - UNAIDS vision
  6. 6. Re-invigorating prevention AIDS 2008, Mexico City – push factors for prevention ‘We can’t treat our way out of this epidemic’ Massive increase in people living with HIV receiving cART But: more people newly infected than newly on treatment Sustainability of financial and human resources (eg GFC) Funds diverted from cost-effective upstream prevention Essential to also address social and behavioural issues Effective response requires combination of approaches
  7. 7. CombinationpreventionCoates et al., 2010
  8. 8. Prevention revolution AIDS 2010, Vienna – pull factors for prevention Evidence (emerging) for biomedical prevention Male circumcision, vaccine, PEP, PMTCT Treatment-as-prevention  Ecological studies: gay men San Francisco; PWID Vancouver  HPTN052: 96% reduction of infections in discordant couples Pre-exposure prophylaxis  Microbicide: CAPRISA004 (TDF)  Oral PrEP: iPrEX, TDF2, Partners PrEP (TDF/FTC); PP (TDF)
  9. 9. Multi-level preventionHayes et al., 2010
  10. 10. From ‘what to achieve’ to ‘what todo to achieve’National Centre in HIV Social Research
  11. 11. 2011 United Nations Political Declaration
  12. 12. Creating global commitment Goal-setting theory ‘Specific, difficult/high/challenging/ambitious goals lead to a higher level of task performance than do easy goals or vague, abstract goals’ Locke and Latham (1990, 2002, 2006) If… High commitment (importance of goal and belief it can be attained) High ability (task complexity, role overload) Positive feedback (evidence of progress in attaining the goal) No conflicting goals (negatively affects motivation and ability)
  13. 13. Implications for Australian response Exciting aspiration to start driving down and work towards elimination of new infections, in particular among gay men Ongoing important and engaged presentations and debates to develop consensus and shared vision Translating global targets to local context  Reducing sexual transmission, in particular among gay men  Maintaining successes among sex workers as well as PWID  Specific focus on regular HIV testing and timely cART initiation What do we want to achieve and what can be achieved? Applicability of findings to Australian context?
  14. 14. Towards astrategicapproach Effective and cost-effective set of policies and programs  Systematic planning, development and implementation  Not only a matter of funding; delivering best possible practice  Social justice and ethical consideration What responses can make most difference, for whom? How are priority prevention responses best promoted? How can responses be tailored to meet different needs? How do different responses form a strong combination?
  15. 15. Mixing and matching options Reducing likelihood of exposure to HIV Consistent, effectivecondom use, with all partners Gradual erosion in MSM; scope to strengthen promotion of default Serostatus-based sexual risk reduction practices Imperfect practice; potential for serodivide; impact on condom use Reducing likelihood of HIV transmission Treatment of sexually transmissible infections Unclear effect; ongoing epidemics; further promotion of testing Medical male circumcision Limited local relevance; cultural/political considerations and beliefs Pre-Exposure Prophylaxis with oral/topical cART Not currently available; cost; adherence; safety; impact on condom use Ensuring increased, timely initiation of cART Good baseline; clinical benefit; accessibility; unintended effects
  16. 16. Policy and program actions Several suggestions in Whittaker discussion paper  Deliver new awareness campaigns targeting PLHIV  Deliver new awareness campaigns targeting MSM  Update health promotion programs about prevention  Promote HIV testing and make rapid testing available  Remove arbitrary restrictions on HIV treatments  Address disincentives to HIV treatment uptake  Inform serodiscordant couples  Make PrEP (pre-exposure prophylaxis) available  Sustain virtual elimination of HIV from IDU and sex work  Mobilize gay community and other key communities
  17. 17. Implementing responses to makechange happenNational Centre in HIV Social Research
  18. 18. Increasing centrality of HIV testing Reduction in risk when diagnosed HIV-positive Potential for counselling when diagnosed HIV-negative Enabler of serostatus-based sexual risk reduction Reduction in people unaware of living with HIV Point of entry for timely initiation of treatment and care Monitoring efficacy of PEP, PrEP and other risk reduction
  19. 19. Improving on a good response Gay Community Periodic Surveys Around 90% of all men ever tested for HIV Around 60% of non-positive men tested for HIV in the last year
  20. 20. Possible interventions and evidence Review of interventions for MSM (Lorenc et al., 2011)  Identified 12 effectiveness studies; range of interventions Type of test and testing protocol  Bundling, community rapid/oral fluid test, home oral fluid test Peer education or recruitment  Peer-led risk reduction campaigns, intensive weekend program Media and web-based campaigns  Community-based media campaigns, online educational video STI clinic service delivery  Opt-out policies, implementation of guidelines No strong evidence of more testing; promising strategies  Few studies, many with limitations; further research required
  21. 21. Systematic health promotion planning Science of behaviour and behaviour change What factors are shown to shape behaviour?  Nature, quality and relevance of the research  Specific community and context; theory-informed assessments  Interviews, rating reasons, correlations, prospective assessments, controlled tests of strategy, field studies of true interventions  Appraising of relative influence: prioritizing, multivariate analyses What interventions can address these factors?  Focus foremost on proven, theoretical change mechanisms  Identify feasible ways of delivering: impact, reach, cost  Ensure appropriate ‘packaging’ for target audience  Contribute to evidence base through robust, comprehensive evaluation: pilot-testing, process, appreciation, impact
  22. 22. What factors shape HIV testing? Many studies, little evidence (De Wit & Adam, 2008)  Diverse communities, methods, factors  Descriptive (k=9) and correlational (k=41) studies; 11 with MSM Convergent themes derived from available studies  Perceiving to have been at risk; differences between communities  Fear of consequences of testing positive; rejection/discrimination  Perceiving more benefits from testing; lay perspective critical Overlapping and complementary themes in recent reviews  Deblonde et al. (2010); Lorenc et al. (2011); Schwarcz et al. (2011)  Accessibility and characteristics of the services Need systematic assessments of barriers and facilitators  Comprehensive inclusion of factors; guiding theory/model
  23. 23. A gentle reminder ‘It is not so much the changing medical aspects of HIV that shape contemporary testing decisions, but the social meaning and social consequence of HIV diagnoses.’ Flowers, Knussen& Church (2003)
  24. 24. Building programs on knowledgeof shaping factorsNational Centre in HIV Social Research
  25. 25. Online survey ‘How much do you care?’ Led by Philippe Adam; funded by HARP Unit Randwick Assessing patterns of HIV/ST testing among gay men  HIV/STI testing as part of a sexual health routine Gay and other men who have sex with men in NSW  Cross-sectional self-completion survey Recruitment from April through October 2011  Advertisement on Facebook and  > 1,100 participants; 787 non-HIV positive; subset analyses
  26. 26. Ever tested and routine testingMen who ever tested for HIV 79.1%Routine testing (among ever tested men)Totally disagree (no routine) 09.4%Somewhat disagree (no routine) 11.8%Neither agree nor disagree (no routine) 13.1%Somewhat agree (moderate routine) 29.0%Totally agree (strong routine) 36.8%
  27. 27. Patterns of HIV testingNever tested 20.9%Ever tested – no routine 27.2%Tester - moderate routine 22.8%Tester -strong routine 29.1%
  28. 28. Factors associated with testing patterns Multivariate Strong Moderate Tested-No Never multinomial routine routine routine tested regression analysisDemographic Age under 27 ref - - ↑Behavioural Regular partner ref - ↓ ↓ Any casual partner ref - ↓ ↓ > 20 partners lifetime ref - ↓ ↓Psychosocial HIV knowledge ref - - ↓ Attitude re testing ref ↓ ↓ ↓ Perceived pros ref ↓ ↓ ↓ Perceived cons ref - - - Fears of testing ref - - - HIV stigma ref - ↑ - Norms re testing ref - - - No effects found for perceived vulnerability to HIV and perceived severity of HIV
  29. 29. Acknowledging ‘causal density’ Behaviour is shaped to some extent by many factors  Differences between individuals and by contexts  No single, simple intervention; clever mix of approaches ‘Social marketing’ remains necessary but is insufficient Appropriate services are required, but more is needed Using more items in the health promotion tool-kit  Beyond awareness raising and service improvement  Nudging and norms: Making ‘the right choice’ easy and normative
  30. 30. Content matters – framing and format What is the message of social marketing campaigns?  Beyond the action recommendation; information and arguments Attitude change/health communication theory and research  Understanding message reception and yielding  Recipient, channel, source and message factors How are arguments to motivate action framed?  Focus on gains/non-losses or losses/non-gains  Rothman and Salovey (1997) How is evidence for recommendation provided?  Abstract statistics or personal testimonials  De Wit, Das, & Vet (2008)
  31. 31. An example from ongoing research Else van Miltenburg, Philippe Adam, John de Wit Health communication promoting condoms in young people Controlled, experimental study; student participants Effect on perceived vulnerability and condom use intention Four different messages; 2 (framing) X 2 (format) design
  32. 32. A taste of difference – message headings Gain/testimonial Matthew (21) recently learned that protecting oneself during sex is the best way to reduce one’s chance of becoming infected with a sexually transmitted infection (STI). Gain/statistical Research shows protecting yourself during sex reduces your chance to become infected with a sexually transmitted disease (STI) Loss/testimonial Matthew (21) recently learned that not protecting oneself increases one’s chance to become infected with a sexually transmitted infection (STI). Loss/statistics Researchshows not protecting yourself during sex increases your chance to become infected with a sexually transmitted disease (STI)
  33. 33. Gains emphasized in testimonial most effect
  34. 34. Nearing the endNational Centre in HIV Social Research
  35. 35. Some conclusions and recommendations Opportunity to strengthen HIV prevention for gay men Building on momentum and new prevention tools Experience cautions of unintended/unexpected effects Community-based health promotion remains critical Making the best use of our experience and expertise in health communication and behaviour change approaches Strengthening the science base of interventions  Making more use of behaviour change theory and research  Supporting knowledge transfer through collaborative projects
  36. 36. Re-inventing revolutionary approaches
  37. 37. Questions & comments? Social Research Conference on HIV, Hepatitis and Related Diseases