SEXUAL RISK BEHAVIOURS IN GAY MEN ATTENDING A LONDON GUM CLINIC BHIVA Autumn Conference 2009 Erasmo Tacconelli, Liz Shaw, Kasia Hennessy Acknowledgements: A. Nageswaran, R. Browne, S. Narayana St Ann s Sexual Health Centre Sexual Risk and STI/HIV STI/HIV risk behaviour continues. People are still becoming infected, as increasing statistics globally, nationally and locally demonstrate (HPA, 2007). Some clients know prevention facts and are intelligent but disregard safe sex information. There is a need for more sophisticated interventions than information giving and health promotion. 1
One of Many Risk Groups There has been much research on the sexual experiences of gay and bisexual men. In both the UK and USA, studies have shown that gay and bisexual men put themselves at risk of HIV infection through unprotected intercourse (McLean, Boulton, Brookes, Lakhani, Fitzpatrick, Dawson, McKechnie & Hart, 1994). In a sample of UK gay men, the number of partners with whom unprotected intercourse had occurred was high. Over two-fifths of the sample reported having engaged in unsafe sex with three or more different men in the preceding year. (Gold & Skinner, 1992). Study Aims To ascertain the prevalence of high-risk behaviour, the risk profile and levels of stress, mood and cognition in gay male attendees (HIV negative HIV positive and unknown HIV status). 2
Hypotheses HYPOTHESIS 1. Precursors: Those who have historically had unsafesex will have had higher stress, worse mood and congruent unsafe sex cognitions compared to those who have historically had safe sex. HYPOTHESIS 2. Predictors: Those who intend to have unsafesex will have higher stress, worse mood and congruent unsafe sex cognitions compared to those who intend to have safe sex. Methodology: Design Cross Sectional Cohort Questionnaire Design Independent variable: Stress, Mood and Cognitions Dependent variable: Condom Use (Historical and Intentional safe or unsafe sex) 3
Methodology: Sample All men attending Zone 15 Gay Men s Clinic were given the opportunity to participate in the study during the study phase. Inclusion criteria: HIV-, HIV+ and Unknown HIV status. Sample size calculation: Alpha =.05 Power =.80 Effect size = 0.5(medium) Sample size therefore = 100-150 participants Methodology: Measures Measure 1. Demographic Data and Sexual Behaviour Data. This measure includes basic demographic information including Historical and Intentional Safe-Sex Behaviour. Measure 2. Social Readjustment Rating Scale (SRRS; Holmes & Rahe, 1967). This well validated measure will ascertain the types of life stressors the participant has had. Measure 3. Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). This well validated measure will ascertain the level of mood (namely anxiety and depression) the participant has had. Measure 4. Sexual Risk Cognitions Questionnaire (SRCQ; Shah, Thornton & Burgess 1997). This well validated measure will ascertain the types of cognitions participants have in relation to safe sex. 4
Response Rate September 2007 to May 2008 data collection period 18 Zones attended from which participants were recruited from 138 attendees asked to participate 18 refusals 120 participants 86.9% response rate Demographics Age: Range 16yrs to 69yrs (Mean 34.7yrs) Frequency Percentage Sexuality Gay 107 89.2% Bisexual 12 10.8% HIV status Negative 72 60.0% Positive 20 16.7% Don t Know 28 23.3% Relationship Status Single 76 63.3% Monogamous 27 22.5% Polygamous 17 14.2% 5
Demographics Educational Level Frequency Percentage Below GCE O Level/GCSE 10 8.3% GCE O Level/GCSE 22 18.3% A Level 18 15.0% Degree 46 38.4% Postgraduate 24 20.0% Ethnicity White UK 54 45.0% Black UK 6 5.0% Black African 7 5.8% Afro Caribbean 5 4.2% Turkish 2 1.7% Other European 17 14.2% Greek 3 2.5% Asian 5 4.2% South American 2 1.6% Australian 3 2.5% Middle Eastern 4 3.3% Other 12 10.0% Sexual Partners over Past 3 Months Figure 5. Sexual Partners Over the Past Three Months 40 30 Percent 20 10 0 None One 2-5 partners 6-10 partners 11-15 partners 16-20 partners 20+ partners 111/120 participants had sex during the last three months Sexual contacts overall for 111 participants =800 6
Stress Social Readjustment Rating Scale (SRCQ) Range 0 to 499 Mean 124.3 (Total possible is 170) Figure 15. Social Readjustment Rating Scale (SRRS) Totals SRRS Totals 499.00 416.00 369.00 283.00 252.00 239.00 225.00 218.00 186.00 168.00 157.00 146.00 135.00 124.00 120.00 111.00 107.00 96.00 90.00 86.00 76.00 71.00 68.00 62.00 49.00 42.00 36.00 20.00.00 0 2 4 6 8 10 12 Mood: Anxiety Hospital Anxiety and Depression Scale (HADS) Range 0-19 Mean 8.94 Total possible = 21 Cased = 8 above Cased 79 (65.8%) Not cased 41 (34.2%) Figure 11. Anxiety (HADS) Scores 12 10 8 Percent 6 4 2 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 18.00 19.00 7
Mood: Depression Hospital Anxiety and Depression Scale (HADS) Range 0-19 Mean 5.17 Total possible = 21 Cased = 8 above Cased 37 (30.8%) Not cased 83 (69.2%) Figure 13. Depression (HADS) Scores 12.5 10.0 Percent 7.5 5.0 2.5 0.0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 16.00 18.00 19.00 Cognitions Sexual Risk Cognitions Questionnaire (SRCQ) Range 34 to 13 Mean 50.6 (Total possible is 170) Figure 10. Sexual Risk Cognitions Questionnaire (SRCQ) Totals 40 30 Percent 20 10 0 34.00 37.00 40.00 43.00 46.00 50.00 53.00 59.00 63.00 69.00 73.00 80.00 85.00 93.00 111.00 8
Hypothesis 1 Results Are there significant differences between historical safe and unsafe sex groups regarding stress, mood and cognitions? T-tests: Anal PAST Safe and Unsafe Sex Groups Anxiety NS Depression NS Cognitions SIG (<.000 level significance) Stress NS T-tests: Anal NEXT Safe and Unsafe Sex Groups Anxiety NS Depression NS Cognitions SIG (<.000 level significance) Stress NS Repeated Measures T-test Cognitions Anal PAST Safe and Unsafe(<.000 level significance) Cognitions Anal NEXT Safe and Unsafe(<.000 level significance) Hypothesis 2 Results Does historical safe/unsafe sex, stress, mood and cognitions predict intentional safe/unsafe sex? Correlation Past Anal Correlation SIG (<.000 level) Next Anal Correlation SIG (<.000 level) Anxiety Correlation NS Depression Correlation NS Cognitions Correlation SIG (<.000 level) Stress Correlation NS Multiple Regression Best predictors of future safe sex in this study = Past Anal =.593 (most predictive) Cognition =.126 (next most predictive) 9
An Unsafe Sex Group? Anal PAST Unsafe = 50/120 participants. Anal NEXT Unsafe = 30/120 participants. 27 of the Anal Next Unsafe (except 3) were Anal Past Unsafe. Those that have had unsafe sex will have unsafe sex. 8=HIV+ 13=HIV- 6=Don t Know Unsafe sex group (n=27) = 225 sexual partners in past 3 months (800 sexual contacts in group of 120 participants) 28.1% of sex is unsafe (nearly a third) Unsafe Sex Group Top Cognitions I enjoy sex more without a condom Sex is more exciting without a condom I ve already had unsafe sex with him, what s the point of using a condom this time He is the same HIV status as me so it doesn t matter I believe him when he says he is negative I ve had unsafe sex so many times so why bother being safe now I want to show him that he is somebody special 10
Results Summary Hypothesis 1 Safe and Unsafe sex groups do not differ with Mood (anxiety and depression) and Stress but do with Cognitions as unsafe group (both historical and intentional) have higher sexual risk cognitions. Hypothesis 2 Past behaviour (safe /unsafe sex) is the best predictor, of variables studied, of future behaviour by 60%. Core Unsafe Sex Group 27 (8=HIV+, 13=HIV-, Don t Know=6) had justifying sexual risk cognitions. Justifying Cognitions? Smoking is dumb because it can kill but I enjoy smoking 20 a day Unsafe sex is wrong but Sex is great without condoms 11
Cognitive Dissonance One of the greatest challenges is persuading people to give up beliefs they hold dear when the evidence clearly indicates that they should. The theory of Cognitive Dissonance (Festinger, 1957) defined dissonance as a state of tension that occurs whenever a person holds two cognitions that are psychologically inconsistent. Dissonance produces mental discomfort and people don t rest until they find a way to reduce it either by changing behaviour or convincing themselves that the behaviour that is at odd with their thinking isn t by a range of cognitive distortions. Minimizing: Denying: Justifying: Oh well, the risk isn t that bad He looks well so he can t be HIV+ Well everyone else does it Dissonance theory is a theory of our mental blind spots and of how and why we block information that might make us question our behaviour or convictions. Conclusions According to NICE Guidance, the key task for local sexual health services is to identify and address risk factors in attendees and where appropriate, implement psychological approaches to reduce unsafe sex. It has been identified that approaches which can make clients think differently such as Motivational Interviewing can be helpful. The implementation of NICE Guidance across clinics is the desired consistent public health goal. As sexual activity is the most important transmission route for STI/HIV infection, prevention strategies for clients attending sexual health settings therefore remains a major task. 12