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.

1. The ‘prevention revolution’:
Implications for health promotion on
the ground, with a focus on HIV testing
National Centre in HIV Social Research
John de Wit & Philippe Adam

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. 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. Fighting HIV by ‘revolutionising’
prevention
National Centre in HIV Social Research

5. Getting to zero - UNAIDS vision

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. Combinationprevention
Coates et al., 2010

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. Multi-level prevention
Hayes et al., 2010

10. From ‘what to achieve’ to ‘what to
do to achieve’
National Centre in HIV Social Research

11. 2011 United Nations Political Declaration

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. 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. 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. 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. 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. Implementing responses to make
change happen
National Centre in HIV Social Research

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. 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

21. 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

22. 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

23. 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

24. 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)

25. Building programs on knowledge
of shaping factors
National Centre in HIV Social Research

26. 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 Samesame.com
 > 1,100 participants; 787 non-HIV positive; subset analyses

27. Ever tested and routine testing
Men 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%

28. Patterns of HIV testing
Never tested 20.9%
Ever tested – no routine 27.2%
Tester - moderate routine 22.8%
Tester -strong routine 29.1%

29. Factors associated with testing patterns
Multivariate Strong Moderate Tested-No Never
multinomial routine routine routine tested
regression analysis
Demographic
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

30. 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

31. 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)

32. 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

33. 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)

34. Gains emphasized in testimonial most effect

35. Nearing the end
National Centre in HIV Social Research

36. 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

37. Re-inventing revolutionary approaches

38. Questions & comments?
j.dewit@unsw.edu.au
12th Social Research Conference on HIV, Hepatitis and Related Diseases