Off the map? The feasibility of HIV prevention workshops for young gay and bisexual men in rural and regional Australiaadmin
Off the map? The feasibility of HIV prevention workshops for young gay and bisexual men in rural and regional Australia
HIV Australia | Vol. 11 No. 1 | March 2013
ALDO SPINA examines whether the extension of existing peer-education models into regional and rural areas is the most effective approach.
Australia’s response to HIV prevention among young gay and bisexual men has been characterised by long standing peer education programs that place HIV prevention within a context of support for coming out, building self-esteem and personal resilience.
Young and Gay in Melbourne and Fun and Esteem in Sydney are examples of these programs. However, a limitation of these programs is their focus on city and major regional settings.
The AIDS Trust of Australia received funds from the Perpetual Funding Round 2010 to undertake a study to examine if these programs could be extended into rural and remote settings. The study was undertaken by the Australian Federation of AIDS Organisations.
The study mapped a range of services available to young gay and bisexual men (under 26), not just HIV prevention programs.
Organisations were included if they were providing a service specifically targeted at young gay and bisexual men. Services that were inclusive of young men, but more broadly targeted at gay, lesbian, bisexual and transgender (GLBT) young people were included within the study.
This was in anticipation that only a few services would be targeted solely at young gay and bisexual men.
Even though the study has a particular focus on how services can be extended into rural and regional areas, it was deemed appropriate to include metropolitan services in the study to hear their experiences of what works and what doesn’t, and whether they think it is feasible to extend existing metropolitan services into rural and regional areas.
Forty-five key information interviews were conducted with service providers working with young gay and bisexual men.
AIDS Councils/GLBT health organisations
The study was premised on an understanding that AIDS Councils/ GLBT health organisations in each Australian jurisdiction have operated HIV prevention and wellness programs for young gay and bisexual men in major metropolitan areas.
These have mostly been time limited workshops that are repeated throughout the year. While it may have once been the case that each Australian jurisdiction operated such programs, this is no longer an accurate assessment of what occurs.
These types of HIV prevention programs are running, but in fact only in three jurisdictions. And even then, in two of these jurisdictions workshops only run two or three times per year.
There is no doubt there are some significant strengths to these programs. They address HIV and sexual health very thoroughly, while doing this in the context of broader health and wellbeing issues.
Another key strength is their peer education and support approach. They are not embedded in a therapeutic approach.
Program staff also indicated that workshop participants provide extremely positive feedback on the programs.
However, these programs also now face a significant challenge attracting participants. There were a range of reasons put forward as to why study informants thought increasingly they were encountering issues attracting participants.
One of the key reasons proposed was increased competition. There are more groups available to young gay and bisexual men than when these workshops first commenced running in the late eighties and early nineties.
Although a few informants did note that the different workshops and groups on offer by various services in their area can attract different demographics.
Another factor that was thought to have lessened demand was the impact of social media and mobile apps.
While it is hard to quantify, there is a plethora of gay male personal websites and mobile apps that are used to facilitate men meeting other men.
This is not imply that all young men use these websites and apps, but it has had a significant impact on the ability of young people to seek out other young people like themselves without needing to attend a group or workshop.
More generally, some informants speculated that an increase in societal acceptance of homosexuals has also meant young gay and bisexual men probably do not feel the same need to seek out support from their peers that they once did.
Another factor put forward is that young people may not be interested in attending workshops. One informant thought it was hard to attract young people to a workshop when they may prefer or already be accessing regular social support groups.
He thought regular social support groups better meet the needs of young people (a common comment made by informants during the study).
Another informant pointed out that even if young people express a desire for workshops, this does not always equate with actually attending once a workshop is scheduled.
This feasibility study was designed to find out if there is a need for existing HIV prevention programs to be extended to reach young gay and bisexual men in rural and regional areas. Ultimately the study did not recommend such a course of action for four key reasons.
Existing HIV prevention programs are not appropriate to be extended: An assumption underpinning this study was inaccurate; most AIDS Councils/GLBT health organisations are not running specific HIV programs for young gay and bisexual men.
This occurs only in three AIDS Councils/ GLBT health organisations. Even in those jurisdictions it was reported the programs are facing significant challenges to their ongoing viability.
Where similar workshops have been implemented in rural and regional areas, they tend to have been extended to include all GLBT young people and have run fairly infrequently.
Informants working with young people indicated that these workshops are generally not preferred by young people in rural and regional areas, as young people prefer regular and ongoing groups.
This means that the model of young gay and bisexual men only, time-limited workshops is not likely to be successful in rural and regional areas.
Young gay and bisexual men in rural and regional areas are not at higher risk of HIV: There is often an assumption that young gay and bisexual men are at greater risk of HIV infection than other gay men.
Australian HIV notification data does not indicate that young gay or bisexual men (under 26) are at greater risk of HIV infection than other gay men, in fact, they indicate the reverse.
The national average age at HIV diagnosis among males has been relatively stable at around 37 years of age,1 indicating men in their early thirties to early forties are probably at greater risk of HIV infection.
And when different states and territories have observed increases in HIV infections among ‘young’ gay men, these have mostly occurred among men between 25–29 years old.
Again, contrary to the assumptions that are often made, social research does not support the notion that young gay and bisexual men’s sexual behaviour place them at greater risk of HIV infection.2 In fact, it shows that their behaviour differs little from older men.
Research has reported older and young gay men have similar rates of unprotected anal intercourse with regular and casual partners. Where there is a difference is that young people’s knowledge levels were lower and they reported low testing rates.
This is a cause for concern, but the response to address this is unlikely to be solved through workshops or groups alone, as these are unlikely to reach adequately large numbers of young men to make an overall population-wide difference.
If there is a need for programs, it relates to mental health and general wellbeing: Research has highlighted that gay, lesbian, bisexual and transgender people have markedly poorer mental health than that of the general population, and that GLBT young people report high or very high levels of psychological distress.3
Research with GLBT young people has reported strong links between homophobic abuse, and feeling unsafe, excessive drug use, self-harm and suicide attempts.4
Perhaps not unexpectedly, given they were running such services, study informants believe there were a need for social support groups for GLBT young people.
They perceived a need for young people to have a safe space to explore their sexuality and gender identity and to facilitate social connectedness.
The primary purpose of such groups is to improve participants’ overall health and wellbeing (including mental health), with HIV prevention being just one of many important issues to address.
Informants working in rural and regional areas, as well as outer suburbs in metropolitan areas, believed such groups needed to be inclusive of sexualities and genders. This was seen as necessary to sustain such groups.
Groups targeted at only certain genders or sexualities were less likely to be successful in attracting sufficient numbers of participants.
Furthermore, some informants believe the best approach to adopt when running these groups was that they needed to be open to all GLBT young people and their allies.
While there may be a need for social support groups for GLBT young people, this is not about HIV, but about overall health and wellbeing.
While AIDS Councils have always recognised the importance of addressing broader health and wellbeing issues, and how that can impact on HIV prevention, it is hard to justify arguing for additional HIV prevention funds when such a program would be broadly targeted at all GLBT young people (lesbians and transgender are not generally priority population groups within national and state HIV strategies) and primarily addressing a social connectedness need.
It is difficult to justify as a priority for HIV prevention funding: In the current environment, it is hard to justify a significant additional investment of HIV prevention funds on social support groups for GLBT young people when new HIV prevention strategies have a real chance to dramatically drive down infection rates.
New strategies include a focus on ‘treatment as prevention’, preexposure prophylaxis, and rapid HIV testing. These strategies, if combined with renewed HIV prevention messages targeted at priority population groups, have the real potential to have an impact.
This requires significant energy, resourcing and realignment of services, in what is largely a non-growth funding environment. In such an environment it is hard to argue that implementing social support groups for GLBT young people is an important HIV prevention priority.
Broader question: Is there a need for social support groups for GLBT young people in rural and regional areas? Putting aside the HIV prevention focus of this study, whether there is a need for social support groups for GLBT young people in rural and regional areas, with funding sourced from elsewhere, is not clearly established by this study as this was not its purpose.
While informants running such services could see a need for social support groups, the reality is that many of the groups reported that sustaining participant numbers can be challenging. And in fact, a number of informants reported that their groups were currently inactive or attracting low numbers.
While those running the groups report a need, and while research has documented the benefits of social support groups,5 many of these groups – and the research evaluating their impact – occurred before the use of social media and mobile apps became so widespread.
There is a question left unanswered as to whether young people today have the same need to connect with other GLBT young people through social support groups, when social media and mobile apps can more easily facilitate such contact.
This does not negate the need to address the greater mental health burden faced by GLBT young people, but it does raise questions as to whether social support groups are still the most appropriate approach.
1 The Kirby Institute. (2011). HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2011. The Kirby Institute, The University of New South Wales, Sydney.
2 National Centre in HIV Social Research, eNewsletter, January–March 2012.
3 Leonard, W., Pitts, M., Mitchell, A., et al. (2012). Private Lives 2: The second national survey of the health and wellbeing of gay, lesbian, bisexual and transgender (GLBT) Australians. Monograph Series Number 86. The Australian Research Centre in Sex, Health and Society (ARCSHS), La Trobe University, Melbourne.
4 Hillier, L., Jones, T., Monagle, M., Overton, N., Gahan, L., Blackman, J., Mitchell, A. (2010). Writing Themselves in 3. The third national study on the sexual health and wellbeing of same sex attracted and gender questioning young people. ARCSHS, La Trobe University, Melbourne.
5 Hillier, L. (2007). This group gave me a family. An evaluation of the impact of social support groups on health and wellbeing of same sex attracted young people. ARCSHS, La Trobe University, Melbourne.
Aldo Spina is a consultant who has worked in the HIV sector for over 20 years. He specialises in evaluating HIV prevention programs.