HIV Australia - Education

Vol. 3 No. 1

September - November 2003

Complex education Getting education messages out there is becoming increasingly complex. DERMOT RYAN addresses some of the challenges facing educators in the current environment.

Victorian Networks Study: shifting the research focus The VINES study looks at gay men’s sexual cultures by focussing on the social and relational networks of gay men in Melbourne. Dr JEFFREY GRIERSON reports.

Sex workers as educators SERENA MAWULISA and KENN ROBINSON look at the unique role that Australia’s sex workers play in HIV and sexual health education.

Complex education

Australia is currently experiencing rises in HIV notifications across a number of states. Getting the message out there is not just as simple as promoting the use of condoms and lube. Dermot Ryan looks at the complexities facing educators working in this environment.

The HIV surveillance figures show 821 new diagnoses of HIV infection in the year to 31 December 2002 up from 750 in 2001. This indicates a national increase of 8 percent for the 2002 year. The states most affected are NSW with a 12.8 percent increase, Queensland with a 20 per cent increase and Victoria with a 7 percent increase. With the exception of Victoria, significant increases in notifications have not been recorded in recent years.

During the late 1980s the rate of HIV infections peaked at over 1,000 notifications annually. In the early to mid 1990s the figures commenced a steady decline and then reached a plateau in most states and territories across the country. The current national increase might that the plateau effect is now changing.

Prior to the release of the current HIV surveillance figures, social and political commentators over the past five to six years have occasionally speculated on potential HIV increases. However, they have largely stayed silent due to the success of Australia’s HIV response. They have also remained silent when it comes to congratulating gay community, sex workers and injecting drug users, who have been on the front line and have done the unimaginable by largely containing the spread of HIV for 20 years.

Often, when increases in preventable health related epidemics occur such as the one we are currently experiencing in HIV, people look for single answers. Sometimes they look for who or what they can blame and often they expect that simple and singular solution should be available. Attack is often the first form of defence and if not challenged, a chorus of ill informed, morally charged voices will soon prevail to blame:

a) gay men for these outrageous drug fuelled and care free sex binges,

b) HIV positive people for the atrocities being committed on the innocent and HIV education naive and,

c) the leadership of the community sector ie AIDS councils, National AIDS advisory bodies and research institutions for failing to act.

No doubt we will see new research that presents both good and bad public opinion as evidence.

It is no surprise that the increase in HIV notifications in Australia has given cause for media speculation and commentary in both the community press and the mainstream media. Some of the media commentary has been sensible, yet some is not so sensible. The usual warning shots have been fired and some singular explanations have been offered about what to do, particularly in response to bare backing.

HIV community organisations have been arguing for some time that HIV is more complex post 2000. Some social and political commentators read this as HIV community organisations and in particular HIV educators making it more complex than it needs to be. However, for a range of reasons, this is not what is happening.

Educators are working in a more complex environment than they have in the past with gay men, HIV positive people, and people who operate in or on the fringe of those communities. A quick example of the complexity facing educators can be demonstrated by examining education issues around the availability of Post Exposure Prophylaxis (PEP). PEP is an easy name to remember, but the issues around how and when to take PEP is not so easy. You need to take PEP within 72 hours of a potential exposure, PEP involves a months worth of pills (not just one day) and because PEP is a prescription medication, people who are exposed need to know where to get it.

The community response to HIV/AIDS for some time has been reflective of the move towards “Combination Prevention Education.”“Combination prevention education” is characterised by the following factors:

• It is programmatic and multi sectorial in approach
• It combines risk reduction with vulnerability reduction
• It recognises and works within the complexities of peoples lives, experiences, culture and interconnectedness
• The target audience is both HIV positive and HIV negative people in areas of development and outcome
• It works towards developing a common language in the promotion of health

In Australia, there are a number of complexities surrounding the dynamic in which HIV notifications are occurring. This in turn leads to complexities surrounding the response to those notifications including:

Gay community

There are now several generations of gay men who have quite varying experiences of a 20 year epidemic. Some are exhausted by close contact over many years and others have no personal experience of knowing someone with HIV or someone who has died of AIDS.

Notions of gay identity and how we define ourselves as a community have changed considerably over the last 20 years. Along with this, the places we meet, our community organisations and the ways we “attach” ourselves to the community have also changed. There are degrees of community ‘disengagement’ from HIV. It used to be the number one issue but now other areas of our lives - like parenting or marriage rights - compete for attention.

Sex cultures

Over the past few years, there has been a reported steady rise in unprotected anal intercourse with both casual and regular partners in many Australian cities and in comparable cities overseas.

There is significant – though sometimes exaggerated - use of illicit drugs within the lived sex culture of many gay men. The impact of drugs can have many different short and long-term consequences such as the feeling of invulnerability associated with some highs or at the other end of the spectrum, the feeling of depression and paranoia associated with long term use or regular binges. All these consequences have different impacts on safe sex practice.

The role of the internet and the emergence of a “cyber-sex space” provides a whole different environment for sex and sexual negotiations. Critically for educators, such encounters take place away from familiar community institutions and are potentially creating new languages and norms of behaviour. HIV positive discrimination is being experienced - particularly in the negotiation of sex – which obviously makes disclosure more difficult.

On top of this, Sexually Transmitted Infections (STIs) have again increased among gay communities and the presence of STIs can assist in the transmission of HIV.

Risk reduction strategies

There is an increased understanding of the role that treatments and clinical markers play in the sex, lives and decision making of both HIV positive and HIV negative men. Risk reduction strategies around who tops and who bottoms based on real or assumed HIV status, or by using clinical markers such as viral load, are becoming a part of some men’s sexual decision making. People make assumptions about their sex partner based on non-verbal and environmental cues, which may or may not be correct. A small percentage of gay men are not aware of their HIV status because they have not tested for HIV for a number of years, have placed themselves at risk of HIV and are assuming their HIV status remains negative.

Post Exposure Prophylaxis

The use and availability of post-exposure prophylaxis (PEP) has grown, however knowledge is not wide spread, especially outside of Sydney and important facts about using PEP are often not understood by many people.

Treatment

The introduction and use of new drug treatments for HIV positive people in 1996 has had a profound impact on the longevity and quality of people’s lives. The use of these treatments is also shifting with deferral of treatment commencement now preferred depending on the base line clinical markers. Other people have started to take “treatment breaks” for medical or quality of life reasons. Different treatment choices may impact on the use and effectiveness of some risk reduction strategies because they affect a person’s viral load.

Changes over time to HIV treatment protocols include the benefits to some people of deferred treatment commencement and the use of treatments breaks for medical or quality of life reasons. The variability of treatment choices is likely to impact on the use of risk reduction strategies (listed above) that people engage with

Education

There is a need to run multiple-level HIV education messages simultaneously. These messages must be balanced to provide simple reinforcement of safe sex messages that are suitable for men new to homosexual sex and highly complex messages based in the realities of people’s lives and based on improving the understanding and interplay of risk, HIV status, viral load, negotiation and sexual positioning in the lived sex cultures of a well-informed, sophisticated population. However, there is limited funding to produce the range of increasingly complex resources to address this complex situation.

Gay men have a lot to take on when they just want a root, or when starting or ending a relationship. Yet gay men have - and continue to - negotiate this complex terrain all the time. There are very few opportunities to thank and congratulate gay men for their high compliance of condom use, and by addressing the reality of the above complexities, we are not suggesting that condoms be thrown away in favour of these highly variable risk based strategies. People who continue to use condoms either all or some of the time need to be congratulated, because apart from abstinence, condoms are still the best prevention strategy.

Gay men whether HIV positive or negative, have not abandoned safe sex, nor have they been left behind as has been recently suggested. In fact, they have done remarkably well by both Australian and international standards at engaging with safe sex and getting on with living in a world where HIV is a part of our community and our lives. It’s tempting for some people at a time such as this to set up the good against the bad and the compliant with the non-compliant. Let’s not head down that path. Let’s work out what we know and what we still need to know and establish who we are and the type of sex we want to have and how we want to play.

Like it or not we need to continue to take responsibility for ourselves, our friends, our lovers, our fuck buddies and those we don’t want to have sex with. Getting informed and communicating is key to understanding our own dynamic culture.

HIV educators and community organisations have not failed, become complacent or made things more complex than they need to be. HIV educators and gay men are as diverse and complex as the community they operate and work in. We live in a different and somewhat more complex world than the one we were in 20 years ago or even 10 years ago. What is needed now is active participation, talking, and creative thinking - not simplistic sloganeering addressing narrow and singular based issues.

Dermot Ryan is the manager of the Australian Federation of AIDS Organisations (AFAO) & the National Association of People living With AIDS (NAPWA) Education Team (ANET) and AFAO Indigenous Projects.

HIV Australia welcomes feedback on this article. Please send your comments to the editor: editor@afao.org.au.

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Victorian Networks Study: shifting the research focus

Dr Jeffrey Grierson

Sexual cultures change. They change from context to context, they change over time and they change depending on the way we look at them. The reports of increases in unprotected anal intercourse among homosexually active men and increases in reported HIV infections has brought about a renewed interest in the sexual cultures of gay men and in what social research can tell us about these. Practitioners ask two major questions of the social research: what is happening and how can we intervene? In response, social research to date can tell us a lot about the practices of individual men, patterns of sexual practice, representations and manifestations of sexual cultures and the impact of health promotion activity on these practices.

A new research project from the Australian Research Centre in Sex, Health and Society (ARCSHS) at Latrobe University and the Victorian AIDS Council (VAC) is asking us to make a shift in the way we look at gay men’s sexual cultures by focussing on the social and relational networks of gay men in Melbourne. The project, The Victorian Networks Study (Vines), looks at the actual social and sexual networks of 213 individuals and begins to ask some fascinating questions about the shape, structure and constitution of these networks and their relationship to sexual practices, knowledges and social influence. As the analyses of these data begin to come out, we will be able to ask, and perhaps answer, some critical questions about the ways in which gay men’s patterns of social relationships constrain and/or support protective and risky sexual practices.

The analyses possible with the data collected in this study fit well with the contemporary best practice in HIV prevention education and health promotion. We know that the best health promotion operates at the level of lived cultures, within the extant social relationships and systems of social influence that constitute people’s lives. Research that also operates at this level has enormous potential to work directly with the conceptualisation and development of health promotion activities, and so may be able to offer some response to both the ‘what’s going on?’ and ‘what do we do?’ questions about increases in unprotected anal intercourse and HIV infections.

The increase in rates of unprotected anal intercourse among gay men is complex phenomena mediated by HIV status, negotiated arrangements within regular and casual relationships and contact with the HIV/AIDS epidemic. We know from social research and the experience of prevention education practice that decisions around protected and unprotected sex are highly dependent on contextual factors like geographical site, alcohol and drugs, access to means of prevention and emotional state. In order to adequately address this increase in HIV infection, prevention education needs to target the appropriate social and sexual contexts in which unprotected sex takes place.

These sexual cultures are not stable, changing as the realities of the epidemic and the meanings around infectivity, prevention and sexual practice change. There has been no substantial empirical inquiry into the sexual culture of homosexually active men in Melbourne since the Melbourne Men and Sexual Health study in 1994 (Prestage et al, 1996). We cannot assume that the sexual culture has remained the same since then.

While community engagement and the use of culturally specific interventions remain basic principles of prevention education, we cannot assume that the relationship between community attachment and prevention strategies has remained stable. Research, such as that conducted in Melbourne, for example the CASE (Community, Attachments, Structures and the Epidemic) study (Grierson, 1998), SSAY (Same Sex Attracted Youth) (Hillier et al, 1998), and results from the CEWT (Community Education Workforce and Training) (Misson et al, 2000) and HIGH (Hepatitis, Injecting & Gay Health) (Dowsett et al, 2002) studies, strongly suggest that homosexually active men no longer engage with the gay community in the same way as they did in the early years of the HIV epidemic. Indeed many gay men who have come out in the recent years of the epidemic do not appear to have a strong connection to gay community either as a physical or social entity, nor do they have primarily gay social networks. Other research conducted in Sydney (for example that conducted by the National Centre in HIV Social Research reported in Mao et al, 2002) and that conducted by David McInnes and Jonathan Bollen with the AIDS Council of NSW (Bollen et al, 2000, Dowsett et al, 2001, McInnes et al, 2000) indicate that understanding the specific local context of gay sociality is essential to effectively target prevention education.

The Vines study, funded by the Victorian Department of Human Services, consists of two integrated projects - the first mapping the social and behavioural contexts of gay men’s sexual behaviour, and the second a set of action research projects that focus on specific identified local contexts to refine and focus prevention educational practice. Vines is the first comprehensive investigation into the social and sexual networks of gay men in Australia. It is unique in that these networks are the primary focus of the study and the principal unit of analysis. Networks are the dynamic social systems through which HIV is spread, and the structures which facilitate the communication of HIV prevention messages provide the normative reference for individuals’ social practices and enable and constrain safe sex cultures.

The first technical report from the Vines project has been released and details (the rationale and methodology of the study, characteristics of the participants and their social and sexual networks) describes some structural and constitutive characteristics of these networks and offers some preliminary analyses of how network characteristics are related to social and sexual practices. Further analyses of these data will be made available through peer-reviewed publications and a series of issues papers addressing specific aspects of gay men’s relationality. In addition, the findings of this research are currently being used to construct three action research projects that, as with Vines, will continue the fruitful collaboration between ARCSHS and VAC/GMHC.

Copies of the technical report are available from ARCSHS by calling (03) 9285 5382 or email arcshs@latrobe.edu.au.

HIV Australia welcomes feedback on this article. Please send your comments to the editor: editor@afao.org.au.

References

Bollen, J., McInnes, D., Couch, C. & Dowsett, G. (2000) “Over it and on with it: Gay community and the scene in inner Sydney', in Considering Australian Gay Communities in HIV Health Promotion, ed. David McInnes, Research Centre in Intercommunal Studies, University of Western Sydney.

Dowsett, G.W., McInnes, D., Bollen, J., Couch, M. & Edwards, B. (2001) 'HIV/AIDS and Constructs of Gay Community: Researching educational practice within community-based health promotion for gay men'. International Journal of Social Research Methodology, 4/3:205-223.

Dowsett, G.W., Wain, D., Peterson, K. and Voon, D. (2002) Double Jeopardy: findings from Project High on gay men who inject drugs and prevention education in Melbourne, Australia. Paper presented at 14^th International AIDS Conference, July 2002, Barcelona, Spain.

Grierson, J. (1998) Community Attachment, Structures and the Epidemic (CASE): A study of the importance of gay community in the lives of gay men. Unpublished doctoral dissertation, Latrobe University, Melbourne, Australia.

Hillier, L. Dempsey, D. Harrison, D. Beale, L. Matthews L. & Rosenthal, D. (1998) Writing Themselves In: A national report on the sexuality, health and well-being of same-sex attracted young people. Monograph Series Number 7. Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne.

Mao, L., Van de Ven, P., Prestage, G. Jin, F., Grulich, A., Crawford, J., Kippax, S., Murphy, D., Allan ,B. (2002) Health in Men Baseline Data. Monograph 6/2002. National Centre in HIV Social Research, Faculty of Arts and Social Sciences, The University of New South Wales.

McInnes, D. & Bollen, J. (2000) Learning on the job: Metaphors of choreography and the practice of sex in sex-on-premises venues. Venereology, 13/1: 27-36.

Misson, S., McDonnell E., Dowsett G.W., and McInnes D. (2000). Who are the Community-based HIV/Hepatitis C Educational Workforce? CEWT Broadsheet #1. Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne.

Prestage, G., Kippax, S., Benton, K., French, J., Knox, S., and van de Ven, P. (1996) Melbourne Men and Sexual Health; a demographic and behavioural comparison by age in a sample of homosexually-active men in Melbourne, Australia. National Centre in HIV social Research, Faculty of Arts and Social Sciences, The University of New South Wales.

Dr Jeffrey Grierson is a Research Fellow, The Australian Research Centre in Sex, Health and Society, Latrobe University, Melbourne

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Sex workers as educators

Sex workers may be doing the some of the most effective sex education work with adult heterosexual and homosexual men in Australia, reports Serena Mawulisa and Kenn Robinson.

Sex workers worldwide have unique and exclusive access to men that may never actively seek information about HIV or STIs. Clients generally view sex workers as ‘sexperts’ and as a result, they may ask questions that they would never dare broach with a health professional, making sex workers a valuable resource in HIV education work.

In Australia, sex workers continue to demonstrate high levels of sexual health of which we can be proud. In over 20 years of HIV in Australia, no cases have been recorded of transmission of HIV between a sex worker and a client or vice versa ¹. Sex workers also have consistently lower rates of sexually transmitted infections (STIs) than the general community.

However, the maintenance of good sexual health among Australian sex workers has occurred despite less than optimum conditions. In most States and Territories, some sex work contexts are still criminalised. Sex workers have shown much skill in continuing such high levels of safer sex practices in what is a far from an enabling environment.

Female workers in particular – the largest and most researched group in the sex industry - use condoms for oral, vaginal and anal sex. The reasons for Australian sex workers having been so successful at implementing wide scale condom usage in commercial transactions are complex, ranging from the obvious prevention of transmission to the creation of a psychological barrier between worker and client during penetrative sex. Female sex workers were using condoms prior to the emergence of HIV in Australia to avoid other STIs such as gonorrhoea, however HIV increased the support of sex industry management for safer sex and also reduced client resistance to condoms. Sex workers have been linked with disease in our culture since the days of syphilis epidemics in Europe, and sex workers use this stereotype strategically with clients - alluding to the fact that the client needs to protect himself ² against the worker to reinforce the expectation of safer sex.

For male sex workers, HIV/AIDS education often involves expelling some of their client’s myths of transmission. For instance, men visiting male and pre-operative transgender workers may try to encourage the sex worker to have sex without a condom with comments like, “I’m married. I’m clean. I/you don’t need to use a condom” or “I’m not gay so I don’t have HIV.” The worker’s insistence of condom usage may go some way towards educating their clients on not only the risk of HIV, but STIs.

Sex work skills

Sex workers use a range of skills within commercial sexual services that increase the comfort levels of clients around safer sex. A good example is the application of condoms using the mouth. This technique is great preparation for safer oral sex and eroticises condom use, so that putting on the condom is less intrusive to the flow of the exchange, ensuring that the client is less likely to lose an erection. Also, some sex workers will open the condoms and have them close by before the sex begins, further reducing interruption.

One of the gifts that sex workers offer their clients is to broaden their sexual horizons. Often, one of the messages our culture promotes is that sex revolves around penetration. Heterosexual men in particular can be focused around penetrative sex almost to the exclusion of other forms of erotic play. For female sex workers on the job learning, informal peer education between co-workers in sex industry workplaces and formalised peer education through sex worker organisations; has developed a broad repertoire of erotic touch. This can include body slides (a sexy form of body contact massage); tit-fucking (known as Spanish within the sex industry) and nipple play on a client. These techniques minimise the length of time spent performing penetrative sex – thereby reducing condom breakages and wear and tear on the body. An additional benefit of these non-penetrative activities can be introducing clients to unfamiliar erogenous zones and lower risk sex play.

Unfortunately, sex workers are not immune to negative messages about sex in our culture. Female sex workers in particular can be affected by stigma attached to sexually active women. However, even when sex workers are not embraced by sex positivity and pride, usually they can talk about sex in a frank and comfortable way. This comfort is developed due to a feature of commercial sex as one of the most heavily negotiated sexual exchanges. The professional framework around sex work has created conditions for explicit conversations about sexual boundaries and desires. The role of sex workers who can talk with ease and knowledge about sex cannot be underestimated in creating an environment for learning about sexuality. This openness allows for non-judgemental exploration of sex, hopefully increasing the chances of clients approaching pleasure in a healthy, joyous and less risky fashion.

References

1 Harcout, C, 1994, "Prostitution and Public Health in the Era of AIDS." In Sex Work and Sex Workers in Australia, edited by R. Perkins, G. Prestage, R. Sharp and F. Lovejoy, University of NSW Press, Sydney: 218-219.

2. The overwhelming majority of clients of sex workers are male, and for the purpose of this article, the focus is on male clients.

Serena Mawulisa is a Project Worker with SIN (Sex Industry Network) in South Australia.

HIV Australia welcomes feedback on this article. Please send your comments to the editor: editor@afao.org.au.

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