The Role of Behavioral Health Providers in HIV Prevention

The Centers for Disease Control and Protection (CDC) reports, “Men who have sex with men (MSM) remain the group most heavily affected by HIV in the United States... MSM represent approximately 4 percent of the male population in the United States but male-to-male sex accounted for more than three-fourths (78 percent) of new HIV infections among men and nearly two-thirds (63 percent) of all new infections.” [i]  It is important to note that these rates are being driven by unprotected sexual activity, and the CDC acknowledges that alcohol and illegal substance abuse remain one of the greatest challenges to stemming the spread of the disease.[ii]

As behavioral health providers, what is our role is preventing HIV infection?  Are our programs (encompassing all ASAM Levels of Care) merely reiterating the message that substance use and sexual activity is a risky combination when, in fact, most MSM are already well aware of this?  Many programs have developed their own “home grown” educational sessions for clients regarding this topic, but they have no research supporting their impact.  In the safe confines of the therapeutic milieu, consensus regarding the dangers of substance use and sexual activity is commonplace, but, during a moment of sexual arousal, this knowledge rapidly dissipates as the brain is hijacked by desire.

Unsafe sex is the result of a conflux of many variables, all of which must be considered in tailoring prevention programs for MSM.  These include:

• Individual traits and characteristics – These include personality traits, beliefs, skills, and personal history (e.g., risk taking personality; self-confidence; impulsivity; expectancies about sex and substance use; emotional state at the time of arousal; refusal skill set). 
• Partner characteristics – The other sex partner (or partners) plays a role in the safety of sexual activity.  Is might be very difficult to turn down the overture of a good looking and available man one has just met and who is actively seeking sex.  However, anonymous sexual encounters may no longer be the primary vector for disease transmission within the MSM population.  According to Michael Newcomb, an assistant professor at Northwestern University studying risk behaviors, “We’ve gotten the message across that you should use condoms with people you don’t know as well.  But the epidemic has moved into couples more than in casual sexual encounters.”[iii]  Recent estimates are that 68% of new disease transmissions occur in the context of two men who engage in sex regularly, and this rate is even higher for those men aged 16 to 24.[iv]
• Situational characteristics – Where are individuals meeting for sexual activity?  A bar?  A bathhouse?  One’s apartment? Are friends available who can “put the brakes on?” Certain environments are more conducive to substance use and unsafe sex. 

Successful prevention programs factor in these aforementioned variables, but incorporating all of this information into “home grown” programs is near impossible.  Thus, as we incorporate an increasing number of evidence-based practices into our treatment settings, we should also consider the use of evidence-based prevention programs. The CDC funds state and local health departments and community-based organizations to support and disseminate HIV prevention services for MSM, and many of these evidence-based behavioral practices are transferrable into the realms of behavioral health providers.  According to its website, The “CDC updates an online Compendium of Evidence-based HIV Prevention Interventions by adding newly identified evidence-based behavioral interventions (EBI) that have been scientifically proven to significantly reduce HIV risk. CDC's Compendium now includes over 74 HIV risk reduction evidence-based behavioral interventions and 8 HIV medication adherence evidence-based behavioral interventions.”[v]

EBIs typically target specific demographics, including black MSM, Hispanic MSM, the transgender population, those already living with HIV, and those with existing substance abuse problems.  Two examples illustrate the importance of targeting specific audiences.  First, the CDC particularly highlights the HIV risk for young black men engaging in MSM since they now account for more new infections than any other subgroup by race/ethnicity, age, and sex.[vi]  Second, a recent report by the San Francisco Human Rights Commission criticized the label “MSM” as it elides the reality that many MSM are better described as “MSMW” (i.e., men who have sex with men and women); in many prevention programs bisexual HIV risk is elided or outright ignored based on an assumption that MSM are gay.[vii]

EBIs far surpass the reminder to “wear a condom” that behavioral health providers commonly proffer.  However, these alone will not stop the spread of HIV, and the CDC reminds us that prevention programs are just one tool in the arsenal to reduce the spread of HIV.  A 2012 edition of the Lancet focused specifically on HIV and MSM concluded that in addition, “New and more effective HIV prevention programs for MSM must reduce infectiousness through markedly expanding testing and treatment of positive men, and reduce risk of acquisition among negative men, through the use of PrEP, the development of a rectal microbicide, and increased access to and coverage for condoms and condom-compatible lubricant.”[viii]

Finally, the Lancet also reminds us, “Stigma, discrimination, and social and health care level homophobia continue to limit access and uptake to essential services.”[ix]  It is only through the creation of safe and respectful treatment facilities staffed by professionals versed in both Affirmative Therapy and EBIs that we will play an active role in HIV risk reduction for MSM.