One of the biggest factors that will impact the progression of Canada's HIV epidemic over the coming decade will be the extent to which biomedical knowledge of HIV risk, transmission and prevention is integrated into our programming, and into individual behaviours.
Resonance refers to the waves of discourse and resulting action generated by new biomedical information about HIV, and its incorporation into the community wisdom and individual decision-making of gay men.
There has been rapid advancement in the science of HIV prevention
over the last 10 years, particularly around the role that antiretroviral drugs can play.
In the Resonance Project, we decided to concentrate on the knowledge that gay men and other men who have sex with men and their service providers have about these new prevention approaches. The focus was on gay men because they are the group that accounts for the largest proportion of new HIV infections in Canada, and the largest group of people living with HIV. Also, gay men tend to be early adopters of new information, new technologies, and new trends, and thus they have been among the first to take on new approaches to HIV prevention.
What Is the Resonance Project?
The Resonance Project: Emerging Biomedical Discourses and Decisions within Gay Men's Knowledge Networks is a community-based research project led by four researchers, with representatives from four national HIV organizations and three gay men's health organizations. The Resonance team set out to critically examine:
- how gay men are taking up biomedical knowledge of HIV;
- how biomedical knowledge of HIV impacts or influences their everyday lives;
- the dialogue gay men and their service providers use to make sense of risk, and inform sexual decision-making and practices; and
- the roles and responsibilities of institutions and service providers to shape and respond to these discourses.
We conducted focus groups in Vancouver, Toronto and Montreal with 22 service providers who provide sexual health, counselling and HIV prevention services to gay men; interviews with eight nurses and physicians working in a clinic or public health setting; and interviews with eight service providers who identify as gay men.
We also conducted focus groups and interviews with 86 gay men in Vancouver, Toronto and Montreal.
It should be noted that the focus groups and interviews were conducted over the winter of 2013-2014 and represents service provider perceptions at a certain point in time. Discussions of new biomedical technologies have developed rapidly since then in the gay community, the media and the HIV sector. A new series of focus groups and interviews would likely show a marked evolution in how these issues are now resonating with gay men and how service providers are responding to the challenges.
This article looks at some key findings from the service providers. Highlights of our findings from gay men will be covered in a future Prevention in Focus article.
What Are the Challenges for Service Providers in Managing New HIV Prevention Information?
Staying on top of it all
One of the challenges service providers face is finding the time to read, interpret and distil research findings, and translate them into simple lay terms in ways that clients understand. Some service providers noted the high expectation from clients and colleagues to have "all the answers" despite their own knowledge limitations. A minority of service providers felt that the messages are relatively straight forward and not all that difficult to communicate to clients.
Service providers also felt challenged when clients asked them for their personal opinion or judgment about prevention strategies.
"I think as service providers we need to acknowledge our limitations as well. ... It's scary that they place a lot of authority on us. ... It's hard for us to admit we have that power over our clients. ... If we are positioning ourselves as the experts, then we need to know what we're talking about. ... We're not all on the same page sometimes. Not all of us have that education or have that capacity to understand all those complex issues going on with HIV."
"There's a bit of a paternalistic tinge to it but I think most gay men are not ready to digest this information. It's not possible for a lot of gay guys to read the peer review papers and to draw conclusions from it. But I think it's really important that people who work in the field try and stay on top of this stuff."
Consensus versus multiple interpretations
The service providers expressed a contradiction in their risk counselling: on one hand wanting to have consensus and be able to provide a definitive statement about a particular biomedical intervention, while on the other hand wanting to be able to provide a variety of viewpoints and interpretations of the science. The lack of consensus leads to conflicting interpretations, messages and advice.
"People want to hear the clear-cut answer. ... So many of us are still squabbling, fighting over things that should have been figured out years and years and years ago. We have some cleaning house to do as a community, as people who work in HIV prevention in gay men's health."
"There's just a real lack of consensus on a lot of new biomedical reasoning. A lot of the research in the last five to ten years has thrown a lot of different potentially innovative and interesting ideas about HIV prevention but there's very diffused and uneven uptake of those things by public health which is traditionally a very conservative institution."
"It can feel really frustrating as an educator working with someone and trying to help them gain knowledge and make their own decisions about what risks they want to take when every answer is 'it depends.'"
Erring on the side of caution
Some service providers tended to give the most conservative messages possible, such as condom use only, but also acknowledged that being overly simplistic, overly complex or too conservative in HIV prevention messages can frustrate or alienate clients who know of risk-reduction options other than condoms.
"We have a really disproportionately skeptical orientation towards things other than condoms and we're really married to this idea of condoms."
"A question that's coming up for me is what does caution look like? Does it look like simplifying the message 'always use a condom' or does it look like bringing in the complexities? If you give them back complexity, does that help? If you give them back a simple answer does that help?"
Heterogeneity of the gay community
Service providers noted the wide range of awareness and openness to new prevention strategies in the gay community. The service providers talked about encountering gay men with very basic knowledge whom they perceive as not being ready for, or open to, the complexities of biomedical aspects of HIV prevention.
At the other end of the spectrum, service providers said they encounter gay men with sophisticated knowledge of HIV prevention, challenging service providers to keep up with the community. They noted that some gay men are quite self-aware, well-informed and inquisitive, and look to service providers for more information about their personal risk-reduction strategies.
"We just have to acknowledge the sheer diversity of the community and uneven distribution of information, resources, connections that facilitate or impede the uptake of different ideas or concepts or even things like safer sex."
"There are three different situations. One, a person is completely ignorant of everything and we bring it to the table for them. Then you have the people that sought out the information and they now have more questions about it. Then you have the people that are very keen and on the ball about it. The last category of people is people who do their homework. ... Definitely the largest group is the second one."
The service provision context
Service providers explained that the risk-reduction messages they give to their clients depend on the setting, duration and frequency of their contact with gay men. If they only see a client in a brief one-time encounter such as in a bathhouse, or only have a brief exchange through online outreach on a cruising app, then some service providers will err on the side of caution in their risk-reduction message, whereas if they are able to have repeated contact with a client over time, the messages can be more nuanced.
"As opposed to a Towel Talk that can last anywhere from like 30 seconds to 10 minutes, some people you see on a regular basis. ... We have a counselling session of 30 minutes, so it can go a lot more in-depth in regards to various different harm reduction strategies and helping them integrate them into their lives."
"In an office that is truly private, it's easier to talk. But during outreach -- in the bathhouses, in the bars -- interactions are a lot shorter. There, I have about 2 to 3 minutes with a person. There is often discomfort because they're in public so they want it done as quickly as possible."