Background
The intervention is based on an evidence synthesis of trials that all focus on brief, individual, behaviour change interventions delivered in a range of settings (n = 11, 10 trials). The systematic review showed that these interventions overall had small medium-term effects, although some were significant when compared with their controls. Some of these interventions have shaped prevention policy within the USA. There have been no UK trials of these kinds of interventions.
The ‘How to stay HIV negative’ intervention is delivered in all sites that offer HIV infection testing. It is delivered within a single session lasting between 30 and 50 minutes. It is not an intervention for the ‘worried well’ or for those with multiple and complex needs. It should be thought of as one of a suite of interventions available to clients. ‘How to stay HIV negative’ is only offered to MSM who meet all of the following criteria:
are seeking or accept an offer of HIV infection testing
have received a HIV-negative test result
report condom-less sex with two or more partners of HIV-positive or HIV-unknown status within the last year
feel ready to change their risk-related behaviour.
Goal
The goal is to reduce client behaviours that can result in the onwards transmission of HIV.
How it works
‘How to stay HIV negative’ works through focused multistage exploration of HIV risk and its personal significance within a single session delivered by a trained individual provider and comprises five components:
It examines contemporary HIV risk through the use of a peer-oriented visual aid such as a short graphic novel (which describes the role of emotions and feelings, serosorting, barebacking, PrEP, TASP, recreational drug and alcohol use in contemporary HIV risk). This has four aims: to enable a general discussion about the range of risks that MSM must manage through using a peer referent; to enable the client to feel confident in subsequently disclosing a broad range of personal information about their own behaviour; to provide information and increase HIV literacy; and, finally, it also demonstrates the cultural competency of the intervention and the practitioner.
It focuses on eliciting the clients most memorable risk event and explores their perceptions of its determinants. It brings to the client’s mind the complexity of the challenges associated with risk and the role of feelings, thoughts and social context in shaping behaviour. The intervention skills have to be translated into real, often complex, sexual contexts, hence it encourages the client to focus on the detail of their risk event in order to build skills that can be transferred to the next risky situation.
The practitioner encourages the client to explore the similarities and differences between their own risk-related behaviour, and that depicted within the graphic novel. Here, the client considers the specific determinants of their behaviour, potential consequences of their actions and their susceptibility to HIV infection.
It assesses, and then builds further, motivation to change behaviour through encouraging the client to both formulate ways they could have done things differently and to focus on the pros and cons of these alternative behaviours. The client rehearses how they plan to do things differently in the future, details an action plan and focuses on their HIV-negative identity. They are also encouraged to consider their identity as someone who used to take HIV risks but now embrace the identity of remaining HIV negative.
The client articulates and commits to their personalised action plan. This supports and encourages the client’s belief in their own capabilities. In this way the client leaves the session having learned about HIV risk, having detailed what made them vulnerable in the past, having identified solutions to this problem, being motivated to change behaviour, having a clear action plan of how to reduce their vulnerability and feeling more confident in their ability to implement their behaviour change plan.
Theory behind the intervention and proposed mechanism of action
‘How to stay HIV negative’ is not based on a single theory and draws on a range of theoretical perspectives. Its direct theoretical antecedents include the information–motivation–behavioural skill model199 and the health action process theory.218 These both draw on Bandura’s theory of self-efficacy198 and the theory of planned behaviour.200 Relevant constructs relating to each component are:
The role of information in terms of potentially increasing knowledge concerning risk-related behaviour and the role of descriptive norms in relation to the visual aid depicting other MSM’s risk-related behaviour.
How motivation is assessed through the disclosure of salient attitudes, norms and attributions.
Uses predictors from the health belief model
61 such as ‘perceived susceptibility’, ‘perceived benefits and barriers’, and ‘cues to action’ (through the comparative task).
Motivation to change is assessed and reinforced in order to focus on the client’s readiness to change and prepare them for the subsequent move from motivational to action phases.
218Utilises self-efficacy
198 via building a sense of the client’s capability in reducing risk in the future and resonates with the planning and rehearsal of the self-regulatory processes required to implement action plans.
218
Research findings
‘How to stay HIV negative’ is adapted from the interventions included within our systematic review. Each of these effective interventions adopted a multicomponent approach that included many of the key elements detailed in the following five points. Commonalities in these studies suggested the importance of BCTs drawn from the problem-solving group of the BCT taxonomy, and suggested action planning, pros and cons and incompatible beliefs may be of particular use.
Core elements
Core elements are the essential parts of an intervention. They cannot be overlooked or modified. BCTs are listed as the irreducible active ingredients of the intervention content.
Peer-oriented visual aid, which details the complexity of contemporary HIV risk (emotions and feelings, serosorting, barebacking, PrEP, TASP and recreational drug and alcohol use) (‘information about health consequences’).
The provision of one-on-one counselling which focuses on the client’s perceptions of the determinants of a single high-risk event [‘social support (unspecified)’].
A client-centered appraisal of personal risk using the visual aid to compare with the high-risk event and examine client’s decision-making processes (‘problem-solving’ and ‘social comparison’).
A practitioner- and client-focused assessment and reinforcement of motivation to change, through retrospective analysis of the ways the client could have done things differently. This is achieved by weighing up the pros and cons of alternative behaviours. The practitioner guides the client to articulate how they would do things differently in the future in order to stay HIV negative (‘pros and cons’, ‘problem-solving’, ‘framing/reframing’ and ‘incompatible beliefs’).
Guide the client to articulate and commit to a specific action plan, persuade them about their capability and focus them on their identity as someone who used to take HIV risks but is now ‘HIV negative’ (‘action planning’, ‘identity associated with changed behaviour’ and ‘verbal persuasion about capability’).
Key characteristics of ‘How to stay HIV negative’
Conduct ‘How to stay HIV negative’ in the context of HIV infection testing and counselling.
Complete the intervention in one 30- to 50-minute session.
‘How to stay HIV negative’ can be delivered by anyone having undergone ‘How to stay HIV negative’ training: a 2-day intensive training course. Within this course they must demonstrate a level of competency in effective delivery.
Procedures
Screening
Potential clients must be screened for eligibility for ‘How to stay HIV negative’. Clients must satisfy all criteria. The key criteria are:
seeking or accepting an offer of HIV infection testing
have received a HIV-negative test result
report condom-less sex with two or more partners of HIV-positive or HIV-unknown status within the last year
feel ready to change their risk-related behaviour.
Purposes
To determine if client is eligible for ‘How to stay HIV negative’ and to briefly orient (introduce) the client to the intervention. Skills required: instructing, open-ended questioning, use of neutral probes and remaining non-judgemental.
Six steps of ‘How to stay HIV negative’
Step 1: the peer-oriented visual aid (e.g. graphic novel)
After the practitioner confirms eligibility, he or she asks the client to look at the visual aid.
Purposes
To normalise the complexity and range of HIV infection risk-related behaviour management issues, raise levels of HIV literacy, to demonstrate the practitioner’s cultural competence with MSM.
Skills required
Instructing/directing, high levels of HIV literacy.
Resources
Peer-oriented visual aid (e.g. graphic novel).
Step 2: depth recall of high-risk incident
The practitioner helps the client recall a single high-risk event and recall how, where and why it happened.
Purposes
To personalise risk, facilitate recall of specific contexts and interactions.
Skills required
Active listening, use of open-ended questions, use of neutral probes and provision of social support with regard to risk reduction.
Step 3: risk and problem-solving
The practitioner facilitates the client’s self-appraisal of risk through comparing the client’s risk with recognised MSM risks as depicted within the graphic novel; the client describes their decision-making and how it led to their vulnerability.
Purposes:
To further personalise risk, identify vulnerabilities, prime for step 4.
Skills required
Active listening, use of open-ended questions, use of neutral probes, high levels of HIV literacy.
Step 4: explore alternative behaviours and reinforce motivation to change
The practitioner reflects back the client’s account of decision-making and his vulnerability, asking the client to identity behavioural alternatives. The client is also asked to list reasons for wanting and/or not wanting to change; the practitioner suggests the deliberate adoption of a perspective that focuses on how to stay HIV negative as a new way of looking at risk-related behaviour and highlights how past behaviours as listed, are incompatible with this.
Purposes
To focus the client on his ability to find behavioural solutions to complex problems, to motivate the client towards behaviour change, to orient the client to an identity based on being HIV negative.
Skills required
Use of open-ended questions, identification and confidence in feeding back to clients their accounts of their vulnerability, facilitating decisional balance, facilitating client-centred behavioural alternatives, facilitating the client’s HIV-negative identity.
Step 5: how things will be different
The practitioner encourages the client to articulate an action plan for the future.
Purposes
To rehearse future plans to build self-efficacy and enable the self-regulatory processes required for implementation of an action plan at further times of vulnerability.
Skills required
Instructing/directing, use of open-ended questions, use of neutral probes, and provision of social support in regards to risk reduction, building clients’ self-efficacy.
Step 6: closing
‘How to stay HIV negative’: the practitioner summarises what the client has achieved and endorses the client’s capabilities.
Differences/similarities from other interventions
Although the intervention does provide knowledge concerning the range and complexity of contemporary HIV risk management, this is not its primary concern. If clients are lacking basic HIV literacy, then they should be offered HIV literacy interventions instead of ‘How to stay HIV negative’.
‘How to stay HIV negative’ draws on many of the central ideas of MI.
‘How to stay HIV negative’ is not a client-centred, or client-led, approach focusing on the client’s feelings. Its focus is to proactively get clients to think about their behaviour in new ways and generate their own solutions to the problems they face.
‘How to stay HIV negative’ is not an approach based on reducing client short-term stress and anxiety. Practitioners may need supervision and support about their desire to contain client’s short-term feelings, but these are not the focus of ‘How to stay HIV negative’.
‘How to stay HIV negative’ is not focused on the practitioner providing the client with prepackaged easy solutions to their risk-related behaviour. It is about providing the client’s self-generated insights and skills for sustainable behaviour change within complex demanding and ever changing environments.
