Low uptake of behavioural interventions by gay men at English sexual health clinics

Only a quarter of gay men who had had unprotected sex were offered and accepted a structured intervention (such as motivational interviewing or counselling) when attending their sexual health clinic, according to an audit published this week in the online advance edition of Sexually Transmitted Infections.

The authors recommend that the reasons why such interventions are not offered to men at higher risk of HIV infection be investigated and addressed. Moreover, practitioners need a better understanding of how acceptable such interventions are to potential participants.

One of the first pieces of public health guidance issued by the National Institute for Health and Clinical Excellence (NICE), in 2007, was that health professionals should offer a structured discussion on risk reduction to people who are at high risk of having a sexually transmitted infection (STI), including men who have sex with men. These one-to-one discussions should be structured on the basis of behaviour change theories, and should address factors that can help reduce risk taking and improve self-efficacy and motivation. Sessions – of which there may be more than one - should last at least 15 to 20 minutes.

Similarly, recent safer sex guidelines from the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) recommend that brief (15-20 minute) evidence-based behaviour-change interventions focussing on skills acquisition, communication skills and increasing motivation to adopt safer behaviours, using techniques such as motivational interviewing, should be routinely provided to those at elevated risk of infection. Motivational interviewing techniques should be used as part of an intensive course of risk-reduction counselling for gay men at high risk of HIV infection.

Compliance with the guidance was assessed by an audit conducted at 15 of the larger sexual health clinics in England. For each, the notes of 40 gay or bisexual male patients who attended in June 2010 were examined, with a total of 598 sets of notes available. Men with diagnosed HIV were excluded.

The average age was 34 and three-quarters were of white ethnicity. One third of men reported unprotected anal intercourse in the past six months.

HIV testing was offered to almost all men (92%), in line with guidelines, and almost all men accepted the offer (92%). In the twelve months that followed, 43% of men tested at least one more time.

Four-in-ten patients (251) received a behavioural intervention, but frequently this was just advice. Fewer than one-in-ten (52) received a structured behavioural intervention as recommended by NICE.

Interventions delivered were counselling (37 men), motivational interviewing (14 men), cognitive behavioural therapy (2 men) and peer education (2 men).

Although men who reported unprotected anal intercourse (UAI) in the past six months were more likely to be offered and to accept an intervention than men who didn’t report UAI, uptake remained low.

The notes didn’t contain much detail on refusals, but it was recorded that 42 men were offered and refused an intervention, including advice. Of these, three men said they didn’t have time and 17 felt that they didn’t need the intervention (of whom six had reported unprotected sex).

The authors discuss possible reasons for the limited number of men who are offered structured interventions. These could include limited resources, lack of training, and guidelines only being published relatively recently. Moreover, while such interventions may have a relatively modest impact on infection rates, they require intensive efforts and should be offered in combination.

The audit also has information on how clinics define which men are at high risk of HIV infection. This is relevant as guidelines recommend that risk assessments are conducted.

Based on examination of policy at 24 clinics, there appears to be great variability. Four clinics considered all men who have sex with men to be, per se, at higher risk. Two clinics had no criteria at all, while the other 18 took into account a mix of unprotected sex (17 clinics), having an HIV-positive partner (14), previous STI infection (13), problematic drug or alcohol use (12), partner numbers (8) and previous use of PEP (7).

The authors comment that UK sexual health clinics need a standardised risk assessment tool, which could be used to target intensified interventions to men with the greatest need.