Australian gay and bisexual men who have not recently tested for HIV often believe that they have not taken enough risks to justify a test or that the psychological impact of a positive diagnosis would be too great, report researchers in the November 2008 issue of the International Journal of STD and AIDS. The researchers recommend health promotion interventions which would help men reassess their own thinking about HIV tests.
Psychologists Ron Gold and Gery Karantzas recruited 97 men at gay bars in Melbourne. To take part, men had to have sex with men, not have been tested for HIV in the last four years, and never received a positive diagnosis.
Very few of the participants had a strong intention to get tested in the next few months. They tended to be well connected to the gay community, and two fifths had had unprotected anal intercourse with more than one partner in the last year.
Participants completed a questionnaire. For one set of questions, they were asked to imagine that someone had suggested they take an HIV test within the next ten days, and to identify what thoughts the suggestion would prompt in them. A list of possible thoughts was provided, although participants were able to add in other thoughts. It’s notable that only negative thoughts were suggested - ideas relating to the benefits of testing were not included.
Participants reported an average of eight thoughts each. The two most common thoughts, suggested by at least two thirds of the group, were:
- ”I don’t really need a test, because I haven’t taken any/many risks, so I’m pretty sure I haven’t got HIV”.
- ”I don’t really need a test, because I haven’t had any symptoms that might suggest I’ve got HIV”.
The researchers then used a statistical technique (Principal Factor Analysis) which analysed the correlations between the different thoughts in order to put them into groups (‘factors’). Five factors emerged.
The first, and most important factor, grouped together a number of perceived long-term problems associated with having HIV. The most important was: “If I find out I’ve got HIV, that might wreck my relationship with my boyfriend/partner. It’s better not to find out”. Another thought in this factor noted that the boyfriend may realise that his partner had not been monogamous. Several other thoughts included the phrase “it’s better not to find out” and mentioned changes to one’s sex life, being set apart from friends, depression and stress.
The second factor grouped together concerns about the confidentiality of the HIV test. The most important statement in this group was: “I don’t want to be listed on some file as having HIV. I’m not sure the test result would remain private.” A similarly worded statement about being listed as having gone for testing also scored highly.
The third factor appears to link together thoughts about short-term problems associated with the test, including dislike of needles and not having enough time.
The fourth factor brought together thoughts which suggest that HIV testing is unnecessary. One thought suggested that the respondent had not taken many risks, another that HIV was uncommon in the respondent’s social circle, and another that the respondent had no symptoms of HIV infection.
The last factor that was significant enough to remain in the analysis included one statement only. It was: “There’s no great urgency about having the test. I’ll have it eventually I guess, but there’s no rush.”
Those men who had had unprotected anal intercourse with more than one man in the last year tended to report a higher number of thoughts (average 11) than men who had taken fewer sexual risks. This group also had higher rates of testing than the rest of the sample, which the researchers believe means that they had some awareness of their level of risk.
Nonetheless, like all others in the survey, these men had not tested in the last four years, and their behaviour could mean that they had more reason to fear a positive result. The researchers suggest that many of the thoughts of these men are in fact rationalisations, and that the greater risk “produced a need to seize on any plausible means” of explaining the decision not to test.
In analysing these findings, Gold and Karantzas suggest that while more factual information about testing and changes to testing procedures could encourage a few men to test more often, it would not change many people’s behaviour.
They note the ‘Prospect Theory’ which is used by psychologists. It states that prospective gains and losses are not weighed equally. Instead, the losses loom larger than the gains, which leads us to prefer to postpone a decision or to leave a situation unchanged.
Gold and Karantzas suggest that it may be possible to design interventions which would help men to understand that their thoughts are in fact rationalisations. In psychology, a rationalisation is a defence mechanism by which your true motivation is concealed by explaining your actions and feelings in a way that is not threatening.
A possible intervention would involve presenting men with a list of justifications for not being tested, asking them to say which ones figure in their own thinking, and then asking them to carefully evaluate the adequacy of each one.
The authors also suggest that rather than trying in vain to get men to see the benefits of testing, health promoters can also focus on ‘losses’. However they should try to change the type of losses that men focus on - not the disadvantages of testing, but the disadvantages of not having tested early enough.
Health promoters could, for example, get gay men to imagine a time in the future when, not having been tested, they discover that they were infected quite some time previously, and are now unable to reap the full benefits of early treatment. The authors state that focusing on ‘anticipated regret’ in this way has been found to be a powerful motivator of other types of health-protective behaviour.
Gold RS and Karantzas G. Thought processes associated with reluctance in gay men to be tested for HIV. International Journal of STD & AIDS 19: 775-79, 2008.