Interventions that engage the identified influence leaders of at-risk YMSM social networks to communicate theory-based counseling and advice can produce significant sexual risk behavior change. This model is culturally pertinent for HIV prevention efforts in former socialist countries, as well as elsewhere for other hard-to-reach vulnerable community populations.
HIV prevention, by intervening within social networks, is potentially important but highly understudied. Approaches that systematically identify, train, and enlist known social influence leaders to advise members of their own networks in risk reduction constitute ways to reach hidden population segments, persons who are distrustful of authorities but trust their peers, and those who cannot be reached through traditional professionally delivered counseling. This article illustrates and provides evaluation data on a program that recruited 14 intact social networks of young men who have sex with men (YMSM) in St. Petersburg, Russia, and Sofia, Bulgaria. Sociometric measures were used to identify the social leader of each network, and baseline risk assessment measures were administered to all members of each social network. The sociometrically determined leaders then attended a six-session group program that provided training and guidance in how to carry out theory-based and tailored HIV prevention conversations with members of their own social networks. Four months after leaders completed the program, all network members were readministered risk assessment measures. Pre- to postintervention data revealed that the program produced: (1) increases in the level and comfort with which network members talked about AIDS prevention topics in their daily conversations; (2) increased network-level AIDS risk reduction knowledge and improved risk reduction norm perceptions, attitudes, behavioral intentions, and self-efficacy; and (3) increased condom use levels among network members. Although not a controlled, randomized trial, these program evaluation findings strongly support the feasibility of social network-level HIV prevention approaches.
Objective To determine the effects of a behavioural intervention for prevention of HIV and sexually transmitted diseases that identified, trained, and engaged leaders of Roma (Gypsy) men's social networks to counsel their own network members. Design A two arm randomised controlled trial. Setting A disadvantaged, impoverished Roma settlement in Bulgaria. Participants 286 Roma men from 52 social networks recruited in the community . Intervention At baseline, all participants were assessed for HIV risk behaviour, tested and treated for sexually transmitted diseases, counselled in risk reduction, and randomised to intervention or control groups. Network leaders learnt how to counsel their social network members on risk prevention. Networks were followed up three and 12 months after the intervention to determine evidence of risk reduction. Main outcome measure Occurrence of unprotected intercourse during the three months before each assessment. Results Reported prevalence of unprotected intercourse in the intervention group fell more than in control group (from 81% and 80%, respectively, at baseline to 65% and 75% at three months and 71% and 86% at 12 months). Changes were more pronounced among men with casual partners. Effects remained strong at long term follow-up, consistent with changes in risk reduction norms in the social network. Other measures of risk reduction corroborated the intervention's effects. Conclusions Endorsement and advice on HIV prevention from the leader of a social network produces well maintained change in the reported sexual practices in members of that network. This model has particular relevance for health interventions in populations such as Roma who may be distrustful of outsiders. Trial registration Clinical Trials NCT00310973.
Studies on HIV and STD risk factors among vulnerable minority groups in Eastern Europe are underrepresented in the literature. The rapid increase in HIV and STD rates observed throughout the region may quickly affect impoverished, stigmatized, and underprivileged communities. Roma (or Gypsies) constitute such a vulnerable group. A total of 324 men aged 14-37 years were recruited during June-July 2001 in a Roma community neighbourhood in Sofia, Bulgaria. HIV/STD risk behaviours were widespread. Men reported a mean of 2.4 female partners in the past 3 months and 77% did not use a condom during their most recent vaginal intercourse. 72% of Roma men said they had engaged in anal intercourse with women in the past 3 months and almost 75% of these heterosexual anal intercourse occurrences were unprotected. 27% reported having sex with other men during their lifetimes, 10% had same-sex anal intercourse partners in the past 3 months, and 58% of the most recent anal intercourse acts by these men were not condom-protected. 16% of men reported selling sex, and 32% paid someone for sex. Positive condom-use attitudes, intentions, norms and self-efficacy, as well as younger age and condom availability, were factors associated with lower sexual risk. These factors should be targeted in rapid, comprehensive, and culturally sensitive prevention interventions for Roma communities.
One's social network was the most powerful predictor of HIV risk behavior. HIV/STD prevention interventions directed toward entire social networks are especially promising.
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