Purpose and principles
Making it Count is the collaborative planning framework of the CHAPS Partnership and is supported by all CHAPS partners. It emerged from the collective understanding and endeavour of a group of well-established organisations serving men who have sex with men (MSM).
KEY CONCEPT: BENEFITS DRIVEN CHANGE
We believe it is possible for the population of MSM to experience both an improvement in their sex lives and a reduction in the harm arising from their sex lives. This is both an ethical position and an effective practical approach. By focussing on the benefits of sexual precautions we engage with what is of value to people - the only route to both effective and ethical change.
Benefits driven change focuses on the up-side of precaution rather than the down-side of risk. We plan to minimise sexual risks by maximising the benefits of the precautionary alternatives and by making those alternatives available and achievable.
The CHAPS partners are committed to reducing the harm associated with HIV infection by minimising HIV transmissions during sex between men, and ensuring swift diagnosis and appropriate treatment when new infections occur.. However, the presence of HIV is insufficient reason to justify using ‘any means necessary’ when intervening in the lives of MSM. Since the purpose of our activities is to improve the quality of life for MSM, it does not make sense to reduce HIV infection through means that reduce that quality of life. The aim is to minimise the harm associated with sex between men while maximising its benefits - or “best sex, least harm”.
The framework is focussed on HIV transmission during sex between men in England and sees this harm within the context of other harms and benefits associated with sex. It describes what the CHAPS partners are willing to do to minimise the number of future infections. In doing so, it describes our understanding of the epidemic, its causes, and our rationale and justification for intervening. This includes stating what we think is the case with regard to MSM and HIV and also what we believe to be common misconceptions about MSM and HIV.
The framework outlines our short, medium and long-term aspirations, which provide a description of the outcomes we are pursuing. It is intended to increase the transparency of our interventions, their intentions, development, implementation and evaluation.
The primary intended users of Making it Count are the CHAPS partners themselves. It has several purposes:
For planning our interventions
- to focus and clarify the purpose of our interventions with men who have sex with men;
- to provide a common vocabulary for collaborative HIV health promotion actions, the people they are intended to influence and the differences they are intended to make;
- to aid the description of interventions and to make planning decisions more transparent;
- to delineate the range of interventions the CHAPS partners find acceptable, including the methods, needs and risk/precaution behaviours they address.
For training our volunteers and staff
- as an aid to staff and volunteer induction and training within our organisations, and to briefing members of the press, students, and others working in the HIV epidemic;
- to help us locate our work within the bigger picture of sexual health promotion;
- to use as a tool for social change at the corporate level in our organisations.
For marketing and evaluating our services
- as a set of agreed parameters for planning that can be included in service level agreements between CHAPS partners and their commissioners, and to support funding applications;
- as a set of programme policies that can be used to kick-start programmes or support exiting programmes;
- outlining the range of methods, needs, risk/ precaution behaviours and health outcomes examined in evaluations of our work with MSM.
For inspiring us
- to inspire collective action among the CHAPS partners and between the CHAPS partners and others working in HIV health promotion.
We are committed to the best sexual health for all MSM in England, across the diversities of sexual identity, HIV status, class and income, age, ethnicity, gender history, faith and disability. We aim to promote the quality of emotional and sexual lives for men both living with and without HIV. We are committed to tackling the disproportionate sexual ill-health borne by black MSM and poorer and less well-educated MSM.
We believe all men have the right to express and enjoy their sexuality. We affirm, value and accept love and sex between men. We insist that all men should be able to express their sexuality free from force, manipulation and coercion. We are therefore committed to increasing sexual self-determination.
We seek to be honest and accurate in our actions. Our benchmark for HIV education and sex education is based on the best scientific evidence. We will not mislead or misrepresent what we know to be the case in order to encourage men to behave in certain ways.
We seek to educate MSM about sex and the law, and how to stay within it. We recognise that, although significant advances in equality have been made, HIV and homosexuality are still widely stigmatised both in this country and around the world. Stigma negatively impacts on MSM and all people with HIV through a variety of mechanisms. We seek to counter stigma and to eliminate the discrimination that arises from it in all our communities, as well as in public policy and practice.
We seek to work in partnership with the MSM we serve, with the communities they live within and with other organisations, services and funders.
Overview of what we are trying to acheive
The following figure provides an overview of the strategy. We are focussed simultaneously on health outcomes, risk and precaution behaviours, prevention needs and programme delivery. Focussing only on the behavioural outcomes of our interventions is insufficient as there are interventions which may bring about the desired behaviours but through unacceptable means.
The actions of the CHAPS partners are represented in box A. In order to act, the CHAPS partners have a number of needs, such as motivation, resources and skills.
The CHAPS partners are only one group of actors impacting on the HIV related needs of MSM. There are also our allies (who positively contribute to meeting needs) and our adversaries (whose actions undermine the meeting of prevention needs).
We will engage in two types of interventions (or actions) - those which directly influence the needs of MSM (direct contact interventions) and those which influence our own needs, the needs of our allies and of our adversaries (structural interventions including community development, sector development and policy advocacy), who in turn act on the needs of MSM. In the first instance then we seek to deliver:
- programmes of interventions which are feasible, within budget, accessible, needed, acceptable, effective and efficient.
Our interventions with MSM are focussed on sexual HIV prevention needs and HIV / STI testing needs. We recognise that economic, social and cultural factors influence the sexual and treatment choices available to MSM, as well as their personal characteristics and resources. We will therefore also work to influence the context in which men live and the choices available to them. By delivering a range of interventions we intend to work toward:
- a population of MSM who are sufficiently knowledgeable, aware, empowered and equipped to best manage their sex lives with maximum benefit and minimum harm, including access to HIV/STI diagnostic and treatment interventions.
We recognise that sex between men has value and that different men place different values on different sexual lifestyles and behaviours. We also recognise that sex carries some risk of harm and that the level of risk varies with different sexual lifestyles and behaviours. These harms include but are not limited to HIV transmission.
We recognise that achieving the above situation will not result in no risk behaviours occurring but we believe it will result in fewer risk behaviours than if men were ignorant, unaware, dis-empowered and lacking resources.
What will it change? describes the range of prevention needs (including testing needs) we are attempting to meet. We will act to increase men’s motivation and ability to manage HIV risks. All men have the potential to be experts in their own lives, including making choices about sex, treatment, utility and risk. We do not seek to control men or make their choices for them. Instead we seek to inform and empower men to make the best choices for themselves and their sexual partners. By ensuring men have their HIV/STI prevention needs met, we seek to ensure that men are able to:
- minimise the number of sexual HIV exposures (fewest sero-discordant sexual sessions which feature anal intercourse not protected by condoms), with the least infected fluid transfer (least amount of ejaculation in the body), fewer transmission facilitators (concurrent sexually transmitted infections, nitrite inhalant use) and maximum transmission impediments (optimum HIV treatment and post-exposure prophylaxis); and
- shorten the period of time between infection and diagnosis among MSM acquiring HIV. These are not the only determinants of HIV incidence but are those causes of new infections that we are trying to influence. What we know about their current contribution to incidence is described in Sexual risks and precautions, where other determinants of incidence are outlined.
Together, minimising these behavioural and biological factors will contribute to:
HIV among MSM in England describes what we think the current state of the epidemic is among MSM. We also expect the changes described above to contribute to an improvement in the overall health and well-being of MSM both with and without HIV. To positively effect both the incidence of HIV and the well-being of MSM means recognising that different men prefer different kinds of sex, and that one risk reduction solution will not suit all men. It would be possible to attempt to eradicate all the harm associated with sex between men by eradicating all sex between men. But this would also eradicate the value of sex and is therefore, from our perspective, counter-productive.
Planning for success
We have a clear focus on our shared goal of minimising HIV transmissions during sex between men. We are also clear about which behaviours cause transmission and which behaviours make transmission more or less likely. While we have a clear focus on behaviours, we do not decide how men should reduce their risk of involvement in HIV transmission and do not seek to impose a singular behavioural choice on the diverse population of MSM. For some men in some situations this may be best achieved by deferring or declining sex. For others it may be by screening for HIV / STIs with a prospective partner before having sex and avoiding sex until any infections are treated or suppressed. For other men or at other times transmission risk may be best reduced by engaging in non-penetrative sex, or by using condoms. If uninfected men do engage in receptive anal intercourse without condoms with men they are not confident are also uninfected, they may best reduce the probability of transmission by avoiding ejaculation in the body, by not concurrently using nitrite inhalants, or / and by seeking post-exposure prophylaxis.
We are focussed on the behavioural causes of HIV transmission. However, it is not acceptable to facilitate behavioural change by unacceptable means, such as disseminating misleading or incorrect information, withholding resources or infringing civil liberties. We therefore also have a clear focus on the needs associated with reducing risk behaviours and increasing precautionary behaviours. This means ensuring that risk behaviours are reduced and precautionary behaviours increased through increasing accurate knowledge, fostering practical skills, distributing relevant resources and creating opportunities for precautionary choices.
We do not see a conflict between our desire for fewer HIV infections and a desire for greater sexual self-determination in the population of MSM. In fact we see the latter as the only ethical approach to the former.
We maintain that our acting to increase the choices available to men and increasing their motivation and ability to make precautionary choices will result in fewer new infections than if we did not act. This is the meaning of success for our work.
HIV in context
In national prevention responses to HIV, UNAIDS guidelines encourage us to:
- know our epidemic;
- match and prioritise our response;
- set ambitious, realistic and measurable prevention targets;
- tailor our prevention plans;
- analyse and use strategic information.
In global terms, the HIV epidemic in England is a ‘concentrated scenario’ where HIV prevalence is high in identifiable sub-populations (such as men who have sex with men, injecting drug users, migrants from African countries with a high prevalence or sex workers) but where HIV is not being passed on with significant frequency within the general population. This framework is a contribution towards all five of the above objectives.
This framework also continues to be wholly in accord with the National Strategy for Sexual Health and HIV and its review. The review concluded that greater attention to MSM is needed. As they apply to MSM, the actions identified as being required consist of the following, all of which the current framework is congruent with:
- the well-being of MSM with HIV;
- swifter diagnoses of HIV / STI;
- the knowledge and skills (ie. motivation and power) to stay healthy and to improve sexual health (ie. have better sex with less harm) at all life stages;
- access to testing and treatment for HIV / STI;
- freedom from stigma associated with HIV / STI;
- HIV testing in a wide range of settings;
- Sex & Relationships Education that integrates same sex relationships;
- lifelong learning programmes in community based organisations;
- regular information/motivation campaigns in the public sphere;
- living well with HIV self-management programmes;
- local investment in prevention programmes for MSM, including MSM with HIV;
- younger MSM.
The approach to influencing behaviour adopted in this framework continues to be one of education, awareness raising, opportunity and empowerment. In addition, this edition of Making it Count assimilates key elements of the social marketing approach. We have created an original and innovative model which melds the best parts of health promotion and social marketing to point the way forward for HIV health promotion that respects individuals’ choices and is also clear about what the desirable changes are in the population. This has been achieved by recognising and maintaining the distinction between the population and the individuals within it. For example, a desire to reduce the average number of sexual partners between STI / HIV screenings should not translate into telling individuals (alone or en masse) to have fewer sex partners. Social marketing is an important part of the armoury in the translation between epidemiological imperatives in the population and the lived experience of gay men, bisexual men and other MSM in England today.
The CHAPS Programme is funded by the Department of Health and is subject to the constitution of the NHS. This constitution enshrines a number of rights among those entitled to NHS services. Making it Count encourages all HIV health promotion funded through the NHS to contribute to the strategic objectives of the NHS to be preventative, people-centred and productive.
The CHAPS approach to influencing choices
In order to influence people we need to understand them. Sexual risk and precautionary behaviours are the outcome of many factors, most of which are amenable to influence by someone (which is not to say anyone can affect all of them).
Experience of working with MSM on sexual health and drawing on social research have provided us with a broad understanding of the HIV prevention needs of MSM, both in terms of what motivates us to manage risks and what enables us to do so. Prevention needs extend beyond motivation to include the abilities, resources and opportunities required to carry out intentions. So we are concerned not only with whether men want to manage risks but also whether they are able to do so. Needs assessment (and formative evaluation) requires consideration of which factors are driving risk or preventing precautions, including the values and social norms of the individual or group we are concerned with. Needs assessment is addressed elsewhere. This section is concerned with our model of choices and our theoretical approach to influencing them (needs description).
We will describe how our interventions are intended to influence men’s choices, that is, how we think they work and what we are intending to change in order to enable men to make better sexual choices. Needs description therefore covers the range of capacities we are willing to address. We will not focus on a particular behaviour and claim that we are willing to do anything necessary in order to change that behaviour. We do not believe we have the right to do anything necessary in order to get men to behave in the way we decide they should.
Although many of the factors determining choices are amenable to influence, we will not make people’s choices for them. Not only is this impossible in most circumstances (we will not be there when men make their choices) but choices made for people are less likely to be sustained than choices people make for themselves. This approach is in line both with social psychological theory as well as with Government policy on healthier living. The consultation for Choosing Health found that:
“Most people were clear that they wanted to decide for themselves what they should do to make a difference to their own health. [...] Health is a very personal issue. People do not want to be told how to live their lives or for Government to make decisions for them.”
Most adults do not want to be told what to do and many MSM are positively hostile to authorities telling them what to do, particularly in the area of sex. This is one good reason for authorities not to attempt to tell all MSM how they ‘should’ behave. The second good reason is that we have a regard not only for the infections men pick up but also for their sexual self-determination and social well-being. The third and most compelling reason against simply telling MSM what to do is that there is no evidence that doing so influences their choices.
No one way of managing sex opportunities will be suitable for all men in all sexual situations. Some men may choose to make different choices with different partners in different situations. There is a gap between behavioural intention (what men intend to do) and behaviour (what men actually do) for all ten choices. For example, men can intend to have an STI screen before their next partner but for the opportunity for sex to come up and for men to take it, to tell their partner about their infection but not do so, or to have intercourse with a condom but actually have unprotected intercourse. So promoting any single risk reduction tactic on its own (or at the expense of all others) is problematic.
We are mindful that when we attempt to influence one factor, all other factors do not necessarily remain equal. We endeavour for MSM themselves to be best able to balance the potential benefits and costs inherent in sexual activity. We acknowledge that there are a variety of risk management tactics which men can use and that they themselves are usually best placed to determine how best to go about managing their risks. We wish to motivate men to engage in as little risk as they require in order to fulfil their sexual desires, that they are comfortable with and that they are able to achieve.
We seek to make precautionary behaviours socially desirable among MSM. We will not do this by telling men what to do. We will not do this by misleading men about the probable outcomes of different actions. It is not our aim to belittle or denigrate men who acquire HIV or who engage in risk behaviours (such as not testing, having new sexual partners, open-relationships, or having anal intercourse, including anal intercourse without condoms). We will increase the extent to which men are able to see the potential consequences of their choices as well as their abilities to pursue their choices.
Strategic Aim: We will increase the motivation and power that enable men to make precautionary choices.
All sex carries risk and the only way to achieve no risk is through no sex. Most people are dissatisfied with the ‘no sex / no risk’ option and are willing to trade some risk for some sex. The role of HIV health promotion is not to decide which risks are worth taking and encourage men to stick to them, but to assist men to decide which risks, if any, for them are worth taking, and to enable them to avoid further risk.
A model of action: motivation and power
This section outlines our theory of what determines the choices people make. Elsewhere we describe the risks and precautions taken in the population of MSM that are determining HIV incidence. Here we introduce the theoretical model that mediates between these behaviours of MSM and the interventions of health promoters. The theory outlined here is an extended version of the Information-Motivation-Skills Theory (see Fisher and Fisher 1992; 1993; and Fisher, Fisher and Harman 2003).
In order to act people usually require both the motivation and the power to do so. This can broadly be characterised as wanting to do something and being able to do something. Both are not strictly necessary: people can be forced to do something they do not want to do if they do not have the power to resist it being imposed on them. Similarly people can be prevented from doing something they do want to do if they do not have the power to engage in it. But people are more likely to engage in an action (or to avoid one) if they are both motivated to do it and able to do it.
It has long been observed that knowledge does not determine behaviour. This is because knowledge alone does not determine either motivation or power. People are both individual and social beings, that is they both think for themselves and are influenced by others. So the motivation to act comprises both psychological and social components: people are influenced both by what they think (their attitudes) and by what they think others do and think (their perceived social norms). This part of Information-Motivation-Skills Theory is taken over from the Theory of Reasoned Action (see Fishbein & Ajzen 1975; Ajzen & Fishbein 1980].
Attitudes are theoretical constructs that represent whether or not people have positive or negative orientations to objects, people or behaviours. An attitude towards an action (or inaction) is the outcome of:
- the awareness of the potential consequences of the action,
- how much those consequences are valued, and
- how likely the consequence is judged to occur.
The consequences of acquiring or passing HIV or not, and the other consequences of the various behaviours associated with doing so, are diverse and wide ranging. Therefore, in any group of people a range of attitudes toward HIV/STI precautionary and risk behaviours will be found.
A consequence may have little weight in a person’s attitude toward infection for three possible reasons: they are unaware of it (or understand it poorly); they think it is unlikely to happen; or they do not care if the consequence does or does not occur. Consequences of value can be both specific to individuals and shared with others. What people attach meaning or importance to is derived from other people and interpreted within their own lives. In other words, everyone influences each other’s consequences of value all the time. Responsibility is inter-subjective because it consists of placing value on specific potential outcomes and those values arise from understandings of others. Values, including responsibility and irresponsibility, are contagious.
Strategic Objective 1: We will investigate which consequences of remaining HIV uninfected, of acquiring HIV, of not passing HIV and of passing HIV on, that are of value to gay and bisexual men, and we will act to increase their awareness of those consequences of value and their probability of occurring; as well as acting to make those consequences actually more likely.
We will focus on consequences which are of value to men themselves as these are the consequences likely to trigger precautionary choices. However, we will not simply attach the things men value to HIV (for example, we will not suggest men can have sex with more men if they remain HIV uninfected). We will focus on consequences (both physical and social) which have a real possibility of occurring and which are in fact related to HIV. We will focus on maximising men’s awareness of both the benefits of remaining HIV uninfected and of not passing on infections (which may also be the costs of acquiring HIV and of passing it on).
We will not mislead men as to the probability of specific outcomes occurring. For example, we want men to know that HIV can kill, especially if untreated for a long time. However, acquiring HIV does not definitely swiftly kill and to encourage men to think so is not only dishonest but damaging to men who do acquire HIV.
We will not compound the negative consequences of HIV on people with HIV by recreating or acting out those negative consequences for the health benefit of men without HIV (for example, we will not suggest that having HIV is shameful and that HIV uninfected men should avoid HIV in order to avoid this shame).
Motivation: social norms
A positive or negative attitude towards acquiring or transmitting HIV does not automatically result in the intention to carry out a particular choice. Motivation is also an outcome of social norms.
People are surrounded by cultural and sub-cultural rules about sexual behaviours and are acutely sensitive to the judgements of others about sexual conduct and performance (Richters 2009). Perceived social norms for an action consist of an understanding of what significant others do and think.
Significant others can have both positive and negative weighting. As well as being inclined to want to be like those they like, people are also inclined to want to be different from those they dislike. People may develop negative opinions of those who tell them what to do and some people may have a stance of rebellion against being told what to do, so some authority figures telling them what to do can have the reverse effect. This may be particularly acute among gay men who have had to develop a culture of resistance simply to exist (Crossley 2004). Since few people are universally regarded positively, any person’s opinion has the potential to incline different people to contrary actions.
‘Peer pressure’ can result in people doing things which they have a negative attitude toward (or avoiding something they have a positive attitude toward). In the absence of a strong positive attitude toward remaining HIV uninfected, a strong social norm for doing so may motivate people to want to remain uninfected. However, in the absence of both positive attitudes and positive social norms for remaining uninfected, people have little reason for avoiding infection and may have reasons for acquiring it. Similarly, a positive attitude toward not passing on HIV is reinforced by a social norm for not doing so. However, in a the absence of a strong positive attitude toward not passing HIV on, a perceived social norm for doing so may on its own motivate people to do so. In both cases a strong perceived social norm toward acquiring or passing on can override a positive attitude toward staying uninfected or not passing HIV on.
Strategic Objective 2: We will investigate whose opinions gay and bisexual men care about (that is, who their liked significant others are), and act to encourage those people to express positive attitudes towards remaining uninfected and not passing HIV on, and towards precautionary choices for doing so.
Through these means we hope to increase the entire community’s sense of responsibility for the HIV epidemic. Responsibility is contagious, and people become involved in HIV transmission because those around them did not express enough concern that they do otherwise.
Power: opportunity, resources and skills
All actions require an opportunity to perform (or avoid) them, and the resources and skills to carry them out. The opportunities, skills and resources required vary depending on what the action is (for example, people need a condom to have protected intercourse but not to have non-penetrative sex, for example).
HIV prevention needs can be defined as those factors about people and their social and physical environments that increase precautionary behaviours and which interventions are able to change. Needs can be considered in two broad categories: needs related to motivation (or the will) to reduce risks and needs related to abilities (or the power) to reduce risks. Knowledge can be considered a subset of each of these two categories of need but it is different knowledge that will motivate us from that which will give us the power to reduce risk. In terms of threats, people are able to protect themselves only if they have knowledge of the consequences of not doing so and knowledge of how to go about reducing the likelihood the threat will befall them. For example, the difference between the knowledge of what HIV might do to health if it is acquired, and the knowledge that HIV can be transmitted during sexual intercourse. So there is knowledge related to motivation and knowledge related to power.
Strategic Objective 3: We will investigate and respond to those unmet needs for knowledge, opportunities, skills and resources which enable us to remain HIV uninfected and/or to keep HIV to ourselves.
Power: consumer choices and supply factors
The distribution of the choices in the population (how many men do one thing rather than another) is driven by more than the choices themselves. The supply of the opportunities and resources required to engage in sexual HIV risk behaviours may influence the level of risk behaviour in the population. These include:
- supply of opportunities to make contact with potential sexual partners;
- supply of ways to communicate with potential sexual partners;
- supply of places to meet sexual partners;
- supply of places to have sex / locations suitable for anal intercourse;
- sale and distribution of condoms and lubricants;
- shops / outlets for poppers (nitrite inhalants).
There has been a major increase in the commercial supply of all of these services in the last decade in England both through the internet and through the creation of semi-public sexual spaces (saunas and sex clubs). These services facilitate risk choices by making the physical opportunities and resources required for them more plentiful. They facilitate better sex because they enable choices to be made. We will not seek to nudge men toward choosing precautions by disabling them from choosing risks. We will not therefore pursue reducing the above supply factors in order to make precautionary choices more likely.
This intention does not preclude or prevent us from acting to influence suppliers of these services to minimise the risks the services may pose. Nor does it prevent us from creating alternatives to sexual activity for MSM.
Page last updated: 26 March 2012