What will it change?
All of the HIV prevention choices of MSM are inﬂuenced by the decisions, activities and resource allocations of people in positions of power and inﬂuence. International research suggests that these key players have the greatest inﬂuence on, and responsibility for HIV incidence (UNAIDS 2002, Barnett & Whiteside 2006). This section focuses on the needs of organisations and policy makers to contribute to the reduction of HIV transmission involving gay men and other MSM in England.
Many of the needs described here can be met by local and national voluntary sector HIV organisations working in partnership to address the continuing inequalities that generate HIV prevention need. In addition to familiarity with strategic planning documents such as this, decision-makers require ﬁnancial resources and the political will to reduce HIV exposure and transmission.
There is no single agency or institution with overall responsibility for reducing HIV incidence through sex between men in England, nor any single group of organisations with sufﬁcient expertise, resources and respect to ensure that it occurs. This plan requires a multi-level, strategic approach to realise its goals. This requires different organisations to select and prioritise different aims and activities according to their targets and strengths. Its success rests on the commitment of a wide diversity of people and organisations and on the degree and success of our collaboration.
Summary strategic organisational (service) aim: Policy makers, commissioners and researchers increase actions that enable organisations (services) and their workforce (paid and volunteer) to reduce the HIV prevention needs of gay men and other MSM, and stop actions that make them worse.
In order to deliver targeted HIV prevention interventions to MSM in England we require a diversity of organisations that are HIV- and MSM-speciﬁc, working in close collaboration with organisations that are neither HIV-speciﬁc, nor MSM-speciﬁc. As this was developed as a planning document for the national CHAPS partnership we concentrated on the needs of organisations delivering interventions that target MSM in England, regardless of whether or not the organisations provide services that are HIV-speciﬁc or MSM-speciﬁc. We also imagined that these organisational aims would be useful to other organisations that deliver HIV prevention interventions to this population.
Ability to maintain ﬁnancial stability: CHAPS has played a role in supporting partner organisations to secure funding for the delivery of HIV prevention interventions by supplying funds to trial novel interventions. This success is challenged at a time when funding has become harder to secure given the economic downturn and as the political proﬁle of HIV diminishes.
While NHS and Local Authority HIV commissioners consistently prioritise MSM in their commissioning intentions (Weatherburn et al. 2007) this prioritisation does not translate into substantial and consistent investment in meeting the HIV-related needs of MSM.
Programme funding is vital for the provision and sustenance of HIV prevention interventions. Those responsible for the management of HIV prevention organisations report spending up to 80% of their time on the completion of funding applications, monitoring, and reporting back on contracts held (Weatherburn et al. 2007). This situation is likely to be particularly acute in organisations that lack core funding.
A continuous crisis-driven existence weakens service user conﬁdence and staff morale, and causes distraction from core prevention activities. All CHAPS partners require senior staff with the skills and resources to ensure successful competition for funding from a diverse range of sources. This requires a good understanding of the funding environment and coherent, conﬁdent relationships with those who commission NHS and Local Authority HIV prevention services and charitable funders. Senior staff will also need to understand the necessity for ﬁnancial accountability and the need for effective monitoring of services contracted and provided.
Ability to provide leadership: The leadership qualities that have been actively supported by CHAPS interventions require strengthening across all partnership organisations, and in their dealings with each other. Staff and volunteers need to provide, and service users need to receive, HIV prevention services that are free from racism, homophobia and gender-bias. Organisations that promote and prioritise equality will function as models for such attitudes in the wider community.
Some organisations delivering HIV prevention to MSM may be inclined to retain an exclusive focus on ‘service delivery’. However, community-based organisations also have a mandate to speak for their service users by: undertaking activism; clearly articulating the HIV prevention needs of users; responding to consultations; and interacting conﬁdently and proactively with the media. MSM- and HIV-speciﬁc organisations that command respect and demand action will help to change discriminatory practices and increase the attention and resources devoted to targeted HIV prevention activities. The actions of such organisations will also provide models of leadership for potential service users.
Political campaigning by local and national HIV organisations working in partnership has led to signiﬁcant policy change in the past. Some examples include: the Disability Discrimination Act 2005, the repeal of Section 28 of the Local Government Act 1988, and modiﬁcations to Crown Prosecution Service policies. All demonstrate that activism and community leadership can have an impact on government policies and hence HIV prevention need. Continued achievement of such change depends on HIV prevention managers working collaboratively to develop and implement joint policy priorities and also to inﬂuence local and national decision-makers, in order to increase the priority given to the HIV prevention needs of MSM. While national policy campaigns may emanate centrally from within Terrence Higgins Trust or NAT (National AIDS Trust), it is essential that organisations understand, value and participate in such campaigns.
Ability to assess and meet need: Needs assessment involves making informed judgements about the extent to which health promotion aims are unmet in target groups. It requires skills to interpret existing research, knowledge of local need, and ability to advocate for the collection of evidence. It also requires partnership work with service users and researchers to ensure that needs assessments result in information that is coherent and useful. The assessment of need is vital to planning - it ensures that resources are targeted in areas of greatest need.
The health promotion needs of MSM described in MSM targets and choices are broadly similar for all men, but the extent to which they are met will vary between sub-populations and between individuals. Undertaking a needs assessment for a sub-population requires an individual or a team that knows how to make an estimate of its size, its relationship to other population groups and make an assessment of how far away each is from the aims described. Whether or not an aim is met for a target group is not dependent on the availability of a service to address that need. An assessment of need should not be guided by the range or conﬁguration of existing services.
Ability to prioritise and promote conﬁdentiality: Potential clients need to know exactly how information about their sex lives and other private details will be managed by staff and volunteers providing an HIV prevention service. Staff and volunteers must be able to operationalise and clearly communicate their agency’s conﬁdentiality policy with all potential service users.
Conﬁdentiality policies should not confuse service users nor be any impediment to service users being open about HIV if they choose. Services must do their utmost to protect the safety and security of service users, staff and volunteers. Concerns about lack of privacy (and its implications) keep MSM from accessing HIV prevention interventions. CHAPS agencies must ensure that conﬁdentiality policies are developed, described, enforced and widely publicised. No person attending an HIV prevention service should fear that their identity or private information will be the subject of gossip.
Ability to work in partnership: HIV prevention interventions across the CHAPS programme should be designed to be complimentary rather than contradictory or competative. This requires ongoing and active communication within and outside the partnership about current research, effective planning and prevention activities. Close working relationships, joint planning, and the provision of HIV training for local statutory and voluntary sector organisations will enable effective referrals and support for individuals with complex needs.
Making it Count has 20 organisational (service) aims.
Workforce development and retention
Staff and volunteers are central to ensuring that effective HIV prevention interventions reach people who need them and are often the ﬁrst point of contact for service users. Hence, staff and volunteers require characteristics and skills that instil conﬁdence in the organisation and the services being provided.
A key challenge for CHAPS partners and other HIV organisations is workforce development and retention of staff and volunteers who have developed skills and expertise. Where staff receive sufﬁcient pay and are supported and valued in their work, they will stay in post for a longer period of time. Where volunteers are motivated and appreciated, they are more likely to dedicate more of their time to HIV prevention, and will be more likely to pursue paid work in the ﬁeld.
Sharing characteristics and understandings with target audiences: People using services may be more likely to identify with health promoters who share some of their own personal characteristics, and an understanding of their experiences, values and beliefs. Shared identity increases people’s trust in staff and volunteers, and will help them to feel that they will beneﬁt from an intervention.
Skilled and approachable staff and volunteers: Shared demographic characteristics are not sufﬁcient to ensure the success of interventions that are delivered face-to-face. Respondents to one survey were asked: For you, what is the most important characteristic or quality of someone giving you information or advice about HIV? (Weatherburn et al. 2005). Answers focussed on the following themes:
- Honesty, conﬁdentiality and non-stigmatising approaches.
- Being able to identify with the service user and gain their respect.
- Keeping a professional distance, speaking with authority, appearing to be trustworthy, knowledgeable and credible.
- Having the required skills and competence in the topic, being easy to understand and being approachable.
All people accessing HIV interventions require health promoters to provide information honestly and credibly and without moral judgement. Ensuring credibility will require that service providers are constantly updating their knowledge through access to training, seminars, conferences, online and print resources relating to the issues that are of greatest interest to the population they serve.
Those accessing HIV interventions require health promoters that establish a professional distance, which allows for mutual respect, and clarity about the anonymity and conﬁdentiality of the interaction. MSM accessing HIV prevention interventions require workers with the skills to assess their existing level of knowledge and needs.
The needs of people accessing interventions are best served when staff and volunteers make it clear what expectations they can meet, and which ones are best addressed elsewhere. This requires that staff and volunteers can utilise resources and contacts relating to a broad range of voluntary and statutory organisations that can help the service user best meet a range of other needs and follow clear referral protocols.
All of the skills described above require continuous organisational maintenance of the basic principles and practices of equality. It must always be made clear to staff, volunteers, board members and service users that homophobia, racism and sexism have no place in HIV prevention.
Making it Count has 20 organisational (service) aims.
Influencing central government
Globally, the most important factor in a nation’s response to HIV incidence is political leadership (Barnett & Whiteside 2006).The actions of governments and their agents determine the level of HIV incidence in a country through their impact on social norms, the size and configuration of the service response and the abilities of communities to address their own needs. Parliamentary legislation, central government policy and subsequent resource allocation set the parameters and limitations on almost all HIV prevention activity. Government policy and behaviour also sets the tone of acceptance or stigma toward people with diagnosed HIV.
The actions of policy makers, commissioners and researchers can impact on the HIV prevention needs of MSM through a variety of routes. They include developing policy, allocating resources and doing research that:
- respects diversity and promotes human rights;
- enables services to maximise their contribution to reducing HIV prevention needs;
- empowers communities to address their own HIV prevention needs;
- fosters joined up policy, funding and research.
For sexual ill-health to be minimised, sexual health and HIV must be given adequate resources and attention across Government departments and policies. The impact of policy changes on the incidence of HIV requires consideration by governmental departments beyond the Department of Health. For instance, policy decisions relating to immigration, criminal justice, prison and detention services, social services, education, and international development can all impact on the sexual transmission of HIV between men in England.
In the UK, it continues to be the case that only a small proportion of the activity done in the name of HIV prevention has gay men, bisexual men or other MSM as its target, and that small amount is expected to do the job alone.
Summary strategic policy aim: Policy makers, commissioners and researchers increase actions that enable organisations (services) and communities to reduce the HIV prevention needs of gay men and other MSM, and stop actions that make them worse.
This framework recognises and supports policy making which brings about social equality for all MSM and all people with diagnosed HIV and which facilitates HIV prevention interventions. Campaigning, lobbying and advocacy can be used to influence government policy both to ensure facilitative policies are in place and to remove policies which are obstacles. The same methods can be used on a local basis to ensure local organisations (for example, Local Authorities) have policies that support effective HIV prevention.
Sexual health in general and HIV prevention in particular must be given adequate attention within Government policy if the epidemics are to be brought under control. If the government is not seen to prioritise these issues, few commissioning authorities will and resources will go to other services. In 2003, a House of Commons Health Committee on Sexual Health characterised the sexual health of the UK and the service infrastructure to address it as a ‘crisis’. It identified the absence of leadership as one of five key drivers of this crisis and called for a National Service Framework for sexual health and HIV. That framework never emerged, and the identified absence of leadership remains deeply problematic.
Health policy: There are many successes in the delivery of HIV prevention, treatment and care services in England that provide a strong foundation upon which all future prevention activity can build. For example, self-referred HIV and STI testing is freely and conﬁdentially provided in clinical and non-clinical settings across England, and high quality HIV treatment and care is freely available for all eligible residents. In addition, the National Sexual Health Strategy (Department of Health 2001) has led to a widespread reduction in waiting times for appointments in clinical sexual health services.
However, spending on HIV prevention targeting MSM in England is widely perceived to be have been diminishing for at least a decade (Weatherburn et al. 2007). The proposed Health and Social Care BIll threatens to exacerbate this problem, when the responsibility for commissioning of local services passes from Primary Care Trusts to Local Authorities.
Continued leadership from the Department of Health on HIV prevention for MSM is required. Further change requires that the Health Protection Agency continues to communicate the extent to which the HIV epidemic in England is primarily comprised of MSM (and African migrants), and that national and local HIV prevention funding should continue to prioritise the prevention needs of MSM alongside those of African people. The high costs of HIV treatment can mean that HIV prevention lacks priority in local planning but the public health and economic beneﬁts of ensuring that fewer people require treatment must be used to challenge such tendencies.
There is a need for political leadership to support the Department of Health to ﬁnd innovative ways to ensure that local services prioritise targeted HIV prevention for MSM with the highest degree of unmet need. Where MSM with HIV are undiagnosed and / or untreated they have an increased likelihood of participation in HIV transmission and a higher viral load (without effective treatment).
The House of Commons Health Committee on Sexual Health (2003) identified lack of involvement of public health at the Strategic Health Authority (SHA) level as being a key reason for the current crisis in sexual health in Britain. SHAs largely failed to fulfill the roles of developing local strategies and priorities or to oversee the development and delivery of services by PCTs. The proposed Health and Social Care BIll threatens to exacerbate this problem, as the responsibility for commissioning of local services passes from Primary Care Trusts to Local Authorities.
Education policy: Educational settings are an important place for young people to explore and learn about sex and relationships. CHAPS partners believe that Sex and Relationships Education (SRE) that reﬂects the experiences and practices of people of diverse sexualities and diverse religious and ethnic backgrounds should be a mandatory element of the National Curriculum. This will help to ensure that expert teachers deliver a holistic programme of education that meets HIV prevention needs among all young people, including those that are, or will become homosexually active.
In establishing SRE as a mandatory element of education, the government would signal that this is a valuable and necessary aspect of developing healthy attitudes and practices among all young people. SRE that is delivered by conﬁdent, open, professionals is judged to be the best way of meeting parents’ and young people’s information and support needs and can improve communication about sex and sexuality at home. Such an approach would require that the Department for Education understands and applies evidence about best practice in SRE delivery to its curriculum planning, as outlined in a consultation paper drafted by the previous government (Department for Children, Schools and Families 2010). Unfortunately preparation of appropriate guidance from the National Institutes for Clinical Excellence has been suspended since the change of government in 2010.
Schools are an important place for sharing core social values. This theme has featured prominently in policy shifts toward the prevention of bullying (Smith 2000, Jennet 2004) and the addition of Citizenship to the mandatory curriculum. Schools are now expected to take a proactive stance against discrimination and harassment - including racism, sexism and homophobia.
As a result of such interventions, young people and those who educate them should be increasingly aware of the importance of promoting diversity and equality for a healthy and prosperous society. Such work needs to be sustained with appropriate resources - which requires that the Department for Education and the Children’s Commissioner, monitor and evaluate current practice and extend the interventions that are most successful.
Policing and prosecution policy: Engagement in civil society for gay and bisexual men is difficult when homophobic hate-crime is widespread. The Crown Prosecution Service has committed to deter people from committing such crimes by making clear “that such behaviour is not acceptable”. They have also recognised the need to provide an environment in which people have the confidence to report such crime and prosecute such cases effectively.
In order to feel reporting a hate crime is worthwhile, gay and bisexual men must have confidence in the police to act on their complaint. Knowing about police policy in response to such reports is essential.
Since much homophobic crime occurs where men meet other men for sex, one of the central obstacles to reporting of homophobic crime is the victims’ fears of prosecution themselves for sex offences. Clear and known policies for dealing with sex offences are also necessary.
Prison and detention policy: People who are conﬁned in prisons or detention centres often lack the resources to avoid involvement in sexual HIV exposure (National AIDS Trust & Prison Reform Trust 2005). This vulnerability and its sexual health (and human rights) implications should be recognised by the Home Ofﬁce and the Ministry of Justice. Departmental support of sexual health promotion programmes currently being carried out in prisons and detention centres (largely funded by PCTs) requires assessment of the level of HIV infection and HIV risk in custodial settings. The Home Ofﬁce and the Ministry of Justice will also beneﬁt from conferring with one another, and with health professionals and relevant communities when considering intervention and policy options for incarcerated populations.
Established health policies in prisons tend to mean that expert treatment and care for inmates with HIV is available. However, provisions for the health of irregular migrants and asylum seekers being held in detention can be ad hoc and intermittent (National AIDS Trust 2007). This is particularly detrimental for people with diagnosed HIV who require regular clinical checks and ongoing treatment.
Where people with diagnosed HIV are in regular contact with HIV clinical specialists, their health outcomes are improved, and they are less likely to transmit HIV as a result. The UK Border Agency (a part of the Home Ofﬁce) will require close liaison with the Prison Service (a part of the Ministry of Justice), Offender Health (a joint initiative of the Department of Health, the National Offender Management Service, and the Ministry of Justice), clinical HIV specialists and community organisations in order to develop and deliver specialist HIV and general health care to detainees.
Criminal prosecution policy: Since 2003, fewer than twenty individuals have been criminally prosecuted for the reckless sexual transmission of HIV in England, under the Offences Against the Person Act 1861. Many of the defendants (as well as complainants) have been African migrants, resulting in custodial sentences that are accompanied by recommendations that deportation is considered. Despite the small number of prosecutions to date, ill-informed and sensationalist media coverage has increased concerns about discrimination among all people with diagnosed HIV (Dodds & Keogh 2006) and undermined the public proﬁle of HIV as a long-term, manageable condition.
Some countries have drafted HIV-speciﬁc legislation, and some undertake criminal prosecutions for HIV exposure (rather than transmission). The current application of existing assault law to cases in England involves only those where HIV transmission has occurred. Despite a host of legal and academic discussion, there remains little clarity about what may speciﬁcally be used as evidence in order to bring a prosecution, and which preventive actions would provide a legal defence (Weait 2007). HIV support organisations report that there is wide variation in the approaches to such cases taken by police investigators, crown prosecutors and HIV clinicians. The Department of Health, Ministry of Justice and a range of HIV organisations have consulted with the Crown Prosecution Service in their development of prosecution guidelines for such cases, which offer some clarity on the issues raised.
Concerns about the detrimental effect that criminal prosecutions have on HIV prevention aims have been brought to the attention of the Department of Health and the Home Ofﬁce. Ongoing liaison between the two departments on the issue of criminal prosecutions is encouraged. HIV experts’ contribution to the development and provision of HIV guidance and training with the Association of Chief Police Ofﬁcers, the Crown Prosecution Service and the judiciary may help to diminish the harmful impact of such prosecutions. Furthermore, the provision of basic legal, data management, and media training for HIV service providers, will help them to better meet the needs of service users. Detailed information and recommendations to help achieve these aims can be found elsewhere (see Anderson et al. 2006, Bernard 2010).
Government policy and religious exceptionalism: For gay and bisexual men, equality at work means being able to pursue a career without fear of harassment or discrimination. It means having equality of opportunity in recruitment, promotion and training, being entitled to the same benefits as co-workers and being protected in law from unfair treatment on the grounds of sexual orientation. The Employment Equality (Sexual Orientation) Regulations 2003 bans discrimination in the workplace on grounds of sexual orientation, except in cases of genuine occupational requirement (where a person’s sexuality is important to the quality of the tasks involved in the job for example), where an employment benefit is limited to married partners and where the employer concerned is a religious organisation.
We believe provision of exceptions for genuine occupational requirement to be sound. Continuing discrimination on the excuse of continuing exclusion from marriage should be addressed by changing the exclusion of same-sex partners from marriage. However, the on-going support of the state for discrimination by religious organisations is unacceptable. As the law stands, religious organisations (which include places of worship, schools, health care centres and many other social institutions) can wholly legally:
- sack an employee for being gay or bisexual;
- refuse to employ someone for being gay or bisexual;
- refuse access to training or promotion to a gay or bisexual man;
- give someone leaving an unfair reference for being gay;
- victimise or treat less favourably a gay employee.
It is ironic that precisely those institutions that warrant protection for their members from discrimination on the basis of religious belief now have a charter for active bigotry toward another minority group in society. The exception gained by such organisations is an indicator of their willingness to damage the mental and physical health of gay and bisexual men in order to support their own gender ideology. Changing this religious exceptionalism in employment law is one of the future challenges of HIV prevention efforts as part of the larger changes required in religious organisations if they are to stop stoking the HIV epidemic.
Under the new law, victims of discrimination (other than employers of religious organisations) are able to sue for damages if they can show that they have been treated differently because of their sexuality. Under the terms of the Directive, workplace benefits provided for unmarried heterosexual partners will also have to be provided for same-sex partners. However pension schemes, like those in the public sector which only provide survivors’ benefits to married couples, may be ruled as exempt from the Directive. Progress on this front requires legal recognition of same-sex couples.
Making it Count has18 policy aims.
Influencing local government and NHS
Strategic planning in the NHS: Currently the NHS is structured by 10 Strategic Health Authorities (SHAs) in England that oversee the activities of about 150 Primary Care Trusts (PCTs). SHAs are responsible for developing plans to improve local health services, ensuring that local NHS organisations are performing well, increasing capacity, and making sure that national priorities are delivered at a local level. For the time being, SHAs are responsible for performance management of NHS services in their area, though substantial structural change has been proposed in the Health and Social Care BIll. If the Bill passes the commissioning and governance arrangements usually applied to local HIV prevention services will be completely restructured.
Under the current system, SHAs require awareness of the strategic plans and patterns of commissioning and service delivery in the PCTs in their area. When Local Authorities, take over responsibility for the commissioning of HIV prevention services (in April 2013) it is not clear what strategic over-sight will be put in place, nor whether any substantial investment in prevention services will be required.
Commissioning of NHS and community-based HIV prevention: Over the last decadde or so, PCTs have controlled at least 80% of all NHS spending on HIV prevention. Beyond, April 2013 Local Authority commissioners will require a high degree of familiarity with the HIV prevention interventions that they fund, as well as reliable evidence of uptake and effectiveness (National AIDS Trust 2007) and strong relationships with MSM and HIV organisations.
Up-to-date knowledge of local HIV prevention need will enable commissioners to advocate for appropriate resources. Consortia commissioning for programmes of HIV prevention for MSM across geographic boundaries will improve the extent to which knowledge, expertise and resources are efﬁciently shared. We hope that in the move away from PCT towards Local Authority commissioning, that the value of consortia commissioning for HIV prevention will be increasingly recognised.
Clinical sexual health (GUM) services should prioritise sexually active MSM as a client group. This will require resources in order to better promote services among, and to provide services that are available at accessible times of the day, in accessible places, and are culturally sensitive.
Provision of NHS services: Local NHS services are partly responsible for HIV prevention interventions that target MSM. Provision for the sexual health needs of this population requires understanding and recognition of cultural and sexual practices that will impact on sexual health outcomes. MSM and HIV organisations’ participation in the design and delivery of services is therefore crucial to their success.
Further to this, all health providers must ensure that health decisions are always subject to informed consent, and that security of personal health information is prioritised. In addition, the NHS is responsible for ensuring that all service users are treated with respect and dignity. This will require that local NHS providers proactively address homophobia, HIV-related stigma, racism, xenophobia, and gender-bias in the attitudes and practices of their staff, and in recruitment and employment practices. NHS managers therefore require the resources and skills to enable them to prioritise equality in all healthcare settings.
MSM without diagnosed HIV who access primary care and sexual health services need to know that HIV testing is available in these settings. This requires that GPs, nurses, acute care specialists and GUM (clinic and community-based) staff have the resources and skills to offer HIV testing.
The work that has been undertaken to improve access to post-exposure prophylaxis (PEP) following sexual exposure to HIV has dramatically improved mens' awareness of PEP as a treatment option (Dodds et al. 2006). It is likely that in time, more people potentially exposed to HIV through sex will come forward to request PEP treatment. Local NHS and Local Authority managers should work in conjunction with HIV voluntary organisations, community groups, and professional HIV clinical associations to ensure that staff in acute services (Accident and Emergency) and sexual health (GUM) service providers understand and can apply the correct assessment and prescribing protocols as described in the recently updated UK PEP Guideline from BASHH (Benn et al. 2011).
Local authority policy: Many services and functions carried out by local government in England impact both on gay men and other MSM themselves and on activities intended to address their needs. Historically, Local Authority functions that have impinged on HIV prevention needs have included: education; housing; social services; libraries; environmental health; trading standards; leisure and recreation; and the police (not a direct function).Through their services Local Authorities can often play a major part in reaching vulnerable MSM.
Commissioning and provision of services other than health: The provision of essential services such as housing, social services, policing, legal advice and welfare beneﬁts advice for MSM in England will help to meet HIV prevention needs. Improving HIV prevention outcomes means that the social care needs of MSM with diagnosed HIV are a priority, followed by the social care needs of all MSM.
Local service providers (schools, police forces, social services etc.) should be vigilant about homophobia, HIV-related stigma and racism in their own employment practices, among their staff, and among those who access their services. This requires clearly articulated and continually enforced equality policies. Those who manage the delivery of services will need access to the resources and skills to enable them to prioritise equality in the work environment.
Making it Count has18 policy aims.
Everyone is a community member. All people delivering education, health and social services, those developing and implementing policy, carrying out and publishing research or allocating resources can also be involved in the community activities necessary to deliver Making it Count. However, here we are mainly concerned with people who do not have an occupational responsibility towards HIV prevention.
Community members can make a number of actions that contribute to a reduction in HIV prevention needs and these can be targeted towards MSM themselves, or towards services, policy makers and other community members. These include:
- Political action and lobbying, informing, prompting and pressurising policy makers to act.
- Gay and bisexual public involvement in service planning and interacting with services and their planning to improve them.
- Forming voluntary associations and mobilising communities to act in their own interests.
- Informal education and support of homosexually active men to reduce their HIV prevention needs.
Increasing community actions such as these are also among the changes that this framework advocates. In order to act communities require knowledge and awareness of the problems, empowerment, leadership, social norms (public opinion), a supportive legal framework, meeting spaces and resources. Below we outline a number of different constituencies (including businesses) that make up the community and describe their actions, potential actions and requirements for action (needs) in more detail. All of the needs described can become the target of actions of others.
Summary strategic community aim: Community members and businesses increase actions that contribute to a reduction in the HIV prevention needs of gay men and other MSM, and stop those actions which make them worse.
Gay men, bisexual men and other MSM interact with and are addressed by every sector of society. They are exposed to all mainstream media, every television programme and film and every radio programme and recording. They are present in all public places, use every business and public service, every sports facility, shop, bar and restaurant. Every taxi, train and bus regularly has a gay man in it, as has every barbers, bookmakers and theatre.
The population of MSM within any country will always be small in proportion to the overall population. The extent to which the needs described are true for a population of MSM will depend on what meaning the majority population ascribe to sex between men and the way gay men and other MSM are regarded and treated.
How MSM are regarded will influence: how people develop social policy and allocate resources; how people deliver education, health and social services; whether and how people deliver or develop the infrastructure in which homosexually active men meet; how homosexually active men act with each other in public and in private.
All areas of the country have young men growing up in them who do or will have sex with men. The way the nation treats these young men today will influence the incidence of HIV in ten years time. Action is needed to tackle the wider social determinants of health for gay and bisexual men. Ten years ago the All-Party Parliamentary Group on AIDS (2001) made the broad recommendation that “the environment in which gay men grow up and live is addressed in order to affect the impact it has on self-esteem, assertiveness and, ultimately, health” (§85). We support this approach and specify below the people who make up that environment and what their actions might achieve.
The general public address gay men, bisexual men and other MSM: Verbal abuse and physical assault are the most tangible indicators of homophobia in the general population. The National Gay Men’s Sex Survey 2002 (*Sigma Research, 2002) found 34% of gay men had been verbally abused because of their sexuality in the last year, and 7% had been physically assaulted. The majority of the violence comes from strangers in public places.
Gay men and MSM address each other: MSM have been HIV health promotion’s largest human resource and many needs can best be met by discussion between them. Our ideal is that men reduce each others HIV prevention needs via social and sexual interaction. Of course, not all prevention needs can be met this way. For example, determining their HIV status cannot normally be met by peers, but require qualified medical personnel. Similarly, peers may be able to give little practical assistance where men are experiencing clinical psychosexual problems. However, these needs are in the minority. Most needs can be met by peers with resources and support. This can only occur in a broader social context that enables such actions. Although the majority of these interventions are informal, an indicator of need for action in this area may be the proportion of gay and bisexual men who have volunteered for a gay or HIV organisation in the last year. The National Gay Men’s Sex Survey found this figure to be 4.2% in 2001 (* Sigma Research, 2001).
Friends and family of gay men and MSM: Just as men can act as health educators to their sexual partners and peers, so too can other people in their social networks can contribute to a reduction in their HIV prevention needs. If there are 500,000 homosexually active men in England there are many millions of friends and family members of gay men, bisexual men and other MSM. Although MSM are often represented as a collection of individuals or a homogenous group, the majority live in social networks containing a range of people diverse in gender, age and sexuality. We estimate an additional three million people in England have close personal relationships with MSM and another ten million socially know a man that has sex with men.
Non-commercial gay infrastructureproviders address MSM: The 44 years since the enactment of the 1967 Sexual Offences Act has seen a steady growth in the non-commercial gay community infrastructure. The main growth of the political or voluntary sector took place throughout the 1970s.With the advent of AIDS in the early 1980s, the community response became largely directed towards activities concerning HIV care and prevention. Today a lively (non-HIV) Lesbian, Gay, Bisexual and Transgender (LGBT) voluntary sector thrives in most of the major metropolitan areas of England.
HIV and other sexual health promotion activities are often only able to occur in places where men meet and socialise due to homophobic resistance to such work occurring in broader settings. As well as challenging such resistance, action can be taken to increase the settings in which interventions can occur. Men’s HIV prevention needs are more likely to be met if there exist places where men can encounter interventions and each other.
The existence of a diverse non-commercial gay infrastructure strengthens public health by providing the social fabric which is a pre-requisite for health as well as the settings in which health promotion interventions can occur. This includes meeting places, social networks, social and interest groups, political groups and organisations, community centres and telephone helplines. People who build or maintain gay and bisexual community infrastructure and social networks without seeking a profit include helplines, support group facilitators and interest group facilitators.
Gay targeted businesses address MSM: The growth of the commercial gay scene over the last 30 years has been dramatic. In the UK, growth has been concentrated in certain cities (notably London, Manchester, Birmingham and Brighton).The largest such growth accompanied the economic boom years of the 1990’s during which time most towns and cities experienced a growth in their gay scene, and London and Manchester became two of the largest gay commercial centres in the world. The opportunities that such an active commercial centre offers for health promotion efforts are manifold. However, such commercial ‘scenes’ exacerbate existing problems of exclusion, based as they are around the tenets of profit. Therefore, younger (and older) men, less well educated, less affluent men, disabled men and men from some ethnic minorities are likely to find themselves excluded from participating in the commercial gay scene. Moreover, concentrating interventions solely within such a sector is likely to
result in greater exclusion for the groups with greater levels of unmet HIV prevention needs. However, for the men who do use them, gay businesses provide a variety of services and products which relate to HIV prevention needs. The gay press has historically been the most important source of HIV information and continues to play an important role. Bars and clubs where men socialise and meet provide a key outlet for the gay press and HIV prevention resources. Commercial venues designed to facilitate casual sex (such as backrooms and saunas) can either maximise or minimise a risk taking environment by their design and services.
The mainstream media addresses MSM: Many people are exposed to health related information and opinion through television and newspapers, and the media has played a central role in the HIV epidemic in Britain. Clause 9 of the National Union of Journalists Code of Conduct states that a journalist should produce "no material likely to lead to hatred or discrimination on the grounds of a person’s age, gender, race, colour, creed, legal status, disability, marital status, or sexual orientation”. There is no mention of HIV in the Code of Conduct and no published research on adherence to these guidelines.
Other mainstream businesses and services address MSM: Although it is mainly gay men who use gay services, all generic services and businesses have clients and customers who are MSM. MSM involvement in service planning makes services better. It can occur either at a service or policy level. The simplest way in which the community can meet the information needs of service providers to deliver the best service possible is through informal and formal feedback, including but not limited to complaints.
The devolution of the NHS to PCTs has increased both its responsibility towards and openness to influence by local community members. PCTs are able to fulfil their roles more effectively when they seek and accept input from lay persons. In the context of their contribution to HIV incidence, public involvement by gay and bisexual men and other MSM is essential to this process.
The propensity of communities to accept and support or to reject and persecute MSM is strongly influenced by the actions and words of its religious leaders. Many MSM have rejected organised religion because of their ideology of heterosexual superiority, cutting off a potential source of spiritual development and excluding them from potentially supportive social networks.
Making it Count has 14 community development aims,
Influencing planning and the evidence base
Needs assessment plays an important role in the delivery of NHS services. All PCTs currently have a statutory responsibility (Department of Health 2001, Department of Health 2003) to assess the HIV health promotion needs of their resident population. They also have a responsibility to commission services to meet as much need as possible in the most equitable manner feasible. However, the extent to which some health promotion aims are met, the obstacles to them being met and the health promotion initiatives that may best achieve them, can transcend PCT boundaries. Some needs therefore require assessments across geographic areas larger than single PCTs. Provision and planning for such assessments will require support from Strategic Health Authorities, from the Department of Health, and from HIV and MSM organisations.
From April 2008 the Local Government and Public Involvement in Health Act (2007) imposed a duty for PCTs and upper-tier local authorities to undertake Joint Strategic Needs Assessments (JSNAs) in order to better understand the current and future health and well-being needs of their populations. This system of joint strategic needs assessment currently informs the commissioning evidence base for interventions that result in improved health and well-being outcomes, and in the reduction of health inequality (Department of Health 2007). In addition to this, the Equality and Human Rights Commission (EHRC) operates to safeguard policy and practice responding to the particular needs of ethnic and sexual minorities. Support from the EHRC may be critical for those agencies and consortia seeking to ensure that the HIV prevention needs of MSM are appropriately met.
A reliable sexual health and HIV evidence base requires not only the participation of individuals and service providers, it also requires that local commissioners and national funders collect and make available transparent data for evaluating policy change, including the surveillance and publication of resource allocations.
Page last updated: 5 July 2013