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i176 Sex Transm Infect: first published as 10.1136/sti.78.suppl_1.i176 on 1 April 2002. Downloaded from SYMPOSIUM From community to clients: the professionalisation of HIV prevention among gay men and its implications for intervention selection D Wohlfeiler ............................................................................................................................. Sex Transm Infect 2002;78(Suppl I):i176–i182 Forces at work are described which encourage In 1996, just after the International AIDS Con- professionalisation and a reliance on one on one HIV ference in Vancouver, Canada, leaders of the six largest US AIDS prevention programmes for gay prevention interventions among gay men. Community men met to compare programmes, exchange involvement is intrinsically linked to epidemic phases; strategies, and reflect on next steps while facing when the threat diminishes, so does the community’s the first days of new and promising treatments. There were two remarkable things about this ability to sustain community level interventions. The area meeting. First, it hadn’t happened before. Second, of structural and environmental interventions, which can while their programmes had once boasted sub- stantial community involvement, four of the six reinforce safe behaviour when community interest in could now count on just a handful of volunteers. collective action wanes, provides a potential Several of the programmes had begun prevention complementary solution for prevention workers, case management programmes, with varying degrees of success in attracting clients. Instead of researchers, and funders alike. participants, programme managers referred to .......................................................................... clients; instead of working within and with their communities, they worried about whether they were culturally appropriate for their “target “Take another leaf out of the smoking story; populations.” set about building a social movement in a In those 15 years, the gay community had conscious and purposeful way. Such 2 dramatically reduced its risky behaviour. Most of movements involve alliances between that behaviour change took place before and as the grass-roots and official forces. Public health community created its own organisations to agencies need first to define the nature of continue those efforts (see fig 1). Since then, the the threat and then to publicise appropriate community had largely delegated the problem of measures. With all else equal, HIV prevention to those organisations. The agen- http://sti.bmj.com/ understanding will first reach those most cies, in turn, had largely accepted responsibility for conscious of the threat and then become both the problem of new infections and the diffused. As momentum builds, all levels of programmatic solutions to attempt to reduce them. the movement must engage with public In other areas of public health, and to a lesser polity, press hard on official agencies, and extent in HIV, there is a growing recognition of advocate legislation and regulation as the need to move towards broad based commu- needed.” Susser M. In: American Journal nity level interventions and even structural and on September 24, 2021 by guest. Protected copyright. of Public Health 1996;86:1713–16. environmental interventions.3–6 Yet the gay com- munity’s AIDS prevention efforts had drifted “I have discovered that whenever I hear the down a path of increasing emphasis on one on statement, ‘if we only save one person, it one interventions. will be worthwhile,’ I am listening to the This paper seeks to help understand the definition of a failing program.” Worden reasons for this drift and its implications for how M. In: Journal of Drug Issues 1979;3:425– we choose interventions. How did it happen? Is it 33. irreversible? How did the evolution of the epidemic affect that drift? How much was the THE DRIFT TO ONE ON ONE community involved in HIV prevention in the first INTERVENTIONS place, and how involved is it today? Most impor- Towards the end of 1981, in San Francisco, a tantly, how should the balance of interventions registered nurse named Bobbi Campbell became change as the epidemic moves through different ....................... the first Kaposi’s sarcoma patient to go public in a phases? Correspondence to: column in one of San Francisco’s gay newsweek- I will argue that community involvement is Dan Wohlfeiler, University lies, the Sentinel.1 A few weeks later, he convinced intrinsically related to epidemic phases; when the of California, San the local drugstore at the corner of 18th and Cas- threat diminishes, so does the community’s Francisco, 1947 Center Street, Suite 201, Berkeley, tro to put up posters with warnings about new ability to sustain community level interventions. California 94704, USA; cases of Kaposi’s sarcoma. In New York,gay activ- When that happens, planners and communities [email protected] ists held their first fundraiser for “gay cancer.” need to make strategic choices. They can choose These were AIDS prevention’s first efforts, and Accepted to place a greater emphasis on individual level or 12 December 2001 examples of grassroots community organising, “downstream” interventions such as counselling ....................... accessing media, and peer education. or prevention case management. Alternatively, www.sextransinf.com Professionalisation of HIV prevention i177 Sex Transm Infect: first published as 10.1136/sti.78.suppl_1.i176 on 1 April 2002. Downloaded from 9000 Figure 1 Incidence and STOP AIDS I prevention of HIV among 1984–87 homosexual and bisexual men in 8000 San Francisco. 7000 KS Foundation 4/82 6000 KS poster 12/81 5000 4000 New HIV infections 3000 STOP AIDS II 1990 --- 2000 716 1000 336 0 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 they can choose to move “upstream” towards community level it so important. The gay community in San Francisco and environmental interventions. represents a potential high water mark of what is achievable in Owing to various forces which I will describe in this paper, HIV prevention. For if a community with this level of threat programme planners’ and educators’ strategies became more and resources finds it difficult to mobilise itself and its and more downstream. I will also argue that this is the wrong resources to dedicate to HIV prevention, communities which direction. This emphasis, given the limited resources available face less of a threat and have fewer resources and more com- to HIV prevention, threatens a balanced approach to interven- peting priorities will face even greater challenges. Simply put, tions, which has the greatest potential to reduce infections, if a community faces other severe competing health issues, particularly in areas of high prevalence. While these forces are poverty, crime, food, violence, or war, it is unreasonable to powerful, there are specific strategies which government, expect them to also participate actively in community efforts funders, and community based organisations have used, and to prevent HIV. may continue to use, to resist them. In conclusion, I will pro- vide some practical suggestions for how funders and practitioners may explicitly confront and address them to THE EPIDEMIOLOGY OF HIV AND SEXUALLY assure a broader spectrum of interventions. TRANSMITTED DISEASES IN SAN FRANCISCO’S GAY AND BISEXUAL MEN GAY MALE HIV PREVENTION AS THE POTENTIAL There are multiple detailed descriptions of the course of the HIGH WATER MARK epidemic in gay men in San Francisco. The epidemic hit so early on that the bulk of infections happened before, and just The gay community in San Francisco is well recognised for its http://sti.bmj.com/ rapid decrease in risk behaviour which resulted in a decrease as, the community built its first prevention efforts in the early in incidence. Most of the behaviour change took place very 1980s. These were quickly followed by a drop in infections. In quickly, and to a large degree was simultaneous with the the mid-1990s, at the same time as new treatments became establishment of AIDS prevention agencies, rather than a available, risk behaviour began to climb, while interest in pre- result of those efforts. It is incumbent upon us as practitioners vention activities declined. These increases in risk behaviours and researchers to examine that mobilisation’s ingredients then triggered an increase in new infections. critically and replicate as many steps as are possible. As this on September 24, 2021 by guest. Protected copyright. paper will lay out, that mobilisation was very brief, and few HIV incidence organisations took it upon themselves to maintain that mobi- Currently, there are approximately 46 800 gay men in San 9 lisation’s momentum. Francisco, who represent a significant portion of the city’s In contrast to anywhere else in the USA, gay men (including entire population, estimated to be around 800 000. gay male injection drug users) in San Francisco continue to HIV was present in the gay community as early as 1978. As make up 85% of all living AIDS cases6a and 85% of new illustrated in fig 1, rates of incidence rose as high as 18.4% by infections.7 In San Francisco in particular, by the time AIDS first 1982 and fell to 1% by 1987.2 Based on these incidence meth- appeared, the gay community had achieved important political ods and other calculations, it is estimated that 8000 new successes. Gay men and lesbians and their allies had achieved infections occurred in 1982. These numbers quickly fell to 500 high ranks throughout city

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