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Expanding the evidence base
To mention controlled trials and behavioural interventions in the same breath can generate sufficient heat to cause spontaneous combustion. Nowhere is this more evident than in the field of sexual health promotion. But our experience suggests that, for those who can stand the heat, controlled trials can also generate an expanded evidence base for HIV prevention.
Controlled trials conducted in the United States provide persuasive evidence that peer education can bring about a significant reduction in high risk sexual behaviour among homosexual men. For example, peer educators recruited from “gay” bars in small towns made a significant impact upon sexual behaviour at a community level.1–3 The proportion of homosexual men who engaged in unprotected anal intercourse (UAI) decreased by about one third following the peer led intervention whereas no change was observed among men using bars in towns without the intervention (controls). The Mpowerment project in California and Oregon also reported a significant reduction in the frequency of unprotected anal intercourse with both regular and casual partners following a peer led intervention.4,5
These peer education programmes drew on a diffusion of innovation model whereby popular opinion leaders engaged in conversation with other homosexual men to promote HIV risk reduction.6,7 According to this model, behaviour change initially adopted and endorsed by the opinion leaders gradually diffuses throughout the population. The model is well suited to community level HIV prevention campaigns that typically require the initiation, diffusion, and long term maintenance of behaviour change.8
Encouraging as the North American studies are, however, it cannot be assumed that their findings are directly transferable to the …