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To curb rising HIV rates, we must target our human flaws

One of the most perplexing risks to public health is human nature. No matter how diligently public health campaigns lay out the facts, we continue to make seemingly illogical decisions. Just look at the…

Today’s global HIV statistics reflect increasingly risky sexual practices. Shutterstock

One of the most perplexing risks to public health is human nature. No matter how diligently public health campaigns lay out the facts, we continue to make seemingly illogical decisions. Just look at the obesity epidemic or binge drinking for evidence of our willingness to knowingly and repeatedly make apparently self-defeating choices; even more so when sexuality and intimacy is thrown into the mix.

In Australia, the HIV epidemic continues. Just like in other high-income countries that offer high-quality, widely accessible HIV prevention, treatment and care, HIV infection rates in Australia have been steadily climbing since 1999, with the single biggest annual jump of 10% reported in 2012.

The reason is human behaviour. Optimism began to creep in when life-saving anti-retroviral therapies (ART) transformed HIV/AIDS from a certain death sentence into a manageable, if medically complex, chronic condition from the mid-1990s.

Today’s global HIV statistics reflect increasingly risky sexual practices, particularly among gay men, and particularly in countries with both the resources and the political will to turn the HIV pandemic around. By contrast, many developing countries are achieving meaningful reductions in their HIV infection rates.

To date, Australia has been at the forefront of global efforts to combat the HIV epidemic since our much debated “grim reaper” campaign of the 1980s. Australia’s world-class medical researchers helped develop ARTs and have made a major contribution to the use of ARTs in prevention, as the drugs drastically reduce the “viral load” in HIV positive people, so reduce the risk of transmission.

ARTs cost around A$18,000 per person, per year. Viacheslav Nikolaenko/Shutterstock

However, increasing risk-taking is outpacing these significant advances in medical science. In 2012 more than 1,200 new cases were diagnosed in Australia, bringing the estimated number of people living with HIV to 25,708.

Every new infection comes with a lifetime of medical treatment, significant risk of medical complications and considerable lifelong costs; about A$18,000 each year for ARTs for one person in Australia.

We urgently need to re-evaluate our approach and bridge the gap between that knowledge and our HIV prevention responses. That a better understanding of human behaviour will help seems obvious. But few public health campaigns are underpinned by rigorous behavioural and social research.

Much of what we currently do is based on common sense and past experience, which is problematic because people do not necessarily behave in their own best interests. People are, in fact, often motivated, well intentioned and well informed but suffer from the common so-called “new year’s resolution” effect; they do genuinely want to change but just don’t quite manage to get started or fail to maintain new behaviour.

We are also, rightly, reluctant to lecture or play on people’s fears because we want them to make their own informed choices. So we assume that if we give people all the information they need they will put it together and act accordingly. But most people have more on their minds than staying healthy, and most assume they are healthy anyway.

Who hasn’t been on a diet and nevertheless eaten the birthday cake because we don’t want to spoil the party and surely one slice won’t hurt, will it? Likewise, it’s easy to imagine that sex is about many other things than avoiding HIV, particularly since HIV has become a less ominous health threat.

There are promising approaches in the behavioural sciences that go beyond limited assumptions around rational decision making and take into account everything from personal beliefs, unconscious influences and the complex “ecosystems” of signals in our environments that determine how an individual acts, even in the heat of the moment.

One of the most powerful strategies it to implement a simple sexual health action plan. Francesco83/Shutterstock.com

Some of the most important insights to emerge from the behavioural sciences in recent years reveal that simple changes can have a profound effect. Implementing an opt-out HIV testing policy at a sexual health clinic, whereby in principle everyone gets tested unless they decline, for instance, substantially increases the rates of HIV testing and so can greatly improve timely diagnosis,

One of the most powerful behavioural science strategies is to help people to make a simple action plan. This takes only a few minutes and has been found to be effective in promoting a wide range of health behaviours, including making appointments for sexual health checks, using condoms, using contraception and getting vaccinated against hepatitis B.

We have a whole range of personalised communication tools such as smart phones that can help; both with gathering information and reaching individuals with tailored health promotion approaches.

There are many human and economic reasons to reinvigorate our efforts to combat HIV. It may no longer be a fatal condition for people with access to ARTs and medical care. But this is not the same as a cure. The best reason of all is that HIV is preventable – if we effectively support people to protect themselves and others.

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10 Comments sorted by

  1. Trevor Kerr

    ISTP

    Excellent article, with principles that are applicable to many public health interventions.
    There is a another side to the equation, though, if I may be so bold. Is it fair to say that every new recruit to the HIV-positive pool is also a tiny fillip for the sexual health industry?

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  2. Christopher Seymour

    Business owner at Location

    Changing human behaviours is an interesting psychological problem. In the 1970 s, the well publicised threat of death or serious injury failed to raise seatbelt use beyond about 40%. But the introduction of a $20 fine brought almost complete compliance.
    Of course the effectiveness of penal measures depends on enforcement - its easy to detect non seat belt use and speeding fines are only effective when speed cameras are ubiquitous. However laws requiring sex workers to use condoms seem to have been effective, since prostitution does not seem to be a major source of HIV infection.
    Laws do seem to make some behaviours socially unnacceptable - for example most people now frown on littering which was a major problem in the 1960s. How do we get to the point where casual sex without a condom is equally unnacceptable?

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  3. Julie Leslie

    GIS Coordinator

    There is a funny thing in business that I have found. If you are on top of your accounts receivable and ask your clients to pay your invoices then about 95% of the time they will get paid on time. It blows me away when so many businesses go out the back door simply because they let their accounts receivable go awol and they never get paid. Most times all you need to do is ask in a non-patronising and non-judgemental way and people will do what they don't really want to do - pay your bills. (Yes…

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    1. Pythinia Preston

      writer

      In reply to Julie Leslie

      How much can you say in 10 or 15 minutes? Doctors usually talk in monologues and ask the occasional question and then out you go while he/she readies themselves for the next patient.

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    2. Julie Leslie

      GIS Coordinator

      In reply to Pythinia Preston

      Yes, how great would it be if health professionals actually cared about your health instead of churning through patients.

      I'm sure the more entreprenurial (?spelling) would charge an additional amount - they would be dealing with a seperate issue then

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    3. Jim Hyde

      logged in via Facebook

      In reply to Pythinia Preston

      doctors are not good at prevention and health promotion and they should leave it to the professionals, or work in a multi disciplinary team without trying to assert they are the leaders to be involved

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  4. Andrew Winter

    -

    "One of the most powerful behavioural science strategies is to help people to make a simple action plan."

    Seriously, people are going to sit down a make a sexual health action plan? This seems like a typical bureaucratic response to an issue that displays a completely academic, rather than practical knowledge of the topic.

    Rather than pursuing behavioural science, why not spend some time looking for an alternative to the condom. In my experience all of this academic waffle comes down to the fact that many people do not like placing a piece of plastic between their body and that of their partners during this most intimate act.

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  5. Jim Hyde

    logged in via Facebook

    I'm sorry to say but this article reads like a why won't people do as we tell hem whinge. There are many complex reasons why gay men have safe sex fatigue and why other people don't listen to sexual health messages. many of these reasons are completely rational.

    First the tome of most sexual health message is sex phobic and moralising and we should be sex positive and celebrating the joy of sex. Every time some moralistic whacker is outraged, we raise the bar of resistance.

    First lets get…

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  6. Margo Saunders

    Public Health Policy Researcher

    Yep, there is little doubt that immediate fun-filled pleasure tends to win out every time. Public health needs to make much better use of consumer psychology/behavioural economics if there is to be any hope of influencing behaviour in ways which compete with the powerful influences of commercial marketing, given its demonstrated understanding of consumer behaviour. It is equally important to ensure that the current emphasis on social determinants of health is balanced by a recognition of the role of human behaviour which cuts across socio-economic factors.

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    kamagra at apotheke2all

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