Safe Connections: Planning, Organizing, and Running an HIV Prevention Workshop for MSM in a Rural Region

David H. Whitcomb, Ph.D.
Patricia Pahl, M.A.

University of North Dakota

ABSTRACT

Despite recent medical advances that have increased the life-expectancy and quality of life for persons living with AIDS, people still prefer not to talk about HIV or AIDS. This paper focuses on lack the of perceived relevance by men who have sex with men (MSM) in a rural region. In contrast to regional inattention, national authorities have recognized the importance of developing HIV prevention programming for MSM throughout the country and have urged every state to implement such programs. The purpose of this paper is to describe the process of planning, organizing, and running an HIV Prevention Workshop for MSM in a rural region where HIV and AIDS have not significantly affected many men or social service providers. It is hoped that the narrative style describing obstacles faced and lessons learned will be useful to rural health service professionals interested in initiating a similar project. A summary of results from participant evaluations and a research survey will be provided.

Safe Connections: Planning, Organizing, and Running an HIV Prevention Workshop for MSM in a Rural Region

Twenty years into the Acquired Immune Deficiency Syndrome (AIDS) epidemic, people still don’t like to talk about AIDS or human immunodeficiency virus (HIV). Although being HIV-positive is no longer equated with an imminent decline in health and, in many professional and non-professional circles, is no longer seen as a death sentence, the fact remains that most of us would rather focus our attention elsewhere. The purpose of this paper is to describe the process of planning, organizing, and running an HIV prevention workshop for men who have sex with men (MSM), in a rural region where HIV and AIDS are typically perceived as irrelevant and where public discourse on these topics is rare.

In contrast to major urban centers the incidence of HIV in many rural regions remains very low. Whereas many gay and bisexual men in major metropolitan centers endured multiple losses to AIDS during the 1980s and early 1990s, there are still rural gay and bisexual men of the same age cohort who never lost a friend or loved one to AIDS. It seems that the motivation for not talking about HIV/AIDS in the former situation might be a way to avoid rekindling the feelings of loss, whereas the motivation for rural men would be to keep the threat as far away as possible. After all, AIDS is something that happens to “them,” to “those people out there,” not to you and me in rural America. The same attitude may hold true for social service providers who are likely to work with or administer programs for HIV-positive men. Despite these attitudes, HIV and AIDS pose a definite health threat outside of the major cities. For the year ending in June 2001, there were 5.4 new cases of AIDS per 100,000 persons living in non-metropolitan areas (under 50,000), compared to rates of 9.4 per 100,000 in smaller metropolitan areas (50,000 – 499,999 population) and 18.3 per 100,000 in larger metropolitan areas (500,00 and above; Centers for Disease Control & Prevention [CDC], 2002).

The same data set (CDC, 2002) reveals that the rates of new AIDS cases are virtually the same in the outlying counties of both large and small metropolitan areas as they are in non-metropolitan areas (i.e., between 5.0 and 5.6 cases per 100,000). To demonstrate that MSM are at risk outside of major metropolitan areas, figures from the state with the lowest incidence of HIV and AIDS, North Dakota, reveal that through June 2001, 52% of the 270 reported HIV/AIDS cases were through male to male sexual contact, with another 10% stemming from intravenous drug use among MSM (North Dakota Department of Health, n.d.).

The preceding review of the numbers demonstrates that MSM are indeed at risk for HIV in rural America. There are, nevertheless, few programs to address the special HIV prevention needs of rural MSM. Recently, a small group of health service professionals and university students initiated one such program. This project involved partnerships among a state agency, a local not-for-profit community HIV/AIDS network with access to university resources, and consultant from large metropolitan area. The authors are the project director and graduate assistant; we try to offer the perspective of our local agency throughout the steps of seeking funding, providing training to regional health care providers, publicizing the event, and delivering an HIV program to MSM in a rural region. We hope that the narrative style describing obstacles faced and lessons learned will be useful to rural psychologists interested in initiating a similar project. In addition, we provide program evaluation results in Table 1.

PLANNING, IMPLEMENTATION, AND RESULTS

Why we Sought Funding

In April 2000, our local HIV/AIDS Network received a one-page request for proposal (RFP) for an HIV-prevention workshop specifically targeted to MSM. The RFP was issued by a state agency and distributed across the state to providers of health services. It specified a due date of June 30, that the workshop was to last for a full day, and listed eight criteria for evaluating the proposal. Our HIV/AIDS Network had never taken on a project this large, but decided to apply for the grant. What we did not know at the time was that this project had been delayed for years and mired in controversy resulting from political differences between state officials and community leaders.

How we Organized a Proposal Committee

After brief discussion, the HIV/AIDS Network decided that it would apply for the grant through the local state university, where the primary author is a faculty member. This would allow access to the Office of Contracts and Grants at the university. Another resource was access to a graduate student assistant (GSA) whose job was to work on faculty grant proposals. Among HIV/AIDS Network members, the chair and two other board members chose to become part of the workshop steering committee. An intern from the Student Health Center and two gay men who are undergraduates at the University rounded out our interdisciplinary steering committee.

We met once or twice a week as a group for approximately eight weeks. The GSA spent several hours a week independently working on the project and frequently consulted with me. Committee members who are health professionals contacted peers across the region for their input. One nurse from the largest city in the state frequently participated in our meetings via conference calling and secured a site for the workshop in that city.

Many service providers in our region have had little direct experience in HIV prevention or in working with men who disclose that they have sex with men. Initially, the committee conceptualized the grant as an opportunity to train professionals to work with gay, bisexual, and other MSM and to increase the trainees’ knowledge of HIV prevention issues. After consulting with the state funding source, however, it became clear that the workshop was to be sponsored only for men (age eighteen and up) who have sex with men and live in the state. This posed a dilemma for us.

Across the state, there are no GLBT community centers, bars, publications, agencies, hotels, or other such establishments. There are no GLBT leaders that are widely known across the state. No neighborhood is identified as predominately gay or lesbian, though certain pockets of the major cities are known to have a higher concentration than other areas. In fact, the only pieces of an GLBT community statewide consist of two small student groups at the largest campuses of the state university system, an Internet chatroom for men, a website centering on a listserv that began in 1999, and a small group organized to promote GLBT civil rights (also formed in 1999). One nightclub that caters mainly to gay men exists across the state line and a couple of other nightclubs, at that time, informally (i.e., mostly by word of mouth) sponsored a gay/lesbian night. Sometimes, the nightclub or student organization would sponsor a dance. Therefore, it was clear that it would be a challenge to publicize an HIV prevention workshop for MSM, much less convince men across a large rural area to attend it.

Another obstacle to focusing our proposal was establishing a budget. The RFP listed an available budget of $2000, but our primary contact at the state agency informed us that their federal funding source might offer additional funds after the proposal was submitted. The total amount available was said to be $7000. It was clear to us that the type of workshop we would run on the smaller budget would be quite different from what we would offer with a budget three-and-a-half times that size. Given a five-page limit for our proposal, we were not clear what to aim for, nor how to persuade the State that we had an attractive proposal at the smaller budget, but a superior product at the higher budget.

Ultimately, we submitted a proposal that included a feasible project at the lower budget and an expanded project, which included a two-day training for heath and human service professionals prior to the one-day workshop for MSM laymen, at the higher budget. Plans for the professional training were only in outline form, but the primary idea was to hire a consultant who could train local professionals specifically on HIV-prevention programming to MSM. We wanted to ensure that staff at our workshop would be qualified to deal with this issue. Although the interdisciplinary nature of our committee shaped our plans, most of the final proposal work occurred within the academic unit and the proposal had a distinctly academic tone. As foreseen, the relatively flexible schedules of those in academics allowed for variability that could not have been offered by committee members who see clients/patients or administer programs on a continuously tight schedule.

Waiting to Hear

After months of waiting the project was approved, at the higher budget level of $7000. The news was tempered by concern that the approval came weeks after the time we were to have been informed and days before the start of the academic year. A two-month hiatus was thus transformed instantly into another scheduling and planning challenge. We were now contracted to train the trainers and then have the trainers run the workshop all before the end of the semester.

National Linkage and Consultation

Whereas the grant-writing GSA was a primary support during the proposal stage, additional support and consultation was needed. This was obtained by Dr. Lee Faver, a private practitioner in Buffalo, NY. Faver has worked with national leaders at the American Psychological Association’s Office on AIDS and elsewhere, as well as being the psychological consultant for years at AIDS Community Services in Buffalo. He therefore brought to our project expertise possessed by no one within a few hundred miles of our community. Faver was familiar with how our state had been lagging in terms of HIV prevention programming and realized the local resistance to proposing programs that could be perceived as gay affirmative by public officials and state residents at large. Although he recognized the importance of understanding community norms, he gently pushed for programming consistent with national exemplars of making HIV prevention personally meaningful for MSM. We contracted with Faver to provide our two-day professional training; most of the work explained below contains his imprint.

Our two-day training was targeted mainly at health services professionals and was designed to assist professionals in conceptualizing the process of behavioral change and implementing programs for non-professionals, with MSM as the primary reference group. Some researchers (Epstein, 1992; Rudolph, 1988; Russell, 1993) propose that MSM have long been suspicious of efforts to stigmatize AIDS as a gay disease. Many gay men realize that certain sexual practices that gay men enjoy do not put them at risk for HIV nearly as much as early public health reports indicated. For example, until very recently, there was little evidence that anyone had contracted HIV by performing or receiving fellatio without a condom. Because the risk of certain sexual practices was overstated, many MSM decided that public health agencies were homophobic. Rather than seeing a continuum of risk, many MSM decided that because all sex was risky, they could either abstain from sex, or ignore public warnings and continue to have condom-free sex as they did before the AIDS crisis. For those with less dichotomous thinking, another option was to use condoms for all penetrative sex resulting in feeling somewhat safe, but then feel like a failure after a sexual incident in which a condom was not used. Our focus for the training was to teach facilitators a model of informed decision-making regarding sexual behaviors.

The transtheoretical model of change (TTM) outlines five to six stages of behavioral change in a cyclical sequence (Prochaska & DiClemente, 1992). People do not skip over stages in the sequence. Relapses are expected and a recycling through the stages is the norm. Although developed for treatment of addictions and related behaviors, including substance abuse, overeating, and smoking, TTM has been adapted for changing risky sexual behavior. In contrast to an abstinence model of HIV prevention, TTM proposes a model of risk reduction in which individuals make informed choices that can meet their needs (Prochaska, Redding, Harlow, Rossi, & Velicer, 1994). Used by the Centers for Disease Control and Prevention (CDC) in community demonstration projects (CDC, 1999a), TTM was chosen as the theoretical model in which we would train our workshop leaders. With the goal of harm reduction, Faver asked trainees to pose the following questions in our HIV prevention work:  what are your personal safer sex rules?  Have you broken any?  Under what circumstances?  How do you feel about it?  What fosters and inhibits your breaking the rules?

Recruiting for the training

To advertise the two-day training, we mailed hundreds of flyers across the state to newspapers, hospitals and other community health facilities, all of the licensed psychologists, social workers, and addiction counselors in the state, HIV testing counselors, and PFLAG groups (Parents, Friends, and Families of Lesbians and Gays). Mailings to college campuses targeted the Medical School, Nursing, Counseling Centers, Health Services, and Departments of Social Work, Counseling, Sociology, and Psychology. A few agencies throughout the state that are known to be sensitive to GLBT issues were also notified of the training.

Our publicity flyers highlighted the outline and goals. 

Twenty nine students and professionals attended the first day of training and 12 of them continued into the second day. Evaluations were completed by 22 of Day 1 attendees and all 12 of Day 2 attendees. Highly favorable ratings were obtained for the vast majority of items on the evaluation. One item will be highlighted here, namely, “the training met its objectives.”  On a five-point scale with “5” indicating agreement, on Day 1, 73% responded “5” and 18% responded “4,” yielding a 91% approval rating. On Day 2, 100% fully agreed that the training met its objectives. Among the 12 participants who attended both days, six were selected to become facilitators of the Connections workshop and two others were selected to be greeters and general helpers.

Determining a focus for the workshop

Although our planning committee included people who identified themselves as heterosexual or GLBT, we learned to transition our language away from such terms as “gay” and “straight” to describe our target population and instead focused on behavior, by using the term “men who have sex with men.”  Against a tide of opposing political forces, AIDS education and HIV prevention efforts gained national recognition largely due to the work of men in the gay rights movement, with significant support from lesbian activists (Vaid, 1995). On a local level, however, the politics of sexual identity may work against the goals of HIV prevention programs. This is because many men who have sex with men do not label themselves as gay or bisexual (Blasius, 1994; Caraballo-Dieguez & Dolezal, 1994). Although no literature on the local MSM population exists, gay men in the local area will tell you that many men who seek non-committal sexual relations with other men are also in relationships with women. These rugged, rural males typically eschew the gay community and any of its trappings. We wanted to reach these men for our workshop, and therefore downplayed “gay” in favor of emphasizing male-male sexual behavior.

Over a series of discussions and some graphic art experimentation, we settled upon a logo, a name for the workshop, and a theme (see Appendix B). As can be seen in our ad (modified to remove local references), the workshop was called Safe Connections. The graphics, coming through somewhere between faintly and vividly, display the torsos of two muscular men wrapped in an erotic embrace. The major text features the words “MEN – SEX – MEN” intertwined, as are the images of the men. The content of the workshop is suggested by four phrases beginning with “Let’s talk about” and ending with “men,” “communication,” “sex,” and “community,” respectively.

Therefore, we decided upon a one-day workshop entitled Safe Connections, in which MSM from around the region would gather to learn about HIV prevention, discuss sexual attitudes and behaviors in terms of healthy decision making, and make contacts with MSM in an atmosphere of open communication and trust. Our workshop objectives were stated as follows: (a) provide risk reduction and HIV prevention information to the MSM population, (b) explore personal behaviors that put MSM at risk for HIV; (c) increase MSM’s adoption of HIV risk-reduction behaviors, and (d) reduce isolation and build a sense of community among MSM population. 

Ongoing dialog with the funding source

Our committee was very pleased with our logo and ad – our funding source was not. They viewed the graphic depiction of two men embracing, naked from the waist up, as potentially violating community standards. Through consultation with Dr. Faver, documentation was provided to our funding source of the stance taken by the community planning group (CPG) component of CDC’s HIV prevention programming. The CDC’s message is that effective community interventions use a social marketing approach that attends to the values, norms, and consumer preferences of the target population, which may not be the same as the standards of the mainstream community (CDC, 1999b).

The content of the workshop was also an issue in our communications with our funding source. They focused on the informational aspect of HIV prevention. We realized that even though knowledge is a necessary component in preventing disease transmission, it is usually not sufficient. Several studies have demonstrated that despite adequate knowledge, some people do not modify their sexual behavior to reduce their personal risk (Prochaska et al., 1994). Through dialog and documentation, our ad was eventually approved and we were permitted to limit the traditional education component of our workshop to two half-hour presentations. Instead, we chose to center our workshop around the “let’s talk about” modules by basing our approach on the theory of group dynamics and group process (Yalom, 1995). Within the limits imposed by pairing an experienced group facilitator with a minimally trained MSM as co-facilitators in some of the small groups, our model emphasized the facilitative and healing qualities of group experience.

Regional Publicity

We were conflicted over the issue of advertising the location. On one hand, prospective participants had to know exactly where the workshop was held, so it seemed to make sense to include the location on the flyer. On the other hand, we were concerned that an advertisement specifying the location would deter the attendance of men whose MSM status is not public. We expected that they would fear being labeled as gay by anyone who discovered that they attended the event at this publicized location. Therefore we developed two sets of ads – one with the location posted and the other asking those interested to contact the primary author via e-mail or a toll-free number; we relied on our judgment regarding tolerance and intolerance in deciding which ad went where.

The workshop was publicized in many venues familiar to the MSM and GLBT population, including:  (a) interviews in our university student newspaper and the regional alternative press; (b) large advertisements in both of those publications; (c) flyers posted throughout the university and surrounding (small) city; (d) flyers in the gay-friendly club across the state line; (e) flyers at the adult bookstores in two of the largest cities in the state; (f) flyers at a gay-owned coffee shop and the (g) GLBT community center, both across the state line; (h) discussions in the statewide chatroom of the gay.com website and (i) at the new statewide GLBT website, including links to the flyer posted from both websites; (j) a flyer posted at a new and now defunct local GLBT website; (k) visits to PFLAG meetings in two cities; (l) visits to a university campus GLBT student organization and a campus counseling center; (m) flyers at another campus’ GLBT dance; (n) flyers and a letter of solicitation distributed electronically across the state and region to participants of the first regional conference on rural GLBT issues (in 1999); (o) flyers and a letter of solicitation distributed electronically across the state and region to the counseling centers of several campuses of the statewide university system; (p) flyers distributed at the World AIDS Day dinner in the state’s largest city; and (q) flyers distributed at the two-day professional training. Many health care workers across the state were aware of Safe Connections due to the previous marketing of that training. Two retail establishments in a smaller city declined to put up the flyers, but every other venue listed above was willing to advertise the event.

One glitch occurred when flyers posted at the gay-friendly bar were removed by a staff member at the only regional service provider that works specifically with HIV-positive persons. It seems that this worker objected to the vague nature of our ad and believed that HIV-positive persons attending the conference would be offended at the HIV-prevention message (i.e., that it would stigmatize persons already infected). This matter was discussed with the worker’s supervisor, who agreed that our projects were fundamentally cooperative in nature. From this experience, our committee learned a lesson in building statewide alliances prior to publicizing a project intended to reach a statewide audience.

Another odd occurrence was resistance by the editor of the alternative newspaper to interview the primary author about the article. To secure the interview, I had to counter his belief that the AIDS issue was passé nationally and never really an issue locally. I also chose to bait him by hinting at the political controversy surrounding the event. When the interview was actually conducted, however, I backed off from this stance, instead emphasizing the cooperative nature of the venture. I had little regret for being a bit duplicitous in attracting the editor’s interest. The article he published was perhaps bland, but served its purpose in drawing interest and, more importantly, attracting participants to the workshop.

Allowable expenses and seeking new funds for the remainder

In line with our original premise that people generally do not like to talk about HIV and AIDS, we thought that food and entertainment would attract both potential facilitators and workshop attendees to our events. Originally we planned to use part of our grant money to host a luncheons for our trainees and workshop participants. We also planned to sponsor an entertainer for an after-hours event that would be promoted in conjunction with Safe Connections. After obtaining price quotes from a few caterers and GLBT entertainers, we were informed that our funding source disallowed such costs. Additional planning led to a successful proposal to the university’s instructional development office to fund the trainee luncheons and a generous contribution from the local HIV/AIDS Network for the workshop luncheon. We had to forego our plans for an entertainer, but the HIV/AIDS Network also helped defray part of the bill for a dinner at a popular restaurant following Safe Connections. The consensus of the committee and participants was that all four meals served an important function in forming bonds within and across groups of trainees, participants, and organizers. After the dinner, festivities continued at the local bar. One facilitator recently reported that nearly one year after the event, he still sees men who met at Safe Connections talking together at the bar.

We learned that even though our funding seemed adequate, it did not cover all areas within our objectives; additional solicitation was needed to meet our community-building goals. We were also careful to use outside funding for all of our promotional materials distributed across the state line, even though residents in border cities often do not make distinctions between states when defining their community.

The Physical Setting of the Workshop

We held the two-day professional training in meeting rooms at the university, but wanted the one-day workshop to be held in a setting that could accommodate overnight travelers. In selecting a setting for the workshop, location, layout, cost, and hospitality were the deciding factors. We chose a site in the state’s largest city. Even though it was not centrally located, many choices were available and rural residents frequently travel for hours across the state to shop, conduct business, and attend special events. Next we decided upon a motel, not knowing of any noncommercial sites that were both affordable and open to a function for MSM. We discussed with motel staff the nature of the event and the need for the sessions not to be interrupted. Only after assurance that the establishment supported our need for discretion did we agree to book the reservation. We reserved one mid-sized conference room and two guest rooms that could double as overnight accommodation for speakers and breakout session rooms. The motel is an attractive and popular venue. Although we expected that some men would prefer to stay in our reserved rooms throughout the day, so as not to be publicly identified, everyone chose to have our catered lunch in the courtyard. In this open space, some participants played shuffleboard while guests used the pool and Jacuzzis nearby. This public recreational experience helped several participants bond with facilitators and each other.

The Workshop Schedule

The day began with registration and distribution of the demographic form, the pretest-posttest surveys, and a packet of informational resources. Then introductions, and ground rules for the day were made before co-leading an ice-breaker activity. Two informational sessions followed. The first was a presentation by a public health epidemiologist on HIV transmission, including local infection rate statistics. The second was a live demonstration of an HIV testing and counseling session, conducted by a public health nurse, with a facilitator as the patient.

After a break, facilitators conducted the first small group session, “Let’s Talk about Men,” focusing on how local MSM meet each other and what they are looking for in a man. Following a catered lunch, the facilitated session “Let’s Talk about Communication” explored how MSM discuss their relationship needs and expectations, as well as the obstacles they face in meeting these needs. Next, a program coordinator from a hospital in the neighboring state’s major metropolitan area led a guided fantasy in which participants brainstormed sexual options and worked with the leader to dispel myths about safer sex. The final small group session followed up on this exercise by personalizing the fantasies in smaller groups and exploring different levels of risk. The final session was a testimonial from a man who has lived with AIDS for many years.

The day concluded with closing questions and comments, evaluations, completion of the posttest, and an invitation for participants to keep in touch with workshop leaders and each other, in an effort to build a supportive community of MSM and allies. Dinner at a restaurant, partially subsidized by our HIV/AIDS Network, followed by an informal gathering in the neighboring city’s gay-friendly nightclub capped the evening

Gender Issues in Facilitating the Workshop

At the state university master’s and doctoral counseling students are trained, and most of the students are women. Most mental health practitioners in the region are likewise women. In conducting a workshop for MSM centered around small group discussion of sexual behavior, fantasies, and attitudes, we encountered a dilemma in how to choose our facilitators. We sought to balance facilitator counseling expertise on one hand with MSM rapport and familiarity on the other. We believed that the most credible group facilitators would be MSM, but did not attract enough of them with prior experience to our training. Although many of CDC’s community demonstration projects center around outreach workers, peer volunteers, and opinion leaders from the target population (Goldbaum et al., 1998; Myrick, 1998) Faver’s experience has demonstrated that women can be effective in HIV-prevention group interventions for men. Given our faith in his leadership and the quality of our experienced, trained female volunteers, we included women in all phases of project planning and the running of Safe Connections.

As a result of these considerations, we settled upon the following composition of facilitators for the four small groups: (a) a gay man with a master’s degree in school counseling and extensive post-master’s experience; (b) a gay man with a teaching degree and supervisory experiences in small business; (c) a heterosexual woman who is a licensed psychologist and tenured faculty member, paired with a traditional-age undergraduate bisexual man studying computer science; and (d) a lesbian master’s student in counseling paired with a male heterosexual classmate. Facilitator feedback, as well as the participant evaluations tabled below, indicate that all four groups provided a comfortable experience for participants, though the ratings were in descending order within the above list. In other words, although all four groups appeared to be effective, having a leader who was a member of the target group and had counseling experience was the most facilitative, whereas lack of an MSM leader was the least facilitative. These differences were small and would not deter us from including women as facilitators in future workshops.

Sexual Orientation Issues

In addition to the issues of sexual orientation discussed in developing our advertisement and choosing our facilitators, sexual orientation was directly addressed in other ways during the workshop. In establishing the ground rules for the day, it was emphasized to the group that people in the room, including the leaders, self-identify with a variety of sexual orientations. The term MSM was explained and participants were asked not to assume a sexual orientation of anyone in the room, though many leaders disclosed their own in the introductions. During the brainstorm activity, female anatomy was included in the list of turn-ons offered by participants, though the Let’s Talk about Sex small group fantasies that followed were decidedly same-sex oriented. Consistent with the ratings noted above, the two groups led by one MSM facilitator reported having the most open sexual discussions, whereas the two groups that had facilitators mixed by gender and sexual orientation generated tamer discussions that were nevertheless productive. Considering our need for experienced group facilitators, the benefits of heterosexual and female facilitators for MSM groups clearly seemed to outweigh the drawbacks.

Homophobia and Internalized Homophobia

Although homophobia and internalized homophobia occur everywhere, in rural communities there often is not a large enough GLBT community to counter these forces to the extent possible in urban centers, and MSM tend to be, to use a favored local term, “discreet.”  The issue of discretion surfaced repeatedly during the publicity efforts. In addition to the reluctance of our funding source to approve our homoerotic ad and the refusal of two sites outside of the population base of the state to post the ad, MSM were hesitant about attending. For example, while corresponding in an Internet chatroom, potential participants would sometimes express interest to an organizer, but voice concerns about showing up at the motel where it was being hosted – this site was too public for them even though most of our advertising did not reveal the location.

Although the primary author only received a handful of phone calls and e-mails, one call in particular was telling. He had seen our ad in an adult bookstore and wanted to attend because he had engaged in sex with men but had never really known a gay man. I repeatedly encouraged him to attend, though he battled with his ambivalence in making this commitment because having anonymous sex during or following an encounter at an adult bookstore is not the same as attending a gay-associated educational event. The latter seems to require a greater level of acceptance in self-identity as MSM. It is uncertain if he did attend, but our registration slips revealed that the bookstore ads succeeded in drawing some participants to the event. In the end, despite our efforts to recruit MSM across the spectrum of sexual orientation, based on voluntary self-reports throughout the day, all but one participant identifyied as gay or bisexual.

Finally, only one participant did not stay for most of the day. He was the only man who did not self-identify as gay or bisexual. During lunch he briefly discussed with leaders how uncomfortable it was for him to hear and talk about HIV/AIDS. He did not discuss his level of sexual risk taking or exposing partners to risk, though he alluded to feeling anxious about putting others at risk. His early departure was a clear signal to leaders that in planning our next workshop, we needed to attend more to the needs of men who are not only uncomfortable with the idea of HIV/AIDS, which we all share to some extent, but are also on the margins of an MSM community. They may need more individual attention at a workshop to meet their safety needs.

Demographics and Program Evaluation

Completing a very basic, anonymous registration slip, a program evaluation, and a morning and evening research questionnaire were voluntary activities that were highly encouraged by workshop leaders. Demographics gleaned from the registration slip show that the 20 participants, including the 3 MSM facilitators, hailed from 4 in-state and 3 out-of-state border counties. Participants traveled as far as four hours from home to attend. Seven men were in the 18-24 age group, 4 were ages 25-34, 7 were 35-49 and 2 were 50 or over. No other identifying information was obtained, due to the need for anonymity by some participants.

Everyone but the earliest departer and one other participant completed an evaluation; all who completed an evaluation rated the event favorably. Results are displayed in Table 1. The MSM facilitators in some ways were also participants at the event, taking in the information offered by invited speakers reinforcing strategies to use in their own lives even while leading groups in a discussion of these strategies. Based on their participation as members of the target population, all of them completed at least one of the registration forms or research questionnaires. Since they also participated in the role of facilitator, none of them completed workshop evaluations.

Participants anonymously responded in writing to the question:  “Where or how did you learn about this workshop?”  Two participants offered two responses. Overall, 6 (including the 3 MSM facilitators) found out about it from the workshop director, 3 from a friend, 1 from a boyfriend, 2 from a counselor or school counselor, 3 from a university GLBT student organization, 2 from the alternative newspaper, 1 from the Internet chatroom, and 1 from an adult bookstore.

Of the 17 participants who were not facilitators, 15 completed evaluations of Safe Connections. To highlight a few items from Table 1, 60% rated the workshop as excellent whereas the remaining 40% rated it as very good. Everyone responded that the workshop was worth his time, would recommend the workshop, and agreed that their facilitator was either helpful or very helpful. Only one participant, who was in the group lacking an MSM facilitator, expressed discomfort in the small group despite the helpfulness of the facilitators.

All of the invited speakers were judged to present useful content. Specifically, the usefulness of content was rated as good to excellent for all speakers except, paradoxically, for the one who received the highest evaluations overall. This MSM speaker, who presented on his experience of living with HIV for 18 years, received a “fair” evaluation by one attendee. The epidemiologist’s presentation on the transmission and infection of HIV, the public nurse’s presentation on HIV counseling and testing, including a live demonstration, and the MSM urban community health worker’s presentation on fun safer sex practices all received positive ratings, within a small range of variation. Although leaders were concerned that the epidemiologist’s presentation was too technical and factually overloaded, his style was nevertheless casual and his ratings were in line with the other presenters. Despite the difficulties inherent in hosting a confidential event at a public location, all who attended were satisfied with the facilities.

Effectiveness in Achieving Workshop Objectives

A detailed analysis of the pretest and posttest (colloquially titled “Safe Connections Survey – Morning Edition” and “…Evening Edition”) are beyond the scope of this paper; the authors plan to compile these results with those of upcoming workshops in preparation for a future publication. A few findings from this initial workshop will be highlighted here. As seen in Figure 1, at pretest a slight majority of participants planned to be tested for HIV within the next six months, but no one had plans to do so within the next month. At the same time, two participants (10.5%) had no plans to be tested. By the end of the day, these two individuals had changed their responses, either by not committing to a response, or to a decision to become tested. In addition four participants (21.1%) had increased the urgency of their testing plans, deciding to be tested within the next month. Several participants also backed up their numeric responses with narratives that clearly demonstrate that they had achieved at least some of our workshop objectives. These post-test narratives as well as pre-test workshop expectations are listed in Figure 1. These results indicate that at least some participants left the workshop feeling more informed, more equipped with communication skills, and enthusiastic about attending future events such as this.

Although anecdotal, it is highly characteristic of a rural community that some feedback on our effectiveness was communicated to us by the nurse who demonstrated the HIV testing and counseling session at Safe Connection. She reported that in the following months, more than one workshop attendee who had never been tested stopped by her office to be tested. It appears that not only did men leave the workshop with intentions to change sexual risk taking behavior, some actually followed through by achieving a major milestone in making informed sexual choices.

CONCLUSION

Safe Connections was the culmination of a multi-year effort that started before most committee members knew the proposal had sparked statewide controversy. Both the two-day preparation training and the one-day Safer Connections workshop were fairly well attended and evaluated very favorably by the participants. An interdisciplinary team, centered within an academic Counseling Department, worked through challenges but established a cooperative alliance with the funding agency, and attracted more MSM to a day-long workshop than many officials had expected. Facilitators, speakers, consultants, and organizers were no less than excited about preparing for these events and their level of enthusiasm only increased when the positive results were apparent. Using the transtheoretical model of change and small group process as foundations, an informative but emotionally intense experiential workshop was conducted that was well received by participants and highly regarded by the funding source.             

This project demonstrated that even in a rural region in which MSM typically do not feel at risk for HIV and are hesitant to participate in events that may reveal their sexual behavior, an HIV prevention workshop for MSM can succeed. We were funded for the following year to provide another program, with no changes requested. A high priority goal for planning future workshops will be to increase the publicity, particularly outside of the population center in the state, and to secure more solid endorsements of support from health care providers, particularly in hospitals and community clinics, throughout the state. We hope that others can learn from the process described above, adapt it to their local rural communities, and achieve a similar degree of success.

REFERENCES

Blasius, M. (1994). Gay and lesbian politics. Philadelphia: Temple University Press.

Caraballo-Dieguez, A., & Dolezal, C. (1994). Contrasting types of Puerto Rican men who have sex with men (MSM). Journal of Psychology and Human Sexuality, 6, 41-67.

Centers for Disease Control & Prevention, National Center for HIV, STD, and TB Prevention, Divisions of HIV/AIDS Prevention. (1999a, April 5). Transtheoretical stage model. Retrieved from http://www.cdc.gov/hiv/projects/acdp/change.htm

Centers for Disease Control & Prevention, National Center for HIV, STD, and TB Prevention, Divisions of HIV/AIDS Prevention. (1999b, April 7). HIV prevention community planning – guidance: Essential elements of a comprehensive HIV prevention plan. Retrieved from http://www.cdc.gov/hiv/pubs/hiv-cp/7elements.htm

Centers for Disease Control & Prevention, National Center for HIV, STD, and TB Prevention, Divisions of HIV/AIDS Prevention. (2002, February 22). Survey Report, 13(1). Retrieved from http://www.cdc.gov/hiv/stats/hasr1301/table4.htm

Epstein, J. (1992). AIDS, stigma, and narratives of containment. American Imago, 49, 293-310.

Goldbaum, G., Perdue, T., Wolitski, R., Reitmeijer, C., Hedrich, A., Wood, R., Fishbein, M., & the AIDS Community Demonstration Projects (1998) Differences in risk behavior and sources of AIDS information among gay, bisexual, and straight-identified men who have sex with men AIDS and Behavior, 2, 13-21

Myrick, R. (1998) In search of cultural sensitivity and inclusiveness: Communication strategies used in rural HIV prevention campaigns designed for African-Americans Health Communication, 10, 65-85

North Dakota Department of Health, Division of Disease Control (n.d.). HIV/STD Epidemiology Report: Semi-Annual Update, June 30, 2001. Retrieved February 25, 2002, from http://www.health.state.nd.us/ndhd/prevent/disease/hiv/pubs.htm

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. American Psychologist, 47, 1102-1114.

Prochaska, J.O., Redding, C.A., Harlow, L.L., Rossi, J.S., & Velicer, W.F. (1994). The transtheoretical model of change and HIV prevention: A review. Health Education Quarterly 21: 471-486.

Rudolph, J. (1988). Impact of contemporary ideology and AIDS upon the counseling of gay clients. In D. R. Atkinson, & G. Hackett (Eds.), Counseling non-ethnic minorities (pp. 279-292). Springfield, IL: Charles C Thomas.

Russell, G. M. (1993, August). Homophobia as political strategy: The passage of Amendment 2 in Colorado. In Countering attacks on gay/lesbian rights: State movements and referendums. Symposium conducted at the 101st annual convention of the American Psychological Association, Toronto, Canada.

Vaid, U. (1995). Virtual equality: The mainstreaming of gay & lesbian liberation. New York: Anchor Books.

Yalom, I. (1995). The Theory and Practice of Group Psychotherapy (4^th Ed.). New York:  Basic Books.

Author Note: As second author, Patricia Pahl was instrumental in organizing and running the events described, as well as compiling data and resources for this article. The use of the first person singular here is intended to facilitate the narrative and not to discount her significant contributions. Correspondence should be addressed to David Whitcomb, Ph.D., Dept. of Counseling, University of North Dakota, PO Box 8255, Grand Forks, ND 58202-8255. Electronic mail: david_whitcomb@und.nodak.edu