Chapter 19

Understanding sexual behaviour change in response to HIV/AIDS has been an enduring puzzle for those working to stop the pandemic. Gay communities in the developed world have rapidly achieved a remarkable level of behaviour change in facing the epidemics they have weathered. What might we learn from the example of the Australian gay communities that might be useful for other communities and populations? It was gay men who invented the idea of 'safe sex'; and some of the 'heterosexual' epidemics may be less heterosexual than we think. An important lesson from the fact of significantly reduced HIV transmission in gay communities is that prevention education works. Second, the concept of 'community' seems to contribute to successful behaviour change by creating a collective sense of commitment to stopping HIV. Third, all communities are different and have different resources to contribute. It is important to work with each community's own capacities. Each community's 'sexual culture' is an important resource. Understanding 'sexual culture' provides rich resources for prevention education. Finally, we need three sources of research knowledge to help us produce effective prevention: epidemiology; social-behavioural monitoring; and cultural and educational research. In 1993, I was asked to review the international literature on HIV/AIDS-related behaviour change among gay men for the journal AIDS (Dowsett 1993). It was an interesting and revealing exercise because gay men have often provided an important indication of new steps and stages in the pandemic as a result of their position at the centre of the earliest epidemics in the developed world. They have also been a central part of the global response to AIDS, particularly in modelling community-based prevention education, and volunteer care and support for people with HIV and AIDS. We have learned much from their efforts. A good deal of our understanding of the importance of sexual behaviour change has also been formed from research undertaken among gay and other homosexually active men around the world (see, for example, Stall et al. 1992). These findings from nearly eighteen years of research are rich in detail and have led to considerable development in our understanding of how effective health promotion works and how behaviour change is complex to achieve and sustain. At times, these research findings and models from gay and other homosexually active men’s responses to the pandemic have been applied to other populations affected by HIV, sometimes usefully, sometimes erroneously. Indeed, there has sometimes been a translation of