Male clients randomized to Hombre Seguro received the active safer sex intervention, which was developed based on our experience conducting several large-scale sexual risk reduction interventions in the U.S. and Mexico, including Mujer Segura and our pilot work. The intervention incorporates principles of MI, SCT, and TRA. Experienced interviewers who are indigenous to these communities were trained to deliver this intervention. The intervention, and control condition, took an average of 60 minutes to deliver. The main steps in the Hombre Seguro intervention are delineated below.
Steps 1 and 2: Determine Readiness for Change and Decisional Balance Exercise: The counselor began the session by having the participant complete the “ready, willing, and able” exercise. This exercise assesses the participant’s readiness for change, thereby providing valuable information to guide the session. This activity is followed by the decisional balance exercise, which is designed to help the client understand motivations that underlie his sexual risk behavior with FSWs. Using this approach, the counselor asked the client to describe the pros and cons associated with not using condoms with FSWs, in order to facilitate the personal realization that these behaviors entail more negative than positive outcomes.
Steps 3 and 4: Explore Participant’s Attitudes Toward Condoms and Unsafe Sex: Build Motivation for Change: Using MI techniques (e.g., key questions, reflective listening, summarization, affirmation), the counselor and participant discussed underlying motivations for risky sexual behavior with FSWs. Through this approach, the client gains insight into his behavior and begins to build motivation for change. This is accomplished by eliciting self-motivated reasons for change and enhancing the participant's self-efficacy for change. Self-motivational statements obtained from male clients in our pilot work include: “I should use condoms to protect myself and my wife” and “The sex will probably last longer if I use a condom with the girls.”
Steps 5 and 6: Assess High-Risk Situations, Explore Triggers of Unsafe Sex (i.e., Drug Use), and Discuss Coping with Cravings and Urges: The counselor asks the male client questions about condom use and drug or alcohol use during sex, his perceived need to change, possibility of change, self-efficacy for change, and stated intentions to change, working to increase his awareness of unsafe sex and associated risks with FSWs (e.g., HIV and STIs). A primary goal of the counseling session was to help participants develop insights into motivations and triggers of unsafe sex with FSWs. A range of motivators and personal triggers of unsafe sex were explored (e.g., negative attitudes toward condoms, negative attitudes toward FSWs). In addition, the counselor queried the participant as to what extent his sexual risk behaviors with FSWs are a function of substance use. The counselor discussed the participant's desire and willingness to change his high-risk sexual practices with FSWs. Using a CBT approach, the counselor and participant explored the role that thoughts, feelings, and actions play in changing high-risk sexual behavior. The counselor taught the participant skills for dealing with cravings and urges for risky sex, including reframing thoughts, avoiding or leaving a high risk situation, engaging in a distracting activity, and delaying the decision to seek out a sex worker.
The counselor helped the participant to see possible links between his substance use and high-risk sexual behavior with FSWs. The counselor explored the participant’s past and current use of substances. The participant was asked to generate a list of problems and concerns regarding his drug use. The counselor and participant then problem-solved each issue and the participant then generated target goals for drug use (e.g., stop using drugs, use on weekends only). Through these exercises, male clients were encouraged to develop at least one attainable goal to reduce their injection risks (e.g., avoid being high with FSWs or wait until after sex to use drugs, obtain their own sterile syringe and “works” before using, bleach used syringes).
Steps 7–9: Problem-solve Barriers to Safer Sex, Knowledge and Skill-Building Exercises, and Safer Sex Role-play: A list of barriers to safer sex were generated; the counselor and participant worked together to problem-solve each by listing advantages and disadvantages of every solution and weighing and prioritizing alternatives to select the most promising. The participant actively participated in problem-solving and was encouraged to come up with his own solutions. He was presented with a menu of safer sex options ranging from using condoms, having oral instead of unprotected vaginal or anal sex, avoiding sex when high on drugs, waiting to use drugs until after sex, and saying “no” to FSWs who want to perform sex without a condom. Role-plays were used as the primary exercise for problem-solving potential barriers to safer sex with FSWs. According to both MI and SCT, belief in one’s ability to bring about change is an important motivator of change. The counselor helped the client define achievable goals (e.g., always use a condom for vaginal or anal sex with FSWs). Once the participant had defined goals and arrived at a plan of action, the counselor aimed to strengthen the participant’s commitment to using condoms by exploring ways to make condom use more appealing. The counseling session also promoted consistent use of condoms through modifying participants’ thoughts, feelings, and actions with respect to condom use. Social cognitive strategies, which include increasing knowledge, self-efficacy, and positive outcome expectancies in relation to condom use, were utilized .
Another step in counseling involved knowledge and skill-building exercises (e.g., condom use demonstration, role modeling). Together, the counselor and participant discussed their successes, and the counselor made suggestions for improvement if necessary. Another goal of the counseling session was to enhance communication and assertiveness skills. Problem-solving barriers to unsafe sex was placed in the context of teaching the participant effective communication skills. Through role-play exercises, male clients practiced effective communication skills so that they felt comfortable turning down any offer for unprotected sex from FSWs.