SEX, DRUGS AND ESCAPE - A PSYCHOLOGICAL MODEL OF HIV-RISK SEXUAL BEHAVIORS

The lack of an effective HIV vaccine or other biomedical intervention means that behavioural change will continue to be critical to the prev ention of HIV infection. Despite near universal knowledge of HIV and s exual safety, and widespread intentions to be safe, rates of unprotect ed sex and HIV sere-conversion remain high among gay and bisexual men. Explanatory models that link risk-caking and prevention to rational p rocesses such as Knowledge, social norms, behavioural intentions, or p erceived vulnerability to infection, cannot fully account for the cont inued risk behaviours observed in virtually all cohorts of gay men. We feel that innovative conceptions of risk and risk prevention are need ed, that emphasize non-rational, affective processes in risk-taking an d decision-making. Consistent with recent models from social psycholog y, we propose that for many people sexual risk does not stem from a la ck of community norms or personal standards, but from a desire to esca pe cognitive awareness of very rigorous norms and standards. Being sel f-aware of HIV risk arouses anxiety and precludes highly-desired activ ities: fatigue, fatalism, or other negative affect over HIV may lead p eople to 'cognitively disengage' within the sexual situation, and not to follow their norms or intentions toward safety. We propose that bot h substance use and the approach of high stimulation or other sexual s ettings facilities this cognitive disengagement, wherein people enact 'automatic' sexual scripts and/or become more responsive to external p ressures toward risk. We briefly review current psychosocial models of HIV risk behaviour, outline a cognitive escape model with particular emphasis on substance use as a behavioural risk factor, and discuss im plications of an escape model for behavioural interventions among gay and bisexual men.