World Journal of AIDS, 2013, 3, 320-326
Published Online December 2013 (http://www.scirp.org/journal/wja)
http://dx.doi.org/10.4236/wja.2013.34041
Open Access WJA
Protocol for a Respondent-Driven Sampling Study
Exploring the Roles of Peer Norms in HIV-Related
Practices of Gay Men*
Iryna Zablotska1#, John de Wit2, Graham Brown3,4, Bruce Maycock4, Christopher Fairley5,
Michelle McKechnie1, Garrett Prestage1,3
1The Kirby Institute, University of New South Wales, Paddington, Australia; 2National Centre in HIV Social Research, University of
New South Wales, Paddington, Australia; 3The Australian Research Centre in Sex, Health and Society, La Trobe University, Mel-
bourne, Australia; 4Curtin University, Bentley, Australia; 5Melbourne School of Population Health, University of Melbourne and
Melbourne Sexual Health Centre, Melbourne, Australia.
Received July 25th, 2013; revised August 24th, 2013; accepted August 29th, 2013
Copyright © 2013 Iryna Zablotska et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Introduction: Sexual behaviour among gay and other men who have sex with men (GMSM) is influenced by the
shared understanding of HIV/STI risk and peer norms regarding sexual behav iour. However, there is little research evi-
dence to support this relationship. The unique geographic spread of Australian communities, the history of Australian
HIV epidemic and the different patterns in risk y sexual practices and HIV diagnoses across Australia present an oppor-
tunity to explore the role of social norms and GMSM behaviours in shaping different patterns of HIV epidemics. We
describe the protocol of the study of contemporary norms in networks and communities of GMSM (CONNECT) which
investigates gay community behavioural norms and practices. Methods: CONNECT is aimed to 1) identify the patterns
of connections between individuals in GMSM communities and assess how they shape HIV-related behaviours; 2) de-
scribe the relationship between social norms and sexual practices; and 3) compare the norms and patterns of behaviour
in geographically and epidemiologically distinct GMSM populations in three Australian states New South Wales, Vic-
toria and Western Australia, in order to identify local community n orms and barriers to effective HIV prevention. This
quantitative cross-sectional study uses respondent-driven sampling (RDS) for recruitment. Results: Analyses will be
carried out on individual and community level and will investigate the relationship between community-level behav-
ioural norms and associated practices of individuals. Conclusion: CONNECT is anticipated to inform HIV prevention
services to better target and increase the effectiveness of the current health promotion for GMSM in the context of in-
creasing HIV/STI incidence.
Keywords: HIV; GMSM; Networks; Behaviour; Community Norms
1. Introduction
Sexual contact between gay and other men who have sex
with men (GMSM) accounts for 85% of newly acquired
HIV infections and is the most important HIV transmis-
sion route in Australia [1]. Therefore, GMSM are the
highest priority group for HIV prevention [2].
Despite Australia’s apparent success in reducing new
HIV diagnoses in 1990 s, ther e has been a steady increase
in the annual number of new HIV cases nationally since
1999 [3]. Similar to worldwide trends [4-6], the resurgent
HIV epidemic among GMSM has been accompanied by
increasing rates of STI [7]. During the last decade, there
have been marked changes in the patterns of the HIV
epidemic across Australian jurisdictions, with a steady
upward trends being recorded in all states, except for
New South Wales (NSW)—the state with the highest
number of newly diagnosed HIV infection [3,7].
*Funding: the Kirby Institute and the National Centre in HIV Social
Research receive project funding from the Australian Government De-
p
artment of Health and Ageing. The CONNECT study is funded by the
Project Grant from the National Health and Medical Research Council,
Australia (NHMRC 630 5 47).
#Corresponding author. Sexual behaviours among GMSM are known to be as-

Protocol for a Respondent-Driven Sampling Study Exploring the Roles of
Peer Norms in HIV-Related Practices of Gay Men 321
sociated with HIV infection, and unprotected anal inter-
course (UAI) is the practice of the greatest risk [8].
Steady increases in UAI among GMSM, reported in re-
cent years in Australia and worldwide, have been linked
to the decreasing perceptions of risk [9], more frequent
reliance on risk reduction practices, particularly sero-
sorting, rather than on condom use [8,10,11], improved
survival and growing numbers of HIV-positive GMSM
[8,9,12], and changes in social and sexual networking.
Recent increases in UAI among GMSM, including UAI
with serodiscordant casual partners, have been linked to
the increasing HIV/STI incidence [3,8,13,14].
In Australia, trends in sexual behaviour across the
states and territories mirror the HIV diagnoses trends and
both differ across jurisdictions [13,15]. These differences
in trends may be due to social differences among juris-
dictions [16], the size and diversity of gay communities
[12], the resources and the scale of the health promotion
campaigns in the states [17], differences in background
HIV prevalence [18], mixing of HIV positive and nega-
tive GMSM, and the patterns of risk management by
both HIV positive and negative men. It has been assumed
that GMSM communities across Australia differ with
respect to their size [12] and culture. However, there has
been limited research into what effect these differences
may have on the interactions of individuals within com-
munities and on their HIV/STI risk and risk reduction
norms and practices [19,20].
It is known that sexual behaviour among GMSM is in-
fluenced by the shared understanding of HIV/STI risk
and shared norms regarding sexual behaviour in GMSM
communities [21 ]. Risk reduction is more likely to occur
if perceived community norms are supported and ac-
cepted. Currently, little is known about norms with re-
spect to HIV/STI risk and risk reduction behaviours in
GMSM communities, how GMSM understand commu-
nity norms, and whether GMSM with different levels and
types of connection to the gay community perceive be-
havioural norms in their own different ways. Previous
studies found that the use of condoms was associated
with men’s attachment to the gay community, while
socio-economic differences mediated this relationship
[22]. However, it remains unclear how attachment to gay
community affects behavioural norms and how norms are
transmitted within and across different strata of GMSM
and translated into sexual practices.
The unique geographic spread of Australian society
and GMSM communities, the history of HIV epidemic
and HIV prevention work across Australia, as well as
different patterns in HIV diagnoses and trends in high
risk sexual practices present an opportunity to explore
and describe the role of social norms and individual be-
haviours in shaping different patterns in HIV epidemic
across Australia. The study of contemporary norms in
networks and communities of GMSM (CONNECT) was
designed to elucidate these knowledge gaps and help to
better understand why increasing efforts in HIV preven-
tion during the last decade have been largely unable to
reduce risky practices and the growing HIV incidence
among GMSM.
2. Methods
2.1. Theoretical Background
The design and implementation of this study is guided by
the current understanding of the central role of social
processes in HIV prevention [23,24]. First, the study in-
vestigates behaviours and risk as the products of dynamic
social interaction rather than “a static individual” phe-
nomena. It is designed to take into account the context,
negotiation and the different socially-constructed mean-
ings that behaviour and risk may have in specific situa-
tions [23,25,26], as well as the reciprocal influence be-
tween the context and th e individual [27]. Understanding
the interaction between individuals and their context is
critical to the impact of the prevention interventions be-
yond the indiv idual to the community level, and are vital
to sustainable behaviour change [28]. Second, the CON-
NECT study investigates the social norms and beliefs
among participants about how people should act in a
given context, particularly the descriptive and subjective
norms regarding sexual behaviours and HIV/STI in their
peer networks [29,30].
2.2. Hypotheses
The CONNECT study is driven by three key hypotheses:
1) HIV/STI sexual risk and risk reduction behaviours
of individual GMSM depend on the behaviours of other
GMSM with whom they interact, both sexually and so-
cially; thus, the patterns of connections between individ-
ual GMSM are likely to have an effect on the overall
levels of risk and risk reduction behaviours among
GMSM.
2) GMSM with higher degrees of attachment to main-
stream gay communities are more supportive of descrip-
tive and subjective norms in their peers related to safe
sex and are more likely to consistently maintain safe sex
practices that conform to these norms.
3) The patterns of connections and behavioural norms
of the geographically distinct po pulations of GMSM may
influence the patterns of behaviour and the adoption of
safe sex messages in local GMSM networks resulting in
differing HIV notification trends in the Australian states.
2.3. Recruitment Methods
The choice of recruitment methodology to address these
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Protocol for a Respondent-Driven Sampling Study Exploring the Roles of
Peer Norms in HIV-Related Practices of Gay Men
322
hypotheses is important. Traditional epidemiological ap-
proaches see individuals, with their characteristics and
behaviours, as independent of each other [31] and ignore
the effect of connections between individuals. Therefore,
they miss to acknowledge larger social forces that drive
different patterns of behaviour. If models of HIV/STI-
related behaviours were to incorporate patterns of social
and sexual interactions between persons in a population,
they would need to use methods that allow the tracking
of connections between individuals, such as peer-referral
methods.
Peer-referral methods have significantly developed re-
cently, particularly respondent-driven sampling (RDS)
[32]. Developed and tested by the US Centers for Dis-
ease Control, this methodology has been successfully
used among GMSM worldwide and has been used in
HIV/STI research to address the issues of hidden popula-
tions [33], the role of networks in infectious disease
spread [34], sexual behaviours [35], and epidemic mod-
elling [36]. The application details and effectiveness of
RDS have been publi sh ed [33].
Although RDS methodology was developed and lar g e ly
used to capture representative samples of popu lations and
recruit hard-to-recruit groups, this is not the only reason
we used this recruitment methodology. We employed
RDS mainly to explore and explain the role of connec-
tions between individuals in shaping personal net-works
and community behavioural norms within these networks.
Stringent confidentiality safeguards of this method also
provide a bonus benefit for studies of sexual behaviours,
like ours, w h i ch use peer-referral [37].
Since this is the first study among Australian GMSM
to use RDS methodology for recruitment, the methodol-
ogy was successfully pretested in a pilot study of 100
GMSM in Sydney, NSW.
The CONNECT study is aimed to 1) identify the pat-
terns of connections between individuals in communities
GMSM and assess how they shape HIV related behav-
iours; 2) describe the relationship between social norms
and sexual practices among GMSM (particularly men
with differing degrees of engagement with GMSM com-
munities); and 3) compare the patterns of behaviour in
geographically and epidemiologically distinct popula-
tions of GMSM in three Australian states New South
Wales, Victoria and Western Australia, in order to iden-
tify local barriers to effective HIV prevention. In accom-
plishing these aims, the CONNECT study is anticipated
to inform state and local HIV prevention services in
Australia to better target and, thus, increase the effec-
tiveness of the current health promotion for GMSM in
the context of increasing HIV/STI incidence.
CONNECT is a cross-sectional quantitative study con-
ducted in three geographically distinct, diverse and large
gay communities in Sydney (NSW), Melbourne (Victoria)
and Perth (WA). Eligible to participate in this study are
men aged 18 years or older who live in proximity to any
of the three research sites (state capital cities Sydney,
Melbourne and Perth) or participate in the life of local
GMSM community and acknowledge having had sex
with another man during the preceding 12 months. Data
collection employs a two stage approach. As stage 1, a
mapping of the local GMSM communities was con-
ducted to enlist local gay community groups, networks
and organizations. The mapping of gay communities in
Melbourne, VIC, was conducted as a separate study in
2009 [38] and other mapping exercises were conducted
in Sydney, NSW and Perth, WA at the start of the CON-
NECT study in 2010, in preparation to the RDS recruit-
ment. The mapping of gay communities in the three
study sites has p rovided information to be tter understand
the size, local context and structure of GMSM groups
and networks. It also served as a preparation for further
RDS recruitment of study participants in stage 2. Based
on the results of the mapping, primary RDS participants
are selected to start recruitment in various community
groups and venues.
2.4. Data Collection
Each of the primary participants completes the study
survey and receives up to three referral coupons with
unique ID numbers to refer only up to three peers to the
study. They are asked to invite their friends and/or sex
partners and receive a referral coupon with a unique
identifying number for each of the referrals. The coupons
also contain detail information on how prospective par-
ticipants can contact the study recruitment officer in their
respective research site and enro l into the study.
To increase awareness about the study, it is promoted
in local GMSM community press, community organisa-
tions and in the popular local GMSM community venues
identified during the mapping stage. Incentives, accord-
ing to previous research, have be en essential to maximise
referrals for data collection efficiency [39]. However,
this study does not use the individual incentive for each
participant as our pilot study showed it would not be
necessary and would not have an effect on recruitment.
Instead, to encourage long wave recruitment, a substan-
tial prize is offered to a winner of a lottery among the
participants of the larg est recruitment wave.
Recruitment and data collection is conducted by
trained data collection officers (DCOs, one per each re-
search site). Confidentiality is ensured by using 1) de-
linked data collection; 2) self-administered online ques-
tionnaire developed in Survey Gizmo, with password
protected access to the dataset available only to the study
project manager; 3) unique study identifying numbers
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Peer Norms in HIV-Related Practices of Gay Men 323
based on the study referral process rather than personal
identifying information; 4) encrypted data storage on
secure computers; and 5) adequate training of all project
personnel. We have further developed the recruitment
method by using unique electronic referral coupons is-
sued by DCOs, which participants could share with their
referrals online.
Data are collected using a standard structured ques-
tionnaire about 30 - 40 minutes long which covers a
broad range of HIV/STI related issues (see insert 1 for
more detail).
To our knowledge this is the first RDS recruitment
study which utilizes both online recruitment directed by
project officers and online data collection.
Insert 1. Content of the CONNECT online ques-
tionnaire:
Section I. Personal information: socio-demogra-
phics; sexual practices in the last 6 months with re-
gular and casual sex partners, HIV disclosure; details
of the recent sexual encounters, drug use; HVI/STI
testing practices, attachment to gay community; size
of personal network.
Section II. HIV status and STI incidence will be
self-reported. We recognise the importance of sero-
status verification, but the use of self-reported sero-
status in this study is justifiable for two reasons: 1)
this study is focused on GMSM behaviours, and these
are determined by what individuals know or believe
to be their serostatus; 2) our previous work shows a
high prevalence and frequency of HIV testing and a
high correlation between self-reported and actual se-
rostatus among Australian GMSM [40]. Very few
men in this study would indeed be HIV positive
while not knowing it; thus, the high cost of HIV test-
ing and counselling for the total sample would not be
justified in this particular project.
Section III. Information about the referee: type
of connection (social or sexual), sexual relationship if
any (regular or casual partner), closeness of connec-
tion (how often they have been meeting in the past 6
months and in what circumstances), discussion of
HIV and risk reduction strategies, perception of the
contacts’ expectations of how the respondent should
act (subjective norms) and perceptions of HIV/STI
risk and risk reduction behaviour of the contacts (de-
scriptive norms).
Section IV. Community-level information: sub-
jective and descriptive norms and beliefs about HIV/
STI risk and risk reduction practices; perceptions of
the knowledge about and attitudes towards HIV pre-
vention methods, and barriers to safe sex practices in
their respective personal netwo rks and communities.
2.5. Data Analyses
Quantitative data collected by this study will be analysed
using RDS analytic methods [41] as well as conventional
statistical methods. Analyses will be carried out in sev-
eral directions. First, a significant body of behavioural
research and surveillance has already been developed in
Australia, and time-location sampling has been widely
used for recruitment of gay men. This is the first study to
use RDS methodology in Australian gay communities.
Therefore, the sample obtained by RDS recruitment will
be thoroughly compared to samples from behavioural
surveillance surveys and other studies to assess its repre-
sentativeness and additive value for research among gay
men.
Second, the main focus of this study is to explore the
understanding of behavioural norms in gay communities
and the effect of norms on sexual practices of individuals.
As behaviours of individuals are not independent, analy-
ses will explore the connections between individuals,
their environment (that is their personal networks) and
the shared understanding of norms and behaviours within
these networks. Furthermore, they will focus on the
shared understanding of norms and how these are trans-
lated into self-reported sexual and other practices associ-
ated with HIV/STI transmission. Analyses will also be
conducted on the extent of concordance in perceived
behavioural norms within dyads of participants con-
nected by recruitment (some of these being sex partners).
As a measure of diffusion of norms through the referral
chains, the concordance in perceived behavioural norms
will also be explored according to the degree of distance
between participants within the chain of referral (direct
connection, separated by one, two or more persons in the
referral chains).
Third, one of the focuses of this study is on the com-
parison of individual-level behaviours and community-
level behavioural norms across geographically distinct
communities of gay men. Comparisons will be drawn
across three Australian states involved in this research to
elucidate the effect of local community norms on behav-
iour. This will contribute to the understanding of how
local behavioural norms with respect to HIV risk and risk
reduction are shaped.
2.6. Ethics
The study procedures have been approved by the Human
Research Ethics Committees of the two participating
Universities (University of New South Wales, Sydney
and Curtin University, Perth, SA), as well as by key gay
community organizations in each of the three research
sites (AIDS Councils of NSW, Victoria and Western
Australia). Significant effort was placed at the stage of
the study design to ensure that the process of peer-refer-
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Protocol for a Respondent-Driven Sampling Study Exploring the Roles of
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324
ral is combined with participant anonymity and confi-
dentiality of collected data.
3. Results
Report on the study findings will be co-produced by the
study advisory committee, whose membership represents
the partnership of behavioural and social researchers,
representatives of community organizations and policy
makers from the Australian HIV sector. We previously
reported the scarce research work as to the behavioural
norms in gay communities. Better und erstanding of com-
munity behavioural norms may inform the development
of more effective HIV/STI prevention and education in-
terventions. Therefore, the findings of this study, much
anticipated by HIV prevention programs, will be dis-
seminated not only to academic audiences, but also
widely presented both locally and nationally, in commu-
nity and public health forums.
4. Conclusion
It is anticipated that the evidence collected by the
CONNECT study will assist in improved targeting of
HIV prevention and health promotion in Australia and
elsewhere. We hope that this study will also contribute to
the debate about the role of personal environment and
broader community in shaping individual decision-mak-
ing and practices which have bared on individual and
community health.
5. Acknowledgements
The authors would like to acknowledge the key commu-
nity partners the AIDS Council of Western Australian,
Victorian AIDS Council and AIDS Council of New
South Wales, as well and PLWHA organizations in each
state, for their support to this study and close involve-
ment in the implementation of this study.
6. Contributors
Iryna Zablotska, John de Wit, Graham Brown, Bruce
Maycock, Christopher Fairley, Michelle McKechnie and
Garrett Prestage assumed principal responsibility for the
design and implementation of this study. All authors
contributed to the preparation of and approved this pro-
tocol manuscript.
7. Conflicts of Interest
None were de clared.
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