Challenging Dogma - Fall 2009

Thursday, December 17, 2009

‘Stop AIDS’ Project in San Francisco - Lucy Stelzner

I. Introduction
HIV/AIDS within the men who have sex with men (MSM) community has been a public health problem since HIV first became known as the virus that causes AIDS in the early 1980’s. During the 1980’s and 90’s large HIV prevention efforts were undertaken by local, state and national-level agencies across the nation, especially within the MSM community, which carried a large portion of the HIV burden.1 In recent years, it has become alarmingly clear that the progress made during this time period within the MSM community has started to deteriorate, as HIV rates begin to rise within this population.2-3 In fact, it was recently reported that the number of young homosexual men that are being newly diagnosed with HIV is rising at around 12% annually, with even higher rates being found in minority groups such as young black men and Asian men.2 These startling numbers highlight the possibility that most young gay men have not been as affected by the AIDS epidemic as their elder cohorts and have different perceptions of the risks and consequences of contracting HIV/AIDS. Through various qualitative and quantitative interviews, it has become apparent that these young men are either choosing to engage in risky sexual behavior because they do not feel vulnerable to contracting the virus or because they believe that HIV is now less of a death sentence than previously thought due to current medications that can manage it as if it were a chronic disease.4
Since the public health community has become aware of the increase in HIV cases, practitioners have implemented various prevention programs and educational media campaigns. One such effort was made in San Francisco in 2002, by the Stop AIDS Project, entitled ‘HIV is no Picnic.’5 The Stop AIDS Project was created in 1984 to prevent HIV transmission among all gay and bisexual men within the San Francisco area.5 The ‘HIV is no Picnic’ campaign promoted four images of real men living with HIV or AIDS. The ads promote the not-often-talked-about side effects of living with the disease or taking the medications for the disease. The four ads depict images of men experiencing the side effects of protruding belly, diarrhea, facial wasting and night sweats (see Appendix for larger pictures).5 The media campaign posted the images around the city at bus shelters and in the local newspaper. Despite severe controversy and pushback, the campaign ran throughout the planned entirety of 16 weeks.
This campaign was received with great controversy by the greater HIV positive MSM community within San Francisco, who claimed that the ads were created as a fear campaign and had the effect of increasing the stigma for those within the MSM community who were living with HIV or AIDS.6 The campaign was defended by the Stop AIDS Project, which promoted it as a way to combat the growing mentality among MSM that acquiring HIV was not that big of a deal and merely requires taking ‘a few pills’ to become better.6 The press release for the program describes the campaign as HIV positive men telling HIV negative men the truth about living with HIV/AIDS.5 The images, which they describe as ‘in your face,’ promote the stark realities of living with the disease and are considered to be a ‘truth in advertising campaign.’5

II. Critique of current intervention
a. Argument 1 – Use of a fear campaign ineffective
There is no doubt that these ads are catchy and controversial. They create an image of HIV/AIDS that most people are not aware of and they effectively educate the audience about the side effects that result from living with HIV and taking the corresponding medications for the disease. However, the ads attempt to appeal to one’s fear instinct by provoking scary images of discomfort and ill health. While the ads are, in fact, eye-opening, they also seek to scare the MSM community in San Francisco into changing their beliefs about the realities of HIV/AIDS and in turn, also change their behaviors. Using a fear appeal campaign for the prevention of HIV is not effective in motivating behavior change and can potentially result in unintended consequences and lack of any behavior change in the target audience.
The fear appeal theory was created in 1953 and states that if a fear-invoking statement or image is displayed to the audience, then the image will invoke fear of the outcome or behavior and will in turn promote an incentive or motivation within the audience to change their current risky behavior.7-8 The theory is based on the idea that changing one’s behavior is the conscious (or subconscious) solution to quelling one’s fear of the unfortunate outcome.7 This theory has been used in various types of programmatic and theoretical implementation and has received mixed results in its ability to effectively change behavior.7
It is important to take one’s social context into account when applying a theoretical model to a problem. A fear appeals theory does not take into account the greater subculture; instead it primarily seeks to provoke a change in behavior based in experienced fear in an individual. It is not a group-based theory and does not take ones environment into account, which is a necessary component for any behavior-change model and a large reason why the fear appeal theory does not always work. This can be especially seen in situations that are high intensity, such as those created during sexual activity, where a person is not acting individually but as part of their greater environment and abiding by the rules of this environment or subculture.
For this reason, the use of the fear appeal theory to promote behavior change related to sexual behavior and HIV within the MSM community is not effective. Sheon and Crosby (2004) cite the extreme range of attitudes towards HIV in the MSM community in San Francisco, from extreme ambivalence to a desire of some HIV negative men to be more like their HIV positive peers.4 They note that this range of emotion and overall ambivalence towards HIV makes the use of a fear appeals campaign less effective.4 Based on their research within the MSM community, they advise that promoting a more realistic view of HIV and the highly active anti-retroviral therapy (HAART) medications needed for the long term care of HIV/AIDS is the most effective approach to erase ambivalences within the population. They note that campaigns that promote the consequences of a behavior to an ambivalent population, like what was seen in the ‘HIV is no picnic’ campaign in San Francisco, can often lead to negative unintended consequences and is not very effective.4
According to fear appeal theory research, the common response to this type of fear advertising is to either accept or reject the fear appeal. If one rejects the appeal, they are likely to experience feelings of avoidance, reactance and denial.7 This type of negative response allows the target audience to ignore the image and prevents them from moving towards any type of desired behavior change. If this were to happen, as is likely the case with such strong images, then the campaign would be rendered completely ineffective if the desired outcome of the campaign is to promote the truth of living with HIV so that the MSM community is motivated to change their behavior and prevent HIV in their lives.

b. Argument 2 – No alternative behavior offered
While this campaign evokes fear or discomfort in the viewer, it stops at that and does not provide an alternative for the audience. The viewer is not offered an alternative behavior that would work to improve their situation and prevent these images from happening to them. The campaign provides a scary reality of living with HIV and taking HAART medications, but it leaves the audience feeling uncomfortable or scared as if they have no way out of the same fate. Left to deal with such feelings, a person is likely to push them aside as not relevant to their own fate in order to assuage their own fears of contracting and living with HIV. Therefore, the audience is likely to push away their discomfort by rejecting the images instead of instigating a behavior change.
Additionally, while the consequences of living with HIV are presented in the images, no detail is given as to how long it takes to reach this point in the disease/medication timeline. This creates an out or excuse for many young men to stop paying attention because it is not relevant to them or their lives. Since the outcomes are not explained, it is uncertain when such a fate would occur. This ambiguity allows the audience to assure themselves that these consequences of HIV are far out of their realm of reality. The audience can reduce the images to something that only happens to those who are in weak health or who have late stage AIDS. It is therefore not a reality for them and not something to which they need to pay attention. They think that it does not affect them or their lives and go on with their day.
The image neither encourages nor provokes a desire to change because if, arguably, the population that this campaign is targeting is already (and possibly has been for some time) engaging in very risky sexual behavior, then they will remain ambivalent after seeing the image since no alternative is offered. This is because they likely might already know that there are serious consequences related to HIV that they are choosing to ignore and also because they subsist within a subculture of society and it would be imprudent of them to go against this culture if they want to remain accepted into it. While the images provoke a reality that is important to educate young MSM about, it is also necessary to offer them a viable strategy to improve and take control of their lives with and this campaign provides no such option.
c. Argument 3 – Lack of clear core values and message
This media campaign promotes a reality of living with HIV that most MSM do not regularly experience; however, its message does not include the core values necessary in any sort of advertising. Core values are the values in one’s life that are held most important and essential to one’s being, such as control over one’s life, freedom and independence to live or the desire to be attractive or sexy. For a media campaign to be successful, advertising theory posits that a campaign needs to sell the new behavior through the promotion of core values, an attractive visual image and a promise that they can make a change in their lives that will be worth their while.8-9 In short, this campaign is selling health, and not the core values that people care about. It opens one’s eyes to the truth, but can be just as quickly set aside and ignored because health is not considered the most important aspect of one’s life, especially when the audience is young MSM who are in good health and feel healthy. Alternatively, the MSM population that has remained HIV negative despite engaging in unsafe sexual activity will continue to behave the way they have been because they are unlikely to associate the outcomes seen in the images as a result of their own behaviors.
While the campaign touches on the ideas of physical discomfort, unattractive appearance and unpredictable bowl movements, it stops of incorporating any core values. The ads show bleak realities of physicality and poor health, but they lack the depth needed to incite the idea of how out of control one is when they have diarrhea as a result of HIV/AIDS. Moreover, the images and the written messages accompanying them do not provide further explanation of the physical consequences of HIV, such as how it affects that person on a daily basis aside from illustrating the discomfort of it in a person’s life.
Each of the ads toes the line of promoting a core value, but ultimately does not make the stretch to connect the image with the core value one really cares about, such as freedom. For example, in every ad there is a line about how a hot guy or great sex is not worth what it feels like to live like this. This text is effective in that it takes into account some of the realities of this subculture, but it lacks the ability to really motivate the audience to change. Moreover, the image of the distended belly and of facial wasting is created to scare you and misses the opportunity to incorporate the core value of attractiveness, sexiness or ability to gain sexual partners. The image of a man sitting on a toilet with diarrhea and the man experiencing night sweats both also fail to incorporate the idea of helplessness and lack of control of one’s life and instead are merely addressing daily physical discomforts.

III. Proposed intervention
a. Defense 1 – Incorporate advertising theory and group behavior change models
This campaign could be further effective if it were embedded within an advertising message that takes one’s context into account. Instead of implementing a fear campaign when addressing the prevention of HIV/AIDS within the MSM community, this campaign could work to incorporate advertising theory and group behavior change models into the images portrayed. If modern advertising theory is applied to this campaign, it could more effectively incorporate core values and motivate viewers to make a change in their behaviors. To do all of this, it is important that the campaign is framed in an attractive way to the target audience and takes cultural beliefs towards HIV into account. For this case, it would be important to respect the ambivalent feelings that surround HIV in the MSM community.
Any type of campaign or program that is going to be successful in affecting change needs to account for the social context surrounding a problem. In this case, it is important to understand the reality of the social factors involved in risky sexual behavior amongst the MSM community. To do this, a campaign needs to show that it understands these realities and directly addresses them with the goal of creating a change in the entire group, not just one person within the group. Moreover, a campaign needs to be targeted towards the entire community and must seek change from all members of that community in order to make a dent in the problem. This can be accomplished in a multi-faceted media campaign that seeks to address the reality of some men who are primarily interested in ‘barebacking’ or unprotected sexual intercourse and not in the prevention of HIV.4 By taking a social norms approach, this campaign can be more effective by contextualizing the problem and utilizing the environment and the culture to change the group. For example, images that promote an understanding of this culture while also promoting the idea of stopping ‘barebacking’ might prove to be more effective than this media campaign. An effective campaign would be one that targeted men within the MSM community who prefer to engage in ‘barebacking’ by illustrating the dangers their behaviors put the entire community in. This could be depicted in images that showed how ‘barebacking’ makes the entire MSM community more vulnerable to the consequences of HIV that lead to lack of control, freedom and independence in their lives.
Lastly, the Sexual Health Model could be incorporated to promote one of the ten key aspects relevant to human sexuality, such as culture and sexual identity, body image or intimacy and sexual relationships to take on a comprehensive approach to the problem.10 If a campaign were able to utilize this model it could more effectively address risky sexual practices from a more informed and cultured approach that sexuality is not just about preventing health outcomes, but that it also involves the need for intimacy, acceptance into one’s culture and protection of one’s sexual identity. If a campaign were able to acknowledge these aspects of sexuality and HIV, then it could provide a more realistic approach to addressing the problem.10 An example of this would be acknowledging the need for intimacy and strong sexual identity within the MSM community by defending these values from the negative consequences that come along with contracting HIV that would prevent them from being able to maintain intimacy or a strong identity within their lives.

b. Defense 2 – Provide alternative behaviors or solutions
Instead of a media campaign solely highlighting the frightening outcomes associated with HIV, the images could be combined with a solution to the problem. By providing alternative behaviors to the images, it allows a way out for people who may experience discomfort or disassociate from the images when they see them. Alternative behaviors need to be simultaneously presented with the stark realities so as to create options and a worthwhile trade for one’s risky behaviors. This could be accomplished by promoting a campaign that motivates youth to defend the control they have over their lives through safer sexual practices or only having intercourse with those who they know are the same serostatus as themselves. An example of this would be for a campaign to incorporate similar images of a these four men, but then to add a line about alternative behaviors. For example, ‘To avoid my fate, value your intimacy through monogamous sexual relationships with men who have the same serostatus as yourself. Don’t take any chances with your future, end barebacking and remain free and free of HIV.’
Additionally, if the campaign was able to create a more realistic timeline of the images in relation to the progression of HIV, then the images would become more real and harder for a person to ‘opt out’ of paying attention to them. For example, if the audience was given a length of time along with the image that told them that they will look like this man after just three months of taking the HAART medications, then it would be harder for the audience to disassociate from the image because this man is in fact not so different from themselves.
It has been reported by Siegel and Lotenberg (2007) that often there is a subpopulation within the MSM community who seek out risky sexual situations on purpose because they are seeking the destructive and dangerous behavior that comes along with unprotected sex in the first place.3 In this way, many public health campaigns have failed because they do not try to understand the deeper meaning of MSM experiences and societal views of homosexuality at large. Since many in the MSM community are surrounded by a ‘culture of silence’ with regards to their HIV serostatus, it is difficult to incite change in and around this issue.4 In order to create an opportunity for change, a campaign must show that it is understanding of this deeper issue surrounding the subculture of MSM and HIV. For example, an effective way of doing this would be the tagline: ‘Don’t allow silence to persist around your HIV status, protect your freedom and communicate with your sexual partners about HIV.’ Without this solid base of context and understanding in any media campaign, it is unlikely than any change will occur.

c. Defense 3 – Incorporate core values of control, freedom and attractiveness
All four of the images of the campaign could be manipulated in some way to include the promotion of core values and also the truth of living with HIV. This campaign could be taken one step further by using the images to promote taking control of one’s life. To do this, the campaign should illustrate the potential loss of control when one is living with HIV and the ability for HIV negative men to remain in control of their lives. The campaign could provide ways to empower the MSM community to take control of their lives through a combination of reality and empowerment advertising.3 If this campaign frames the issue as a control issue, then its message would be considerably more effective. For example, someone who is living with HIV is not in control of their life anymore and ideally one would seek to sustain their own control over their life by preventing this outcome from happening to them. The core message would be to take control of your life and defend your freedom.
The core message of freedom could be illustrated by promoting the absence of freedom for men who are living with HIV/AIDS, as well as a loss of independence. This could be shown in the image of the guy who suffers from diarrhea, emphasizing that he is always stuck over the toilet. Not only does he lack control over when he does and does not have to go to the bathroom, but he lacks the freedom to go out some nights and to travel based on this physical impediment. Additionally, the core value of sexy/attractiveness could be used in the ads of the distended belly and facial wasting to take it a step further and talk about getting guys to have sex with you or being attractive. For example, ‘I used to be able to get any guy I wanted, now I can only get other guys who look like they’re pregnant as well.’ Or, ‘I’m no longer the hottest guy at the bar and some nights I have such bad diarrhea that I can’t even leave my house.’

IV. Conclusion
Overall, this media campaign was successful in promoting the reality of living with HIV and taking HAART medications, but it was unable to reach its full potential to grasp the MSM population with its message of ‘HIV is no Picnic.’ The campaign mainly failed by promoting a fear appeals message that was focusing on individual behavior change and did not take the wider context into account. The campaign did not provide any alternative behavior or solution to the image and was focused on selling health and physical discomfort to the target audience. To improve this campaign, its creators should take into account the social environment and ambiguous culture that exists around HIV in the MSM community. This can be accomplished by incorporating advertising and social norms theories, as well as the Sexual Health Model, to create a broader understanding of the issue in the context that it is occurring. Further improvements should involve providing an alternative behavior so that the target audience feels like they can make a change in their lives. Lastly, the entire campaign should be tweaked to incorporate the core values of control, freedom and attractiveness by promoting the loss of these values when one is infected with HIV. If these changes are made to the campaign, it would be much more effective, relevant and viable for the MSM community to change their risky sexual behaviors and prevent the spread of HIV.

[1] Shilts, Randy. And the Band Played On. New York, NY: St. Martin’s Press, 1987.

[2] Brown, D. HIV rate up 12 percent among young gay men: steepest rise is in black males ages 13 to 24. Washington Post, June 27, 2008, page A14.

[3] Siegel, M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change, 2nd edition. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp.73-78.

[4] Sheon N, Crosby MG. Ambivalent tales of HIV disclosure in San Francisco. Social Science & Medicine, 2004. V.58: 2105–2118.

[5] The Stop Aids Project: AIDS is no picnic. Available at: Accessed on November 21, 2009.

[6] Centers for Disease Control and Prevention: The Body. San Francisco: New AIDS Ad Campaign Hits a Nerve. November 8, 2002. Available at : Accessed on November 21, 2009.

[7] Witte K, Allen M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Educ Behav, 2000: 27, 591.

[8] Hovland C, Janis I, Kelly H: Communication and Persuasion. New Haven, CT, Yale University Press, 1953.

[9] Marketing Public Health—an opportunity for the public health practitioner (Chapter 6). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change, 2nd edition. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp.127-152.

[10] Robinson BE, Bockting WO, Rosser BRS, Miner M, Coleman E. The Sexual Health Model: Application of a sexological approach to HIV prevention. Health Education Research, 2002:17: 43-57.

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