Challenging Dogma - Fall 2009

Thursday, May 20, 2010

Turning The Tide On HIV In Young Men Who Have Sex With Men – Steven Ralston

One hates to begin paper with a cliché, but sometimes a picture really is worth a thousand words:

This graph comes from the Centers for Disease Control and Prevention (CDC) and clearly demonstrates the failure of Human Immunodeficiency Virus (HIV) prevention strategies to reach young men who have sex with men (MSM) (1). From 2001-2006, the incidence of HIV/AIDS cases in every other age group decreased, but in the adolescent age group, the number HIV cases continued to rise. Sadly, we see this trend despite clear indications and predictions that this group was particularly vulnerable to such a resurgence (2).
Traditional HIV prevention programs aimed at young MSM have usually involved advertising and educational campaigns encouraging one of three behaviors: abstinence, condom use, or HIV testing. And while some of these campaigns may have been more effective than others, and while some interventions have been based on sound theoretical bases (3-5), the overall result has been a dismal failure as the CDC data demonstrate: HIV infections continue to rise in this age bracket (1). I posit that these campaigns have failed in this demographic because behavioral change in this group cannot be achieved through traditional rational choice models of health behavior for several reasons: the young men who are the targets for these campaigns have a sense of invulnerability and a natural distrust of authority and they are making decisions about condom use at the wrong time, i.e. when they are already having sex; the messages we send young men are inconsistent and contradictory; and, finally, the stigma of being gay or having sex with other men is so great that it renders ineffectual any public health campaign that is based on a supposed rational framework that adolescents might use to make decisions.
Promoting Abstinence, Condom Use and HIV Testing: The Traditional Public Health Approach
Attempts to change the sex behaviors of men at risk of acquiring HIV have not been very successful overall. Even very intensive interventions aimed at preventing risky behaviors have achieved only modest changes that tend to dissipate with time (6). Young men, especially, are likely to be resistant to such interventions due to their self-perceived invulnerability and their distrust of authority. Condom ads exhorting them to “Respect Yourself, Protect Yourself” may have catchy rhyme, but probably do not resonate with young men who perceive themselves as invincible (7). And abstinence-only education has been a dismal failure for this demographic (8).
In addition, young men do not make sound decisions in the heat of passion. This is compounded in a particularly problematic fashion by the well-documented fact that risky behavior in MSM is directly tied to alcohol and substance abuse (10-11). It is not clear, therefore, how effective the rational framework based models can ever hope to be in affecting behavior at the time of a sexual encounter that is so patently wrought by emotion and irrationality.
The Problem of Mixed Messages
Other salient aspects of the public health thrust for abstinence, greater condom use, and HIV testing are the inherent contradictions in these campaigns. On the one hand, condom use is promoted as the means of protecting oneself from HIV and other sexually transmitted infections (STIs); however, this information is often couched within the context of an abstinence-based curriculum. There is a striking incongruity between being told that “waiting is best” and that condom use is crucial.
In those campaigns targeting at-risk youth, the reason often given to make HIV testing seem worthwhile (the theory being you are more likely to spread HIV if you don’t know you have it) is that there are now effective treatments for HIV available. This seems to be saying at once that HIV is bad (i.e. you don’t want to spread it), but actually, not so bad because there are good therapies. In fact, it may be this perception (i.e. that HIV can be avoided with post-exposure prophylaxis and that HIV is now a treatable illness) has contributed to the increase in unsafe sex practices and HIV rates in young MSM (12). It is no wonder, therefore, that the messages of abstinence, condom use and testing have become diluted or lost amidst these contradictory messages from educators, politicians, and public health authorities.
The Problem of Stigma
My final argument as to why the traditional behavioral changing models and public health campaigns have failed to adequately reach young MSM is that the context within which these men are living in the world is one of stigma and discrimination and this makes it difficult for them to perceive a rational basis for their behavioral change. In many of the individual change models (e.g. the Health Belief Model or the Theory or Reasoned Action), there is a rational calculation required of the actor – a balance of needs, inputs, risks, benefits, etc. – that results in the behavior modification towards greater health. But, MSM are growing up in a world replete with unequivocal messages – both overt and covert – that their lives will be miserable: full of loneliness, social isolation, and perhaps even eternal damnation. Any campaign to convince these men that abstinence or condom use or HIV testing is worthwhile will fail unless these perceptions can be changed and they can believe in a happy future for which saving themselves is desirable.
Stigma theory was originally described in the 1960s by Erving Goffman (13) and has been used to explain behaviors and health outcomes in disease ranging from psychiatric illness (14) to epilepsy (15) to STIs (16). Goffman defined stigma as an attribute that discredits persons who possesses it; these individuals are seen as different and deviant. Stigmatization thus leads to discrimination and internalized self-hatred which both act as barriers to healthy behaviors. Later theorists moved to “reframe our understanding of stigmatization and discrimination to conceptualize them as social processes that can only be understood in relation to broader notions of power and domination” (17). Stigma theory, as it applies to people with HIV or those at risk for getting HIV explains the difficulty in effecting behavioral change in these oppressed populations.
And while some programs to promote safer sex practices have been framed as empowering MSM, this is usually within the narrow context of a particular sexual encounter or a particular health behavior being promoted, and not as broad-based notion to combat a systematic pattern of discrimination and marginalization in society. And without addressing these more far-reaching aspects of stigma, public health initiatives to promote healthy behaviors may be hampered as intimated by Parker and Aggleton:
“Precisely because they are subjected to an overwhelmingly powerful symbolic apparatus whose function is to legitimize inequalities of power based upon differential understandings of value and worth, the ability of oppressed, marginalized and stigmatized individuals or groups to resist the forces that discriminate against them is limited”. (19)
Thus, without addressing the underlying world of stigma and discrimination in which young MSM find themselves, public health authorities are left with a panoply of cognitive-behavioral or social-cognitive models for behavioral change which will only be marginally effective at best.
A New Path: Empowerment as a Precursor to Change
My proposal for a strategy to combat increasing HIV infections in young MSM is not to reject the behavioral change models that have been used in the past, but to continue them in a context in which change is more likely to occur. This context is one in which being gay or bisexual or having sex with other men is less stigmatized and that the message of having healthy sexual relationships is equated with having both healthy loving relationships and fulfilling lives despite being gay or bisexual.
My vision is one of a public health campaign whose goal is to bolster the self-esteem of young MSM by providing them a framework in which to see their lives as having purpose and a bright future. Instead of a life of isolation, fear, misery and disease, we should be offering them a future of professional and personal success. Such a campaign might consist of a series of ads that highlight the lives of successful gay or bisexual men. (Success in this context could be financial, professional, or personal.) These could be men playing sports, or graduating from college, or running their own businesses, or flourishing in supportive relationships, or having families of their own. The promise would be one of access to the American Dream, one of possibility, one of acceptance. If there were even a hint of traditional behavior modification in these ads, I would certainly not specifically mention condoms or HIV testing, but would favor keeping it vague: e.g. “I take care of myself, and those I care about, so I can keep my future safe.”
I also envision a series of more political ads which highlight the successes of the gay rights movement from discrimination law to civil rights and, now, even to marriage rights. This part of the campaign may need to come from private sources of funding, through foundations and gay-rights groups (e.g. the Human Rights Campaign), but is yet another means of shifting the context in which our public health messages are heard.
Now, I am not so naïve to think that the stigma of being gay, or bisexual, or being a MSM can be eliminated with a public health campaign, but I believe the effects of discriminatory societal pressures can be ameliorated through well-planned communications, marketing, and public relations strategies. And that without a change in how young MSM perceive themselves and their futures, any effort to change individual behavior will likely be ineffectual.
A Move Away From Individual Change Models
One of the strengths of this strategy is that the target is not necessarily an individual, but a group or social network of individuals. Attitudes about sex and safer sex practices may be largely influenced by the social networks in which individuals find themselves, as Fisher states:
“A social network theory approach to STD/HIV prevention suggests that individuals function within social networks that establish norms for behaviour [sic], including safer sexual behaviour [sic] and that these social networks enforce adherence to these norms”. (3)
If young men see themselves as part of a group that has a future worth staying healthy for, then they are more likely to make choices that will protect that future. And this will only be reinforces as they see others around them making similar choices.
Similarly, the use of gay leaders as a focus for the campaign will help to create role models for young MSM. But at the risk of seeming elitist, I would steer the campaign towards featuring role models that seem accessible to the target audiences: not just movie idols and star athletes, but regular guys who happen to be gay or bisexual and have managed to build successful lives. Such role models can be a source of opinion that can influence the behaviors of those men in similar social networks, as intervention models have used “community popular opinion leaders” to help propagate new ideas and behaviors (20). I think this strategy will be especially crucial in trying to reach the young men in the African American community whose HIV rates have increased the most in recent years.
A Consistent Message
A second strength of my proposed campaign is that its message is both clear and consistent. There is no incongruity between the promise of a better life and the facts presented: decent, admirable role models; broadening legal protections for gay and bisexual men; and increasing societal acceptance of these lifestyles. The message is clear, on point, even redundant. But consistent. In contrast to the many ads and campaigns promoting condom use and HIV testing, there is no waffling on the bottom-line message being sent to the target audience: protecting your future is important, because you have a future. The details of how the future is protected – whether by safer sex, or delayed intercourse until marriage – are less important than the promise of the future itself. It is the possibility of a future that is being sold, not the HIV test, not the condom, and certainly not the delay of sex until marriage. The product – the future – needs to be one that young men will want.
Challenging Stigma as Inevitable
Finally, the ultimate goal of this campaign is to shift the context of these young men’s lives and thus improve their self-esteems. And, the enduring power of improving these young men’s self esteem cannot be underestimated. Or, conversely, the adverse effect of continued discrimination will be immense. If MSM experience the world as one where marriage and committed relationships are impossible or stigmatized, how can they ever be motivated to protect themselves for such a bleak future? But in a world where gay marriage, civil unions, and committed monogamy are not just European curiosities, but part of mainstream – (think Iowa ) – American ideals, these young men might be motivated to reframe their decisions and choose healthier alternatives to unprotected sex.
My campaign poses several challenges for any organization that seeks to implement it. The political and public discomfort with addressing issues of sex and sexuality are readily apparent in reviewing the difficulties public health authorities had in addressing the AIDS crisis during the 1980’s and 1990’s (21). Civic equality for homosexuals is far from mainstream in many parts of the country. Because of this, it may be that much of the funding for this program will need to come from private sources or begin in some of the more liberal parts of the country.
Finally, the difficulty in reaching African American youth needs to be addressed. One explanation why African American men seem to have been left behind especially by our current educational tools is that they are already stigmatized and marginalized by their race. And this compounded with the stigma of homosexuality (especially harsh in many African American communities) will likely make the young African American MSM a particularly intransigent population to be affected by this campaign. So, great effort will need to be made to include and keep this group in the sights of any agencies or organizations addressing this issue.
Nevertheless, despite these challenges, the long-term benefits of this campaign could be profound and long lasting. Establishing the legitimacy of gay and bisexual lifestyles in our society is crucial to enabling young men to see themselves as having futures in which they have more choices available them than short-term sexual conquests in the context alcohol or drug use. These men need the promise of a brighter future and the accessibility of the American Dream; the need a reason to stay healthy.


2. Wolitski RJ, Valdiserri RO, Denning PH et al. Are we headed for a resurgence of the HIV epidemic among men who have sex with men? Am J Public Health 2001;91:883-888
3. Fisher WA. A Theory-Based Framework for Intervention and Evaluation in STD/HIV Prevention. Can J Hum Sexuality 1997;6(2).
4. Eke NA, Mezoff JS, Duncan T, et al. Reputationally Strong HIV Prevention Programs: Lessons from the Front Line. AIDS Education and Prevention 2006;18(2), 163-175
5. DiClemente RJ, Crittenden CP, Rose E, et al. Psychosocial Predictors of HIV-Associated Sexual Behaviors and the Efficacy of Prevention Interventions in Adolescents at-Risk for HIV Infection: What Works and What Doesn’t Work? Psychosomatic Medicine 2008;70:598-605
6. The EXPLORE Study Team. Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomized controlled study. Lancet 2004:364:41-50
8. Santelli J, Ott MA, Lyon M, et al. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 38 (2006) 72– 81
9. Ariely D. Predictably Irrational New York: HarperCollins, 2008.
10. Koblin BA, Husnik MJ, Cofax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS 2006, 20:731-739
11. Koblin BA, Chesney MA, Husnik MJ, et al. High-Risk Behaviors Among Men Who Have Sex With Men in 6 US Cities: Baseline Data from the EXPLORE Study. Am J Public Health 2003;93:926-32
12. Morin SF, Vernon K, Harcourt JJ, et al. Why HIV Infections Have Increased Among Men Who Have Sex With Men and What to Do About It: Findings from California Focus Groups. AIDS and Behavior 2003;7(4):353-362
13. Goffman E. Sigma: Notes on the Management of Spoiled Identity. New York: Prentice Hall, 1963.
14. Yang LH. Application of mental illness stigma theory to Chinese societies: synthesis and new directions. Singapore Med J 2007;48(11):977
15. Westbrook LE, Bauman LJ, Shinnar S. Applying Stigma Theory to Epilepsy: A Test of a Conceptual Model. J Ped Psychology 1992;17(5):633-649
16. Breitkopf CR. The Theoretical Basis of Stigma as Applied to Genital Herpes. Herpes 2004;11(1):4-7
17. Parker R and Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science & Medicine 2003;57:p16
19. Parker and Aggleton, ibid. p.18

20. The NIMH Collaborative HIV/STD Prevention Trial Group. The community popular opinion leader HIV prevention programme: conceptual basis and intervention procedures. AIDS 2007, 21(suppl 2):S59-S68
21. Shilts R. And the Band Played On: Politics, People, and the AIDS Epidemic. New York: St. Martin’s Press, 1987

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