Social Marketing and HIV Stigma: The Need of Community Help with Marginalized Populations – Nicolas Karr

In 2008, 33.4 million people had a positive HIV status (1). Through out the year, 2.7 million new infections joined the tally and 2 million left because of AIDS-related deaths (1). The infection devastates low-resource populations. Prevention programs intervene to help these populations and provide the resources that could change the tide of infection. Unfortunately, while HIV/AIDS prevention programs provide the tools to fight infection, the populations do not necessarily change their behaviors. Content-rich interventions fall short when the target community does not use the resources.
In a summary analysis and critique of 21 interventions to reduce HIV/AIDS stigma, Brown, Trujillo, and Macintyre stated that HIV/AIDS stigma “undermines public health efforts to combat the epidemic” (2). They found that stigma affects the magnitude of reactions to epidemics and causes violence against infected people (2). Populations affected by stigma might fear societal attitudes and could deny their risk of infection. This denial could lead to inaction and ignoring risk factors; inaction could manifest as not using condoms, not testing for HIV, and not disclosing HIV status (2). Stigma can trigger actions to avoid a loss of a job, health benefits, or social ostracism (2). These actions on the part of the stigmatized could cause harm to themselves and the surrounding population. Acting in fear, marginalized populations experiencing HIV/AIDS stigma could endanger their relationship networks.
Stigma has prevailed throughout generations as an impediment to public health. When confronting disease, stigma causes negative views and reduces access to care. Stigma embeds itself within a population and breeds a culture of fear. In order to reduce infections in high-risk populations, interventions need to address stigma. In a meta-analysis of twenty-four studies, occurring between 2000 and 2007, of people living with HIV/AIDS in North America, Logie and Gadalla found that marginalized populations experienced higher stigma levels (3). Specifically, the researchers found stigma highly associated with low social support, poor physical health, poor mental health, lower income, and younger age (3). Consequently, according to Herek and Capitanio, who looked at behaviors towards people living with HIV/AIDS, stigma causes reduced access to care due to discrimination through violence and exclusion (4).
Marginalized populations endure the most stigma and these misunderstandings lead to low resources, poor funding, and inconsistent interventions and treatments. In order to help these populations the current interventions need to make changes. This paper focuses on three specific sub-populations at high-risk for HIV/AIDS and stigma: young black men, female substance abusers, and young men who have sex with men (MSM). The first section presents critiques on interventions targeted at each group and the second section provides ideas for improvements upon the current interventions. To stop the spread of HIV/AIDS, health interventions need to reach the high-risk, marginalized populations; interventions need to mitigate stigma to facilitate proper care.
Young Black Men: Bearing the Brunt of New Infections
According to the Centers for Disease Control and Prevention (CDC), African-Americans make-up 13% of the U.S. population, but account for 50% of all new HIV/AIDS cases, demonstrating a highly prevalent, yet underserved population (5). Along with high prevalence among the entire population, African-American men continue to acquire more infections than their female counterparts (5). HIV/AIDS prevention programs tend to show effectiveness in controlled settings, but the transfer to the real world has less than promising results.
When developing improvements for a current intervention to target young black men, O’Donnell et al. found that interventions have too many requirements and attrition sets in(6). This issue arises specifically with stigmatized populations who choose to avoid over exposure in HIV/AIDS programs. Dworkin, Pinto, Hunter, Rapkin, & Remien found that research tested the efficacy of prevention programs, but failed to design programs acceptable, affordable, sustainable, and adaptable to the population (7). HIV/AIDS has greatly affected young black men, but interventions have failed to address this issue. In order to reach the population O’Donnell et al. stressed the importance of tailoring the intervention for population penetration (6). The prevention programs fail to address barriers to care; HIVS/AIDS stigma limits accessibility to care and the interventions fail to reach the high-risk population.
O’Donnell et al. noted that a significant level of HIV/AIDS stigma develops from internalized and externalized homophobia (6). This stigma leads young black men to test late or avoid testing at all (6). O’Donnell et al. found that African-American females would seek medical care while young black males, more commonly, self-treat (6). This could explain why interventions fail to reach young black males, due to the medical services involved with HIV/AIDS testing. In addition, issues of stigma related to medical services inhibit access to care. Stigma of medical services among the population interacts with HIV/AIDS stigma and makes seeking care significantly less likely.
In order to overcome these obstacles, interventions need to address these issues of avoiding care. If evaluations of these prevention programs only focus on the efficacy in controlled settings, they fail to deal with issues of adaptability. The population at risk avoids medical services and HIV/AIDS care because of stigma. Until the interventions acknowledge this stigma surrounding the access to care, the programs cannot effectively reach those at high risk for infection.
HIV/AIDS interventions have many flaws, but simple changes in approach can lead to greater success. Evaluations of prevention programs need to address the dynamics within each high-risk population. Without adjustments to target different contexts, interventions cannot reach the populations. As stipulated, population penetration remains an important factor in all HIV/AIDS interventions (6); interventions must change to understand their population or fail in trying to reach them.
Female Substance Abusers: Inequality and Instability
HIV infection might come directly from sharing needles, but injecting and non-injecting drug use has developed as a risk factor for risky sexual behavior, a risk factor for HIV/AIDS. Among female substance abusers, risks for violence and HIV increase. Due to gender-specific inequality and violence, female substance abusers need interventions tailored to their issues.
Interventions of the past failed to address the gender-based issues of substance abusers. Wechsberg found, through a survey of past and present HIV/AIDS interventions for women, that past interventions did not account for low status in the culture and community, low education levels, and high rates of unemployment among female substance abusers (8). These factors significantly stigmatized the population. The interventions never reached the people because they could not access medical services. Beyond low access to health care caused by these factors, the high unemployment rates led the women to sell sex (8). The factors that increased stigma also increased the likelihood of acquiring HIV/AIDS.
With the increased stigma surrounding female substance abusers, the difficulty in reaching them increases. Wechsberg noted that failed interventions did not provide knowledge and personal enhancement training specifically targeted to changing behaviors (8). These behavior specific interventions could change behaviors when issues such as substance abuse, violence, and sexual risk arise (8). Culturally specific interventions targeted at females could improve the success of the programs. Unfortunately, the failed interventions did not acknowledge cultural specificity. The women find themselves without any power to act. The interventions fail to reach women who cannot make the decisions themselves or fear losing social support.
Interventions have low compliance to condom use because the programs ignored community context. In the case of sex worker interventions, Evans and Lambert, through an ethnographical study of HIV/AIDS community interventions, found that their noncompliance stemmed from lack of control over their work and social conditions (9). If prevention programs cannot change the dynamics within high-risk populations, distributing condoms makes no difference.
Evans and Lambert also observed that government policy and bureaucrats often disrupt interventions (9). Interventions unable to adapt to changing political tides must confront possible failure; police raids due to changing political temperaments could easily ruin months or years of community-building (9). Prevention programs must adjust to the changing political, cultural atmosphere in order to succeed.
The dependence the women have on the men controlling their lives continues to impede interventions. Failure to address gender inequality means more unsuccessful prevention programs. In order to aid female substance abusers, interventions need to provide ways to increase access to care. The women need to have feelings of safety and support if they choose to seek medical services. Without stability, predominant stigma and fear prevents access to care.
Young MSM: New Generations Facing Decade Old Problem
Stigma has been an impediment to care for all people living with HIV/AIDS. Among men though, internalized and externalized homophobia has led to fear of negative social consequences (10, 11). Valdiserri noted in his review of HIV/AIDS stigma literature that internalized homophobia led to lower self-esteem and consequently, a reduced sense of self-protection (10). This lack of self-protection leads to higher risk sexual behaviors and increased susceptibility to infection (10). These factors impede public health interventions that provide tools for safer sex, but ignore the inaction by participants.
The stigma surrounding young MSM and HIV/AIDS interact and result in negative self-feelings. According to Valdiserri, young MSM experiencing self-doubt seek validation through multiple partners (10). The environments where these encounters occur also facilitate alcohol and drug use and reduced inhibitions to practicing unsafe sex (9). Interventions fail to address young MSM dealing with negative self-feelings. Prevention programs do not work if the participants assimilate information, but make different choices in the heat of the moment.
Dowshen, Binns, and Garofalo studied the effects of HIV/AIDS stigma on four psychosocial measures among MSM. The measurements included depression, self-esteem, loneliness, and social support (11). They found some correlations between perceived stigma level and psychosocial measures, but due to a small sample size, could not declare significance (11). Among their study participants though, they found a correlation between perceived levels of stigma and discovery of a positive HIV status; both of these measures highest at the beginning and reducing with time (11).
Current interventions targeted at young MSM fail to change behaviors because they do not acknowledge how MSM incorporate stigma into their decisions (10). From sexuality to gender identity to HIV/AIDS, these young men deal with multiple levels of stigma (10). Until current interventions address how MSM deal with all levels of stigma, the ability to change behaviors significantly drops.
Prevention programs fail when they ignore the needs of the population. Many programs plan interventions based on best practice protocol. In the case of people living with HIV/AIDS, the programs focus on distributing prevention tools and education. The ethnographical research of Evans and Lambert found that different dynamics influence the decisions individuals make (9). These dynamics include context, practice, agency, and power (9). The researchers found that intervention evaluations review content and the relationship to the results (9). This traditional critique leads evaluations to base success on effectiveness of distributing project resources; grading the efficacy of interventions based on the number of condoms distributed or the prevention classes taught does not demonstrate the true intervention results.
Many problems dealing with population dynamics develop from transferring intervention models from one context to another. Evans and Lambert found that evaluations of efficacy for HIV/AIDS interventions lead to best practice protocols that ignore the context and dynamics of populations (9). Best practice guidelines fail to account for distinct circumstances of marginalized populations (9).

A New Design: Ideas for Change in HIV/AIDS Interventions
Stigma involves many different issues and they affect all facets of an intervention. However, interventions that deal with stigma can change the behaviors of high-risk populations. Valdiserri states that HIV/AIDS interventions need to empower people about health issues, mobilize communities to solve the health problem, develop policies and plans in support of individual and community health, and conduct research to find innovative solutions to health problems (10). By accomplishing these health services public health can mitigate the effects of stigma and effectively reach populations (10).
Behavioral theory remains an important part of affecting change among HIV/AIDS populations. Interventions that focused only on distributing resources to combat infection need to adjust for population-level behavioral dynamics. In a review of the AIDS Community Demonstration Projects, Yzer, Fishbein, and Hennessy found that behavioral theory plays an important role in designing HIV interventions; theory identifies thoughts and feelings that can determine behaviors (12). The researchers also determined that evaluations of interventions need to measure effects of behavior change associated with the variables the intervention modified (12); evaluations should look at how the intervention changes behaviors based on the targeted variables. This way the evaluation determines how the methods of intervention truly affected the population (12).
In their ethnographic study of community HIV/AIDS interventions, Evans and Lambert found that success developed from peer education, community mobilization, and structural interventions (9). These key points emphasize the importance of involving the target community in the intervention. Community involvement ensures individual empowerment and this leads to behavior changes. Brown, Trujillo, and Macintyre note that many of the successful interventions in developing countries utilized community-based approaches opposed to the individual level approaches employed in the U.S. (2). They speculated that the use of community-based approaches reflects an understanding that confronting stigma involves both collective and individual level action (2).
With these factors in mind, new HIV/AIDS interventions should utilize social marketing campaigns within high-risk communities to find opinion leaders and start programs for peer education, community involvement in promoting prevention techniques, and individual enhancement to mitigate HIV/AIDS stigma. An important focal point involves finding respected community leaders to lessen the fear of stigma. With proper influential leaders among the intervention, the programs can more effectively reach the target population. In the following sections, this paper focuses on specific techniques for intervening with young black men, female substance abusers, and young MSM.
Lessening the Burden of Young Black Men
In developing a new HIV intervention for young black men, O’Donnell et al. found that successful interventions must overcome barriers to disseminating information (6). The researchers also stated that the failure of medical services remains the inability to link young black men with needed medical services (6). Available resources do not translate to effective interventions.
O’Donnell et al. stresses the importance of a community review of program components before implementation of the intervention (6). This step makes sure the community understands the intervention approach and, more importantly, the design fits with community dynamics. The next step in a successful intervention includes social marketing. O’Donnell et al. used the community meetings to identify potential spokespersons that have influence (6). Along with recognizing leaders in the community, the discussions identified people young black men would listen too. The discussions determined peers had the greatest impact (6). Utilizing opinion leaders helped get young black men to seek medical services, but the next step involves reducing the requirements of the screening test. If the men find the screening test invasive, time-consuming, or overly demanding they might avoid testing (6). O’Donnell et al. noted the value of using context-pertinent learning models. The intervention utilized computer-based modules that the men found interesting and engaging. The learning module incorporated videos, games, and an overarching storyline that kept the interest of participants (6). Lastly, O’Donnell et al. stressed the importance of developing individual risk reduction plans. This allotted for population dynamics and allowed the men to voice their concerns (6).
Overall, the intervention proposed by O’Donnell et al. focuses on the effects of social marketing. Without the social marketing element, the men would never reach the screening test, learning module, or individual risk reduction plan. Most importantly, the social marketing approach involved the community. The community discussed each approach and component and aided in the successful implementation of the program.
Providing Stability and Equal Footing for Female Substance Abusers
In situations where a person living with HIV/AIDS has dependency issues, interventions fail to change behaviors. This problem stems from a persons’ inability to give up control, but interventions focus on their unwillingness to change. Resources do not aid those who need stability to utilize prevention methods. HIV/AIDS interventions focusing on female substance abusers need to incorporate personal enhancement programs into their prevention methods.
Commercial sex work, violence, and substance abuse usually intersect and complicate the issue of HIV/AIDS infections. Wechsberg found that interventions incorporating knowledge enhancement and hands-on skills training strategies could change behaviors in this population (8). The intervention needs to focus on empowering the woman to make assertive decisions.
Sex facilitates a main conduit for infection and improved condom use could come from enhanced negotiation skills (8). The women of this marginalized population tend to deal with inequality issues. This inequality leads to contexts with high risk of infection. Wechsberg notes that the ability to empower and enhance negotiation skills increases the likelihood of assertiveness with sex partners (8). The disparate contexts these women live in causes dependency and lack of power. In order for prevention resources to find use, the women need a feeling of stability. Effective enhancement and empowerment interventions could overcome the treatment barriers.
Utilizing community support in these situations could prove difficult. If the women do not have a network connecting them, peer influence might have little effect. With the right approach, communities could develop for these women. Sometimes, the health workers need to think creatively to piece together a network or community. If possible, this social support could improve the chances of behavior change after empowerment and enhancement training strategies.
A New Solution for Young MSM
The stigma surrounding MSM develops from both HIV/AIDS and sexuality. The issues intertwine and result in added fear of negative social consequences. In order to address MSM, interventions need to mitigate the stigma surrounding both HIV/AIDS and sexuality. Valdiserri noted that young MSM might avoid clinicians because of fear of judgment (9). If public health officials expect at-risk men to screen for HIV, they must account for worries of social ostracism. Brown, Trujillo, and Macintyre state that information, counseling, coping skills acquisition, and contact demonstrated effectiveness in interventions (2). The researchers also found that different approaches to coping skills acquisition occurred in several interventions and each showed effectiveness in the specific population (2). This point demonstrates the importance of tailoring the intervention to the community. The prevention program must work with the community to reach the target population.
Brown, Trujillo, and Macintyre present a different concept for interventions: contact. This method involves combating stigma through inducing empathy for people living with HIV/AIDS (2). They saw positive results associated with the contact method, but overall the method failed to provide lasting reductions in stigma overall (2). However, a community-based approach provides a means of utilizing contact (2). The influence of opinion leaders in a community and the use of community discussions on interventions could lead to changing attitudes towards infected people.
As with the other high-risk populations, interventions need to employ the power of the community and social networks. The community can help develop effective programs that target the at-risk populations. In order to affect a difficult to reach group the intervention needs to utilize the community to adapt to the group dynamics. No individual health official understands the community as well as the members.


Conclusion and Discussion
While many factors affect the behaviors of at-risk populations, perceived levels of stigma can predict possible behavior change. The presence of stigma has negative effects on public health interventions and leads people living with HIV/AIDS to avoid health services. Sivaram et al., when looking at social capital and HIV stigma in consideration for HIV/AIDS prevention intervention design, stated that stigma manifests from “social norms that render an attribute or condition inferior or inappropriate” (13). These social norms lead to reactions of fear and perceived threat (13). Under this perceived threat, people living with HIV/AIDS find difficulty in seeking health and medical services.
Beyond perceived threat, Sivaram et al. found situations where clinicians refused care to infected people (13). When an example such as this happens, stigma finds a new hold among the population. Trepidation can cause victims of stigma to avoid health and medical services. This not only makes intervention efforts ineffectual, but also creates a high risk dynamic. Stigma leads people to develop negative self-feelings and these feelings lead people to seek validation. Engaging in high-risk behaviors because of feelings of low self-worth not only puts the individual in danger, but the rest of the population. Sivaram et al. speculates that individuals hesitate to engage in prevention and care-seeking behaviors because they anticipate discrimination and possible violence (13).
HIV/AIDS interventions need to focus on community-level approaches. Most importantly, interventions should involve the community in the development of prevention programs. In this way, the program can identify key community members and opinion leaders. These influential leaders can help adapt the intervention to the group dynamics. Outside of opinion leaders, the community can help develop proper implementation methods for the intervention. Community members understand how the population digests information and ideas; their ideas can help the intervention penetrate the population (6). Key to intervention success, social marketing helps open the door for prevention programs. Without social marketing, the key components of a successful intervention cannot find their audience.
In summary, interventions need to utilize opinion leaders, peer education, enhancement training, and prevention techniques to change behaviors in people living with HIV/AIDS. These techniques help to mitigate stigma among the population and surrounding community. The interventions must involve the community every step of the way to reduce fear of exposure. Stigma exemplifies a real fear of people living with HIV/AIDS and a true deterrent to successful interventions. Prevention programs can reach marginalized populations if confronting stigma becomes a focal point of HIV/AIDS intervention.
References
1. UNAIDS. (2009). AIDS Epidemic Update 2009. UNAIDS. http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp
2. Brown, L., Trujillo, L., & Macintyre, K. (2008). Interventions to Reduce HIV/AIDS Stigma: What Have We Learned? Horizons Program Tulane University.
3. Logie, C., & Gadalla, T. (2009). Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care, 21(6), 742-753.
4. Herek, G.M., & Capitanio, J.P. (1999). AIDS stigma and sexual prejudice. American Behavioral Scientist, 42(7), 1130 – 1147.
5. Centers for Disease Control and Prevention. (2008). HIV/AIDS Surveillance Report, 2006. Atlanta, GA: U.S. Department of Health and Human Services. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/
6. O'Donnell, L., Bonaparte, B., Joseph, H., Agronick, G., Leow, D., Myint-U, A., et al. (2009). Keep It Up: Development Of A Community-Based Health Screening And HIV Prevention Strategy For Reaching Young African American Men. AIDS Education & Prevention, 21(4), 299-313.
7. Dworkin, S., Pinto, R., Hunter, J., Rapkin, B., & Remien, R. (2008). Keeping the Spirit of Community Partnerships Alive in the Scale Up of HIV/AIDS Prevention: Critical Reflections on the Roll Out of DEBI (Diffusion of Effective Behavioral Interventions). American Journal of Community Psychology, 42(1/2), 51-59.
8. Wechsberg, W. (2009). Adapting HIV Interventions For Women Substance Abusers In Internationalsettings: Lessons For The Future. Journal of Drug Issues, 39(1), 237-243.
9. Evans, C., & Lambert, H. (2008). Implementing community interventions for HIV prevention: Insights from project ethnography. Social Science & Medicine, 66(2), 467-478.
10. Valdiserri, R.O. (2002). HIV/AIDS Stigma: An Impediment to Public Health. American Journal of Public Health, 92(3), 341-342.
11. Dowshen, N., Binns, H., & Garofalo, R. (2009). Experiences of HIV-Related Stigma Among Young Men Who Have Sex with Men. AIDS Patient Care & STDs, 23(5), 371-376.
12. Yzer, M., Fishbein, M., & Hennessy, M. (2008). HIV interventions affect behavior indirectly: results from the AIDS Community Demonstration Projects. AIDS Care, 20(4), 456-461.
13. Sivaram, S., Zelaya, C., Srikrishnan, A., Latkin, C., Go, V., Solomon, S., et al. (2009). Associations Between Social Capital And HIV Stigma In Chennai, India: Considerations For Prevention Intervention Design. Aids Education & Prevention, 21(3), 233-250.

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.
Caveats
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.


REFERENCES

1. www.cdc.gov/healthyyouth
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
7. www.advocatesforyouth.org
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
18. http://www.aids.gov/takecontrol/factssheets/nhmtc_flyer.html
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

Health Belief Model and HIV Prevention Programs: A Failure to reach Black Men Who Have Sex With Men

-- Beatrice C. Martin

Introduction

HIV/AIDS has become one of the major public health problems during the twentieth century. Because of the high Incidence of HIV infection in the gay community, much effort to reduce risky sexual behaviors has been targeted at gay men. Nearly half of the people living with HIV in the United States are MSM (10). Moreover, MSM are the only group in the United States in which HIV infection is steadily increasing every year, they account for more than half of new HIV infection each year (10). Public health intervention efforts to educate gay men about safer sex practices have been proven quite successful at the beginning. Gay men reported to have been engaging in sex with fewer partners and have been using condoms more frequently during sex (8).

Despite many public health HIV prevention programs targeting the gay community, there is a concern of the reemergence of the epidemic. Evidence suggests that although rates of new HIV infections declined between the years of mid- 1980 to mid-1990, rates of HIV infections are starting to increase (5). Moreover, black MSM are disproportionally hit by the epidemic compared to any other race and ethnicity. According to Wolitski et al., in 1999 the AIDS incidence rates among African American were more than five times that of the white MSM. Recent trends indicate that black MSM are at greater risk of contracting HIV infection compared to white MSM. Between the years of 1990 and 1995, black MSM AIDS cases increased among African American MSM by 45%, while AIDS cases decreased by 2% among white MSM(5).

One theory widely used to guide HIV prevention interventions is the health belief model. The health belief model is applied in the development of prevention programs to modify health behavior. It elucidates the relationship between individual health beliefs associated with a disease and the likelihood of engaging in preventive health actions (1). A number of studies of AIDS-preventive behavior have been based, in part, on the health belief model (1). The main components of the health belief model to HIV prevention are as follow: AIDS preventive behavior is a function of perceived vulnerability to HIV infection, perceived severity of HIV infection, perceived costs and benefits of HIV/AIDS preventive behavior, and cues to action (1) and self- efficacy, which is defined as the conviction that one can successfully execute the behavior required to produce the outcomes (12). HIV-preventive programs based on theoretical frameworks like the health belief model has not proved to be effective among the black MSM as the rise of HIV incidence rate is higher than the white MSM population. The efforts of HIV risk reduction strategies were not effective in decreasing the rate of HIV infection among the African American Population (11). The health belief model is an individual-focused model that has limitations in addressing the historical, social context of black MSM living in African American communities.

Failure to address the historical context of Black MSM as African Americans in the country

A limitation of the health belief model is the implication that people exist in similar cultures and have similar degrees of control over their environment (12). As an individual -focused model, the health belief model fails to address the historical and social context of HIV/AIDS among the black MSM communities. The experience of African American in this country is unique due to their history of racism and slavery. A lack of mistrust in the government makes it more challenging for public health messages to effectively reach African Americans. According to Bogart et al. article, a handful of studies shows evidence that a significant group of African American hold conspiracy beliefs that HIV/AIDS is a form of black genocide. Hereck and Glunt conducted a national telephone survey in which they found that two third of blacks (67%) agreed that the government is not telling the truth about AIDS, and another national telephone survey conducted by Hereck and Capotino found that twenty percent of black Americans believe in the statement that the government in using AIDS as a way of killing minority groups (7). The revelation of the Tuskegee Syphilis study confirms long held beliefs among the black communities that the government should not be trusted. After the study has been exposed, charges surfaced that the experiment was part of a governmental plot to exterminate black people (3). Thomas and Quinn argued that the legacy of this experiment with its failure to educate the study participants and treat them adequately, laid the path for today’s pervasive sense of the black distrust of public health authorities (3). The belief of genocide and the distrust of the health authorities are foundation for opposition to many strategies that will directly reduce transmission of HIV. Intervention programs framed by the health belief model to modify the individual’s health behavior will not be effective if the targeted black MSM hold beliefs of genocide and if they mistrust health authorities. They will not take into consideration information and messages they receive about AIDS. This mistrust will get in the way of AIDS education strategies that use theoretical framework like the health belief model to target black MSM within the black communities.

Failure to approach Homophobia in black communities

The HBM model views the individual as devoid of emotion and has the capacity think rationally (1). However, the interaction of the individual and the social environment may bring about situational and emotional difficulties that affect HIV risk behaviors (1). In the United States, HIV- related stigma and discrimination are closely related to negative thoughts surrounding homosexuality (9). African American communities often condemn homosexual behavior, and being homosexual is seen as weakness and embarrassment. As a result, African American men who have sex with men are more “closeted” than white men who have sex with men (9). Research shows that African American gay men and MSM are likely to experience prejudice, discrimination and even threats of physical violence based both on their status as gay and MSM in the black community (9). Therefore, Black MSM who fear discriminations and who do not want to be perceived as weak homosexuals in their community hide their sexual orientation. They stay “in the closet” in order to avoid prejudice and threats of physical violence. They tend to identify themselves as heterosexuals, while secretly having sex with other men. Black MSM who hide their sexual orientation are more likely to engage in risky sexual behavior.

Fear of being perceived as gay in their communities may cause Black MSM to avoid expressing any concerns about the HIV epidemic and discussing condom use. This group is less exposed to HIV prevention messages targeting the gay community. They are not aware of the risk factors associated to HIV transmission and how they can reduce their risk of getting infecting. Relative to white men who have sex with men, African American men has less accurate knowledge about HIV risk reduction steps (6). Moreover, AIDS education campaigns targeting the gay community have not successfully reached black MSM who are not open about their sexual orientation (6).

Failure to approach poverty and HIV risk behavior

From an ecological perspective, understanding HIV risk behaviors means understanding how the environment shapes the choices and opportunities available to the individual (12.). The rational presumption that individuals have resources to make preventive HIV risk decisions and that they have control over their environment to change their risk behavior can be challenged. The health belief model does not address the interaction of individuals and their environment. Individuals living in poor neighborhoods have limited resources and are mostly under stressed. When African American men have a prolonged exposure to stress, it may result in individuals denying the threats of a stressful situation or refusing to think about it. African American males denying their risk of contracting HIV may engage in higher risky sexual behavior; they may also deny the realty of HIV/AIDS in the African American community (12). Black MSM living in poor neighborhoods are more likely to have sex with men in exchange for money or drugs. A study found that homosexual and bisexual men with low income who had been paid to have sex with men are less likely to use condoms (11).

An effective approach to HIV prevention among black MSM: Community-Level Intervention.

Research potentially helpful to African Americans has been severely limited because of the exclusion or underrepresentation of this specific group in prevention intervention research or the lack of focus on African Americans at higher risk for HIV infection like the MSM (12). Effective intervention programs to HIV prevention among black MSM should take into account the cultural, historical and socio-economic factors of that group. Public health efforts to change black MSM sexual risky behaviors should promote positive views and acceptance of homosexuality among the black community. Moreover, the messages of HIV prevention programs that target black MSM population should be culturally sensitive in order to successfully reach that community.

Community- level interventions to HIV prevention can be an effective approach to decrease HIV-risk behavior among the black MSM community. Community-level interventions are those that target communities often defined by sex, geography, sexual orientation, risky behaviors and sexual orientations rather than a specific individual. This intervention includes the involvement of community members in the actual design and delivery of the intervention. Community-level intervention aims to change community norms about high risk behaviors. An important aspect of this intervention is the involvement of the target population in formal or informal activities, programs, group discussions, to come up with planned improvement and change in community life, resources(4).

This intervention approach to HIV prevention among black MSM can be effective in addressing the experience of African Americans in this country with discrimination, racism and the mistrust that they hold against public health professionals. The intervention should first choose one or more black MSM leaders within a black community. The involvement of black gay men in the design and study of the intervention may have more positive response to HIV prevention messages targeting black MSM. Black MSM may listen and trust one of their peer leaders rather that a white counterpart. Kelley and colleagues recruited opinion leaders from communities of gay men, trained them in HIV prevention messages and message delivery, and asked them to take these messages back to their communities. Controlled studies showed that these interventions changed community norms, and self-reported risky sexual behaviors among these communities (6). CDC study’s findings provide evidence that HIV prevention endorsement messages, modeled and delivered in outreach fashions by members belonging to the same social group can reduce risk behavior levels in community population (2).

Community-level intervention is mostly founded in the effort to influence individual behavior by changing the social context of communities. In this view, widespread and enduring reduction in risky sexual behaviors among black MSM will not be achieved without new norms governing condoms, and an increased tolerance of homosexuality by African American communities and organizations (4). With an increased acceptance of homosexuality in the black community and changing community norms about HIV-related stigma, black MSM may be able to be open about their sexuality and seek HIV prevention messages. An important factor of the community level in reducing risk behavior among black MSM is the involvement of black gay men members who are conveying the message of condom and promotion of safe sex within their communities. Social theory tells us that peers are important behavioral role models who can establish and redefine population norms, including those of condom use (2). Unemployment may encourage some black MSM to have sex in exchange for money. This situation increases risk behavior because this group has no control over the use of condoms. Community-level interventions find the need for communities to pursue economic and political development, to help men in their community find jobs (4). Trained MSM leaders or peers can work in African American neighborhoods to address common problems such as unemployment and drug abuse.

Conclusion

As shown, the health belief model approach to HIV prevention among black MSM fails to address the social, economic and historical context in which individuals interact. Moreover it assumes that individuals control over their behavior. However, individuals with low social economic status have no control over choosing to use condoms if they engage in sex for money. The community-level approach to HIV prevention addresses the social context of individuals by trying to change the community norms and decreasing homophobia in the black community. Community- level HIV prevention interventions must grow from and be owned by the target population one wants to reach in order to be successful.

References

1. Choi KH, Yep GA, kumekawa E. HIV prevention Among Asian and Pacific Islander American men who Have Sex with Men: A Critical Review Theoretical Models and Direction for Future Research. Aids Education and Prevention 1998; 10: 19-23.

2. Kelley AK. Community-Level Interventions Are needed to prevent New HIV infections. American Journal of Public Health 1999; 89: 299-300.

3. Vanessa NG. Under The Shadow of Tuskegee: African American and Health Care. American Journal of Public Health 1997; 87: 1773-1777.

4. Kraft JM, Beeker C, Stokes J et al. Finding The “Community” in Community-Level HIV/AIDS Intervention: Formative Research With Young African American Men having Sex with Men. Health Education and Behavior 2000; 27: 430-441.

5. Wolitski RJ, Valdiserri RO, Denning P, Levine W. Are We headed for a Resurgence of the HIV Epidemic Among Men who Have Sex with Men? American Journal of Public Health 2001; 91:883-885.

6. Holtgrave DR, Qualls NL, Curran JW, et al. An Overview of the Effectiveness and Efficiency of HIV Prevention Programs. Public Health Reports 1995; 110: 134-146.

7. Bogart LM, Bird ST. Exploring the Relationship of Conspiracy Beliefs About HIV/AIDS to Sexual Behaviors and Attitudes Among African American Adults. Journal of National medical Association 2003; 95:1057-1065.

8. Greenberg JS, Bruess CE, Conklin SC. HIV and Aids in: Exploring the Dimensions of human Sexuality. 3^rd ed. Sulbury, MA: Jones and Barlett publishers, Inc. 2009:608-619.

9. Brooks RA, Etzel MA, Hinojos E, et al. Preventing HIV among Latino and African American Gay and Bisexual Men in a Context of HIV-related Stigma, Discrimination, and Homophobia: Perspective of Providers. AIDS Patient Care and STDs. 2005; 19: 737-743.

10. Center for Disease Control and Prevention. HIV and AIDS among Gay and Bisexual Men: http://www.cdc.gov/nchhstp/newsroom/docs/FastFacts-MSM-FINAL508COMP.pdf

11. Beatty LA, Wheeler D, Gaiter J. HIV Prevention Research for African Americans: Current and Future Direction. Journal of Black Psychology 2004; 30:41-53.

12. Neff JA, Crawford SL. The Health Belief Model and HIV Risk Behavior: A Causal Model Analyisis among Anglos, African Americans, and Mexican Americans. Ethnicity and Health 1998; 3: 283.

Critiquing the Condom Code: How The Public Health Approach To HIV Prevention In Men Who Have Sex With Men May Be Doing More Harm Than Good

—Anna Suojanen

Since the beginning of the HIV epidemic in the 1980s, the public health effort to prevent new cases of the disease among men who have sex with men (MSM) has been largely predicated on the message of “a condom every time”, or the “condom code”. The failure of these campaigns is illustrated in recent data, which indicate that, despite critical advances in the prevention and treatment of HIV, the disease remains a critical health issue among men who have sex with men (MSM) in the United States. This population accounts for more than half of all new cases annually and are the only risk group in which the number of new cases is rising(1).

This paper will utilize social science theory in an attempt to explain the failure of the condom code approach to HIV prevention in men who have sex with men in the United States. Among other things, it will argue that the approach makes unfair assumptions, ignores core values, encourages reactance, and does not consider the extremely complicated and largely homophobic environment in which gay men live. It will then outline a more suitable approach, arguing that men who have sex with men should not just be passive recipients of public health programs designed to reduce HIV incidence. The public health community has to engage and empower MSM to take control in the face of this crisis. It has to strive to make MSM feel respected, supported, accepted, meaningful, and worthy and make them feel that they are responsible for their decisions.

THREE FAILURES OF THE PUBLIC HEALTH APPROACH TO HIV PREVENTION IN MEN WHO HAVE SEX WITH MEN

1.) The condom code assumes rational behavior and ignores social context/the impact of homophobia

Assuming Rational Behavior

The earliest social behavior models emphasized the rationality and invariability of human behavior, assuming that people exercised a significant level of control over their actions. There was little weight given to the social contexts in which people lived, worked, and made decisions. Many public health interventions designed to change the way people act were predicated upon these theories. The “condom every time” approach to reducing HIV incidence in men who have sex with men is one example.

The condom code assumes that, if educated about the modes of transmission of HIV and safer sex, men who have sex with men will disengage in risky sexual behavior. However, as one gay advocate notes:

“We have been ‘educated’ to death. We have been directed, instructed, commanded, suggested, harangued and manipulated – all by people who believe that if you tell people

repeatedly what to do or not to do with their sex, they will comply.(2)”

This statement is illustrative of the fact that men who have sex with men are well informed of the risks of unsafe sex. A public health message that assumes they are not is not only unlikely to be heeded, but is also probably insulting. However, that is not the fundamental problem when considering rationality. The problem is that this knowledge has clearly not translated into action. Gay men know that using a condom reduces their likelihood of acquiring and transmitting HIV. But they engage in risky sexual behavior anyway. This is not rational behavior, and the public health approach clearly needs to change in order to attempt to understand what draws men to engage in these behaviors in spite of the known risks.

There are two social science arguments that lend themselves to explaining why it is MSM act irrationally despite understanding the potential negative outcomes that could be associated with their behavior. The first emphasizes the importance of visceral influences on behavior. Nordgren and colleagues found that when people were in a hot state (e.g., sexually aroused), they attributed their subsequent behavior primarily to visceral influences. This was in contrast to findings that when people were in a cold state, they underestimated the influence of visceral drives and attributed their behavior primarily to other factors(3). The implications of these findings are that when people are in hot state, they have no self-control. The implications with regard to condom use among MSM is that lack of a condom will probably not preclude a man from engaging in sex, as the desire to engage in sex when given the opportunity to do so will overwhelm the knowledge that an unprotected sexual encounter will increase the likelihood of transmission or acquisition of HIV.

A second consideration is optimism bias. Oftentimes people are well of the negative repercussions of a particular behavior but engage in it anyways because their perceived level of risk is low. With regards to MSM, this has been well documented through data demonstrating a disproportionate number of MSM whose perceived risk of acquiring or transmitting HIV is low, despite the fact that they regularly engage in unprotected intercourse.

Deemphasizing social context

Newer behavioral models have emphasized the importance of the role of social context in considering why people act the way they do. However, the public health community’s assumption that MSM can, and should, use a condom every time they have sex reflects a lack of regard for situation and environment.

The problem with disregarding context is marvelously summarized by Walt Odets in a conversation he had with Jesse Green:

“If you say to a man, 'In order not to get H.I.V. you are never going to have sex again without a condom,' his response would be that that seemed impossible. But there's a difference between going out with a guy you've never met whose status

you don't ask about, and a friend you've known 10 years who tells you he's negative. Education has refused to allow gay men even to think about that difference. It's like telling people that if they want to be safe drivers, they must always drive 35

miles per hour without regard to when, where or road conditions. Which any sane person will instantly reject(4)”.

Odets is right, and furthermore, public health practitioners would never dream of delivering this same message to the heterosexual community. This well-intentioned approach to limit the spread of HIV among MSM by promoting condom use every single time a MSM engages in sex is thus illustrative of an underlying prejudice. Generally speaking, our society greatly respects the importance that heterosexuals place on long-term commitment, love, and marriage(5). Unfortunately, the same cannot be said with regard to homosexual relationships. Many gay men interpret this as a dismissal of the value of sex and relationships between men. From a public health perspective, this has very important implications.

Research has found that the loneliness born out of negative societal perceptions of homosexual relationships is a cofactor for long-term risk for unsafe sexual behaviors (6) and that negative attitudes towards homosexuality result in high levels of psychological distress. Acceptance and comfort with sexuality are associated with increased condom use. Conversely, feelings of guilt are associated with decreased use(7). This research is illustrative of Maslow’s Hierarchy of Needs. According to this particular behavioral theory, people need to feel a sense of acceptance and belonging. They need to love, and in turn, be loved by others. They need to be respected, have self-esteem, and self-respect. In the absence of acceptance, love, belonging, and respect, people become likely to suffer from anxiety, depression, low self esteem, loneliness, and a feeling of helplessness(8).

Understanding that men who have sex with men often find themselves feeling alone, ostracized, and rejected as a consequence of their sexuality, it is easy to see why sex is such “core component(5)” of the gay identity. Sex confers a feeling of being loved, accepted, and needed, if only briefly. For many gay men, these feelings justify and even motivate high-risk sexual behavior. Negative emotional states and general urges to simply engage in sex have been shown to precede violations of safe-sex goals(6).

Ignoring the role the homophobia plays in HIV prevention in the U.S. means “ignoring an element of the disease as important as biology”(4). The refusal of our society to acknowledge and celebrate homosexuality in the same way we do heterosexuality has unwittingly encouraged the continued engagement of MSM in risky sexual behavior. According to the social research and theories outlined above, the importance of social context in designing a public health intervention cannot be overstated.

2.) The condom code sells health (A critique based on marketing theory)

The condom code message sells good health. In most regards, it sends a simple, clear, rational message: if you use a condom every single time you have sex, you will not transmit or be infected by HIV, and you, your partner, or both of you can avoid this dreaded scourge. It assumes that men who have sex with men want to be healthy. However, this fallacy is one of the failures of the public health message about HIV prevention to MSM.

Traditional public health interventions have relied on intuition about what people want, need, and desire. But, marketing theory suggests that intuition about what people want is often off the mark, and thus leads to inefficient interventions. Marketing theory says that in order to create a successful product, the wants of your target population have to be fulfilled. Public health practitioners need to identify the needs and desires of the target intervention group and design products, or interventions, that meet this demand(9). The key is to abandon the traditional approach of deciding what people want and then trying to sell it to them. In order to obtain this information, formative research about your group is needed.

There has been remarkably little formative research done into the hearts and minds of men who have sex with men living in the United States(5). However, based on the experience of the gay community in the 1970s and an examination of some of the grey literature, some of the core values of this particular population can be gleaned. Gay men struggled against a backdrop of fear, hostility, and discrimination throughout the 1970s to achieve some degree of self-determination, empowerment, and equality (2). The arrival of HIV changed all that. According to Eric Rofes, “It was as if a bomb had been dropped…and ground zero was gay men’s sex” (2). From that time forward, with regards to their sexual behavior, gay men have been told what to do and when and how to do it by an HIV prevention community that by and large does not understand what it means to be gay in the U.S.

Based on marketing theory, one of the problems with the condom code is that it sells health. Though public health professionals see health as something people should want, it is generally not a basic human value. Public health interventions designed to reduce HIV incidence in MSM communities have to sell the values that these men fought so hard to achieve throughout the 1970s. Sex, freedom, equality and independence are all likely to be valued more by MSM than health. Though it is counterintuitive to the public health community, the promise of good health does not meet the wants of MSM in the way that these values do. The problem with the condom code is not that it is ill-intentioned or unfounded. The problem is that, for a variety of reasons, some of which are outlined above, it doesn’t appeal to MSM living in the United States. Public health professionals have to present a position or a policy that is consistent with the core values, desires, and needs of men who have sex with men. As difficult as it is for the public health community to grasp, health is not one of these values, in this community, or in most others.

3.) The condom code may increase resistance to condom use: a critique based on Psychological Reactance Theory

Reactance occurs in response to threats to behavioral freedoms. It asserts that if a person is told not to engage in a behavior that they become motivated to do whatever it is they are being told not to. The degree to which an individual feels pressured, manipulated, or angered by being told what to do determines the likelihood of their reactance. Reactance increases resistance to persuasion, and is thus considered by social scientists such as Miller to be a risk factor for harmful behaviors. Psychological reactance theory is the most violated behavior model in all of public health. The public health community’s HIV prevention campaign is an example of how the ill-delivery of the message to wear a condom every time promotes reactance.

The theory argues that trust of the source of messages regarding one’s health is an important indicator of whether or not those messages will be heeded. This has been a failure of the “condom every time” message delivered by public health campaigns to the gay community. As Rofes noted: “A population with a long history of victimization by government, medicine, scientific research, and the media will not easily and quickly see these sectors as trustworthy partners in [HIV] prevention”(10). Unless gay relationships are accepted and celebrated in the same way that heterosexual relationships are, it is unreasonable to expect gay men to take messages about safe sex, stable relationships, and decreased promiscuity seriously(5). Especially when these messages are coming from the exact people who have historically discriminated against them. In order to reduce reactance, the messenger should be similar, or at the very least relatable, to the target intervention group. A man who engages in sex with men will be much more likely to consider a message about the importance of condom use if it comes from someone like him.

Furthermore, the message about safe sex and condom use has historically been serious, judgmental (though not outrightly so), and driven by scare tactics about the dismal outcomes associated with HIV. It is an overtly negative message, one that is delivered by people removed from HIV and the realities of life as a gay man in a homophobic society. A respectful, reflective approach is more likely to inspire change than is a strong, disciplinary, and reproachful message, as feelings of pressure, irritation, and manipulation that result from being told what to do all increase reactance.

~

As Green wonders, in a world where financing for AIDS research keeps increasing but agencies that serve gay populations are chronically underfunded, should we really be surprised if gay men wonder whether the disease itself matters more than they do? In cataloging the failures of the public health campaign to decrease incidence of HIV in men who have sex with men, it becomes clear that a new approach, one that affirms and celebrates their sexuality, is needed.

Recommendation: Application of the Sexual Health Model to Existing HIV Prevention Programs

Health promotion campaigns that combine personal freedom and personal choice with a practical response are more likely to be effective than those that inhibit desires or prohibit desired activities(11). Sex is a core value for gay men, and given that the current public health policy is essentially directed at restricting sex practices, it is easy to understand why it has not met with much success.

As a result of these failures, numerous researchers have recommended the use of more targeted HIV prevention efforts, so as to increase the relevance and effectiveness of the intervention for the particular at-risk population(12). With regards to MSM, HIV researchers have recognized the need to address sexuality and relationships when designing HIV prevention programs(6), especially in the face of evidence that suggests the incidence of new cases in this population is rising.

The Sexual Health Model is a behavioral model that offers a holistic approach to sexuality. The model promotes a sex-positive, culturally specific, multi-faceted approach to sexual health informed by both qualitative and quantitative research. Grounded in sexological theory, the model takes into account the need for sexual fulfillment, intimacy, and affirmation of self and identity(12).

Underlying the Sexual Health Model is a belief that HIV interventions need to encourage participants to think for themselves, to identify their sexual needs and desires, to develop their own sexual morality, and to make informed choices about their sexual behavior(6). The Sexual Health Model posits that sexual health cannot be obtained without personal awareness and self-acceptance. The assumption is that sexually healthy persons, that is, people who are sexually literate, comfortable, and confidant will make healthy choices when it comes to sexual behaviors (6). These choices include, but are not limited to: condom use and non-penetrative safer sex practices; strategies that focus on sexual relationships, such as developing rules for primary and casual partners; reserving penetrative sex for more intimate relationships; and agreeing that condom use is not necessary if both partners test negative and practice monogamy (6). Based on these principles, it is clear that the Sexual Health Model, unlike the current public health approach, emphasizes the importance of context or situation, and relays the understanding that there are circumstances in which condom use is not necessary. It also acknowledges the difficulties MSM face with regards to awareness and self-acceptance within a largely homophobic and unequal society.

The application of the program begins with an acknowledgement of the importance of the background of the target population(6) and focuses on the importance of exploring and celebrating sexuality. HIV prevention is an integral part of that emphasis, but the approach is positive and empowering, focusing on strengths rather than weaknesses (6). Rather than selling health, the model sells sex, empowerment, independence, and control, the values that the MSM community prioritizes. In addition, this shift in focus to a positive, affirming message reduces the kind of reactance that the current campaign elicits. Already, it is clear that the Sexual Health model eliminates most of the breakdowns of the current model.

Though the data supporting the use of the Sexual Health Model in HIV prevention programs is limited, initial evidence is encouraging. In a randomized control trial assessing the theory’s effectiveness, MSM who attended intensive two-day seminars designed to promote sexual health and explore sexuality reported an 8% increase in condom use, while the control group reported a 29% decrease. In addition, a significant reduction in internalized homonegativity was found in the experimental group (6). In the face of the failures of the current public health approach, it seems prudent to recommend that existing HIV prevention programs targeting MSM consider incorporating the types of seminars, focus groups, and educational campaigns that the Sexual Health Model advocates.

This is not to downplay the importance of condom use as a means of preventing HIV transmission in men who have sex with men. Safer sexual practices should undoubtedly at the core of any intervention designed to reduce HIV incidence among men who have sex with men. The Sexual Health Model supports this. However, the message as it is being relayed now is both unfeasible and unfair. Thus far, most public health programs designed to prevent HIV in men who have sex with men have demonstrated a total failure to seek to understand the reality of sex and relationships for gay men. Public health interventions designed to change the sexual behavior of gay men must include efforts to improve sexual awareness and sexual well-being. They must validate the legitimacy of homosexual relationships, and must empower men who have sex with men to make their own decisions. The Sexual Health Model provides an ideal framework by which the public health community can finally begin to do this.

References

1. Fact Sheet: HIV/AIDS among Men Who Have Sex with Men | Resources | HIV/AIDS and Men Who Have Sex with Men (MSM) | Topics | CDC HIV/AIDS [Internet]. [cited 2009 Dec 10];Available from: http://www.cdc.gov/hiv/topics/msm/resources/factsheets/msm.htm

2. AEGiS-WashBlade: OPINION: Time for time out on safe-sex push We've been 'educated' to death about safe sex, and it has driven some gay men to do exactly the opposite. [Internet]. [cited 2009 Dec 10];Available from: http://www.aegis.com/News/WB/2005/WB050605.html

3. Nordgren LF, Pligt JVD, Harreveld FV. Visceral Drives in Retrospect: Explanations About the Inaccessible Past. Psychological Science. 2006;17(7):635-640.

4. Green J. Flirting with suicide. The New York Times Magazine. 1996 Sep 15;:39-45, 54-55, 84-85.

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

6. Robinson B`E, Bockting WO, Simon Rosser BR, Miner M, Coleman E. The Sexual Health Model: application of a sexological approach to HIV prevention. Health Educ. Res. 2002 Feb 1;17(1):43-57.

7. Gerrard M. Sex, sex guilt, and contraceptive use. Journal of Personality and Social Psychology. 1982;

8. Maslow, AH. A Theory of Human Motivation. Psychological Review. 1943;50:376-396.

9. Michael Siegel. Marketing Public Health-An Opportunity for the Public Health Practitioner. In: Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers; 2007. p. 127-152.

10. Rofes E. Context Is Everything: Thoughts on Effective HIV Prevention and Gay Men in the United States. In: New international directions in HIV prevention for gay and bisexual men. Journal of Psychology and Human Sexuality; 1998.

11. O'Leary A. Beyond condoms: alternative approaches to HIV prevention. Springer; 2002.

12. Robinson B?E, Uhl G, Miner M, Bockting WO, Scheltema KE, Rosser BRS, et al. Evaluation of a Sexual Health Approach to Prevent HIV Among Low Income, Urban, Primarily African American Women: Results of a Randomized Controlled Trial. AIDS Education and Prevention. 2002 6;14(3 Supplement):81-96.