NYC Department of Health’s “It’s Never Just HIV” Campaign: An Impractical Public Health Approach - Leilani Hernandez

Introduction

The population most severely impacted by HIV in the United States is men who have sex with men (MSM). The Centers for Disease Control estimates that men who have sex with men are 44 to 86 times more likely to be diagnosed with HIV compared to other men (3). The high prevalence of HIV infections coupled with unawareness of having an infectious disease increases the risk of men transmitting HIV to other men. A study conducted by the CDC revealed that in 2008, 19% of men who have sex with men in 21 U.S. cities were infected with HIV and 44% of these men were unaware that they were infected (3). New York City recognized that MSM in their city are particularly vulnerable to HIV since men with male partners account for 55% of annual new diagnoses in their city (5). They decided to address this problem by convincing men who have sex with men to adapt to the behavior of using condoms and their means of persuasion to doing this was creating a poorly designed educational campaign that appealed to men’s fear for their health.

New York City’s Response to the HIV Problem

In December 2010, New York City’s Department of Health and Mental Hygiene debuted their new educational campaign for combating HIV in the MSM community which revolved around the saying “It’s Never Just HIV (5).” The outright, threatening message of their campaign’s catch phrase meant that becoming infected with HIV will ultimately ruin your life. The sad video associated with this campaign has a deep-voiced, disembodied narrator bluntly stating that having HIV puts you at higher risk for ‘dozens of diseases even if you take medications,’ and in addition to having many sad-faced male models, the commercial showcases three types of medical conditions (bone loss, dementia, and anal cancer) which it deems are follow-up diseases to getting HIV and then finally ends by telling the viewer to stay HIV free by always using a condom (18). This video ran on television for two weeks in December 2010, two weeks in January 2011, and can still be viewed on YouTube today (5). This campaign also included a subway advertisement component which started in February 2011 (6). The poster component used in the city’s subways displayed identical images and written scripts that were from the video.

Why this campaign was ineffective

NYC’s public health department had had previous success in using a fear appeal message for an anti-smoking campaign so they decided to apply this same fear tactic into convincing MSM into wearing condoms. However this just demonstrated that there are not one-size fits all solutions for public health problems since this campaign was met with much criticism from the media. The practice of not using a condom during anal sex with someone is a high risk behavior for HIV infection; however, this is not the only behavior that needs to be addressed in order to reducing HIV transmission among men who have sex with men. Other behaviors that impede our goal of reducing transmission in the MSM population is being unaware that you have HIV (which is more prevalent amongst young black men), having multiple sexual partners, and using drugs during sex (3). Also homophobia and the stigma are social factors associated with HIV which create significant barriers to reducing the prevalence of HIV within the MSM population. Homophobia can affect these men’s ability to make health choices for themselves while stigma can affect these men’s disposition for seeking methods of prevention or care for HIV (3).

The New York City campaign, which only had the goal of convincing men who have sex with men to wear a condom, mainly took the appeal to fear route but also included other social behavior models such as the Health Belief model and Theory of Reasoned Action. These theories and New York City’s inappropriate application of them will now be dissected in order to prove why the “It’s Never Just HIV” Campaign was an impractical approach to reducing HIV transmission among MSM living in NYC.

Fear Appeal: Extended Parallel Process Model

The most obvious theory that officials at the department of health tried to apply when designing this campaign was appealing to people’s fear of contracting a serious medical disease on top of HIV. Fear appeal models posit that “an emotional response and a desire to eliminate the danger are triggered upon exposure to a fear appeal.” (2). The most modern fear appeal model is called the Extended Parallel Process Model (EPPM). This model simply states that a “perceived threat contributes to the extent of a response to a fear appeal whereas perceived efficacy contributes to the response of the nature and if no information on the efficacy is provided then individuals will rely on past experiences and beliefs to determine perceived efficacy (17).” And while fear appeals have been highly criticized in class and in the literature for use in public health interventions they have proved to be effective for certain issues used with certain populations. A campaign in Uganda was extremely effective in changing Ugandans attitudes towards sexual behavior thus significantly reducing HIV prevalence in this country. The campaign’s simple ‘ABC message’ was that you can choose either choices A, B, C or you can choose D with D standing for Death and used imagery of skulls, coffins, and grim reapers to get this message across to Ugandans (9). Ugandans surveyed were asked why their sexual behavior was changed and their two most common responses were first ‘Fear of AIDS’ and second ‘so many people are dying from AIDS (9).’

However Americans have a more ‘sex-positive’ culture than Ugandans do which could be the reason why the NYC campaign’s use of the instilling fear was not very effective for changing sexual behavior over here (9). A meta-analysis conducted on fear appeal research highlighted certain implications for using this model. These implications are that fear appeals are effective only if they show a significant and relevant threat and when they increase perceptions of self-efficacy by outlining a response that is easy to accomplish(17). The imagery and messages sent out by the NYC campaign failed to take into account both of these implications. First off, while HIV is associated with anal cancer, osteoporosis, and dementia the way that the video depicted these medical conditions was not done in a manner that would incite fear in the viewer especially in a an age where most people are extremely de-sensitized to the most shocking images. Showing x-rays of bones, brains, and other body parts is not very frightening to most people nowadays. Also these diseases that HIV can lead up to are too far into the future for a person to consider as significant threat or even possibly relevant to them. As a public health student interested in HIV, I was not even aware that these diseases are associated with HIV so I’m not sure how the common lay person would know this thus believing that they could actually affect him if he gets HIV. This video and its images are not enough to elicit a strong response to perform the video’s recommendation which is to start using condoms. The very best possible scenario that these scare tactics would accomplish is have the individual use condoms for a short time period. Secondly, while wearing a condom seems like a simple thing to do it is not easy to do if a person does not have a condom on them at the time of sex or if alcohol and/or drugs are clouding a person’s judgment. A report by the CDC states that men who have sex with men continue to engage in sexual and drug-use which increases the risk for HIV infection (8).

Health Belief Model

The New York City campaign also applied the Health Belief model (HBM) since they sought to educate men who have sex with men about the dangers of not wearing a condom. HBM is an individual level model which identifies factors associated with influencing a person’s behavior. Decisions that a person makes are based on the susceptibility or the subjective risks of contracting a condition, perceived seriousness or perceived difficulties that person believes a given health condition will create, and the perceived benefits and barriers of performing the recommended action which will be determined by that subject’s beliefs and availability and effectiveness of taking this action (13). The primary focus of the Health Belief Model is on health education which the video does do. New York City thought that simply educating people on the risks associated with HIV and telling them that a condom would offer them enough protection from these risks was convincing enough evidence for MSM. Dialogue from the “It’s Never Just HIV” Video states, “HIV puts you at higher risk for dozens of diseases even if you take medications, like osteoporosis a disease that can dissolve your bones, dementia a condition which causes permanent memory loss, and you’re over 28x more likely to get anal cancer.”

In this video, new information regarding the severity of AIDS was clearly communicated in this video. However, men who have sex with men are most likely already aware that they are highly susceptible to getting HIV and the message of the severity of HIV/AIDS is also probably already well known to them as well. So the HBM was an inappropriate use of this theory in attempting to get people to change their behavior since most MSM are already aware of this information and yet still continue to engage in risky behavior. The message and the images shown were not persuasive enough to change a person’s perception of how HIV can change his life. But most importantly, this theory assumes that people are rational thinkers so educating them about the dangers of HIV will convince them into using condoms. But in reality most people, not just men who have sex with men, are not rational thinkers in the moments leading up to or during sex.

Theory of Reasoned Action

Lastly, the campaign also included elements from the theory of reasoned action since the models in the video acted their best to make the viewer feel guilty for not having worn condoms in the past. This theory assumes that people are rational beings and so they consider their actions before they decide to perform or not perform a behavior; thus intention is a function of two basic determinants: the person’s attitudes towards the behavior on whether it is good or bad and the person’s perceptions of social pressures to do the behavior or not (14,15). The recommended behavior of the “It’s Never Just HIV” Campaign for men who have sex with men is to use condoms. For their HIV campaign, New York City employed attractive men in their video and subway posters. The men used in the video would be considered a social group that a man who viewed the video might be concerned about their perception of him for not using a condom. In the video, these men are seen looking glumly into the camera. A few of them even give accusing glares into the camera as the video talks about the consequences of HIV. You as the viewer feel as if you’re the one that had unprotected sex with them and accidently transmitted the disease and now it’s your fault that they are being diagnosed with anal cancer. The intention of doing this is to make men who do not wear condoms feel guilty and shame for this behavior. Unfortunately, another side effect of this video places a higher burden of shame and guilt on those men who already have the HIV infection. This video is blaming them for other men getting osteoporosis, dementia, or anal cancer since they are the ones who can spread the HIV to others. And like the HMB, the theory of reasoned action also assumes that people are rational thinkers and again it’s ridiculous to use this theory for promoting condom use since most people don’t think rationally during sex.

Proposed, alternative intervention

When used consistently and correctly, condoms are an effective way to reduce HIV transmission so I agree with this campaign’s message to promote condom use. However condoms are not the only preventative measure against HIV transmission. The “It’s Never Just HIV” campaign did not address the underlying causes of HIV transmission amongst men who have sex with men and further did not mention other preventative measures. We also need to discourage multiple sexual partners and use of drugs during sex since they increase the risk of becoming infected. HIV stigmatization compounded with homophobia is an underlying root cause of why this is such a problem in this population. Also none of NYC’s advertisements mentioned the importance HIV testing especially since symptoms of having the disease do not begin to appear until later stages of the disease. Knowing one’s HIV status is important because obviously you would make more conscious choices in regards to sex and you will also be referred to the health care and treatments you need to properly manage the disease. Furthermore, I also feel as if the way that HIV is spread is also important information that not many people know. If people understand the methods by which HIV is transmitted then they would be able to recognize situations in which they could possibly be at risk for infection.

My proposed alternative to is a multi-fold intervention that includes not only encouraging condoms during sex but also promoting HIV testing, reducing HIV stigmatization in the MSM community, reducing homophobia, promoting safe sexual practices, and educating men who have sex with men on how HIV is spread. Gary Marks from the Division of HIV/AIDS Prevention at the CDC wrote an editorial review about the need for collective responsibility in order to reduce HIV transmission. He wrote that “Collective responsibility emphasizes that all of us, infected or now, low right or high, bear a responsibility to change our attitudes and behaviors that promote HIV infection (11).” He suggests strategies to reducing HIV transmission at the population level would be promoting use of condom usage and HIV testing, promoting norms of responsibility and protection during sex, and fostering the perception that HIV is still a life-threatening disease (11). Due to this idea of collective responsibility not all components of my campaign will be targeted to the MSM community especially the components aimed at reducing HIV stigma and homophobia.

My campaign will have a positive, hopeful video that depicts gay men in a positive light and will also include a message that encourages sex safe practices and getting tested for HIV. Secondly, it will also have an educational component toward it geared towards educating these men about the different methods of HIV transmission, recognizing high risk situations, and again encouraging safe sex practices. Lastly, my intervention will include a program aimed at creating awareness of sexual diversity and HIV in the community by encouraging MSM to be more active thus increasing their visibility within the community.

Framing the message in a Positive Light

One of the reasons why the NYC campaign was such a failure amongst the MSM community was because of the video’s negative tone and the dreadful information they decided to include for supporting their message. For framing, it is important to incorporate emotional processes to influence a person’s decision-making between choices (12). While this campaign obviously had an emotional component to it, the tone and images used to bring about emotions were not persuasive enough to spur someone into using condoms.

For my intervention, I plan to frame my recommended action of using condoms and getting tested in a positive way. Like NYC, I will also create a short video that uses men to deliver message. Having gay men deliver the message to other gay men is a way to reduce resistance to the message. Similarity between the message deliverer and its recipient has been shown to increase persuasion by increasing the liking of the message heard and making the message less threatening (16). My video will involve men talking directly into the camera rather than having a creepy disembodied voice narrate it. I will recruit two gay men who are in a serious long term relationship to talk about their experience of one discovering the other has HIV, how they cope, and how one supports the other one. Most importantly they will say that having this discussion demonstrated mutual respect and trust in their relationship. The reason why their relationship has such a strong foundation is because they were courageous enough to talk to one another about it. This will shed light on the importance of using condoms, practicing other safe sexual practices and disclosure of the other’s HIV status. The video will show how in love they are with each other as a result of them sharing this information with each other. Framing the message positively is a more effective way of promoting condom use and testing rather than scaring people into doing it.

Promoting Self-Efficacy

Know your status and get tested! Have either you or your partner wear a condom so that you can protect yourselves from HIV! The NYC campaign did nothing to promote self-efficacy in their campaign. They just hoped that the information they provided would be enough to convince people to do what they want them to do. My intervention will support self-efficacy for doing the following actions: getting tested and using condoms. Whereas the NYC campaign utilized concepts from the Theory of Reasoned Action (TRA) into the design of their video, mine will use the most recent theory for this, Theory of Planned Behavior (TPB). This theory extends upon TRA by adding in an additional component called behavior intention which is the “degree to which a person believes they have control over whether they can do that action and the strength of the belief they can do it.” (7).

To promote self-efficacy, the men in my video will stress to MSM viewers that they have the control and the power to safeguard their health and their partners and make a difference in the fight against AIDS/HIV. They can do this if they speak up to their partners about condom use and knowing one’s HIV status. I am hoping that the video made for use in my intervention will be an empowering one, which is difficult to achieve. It will highlight how one man’s decision to talk with his partner about the sensitive issue of sex and HIV brought about a sense of admiration and respect from his partner. Hopefully this video will increase the viewer’s perception of how easy and most importantly rewarding it is to have this serious discussion before engaging in sex.

Increasing the general Community’s awareness of MSM and HIV

The third component of my intervention is not at all directed at men who have sex with men but includes everyone in the community since two of my intervention’s aims of this component are reducing HIV stigmatization and homophobia. This component involves a program that would increase the general community’s awareness of HIV and stigmatization. The program encourage men who have sex with men to increase their visibility in the community by engaging in activities in an effort to counter people’s perceptions of the homosexual lifestyle and those living with HIV (1).

In his article on preventing HIV in a context of HIV stigma, discrimination, and homophobia, Ronald Brooks suggests activities for gay men to do in the community would be ‘participating in HIV prevention programs at local health fairs, participating in gay and lesbian group festivals, and/or establishing a gay/straight alliance.” He also recommends venues for HIV prevention activities to take place in to be “churches, barber shops, beauty salons, jails and prisons, social service agencies, health clubs, schools, neighborhood center, needle exchange programs, and non-gay setting and non-HIV community events.” One community level HIV intervention program targeted towards young gay men recognized the importance of creating new setting and events to attract their target population. Setting for events to promote safer sex included dance parties, picnics, hikes, and bicycle rides (13). In my intervention, I would suggest that participants go to any of the places listed above as a starting point for spreading the word on HIV prevention and getting involved in the community.

Also gay role models from the community will be recruited and trained. These role models will educate everyone on the methods of HIV prevention and on how HIV is transmitted so that people can recognize situations in which they could possibly be at high risk for HIV infection. They will also dispel rumors on how HIV spread (which is not by casual contact, kissing, or sharing air or water with someone with HIV) in order to try to reduce HIV stigmatization. These role models will also be trained to act counselors for any MSM who experience homophobia and need the social support so that they won’t engage in self-destructive behavior in reaction to it.

Conclusion

Even though HIV transmission is preventable, sadly, the CDC estimates that 1.2 million people in the United States are living with HIV infection and 20% of those people are unaware of their infection (4). It is important that people, especially vulnerable populations such as MSM, know their status and understand ways to protect themselves and others from HIV because even though treatment is available, HIV is still a life-threatening disease. Prevention campaigns such as the “It’s Never Just HIV” campaign do not effectively showcase all of the prevention methods available or address underlying social factors of why MSM are the ones most severely impacted by HIV. Interventions to combat HIV need to be multi-fold in its approach since the root causes of this problem for the MSM population are multi-fold. Not only should they be aimed at promoting safer sexual practices but they also need to tackle the daunting task of reducing the social factors which are barriers for MSM to receiving the care they need. If these multi-fold interventions are implemented then we will be able to see a significant reduction in HIV prevalence for this group.

References

1. Brooks, Ronald and Mark Etzel, Ernesto Hinojos, Charles Henry, ad Mario Perez. “Preventing HIV among Latino and African American Gay and Bisexual Men in a Context of HIV-related Stigma, Discrimination and Homophobia: Perspectives of Providers.” AIDS Patient Card STDS. 2005 November; 19 (11): 737-744.

2. Camerson, Kenzie. “A Practitioners Guide to Persuasion: An Overview of 15 Selected Persuasion Theories, Models, and Frameworks.’ Patient Education and Counseling 74, 2009. Pp 309-317.

3. CDC. “HIV among Gay, Bisexual and Other Men Who Have Sex with Men (MSM).” http://www.cdc.gov/hiv/topics/msm/index.htm. December 7, 2011.
4. CDC. “HIV in the United States.”

http://www.cdc.gov/hiv/resources/factsheets/us.htm. December 7, 2011.

5. Craig, Susan and Celina de Leon. “New Health Department Media Campaign Shows How HIV can Compromise Health and Well Being, even when Treatment Controls the Infection.”

http://www.nyc.gov/html/doh/html/pr2010/pr059-10.shtml. December 7, 2011.

6. Craig, Susan and Zoe Tobin. “Health Department Takes Its Latest HIV Awareness Campaign to the Subway- Agency’s new subway posters show how HIV can lead to other serious diseases.”

http://home2.nyc.gov/html/doh/html/pr2011/pr002-11.shtml. December 7, 2011.

7. Edberg, Mark. ‘Chapter 4: Individual Health Behavior Theories.” Essentials of Health Behavior: Social and Behavioral Theory in Public Health, Sudbury, MA: Jones and Bartlett Publishers, 2007. Pp 35-49.

8. Finlayson, Teresa and Binh Le, Amanda Smith, Kristina Bowles, Melissa Cribbin, Isa Miles, Alexandra M Oster, Tricia Martin, Alicia Edwards, Elizabeth DiNenno. “HIV Risk, Prevention, and Testing Behaviors Among Men Who Have Sex With Men --- National HIV Behavioral Surveillance System, 21 U.S. Cities, United States, 2008.” MMWR Surveillance Summaries October 28, 2011 / 60(SS14);1-34.

9. Green, Edward and Kim Witte (2006). “Can Fear Arousal in Public Health Campaigns Contribute to the Decline of HIV Prevalence?” Journal of Health Communication, 11:3, 245-259.

10. Kegeles, Susan M and Robert Hays, Thomas Coats. “The Mpowerment project: A Community-Level HIV Prevention Intervention for Gay Men.” American Journal of Public Health. 1996 :86 :1129-1136.

11. Marks, Gary and Scott Burris, Thomas Peterman. “Reducing Sexual Transmission of HIV from those who know they are infected: the need for personal and collective responsibility.” AIDS 1999, 13: 297-306.

12. Martino, Benedetto and Dharshan Kumaran, Ben Seymour, Raymond Dolan. “Frames, Biases, and Rational Decision-making in the Human Brain.” Science, 313 August 4, 2006. Pp. 684-687.

13. Rosenstock, Irwin. “Historical Origins of the Health Belief Model.” Health Education Monographs, 2(4) Winter 1974. Pp. 328-335.
14. Salazar, Mary Kathryn. “Comparison of Four Behavioral Theories.” AAOHN journal, 39 (3) March 1991. Pp. 128-135.
15. Sheppard, B.H.; Hartwick, J. & Warshaw, P.R (1988). The theory of reasoned action: A meta-analysis of past research with recommendations for modifications and future research. Journal of Consumer Research, 15, 325–343.

16. Silvia, Paul. “Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistanc.” Basic and Applied Social Psychology. 27 (3) 2005. Pp 227-284.

17. Witte, Kim and Mike Allen. “A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns.” Health Education Behavior 2000 27:591.
18. YouTube video by NYC Health- “It’s Never Just HIV.” Available at:

http://www.youtube.com/watch?v=d0ANiu3YdJg. December 7, 2011.