Challenging Dogma

Sunday, May 6, 2012

A Critique of the “It’s Never Just HIV” Campaign, NYC Health 2010 – Jamie Branco

The condom-use awareness campaign, “It’s Never Just HIV,” debuted in New York at the end of 2010 to harsh criticism and a petition to end the campaign (35,39,40).  The campaign – which was put out by NYC Health via print ads, television, web site, and social media (12) – is more akin to the preview of a horror film than it is to a public health announcement.  The ads feature handsome but somber looking young men accompanied by graphic images of the various diseases that the viewer is being told they have a higher risk of developing once acquiring human immunodeficiency virus (HIV).  These diseases include osteoporosis, anal cancer, and dementia.  The visuals are supported by eerie sound effects and narration that succeed in creating a message of utter dismay and hopelessness.  The campaign’s target demographic is Black and Latino men who have sex with men (MSM) and was put together in response to the disproportionate increase of new HIV infections amongst that population in New York City (12,21). 
More MSM are diagnosed with HIV than any other group and a study conducted between 1994 and 2000 found that 82% of New York study participants who were HIV positive did not know their status (22).  In New York City, the incidence of HIV is on the rise in the MSM population (34) with Black and Hispanic men comprising the majority of those testing positive (19,27).  This reported incidence, however, is estimated based on individuals receiving an HIV positive diagnosis versus date of initial infection, events that could be upwards of 10 years apart (25). 
One of the major faults of the “It’s Never Just HIV” campaign is the assumption that the viewer is at a place where he perceives himself as being susceptible to not only contracting HIV but also to developing every other disease mentioned in the ad.  A second fault of the campaign is the use of a messenger whose voice is demanding, scolding, monotone, emotionally detached, and older than the men in the ad.  A third fault is the advertising promise that one will get these diseases and HIV will be the least of one’s worries. 
The Health Belief Model and Perceived Susceptibility
The “It’s Never Just HIV” campaign draws on the conclusion that people make rational decisions to avoid negative consequences.  HIV has often been thought of as the end all of negative consequences.  Surely people would do everything in their power to avoid getting HIV.  Over the past thirty years of combating the disease we’ve seen the advancement of antiretroviral drugs and infected people living relatively healthy, happy, and lengthy lives (36) when just a short time ago HIV was equivalent to a death sentence.  While there is still no cure or vaccine for HIV, the advancement of antiretroviral drugs may have diminished the perceived severity of the virus and in turn diminished the perceived susceptibility of contracting the virus to begin with (6).  This diminished susceptibility can be quantified by the startling increase of unprotected anal intercourse and multiple sex partners amongst men who have sex with men (MSM) in the U.S.  Between 1994 and 1999 the self-report of these behaviors skyrocketed from 24% up to 45% (20).
The premise of the health belief model is that health-related decisions are reliant on: the health issue being relevant to the individual, the belief that one is susceptible to the health issue, and that following health recommendations will lead to favorable outcomes at acceptable costs (17,23,33).  As per the health belief model, the campaign takes a look at the severity of the virus by showcasing several of the diseases on the spectrum of possible co-occurring conditions associated with HIV.  What is fails to consider is that if one doesn’t feel susceptible to contracting HIV, one couldn’t possibly feel susceptible to developing osteoporosis, dementia, or anal cancer in direct relation to contracting HIV.  MSM without HIV have reported decreased concern in contracting HIV and men already HIV-positive have reported less concern about transmitting HIV to their partners (20).   It doesn’t help that osteoporosis and dementia are conditions more commonly associated with the elderly, not the young age-group that the campaign is targeting.
It would be a rational decision to wear a condom to help avoid contracting HIV and wearing condoms is the parting message of the ads in this campaign.  Unfortunately, not all human behavior is rational especially in situations that are highly charged by emotion, such as sex (2).  What one may view as appropriate and responsible in neutral situations differs greatly from the thoughts and motivations that fuel behavior once involved in an arousing or highly emotional situation.  Dan Ariely reports on this contradictory behavior in his book Predictably Irrational.  When male undergraduates at UC Berkeley were asked to report on their sexual preferences and predicted behaviors while in a cold state, their answers were startlingly different than when they reported their sexual preferences and predicted behaviors while in a hot or aroused state (4).  When it came to condom use, there was a 22% decrease between cold and hot states when participants were asked if they would always use a condom if they didn’t know the sexual history of a new sexual partner (4).  This difference in predicting one’s own actions poses an interesting twist to the promotion of safe-sex practices.  Using condoms to avoid sexually transmitted infections can be engrained during sex education classes in school or health promotion campaigns in the media but Dan Ariely and others have shown that the rational cold state and the aroused hot state differ greatly in a person’s recollection and application of this knowledge when it is most needed (4,11). 
The state of arousal may cloud one’s perceptions of the susceptibility to HIV as well.  The heat of the moment, the attraction to and lust for a new partner, a false sense of security based on the initial bond between partners – these are all things that could further the distance between knowledge that one should wear a condom and the failure to do so.  Generally, the behaviors that determine one’s sexual risk occur in the sexual moment (11).  Furthermore, if one has low or no perceived susceptibility to getting HIV, there would likely be very little conflicting feelings about one’s sexual practices both in and out of the moment.  This distinction between cold state and hot state behaviors is an important realization when putting together HIV prevention campaigns, especially given the growing evidence that being knowledgeable about HIV and being willing to take part in preventative actions are unrelated (5,17).  This irrational disconnect between knowledge and action highlights how people illogically discount the risks of HIV and optimistically perceive themselves as invulnerable to the known consequences of risky sexual behavior (2,18). 
Communication Theory and the Likeability of the Messenger
The message itself is only part of the package when delivering a public health intervention.  Who is delivering the message is also of great importance.  The target demographic for the “It’s Never Just HIV’ campaign is men who have sex with men in the age-range of early 20s to mid-thirties.  By contrast, the narrator sounds much older than the target demographic and sounds like he is scolding the younger men in a very demanding, monotone, and emotionally detached manner.  The messenger has no face or identity to provide any similarity between him and the men in the ad or to the men in the target audience.  There is nothing likable about the voice of the messenger.  Since he is older than the men in the ad and shows no appearance, we don’t know who he is.  He appears to just be a man with a creepy voice who was hired as part of the ad’s scare tactic.  The narrator doesn’t sound trustworthy; he sounds like he’s out to scare the viewer. 
A messenger’s trustworthiness is the audience’s perception of the spokesperson to be honest, believable, ethical, sincere, and credible (31,37,38).  In their research, Priester and Perry found that a high level of trustworthiness garnered more unquestioned acceptance of a message than untrustworthiness, which elicited scrutiny (31).  The unknown narrator in the “It’s Never Just HIV” campaign projects a lack of concern or sincerity.  He fails to connect an emotional appeal to a highly emotional behavior and plausible consequence.  The ad takes on the feel of an urban legend – the message is cautionary but the intended fears come out as questionably trustworthy.  The probability of personally developing the negative outcomes highlighted in the ad seem distant, much like urban legends seem to always happen to “a friend of a friend.”  Personal stories by members of the targeted demographic tend to be more trustworthy and believable since the level of expertise and concern stems from personal experience and there is no alternative motive for speaking out (37). 
Advertising Theory and the Promise of Disease
“It’s Never Just HIV” is not a message of hope, nor is it a message of empowerment.  “It’s Never Just HIV” is a message with the promise that if one acquires HIV, one will get a myriad of other horrible diseases as well.  These diseases are portrayed as being much worse than “just HIV,” as if just HIV would be okay on its own if it didn’t come with these other horrible conditions.  The diagnosis doesn’t end with a positive HIV test result.  It only gets worse and the viewer is basically hopeless if this were to so unfortunately happen.  The ad is promising the extreme.  “If you have unprotected sex you will become horribly diseased, with HIV being the least of your worries.”  The utilization of the words “just HIV” affirms the diminished perceived severity of HIV due to antiretroviral therapies. 
In promising disease, the campaign sends the message that it is not possible to be healthy once acquiring HIV and the campaign assumes that health is an attractive core value on its own that no one would want to risk losing.  Health is reserved for those without the virus and those who are infected with HIV are associated with being ill (2).  Creating this distinction between who is “sick” and who is “well” only perpetuates and intensifies the stigma related to being HIV positive.  The ad further marginalizes men who have sex with men by attaching additional negative health outcomes that don’t appear in other campaigns for HIV targeted to women or heterosexual males.  Is the viewer to believe that if they are not part of the target demographic that this ad and these outcomes don’t pertain to them?  This message of dissimilar consequences to sex and HIV could be misconstrued as being punishment for a preference or behavior that is unpopular with many.  Many gay/AIDS activists have debated the merit of the ad that some have referred to as sadistic and bullying to the gay community (30,35).  The health claims have also been called into question, specifically as they pertain to the campaign’s target demographic (21,30,35).  While decreased bone density has been reported in HIV-positive patients receiving antiretroviral therapy (10,15) osteoporosis is still more common with increased age.  HIV does interfere with the central nervous system early after infection and the prevalence of mild cognitive impairment has increased, however; antiretroviral therapies have decreased the incidence of HIV-related dementia, which has historically been a feared complication of HIV infection (26).  Anal cancer has been found to be higher in those who are HIV-positive compared to the general population (29).  Even with the correct portrayal of the increased risk for these outcomes, osteoporosis, dementia, and anal cancer are more common among older patients and those diagnosed in later stages on HIV infection (10,15,26,29,35).  These long-term threats may not resonate with a younger audience. 
The visual and audial support of the promise of disease further elicits a message of dismay and hopelessness.  Not only is the message itself dismal, the sound-effects, the narration, the dreary environment, and the highly graphic content all lend to the ad’s fear-factor.  The ad contains images of people in pain and suffering, visuals of the other diseases shown via animated medical imaging, a man in a hospital bed, and a graphic and startling picture of advanced stage anal cancer.  In addressing a familiar topic like HIV, using fear tactics does little to change behavior or increase the perceived severity of the disease (14).  Information coupled with a strong graphic threat does not result in a significant difference in the perceived threat of disease while the combination of information and weak graphic threat does increase perception (14). 
Social marketing campaigns targeting condom use and HIV prevention have been criticized for their unethical and manipulative use of fear to change behavior.  If the viewer fails to adhere to the recommendations made in the message, negative consequences await them (2).  Fearing that one may be susceptible to acquiring a disease is much different than one feeling threatened with disease as an outcome for disobeying the message of the ad.  The “It’s Never Just HIV” campaign is fear driven and overwhelmingly so.  The campaign has so many variables that the message of HIV prevention almost gets lost.  Humans commonly cope with exposure to fearful information in several ways including avoidance, denial, counter-arguing, or ‘othering’ (claiming the message is for someone else, not them) (7).  Dolores Albarracin and colleagues found that “fear inducing arguments were not effective when introduced in either passive or active interventions, either immediately or later in time, for any population or in combination with any other strategy” (3).  This strong statement highlights the need for something other than fear-based intervention when addressing HIV to any demographic. 
Intervention change
Instead of focusing on all of the other diseases that might eventually occur after an HIV diagnosis, the campaign should use the “just HIV” wording to highlight how HIV is still a big deal on its own despite antiretroviral therapies.  A cold may be “just a cold” and allergies may be “just allergies” but a doctor would never diagnose a patient as “just” having HIV.  This reconnection with the realities and life-long implications of the disease can be made by showing the emotional toll of diagnosis, the financial costs of doctor’s visits and medications, the interpersonal difficulties of telling friends and family that one is HIV positive, or the inner conflict of acceptance of self and prospect of future love.  These are all scary realities of an HIV diagnosis but they are relevant and not invented to promote fear.  Recognizing these realities in connection to the severity of the virus does not have to leave the viewer feeling hopeless or doomed.  The viewer should feel empowered to get tested, have an open dialogue with sexual partners before the state of arousal, and feel that their sexuality is not being condemned or punished. 
Addressing Perceived Susceptibility 
The “It’s Never Just HIV” campaign wrongly attempts to increase the perceived severity and susceptibility of acquiring HIV by sensationalizing health risks that are not relatable to the target demographic.  One of the conditions of the health belief model is that a health issue is perceived as relevant to the individual (17,23,33).  For the general population, the recommended age in which to get screened for osteoporosis is 70 years old for men (1) and the median age for onset of dementia in men is 83 years old (8).  With the target demographic being so young, it is necessary to focus on the aspects of an HIV diagnosis that a younger age-group would recognize as real and immediate threats.  One of the obstacles of getting people to adapt safer sex practices is that HIV infection itself is not observable and the symptoms of HIV/AIDS may not appear for several years (6).  A more successful campaign would choose one of several highly personal situations to focus on versus the incomprehensible diagnosis of osteoporosis, dementia, or other physical symptoms that may or may not develop several years or decades down the line. 
Receiving the results of an HIV test is one such highly personal and highly emotional example.  A doctor will never say, “Oh, it’s just HIV.  Take this pill and proceed as normal.”  While an HIV diagnosis isn’t the death sentence it was 20 years ago, it is still a very serious finding.  To focus on possible long-term consequences of HIV distracts from the very real situations anyone diagnosed with HIV would face immediately following diagnosis. 
Medical costs, social roles, and interpersonal relationships are several of the uncertainties that HIV and other patients of chronic disease face that help fuel the stress, anger, and depression of an HIV diagnosis (9).  In focus groups, HIV patients reported feeling shocked, numb, angry, panicked, and suicidal upon receiving an HIV-positive diagnosis and realizing that their lives would be cut short (13).  Other patients have emphasized the importance of allies when obtaining and retaining information from doctor’s appointments (9).  These emotions may not be pretty but they are more relatable than gruesome physical outcomes and have a better shot at increasing the perceived severity and susceptibility of the disease. 
Message Communication
The message of this HIV campaign should come from members of the target demographic, not from a nameless and faceless voice.  In health communication, two of the most important qualities of a messenger are trustworthiness and credibility (38).  Survivors of disaster are often the most credible and believable spokespeople (37) and are the most sensible choice when addressing specific populations.  In contrast to the narrator’s voice in the “It’s Never Just HIV” campaign, the men featured as the backdrop of the ads are clearly young and, in contrast to the dreariness, are all quite handsome.  This casting may have been an intentional effort to get people thinking about the ‘face’ of HIV and to realize that being young and pretty doesn’t make you immune to disease.  This point can be more directly utilized by having members of the target demographic relay personal stories about their beliefs about HIV before and after diagnosis or about the uncertainties associated with life events of the chronically diseased. 
Personal risk is more effectively conveyed when a message is more personally involving (5) and narratives are among the most powerful ways to relay personal messages (16).  By attaching a real story to an attractive and representative member of the target demographic, the message that HIV can happen to anyone is less obscure.  This association with real people is important since one often assesses the likelihood that a potential sex partner may have HIV or another STD based on one’s perceptions of what an HIV-infected person is like rather than taking logical account of possible lifestyle exposures that may have put that person at risk (11).  Having a spokesperson that the viewer can identify with and is representative of the type of person they would socialize with or date helps bridge the gap between what one may think HIV looks like and HIV’s actual face. 
An example of a very successful campaign that follows a similar format to the new proposed campaign was launched in San Francisco in 2003 to target the Latino gay community.  The ads feature pictures of Latino men with messages in both English and Spanish relaying affirming messages like “I don’t want to hurt my family. That makes talking about the truth so hard” and “Because I love my friends and family I can’t risk my health.”  The ads were created based on the ideas, concepts, photos, and concerns of the target community and the community was involved in every stage of development.  The photos in the ads are of real community members and their families and were put out by the Asociacion Gay Unida Impactando Latinos/as A Superarse (AGUILAS) – an organization that has successfully reduced the HIV risk behavior of the organization’s participants by between 50 and 70% between 1999 and 2003 (24). 
A New Promise
The promise of the current campaign is that if one acquires HIV, one will get a myriad of other horrible diseases as well and the future is hopeless after an HIV diagnosis.  While the proposed changes in the previous sections still address the negative realities of HIV, the promise isn’t nearly as harsh.  Times will be rough should one acquire HIV.  Life will be emotionally, socially, and financially challenging.  Things will be more complicated and if a viewer is already infected, he knows that he is not alone in the emotional struggles.  If the viewer is uninfected, there is still hope to avoid infection.  There is still time to be more accepting of one’s sexuality even if family members or certain segments of society don’t approve.  Greater condom use was found to be associated with greater acceptance and comfort with one’s sexuality (32). 
The original campaign has a dark quality to it that seems to associate the worst possible outcomes of HIV with the MSM community.  The ad sends a message to men who have sex with men that “this is what will happen to you because of your behavior.”  The amended ad avoids chastising viewers’ behavior by focusing on the humanistic side of HIV.  Emotions surrounding HIV are more complex than other health-related behaviors (18) and unsafe sex practices may be a symptom of more complicated underlying issues that prevention efforts should attempt to address when possible (32).  The AGUILAS campaign is a great example of addressing HIV prevention while simultaneously attempting to reduce social stigmas surrounding HIV and being a sexual minority (24).
By bringing forth an emotional experience by a real person, issues around sexuality are at least presented in a neutral versus scolding manner and the viewer is able to connect emotionally to the message, not feel like they are being told that who they are is wrong and that their behavior will be punished. 
In conclusion
When dealing with a serious topic like HIV, “it is important to promote the positive, recognize and affirm the existential, and contextualize the negative” (2).  Addressing HIV comes with the complicated challenge of relaying the severity of the virus to those uninfected while also letting those infected know that there is hope for a normal and happy life.  These conflicting arguments both have a place in HIV awareness and education but run the risk of sending mixed messages or one message diminishing the importance of the other (35).  A new campaign that presents the experience of HIV in a very humanistic and relatable manner could avoid attaching stigma and shame to those already infected while still relaying the severity of diagnosis to those uninfected.  Those who are uninfected should see the ad and feel empowered and motivated to protect themselves.  Those who are already infected should see the ad and feel a connection with the spokesperson and think, “I am not alone.” 
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