Sean Strub v Larry Kramer:
Fearful HIV NYC Ad
My utmost hope is that the debate swirling around the release of a controversial and alarmist social marketing campaign for HIV prevention among gays, and the exchange below, is of interest beyond the usual circles of AIDS advocates and gay men's health experts.
I've blogged in the past about my objections to the fear-based, stigmatize the person with AIDS campaigns in San Francisco, for many reasons starting with I think poking someone in the eye, shouting at them, and demanding they pay attention to a health message is not a healthy way to talk to anyone about sexuality and infection issues.
Regarding the debate between my two friends, Larry and Sean, I'm in Sean's camp. As someone who links to stats and studies to make my points about ads or stats, unlike Dana Van Gorder of Project Inform who maintains there are studies about the loneliness of the SF homosexual yet can't produce the studies, I give Sean extra points for providing an excerpt from a study and a link to it.
Let's get to the exchange, beginning with Sean addressing Larry:
I just saw Michael's post about comments you made concerning the NYC DOH campaign.
There is plenty of literature addressing the inefficacy, over the long-term, of fear-based social media campaigns seeking to change sexual behaviors, such as this:
On page 291, the report states the following:Finally, threatening health messages may elicit other negative reactions along with fear. The risk in trying to induce fear in an attempt to persuade is that HIV prevention messages may engender other unintended affective responses such as anger or sadness. These various emotions may in turn initiate different action tendencies that may compete with or contribute to persuasion. For instance, it has been shown that participants experiencing a sad mood perceive themselves as less able to carry out health-promoting behaviors but as more vulnerable to diverse negative health outcomes (Salovey & Birnbaum, 1989). Threat appeals arousing sadness as well, especially those calling upon death or suffering, may be counterproductive in that this state leads to decreased self-efficacy in terms of the behavior promoted and, hence, a greater reluctance to adopt safer behaviors despite greater perceived vulnerability.
You may dismiss these findings, but I don't, because they support what I see and hear from young people who turn off or are demoralized by fear-based messages. What will empower them is real HIV prevention and harm reduction education, the facts they can use in assessing risk and modifying behavior.
I agree with you that fear is a powerful motivation and it was definitely played an important role earlier in the epidemic in changing behavior. But that wasn't because people were told to be afraid, it is because they felt fear driven by their own experience, what they witnessed first-hand.
Imagine how much more effective it would be if NYC DOH spent this money educating young gay men about post-exposure prophylaxis? That would prevent infections immediately and it could be measured. Here are some more citations concerning efficacy of fear-based behavioral change campaigns:
I would like to see some of those who are such advocates of this kind of campaign to provide some studies supporting why they believe they will work.
Larry's reply to Sean:
i could not disagree with you more. this stuff has not worked so it's time to try something else. ironic that the study comes from yale and peter salovey, who is a friend. i shall contact him.
your "something else" is unrealistic and a huge pipe dream and will cost a zillion dollars and is what we have been asking for since the beginning and no one would then or is now going to fund. better i now think to show the dire consequences which will hopefully provoke the curiosity for real fact that you are rightly claiming are lacking to them. the fact that the bard kids were so dumb is the awfulness of the enormous failure all prevention efforts have reaped so far and what i am talking about. the utter failure of all education about aids.
peter salovey is now provost of yale. he is one of the happiest, cheeriest slap you on the back fellows you will ever meet. he will probably be the next president of yale. i can see how a personality such as his would determine his results before he even dreams up the study. in reading just the paragraph you excised, showing that sadness and depression result if you tell the truth, so fucking what? for this we let one out of every five gays get infected because if we told them the truth they would get sad and depressed. excuse me, but these studies were done before the plague became the plague.
Here is what Sean said back to Larry:
You might check out the Sigma Research report on the ineffectiveness of scare tactics in HIV prevention campaigns.
It provides a summary of some research, but there are stacks of such studies. The best that I can see coming out of the DOH campaign is a generic greater awareness of HIV being a pain and possibly an increase in HIV testing. But the research shows it isn't likely to change the behaviors of the intended audience. Those who are already protecting themselves--and those who've lived through the trauma of the epidemic--are much more likely to like and "respond" to the campaign, but not those whose behavior we need to change.
What I propose is not a pipe dream. Much of it we have had in the past and other parts, like post-exposure prophylaxis, there's never been any serious effort to promote. I helped a young guy create a website, pepnow.org, to provide education and access to PEP. We're just now starting to promote it.
But to get PEP at most ERs in NYC is a nightmare, if you can get it at all. Read Louis Jordan's account of his PEP nightmare that we published in POZ.
Why doesn't the NYC DOH mandate a protocol for ERs to expedite access to PEP for those who present themselves at having been just exposed? Why don't we distribute three-day "starter kits" for young gay men to have in their medicine chests and available when the condom breaks at 3 am or they do something they quickly regret? Then they could start treatment immediately and buy some time until they can talk to their doctor or someone to assess risk and decide if they should go on the entire 28 day protocol or not? Why doesn't DOH or GMHC or other groups provide a 24 hour PEP delivery service?
Larry's response to Sean:
WHY WHY WHY WHY WHY. SEAN YOU KNOW WHY. BECAUSE "THEY" DONT AND WONT. PERIOD. YOUR ONE AT A TIME STUFF IS JUST BANDAIDS. PERIOD. AND THERE IS NO ACT UP TO DO WHAT NEEDS TO BE DONE. PERIOD. YOU AND I ARE PRACTICALLY THE ONLY ONES OUT THERE SAYING ANYTHING. PERIOD. ACT UP WORKED BECAUSE PEOPLE WERE FRIGHTENED. MAYBE WE HAVE TO SCARE THEM AGAIN. AT LEAST THE CONTROVERSY SHOULD STIR UP SOME VISIBILITY. OR IT WON'T. WHICH IS AS SCARY AS THE ADS. XXXX
And based on info supplied by Sean, Larry sent this apology to the executive director of the Gay Men's Health Crisis, Marjorie Hill:
MARJORIE, sean strub has forwarded me a number of studies that support your assertion that scare tactics do not work in changing behavior. at the same time several people have criticized them. ironically i happen to be a friend of the author of one of the main studies, peter salovey at yale, and i am hoping to discuss this issue with him when he is free. (he is now the provost.) so i apologize for calling you a liar on this issue. i do think that these studies were done so long ago that i wonder if in light of their own failure to be effective tools of prevention, they can be questioned as useful today.
That radical idea of Sean's to have the Department of Health or a service org deliver the PEP drugs is something I endorse, as something that could prevent a new infection. From San Francisco, I say, let the debate continue . . .