Wednesday, December 15, 2010

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,, 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:


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 . . .


Ken Howard, LCSW said...

I have always been very interested -- and VERY angry -- at the use of "fear-based" so-called HIV "Prevention" campaigns.

Along with my activist colleagues Al Benson, Tony Valenzuela, Peter McQuaid, and others, I believe we effectively quelched the disastrous "HIV: Not Fabulous" campaign a handful of years ago in Los Angeles, when I publicly INDICTED AIDS Healthcare Foundation on endorsing and funding such tactics (devised by some private, for-profit, "social marketing" agency in San Francisco). The campaign included deliberately negative images of a Black man in a diaper, an older gay man with advanced lipodystrophy, and other denigrating and mean-spirited "images", exploiting the HIV-positive "models" they recruited for the campaign.

At that time, as now, we demanded REAL PREVENTION. Not scare tactics, not campaigns which would pass muster with the Religious Right in order to receive Federal funding under the Bush Administration's Dept. of Health and Human Services and CDC, not stigma-producing, vague, USELESS "campaigns" that taught no one, nothing, except how to fear and hate those living with HIV/AIDS.

As a licensed psychotherapist and specialist in HIV mental health for over 20 years, the levels of HIV stigma even WITHIN the gay community continue at unacceptable levels, all while REAL prevention is COMPLETELY un-funded, such as REAL information on safer sex and preventing viral transmission in appropriate cultural contexts (gender, race, socioeconomic status, sexual orientation, gender identity).

I see the ravages of the stigma these "fear-based" campaigns cause EVERY day in my office. And it CAN lead to the suicide of those who are newly-infected. That's not these campaigns saving lives, that's TAKING them.

Larry Kramer has been through the mill, and he's a hero of an activist, and he's a hero of challenging "complaceny". But shrill, grotesque, fear-based tactics DO NOT work, unless the goal is to promote HIV stigma AMONG THOSE ALREADY POSITIVE, to the point where they avoid life-saving medical care, or getting tested in the first place.

We have to continue to fight the notion that "Neg" equals "Good Gay" and that "Poz" equals "Bad Gay". Too many gay men today feel that all they have to do is "shun" their poz peers and that will make them "safe" to have unprotected sex with their "neg" peers (who are sometimes newly-infected themselves, don't know it, and are highly infectious with high viral loads). Young gay men today receive NO formal HIV prevention education training; it's all left to hearsay, Wives' Tales, lies, guesses, and speculation. Meanwhile, new infections continue while stigma ABOUNDS.

All because agents of the Religious Right and their public-health abstinence-only "sympathizers" have been controlling HIV education for years, especially at the Federal level.

REAL HIV prevention is about education -- EXPLICIT, sexually-based education -- and mechanisms that prevent REAL infections, such as PEP and even perhaps PrEP. I would even add to that, how to successfully navigate the emotional and PHYSICAL aspects of a gay, long-term, poz-neg relationship (with PLENTY of sex) without viral transmission (I'm living proof of this, and there is a two-part article on this on my website,

NO to stigma, NO to scare tactics, NO to ineffective (expensive) campaigns, and NO to viral transmission.

It CAN be done!

Guscairns said...

Yes, fear-based campaigns can work: I believe, for instance, the US is about to follow the UK and a number of other countries in putting graphic images of rotting lungs etc on cigarette packets, because these work.

But unlike smoking, drink-driving etc HIV is an infectious disease and it takes both sides to modify their behaviour. I don’t think this will do anything to encourage healthy behaviours in guys with HIV – either diagnosed (it won’t help them disclose) or undiagnosed (it won’t encourage testing).

Ah, but the NYPHD is saying, it’s factual. Bollocks.

Yes, having HIV makes it more likely that you will develop certain conditions, some of them nasty.

But we do not know that bone mineral loss will mean our bones snap on the dancefloor: we do not know that the observed mild impairment seen in people with HIV will make our brains implode with Alzheimer’s 15 years early, and while we do know PLHAs have much higher rates of anal cancer, no one should ever actually develop it if they get their ass checked out regularly (but who would want to, seeing this ad?)

In any case, don’t talk to me about the factual truth of the text. This deliberately used images designed to terrify and was not a discourse about rates of osteopenia.

Crying wolf has a long history of failure in HIV prevention. Remember superinfection? You mustn’t fuck bareback if you’re positive because you’ll get another nastier virus. That was based on a few cases; because we never actually met anyone who’d suffered from a superinfection, it was widely discounted as a myth put out by ‘them’ to get ‘us’ to behave.

Yes, PLHAs currently have lifespans about 13 years shorter than the general population but 10 of these (this is the UKCHIC study) are due to late testing. Who would test, seeing this?

But that’s not the main reason it’s so nasty. Its nastiness is to do with issues that are, for gay men, much bigger than this lifelong and yes, still serious but increasingly treatable STD. I've been much more injured by divorce and heartbreak, being bullied at school, and my own internalised shame of being gay than I ever was by 25 years of living with HIV.

I hate this ad because it’s sadistic and bullying or – because no doubt gay men were involved in it – masochistic too. It’s horrified by gay men and gay sex in general, using images of bodily corruption and disease to ram home things that – despite 50 years of gay lib – we still feel about ourselves: look at the suicide, depression and drug use statistics. The message it gives –not factually, but with all the visceral power of that 5-frame shot of a ruined ass – is that if you’re out on the scene death and decay are stalking you, and serve you right if they get you.

I suspect it will work, a bit. A few young guys will probably be even more scared of gay sex than they already are and will probably shy away from the whole nasty business rather than stick a condom on. Abstinence programmes work for a while if you put enough fear of hell and damnation into people. But for a while is the point, and we know that when they stop being abstinent they’re less well equipped to have sex.

I recently found that the percentage of gay men in the UK Gay Men’s Sex Surveys who sometimes bareback has scarcely varied in the last decade: from 1998 to 2007, every year, it was 45% of all respondents, and 50% to 55% of men who had anal sex.

To the NYDPH (and Larry) that means we should do something NOW that’s much scarier and gives gay men a good SLAP!

To me it says that this is a refractory issue, a homeostasis, something balanced between gay men’s fear of HIV and their dislike of condoms. The problem is not that young gay men are 'complacent' and don't fear HIV: the problem is that they do fear HIV, but don't fear it enough. And the reality is that, no matter how horrifying the ads, they are never going to fear it enough again.
Gus Cairns
Editor, HIV Treatment Update