A new 30-second HIV prevention advert,¹ from the New York City Health Department (NYC Health) and aimed at gay men, has caused a lot of controversy and divided HIV prevention advocates.

“It’s never just HIV,” it warns. “Having HIV puts you at higher risk of dozens of other diseases, even if you take medication.” It then goes on to list three: osteoporosis, dementia and anal cancer. “Stay HIV-free: always use a condom,” it ends.

Every fact in it is true and is something its target audience should probably be more aware of. But the controversy isn’t about what the ad says, but the way it says it.

It starts with spooky music and the kind of voiceover heard in horror movie trailers. Pretty, yet troubled, young men eye each other suspiciously as the actor intones the text. This gives way to a set of frightening images. Someone’s thigh bone snaps on the dance floor. A scan shows a brain shrinking to nothing (accompanied by a kind of frying sound). Then, introduced by the accelerating heartbeat that always precedes something really awful in a horror movie, there’s a blink-and-you’ll-hopefully-miss-it shot of what anal cancer really looks like (grim). Cue the young guys languishing in hospital beds.

Veteran US gay and HIV organisations GMHC and GLAAD quickly condemned the ad, calling it “sensationalistic and stigmatising”. In a letter to the mayor, requesting the withdrawal of the ad, the city’s HIV Health and Human Services Planning Council said that the ad implied young men were getting the conditions shown.² In fact, osteoporosis and dementia, though more common in people with HIV, are primarily conditions of age; anal cancer, while potentially lethal and a lot more common with HIV, is preventable with regular check-ups. In a press release, GMHC boss Marjorie Hill said that “studies have shown that using scare tactics is not effective” in HIV prevention.³

Some prevention campaigners, however, thought the ad was great. Writer Larry Kramer, instigator behind the pioneering activist group ACT UP, applauded the ad. “Thank you,” he said in an online response.⁴ “It’s about time. This ad is honest and true and scary, all of which it should be. HIV is scary and all attempts to curtail it via lily-livered nicey-nicey ‘prevention’ tactics have failed.” He went on to accuse Hill of lying when she said fear-based prevention campaigns did not work.

Clearly, if scary public health ads don’t work, then an awful lot of money has been wasted on pictures of diseased lungs on cigarette packets. Trying to make people afraid of the negative health consequences of behaviour goes back to World War II VD ads and further.

And yet there’s actually no terrifically strong evidence either way as to whether scaring people or, instead, giving them positive and empowering messages actually works better in HIV prevention. The most thorough review, conducted by two Yale University psychologists, dates from 2002.⁵ Its conclusion? Fear works...sometimes.

The authors pointed out that if you show someone a scary health-awareness ad, they can either react by avoiding the behaviour (good) or avoiding the fear (bad). Which way they will go tends to depend on whether they think they can avoid the negative consequences. So there are scary ads about cigarettes (because people can give up smoking) but not scary ads about Alzheimer’s (because there’s not a lot you can do about it).

The study showed that scary ads could increase HIV testing rates. But when it came to sexual risk behaviour, scare tactics only tended to have an effect on the people who were already ‘low risk’. It might, for instance, cause gay men who were already careful about HIV to avoid sex altogether.

But scare tactics don’t work, they found, on people who are already ‘high risk’; they only scare them further into being fatalistic. While citing ads with positive effects, it found some had negative ones, such as an Australian ad featuring HIV as the Grim Reaper. After that was aired, risk behaviour actually increased in gay men who’d seen it.

What people reporting high-risk sexual behaviour need instead are positive messages: you can adopt healthy behaviours, there will be positive consequences. Such ‘gain-framed’ messages have been found to work better – at reducing unprotected sex – for high-risk HIV-negative gay men than for HIV-positive ones.⁶

Scary ads like the New York one come from a frustration that HIV infection rates seem constant in gay men and so does risk-taking: in the last ten years, the regular UK Gay Men’s Sex Surveys reveal, the proportion of gay men who sometimes don’t use condoms has stayed stuck at around 50%.⁷ Gay men adopted condoms en masse in the late 1980s because there was something really scary around: a disease that was killing their friends young, and hideously. Gay men are unlikely to be that scared ever again.

We should continue to promote condoms, because they protect you against HIV and other sexually transmitted infections. But we may be at saturation point when it comes to achieving increased use, and fear campaigns may have unintended, negative consequences. The answer is probably not ‘condoms or else’, but, as we learn more about the effects of treatment as prevention, pre-exposure prophylaxis (PrEP) and other measures, ‘condoms plus’.