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
“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
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
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’.