Media campaign on acute HIV infection symptoms has limited impact

A advertising campaign and website that aimed to raise awareness among gay men in Seattle, Washington, of the symptoms of acute HIV infection was recalled by a quarter of the target audience and had no impact on gay men’s knowledge or testing behaviour, researchers report in the advance online edition of Sexually Transmitted Infections.

Joanne Stekler of the University of Washington, who led the project, says that the results underline the importance of rigorous evaluation of media campaigns, in order to compare their effectiveness with that of other interventions.

Although up to 90% of people have symptoms of seroconversion in the first weeks of HIV infection, acute (or primary) HIV infection is rarely diagnosed because the symptoms are non-specific and because older testing technologies (such as antibody tests) cannot diagnose that people are in the acute infection stage.

Epidemiological modelling studies have produced conflicting estimates of the contribution of people in the primary infection phase to onward transmission of HIV. Anywhere between 9 and 50% of new infections could be attributable to onward transmission from a person in the primary phase of HIV infection, according to estimates drawn largely from models constructed using data from generalised epidemics in sub-Saharan Africa.

A study using data from a London sexual health clinic estimated that one-in-four new infections was attributable to onward transmission from a person in the primary phase of HIV infection.

If these models are correct in their estimates, alerting people to the symptoms of primary infection and encouraging early diagnostic testing might contribute to a reduction in onward transmission – if people act on the information provided through public health campaigns.

Diagnosis during primary HIV infection may also enable people to begin treatment at this time, although results from the recently published SPARTAC study suggest that a short period of treatment during primary infection has only a modest effect on HIV disease progression.

The ‘ru2hot?’ campaign aimed to increase gay and bisexual men’s knowledge of the symptoms of acute infection (especially fever, but also fatigue, rash, swollen lymph nodes, sore throat, joint and muscle aches, etc.) and to encourage men with symptoms to seek RNA testing. This is a testing technology able to diagnose people around nine days after infection, before antibodies have developed.

Press adverts and wallet cards directed men to the ‘ru2hot?’ website, which expanded on the campaign slogan. However, there were very few visitors to the website for the first year of the campaign, until it was relaunched with two billboard posters in Seattle’s main gay neighbourhood as well as banner adverts and an online presence on the Manhunt dating website.

Nonetheless, only 1164 unique visitors came to the website during a two-year period (usually for one visit only). The authors note that total spending on the campaign, including staff time, was $19,038 over three years – considerably less than a number of other campaigns, and possibly insufficient to reach a greater proportion of the target audience. Unfortunately the evaluation does not analyse the cost and reach of advertising in different media (billboards, wallet cards, etc.).

Four surveys were conducted among gay men attending a large sexual health clinic in Seattle. Two were conducted before the campaign began (total 200 men), one approximately six months after the campaign launch in 2009 (87 men) and one around six months after the billboard relaunch of the campaign in 2010 (79 men).

A minority of respondents remembered the campaign but levels of knowledge did not generally change.

• Recall of the ‘ru2hot?’ slogan: 10% after launch, 23% after relaunch.
• Understood ‘ru2hot?’ to refer to acute HIV infection: 9% after launch, 25% after relaunch.
• Could name at least two acute infection symptoms or mentioned a “flu-like illness”: ranged from 57 to 61% in the surveys, not a statistically significant difference.
• Named fever as a symptom: ranged from 31 to 44% in the surveys, not a statistically significant difference. However, more men who remembered the campaign mentioned fever – 72% in the final survey.

Moreover, an analysis of data on gay men taking HIV tests in Seattle, between 2004 and 2010 (including the campaign period of 2009 to 2010) did not suggest that the campaign changed health-seeking behaviour.

• HIV testing: increased significantly over time, but there was no additional change following the campaign launch.
• Men diagnosed during acute infection: increased significantly over time, but there was no additional change following the campaign launch.
• Men reporting concern about possible symptoms when testing: no statistically significant change over time

Concluding, the authors underline the importance to public health of diagnosing people who have acute infection, as they are thought to contribute disproportionately to onward transmission. But health education campaigns need to be evaluated so that their effectiveness can be compared to that of other strategies.

They authors say a multifaceted approach to the issue may include the use of more sensitive tests (such as fourth-generation tests or RNA tests), frequent testing in populations at risk, health promotion campaigns on symptom recognition and education for healthcare providers.

Stekler JD et al. ru2hot?: A public health education campaign for men who have sex with men to increase awareness of symptoms of acute HIV infection. Sexually Transmitted Infections online advance edition,  10.1136/sextrans-2012-050730, 2013,