Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

“Assumptions” Fails to Reduce HIV Transmission– A Critique of the First HIV Prevention Campaign Targeting Gay Men in Canada – Danielle Finkelstein

The incidence of HIV among men who have sex with men (MSM) in Canada had been declining through 1996 due to effective prevention campaigns and widespread education about the importance of practicing safe sex. But, during the late 1990’s through 2000, researchers found an increase in incidence among all populations; however, gay men in Canada continue to be most affected by HIV. By the end of 2002, of approximately 56,000 Canadians living with HIV, 32,500 (58%) were MSM. MSM also made up the largest group of new infections for that year – approximately 40% of the nation’s total (1). Research conducted across all of the provinces in an effort to explore reasons for the recent change showed an increase in risky behavior among MSM, specifically related to unprotected anal intercourse (UAI). As a result, for the first time since HIV/AIDS first appeared in Canada, a handful of major health organizations began collaborating in order to implement the first nation-wide HIV prevention campaign targeting gay men: The Assumptions campaign.
The Assumptions campaign’s design was based on research data from San Francisco, California in the late 1990’s when researchers found that the increase in UAI among MSM was due to men’s faulty assumptions that their sexual partners were of the same serostatus as themselves (2); “serostatus” is a term that refers to HIV negative or HIV positive status. To address this issue, the Assumptions campaign was created with the intention of lowering HIV transmission by convincing men to disclose their serostatus to their partners. The message was specifically targeted towards men who have frequent, and sometimes anonymous, sex partners of unknown serostatus. The campaign consisted of billboards, posters, washroom ads, transit ads, coasters, and condom packages (2). A majority of the billboards and ads featured two men who were shirtless and, from their positioning, appeared to be engaged in various sexual acts. The text on the ads was placed so that one man is thinking “He’d tell me if he’s positive,” while his partner is thinking “He’d tell me if he’s negative.” Other variations of ads included the text “He does it raw. He must be positive,” “I don’t have it yet. I must be immune,” and the pair “He hasn’t asked for a condom. He must be positive; He hasn’t asked for a condom. He must be negative” (2). The text “How do you know what you know?” appeared on the bottom of all of the ads, along with the campaign’s website “” (2).
The campaign was initiated in San Francisco in 1999 and 2001, before Canadian organizations decided to implement it across the country. The Canadian health organizations slightly modified the campaign to better suit their population, specifically by developing identical advertisements in both English and French. Assumptions was implemented in Canada during the summer of 2004. This critique will discuss existing evidence that proves the Assumptions campaign was designed with fundamental flaws, such as reliance on ineffective theories, assumptions, and marketing tools. These flaws ultimately set the campaign up for failure and therefore explain its inability to reach the desired goal: to significantly increase disclosure of serostatus to reduce the transmission of HIV among MSM in Canada.
The theoretical design of the Assumptions campaign is based on an individual model of behavior change, such as the Health-Belief Model. This type of model assumes that invoking thought about a healthy or risk-reducing behavior, such as wearing a condom or disclosing HIV status, will lead to performing that behavior. Due to the faulty design, the campaign disregards the idea of self-efficacy and other factors known to influence behavior. The Health-Belief Model, which was developed in the 1950’s by social psychologists Hochbaum, Rosenstock, and Kegels, states that behavior is motivated by perceived susceptibility, severity, benefits, and barriers (3). Each of these terms is defined as the following: Perceived susceptibility is the degree to which a person feels at risk for a health problem; perceived severity is the degree to which a person believes the consequences of the health problem will be severe; perceived benefits are the positive outcomes a person believes will result from the action; and perceived barriers are the negative outcomes a person believes will result from the action (3). According to the Health-Belief Model, the individual weighs all of these elements when he decides whether or not to perform the behavior in question. The model assumes that as long as the perceived susceptibility and perceived benefits are strong enough to outweigh the barriers, the person will make the rational decision to perform the healthy behavior.
The Assumptions campaign applied elements of this model in its advertisements by presenting the perceived susceptibility and perceived benefits of disclosing one’s serostatus. Perceived susceptibility is represented by the text “He’d tell me if he’s positive” and “He’d tell me if he’s negative,” followed by the phrase “How do you know what you know?” (2). The message attempts to convince men that as long as they are unaware of their partner’s status, their guess could be wrong and therefore they might have a high risk of either contracting HIV or infecting their negative partner. Perceived benefits are implicit also in the phrase “How do you know what you know?” This phrase is used to subtly convince men that they would be better off knowing, rather than guessing, the serostatus of their partner. The advertisements are designed with these phrases to show that one is susceptible if he does not talk to his partner about serostatus. The benefits of this conversation are knowledge of serostatus and, consequently, the ability to decide whether protection against HIV is necessary. Unfortunately, behavior is not so easily swayed, and trying to convince men to disclose serostatus simply because their assumptions or guessing skills are not up to par is a one-dimensional, ineffective approach. This is a result of the lack of consideration of any factors that influence behavior outside of perceived susceptibility and perceived benefits.
One of the most important determining factors in health behavior is self-efficacy. Self-efficacy, which was developed by psychologist Albert Bandura, is defined as “a person’s belief in his or her ability to take action” (3). When applied to disclosing serostatus, self-efficacy is the belief that one can successfully disclose his serostatus to his partners or ask for his partner’s serostatus. A major reason the Assumptions campaign’s application of the Health-Belief Model is ineffective is because it lacks this construct. Research concerning serostatus disclosure among MSM has shown that low self-efficacy is a great risk factor for non-disclosure (4, 5, 8). A study that included 1168 seropositive gay and bisexual men in New York City and San Francisco showed that significantly higher levels of self-efficacy to disclose were reported by consistent disclosers (men who disclosed serostatus to all partners) as compared to inconsistent disclosers and non-disclosers (4). Additionally, seropositive non-disclosers report more frequent risky behavior, such as unprotected anal intercourse (UAI), with multiple partners of either HIV-negative status or unknown serostatus (4, 8).
Ultimately, if a man does not feel that he can disclose his status, then he will most likely not do so. The Assumptions campaign advertisements were not designed with self-efficacy in mind, and there is no attempt among the text or images to convey the message that serostatus disclosure is an achievable goal. No information is given on how to go about having this conversation, and therefore, one could argue that the lack of resources insinuates that disclosure is such a difficult act that not one piece of advice could possibly be relayed through a simple billboard or coaster.
The Assumptions campaign advertisements were designed to increase serostatus disclosure in hopes to reduce HIV infections; however, in 2002, after the Assumptions campaign had been implemented twice in San Francisco, research became available which showed that increasing serostatus disclosure does not necessarily lead to decreased HIV infection (8). There are a number of reasons for this, one of which is a relatively recent trend in the MSM community called “barebacking.”
Men in the MSM community who intentionally seek out UAI are called barebackers. Some men choose to participate in barebacking only with men of concordant serostatus, whereas others will participate with men of either serostatus, including those with unknown serostatus (6). This term has been defined in a number of different ways among MSM and behavioral researchers, and therefore many questions remain surrounding it and the men who consider themselves to be barebackers. In the following research, barebacking was defined as “intentional anal sex without a condom with men who are not a primary partner” (6). A study with a sample of 554 men in San Francisco in 2001 showed that 10% of MSM had participated in barebacking in the previous 12 months. Of these men, 35% were seropositive, 61% were seronegative, and 4% were of unknown serostatus (6). In another study of 1168 seropositive MSM in New York and San Francisco in 2005, 27.2% participated in barebacking. Of these men, 42.7% engaged in barebacking only with seropositive men, 2.2% only with seronegative men, and 11.7% only with men of unknown serostatus. The remaining 43% engaged in barebacking with all groups (7).
Ultimately, men who participate in barebacking are intentionally seeking high-risk sexual behaviors such as UAI, and an ad campaign like Assumptions will most likely be ineffective in this population. These men already know that they are putting themselves and/or their partners at risk of either spreading or contracting HIV; in fact, they make the conscious decision to do so. Consequently, an advertisement that informs them that they could be having UAI with non-concordant partners is old news. The reasons why men participate in barebacking, such as “greater physical stimulation” and “feeling emotionally connected with a partner,” (6) are not outweighed by the risk of HIV for men who engage in this behavior with discordant partners. And not surprisingly, the Assumptions campaign does nothing to address this issue. The advertisements carry the assumption that if men knew they were engaging in UAI with discordant partners, they would change their behavior. Research on barebacking has proven that this is not always the case.
Another reason why increasing serostatus disclosure is an ineffective way to reduce HIV infection is because disclosure does not necessarily increase use of condoms (8). For example, among seropositive men who disclosed to some of their seronegative or unknown status partners, 49% still engaged in UAI (8). These men believed that “they had done their part and that the responsibility for safer sex rested on their partner” since they had disclosed, and if their partner wanted to have unprotected sex, “they viewed it as his choice because he had been informed” (8). The researchers also stated that disclosure of seropositive status “may promote a greater sense of trust, intimacy, or emotional closeness that can cause some serodiscordant couples to be more willing to have unprotected sex” (8). Surprisingly, this research was conducted by the same organizations that designed the Assumptions campaign in San Francisco. And yet, even though they were aware that the basic design of the campaign was proven to be ineffective for a number of reasons, they still allowed Canadian health organizations to adapt the campaign for their use.
The extreme complexity of serostatus disclosure renders advertisements less effective, such as those in the Assumptions campaign. For example, some seropositive men will go to great lengths to avoid disclosing their serostatus by not having sexual relationships or by only being involved with anonymous partners (8). These issues need to be addressed in a much more in-depth and comprehensive manner.
The Assumptions campaign was designed and implemented with social marketing theory in mind. Social marketing theory is defined as an “approach to health communications and behavior change in groups or populations that incorporates principles of marketing to achieve health aims,” and it relies on “the four P’s: Product, price, place, and promotion” (3). When applied to the Assumptions campaign, the product being offered is disclosure of serostatus; the price is the difficulty involved in disclosure; the place is where the ads were distributed, including billboards and washrooms; and promotion is how the MSM population was informed about the campaign, possibly through the campaign’s website or through its sponsoring health organizations. While this approach may be effective for influencing other health behaviors such as HIV testing (9), in this case, social marketing was not practical. A great deal of research exists that shows the benefits of using a community-level approach in HIV prevention efforts, and furthermore, the researchers themselves who were behind the Assumptions campaign stated in 2002 that a “1-size-fits-all approach to prevention with HIV-positive MSM will not succeed” (8).
It seems apparent that social marketing theory would not be effective in a campaign such as the Assumptions campaign solely because the target population was so small and not confined to specific areas throughout Canada. The billboards used in the campaign were erected in major metropolitan areas of Canada’s provinces including Toronto, Montreal, Vancouver, Halifax, Edmonton, and Winnipeg; as expected, there was much negative feedback from local community members who felt that the advertisements were too graphic to be displayed in public areas visible to children (2). Some of the feedback from community members included “’Your subway posters are offensive and border on pornography!’” and “’This is pornography, not health,’” (2). Some companies even refused to display the billboards and public transportation ads because they could be “viewed as offensive to the general public and [the company’s] land owners” (2). Because of the public displays used, a majority of the population was unnecessarily exposed to the campaign, which created a lot of controversy and possibly took away from the initial message of the campaign.
Instead of social marketing, a community-level, evidence-based approach would have been much more effective since this type of intervention has “demonstrated impressive reductions in HIV risk behaviors […] among a range of target populations” (10). For example, a study of community-level HIV interventions in 5 cities across the US found that handing out condoms to high-risk populations was effective in increasing condom use and condom carrying, including among the MSM population (11). Another study of 8 US cities found that training a popular gay male in the community to discuss safe-sex practices with other MSM was an effective way to increase condom use and decrease UAI (12). The main difference between these community-level approaches and the social marketing used for the Assumptions campaign is human interaction. When billboard ads are used to deliver an important message, they should be clear and concise; however, many men found the ads to be confusing: “'Some people might see these as true statements’” [i.e. “I must be immune” or “He likes it raw. He must be positive”], “’I don’t get the message. I just get a little ‘thought,’’” and “’It takes a lot of work to actually get to the meaning’” (2). Therefore, even though a majority of the target population was exposed to the campaign in one way or another, many might have walked away either confused or with misunderstanding concerning the message of the campaign. Conversely, with a community-level approach, professionals are more likely to be available to answer questions and encourage communication between the target population, relevant local organizations, and other health professionals.
It is apparent that the initial design of the Assumptions campaign was flawed as a result of its reliance on the Health-Belief model, false assumptions about serostatus disclosure, and by choosing to use social marketing theory. Though it may have been deemed partially effective because a majority of MSM were exposed to the advertisements (2), greater efficacy should be expected from HIV prevention programs that have been used repeatedly. Even though there is still much to be done in HIV prevention, researchers and public health professionals can learn from those interventions that have been found to be effective, such as many community-level prevention programs, and build on these valuable resources to further promote health among gay men by reducing HIV infections.
1. Health Canada. Estimates of HIV prevalence and incidence in Canada. Canada Communicable Disease Report, 2003.
2. Trussler T, Marchand R. Prevention Revived: Evaluating the Assumptions Campaign. Community Based Research Centre, 2005.
3. Edberg M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. Semple SJ, Patterson TL, Grant I. Psychosocial Characteristics and Sexual Risk Behavior of HIV+ Men Who Have Anonymous Sex Partners. Psychology and Health 2004; February; 19(1): 71-87.
5. Parsons JT, Schrimshaw EW, Bimbi DS, Wolitski RJ, Goemez CA, Halkitis PN. Consistent, inconsistent, and non-disclosure to casual sexual partners among HIV-seropositive gay and bisexual men. AIDS: Official Journal of the International Aids Society 2005; 19(1):87–97.
6. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. ‘Barebacking’ in a diverse sample of men who have sex with men. AIDS: Official Journal of the International Aids Society 2002: 16(4):653-659.
7. Halkitis PN, Wilton L, Wolitski RJ, Parsons JT, Hoff CC, Bimbi DS. Barebacking identity among HIV-positive gay and bisexual men: demographic, psychological, and behavioral correlates. AIDS: Official Journal of the International Aids Society 2005; 19(1):27-35.
8. Wolitski RJ, Parsons JT, Gómez CA. Prevention with HIV-Seropositive Men Who Have Sex With Men. Journal of Acquired Immune Deficiency Syndrome 2004; 37(2):101-109.
9. Futterman DC, Peralta L, Rudy BJ, Wolfson S, Guttmacher, S, Rogers A. The ACCESS Project: Social Marketing to Promote HIV Testing to Adolescents, Methods and First Year Results From a Six City Campaign. Journal of Adolescent Health 2001;29s:19-29.
10. Collins C, Harshbarger C, Sawyer R, Hamdallah M. The Diffusion of Effective Behavioral Interventions Project: Development, Implementation, and Lessons Learned. AIDS Education and Prevention 2006; 18:5-20.
11. Wolitski RJ, et al. Community-Level HIV Intervention in 5 Cities: Final Outcome Data From the CDC AIDS Community Demonstration Projects. American Journal of Public Health 1999; 89(3):336-345.
12. Kelly JA, Murphy DA, Sikkema KJ, McAuliffe TL, Roffman RA, Solomon LJ, Winett RA, Kalichman SC. Randomized, controlled, community-level HIV-prevention Intervention for sexual-risk behavior among homosexual men in US cities. The Lancet 1997; 350:1500-1505.
13. Gorbach PM, Galea JT, Amani B, Shin A, Celum C, Kerndt P, Golden MR. Don’t ask, don’t tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practicing high risk behaviour in Los Angeles and Seattle. Sexually Transmitted Infections 2004: 80:512-517.

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