The Get Talking, Get Tested Campaign: A Social Sciences Critique and Recommended Improvements – Dana Greeson

HIV/AIDS has been a highly stigmatized illness since the epidemic began in the United States in the early 1980s. The “4 H’s” referred to the groups who were most associated and often blamed for the spread of the virus: homosexuals, heroin addicts, Haitians, and hemophiliacs (1). HIV has had a devastating impact on these groups and each has reacted in different ways. In recent years, with the advent of antiretroviral treatment, HIV has shifted from a death sentence to a chronic disease in high-income countries. The Office of HIV/AIDS within the Massachusetts Department of Public Health provides services such as prevention, education, counseling, testing, client services and health and support services (2). The MDPH emphasizes multicultural health and recognizes that minorities and those living in poverty face a high burden of HIV/AIDS (2). The Get Talking, Get Tested campaign through the MDPH encourages African Americans and other black residents in Massachusetts to get HIV testing and talk about it with their loved ones (3). While this campaign targets one of the highest-risk populations in the state, the message is too narrow, with certain key issues ignored. In this paper I will use principles from the social and behavioral sciences to critique the Get Talking, Get Testing Campaign (GTGTC) and present ways to improve the campaign based on these principles.

Get Talking, Get Tested

According to MDPH Commissioner John Auerbach, "this campaign encourages people to get tested, not just for their own sake, but for the sake of their family and for their community as a whole. We want people to know that testing is fast, free and confidential, and to understand that getting tested for HIV should be a regular part of their health care routine" (3).

Campaign posters state “HIV testing is fast, free and confidential.” There are three styles of posters: one with two black men, another with a black man and a black woman and a third with two black women (see Annex 1). The relationships between the pairs are ambiguous. For example, the poster with the two women can be perceived as two friends, sisters, a mother and daughter, or partners.

Why Focus on the Black Population

The African American and black populations in Massachusetts carry an inequitable burden of HIV/AIDS compared to other race ethnicities. Data from the MDPH show that 50% of recently diagnosed women and 25% of recently diagnosed men are black non-Hispanic (4). Among those living with HIV/AIDS, 41% of women and 23% of men are black (4). Aside from race, country of origin also plays a role in the HIV/AIDS disparity. From 2004 through 2006, 44% of women and 22% of men diagnosed with HIV were born outside of the U.S. (4). Different populations differ in their modes of exposure to HIV/AIDS and therefore require separate interventions. For example, drug use is the primary exposure for white women where as heterosexual sex is the primary exposure for black women (4).

The Biopsychosocial Model of Health

The first social science approach that I will use to critique the Get Talking, Get Tested campaign is the Biopsychosocial Model created by Dr. George Engel in 1977 (see Annex 2). Dr. Engel was a psychiatrist who sought to address the shortcomings of the biomedical model of health. He recognized that the gap between the fields of medicine and psychology was negatively affecting patients. Dr. Engel stated that health and disease were strongly influenced by society, culture, and psychology and that providing patients with quality care required practitioners to look beyond biology and physiology (5).

Although there are effective testing and treatment methods for HIV/AIDS that fit within the biological circle of the Biopsychosocial Model, the sociological and psychological circles require more attention. Within the U.S., there has been substantial HIV/AIDS social marketing that promotes prevention and testing. Although these campaigns have aimed to reduce HIV/AIDS stigma, it remains deeply embedded in many cultures. In this sense Positive Deviance (PD) may be an effective approach in targeting specific cultures and communities and enhancing the sociological circle of this campaign. PD is a behavior change approach based on the idea that community problems have existing solutions within the community (6). This approach takes advantage of existing community resources and solutions and often leads to more practical interventions than those that come from outside of the community (6). Using Positive Deviance to decrease HIV/AIDS stigma could work by presenting respected HIV positive community members, who are leading productive lives, to the specific cultural groups of which they are members (these people are referred to as “positive deviants”). For example, if gender inequity was an issue within a culture, a campaign could show a well-respected man in the community supporting his wife or girlfriend getting tested. This could effectively reduce stigma and decrease gender barriers to testing.

The Lazarus Effect is a phenomenon that can also be used to reduce HIV/AIDS related stigma. This refers to the idea that antiretroviral drugs (ARVs) can transform a person from nearly dead to relatively healthy and could also be applied the sociological circle of this campaign (see Annex 3). This effect received its name from the bible, where Jesus raises Lazarus from the dead, which is essentially what ARVs are doing for people living with HIV/AIDS. The Lazarus effect is perhaps the most effective type of social marketing for community members as it provides proof of the efficacy of ARVs and the benefits of being tested and taking appropriate medications. Positive Deviance and the Lazarus effect are some examples of how the sociological circle can be improved.

The psychological circle of the Biopsychosocial Model should be addressed through culturally appropriate counseling and support groups. Although the Office of HIV/AIDS provides counseling, the Get Talking, Get Tested Campaign does not mention counseling in its advertisements. This information should be more explicit for target populations. Studies have shown that fear and avoidance play a large role in why many people go unscreened for a variety of illnesses (7). Counseling has been one effective method of addressing these fears (8).

The Political Economy Approach

Although HIV was originally associated with homosexual men, prevalence among women has been steadily increasing in Massachusetts (4). As discussed above, incidence in women is higher within cultures and communities where women are marginalized. Risk factors for women are related to socioeconomic status, country of origin, religion, education level and power differentials within romantic relationships.

Political Economy provides a macro level approach to understanding and addressing these types of disparities in health. There are three key components to the Political Economy approach. The first step is to think of a health issue as the result of certain societal interactions such as those mentioned above (class, gender, etc.) (9). Next, this approach looks at health issues as being part of a trajectory of risk, which is influenced by relationship patterns in society (9). The Political Economy approach states that public health interventions must address societal relationships that contribute to the issue (9).

The Get Talking, Get Tested campaign addresses societal components of HIV/AIDS, but not some of the most important ones. The campaign recognizes that HIV/AIDS prevalence is higher for black residents than white residents in Massachusetts. Black residents make up six percent of the Massachusetts population, but account for 28 percent of residents with HIV/AIDS (3). They are 11 more likely to have HIV/AIDS than white residents (3). The campaign has been effective at targeting black communities through health care centers and advertisements in the Massachusetts cities with the highest incidence of HIV among black residents (32-61%: Boston, Springfield, Worcester, Lynn and Brockton) (3) (10).

While it is extremely important that the black community receive targeted HIV/AIDS messages, it is also important that gender inequality is addressed. Gender inequality is a relationship pattern that can contribute to a trajectory of risk for HIV/AIDS within and outside of the black community. Some of the highest-risk residents in Massachusetts are immigrant and refugee women who do not speak English, have low levels of education, are uninsured, and face substantial gender inequality within their relationships (4)

In a recent lecture, Dr. Nicole Prudent, a Haitian physician at Boston Medical Center, discussed some of the societal obstacles for young Haitian immigrant women related to HIV. She explained that Haitian women are valued most in their roles as wives and mothers (11). Many of these women have already experienced trauma when they arrive in the U.S. They have difficulty finding jobs and gaining financial independence and are unsure how to access health care. If they are in a relationship, they probably lack decision-making power. If they are not in a relationship, they are likely feeling pressure from their families. These women also come from a culture in which HIV has been highly stigmatized. Dr. Prudent explained this scenario so that we could understand all of the factors that might prohibit young Haitian women from getting tested for HIV. These women are already feeling completely overwhelmed and the possibility of being diagnosed with HIV is terrifying. If a married Haitian woman is diagnosed with HIV her husband may abuse her and/or leave her. If a single woman is diagnosed she is unlikely to fulfill the valued role of wife and mother and may be shunned by her family. While Dr. Prudent agreed that testing is absolutely necessary, she explained that it cannot be the first step in a HIV campaign. Although this example is about Haitian women, it is generalizable to other marginalized groups who are already struggling with an overwhelming amount of issues and cannot imagine facing one more challenge.

The GTGTC does not mention anything beyond the test itself. What kind of support will be provided for those who test positive? Are there examples of people from similarly marginalized groups who are better off for being tested? What kinds of treatment barriers exist for undocumented persons with HIV? These are important societal questions that would be addressed in the Political Economy Approach.

The Communications Theory

The Communications Theory is based on the communication process where the goal is for the message receiver to interpret and act based on the message (9). The first thing to consider when disseminating public health messages is whether the target population can relate to the messenger. The messenger must encode the message to have the optimal effect on the population. A major communications challenge with HIV/AIDS campaigns is that high-risk people speak a variety of languages and literacy rates are sometimes low. The GTGTC has only printed materials in English. This is a major flaw in the campaign. In the Haitian community, a respected Haitian woman, such as Dr. Prudent, might be the ideal messenger since she shares a cultural background with the target population. The GTGTC could distribute materials in various other languages depending on the venue and target population. Of course, this still leaves the issue of illiteracy in ones native language, which can be addressed through other channels such as the health radio program that Dr. Prudent does in French Creole. Another ideal channel within the Haitian community is church since the population is almost exclusively Catholic and attendance is high. This may prevent many women who cannot read from missing out on important information.

Improving the Get Talking, Get Tested Campaign

In this section of the paper I will explore improvements that can be made to the Get Talking Get Tested Campaign by applying the three social science models previously discussed. The goal of these improvements is to better reach high-risk subgroups within African American and other black communities in Massachusetts.

Improvements based on the Biopsychosocial Model of Health

I explained earlier how the GTGTC falls short of meeting the Biopsychosocial Model of Health and how other approaches, such as Positive Deviance, may be more effective in addressing the sociological and psychological circles within the model. Positive Deviance looks to solutions already present within a community and relies on respected community members to disseminate health messages. Several ideas that I will present in this section can also be applied to the Communications Theory.

Kalichman and Coley designed a study to test the idea that people are more receptive to messages delivered by someone who they perceive as similar. Factors that one may have in common with the messenger are age, race, sex, ethnicity, religion, education level and socioeconomic status. They randomly assigned 100 black women in a health clinic to watch one of three videos on HIV testing. The narrator in the first video was an African American man. An African American woman narrated the second and third videos, but the third video also included culturally relevant consequences of not getting tested such as not living long enough to raise ones children (12). Results showed that the women rated the narrator in the third video as being significantly more concerned about them, their families and their communities. Of the women who watched the third video and stated intention to be tested within two weeks, 63% followed up compared to 23% who watched the second video and none who watched the first video (12).

Although the GTGTC did not use video as a communication channel, an issue I will discuss below, I would recommend that the MDPH partner with trusted organizations within the black and immigrant communities of Massachusetts. Berlo and colleagues state that trustworthiness and expertise are the most important factors that one considers in determining whether a source is credible (13). Currently, the only emblem on GTGTC material is the one for the Massachusetts Department of Public Health. Since the state government runs the DPH, there may be issues of trust for undocumented immigrants, and black people in general, who have a history of being mistreated by the government and medical institutions. If these subgroups see that trustworthy organizations are partnered with the Department of Public Health on the HIV testing initiative they will likely be more apt to get tested, just like the women in the Kalichman and Coley study. The Multicultural AIDS Coalition, run through the African Health Initiative Boston, is an example of an organization that works specifically with the immigrant and black populations and is therefore likely to be perceived as more trustworthy.

Levy and colleagues studied the reasons for delayed HIV presentation among immigrants and found that it was associated with a lack of knowledge, secrecy, stigma and symptom specific health seeking behavior (14). Undocumented immigrants who avoid testing due to fear of deportation would likely be more apt to get tested if they could identify a trustworthy organization in partnership with the campaign. At the very least, they could seek guidance and have their concerns addressed by the organization. The Lazarus Effect could also be incorporated into campaign materials to demonstrate that diagnosis can lead to better health and quality of life. While source credibility, Positive Deviance and the Lazarus Effect address the sociological circle of the Biopsychosocial Model, the campaign should also communicate the availability of appropriate counseling services and supports to address the psychological circle.

Improvements based on the Political Economy Approach

The subgroups of the population that are most negatively affected by HIV/AIDS mirror many of the subgroups that are vulnerable to poor health outcomes in general. According to the Political Economy approach, interventions must consider various societal interactions, such as class and gender, which may put people at increased risk of various health outcomes. (9). One of the most concerning factors is that the relative risk of HIV infection is 11 for blacks compared to whites. This disparity is exacerbated among women of color who make up 83% of new HIV diagnoses among women in Massachusetts (2). People of color living with HIV/AIDS also face increased mortality compared to whites with the virus. Another trend is for immigrants to be diagnosed much later than those born in the U.S. A significantly higher percentage of immigrants are diagnosed with AIDS within two months of their HIV diagnosis (36% versus 25%) (2). These statistics show the importance of targeting not only the black population as a whole, but also immigrants and women within it.

The Political Economy approach is another example where a positive deviant within a community can set a good example. In this case, a respected male can encourage other men to respect the women in their lives, both in general and in regard to health. Similarly, respected black men can encourage their peers to come together and get tested in an effort to decrease stigma and the spread of HIV within the black community. A positive deviant woman or a group of women can strategize safe and realistic ways of gaining power and respect within their relationships, families and communities. Since contracting HIV is often a product of marginalization, increasing women’s self efficacy and power, which is certainly easier in theory than practice, should serve to decrease their vulnerability to contracting the virus and delayed testing. Campaigns that promote HIV testing, must emphasize and provide adequate support both pre and post-testing. The more marginalized a person is who is being tested, the more severe consequences s/he may face upon testing positive.

Improvements based on the Communications Theory

Since I have already addressed the importance of perceived similarity, trustworthiness and expertise in health messengers, I will focus on the channel and language components of the Communications Theory. The GTGTC material is only presented on billboards and other printed media, which may be missing the most vulnerable subgroup: immigrant women of color who do not read English. Instead, I propose that airing short commercials on specific television channels watched by these populations would be more effective in reaching this target audience. Women from the various subgroups should be consulted for their ideas and opinions throughout the creation of these commercials. Research is needed to determine the channels and times of television viewing among specific population subgroups. Next, several versions of the commercial would be piloted among subgroups to ensure cultural and linguistic appropriateness. This channel of communication would reach those who cannot read English or do not commute to work and are therefore less likely than their male counterparts to see advertisements on buses and billboards. Other communication channels to consider are beauty parlors, churches and antenatal clinics depending on the specific subgroup.

Conclusion

While the Get Talking, Get Tested campaign is off to a good start in that it targets high-risk populations, it does not delve deeply enough into the trauma associated with HIV testing and the cultural barriers that may inhibit someone from being tested. Applying the Biopsychosocial Model of Health to this campaign emphasizes the need for some cultures to have more positive examples of people they can relate to who have been tested and/or are HIV positive and leading productive and meaningful lives. Culturally appropriate counseling and support groups may help with the avoidant behavior associated with testing. The Political Economy approach encourages campaigns to look at the big picture in order to understand the societal barriers that people face in seeking health care. Finally, the Communications Theory stresses the importance of using appropriate messengers, language and channels in disseminating public health messages. Applying these three social science theories to the Get Talking, Get Tested Campaign could help it to impact the most vulnerable members of society through increased HIV testing and use of comprehensive HIV/AIDS services.

References

(1) Gallo RC. A reflection on HIV/AIDS research after 25 years.. Retrovirology 2006, 3:72 2006 10/20/06;3(72).

(2) Massachusetts Department of Public Health HIV/AIDS Bureau. An Added Burden: The Impact of the HIV/AIDS Epidemic on Communities of Color in Massachusetts. World AIDS Day December 1, 2007. 2007 12/1/07:1-14.

(3) Health and Human Services. Get Talking, Get Tested. DPH Office of HIV/AIDS Expands Awareness Campaign. 2009; Available at: http://www.mass.gov/?pageID=eohhs2pressrelease&L=1&L0=Home&sid=Eeohhs2&b=pressrelease&f=090203_get_talking_tested&csid=Eeohhs2. Accessed 4/2, 2009.

(4) Massachusetts Department of Public Health. Massachusetts HIV/AIDS Data Fact Sheet. Women at Risk of HIV Infection. 2008 6/08:1-3.

(5) Engel G. The Need for a New Medical Model: A Challenge for Biomedicine. Science, New Series 1977 4/8/77;196(4286):129-136.

(6) Sternin M, Sternin J, Marsh D. Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach - A Field Guide. 1998 12/98:1-85.

(7) Vermunda SH, Wilson CM. Barriers to HIV testing-where next? The Lancet 2002 10/19/02;360(9341):1186-1187.

(8) Irwin KL, Valdiserri RO, Holmberg SD. The acceptability of voluntary HIV antibody testing in the United States: a decade of lessons learned. AIDS 1996 12/96;10(14):1707-1717.

(9) Edberg M. Essentials of Health Behavior. Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2007.

(10) Goodhue T. Executive Office of Health and Human Services Department of Public Health, Memo. 2008 6/6/08:1.

(11) Prudent N. 2009 4/2/09;Lecture.

(12) Kalichman S, Coley B. Context framing to enhance HIV-antibody-testing messages targeted to African American women. Health Psychol. 1995;14:247-254.

(13) Berlo D, Lemert J, Mertz R. Dimensions for evaluating the acceptability of message source. Public Opin. 1969;33:563-576.

(14) Levy V, Prentiss D, Balmas G, Chen S, Israelski D, Katzenstein D, et al. Factors in the Delayed HIV Presentation of Immigrants in Northern California: Implications for Voluntary Counseling and Testing Programs. J Immigrant Health 2007;9:49-54.

Foundations Of A New HIV Intervention Among Young Black MSM –Allan Welter

Introduction
Evidence shows that individual, interpersonal and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (men who have sex with men) (5, 6, 12). The individual-level component of an intervention is effective when modifying HIV-related knowledge, attitudes and beliefs held by MSM. Increasing perceived self-efficacy among MSM in relation to safer-sex behaviors is also crucial in the individual-level component of the intervention. The interpersonal-level component of an intervention is effective when aimed at changing knowledge, attitudes and beliefs about MSM in small groups of people. Group intervention among family members and close acquaintances of MSM is the main focus of the interpersonal-level. Finally, the community-level component of an intervention is effective in motivating and reinforcing behavior change among those who do not participate directly in the individual and interpersonal levels of the intervention (6).
A Hypothetical Alternate HIV-Intervention to the “Use a Condom Every Time” Campaign
New studies have shown that the annual increase of HIV among young black MSM is as high as 15% (3). In response, the public health department of Washington DC chose young Black MSM in metropolitan Washington DC as the key population of interest for a new culturally sensitive HIV intervention campaign running on individual, interpersonal, and community levels. The goal of this intervention was to increase rates of safer sex practices among young Black MSM.
Individual-Level Component of the Intervention for Young Black MSM:
To modify HIV-related knowledge, attitudes, and beliefs among young Black MSM, culturally sensitive advertisements were spread throughout the metropolitan DC area via brochures, dance clubs, radio stations, top40 podcasts, NPR, and common MSM-oriented websites. Advertisements promoted positive attitudes toward safer sex practices among young Black MSM. These attitudes were promoted through images of men participating in safer sex practices. Young black MSM couples were shown valuing safer-sex practices by saying slogans such as, “I love my Boo. Safer Sex is one way we Show our Love” (13). Men in the advertisements were young and relatable to young Black MSM in the metro DC area.
A general sense of well-being and perceived self-efficacy in relation to safer-sex practices were promoted through confidential private and group sessions in open, supportive environments. Sessions were held on weekdays and weekends and were conducted by trained professionals. These sessions ranged from safer-sex demonstrations to discussing difficulties associated with having sex with men and being a young Black man (5). Young Black MSM were recruited through social websites and after-school programs. Incentives such as food, public transportation tokens, and free passes into local 18+ and 21+ clubs were offered to increase turnout rates.
Interpersonal-Level Component of the Intervention:
To modify the knowledge, attitudes, and beliefs of young Black MSM among families and proxy contacts of young Black MSM (5), culturally sensitive messages were spread via brochures, the media, grocery stores, fast-food restaurants, the Internet, and any other accessible place. Respectful images showing families embracing MSM children were circulated. Individual MSM and MSM couples were shown everyday settings being welcomed, loved, and respected by family and friends. Culturally sensitive images were also circulated showing parents and close contacts of MSM playing active, respectful and positive roles in accepting a young Black MSM’s sexuality (6).
Through social networking, use of bulletins, media sources, and Internet advertisements, families and proxy contacts of MSM were actively recruited into the intervention. Incentives such as food, public transportation tokens, BP gasoline cards equal to the value of public transportation tokens, and $20 gift cards to whole foods with free delivery were offered to increase turnout rates. Sessions were offered on weekdays and weekends and were led by experts in this area of intervention. Counseling for families and proxy contacts were aimed at increasing open communication about sexuality with young Black MSM and transitioning to more positive attitudes relating to MSM persons. Support groups composed of multiple families and contacts were formed to help share experiences related to raising MSM children. Social networks supportive of gay children were introduced to families holding negative attitudes toward young Black MSM (5).
Community-Level Component of the Intervention:
A community intervention among young Black MSM was run on the national-level. Upon research, the campaign discovered that most young Black MSM considered safer-sex to be labeled as “good” and unsafe safe to be labeled as “bad” by the public. These beliefs were problematic for two reasons. First, there was a strong sense of masculinity among young Black MSM that corresponded with being “tough” and daring. Engaging in “bad” and unsafe sex could lead to a conscious or subconscious increase in perceptions of masculinity. Second, young Black MSM felt a sense of homophobia imposed upon them when told to use condoms. They felt heterosexuals imposed the belief that engaging in unsafe sex among MSM individuals is and will always be bad, regardless of any relationship circumstances (6). The campaign also discovered that definitions of “healthy” differed between public health officials and young Black MSM. Young Black MSM did not consider an HIV+ person unhealthy until they were diagnosed with AIDS. This potentially rises from high recognition between young Black MSM of effective HIV treatment (11). There were high levels of awareness of the high HIV infection rates among young Black MSM. This awareness may have led to the feeling infection as inevitable and therapy as painless. Low self-efficacy in relation to protecting oneself from HIV may be leading to higher rates of unsafe sex among young Black MSM.
The nationwide intervention used mass-media campaigns, taking advantage of the culturally sensitive data gained. Prime-time commercials, newspapers, popular magazines, websites commonly frequented by young Black MSM, NPR, and various radio stations transmitted the intervention. Advertisements portrayed HIV as sneaking into the body and hiding in an infected human’s DNA so the treatment could not touch the virus. This shifted the young Black MSM view of engaging in safer-sex as “good” to engaging in safer-sex as actively defending oneself against the sneaky and cowardly virus. It also challenged the notion of having only HIV as being in a healthy state because it made visible the fact that the virus lives inside the individual. To combat the perception of masculinity, advertisements showed young Black MSM protecting others from HIV through engaging in safer-sex practices, effectively associating masculinity with safer sex practices.
Peers of young Black MSM began delivering messages advocating for safer-sex practices. MSM oriented safer-sex demonstrations were made mandatory in public schools [through the wand of Barack Obama?], increasing the perceived self-efficacy relating to safer-sex among young Black MSM. To deconstruct homophobic undertones of safer-sex interventions, open dialogue relating to engaging in unprotected sex within monogamous MSM couples was encouraged. The term monogamous was emphasized, just as is true for heterosexual couples. Finally, role model stories of young Black MSM were distributed throughout the country over various forms of media in an attempt to increase a sense of value and well-being among young Black MSM.
Improvements of Proposed Intervention on the “Use a Condom Every Time” Campaign
Proposed Intervention Does not Run Only on the Individual Level:
One fundamental improvement of this intervention over the “Use a Condom Every Time” campaign is that it is not run merely on the individual level. Accounting for the group dynamic (4), this intervention will be able to shift behaviors of entire groups of young Black MSM rather than individual MSM (4). Essentially, people who do not participate in the intervention on the individual level are still influenced by the intervention through the cultural shift of attitudes related to safer-sex practices (5). The community and interpersonal proportions of this intervention attempt to shift HIV-related beliefs for entire groups rather than individuals.
Additionally, this intervention specifically addresses the wider social context affecting health related behaviors of individuals (4). Contextual issues are put forth regarding masculinity and unprotected sex among young Black MSM. Young Black MSM may have had unprotected sex to increase their sense of masculinity. This intervention used masculinity as a contextual tool of intervention, showing young Black MSM protecting others through safer-sex as masculine. This would not be possible in the “use a condom every time” campaign.
Homophobic Societal Undertones related to Condom Use are Eliminated:
MSM have “experienced hatred, abuse, and a lack of acceptance by their families, friends, communities, and society in general” (5, 6, 14). We have shown that these negative experiences, potentially leading self-destructive psychological natures, can result in MSM engaging in unprotected sex because it is dangerous (6, 14).
This intervention works on the interpersonal level to decrease homophobia among families, friends, and close contacts of MSM. This will hopefully lead to a decrease in self-destructive tendencies caused by homophobia. A potential decline their rates of unprotected anal sex may be observed as a result (14). Additionally, homophobia is addressed on the national level. Counter to the “use a condom every time” campaign, this intervention opens publicly accepted discussion among monogamous MSM couples to decide whether they want to use condoms in their relationship. In effect, the intervention removes society’s homophobic desire to dictate the behaviors of MSM through “always use a condom” campaigns. This allows MSM and the intervention to interact without the negative pretense of perceived homophobia. In circumstances such as these, MSM are less likely to be defensive and more likely to listen to the message being put forth by the campaign (5, 14). Intervening at the group and interpersonal level allows maximum efficiency in decreasing homophobic experiences of MSM individuals, leading to increases in safer-sex practices (12).
Health Not Assumed to be Highly Valued by most MSM:
The proposed intervention directly addresses the fact that the definition of “healthy” differs between young Black MSM and public health professionals. To get around this discrepancy in definitions, the intervention circulated images depicting HIV as deceptive and cowardly. This image of deception leads to young Black MSM acting in defense of their body, regardless of the definition of health.
MSM may hold a high value for not contracting HIV, but they may also have a low perception of self-efficacy in relation to engaging in safer sex. The new intervention addressed this potential low perceived self-efficacy for using a condom among young Black MSM, an aspect completely left behind by the “use a condom every time” campaign. Since the new intervention does not require that MSM use a condom every time, the pressure associated with having to use a condom in every sexual encounter for the rest of one’s life is diluted. Additionally, confidential group and private sessions were run that showed MSM how to engage in safer-sex practices. Role-playing was implemented to help MSM gain the strength and courage to insist to their partners that a condom be used if they feel it is necessary. Note that both individual and group level interventions were required to address the potential effects of low perceived self-efficacy relating to safer sex among young Black MSM.
Concluding Statement
The proposed intervention improves upon the “how to use a condom every time” campaign in three significant ways. First, this campaign is run on the individual and group level. While increasing perceived self-efficacy relating to safer-sex practices among young Black MSM, we are also shifting beliefs and behaviors of entire groups with relation to HIV (4, 12). Second, young Black MSM men do not perceive the intervention as homophobic. As a result, it is more likely for young Black MSM to take in messages of the intervention. The campaign also addresses homophobia through interventions among families and proxies of young Black MSM. Lower levels of homophobia among MSM proxies will lead to an increased sense of well-being. Young Black MSM will feel more valued and welcomed in everyday aspects of life, which can lead to decreased self-destructive actions and increases in the frequency of safer-sex practices. Finally, the proposed campaign improves on the “use a condom every time” campaign in that it does not assume “health” to be highly valued among most young Black MSM. Without this contextual assumption, the intervention was able to target factors that were truly related with low frequencies of safer-sex practices and intervene based on those factors.
Evidence shows that individual-level, interpersonal-level and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (5, 12). It is crucial for all three components to be a part of the intervention. The community level component is necessary because it allows those who were not directly involved in the intervention to still be influenced by the intervention and because it analyzes health-related behaviors within the cultural context (4). The interpersonal level is essential because reduced levels of homophobia among proxies of MSM will lead to higher senses of well-being among MSM. This may correlate with decreases in self-destructive behavior, and potentially increases in safer-sex practices. Finally, the individual level component is essential because it provides HIV-related knowledge directly to individuals and increases individual perceived self-efficacy relating to safer-sex practices. Implementing all three components into an intervention significantly improves on the “use a condom every time” campaign, and will be effective in increasing the frequency of safer-sex practices within the target population.
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