September 15, 2008 found me feeling rather lost and out of place in a dull-looking buidling, at least from the exterior, but which housed an impressively professional looking movie studio. We were in an industrial area of East York (Toronto). I was there to film an interview for Top Drawer Creative, the ad agency GMSH (Gay Men’s Sexual Health Alliance) had engaged to produce the campaign for us.
It was an intimidating set-up. Real lights, drapes, BIG cameras, sound booms, a crew of half a dozen or more, a make-up studio. You can see the set-up in two of the pictures below.
Myself and the other interview subjects destined to appear on the campaign website, talking and blogging about stigma, weren’t even exactly sure what we were going to be asked. The decision had been made that spontaneous answers were the key. But James Murray, a colleague from GMSH who I trusted implicitly, was to be the interviewer, so that helped dampen the nerves.
There were eight of us in that campaign – four negative and four positive gay guys. I think there were four of us scheduled to be filmed that day. I knew them to varying degrees. One of them was Brian Finch. We’d met briefly before; when I came in to the make-up room, it being almost time to go on, he was being worked on.
The rest is history. We did the interviews: you’ll see two of them below including Brian’s and the one from Murray Jose, the talented ED of PWA, both of whom did a great job. The Top Drawer people made us all look good in fact. I loved the edgy look they brought to the campaign that you’ll get a taste of in the interviews.
The stigma campaign (unfortunately the campaign website is no longer up) turned out to be an unexpectedly intense experience for all us, blogging for a full and sometimes exhausting six months about HIV stigma and its impact on HIV transmission. The campaign was web-based and designed to create a dialogue, using the slogan “If you were rejected every time you disclosed, would you?” Those words, intentionally provocative, came out of the sense that gay men don’t talk enough about their status – positive or negative – which leads to assumptions being made about status - and risk taking. Creating a dialogue around stigma was seen as a way to contribute to reduced risk taking, in fact. That dialogue was to be largely by way of blogging – a somewhat innovative approach at the time.
As the evaluation indicates – it’s referred to in the article below - that dialogue was especially rich. For this blogger at least, it was also transformative. The responsibility of fronting such a high-profile, province-wide campaign weighed heavily; we watched our words a lot, and often engaged in lengthy discussions about individual responses. (PositiveLite blogger Stephen Lincoln was our amazing coordinator/confidante in that process.) In short we became immersed in all things HIV stigma for the length of the campaign, and even afterwards when some of us took it on the road.
I don't think many of us realized initially how big everything would become. There was an enormous print and outdoor advertizing campaign aimed at directing people to the site. Wellesley subway, the TTC (Toronto Transport Commission) station that serves Toronto's gay neighbourhood, was virtually taken over, for instance. You can see photos of this massive advertizing campaign throughout this post. We were kind of in awe of it all at the time.
But it was all good. Particularly, the evaluation which indicated we did in fact make a measurable difference. You can read about that in the article which follows.
(This article by Roger Pebody first appeared in aidsmap September 21, 2011.
Media campaign on disclosure and stigma changes gay men’s attitudes
A Canadian campaign which asked gay men “If you were rejected every time you disclosed, would you?” appears to have raised men’s understanding of the dilemmas which men with HIV face. The campaign also succeeded in reducing the number of men who try to avoid infection by relying on men with HIV disclosing their status, researchers report in the October issue of Health Education Research.
The campaign was not intended to broadcast a ‘message’ or give instructions, but to stimulate dialogue within local communities. Moreover the authors suggest that the extensive community consultation which went into its development contributed to the campaign’s success.
Staff from frontline HIV prevention work, public health, government and academia participated in the consultation which identified HIV-related stigma as a priority issue. Moreover they focused on stigma within gay communities as it is manifested in the attitudes of some HIV-negative men towards potential sexual partners who have HIV. The campaign developers believe that there are links between the problems of stigma, disclosure, conflicting assumptions and risk taking.
In particular, some of those involved in this project have previously researched gay men’s sexual interactions in which “potential partners interpret risk by bringing sometimes conflicting and inaccurate assumptions to bear in making decisions about safe sex”. For example, men may make different assumptions about a partner’s willingness to have unprotected sex, with some HIV-positive men assuming that only another positive man would do so, and some HIV-negative men thinking the opposite.
To further complicate the expectations and understandings of men seeking sexual partners, the Canadian judiciary has also asserted that disclosure of HIV status is an obligation for people with HIV before any sex in which there is a significant risk of HIV transmission.
Given the incompatibility of these different assumptions, the campaign was intended to allow men to move beyond the conversations they had within their own social circles and engage in “a more broad based community discussion” about stigma, disclosure and sexual decision making.
The campaign drew attention to itself through press advertising, outdoor advertising, online promotion and community outreach activities.
It was centred on the question “If you were rejected every time you disclosed, would you?”. This question was intended to be sufficiently provocative that it would encourage public reflection and conversation.
Moreover a key part of the campaign was its website. Blogs on the website written by eight different HIV-negative and HIV-positive men invited men visiting the site to respond to the issues raised and to post comments.
Over five months, the web site had 20,844 unique visitors (80% from Ontario), who stayed an average of six minutes per visit. Some 4,384 visitors came back to the site ten times or more.
The researchers describe the blog discussions as “lengthy and lively”. Topics included the sources, forms and consequences of HIV stigma; how to separate rejection of the virus from rejection of men who have the virus; the ethics and practicalities of disclosure of status; challenging stigma; and responsibility and consent in HIV transmission.
Despite the central role of behaviour change media campaigns in many countries’ HIV-prevention programming, careful evaluation of their impact remains rare.
The evaluation described here is not a randomised control trial (which provides the most reliable form of evidence), but assessed the impact of the campaign by means of cross-sectional surveys before and after the intervention. The campaign was promoted throughout the province of Ontario (including Toronto, a major gay centre) and was largely delivered via the internet, so it would have been difficult to identify a control group of gay men who were not exposed to the campaign and who had similar characteristics to those in Ontario.
Recruitment to the before and after web-based surveys was by identical means (an e-mail to local subscribers of a cruising website, www.squirt.org), and this was separate from delivery of the media campaign. A total of 1942 and 1791 men took part in the first and second survey, respectively. The characteristics of those taking part were broadly similar on each occasion.
Of those completing the second survey, 42% were aware of the campaign. Awareness was higher in gay-identified men, residents of big cities, men under the age of 45, better-educated men and men who reported unprotected sex with casual partners. Awareness did not vary by ethnic group or income. But far more HIV-positive men (68%) than HIV-negative men (42%) or men of unknown HIV status (31%) recalled the campaign, perhaps suggesting that its themes were particularly salient for men with HIV.
In terms of attitudes towards disclosure, the men who completed the pre-campaign survey had similar responses to the men who completed the second survey but weren’t aware of the campaign.
Moreover, comparing respondents of the second survey who were aware of the campaign with those who were not, there are statistically significant differences in their attitudes, even after controlling for confounding factors such as age, HIV status and sexual risk behaviour. The researchers believe that this shows the impact of the campaign on those who saw it.
Men who were aware of the campaign were more likely to agree that “gay men with HIV face stigma and discrimination within the gay community” (odds ratio 1.82) and that “gay men with HIV are reluctant to disclose their HIV status to their sexual partners because they do not want to be rejected” (odds ratio 1.48).
They were less likely to use terms like ‘clean’ or ‘disease-free’ when cruising for sex on-line (odds ratio 0.64) or to seek sexual partners with the same HIV status as a way to prevent HIV transmission (odds ratio 0.67).
They were also less likely to agree with the following statement: “If a gay man has HIV, there is no excuse for him not to talk about his HIV status before having sex with a new partner” (odds ratio 0.63). Nonetheless a large majority of respondents did agree with this statement – 85% of those unaware of the campaign, and 73% of those aware of it.
The authors believe that these results, along with the extensive activity and postings on the campaign website, “indicate that the site struck a chord with many community members and stimulated dialogues that likely spilled over into other contexts of daily life… Those who were aware of the campaign were significantly more aware of stigma and its role in HIV transmission at the conclusion of the intervention.”
Adam BD et al. hivstigma.com, an innovative web-supported stigma reduction intervention for gay and bisexual men. Health Education Research 26: 795-807, 2011. Click here for the free abstract.