There are an estimated 35.3 million people living with human immunodeficiency virus (HIV) infection worldwide (1). Of these, 1.1 million are living in the United States (2). Progress in treatment options and prevention strategies has led to a 33% decline in the global incidence rate of HIV, since 2001 (1). Despite forward progress, the rate of new infections has increased in some populations (1-2). In the United States, there are approximately 50,000 new HIV infections every year (2). From 2008 to 2010, the number of new infections per year among men who have sex with men (MSM) increased from approximately 26,700 to 29,800, a 12% change (2). MSM represent just 4% of the US population, but male to male sexual contact was believed to be the mode of transmission for 63% of all new infections in 2010 (2). There are a variety of factors believed to contribute to the HIV epidemic among MSM, including unprotected anal intercourse (UAI), concentration of the community viral load among MSM, and lack of awareness of HIV status (3). Concurrent with the rise in HIV incidence rate among MSM are more data that show increased UAI among MSM (3). From 2005 to 2011, the percentage of MSM reporting UAI in the past 12 months rose from 48% to 57% (3).
Given the decreased reliability of condoms as a realistic primary prevention strategy, public health professionals have long searched for other solutions, such as vaccines or the use of antiretrovirals for chemoprophylaxis (4). Chemoprophylaxis of HIV has now been shown to be efficacious with two approaches. The first, known as treatment as prevention, involves the early usage of antiretroviral drugs in HIV-positive people, with the goal of achieving viral suppression and reducing infectivity (5). The second approach, known as pre-exposure prophylaxis (PrEP), is more controversial (6-8) and involves the usage of antiretroviral drugs in HIV-uninfected, but high-risk persons, with the intention of preventing infection (9). A 2010 randomized controlled trial of 2499 HIV-uninfected men or transgender women who have sex with men showed that once-daily tenofovir disoproxil fumarate (FTC-TDF; a combination of antiretroviral drugs used for the treatment of HIV-infection) provided a 44% reduction (p=0.005) in HIV-incidence, when compared to placebo. Among study subjects with a detectable blood level of the study drug, there was a 92% reduction (p<0.001) in HIV incidence (9). On July 16th, 2012, the Food and Drug Administration (FDA) approved TruvadaTM, an antiretroviral manufactured by Gilead Sciences for the treatment of HIV-infection (10), for use as PrEP (11). PrEP has been suggested for use in multiple high risk populations (4), but this paper is limited to the promotion of PrEP among MSM in the US.
Despite the potential to greatly protect against HIV-infection, a limited number of MSM know about PrEP and almost none are using it (12). The low immediate uptake of PrEP has been discussed in a number of recent widely circulated editorials, including one by Christopher Glazek in The New Yorker (7). Glazek explores the tepid response to PrEP and points out a number of concerns by healthcare professionals about PrEP efficacy and toxicity. Advocates for HIV-infected persons, Glazek explains, are also concerned about the availability of antiretrovirals in resource limited settings or the emergence of viral resistance to TruvadaTM, which is a first line drug to treat HIV. Other public health officials are worried about the implications of suggesting that there is an alternative to condom usage. These opponents have publicly argued against PrEP usage. A further setback to PrEP implementation is the unprecedented decision by Gilead Sciences not to promote or research TruvadaTM as PrEP. (7) In the absence of Gilead Sciences’ participation in the promotion of TruvadaTM as PrEP, public health officials have failed to create campaigns that would adequately promote its use. Perhaps, it was initially assumed that the benefits of PrEP alone would be enough to promote its use. This “if you build it, they will come” approach to intervention promotion did not work (7-8, 12). In response to low interest in PrEP, advocates have started to make promotional materials. These materials have not effectively increased interest in PrEP (7-8, 12). This paper will critique three aspects of the campaign to promote PrEP that have contributed to its ineffectiveness along with solutions to those challenges.
Critique 1: Reliance on the Health Belief Model
The primary way that PrEP has been promoted is through the use of educational campaigns, such as fact sheets and videos. These promotional materials have emphasized the health benefits of PrEP (i.e. HIV risk reduction) and have served as informative educational tools. These materials are essential resources for people already interested in PrEP, but do little to actually disseminate information and promote interest in the intervention. Using health education as a way to promote an intervention is a common approach, which relies on rational decision making. The model of behavior, known as the Health Belief Model, assumes that people make rational choices about health by weighing the risk for and severity of a disease, with the costs and benefits of adopting a new behavior (13). In this logic structure, a public health official would only need to educate and inform a person about a disease, while offering education about interventions or alternative behaviors that prevent that disease. The Health Belief Model can be an effective strategy for one time interventions, like vaccines; unfortunately, the Health Belief Model is not a very effective way to promote an intervention that may need sustained commitment or a more complex decision calculus (14).
The Health Belief Model is not an effective approach for the promotion of PrEP (14-15). To understand why, it is helpful to analyze the assumptions that the Health Belief Model uses. First, the Health Belief Model for PrEP requires that MSM accurately perceive their own risk for HIV infection. Research has shown that while many MSM are able to accurately define behaviors that are high risk for HIV, they inaccurately use those criteria while assessing their own risk (16). As a result, many men perceive their own personal risk for HIV to be lower than what it actually is. Second, the Health Belief Model assumes that MSM perceive HIV/AIDS to be severe. Advancements in treatment options, and the common belief that HIV can be managed with “one pill, once a day,” may have decreased community perception of HIV disease severity (17). Many MSM now perceive HIV to be an inconvenient, but manageable disease. This reduction in the perception of disease severity may partially explain the decrease in condom usage among MSM (3, 17). Taken together, the miscalculation of HIV susceptibility and diminishing perception of HIV severity are major barriers to individuals self-necessitating PrEP (14-17). Third, the Health Belief Model requires an individual to negotiate the perceived benefits of PrEP with the perceived costs. While the educational materials that have been created could be used to aid in this decisional analysis, it is unlikely that most MSM would take the time to carefully assess each factor (14). Decisions about PrEP are more likely to be made based on a quick assessment and emotional instinct. The second problem with the implementation of PrEP are those emotional instincts, such as reactance, that occur.
Critique 2: Activation of Psychological Reactance
The use of educational materials to promote PrEP may create reactance and have opposite the intended effect. Psychological Reactance Theory shows that people hold tightly to their beliefs and statements, even when given logical reason to change position. This occurs because people take ownership of their beliefs. Challenging someone’s behaviors or beliefs is to take something away and violate their freedom. The natural response to having something taken away is to hold tighter. (18)
Psychological reactance occurs in health campaigns when people feel that someone else is telling them how to live or behave. The implications of reactance and the clinging to behaviors often results in increased frequency or magnitude of the bad health behavior (18). Since sexual contact was first identified as a way to transmit HIV, authoritative figures have been telling MSM how to have sex (19). Compounded with decades of stigma against homosexuality and same-sex sexual relationships, many MSM may be feeling attacked and defensive of the way they have sex, establishing them as a high reactance group (19). As such, reactance may be another contributing factor to why men are using condoms less. In that context, it is difficult to continue telling men who to have sex with, how to have sex, and how to manage HIV risk.
In the case of PrEP promotion, the response by many MSM is likely aversion to being told to adopt yet another strategy to avoid HIV. Many of the promotional materials being presented are steeped in medical information and statistics, so the message is received as a patronizing instruction (20). The underlying message is: “you’re not being safe enough, so you need to take a pill now as well.” With reactance, the introduction of PrEP is viewed as another way that authoritative healthcare figures are exerting control over the sex lives of MSM (18-20).
Psychological reactance is also occurring in the resistance by medical professionals and HIV advocates to shift away from a condoms-only approach to HIV prevention (21). For almost three decades, public health professionals have asserted (and believed) that condoms are the only way to practice safe penetrative anal sex among MSM (4). For three decades, that was largely true. Accepting an HIV prevention strategy that does not completely rely on that approach is a difficult change for many advocates. The result is a backlash to PrEP that questions everything from medication safety to efficacy. The reaction has been a well-articulated campaign against PrEP. The framing of this rhetoric by both health care professionals and patient advocates is the third problem with the campaign to promote PrEP.
Critique 3: Ineffective Use of Framing Theory
The usage of PrEP is a controversial and new approach to HIV prevention, with vocal opponents on either side of the debate (6-8). Proponents of PrEP have been persistent in discussing the benefits of PrEP as a tool to reduce risk for HIV acquisition and a pathway to maintain health. Opponents of PrEP question the implications of PrEP on the individual level, as well as on the community level. On the individual level, opponents look at the paradox of using a drug in a person who is actually healthy and introducing the risk of side effects and toxicities. The potential to increase sexual risk, along with poor compliance to a daily regimen of medication, are factors often used as evidence against PrEP efficacy. Other opponents worry about the community implications of using TruvadaTM in HIV uninfected persons, including the distribution of drugs in resource limited settings and the selection for and dissemination of TruvadaTM resistant HIV in the community. Finally, there has even been speculation of the validity of study data and ulterior motivations of study investigators, the government, and Gilead Sciences. (7) The collective opposition to PrEP is likely encouraging both MSM and the healthcare providers who would prescribe PrEP to be skeptical and avoidant of use. The reason opponents of PrEP have been more convincing is due to the way the discourse has been presented (22-23). Framing Theory shows why the ideas opposing PrEP resonate much stronger with MSM and healthcare professionals.
Framing theory explains that an audience responds to discourse based more on an emotional response and less on facts (22-23). As such, people are much more likely to be convinced by an argument that speaks to their core values. To capture this emotional response, a properly framed argument is constructed surrounding a core value, which is supported by a core position, metaphors, symbolism, and catch phrases. The core value should be universal and in the subconscience of the target audience. Examples of strong core values are freedom, security, and love. The core position is the actual argument being communicated. The metaphors, catch phrases, and imagery are used during communication of the core position, in order to associate the argument being stated with the desired core value. (23)
Opponents of PrEP rely heavily on core values like safety (PrEP is a dangerous medication with toxicities), freedom (PrEP compromises a person’s freedom by requiring compliance to a daily drug regimen; PrEP is a ploy by “Big Pharma” to sell drugs), and tradition (medications should only be used in sick people). (7) These arguments speak to the core values of MSM as well as healthcare providers. There are clear images in these frames, such as doctors prescribing a pill that will make people sick or predatory corporations trying to turn a profit at the expense of the public. Comparatively, proponents of PrEP are much more likely to use health as a way to frame PrEP. The flaw is that health is not a particularly strong core value when used in a frame. This may be counter intuitive, but the tangible value of health is difficult to conceptualize until it is lost (14). As a result, people often don’t respond strongly to campaigns that use health as the core value (23). The advocates for PrEP have failed to adequately frame the intervention in a way that addresses the core values of high risk MSM.
Solution 1: Group Level Approaches to PrEP Implementation
Advocates for PrEP can avoid the fallacies of the Health Belief Model by shifting away from an intervention that focuses exclusively on changing behavior on the individual level. One approach to influencing the normative behaviors of a population is to use strategies employed in marketing (24). Gilead Sciences is not promoting PrEP the way any other medication would be (7), so it is the job of PrEP advocates to do the marketing. A marketing based approach would follow a very careful campaign design strategy. Rather than define the intervention and create a campaign based on selling the merits of PrEP, advocates should first question what the needs and core values of its target population are (25). By identifying these characteristics, a campaign can be designed without any specific information about PrEP. Because PrEP is an ideal intervention for sexually active MSM at high risk for HIV, the campaign should include values important to that population. The common experience with this group is sexual encounters without a condom. Therefore, the campaign should incorporate messages that use sex as a primary core value. The core position of this campaign would be: “PrEP keeps sex enjoyable by offering a second line of defense when condoms are skipped.” The fear that this type of message will cause men to have more unprotected sex does not acknowledge that many MSM are already not using condoms (3). By adding PrEP, the risk for HIV acquisition is dramatically decreased. A campaign based on sex acknowledges the prevalence of UAI and invokes the core values desired by this population (19). The campaign can take cues from some of the more effective condom and HIV prevention campaigns that feature attractive men and employ sexual innuendo (19, 25, 26).
The second component to the group level implementation of PrEP is to analyze the Diffusion of Innovations Model (27-28). The Diffusion of Innovations Model identifies an S-curve of innovation adoption, in which the proportion of the population that adopts an innovation grows slowly, then accelerates quickly, and finally tapering off. A small group of innovators are the first people to adopt a new innovation. The innovators are followed by a second, slightly larger group known as early adopters, who are followed by a large early majority and then late majority. Once a product or innovation has reached the early majority, its uptake accelerates dramatically as the innovation becomes popular. This phenomena occurs due to the herd-mentality and desire to participate in trends. Diffusion of Innovations is often a natural process, but by taking advantage of how this pattern occurs, advocates for PrEP can accelerate the process in the same way that marketers create demand for a product. To do this, it is important to understand the transition from slow early adoption to accelerated population adoption. Early adopters often begin buying a new product because it is scarce and only the innovators have it. The early and late majority will buy the product once social proof has developed and the product is viewed as trendy. (28)
PrEP is a new intervention and so far only a few innovators have started to use it (12). The challenge now is to encourage early adopters to use PrEP by creating the idea of scarcity. Instead of the product itself (PrEP) being promoted as scarce, the benefit of PrEP (reduced risk for HIV) could be promoted as a scarce (i.e. brand new and unique) opportunity to reduce HIV-risk. The message will be: “This is a whole new way to protect against HIV and there is nothing else like it.” The campaign will also attempt to create social proof by creating the illusion that PrEP is already popular. To do this, the campaign should incorporate testimonials and statements from men who are using PrEP, explaining how it has improved their lives.
Solution 2: Understand The Role Of Reactance In Health Promotion Campaigns
The reactance created by PrEP promotion is avoidable, if there is attention paid to this psychological reactance during the planning of the campaign (18). As discussed previously, reactance can often occur if the audience feels that an authoritative figure is commanding which behavior is acceptable and which is not. A great way to avoid the reactance is to have the message communicated from someone that the target audience identifies with (29). This similarity will reduce the likelihood that the audience feels like it is being told what to do. The messenger cannot be a scientist or healthcare professional, because they are seen as authority figures (18-20, 29). Since this particular campaign for PrEP is being targeted toward MSM, the messenger should be a gay (appearing) man who is speaking as a peer (29-31). A great approach would include real men discussing their real experiences with PrEP and how it has impacted their life. If the messenger is seen as an equal or peer, the reactance will be minimized (29).
To avoid reactance in healthcare professionals, who are the gate-keepers for prescribing and promoting PrEP, there needs to be well designed physician oriented trainings. These trainings should focus on promoting PrEP as a single option to reduce HIV risk in a provider’s practice (21). The goal would be to deemphasize the failures of condom campaigns and safer-sex counseling and focus instead on adding to the tools that a provider has available. In this way, it reduces the possibility that a provider or public health advocate feels criticized for using other strategies in the past.
A key part of avoiding reactance is to actually do research (25). Before old strategies are selected and the campaign is implemented, formative research should occur to determine whether those strategies are effective or actually create reactance. Focus groups can serve as a way to collect ideas from the target audience. Qualitative interviews can discuss certain themes more in depth, if needed. From focus group research the campaign can be proposed. Finally, before launching the campaign, the idea should be presented to a sample from the target population for quantitative assessment. Tools like the Therapeutic Reactance Scale (32) and the Questionnaire for Measuring Psychological Reactance (33) can be used or adapted to detect psychological reactance in the sample based on the proposed PrEP advertisements. The sample should be surveyed to determine what the emotional response to a particular advertisement is, if it creates reactance or not, and if it effectively promotes any interest in PrEP.
Another factor to consider with psychological reactance is how it can be used to intentionally create a desired emotional response. For example, part of the campaign to promote PrEP can be messaging that directly draws attention to the opponents of PrEP. The message in this part of the campaign will focus on the doctors and pharmaceutical industry forces that are trying to keep PrEP away from people. HIV-prevention strategies that do not rely on just condoms have long been desired by MSM (4, 7-8, 17) and it would be a powerful statement to point out that PrEP is being withheld. Counter-industry campaigns have been effective in other public health campaigns, like the successful Truth Campaign for smoking cessation (25). The take away feeling is a desire to have what is being restricted.
Solution 3: Reframe the Rhetoric Using Strong Core Values
The final part of the campaign that needs to be restructured is the framing of the debate over the effectiveness of PrEP as an HIV prevention strategy and the appropriateness of using antiretroviral drugs in HIV-uninfected persons. The proponents of PrEP are confident that the primary research supports implementing PrEP as an effective way to reduce HIV-risk. It is important to now communicate that confidence outside of the context of data and scientific literature. It has not been effective to allow the data to stand alone. Furthermore, it is not effective to just assert that PrEP is useful for its potential to maintain health (i.e. HIV uninfected status) (23). Instead, the defense and promotion of PrEP should be re-framed to have stronger core values. The actual goal of the message does not need to be different (PrEP is safe and effective) but the way in which the message is communicated will need to change.
Successful core values will create an emotional response in the target audience that will be more compelling than facts or statistics alone (22-23). For many MSM, using condoms consistently is a challenge and there is constant anxiety of HIV infection (17). PrEP can be a second line of defense when passion precludes rational decision making and condoms are not used. In this way, PrEP is a provision for security and not simply a tool for health maintenance. Therefore, the promotion of PrEP should focus on security as its core value instead of health. The core position of this message is that “mistakes happen, but everyone deserves to be protected.” Catch phrases could be created from the type of familiar messages used in insurance advertisements. For example, phrases like “peace of mind” (Chubb Group of Insurance Company; 34); “when accidents happen, [PrEP] is there” (State Farm®; 35); and “responsibility, what’s your policy?” (Liberty Mutual Insurance; 36) are effective ways to frame security. Additional analogy could be made with a comparison to birth control medications, which similarly protects against a potential consequence of sex without a condom. This core value can be used in written media as well as promotional materials, like videos.
Advocates for PrEP may be remembering the 1980s and 1990s, when fear of HIV fueled the mobilization of community advocacy and quick uptake of new ways to fight AIDS. With the advancements in HIV treatment, it is likely that community fear of HIV has diminished and taken a back seat to other community aspirations, like marriage equality and non-discrimination policies. Given this environment, it is unlikely that fear will create excitement about PrEP. A well strategized marketing campaign for PrEP can surpass community apathy and promote increased use of PrEP among high risk MSM.
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