City-funded HIV prevention campaigns have used such "social marketing" methods -- a popular technique that applies commercial marketing principles to social and behavioral issues -- since the late 1980s as a way to persuade gay men to practice safer sex. The ads often employ sexy models and pithy slogans to get their messages across. Evidence shows that these campaigns can work, and it is true that infection rates are sinking in San Francisco. But a recent article in a local gay newspaper has reignited a strong and long-standing debate over the ads, and the community is once again wondering whether the city needs a new approach to HIV prevention. Besides, new evidence proves that another factor -- tied neither to city programming nor to advertising -- is what's really causing infection rates to drop.
Two weeks ago, Trevor Hoppe, a 22-year-old graduate student, wrote an angry guest opinion article in the Bay Area Reporter, the local gay, lesbian, and transgender community newspaper. Hoppe's column took issue with the city's reliance on social marketing. In particular, he was enraged by a billboard above Cafe Flore on Market Street that was part of the city-funded "HIV Stops With Me" campaign, which read: "New Year's Resolution: I won't infect anyone."
"On the surface," Hoppe wrote, "this message may seem entirely innocent -- after all, who wants to infect anyone this year? However, there is an insidious subtext that lives just below the superficial, as is often the case with public health campaigns." Hoppe explained that the assumption that HIV-negative men play no role in HIV prevention is insulting and makes HIV-positive men look predatory. He went on to suggest that the city should "immediately defund all public health organizations in San Francisco."
Social marketing is one of the most commonly used prevention techniques by health departments around the country. "HIV Stops With Me," for example, has been used in San Francisco for five years and has expanded to nine other cities. Many of these campaigns have won national advertising awards.
"I think that the person [Hoppe] who wrote that is misguided about what San Francisco and what HIV prevention is all about," says Les Pappas, the president of Better World Advertising, the company behind the campaign. "San Francisco has always been the leader in HIV prevention and social marketing. The results speak for themselves. This is one of the few places in the country where we continue to see decreasing rates of infection."
Steven Tierney, the AIDS Foundation's new deputy director for programs and services, agrees that such campaigns are effective, though he thinks they need some tweaking. San Francisco, he explains, is shifting its messages to focus on "root causes" of HIV infection, like depression and drug abuse, rather than prevention strategies alone. The first step, he says, will be to "start up some new social marketing campaigns designed to help people reassess risk."
The technique has its proponents. Academic studies have determined that social marketing can be used successfully to recruit gay men into prevention counseling and to increase awareness and dialogue. Of notable success in San Francisco, for instance, was a drive that aimed to reduce syphilis rates, which had skyrocketed between 1999 and 2002. The "Healthy Penis" campaign, also designed by Better World Advertising, left the sex appeal behind and used a cartoon penis to discuss the disease. Independent sources, including the National HIV Prevention Conference, credit the recent fall in syphilis cases, from 680 cases in 2004 to 509 in 2005 (a 25 percent reduction), in part to the ads.
However, that effort is something of an exception, because the majority of these campaigns still use sex and anger to get their messages across.
"Social marketing campaigns are designed to stir up controversy and spark dialogue. They will appeal to some and not others," Tierney says.
Tracy Packer, the acting director of HIV prevention at the San Francisco Department of Public Health, says, "Any conversation about sex is a step in the right direction."
Some of the ads' intended targets aren't so sure. "[I]f people are only talking about a campaign to say that they hate it and it's ineffective, how is that changing the decisions anyone is making about sex?" asks Frankie Diaz, 30.
As is the case with all advertising, it's difficult to measure a campaign's direct impact. Better World Advertising claims that 70 percent of gay men in the city "like or strongly like" the "HIV Stops With Me" effort, according to a 123-person survey it conducted in 2003. The S.F. Department of Public Health has never retained an independent firm to analyze the effectiveness of its ad campaigns.
For many gay men and activists, frustration with the tone of recent HIV prevention messages is rising. When SF Weekly interviewed more than two dozen gay men in and around the Castro District last week, only one man said he liked and was affected by "HIV Stops With Me." Comments about other HIV ad campaigns in the city were equally negative, the impression being that the messages of prevention and testing are often lost amid sexy models and harsh slogans. It appears that muscular, nearly naked men have become the norm in many HIV prevention campaigns.
For example, the Stop AIDS Project ran advertisements in June 2005 during its "Shining a Light on HIV" campaign that were described by men in the community as both "edgy" and "insulting." Two of the catchphrases were "I'm pretty sure I only gave it to one guy" and "Safe Sex Bottom: Serving the Community as a Hole."
"I just feel dirty when I see a lot of these ads," says Daniel Holloway, 44.
Some men express confusion at the idea of using fear or sex to spread messages of safety, trust, and communication; others have chosen to ignore the ads altogether.
When Castro resident James Serrano, 27, was asked about the effectiveness of HIV marketing campaigns, he replied, "Don't ask me. I haven't paid attention to that shit for years."
Despite the controversy over social marketing, San Francisco does have reason to celebrate. New evidence shows that HIV infection rates are dropping, but not because of any ad campaign or city-funded program.
A study published last June by the Centers for Disease Control and Prevention found the HIV incidence rate among gay men in S.F. had decreased from 2.2 percent to 1.2 percent since 2001. Mounting data now suggests that "serosorting" -- the practice by which gay men choose to have sex only with those who share their HIV status -- might be primarily responsible for the decrease in new infections.
"Many HIV-positive individuals are choosing partners who are also positive as a way to stop the spread of the epidemic," Dr. Robert Grant of the UCSF Gladstone Institute of Virology and Immunology told SF Weekly in a December interview.
But neither the city nor the AIDS Foundation has endorsed or sponsored any programming or advertising about serosorting. This successful technique has emerged from within the gay community itself without any sexy models or punchy slogans to urge it on.