A flurry of commentary has exploded this past week online over New York City's Health Department's recent HIV prevention PSA. The ad -- complete with CSI:Miami voice-over -- has been criticized for its stigmatizing messages and for its use of fear to promote prevention. Click any of the links to see it, or expand the thumbnail to see (GRAPHIC!) stills from the ad below:

I know that many gay men's health advocates (myself included) have had visceral, angry responses to this ad. Those responses are absolutely valid and deserved. This ad is repugnant and clearly provokes an emotional response. I'll give my own version of this at the end of this article.

But for just a second, I want to try and cool off a bit and evaluate the various arguments that have been made for and against the advertisement in terms of health behavior and the use of fear in HIV prevention. I'm not going to discuss the claims made in the ad about anal cancer and various medical outcomes -- I'm not familiar enough with those literatures to be able to comment effectively. But I do want to talk about what seems to be the crux of most conversations about this ad: Whether using fear is an effective prevention strategy.

I'll begin here with the kinds of arguments I've heard in favor of the ad, and then get to the meat of why these arguments -- well intentioned as they may be -- are not backed by sound evidence. If you're interesting in reading more about this subject, you might start with a recently published review of the scientific literature, "The Role of Fear in HIV Prevention" (PDF).

Argument 1: Young Gay Men Aren't Scared Anymore

Response: Perhaps - and We Should be Thankful It's So!: Younger gay men may well be less fearful of HIV, though the evidence to support that assertion is shaky. What we know is that most HIV-negative gay men are already scared to some degree of HIV infection -- but perhaps its not to a threshold satisfying to a different generation that lived through a time when treatment was not available, and when HIV was indeed a terminal illness. It is of course thankfully not a terminal illness for those who have access to medication anymore. As a so-called "younger" gay man myself, I want to take a moment and explain why it's not acceptable to be mad at young gay men for not being terrified of contracting HIV. The implication here is that you wish our friends were still dying so we'd be a bit more scared. I'm glad my friends are alive. I'm thankful that my HIV-positive mentors, colleagues, friends, tricks, teachers, and past lovers have access to ARV treatment that keeps them alive and healthy. And doesn't it make intuitive sense that a terminal illness would be scarier than a chronic disease? We know this from research in the risk sciences! HIV as a chronic disease is less scary than HIV as a terminal illness. Obviously. And we should be absolutely thankful that this is the case.

Argument 2: Using Fear is a Necessary Tool to Induce Behavior Change

Response: Evidence Shows Fear Doesn't Change Behavior: Underlying this argument is the notion that fear will in fact result in behavior change. But what we know is that fear campaigns are only persuasive to men who are ALREADY using condoms. Fear is not effective at encouraging men not using condoms -- presumably the population this ad is intended to impact -- to start using them. Moreover, research has shown that fear is especially ineffective at persuading young gay men, and only tends to persuade older gay men. So again we have evidence to conclude that this argument is ill-founded.

Argument 3: Fear is the Only Way to Change Behavior:

Response: Culturally Sensitive, Relatable Approaches Actually Work There are many different ways to communicate effectively about HIV risk: inducing the fear of God is not the only option. I don't have time to relay to you all of the things that work in prevention, but I do want to highlight one that is useful in rebutting arguments in favor of this ad. Research has shown that prevention works best when its approach is relevant and culturally sensitive. There are a litany of studies to back this claim up. Gay men have friends who are HIV-positive, and their bones aren't shattering before our eyes and their asses don't resemble something from the SAW franchise. The images included in this ad are just not relatable -- they're the opposite. Prevention should take the community's experiences as a starting point, rather than forcing down our throats some horrifying alternate reality that just doesn't exist in our lives.

Conclusion: We Need to be Angry and NYC DPH Must be Accountable! The ad's tactics are clearly not based on what we know about effective and useful HIV prevention. But this is just the rational, evidence-based response. Now that I've gotten that sensible approach out of the way, let me add a few more strongly colored words based on my experience and a more emotive analysis.

As a gay men's health advocate, I have to say that this ad is incredibly socially irresponsible and, as such, should be retracted immediately with apology. It is precisely this noxious brand of HIV prevention spear-headed by well-meaning but ultimately ineffective and potentially destructive public health officials who are willing to smear our names on the way to health promotion that make so many gay men like myself resent their work.

Let me be clear: Such antagonizing (which they write off as provoking "dialogue") alienates the communities you intend to work with, and it will have ill-intended, longterm consequences. Gay men have a collective memory that bears the burden of nasty campaigns like this one -- we won't forget, as much as we'd like to! Moreover, bad memories aren't the only outcome in question here: Homophobia, HIV stigma, and sexual shame are all direct outputs of stigmatizing campaigns like this one. If this ad doesn't come down with apology, I will do whatever I can to defund and shame your health department's HIV prevention efforts, and other health departments who continue to make ineffective, socially reprehensible prevention messages.

NYC's Health Department must be held accountable for this reprehensible ad. Where were the community partners in its development? Who approved the ad? How was it developed in the first place? Was there internal dissent over its release, as there has been recently in other NYC DPH efforts? These questions must be answered, and gay men everywhere have the right to ask them. This campaign may well have been made in New York, but it was disseminated internationally. We demand answers! We demand accountability!

If you're as outraged as I am about this ad, and wish yo share that outrage with the people responsible for it, you can contact:

Nichole Melendez
Administrative Assistant to Dr. Monica Sweeney, Assistant Commissioner of the Bureau of HIV/AIDS Prevention and Control at the NYC Health Department
212-788-3686
nmelend1@health.nyc.gov