"Bring back the Grim Reaper!" they say. "You need a fear-based campaign to shock people into the awful reality of HIV."
We’re familiar with this type of sentiment. It usually appears in the letters column of the gay press following any announcement that HIV numbers are up in the community.
The Australian Government’s Grim Reaper advertisement appeared for less than three weeks on prime-time television in April 1987. Showing the medieval icon of death with sombre black hood and scythe cutting down the lives of ‘ordinary Australians’, it has entered the psyche of the Australian public like no other advertising campaign ever has. A man in shirt and tie, a footballer, a little girl, a housewife and her baby – all bowled over like ninepins in a bowling alley.
There is no doubt that these shock tactics worked to alert people to the existence of AIDS as a threat to Australian society. Some say they worked because of the controversy they provoked. Columnists like Phillip Adams from The Australian mocked them as unnecessarily scaring the wrong people. Heterosexuals were never going to be affected anywhere near as much as gay men or people who injected drugs.
It did however increase condom use slightly among heterosexuals and it did help raise awareness among politicians and bureaucrats about the need to fund more public health campaigns – including more targeted ones aimed at gay men, and needle and syringe programs to combat intravenous transmission.
Late last year, when confronted with high rates of HIV infections among African American and Latino gay men in New York, the city’s Health Department released a similarly graphic advertisement to jolt people out of the view that HIV treatments have made everything all right.
Using the slogan ‘It’s never just HIV’, these ads portray gloomy, yet attractive young men looking scared as messages about the supposedly awful health risks associated with HIV flash across the screen…
"When you get HIV, it’s never just HIV. You’re at higher risk to get dozens of other diseases, even if you take medications. Like osteoporosis, a disease that dissolves your bones. And dementia, a condition that causes permanent memory loss. And you’re over 28 times more likely to get anal cancer. It’s never just HIV. Stay HIV free. Always use a condom."
Probably the worst and most controversial aspect of the ad is a graphic photo of anal cancer. It is a shocking image and has led to a barrage of criticism claiming that the advertising has gone too far.
There has been a chorus of protest from gay and PLHIV organisations across America. The Gay Men’s Health Crisis wrote to the Mayor of New York, Michael Bloomberg, asking that the ad get pulled because it "intensifies stigma against people living with this condition and against gay and bisexual men, in general, at a time when we are encouraging young MSM to be tested for HIV and people living with HIV/AIDS to enter care and anticipate a long and healthy life".
Others, such as long-term HIV activist and author, Larry Kramer, came out in support saying: "This ad is honest and scary, all of which it should be. HIV is scary and all attempts to curtail it via lily-livered nicey-nicey 'prevention' tactics have failed."
But will such a fear-based approach work? The UK-based Sigma Research, has studied the use of fear in HIV prevention campaigns and thinks not. They have found that such campaigns can be effective in raising awareness and changing attitudes but few have demonstrated the desired change in sustainable behaviour.
This style of using fear tactics tends to be favoured by individuals who are already engaging in the desired, health-protective behaviour. Fear campaigns, it seem, can reinforce existing safe sex behavior but not necessarily change it in those the campaign is targeting.
One of the reasons for this seems to be that when people are fearful they engage in a range of coping strategies including: avoidance (changing the TV channel or turning the page in the magazine); denial (believing that the harmful consequences portrayed by the ads are unlikely or even impossible); counter-arguing (e.g. "I’ve had lots of unprotected sex and I’ve never caught HIV"); and othering (e.g. "This message is for others, it’s not meant for me").
Bernard Gardiner, former manager of the Red Cross International HIV program, has commented that "invoking fear may make people less rational and less likely to make safer decisions. Sex and fear may even end up compartmentalised if the person is overloaded enough," he adds.
He believes (correctly, in my opinion) that the subtext of the NYC Health Department ad is to invoke stigma and terror about cancer, and by combining this with anal sex the ad ends up creating a message of guilt and shame about gay sexuality.
Any long-term impacts, such as it contributing to lower self-esteem or internalised homophobia in gay men (all risk factors themselves for increased infections) have clearly not been considered. Neither really has the message the ad sends to people with HIV.
It is simply not truthful to imply that all people with HIV are going to get these diseases. Nor is not the case that (as the faces in the ads are those of young men) young people with HIV are likely to get these conditions synonymously with HIV infection.
Research into HIV and ageing is showing us that as people with the virus get older, they may face a greater risk of getting these age-related morbidities. But it will not affect all people the same way and many of us will most likely die of simple old age.
It will take savvy HIV-negative gay men only a short while to realise that, as most of their positive friends don’t have these conditions, the message loses credibility. And for those who don’t know positive people, these images will only serve to reinforce their view that people with HIV are helpless and diseased, and not like them in any way.
In Australia, we have long rejected the use of fear in HIV prevention education. When transmissions started to rise several years ago, HIV educators were under pressure to produce fear-based messages. It was around then that lipodystrophy (wasting in the arms, legs and face and abdominal or breast fat accumulation) was appearing as a common side-effect of HIV treatments. The suggestion was that photos of people with lipodystrophy might act as a deterrent to those who had become complacent about HIV.
Colin Batrouney, Manager of Health Promotion at the Victorian AIDS Council/Gay Men’s Health Centre said at the time: "While the available literature clearly shows that a 'fear appeal' based on the horrors of antiretroviral therapy would not work in persuading HIV-negative men to maintain condom use, the same literature strongly suggests that the same strategy would persuade HIV-positive men of the poor quality of life outcome of antiretroviral therapy and act as an effective barrier to the uptake of therapies necessary in the control of viral load and disease progression."
What works in HIV prevention messages is beyond my capacity here and I will leave that to the trained educators in our midst. But it seems clear to me that any campaign that talks about the realities of sex in our lives is more relevant and likely to succeed than any grim messages about disease and death.
There are difficult discussions to be had about sexual risk in an era of continuing HIV, and a candid acknowledgement of that, in education messages, will resonate more than Grim Reaper-style warnings that have lost their power to shock as HIV has become a more manageable condition.
One of the more successful HIV prevention programs in Australia at the moment – the Drama Downunder campaign – uses clever and funny messages on billboards, bus shelters and gay magazines to get the message across about regular testing for STIs, including HIV. Evaluation of the campaign shows that young and older gay men as well as heterosexuals identify with the campaign – with all groups believing that "that guy in the underpants is just like me".
A new campaign from AFAO and NAPWHA to be released this year aims to challenge the stigma that still seriously affects the lives of many people living with HIV. The ‘Fear Less, Live More’ campaign will confront the subject of rejection that many positive people regularly face from their sexual partners and will also present uplifting stories from both positive and negative people about how they have overcome the fear associated with HIV.
This campaign aims to overturn a stigma which, some say, goes all the way back to the Grim Reaper campaign of the 1980s. While it may not have been the intention, that campaign added greatly to the burdens carried by those of us who were living with HIV at the time. With our sunken cheeks and thinning limbs, many of us, looked not unlike the Reaper himself. So, rather than fearing the virus, people began fearing those with HIV and discrimination against us occurred as a result. With the message that "AIDS kills" it also gave people who were ill at the time less hope that they would survive.
We don’t need a return to those days to stop HIV transmissions. Positive stories about how people overcome the stigma and fear of HIV and are able to maintain safe sexual behaviours is a much better way forward.