Monday, May 19, 2014

A Critique of the Act Against AIDS Initiative – Jesse Anderson

            The White House and Centers for Disease Control and Prevention spearheaded the Act Against AIDS (AAA) initiative in 2009 in the Unit States.  The rapid spread of HIV over the past two decades raises concerns for both government organizations.  The initiative hopes to fight complacency with HIV/AIDS amongst Americans by increasing awareness and reducing the incidence of infection in high-risk populations.  These populations include men who have sex with men (MSM), African Americans, and Latinos (1).  
The AAA initiative consists of eight different programs.  Four of these programs target patients while four target healthcare providers.  Three of the four patient programs target a specific subgroup in the United States.  “Let’s Stop HIV Together” targets the stigma of HIV amongst Americans is the only generalized campaign in the organization.  “Reasons/Razones” encourages the Latino MSM community to get tested while the other two, “Take Charge. Take the Test” and “Testing Makes Us Stronger” aims to empower members of the African American community to get tested for HIV.  The former targets African American women while the latter targets African American MSM (1).  All of these programs help to raise awareness about the complications and consequences of HIV but have very different methods of conveying this information.
The four physician programs target specific subgroups amongst healthcare providers.  “One Test. Two Lives” targets obstetricians and encourages them to test any pregnant woman in their clinic for HIV.  “Prevention is care” aims to ensure clinicians council patients on reducing risky sexual behaviors.  “HIV Screening. Standard Care” encourages all primary care providers to screen all patients for HIV while “Testing and Linking Minority Patients to Care” aims to help providers support the minority African American and Latino communities screen for HIV (1).  As with the patient programs, all of these target specific subgroups within the medical field.  Unlike the patient program, they tend to have the same overall prevention and screening messages. 
Though two powerful organizations back this important initiative, their method of conveying the information may not maximize the full potential of these programs.  The initiative’s overall presentation, use of statistical facts, and lack of people recognition could lead to unsatisfactory results.  The leadership should consider adjusting some of its campaign strategies to effectively reach more people.  If executed differently, this initiative could have a substantial impact on the number of HIV tests as well as raise awareness about the disease.
Overall Presentation
            Many public health programs base their campaigns on individual level models.  These models suggest an individual’s will power alone will help them overcome a perception of a problem.  Unfortunately, these programs do not account for other external factors, such as someone’s environment, social support, or education.  The AAA initiative is another example of a public health program using individual level models.  For example, if an AAA advocate were to ask people on the street whether they should get tested for HIV, the overwhelming majority would likely say they should.  However, there is a substantial disconnect between HIV testing awareness and utilization.  Multiple studies show an association between lack of HIV status awareness and HIV transmission (2-3).  This implies these people do not get the annual screening the CDC recommends and unknowingly pass HIV on to intimate partners (2). 
            Though studies repeatedly show a lack of utilization, the AAA initiative never shows a specific community how or where to get tested.  Instead, they simply state facts, statistics, and reasons to go get tested.  This suggests this initiative follows the Health Belief model.  In this model, an individual will weigh their perceived susceptibility to and severity of the illness against the cost-benefit analysis of getting tested (4).  This model does not take into account the many external factors that affect the potential audience’s ability to get HIV testing.  For example, an individual may realize the importance of getting HIV tests but are unavailable when their local testing center is open due to other commitments.  Even worse, this individual may be unaware of where they could get tested.  This is one of many factors the leadership did not take into account while developing this program. 
            Additionally, the core values the organization use, as arguments throughout the campaign are insufficient.  The organization uses health and love as core values to support their goals.  Most of the current campaign emphasizes the need to protect loved ones from HIV or getting family support after a HIV positive diagnosis.  For instance, one campaign suggests it will be good for you and your partner to be aware of your status to protect each other.  Also, the “Testing Makes Me Stronger” campaign suggests you will be healthier and a stronger unit if you get tested (5).  While it is helpful for couples, this type of initiative will likely not be helpful for singles who fall into these at-risk communities.  This will not speak to them as much as it will to partners.  Additionally, the “Reasons” campaign suggests reasons the Latino MSM community should get tested.  One of the reasons proposed is getting tested for the person’s family.  Because the diagnosis goes to the individual and not their family, this argument might be flawed.  Furthermore, given the stigma associated with the disease, this individual’s family might abandon and no longer speak to them.  Ultimately, health and love may be insufficient to get people motivated to get tested. 
            Finally, each program created by the organizers targets each of the high-risk communities using different messages.  These messages utilize different core values that are important to the community it targets.  For example, Latinos tend to value family more than other groups.  This is evidenced through increased family cohesion as compared to other ethnicities (6).  However, these values might not be congruent with certain groups within that ethnicity.  For example, the lesbian, gay, bisexual, and transgender (LGBT) community might not have these same values they associate with these groups.  Some LGBT individuals’ families meet them with hostility after their children reveal their feelings (7). Thus, family might not be as important to them as the initiative’s organizers believe, especially if they are heavily religious.  It is important to consider the beliefs of a few in the high-risk population might not be congruent with that ethnicity’s stereotype.
Statistics and Bias
This initiative provides facts, statistics, and information about HIV infection in one of the first portions of its website (8).  Statistics are important for scientists to understand the current problem and its potential impact.  However, it will not help convey the importance or an individual’s risk of getting the disease.  People tend to believe a disease with a relatively small incidence rate in the overall population will never affect them personally.  If they are less likely to believe it will occur to them, they will not take the necessary precautions to prevent it.  This is an example of the Law of Small Numbers.
The Law of Small Numbers states an individual will believe a small sample’s outcomes accurately reflect the overall probability of that event occurring to them (9).  However, the outcomes in that small sample of the population could convey they have a significantly smaller risk than the standard incidence rate.  Consider an individual who practices a risky behavior (i.e. unsafe sex) multiple times with multiple partners.  If this individual experiences no adverse outcomes over a period of time, they are less likely to believe these outcomes will occur to them.   Similarly, if adverse outcomes do not occur to friends, this individual is less likely to take the necessary precautions to prevent any diseases.  It is not until after the disease occurs when they realize their error.  This is one of the many reasons HIV spreads through humans. 
Compounding this problem is issues raised as a result of the Theory of Optimistic Bias.  This theory states that people tend to underestimate the probability of bad things happening to them (10).  The AAA campaign features an individual who felt she was protected against HIV.  She did not believe HIV would happen to her since the risk was so small and none of her friends had it.  It was not until after she got infected that she realized she should protect herself from this disease (11).   This irrational thinking emphasizes the need to provide a different perspective on HIV testing.  Eldrige et al. (1995) discussed the Theory of Optimistic Bias in a study on low-income African American women’s barriers to condom and protection methods in sex.  The study did not show that African American women believed others were more at risk of getting HIV than themselves.  However, this study did show women believed the barriers to condom use for other African American women were worse than their personal barriers (12).  These women believed they would personally be able to use a condom when they wanted to while their counterparts would be unable.  It is important to note a woman’s’ ability to use condoms does not necessarily mean they will utilize them to protect themselves against sexually transmitted infections (STI).  Regardless of access, these women will be less likely to use condom if they perceive their risk of getting infected with HIV as low.  The leadership should consider changing their framing of the issue to eliminate these population-based biases.
People Recognition
Some campaigns choose to use celebrities or well-known names to help convince people their ideas are worthwhile.  Others choose to use everyday people to push their support for a certain campaign.  Utilizing either can be an effective method to bring people to a consensus.  However, an organization’s leadership must choose their spokesmen carefully.  The spokesman’s message might not get through to their audience as intended for any number of reasons.  Furthermore, the spokesman’s message might backfire and push people away from their overall message.  While the AAA initiative obtains both everyday individuals and a celebrity spokesperson, further changes could be made to ensure people are receptive to their message.
The AAA initiative uses every day people either infected with HIV or affected by a HIV diagnosis.  These individuals are either a person living with HIV or a family member of an HIV-infected person.  In addition to changing the core values, the organizers could change the people delivering the message as well.  Currently, a middle-aged mother, an African American man, and middle-aged Caucasian male are featured in the campaign’s videos.  There are several important groups not included in any of these videos.  A Latino, young teenager or early adult, or LGBT individual (either individually or with a partner) are all not included.  Not only does the organization try to target these groups, but people who are part of these groups need to hear this message coming from them without a family member next to them.  Their current every day spokespeople could promote the Psychological Reactance Theory. 
The Psychological Reactance Theory says an individual will either ignore or respond negatively to someone’s requests if they do not identify with them (13).  Some studies show if information disseminators are unlike the target audience, it will likely not affect their perceptions or attitudes.  For instance, Driscoll et al. showed that teenage lovers were more likely to stay together if their parents attempted to interfere with their relationship (14).  Similarly, drug abuse campaigns demonstrate the effects of doing various drugs (e.g. marijuana) for an extended period of time (15).  Since its creation, there are a number of parodies of that campaign floating around on the Internet.  This is an opportunity for the AAA campaign to learn from the mistakes of previous campaigns and change certain aspects to promote a more effective campaign.
In addition to everyday individuals, the AAA initiative uses one celebrity, Jaime Gomez.  He presents the importance of getting tested for HIV and suggests it is critical to do so.  He mentions some statistics and discusses his first cousin’s recent HIV diagnosis (16).  There are several issues associated with the AAA strategy with this video.   He is a lesser-known celebrity, which might not make him as effective at changing people’s attitudes.  Thus, people might be less likely to listen to him, as he is not an authoritative figure in pop culture.  Additionally, he might provoke the aforementioned psychological reactance in some since people may not be able to relate to or know of him.  Finally, he references some statistics, which might not promote his cause.  Mentioning these statistics violates the Law of Small Numbers (9).  Combine all three of these issues and there is a recipe for resistance from the targeted audience.  The leadership team should consider developing a new type of intervention that will effectively bring this audience on board. 
Proposed Intervention
            The proposed intervention blends all aspects of the current intervention together.  The initiative will no longer have four programs for both patients and caregivers.  Instead, one program will target all patients while another will target all healthcare providers.  Because the intervention amongst healthcare providers is fairly consistent, most of the changes below will apply to the patient programs.  The new patient initiative may contain videos, posters, and brochures that discuss the importance of getting tested for HIV.  These materials could use a wide variety of people or celebrities and contain emotional stories in different regions of the United States and will contain no statistics.  These stories could have justice and freedom as core values and will have a listing of prominent local testing centers in the area along with contact information and hours. 
Stories Tailored to Targeted Population
The organization could tailor these stories to multiple populations to try to ensure they react a certain way.  The organization could create multiple versions of brochures, flyers, and advertisements that show multiple people within a specific target population.  These materials would focus on the Latino, African American, and LGBT communities.  They could also have several materials tailored to those communities less at risk, such as middle-aged females.  The organizers could disseminate these materials through primary care offices, local health departments, and local supermarkets.  Since people frequent all of these places, they will likely be exposed to the campaign’s message.  If the message is effective, the organizers will encourage the target audience to go to their local testing site for a HIV test.
For example, the organizers could tailor a brochure towards the Latino MSM community.  The brochure should have one or more LGBT Latino/a(s) discuss his or her experience with HIV.  They should tell some type of emotional, personal story that has justice or freedom core value.  For instance, this story could talk about their family rejecting them after being diagnosed with HIV, moving out of the house after a rough breakup with a cheating partner, or something similar.  Tailoring these HIV testing campaigns to specific communities with strong core values could create a lasting impression.  More people will likely have some type of reaction, which will encourage them to act. 
Furthermore, messages coming from similar people will lessen the psychological reactance from these target populations.  Because many fear getting tested for HIV, they need a strong enough reason to do so.  If the spokesperson is similar to them in many respects, the person will be able to identify with individual telling the story.  It will likely encourage them to pay attention to the campaign’s message, and they will be less likely to have a negative reaction.  This might encourage people to go get tested as soon as they can, which is the ultimate goal of the campaign. 
Distribute Organization into Regions
            Some current materials offered by the AAA initiative website provide some general contacts for support and testing.  While one website has a zip code search of local testing sites, none of the other websites offer this tool.  None of their print materials have much contact information listed, if any.  Their print material also assumes their audience has Internet access, which is not always true.  It would be worthwhile for the organization to offer specific contact information for testing sites in someone’s area.  The organization should consider breaking up into regions to better serve their target population and their specific communities.
            To accomplish this, the organization could split the United States into regions much like the Veterans Health Administration (VHA) (17).  This will give distinct, pre-defined zones that give guidance on how and where to define the program boundaries.  Within each of these zones, the organization could identify major metropolitan areas as well as key towns in rural areas that offer testing services.  To simplify this process, they could simply target areas currently with VHA outpatient and medical centers.  While the actual VHA centers themselves would not provide the testing, this could inform organizers as to where they should look for potential testing centers.  It could make it easier for individuals to obtain HIV testing.
Moreover, distributing this organization into zones will help to efficiently manage this organization.  Currently, it appears the organization operates on a national scale with little to no regional offices anywhere.  Operating in a regional system will allow for more unique, tailored approaches to reaching the target populations.  For instance, the beliefs and challenges for the LGBT community might be different in Mississippi as compared to Massachusetts.  In addition to listing the contact information for local testing centers, the organization could tailor their messages to directly match the issues affecting these communities most. This could help increase HIV testing in the communities hardest hit and prevent the spread of HIV.
Utilize Theory of Reasoned Action
Although it is an individual level theory, organizers should consider incorporating the Theory of Reasoned Action for this campaign development.  This theory suggests an individual has certain outcome expectancies related to an event.  All individuals getting tested have an attitude about what will happen if they get tested and assign it a weight.  Societal social norms will play a factor in any decision they make, and they will consider who might not approve of it and to what degree (18).  For example, a patient might not get tested due to the stigma of being HIV positive.  This stigma, rooted in social norms, will be weighed against the outcome expectancies of tested for HIV.  An individual’s attitudes about their perceived outcome expectancy and the weight given to that attitude will help determine whether the individual will get tested at all.  If organizers emphasize support services offered to HIV positive patients, this might encourage more people get tested. 
Organizers could also ask people to give stories that describe their reaction when they received a negative result.  It seems most stories people hear about are those that test HIV positive.  However, there are substantially more patients who test negative for this condition.  This might encourage more people to get tested to just know their status.  Studies show that the stigma surrounding HIV is the biggest reason people do not get tested (2-3).  Using this method, the organization could show not all who get tested end up HIV positive.  Also, they could show that someone should simply know their status for their own peace of mind as well as for others.
Finally, the organization could emphasize there are support services out there for those who test positive for HIV.  This could show there are people with this diagnosis who support others.  This campaign could emphasize a nurturing, caring environment where people support each other through their recent diagnoses and learn how to cope.  They could also emphasize that people live with HIV daily, and it is no longer a death sentence.  All are methods to get people to change people’s perceptions of the standing social norms.  It might also encourage people to think more about who would approve and by how much.
            HIV testing is vital to HIV prevention and treatment.  Initiatives, such as AAA, attempt to get patients and healthcare providers alike to understand the importance of HIV testing.  These organizations specifically target high-risk communities to ensure they are not prone to getting infected.  While the CDC and White House established a very important and worthwhile organization, these organizations could take steps to improve the organization’s overall effectiveness.  They could tailor the organization’s messages further, regionalize the organization, and approach social norms from a different angle. 
This organization will continue to grow as word continues to spread and is one of many trying to fight the spread of HIV.  More should be done to fight the war against HIV.  Scientific advancements continue to push towards a cure.  Until scientists find a cure, this war will not stop.  Prevention through HIV awareness, safe sexual practices, and HIV testing are the best methods of protecting the population from this disease.  This organization promotes all of these, but it can do all more effectively.  Incorporating these changes could have an impact on the efficacy of the organization, and it could reach more people than it thought possible. 

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  2. Centers for Disease Control and Prevention.  HIV testing and risk behaviors among gay, bisexual, and other men who have sex with men – United States. Morbidity and Mortality Weekly Report (MMWR) 2013; 62:958-962
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  15. National Youth Anti-Drug Media Campaign.  Above the Influence.  Washington, DC:  Office of National Drug Control Policy.
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  17. Veterans Health Administration.  Locations – Veterans Integrated Services Network.  Washington, DC:  Department of Veterans Affairs.
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