US Black gay and bisexual men stigmatised by PrEP ads targeted for them

Black gay and bisexual men in the US prefer PrEP advertisements that feature couples with racial, sexual, and gender diversity, according to a mixed methods study published in PLOS ONE. The men found diverse couple composition in ads to be less stigmatising than ads solely featuring Black gay and bisexual male couples, and more appealing than ads featuring no couples.

There’s an urgent need to improve PrEP use among Black gay and bisexual men in the US. Marketing campaigns that aim to do so must navigate the intersection of racism, homophobia, and stigma around sex, PrEP and HIV; it is easy to miss the mark and further stigmatise this under-served population.

The current study is part of a larger longitudinal study on PrEP advertisements and US Black gay and bisexual men. As previously reported, researchers first looked at how US Black gay and bisexual men felt about the messaging used in a series of PrEP ads, which highlighted a balancing act between simple and comprehensive messaging.

Methods

Building on that, Dr Sarah Calabrese of George Washington University and colleagues looked at the impact of the visual elements of these same ads for the current study, particularly the composition and demographics of couples featured in the ads. The mixed methods study had participants provide feedback on PrEP ads through online surveys and four in-person focus groups.

The ads used in the study were 12 social marketing images adapted from three major US PrEP campaigns: Washington DC’s “PrEPare for the Possibilities”, New York City’s “PlaySure”, and Chicago’s PrEP4Love”. Participants viewed four ads from each campaign: one with a Black sexual minority couple (queer couple), one with a Black heterosexual couple, one with multiple couples with racial, sexual, and gender diversity, and one with no people in it. Ads were modified for consistency to eliminate things that could influence their relative acceptability, such as covering city names and adding condom messaging to ads that did not previously contain this. 

Eligible survey participants were Black cis and trans men of HIV-negative or unknown status who had anal sex with a man in the previous year and lived on the east coast. Participants were recruited through dating apps, social media, email listservs, and referral. The survey aimed to look at the impact of the PrEP ads on initial PrEP uptake; for that reason only those who had not previously used PrEP were eligible.

The survey design included an initial survey where participants were asked to view one of twelve images described above, and subsequent weekly email and text reminders to view the ad from the first survey again. A second survey was done eight weeks after the first in which participants viewed and rated all 12 ads.

Focus group participants were recruited through the same channels and by inviting survey participants. Eligibility was restricted to cisgender men but expanded to include those who had previously taken PrEP. The in-person format meant that recruitment was focused on the Washington D.C. area.

Participant characteristics

Ninety-six participants participated in the first survey. All identified as a man and none as a transgender man. Twenty-seven per cent of participants were aged 18-25, 59% aged 26-45, and 14% were 46 or older. Thirty-eight per cent were Latinx/Hispanic. Most (83%) were employed full-time and had an income greater than $30,000 annually (79%).

Most identified as gay (78%), 15% were bisexual, one participant identified as heterosexual, and 6% as other. Sixty-eight per cent had previously heard of PrEP, 25% had discussed PrEP with a provider, 4% had received a PrEP prescription, and none had taken PrEP. Seventy-six per cent of survey one participants completed the second survey. Those doing both surveys were more likely to be Latinx, have a higher income and not have previously heard of PrEP.

Eighteen people participated in the focus groups, half of whom had participated in the survey. Most (73%) were aged 26-45, 17% were 18-25, and 11% 46 or older. Most (90%) were non-Hispanic. Participants identified as gay (61%) or bisexual (39%). All reported an HIV-negative status. Most (88%) had heard of PrEP. 47% had ever taken PrEP, and 35% were currently taking PrEP. Data was not collected on education, employment, or income for focus group participants.

Results

The first survey found that couple composition affected how eye-catching, motivating, stigmatising, relatable, memorable, and pleasant the ads were. Forty-two per cent of participants rated ads featuring a queer couple as very or extremely stigmatising. Focus group participants agreed, noting that such targeting can alienate Black gay and bisexual men and associate them with HIV:

“To certain people it can come across as insulting ‘cause it’s almost like saying we are the ones who have the disease, like we’re the only ones with the problem.”

“That can also build conspiracies around the drug as far as, well why they always, uh, you know, buildin’-why they always marketin’ towards Black men, um, or Black gay men? Can you trust it…a lot of us think-know it’s somethin’ that can help us, some, uh, think that is it somethin’ that’s out to get us as well.”

“Do only gay people take this? Like, is it a gay drug?...That’s what is looks like.”

Survey participants rated multiple diverse couples as being less stigmatising than queer or heterosexual couples, with only 19% rating them as very or extremely stigmatising. They were also rated the most motivating, relatable, and memorable, significantly more so than those with no couples. Many focus group participants agreed, noting that diversifying can make ads relatable to more people:

“I would love to see a line of people standing up, um, every height, every age, every race, just standing there, and then it’s PrEP. That’s it. This is who it represents. It doesn’t just represent Black men. It represents everyone who is sexually active. This day and age, anyone can contract HIV, so I think it needs to be broadcast to every type of person.”

However, some differed in their take:

“I think having some diversity matters… I think representation matters more…. Diverse representations of Black love and -and acknowledging that like this doesn’t just affect Black people…There are a lotta different kinds of Black people. And like that diversity matters just as much.”

One participant highlighted that there is often not a lot of representation of masculine Black men in the Black gay community, and that they appreciated seeing masculine Black men in the ads featuring queer and diverse couples.

A minority of focus groups participants favored targeted ads, noting that prioritising limited resources based on who is most impacted by HIV is reasonable:

“I don’t think it’s would be stigmatizing to, uh, focus on the gay community. I mean, it’s – it’s just a fact.”

Survey participants thought the ads with no couples were the least stigmatising, with only 4% rating them as very stigmatising and none as extremely. But they also rated them as the least eye-catching, motivating, relatable, memorable, and pleasant. Focus group participants called them boring and said they wouldn’t catch their attention.

The survey participants had minimal differences in how they judged ads from different campaigns; however, focus group participants did have preferences. They thought that sexualised images are unnecessary and may turn off people who do not perceive themselves as highly sexual:

“It kind depicts it as like, okay, well if you- like if you are a little more promiscuous…PrEP is for you. And if I’m not as promiscuous, maybe it’s not for me.”

However, they did note that where adverts are displayed matters:

“I think it just depends on the context of the advert as well… on dating apps, um, there is the assumption that people will be there looking for a sexual encounter… whereas, if it’s something on the Metro they might use something a bit less salacious that’s more family friendly…”

They also noted that targeted ads that are sexual in nature can be especially stigmatising by hypersexualising Black people, especially in public spaces.

In terms of limitations, the small sample size and focus on specific locations means that results may not be generalisable to other Black gay and bisexual men in and outside the US. The online nature of the surveys may have impacted how participants responded. The changes made to the ads might affect how realistic the findings are.

Conclusion

This study offers insights to those undertaking the challenging yet critical task of creating effective and appealing ads to increase PrEP uptake among Black gay and bisexual men. Takeaways include:

• Ads featuring only queer couples can be stigmatising, posing a risk to alienate the audience, associate Black gay and bisexual men with HIV, fuel conspiracy theories, or lead to misunderstanding about who PrEP is for.
• Ads featuring multiple diverse couples was generally viewed more favorably and can make advertising more relatable to more people.
• Context and placement of ads matter. Sexualised ads in public spaces can lead to further stigmatisation or hypersexualisation of Black people; however, these same ads may be acceptable and effective on dating and hookup apps.

While useful to guide campaign development, these suggestions should not be used to replace the meaningful participation and co-creation with the intended audience. Context, placement and the balance between representation and diversity matter. To get it right, agencies marketing PrEP should ensure that the people they are serving are involved – and compensated – every step of the way.