A study published in Culture, Health & Sexuality explored how Black gay and bisexual men in Washington DC felt about a series of PrEP advertisements. Many participants wanted more information about PrEP than the ads provided; yet their preference for simple and short messaging was also very clear. The men prefered ads that normalised PrEP use and had mixed views on highlighting condoms in PrEP ads.
Black gay and bisexual men are disproportionately impacted by HIV in the US. Compared to their White counterparts, Black gay and bisexual men are less likely to be aware of PrEP, discuss PrEP with their health care provider, or to take PrEP.
Previous research on social marketing campaigns that aim to increase PrEP uptake among Black gender and sexual minorities has yielded mixed findings. For example, a large campaign in Chicago was positively associated with perceptions of community support in one study; in another study the same campaign was criticised for singling out – thus stigmatising – the Black community by others.
David Kalwicz and colleagues at George Washington University held four focus groups with Black gay and bisexual men in Washington, DC to hear get their feedback and recommendations on PrEP ads to inform future campaigns.
The study
Eligible participants were Black men aged 18 and older who had an HIV-negative or unknown status who had anal sex with a man in the previous year. The study relied on purposive sampling, with recruitment being done through dating apps, social media, and participant referrals.
Eighteen men participated in the study. All were born in the US, with the exception of one participant born in the Caribbean and another in Africa. Eleven participants identified as gay, seven as bisexual.
The participants had good engagement with physical and/or mental health services: 13 participants had used such services in the previous six months, but four had gone a year or more since last receiving services. Fifteen participants reported knowing about PrEP before the focus group, six were currently taking it and two were former users.
The semi-structured focus groups included a scripted description of PrEP and a series of questions related to PrEP advertisements. Each of the focus groups asked participants to reflect on a series of 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”.
The researchers modified the ads to eliminate things that could influence their relative acceptability. Changes included covering city names and adding condom messaging to ads that did not previously contain this, for consistency.
Results
Most participants found that the ads did not contain enough information. Many wanted more information on effectiveness and side effects. As one participant shared:
“I want more information than like one pill once a day. I would need to know like what the success rate is, I would need to know what the side effects are, um, to know like what’s it doing to my liver. Um, so I would need way more information than all these are giving me. Um, and I don’t know like how to frame that in an advertisement but it’s definitely worth considering because there are people like me who will see that, and it will just wash over them.”
Participants shared that the advertisements seemed to be geared towards those with pre-existing PrEP knowledge, rather than those who were unfamiliar with PrEP:
“I think that there are some assumptions that you have a base understanding of what PrEP is, which I don’t know if everyone who is sexually active in this way would.”
The participants discussed ways that the ads could provide more information, such as prominent phone numbers and websites, or QR codes that people could scan. Another suggestion was a stronger call to action to engage with a healthcare provider:
“I would look at it and I would say, okay, like, this is something I would like, you know, I could be interested in but it doesn’t tell me what I need to do next. So, like – So, just like the quick steps, like… find a clinic, talk to a doctor, get a test. Uh, so I mean it doesn’t – it changes my mind at, like, it makes it relatable and it makes me think about being open to it, but then it doesn’t make me do action because I – it doesn’t tell me what I would need to do.”
The desire for more information was accompanied by another clear preference: short and simple messages. As one participant put it:
“It applies to the KISS method, which is keep it, um, keep it short and simple… one pill a day protects [against] HIV, that like pump and play, it just goes straight to the point right there.”
They cautioned that however simple, messages still needed to resonate. Participants had strong opinions about messaging that turned them off:
“I don’t really like any of ‘em… I don’t like the wor – I mean, I get what they’re tryin’ to do, but, like, spread, transmit, catch are not words that make me feel like I wanna be intimate with that person. So, like, I get they’re, like, tryin’ to say, like, ‘Oh, instead of catching HIV, transmit love,’ but I don’t know. It doesn’t [get] me there.”
Participants appreciated plain and clear messaging:
“So I gravitate more towards like just the simple English, like ‘Prepare for the Possibilities.’”
Many suggested normalising PrEP in the context of a self-care routine. They referenced popular slogans from television:
“The gym, tan, PrEP. Like something that like will like stand out to people and it kinda shows it’s like in the daily regimen of things. Or like an ad that has like a toothbrush, a stick – a bar of soap and like your PrEP pill.”
“I think that’s compelling … like, anything that talks about or shows the ease of use just of taking, like, a pill once a day, like a multivitamin. I think makes it like it can just be part of a very easy daily routine.”
Participants had wide-ranging views on whether to include condoms in ads about PrEP. Some participants felt that including condoms undermined the effectiveness of PrEP:
“It just sorta hit me that every single one of these ads has PrEP plus condoms. And I think just the average person on the street would – might ask, well, what’s the point of taking a pill every day if I still have to use condoms.”
Others felt that it made them doubt condoms:
“It’s makin’ me question whether condoms were ever enough to protect yourself. That’s the only thing that I’m thinkin’ about when I see these.”
A similar number of participants advocated strongly in favour of including condoms messaging, to avoid misconceptions that PrEP prevented anything other than HIV:
“I think it’s dangerous when you advertise PrEP but don’t advertise condoms. Because what you don’t want is for people to think that they can take this pill, it’ll prevent HIV and everything else because it won’t prevent everything else, it’ll only prevent HIV.”
Others agreed, but suggested modifying the ads to make it clear that condoms were being mentioned in relation to other STIs:
“If you’re gonna talk about condoms … you need to mention somethin’ about STDs. You can’t just say, ‘Oh, yeah, with a condom, too.’”
Finally, some participants understood the inclusion of condoms in PrEP ads as demonstrating the array prevention methods:
“I think of it like a toolbox, right? Like, you got different tools. PrEP – PrEP’s one. Condom’s another. I don’t have any problem with condoms being added. Like, it doesn’t confuse me.”
Conclusion
While highly effective, PrEP can do nothing to prevent HIV among Black gay and bisexual men unless they are aware of it and take it. Public health campaigns can help, and this study provides valuable insight to how some Black gay and bisexual men in Washington DC feel about messaging used in several high profile PrEP campaigns in the U.S.
Lessons learned from this campaign include:
- Include enough information about PrEP. Failure to do so may only reach those with a baseline familiarity with PrEP.
- Take care to use clear and simple messaging that resonates with the audience. These participants did not like approaches with ambiguous, confusing, or unsexy messages.
- Normalise PrEP as a part of a self-care routine and/or through comparisons, such as to a multi-vitamin.
- If condom messaging is included, ensure it isn’t undermining the effectiveness of either PrEP or condoms through ample context. This may include being clear that PrEP doesn’t prevent STIs or being clear that PrEP is one of many effective tools to prevent HIV.
There’s a balance between being comprehensive and keeping things short and simple in a medium with finite space. Participants in this study suggested making it easy for viewers to learn more, through the use of websites, phone numbers, QR codes, or a call-to-action to follow up with a healthcare provider.
The best practice in creating a public health campaign is to develop messaging and visuals with the meaningful involvement of the intended audience. However, insights from this study can be used as a starting place when setting out to create local campaigns.
Kalwicz DA et al. ‘There are people like me who will see that, and it will just wash over them’: Black sexual minority men’s perspectives on messaging in PrEP visual advertisements. Culture, Health & Sexuality, online ahead of print, 4 January 2023.