Calculating risks

John Maxwell gets up from his desk, heads to the elevator down to the lobby and hauls out a pack of cigarettes emblazoned with a photo of the most off-putting set of bad teeth Health Canada could find for its anti-smoking packaging campaign.

This doesn’t make Maxwell much different from the other six million Canadians who smoke, despite the tens of millions of dollars spent each year by the federal government to get them to quit.

Except that Maxwell is the director of community development for the AIDS Committee Of Toronto and has just spent the past hour talking about how ACT will spend a brand spanking new $350,000 to persuade Toronto men to have safer sex (ACT typically spends closer to $40,000 annually). Even the brightest, boldest and most expensive campaigns can’t provide a magic bullet for everybody.

And the safer sex message is far trickier than messages to reduce smoking or eliminate drunk driving.

“It’s okay to say drunk drivers and smokers should feel like bad people,” says Jim Whitney of Naked Creative Consultants. The firm is putting the ACT campaign together for free. “But when you get into the MSM [men who have sex with men, but don’t necessarily identify as gay] and gay communities, you can’t do that. You can’t make people with HIV look like losers.”

That’s just one in a long list of obstacles to convincing MSM to have safer sex. Theories on why they don’t are a dime a dozen. Could it be drug advertising campaigns have taught us HIV-positive men are gorgeous and athletic? Condom fatigue? The absence of the fear? New medications make AIDS seem like a snap? An embrace of recklessness in a regulated world?

It doesn’t help that there hasn’t been a major study of HIV transmission in Ontario since 1990.

All anyone knows for sure is that HIV infection rates are up among men who have sex with men in Ontario, especially Toronto. A University Of Toronto study released last November said new infections were 22 percent more than what was predicted for 2000.

Stats like those allowed ACT to declare the situation an emergency and finagle $250,000 in provincial funds and $100,000 in federal funds to wage a safe-sex campaign the size Toronto has never seen before. The project is slated to launch Pride Week (which runs Mon, Jun 18-24).

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What is “normal” sexual behaviour for men who have sex with men?

If your goal is to get people to change what they’re doing, you’ve got to figure out what they’re doing now and – this is the clincher – why.

“I think we’re seeing a sexual revolution,” says Ted Myers, who studies behaviour and attitudes in relation to HIV at the U of T and who co-authored the November report.

Myers says it’s difficult to understand the web of factors that makes men more or less likely to use a condom for anal sex – the biggest risk factor for gay men. For example, homos are being increasingly accepted in the mainstream; that should lead to increased self-esteem, right? And that would make a person more likely to have safe-sex, right? Not necessarily.

“More openness to gay relationships, for example, could lead to more risk-taking by people in couples. Or it could result in safer relationships,” says Myers.

Myers has secured funding for two major studies that will look at these issues: $500,000 from Ontario for a two-year study of 5,000 Ontario men (the biggest national study to date looked at 4,000 men) and $236,000 from the province-funded Ontario HIV Treatment Network to look at the relationship between alcohol, drugs and HIV infection.

“It’s not a matter of changing an individual’s behaviour,” says Myers. “It’s a matter of providing a context where they can have safe sex. There will be slip-ups, condom breakage. But you have to enable people to see solutions to their problems.”

In San Francisco, new infections are also on the rise, and there’s been more research there. Brian Byrnes, the director of prevention services for the San Francisco AIDS Foundation, says sophisticated urban gay populations have complex reasons for doing what they do in bed.

“When there’s a high degree of HIV knowledge and savvy, men are making different risk/benefit decisions,” says Byrnes. “To get their sexual and emotional needs met, they’re willing to relax their rules for behaviour. Back in 1988, you walked around the Castro district here and you saw a debilitating disease everywhere. Now you don’t see it and people are behaving differently. It’s not that gay men are stupid. It’s that they calculate the risks they need to take to get what they want.”

Sounds complicated? It’s this easy: You’re a gay man of 45. You really want to get fucked. You at look at the unexpectedly lustful and healthy-looking 23-year-old in front of you. You aren’t going to do anything that could scare him off.

A study of 102 gay and bisexual men by Barry Adam and Alan Sears at the University Of Windsor looked at this “irrational” risk/benefit behaviour. The men were asked about recent incidents of unsafe sex and the researchers came up with five recurring themes.

* Couples who chose not to use condoms because of perceived monogamy or to demonstrate trust and intimacy

* Men who occasionally had “accidental” unsafe sex because of the circumstances: they were drunk, they didn’t have condoms or they felt they couldn’t say no

* Men with a negative self image or mood who sought wild, often unprotected sex as a way to escape everyday life

* Men who believed they could evaluate their partner’s HIV status from various clues: he didn’t use a condom so he must be positive

* Men who had unclear ideas about safe and unsafe activities. Is condomless anal sex without ejaculation safe or unsafe?

“I have some suspicions about popular reasoning nowadays,” says Adam. “There’s a tendency to pick the scandalous reason: barebacking is rampant, complacency is setting in. There’s lots of reasons that are less dramatic, more mundane.”

Having unsafe sex seems closer to casually forgetting to wash your hands in a public washroom because there’s no paper towel, rather than a life and death decision.

James Murray, ACT’s men’s outreach coordinator, says there are subcultures within the MSM community – like the barebackers who actively seek condomless sex or all-night partiers who mix a lot of drugs with their sex.

“Barebackers, for example, develop a politics and code and language about their behaviour. How much effect does that have on everybody else? It’s hard to say,” Murray says.

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If the influence of subcultures on queer sexual behaviour is hard to measure, the influence of mass media is even harder.

This year, the San Francisco AIDS Foundation will spend US$250,000 on its social marketing campaign, which has been an inspiration for ACT’s initiative. It includes ads on billboards, bus shelters, the underground transit system and bars. The foundation then spends $15,000 annually evaluating its success; ACT plans a similar follow-up to its project.

“To think you will reduce infection rates is an unrealistic expectation,” says SFAF’s Byrnes. “We try to measure the saturation of the message, how well they understood it, how relevant it is to their sexual decision-making.”

In 2000, the foundation launched its “How do you know what you know” campaign, which challenged the intuitive judgments gay men make about their partners. “He’d tell me if he’s positive…. He’d tell me if he’s negative” one poster reads. In the follow-up, the foundation discovered that a lot of people saw the ads, but fewer people than they expected understood them.

“The messages needed to be simplified,” says Byrnes. “And we learned that the beautiful design distracted from the text-based message. We made some changes.”

Though the message seems to promote gay men disclosing their status and negotiating safe-sex issues more openly, Byrne says even that’s too much to ask of any media campaign.

“What we hope our social marketing does is switch on the light bulb,” he says. “We want to make guys conscious of the issue, so they’ll go to our website or attend a workshop.”

In the past, sexually provocative messages have been seen as a way to “turn on the light bulb.” That’s changed. San Francisco AIDS activists have gone so far as lobbying to stop an AIDS vaccine recruitment campaign from using hunky topless porn stars in a bus shelter campaign.

Sex might sell, but it’s becoming taboo. For the ACT campaign, too.

“We had looked at the possibility of having a sexual message, since it’s a sexually transmitted disease,” Naked’s Whitney says. “It felt right initially to approach it that way, but then it feels like we’re glamourizing the disease. Fashion Cares is a great event, it is. But because it’s such a great event, it’s glamourizing AIDS.”

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So you’re given $350,000 for a mass media campaign to reduce HIV infections in Toronto. You can’t use sexual imagery. You can’t use fear. You can’t make people with HIV feel bad. Your target population ranges from bar-hopping gay village fags to married immigrant men in the suburbs. Your target population has unsafe sex for reasons ranging from the deliberate defiance of barebacking to subtle psychological reasons like being too shy to ask for a condom. What exactly can you say?

“It comes down to making a condom a badge,” says Whitney. “What kind of person wears a condom? I think it’s an attribute to wear a condom. It sends a message about you. ‘I want to be seen as a confident, considerate person.’ Like in beer commercials. ‘The person that drinks that beer is confident, funny. I want to be that person.'”

Naked’s main claim to fame is an ’80s ad campaign for the Catholic group, Knights Of Columbus. It featured a garish photo of Jesus on the cross, with the line, “Dare to be a priest like me.” It got attention and, Whitney says, a few priests.

Again this time, Whitney sounds ready to produce another attention grabber. How about underwear printed with “Ask before you enter,” thrown from a Pride float? Could the slogan, “Spread the word, not the virus” make gay men talk before having sex? How far can the campaign go without causing a backlash from the Christian right?

Back at ACT, Maxwell is less concerned with the big idea and more concerned with the breadth of the campaign and how to sustain any momentum it builds.

“We need an overreaching campaign that can be tailored to different groups,” Maxwell says, like the black, Asian and Portuguese communities. He’s also looking at ongoing awareness campaigns. Bar washroom advertising and permanent advertising in bathhouse cubicles are two ideas.

“We want to formalize our relationship with the business community,” Maxwell says. “Community businesses should have a role in helping men stay healthy.”

Murray just wants to make gay men think seriously about their health again.

“I want to see some stimulation in the community about HIV,” Murray says. “Some kind of health movement for gay men would be a dream.”