To a welcome reception on Monday, November 6, the San Francisco Department of Public Health released its long-anticipated "Disclosure" campaign. Featuring psychedelic photographic images by photographer Duane Cramer--and emphasizing HIV status disclosure as a means of prevention-- the DPH bus stop and billboard effort is a groundbreaking, community-led prevention method that marks the first time a public health agency has recognized the validity of "serosorting" – a longtime gay community practice where men have a variety of sex, some of it unprotected, with men of the same HIV status.

"We as a health department are acknowledging what many men in the community have embraced as a harm reduction strategy," said Disclosure Initiative director Doug Sebesta. "Our campaign was really initiated to help people make better informed decisions. It's really empowering, and sex positive, and really about arming ourselves with more knowledge."

The colorful advertisements are a piece of a much larger DPH project known as the Disclosure Initiative, which involves prevention and care professionals and community members, and aims to help men normalize HIV conversations and disclose their status. More information is available at www.disclosehiv.org, which also links to www.hivdisclosure.org.

The San Francisco campaign comes several weeks after the Los Angeles Gay and Lesbian Center launched its controversial "HIV is a gay disease" campaign, and about 10 months after gay men grew vocally critical of the billboard in San Francisco's Castro District earlier this year that proclaimed, "New Years Resolution: I Won't Infect Anyone." All of the campaigns were designed by the San Francisco-based firm Better World Advertising, which has attracted a growing number of critics in recent years.

Critics of HIV social marketing campaigns often find that their objections are interpreted as problems with prevention messages, while sponsors of these messages often point to the discussion generated by the controversy as a mark of success.

But there is more to the debate than a simple disagreement over the slogans and images in HIV prevention advertisements. At the core of such campaigns is a set of assumptions or conclusions drawn about gay men, namely, that they are not talking enough about HIV.

That's a reasonable conclusion, said Les Pappas, founder and president of Better World Advertising and a former HIV prevention staffer at the San Francisco AIDS Foundation. Pappas – who conducts focus groups with men who have sex with men and who said he has been astounded by some of the misinformation that continues in the gay community – said there is no other way to explain why seroconversions continue.

"I do believe there's a disclosure problem. I think some people want to believe that everybody is doing the right thing and behaving properly and taking care of each other, but that's not what's happening. I don't see the benefit of sugar-coating and glossing over problems," said Pappas, who has proudly remained HIV-negative through the AIDS crisis. "We know there are people getting infected and we know that some of these people getting infected because they are having unprotected sex with somebody who is positive."

Pappas places the HIV infection rate at three per day in San Francisco, and five to six daily in Los Angeles. Although he said he does believe the majority of gay men do the right thing, he also believes "most of the positive men know they are positive. Some of them don't, but there are men out there who are out there and know they are positive and are allowing themselves to infect other people. I want people to be more honest, be more respectful, be more considerate. Getting tested, disclosure, and using condoms --this is basic human consideration and compassion for yourself and the community."

The right conversations

The right kinds of HIV conversations obviously aren't happening with frequency in the gay community, said Pappas, otherwise, "How do [his critics] explain the infections? If we were all doing that, this thing would end tomorrow."

But there is another possibility, say some longtime AIDS activists and educators: that gay men are in fact talking about HIV and taking care of each other, but that a post-crisis climate has meant more people – positive and negative – are using harm reduction approach

Writer and activist Tony Valenzuela

es and taking calculated risks they can live with. Critics of prevention marketing said the evolution of the disease from a death sentence to a more manageable condition – combined with the declining HIV rates among gay men – mean that sex without condoms is often practiced with thought, discussion, and safety rather than recklessness.

"The tone of many of these campaigns presume the lowest common denominator of gay men. But the gay men I know are smart, savvy, sophisticated, and caring of one another. They are talking about HIV and interested in serosorting and knowing more of the science behind it," said Los Angeles-based HIV activist and writer Tony Valenzuela. "With or without the blessing of health departments and AIDS service organizations, men are figuring out how to have the sex they want to have more safely. Some are choosing only oral sex. Some [negatives] are choosing unprotected sex only if they top. Just because things have improved doesn't mean people think it's no big deal. I have spoken with people who understand HIV to be a manageable disease but who still do not want to get it. But it's reasonable to assume that if the meds continue to get better, and there is a reduced threat of HIV, people will be taking calculated risks as a means of harm reduction and HIV prevention."

Such a prevention trend is something that has already been acknowledged by AIDS health advocates: earlier this year, San Francisco's DPH predicted a 10 percent drop in new HIV infections in San Francisco in 2006 compared to 2001, with another 20 percent decline in the rate of HIV transmission among gay and bisexual men. Chief reasons cited by AIDS groups for such progress was the decline in meth use and the increase in serosorting.

Pappas, too, has at least by proxy acknowledged the effectiveness of this practice: his most recent DPH disclosure campaign does rubber-stamp serosorting – called "status sorting" in the ads – while noting that people must be honest and actually know their status for the practice to work. But the ads themselves stop short of celebrating gay men for already practicing this prevention method on their own for years. As Pappas emphasized, they also promote the idea that gay men are not discussing HIV or disclosing their status, though many activists note that the well-documented trend of serosorting clearly requires disclosure.

Messages that imply an irresponsible community can further stigmatize gay men and thus encourage new infections, said Walter Armstrong, former editor-in-chief of the internationally distributed Poz magazine. Recently troubled by the Los Angeles "HIV is a gay disease" campaign, Armstrong is among a growing chorus calling for an absolute end to all HIV social marketing.

Such drastic measures "may seem controversial or even counterproductive on the surface. . .but I think this would, at best, force us and the prevention 'establishment' to find more scientific, more innovative, more responsive forms of HIV prevention and, at worst, just silence all the slogans that have never been anything but truisms, half-truths, or outright lies, starting with 'Safe Sex Is Hot' back in 1986."

Armstrong said such campaigns are always steps behind what gay men are already doing; "it wasn't until the mid-1990s that the big gay groups officially ranked oral sex as low risk, despite the fact that gay men had never used condoms for blowjobs."

Armstrong takes issue with the LA Center's implied "HIV is a gay disease" message, which "may reinforce for young gay men that HIV is inevitable if you are gay and that you are not fully gay until you become HIV-positive."

San Francisco HIV activist Michael Petrelis said there also is a problem with prevention campaigns that do not include measurable outcomes and markers of success – the goal of the LA campaign, said LA Center spokesman Jim Key, was simply "to get gay/bi men talking about HIV again."

LA Center officials said they were responding to a "degaying" strategy of HIV that went too far: the recent International AIDS Conference in Toronto barely addressed same-sex transmission, they said, and recent Better World focus groups included many gay men who said they wanted to see more images of heterosexuals with HIV and who wondered, "What about the babies born with HIV?"

"There are no babies being born with HIV in San Francisco. Period. So that's what about babies," is Pappas's response.

In Los Angeles, where 75 percent of people with HIV are gay and bisexual men, LA Center CEO Lorri Jean said there is an underlying internalized homophobia behind the desire to degay HIV, and she is confused by the campaign criticism – much of it from sex-positive activists – that seems overly invested in the right-wing reaction to the ads, or "what straight people think." Regaying HIV, she said, was meant to re-invigorate the spirit that once demanded research and funding for marginalized populations.

"We've become largely invisible in the world of AIDS policy and funding structures. . .we're being written out of the epidemic even though we're still the most impacted," said Jean. "In the old days, we would demand attention and recognition of these realities. Today, we are responding out of fear and silence."

It should also be noted, said the LA Center's chief of staff Darrel Cummings, that much of the controversy stemmed from a Los Angeles Times article that contained inaccuracies; the two public billboards never contained the words, "gay disease;" that phrasing was reserved for the LGBT newspaper ads to generate discussion inside the community. Placing the HIV discussion back in the cultural context of the gay community is critical to HIV prevention, he said, noting that epidemiological terms like, "MSM" do not resonate with gay men who make their decisions within their own community. He added that one HIV-positive man recently spoke about how isolated and unwelcome he felt at gay events as a visibly sick person, until the LA campaign was launched.

Valenzuela, whose grassroots group "Real Prevention" has taken to task recent HIV marketing efforts, said his group was mixed on the LA campaign, but that most people agreed it's counterproductive to measure a campaign's success by the community in-fighting that occurs as a result of its controversy.

"[LA Center officials] said their goal was to get people talking. In the forums and meetings I attended, people were talking, but not about how to have safer sex or do real HIV prevention," said Valenzuela, who also takes issue with the campaign's "Own It. End It" slogan, which he says promotes a "fantasy" that it is possible to end HIV through prevention alone.

Valenzuela is not convinced that a moratorium is the solution to the inherent limitations of HIV prevention marketing – "maybe we are expecting too much of this vehicle" – but he would like to see posters that are arming gay men with information that is useful for what they are already practicing, rather than telling them what to do. A recent anti-smoking ad, he said, told people who wanted to quit that they would "need a plan," acknowledging the complexities of that decision without resorting to scare tactics.

That's exactly the spirit of the San Francisco's Disclosure Initiative, said DPH officials. Even the outspoken Petrelis – who has made a career of criticizing "AIDS Inc." – saw the merits of San Francisco's most recent campaign, though he remains troubled that financial figures on the costs of the program were not readily available.

San Francisco DPH officials such as Tracey Packer, interim director of HIV prevention at DPH, said she has agreed with many of the concerns about HIV social marketing, and believes this disclosure initiative in many ways responds to that.

"I think it's good that we're hitting the mark," said Packer.

Meanwhile, this week the LA Center launched another Better World advertising campaign, entitled, "I Am the Cure," an extension of the "HIV Stops With Me" campaign that encouraged HIV-positive individuals to take control of limiting the virus' spread.

But already, community members are taking issue with that premise.

"I beg to profoundly differ with Better World; poz guys are not the cure," said one man in response to the ads on an e-mail list that discusses prevention campaigns. "The cure is a scientific breakthrough that we have been denied as a society by inadequate early response and funding for research that goes all the way back to the Reagan administration. The cure is not anything young poz men can do; it's the charge of scientists and researchers the world over from an infectious disease, medical, and biochemical approach. Even if there is a role for positive men to attempt to prevent new infections, they share this responsibility with negative men who need to also protect themselves."