The Two Faces of Fear: A History of Hard-Hitting Public Health Campaigns Against Tobacco and AIDS.

Fear is now commonly used in public health campaigns, yet for years ethical and efficacy-centered concerns provided a challenge to using fear in such efforts. From the 1950s through the 1970s, the field of public health believed that using fear to influence individual behavior would virtually always backfire. Yet faced with the limited effectiveness of informational approaches to cessation, antitobacco campaigns featured fear in the 1960s. These provoked little protest outside the tobacco industry. At the outset of the AIDS epidemic, fear was also employed. However, activists denounced these messages as stigmatizing, halting use of fear for HIV/AIDS until the 21st century. Opposition began to fracture with growing concerns about complacency and the risks of HIV transmission, particularly among gay men. With AIDS, fear overcame opposition only when it was framed as fair warning with the potential to correct misperceptions.

It's Never Just HIV: Exposure to an HIV Prevention Media Campaign and Behavior Change Among Men Who Have Sex with Men Participating in the National HIV Behavioral Surveillance System in New York City.

PURPOSE: The aim of this study was to assess the exposure to and impact of the It's Never Just HIV mass media campaign aimed at HIV negative men who have sex with men (MSM) in New York City. METHODS: Questions about the campaign were included in the local questionnaire of the Centers for Disease Control and Prevention (CDC)-sponsored National HIV Behavioral Surveillance (NHBS) study of MSM in NYC conducted in 2011. Participants in this cross-sectional study were recruited using venue-based sampling. RESULTS: Among 447 NYC National HIV Behavioral Surveillance study participants who self-reported HIV negative or unknown status and answered questions about the NYC Department of Health and Mental Hygiene's It's Never Just HIV campaign, more than one-third (n = 173, 38.7%) reported having seen the campaign. Latinos (34.8%) and blacks (34.4%) were less likely to report seeing the campaign compared to whites (47.7%). Most of those who reported seeing the campaign saw it on the subway (80.1%). Only 9.4% of those who saw the campaign reported having changed their sexual or health behaviors in response to the campaign. CONCLUSIONS: These data suggest that thousands of HIV-uninfected MSM in NYC have been reached by the campaign and recalled its message.

Averting HIV infections in New York City: a modeling approach estimating the future impact of additional behavioral and biomedical HIV prevention strategies.

BACKGROUND: New York City (NYC) remains an epicenter of the HIV epidemic in the United States. Given the variety of evidence-based HIV prevention strategies available and the significant resources required to implement each of them, comparative studies are needed to identify how to maximize the number of HIV cases prevented most economically. METHODS: A new model of HIV disease transmission was developed integrating information from a previously validated micro-simulation HIV disease progression model. Specification and parameterization of the model and its inputs, including the intervention portfolio, intervention effects and costs were conducted through a collaborative process between the academic modeling team and the NYC Department of Health and Mental Hygiene. The model projects the impact of different prevention strategies, or portfolios of prevention strategies, on the HIV epidemic in NYC. RESULTS: Ten unique interventions were able to provide a prevention benefit at an annual program cost of less than $360,000, the threshold for consideration as a cost-saving intervention (because of offsets by future HIV treatment costs averted). An optimized portfolio of these specific interventions could result in up to a 34% reduction in new HIV infections over the next 20 years. The cost-per-infection averted of the portfolio was estimated to be $106,378; the total cost was in excess of $2 billion (over the 20 year period, or approximately $100 million per year, on average). The cost-savings of prevented infections was estimated at more than $5 billion (or approximately $250 million per year, on average). CONCLUSIONS: Optimal implementation of a portfolio of evidence-based interventions can have a substantial, favorable impact on the ongoing HIV epidemic in NYC and provide future cost-saving despite significant initial costs.

Assessing the impact of a community-wide HIV testing scale-up initiative in a major urban epidemic.

BACKGROUND: The Bronx, one of 5 boroughs in New York City (NYC), bears a high burden of HIV. We evaluated the impact of HIV testing initiatives in the Bronx, including the 2008 The Bronx Knows campaign. METHODS: We used data from an annual telephone survey representative of NYC adults to compare 2005 and 2009 estimates of HIV testing prevalence among Bronx residents and to identify correlates of testing. We used NYC HIV surveillance data to evaluate changes in the percentage of persons concurrently being diagnosed with HIV and AIDS, an indicator of delayed HIV diagnosis. RESULTS: Between 2005 and 2009, relative increases of 14% and 32% were found in the proportion of Bronx adults who have ever been HIV tested and who have been tested in the past year, respectively (P < 0.001). The largest increases were among those aged 24-44 years, men, non-Hispanic blacks and Hispanics, and those with low income or education, nonheterosexual identity, a personal doctor/provider, or health insurance. Factors independently associated with being recently tested included black or other race, Hispanic ethnicity, and bisexual identity. The proportion concurrently diagnosed with HIV and AIDS fell 22% from 2005 to 2009, and decreases generally occurred among subgroups experiencing increases in testing. CONCLUSION: Community-wide testing in the Bronx increased the proportion of people with known HIV status and reduced the proportion with delayed diagnoses.

Men who have sex with men have a 140-fold higher risk for newly diagnosed HIV and syphilis compared with heterosexual men in New York City.

OBJECTIVES: To describe the population of men who have sex with men (MSM) in New York City, compare their demographics, risk behaviors, and new HIV and primary and secondary (P&S) syphilis rates with those of men who have sex with women (MSW), and examine trends in infection rates among MSM. DESIGN: Population denominators and demographic and behavioral data were obtained from population-based surveys during 2005-2008. Numbers of new HIV and P&S syphilis diagnoses were extracted from city-wide disease surveillance registries. METHODS: We calculated overall, age-specific and race/ethnicity-specific case rates and rate ratios for MSM and MSW and analyzed trends in MSM rates by age and race/ethnicity. RESULTS: The average prevalence of male same-sex behavior during 2005-2008 (5.0%; 95% CI: 4.5 to 5.6) differed by both age and race/ethnicity (2.3% among non-Hispanic black men; 7.4% among non-Hispanic white men). Compared with MSW, MSM differed significantly on all demographics and reported a higher prevalence of condom use at last sex (62.9% vs. 38.3%) and of past-year HIV testing (53.6% vs. 27.2%) but also more past-year sex partners. MSM HIV and P&S syphilis rates were 2526.9/100,000 and 707.0/100,000, each of which was over 140 times MSW rates. Rates were highest among young and black MSM. Over 4 years, HIV rates more than doubled and P&S syphilis rates increased 6-fold among 18-year-old to 29-year-old MSM. CONCLUSIONS: The substantial population of MSM in New York City is at high risk for acquisition of sexually transmitted infections given high rates of newly diagnosed infections and ongoing risk behaviors. Intensified and innovative efforts to implement and evaluate prevention programs are required.

NYC condom use and satisfaction and demand for alternative condom products in New York City sexually transmitted disease clinics.

In 2007, via a high-profile media campaign, the New York City Department of Health and Mental Hygiene (NYC DOHMH) introduced the "NYC Condom," the first specially packaged condom unique to a municipality. We conducted a survey to measure NYC Condom awareness of and experience with NYC Condoms and demand for alternative male condoms to be distributed by the DOHMH. Trained interviewers administered short, in-person surveys at five DOHMH-operated sexually transmitted disease (STD) clinics in Spring 2008. We systematically sampled eligible patients: NYC residents aged ≥18 years waiting to see a physician. We approached 539; 532 agreed to be screened (98.7% response rate); 462 completed the survey and provided NYC zip codes. Most respondents were male (56%), non-Hispanic black (64%), aged 18-24 years (43%) or 25-44 years (45%), employed (65%), and had a high school degree/general equivalency diploma or less (53%). Of those surveyed, 86% were aware of the NYC Condom, and 81% of those who obtained the condoms used them. NYC Condom users were more likely to have four or more sexual partners in the past 12 months (adjusted odds ratio [AOR] = 2.0, 95% confidence interval [CI] = 1.0-3.8), use condoms frequently (AOR = 2.1, 95% CI = 1.3-3.6), and name an alternative condom for distribution (AOR = 2.2, 95% CI = 1.3-3.9). The most frequently requested condom types respondents wanted DOHMH to provide were larger size (28%), ultra thin/extra sensitive (21%), and extra strength (16%). We found high rates of NYC Condom use. NYC Condom users reported more sexual partners than others, suggesting the condom initiative successfully reached higher-risk persons within the STD clinic population. Study results document the condom social marketing campaign's success.

The NYC Condom: use and acceptability of New York City's branded condom.

We assessed awareness and experience with the NYC Condom via surveys at 7 public events targeting priority condom distribution populations during 2007. Most respondents (76%) were aware of NYC Condoms. Of those that had obtained them, 69% had used them. Most (80%) wanted alternative condoms offered for free: 22% wanted ultra-thin, 18% extra-strength, and 14% larger-size. Six months after the NYC Condom launch, we found high levels of awareness and use. Because many wanted alternative condoms, the Department of Health and Mental Hygiene began distributing the 3 most-requested alternatives.

PERCEIVED RACISM AND NEGATIVE AFFECT: ANALYSES OF TRAIT AND STATE MEASURES OF AFFECT IN A COMMUNITY SAMPLE.

Racism is a significant psychosocial stressor that is hypothesized to have negative psychological and physical health consequences. The Reserve Capacity Model (Gallo & Matthews, 2003) suggests that low socioeconomic status may influence health through its effects on negative affect. We extend this model to study the effects of racism, examining the association of lifetime perceived racism to trait and daily negative affect. A multiethnic sample of 362 American-born Black and Latino adults completed the Perceived Ethnic Discrimination Questionnaire-Community Version (PEDQ-CV). Trait negative affect was assessed with the Positive and Negative Affect Schedule (PANAS), and state negative affect was measured using ecological momentary assessments (EMA), in the form of an electronic diary. Analyses revealed a significant relationship of lifetime perceived racism to both daily negative affect and trait negative affect, even when controlling for trait hostility and socioeconomic status. The relationship of perceived racism to negative affect was moderated by education, such that the relationships were strongest for those with less than a high school education. The findings support aspects of the Reserve Capacity Model and identify pathways through which perceived racism may affect health status.

Racism and ambulatory blood pressure in a community sample.

OBJECTIVE: Racism has been identified as a psychosocial stressor that may contribute to disparities in the prevalence of cardiovascular disease. The goal of the present article was to investigate the relationship of perceived racism to ambulatory blood pressure (ABP) in a sample of American-born Blacks and Latinos. METHODS: Participants included English-speaking Black or Latino(a) adults between the ages of 24 and 65. They completed daily mood diaries and measures of perceived racism, socioeconomic status, and hostility. Participants were outfitted with ABP monitors; 357 provided data on waking hours only, and 245 provided data on both waking and nocturnal ABP. RESULTS: Perceived racism was positively associated with nocturnal ABP even when controlling for personality factors and socioeconomic status. CONCLUSIONS: The results suggest that racism may influence cardiovascular disease risk through its effects on nocturnal BP recovery.

Perceived ethnic discrimination in relation to daily moods and negative social interactions.

Ethnic discrimination experienced in an interpersonal context has been identified as a stressor contributing to racial disparities in health. Exposure to racism may influence the way people view their ongoing experiences, making it more likely that individuals will appraise new situations as threatening and harmful, adding to their overall stress burden. A multiethnic sample of 113 adults completed a diary page every 30 min for one day. The diary inquired about moods and perceptions of social interactions. When controlling for personality characteristics, mixed models regression analyses indicated that baseline measures of ethnic discrimination (assessed with the Perceived Ethnic Discrimination Scale-Community Version) were positively associated with daily levels of anger and the intensity of participants' rating of routine social interactions as harassing, exclusionary, and unfair. These findings have implications for models of the contribution of psychosocial factors to racial disparities in health.

The relationship of racism to appraisals and coping in a community sample.

Ethnicity-related maltreatment (racism) is a significant stressor for many Americans and may contribute to racial disparities in health. Mechanisms linking this stressor to health status are not yet understood. This study tests the hypothesis that lifetime exposure to racism influences individuals' appraisals of and coping responses to new episodes of maltreatment. Participants included 420 Black and Latino patients and staff of community primary care practices in New York City. Participants completed the Brief Perceived Ethnic Discrimination Questionnaire--Community Version. They also completed measures of appraisals and anger coping modified to inquire about responses to new episodes of ethnicity-related maltreatment. Individuals who had higher levels of lifetime exposure to discrimination were more likely to experience new episodes as threatening and potentially harmful. Exposure to ethnic discrimination was also positively related to the use of anger coping styles, but the magnitude of the relationship varied depending on the type of discrimination. Individuals who had been exposed to higher levels of workplace discrimination were more likely to suppress anger in new situations. Those who were exposed to ethnicity-related social exclusion or harassment were more likely to confront others and aggressively express their feelings. The significance of the relationship held even when controlling for mood and personality variables that might account for both racism and coping. No differences were found between Blacks and Latinos in the relationship of racism to appraisals and coping. These findings add to the growing empirical literature on strategies for coping with racism.