| AIDS prevention through health promotion: Facing sensitive issues |
|PART 3 Increasing the credibility of the message: peers and patients as health promoters|
If the name Switzerland evokes for you images of mountains, cows, yodelling, and chocolate you would not be exactly wrong, but you would miss a large part of Swiss reality. You would be right in thinking of Switzerland as conservative. However, there is a vivid contrast between, on the one hand, the Switzerland of tourist advertising and conservative politics, and on the other the country with one of Europe's highest per capita AIDS rates, an enormous drug problem, and a government with an extremely liberal approach to AIDS.
By March 1991, there were 1778 reported cases of AIDS in Switzerland. The rate of increase in the number of cases in Switzerland is similar to that in the United States of America and Europe as a whole. Switzerland, however, together with France, has the highest per capita rate of AIDS cases in Europe. The rate of HIV infection among male homosexuals is estimated to be between 10% and 20%.
The Swiss AIDS Foundation, established in June 1985 by all the Swiss gay organizations, has played an important role in the initiation of action to prevent HIV infection. Its intention from the start was to combat AIDS in all population groups rather than just among gays. It has become the national umbrella organization for gay groups, drug users, prostitutes, people with haemophilia and others interested in combating AIDS, as well as for the many local AIDS organizations in all Swiss cities.
The Hot Rubber
By the end of 1984, AIDS and the rumours about it began to cause great alarm, above all in the homosexual community. Certain groups in this community wanted to take swift preventive measures. They began to talk to other homosexuals about condoms, since it was already known that anal intercourse was a major mode of transmission of HIV. Homosexuals had previously perceived no need to use condoms.
The first thing the groups did was to distribute a simple booklet on safer sex, which pointed out the dangers of penetration without protection. To help gays make their choice in what was to them a new area, this advice was accompanied by an advertisement for a well-known brand of condom. The meeting between these two worlds was effected through exchange; the manufacturer paid for the advertisement, not in cash but in condoms, thus enabling 5000 condoms to be distributed with the booklet.
Gays were not very keen on the idea of using condoms. They felt a sort of repugnance for them, having, they thought, consigned them permanently to oblivion. But even though this first experiment was not a great success, it did show the way ahead; it would be useless to try to exploit fear or to ask people to abandon an established practice. The change called for must appear simply as an adaptation, so that it would be widely accepted.
It was thus decided to direct efforts towards a publicity campaign aimed at making the condom familiar and even smart and fashionable. Gays in the advertising profession joined forces with the initial group to help with this campaign. They recommended that information should be supplemented by a marketing campaign based on solid realities. That would mean having the best product, the best design, and as many easily accessible sales outlets as possible. As a back-up to all this there had to be continuous publicity designed to reach all segments of the homosexual population.
Finding the right product required no more than a little common sense. What professional prostitutes used with success could be just as useful for others. So the product existed, but it was of a rather clinical whiteness (Fig. 1). A number of tests had to be conducted to develop a suitable marketing approach. The first attempt failed because the homosexual population did not accept it, but the second achieved very wide acceptance; it had an attractive design and packaging, which did not lend themselves to too many connotative interpretations (Fig. 2). An English name was chosen to cope with the problem of Swiss multilingualism and to appeal to the cosmopolitan attitudes of gays; a trademark was chosen and a distributing firm set up-the Hot Rubber Company, owned by the Swiss AIDS Foundation. In November 1985 the Hot Rubber Company began selling Hot Rubbers in their definitive form at the price of one Swiss franc for two. The entire profits of the company were reinvested in the prevention campaign. Although those who tested the product during its development had not been impressed, when they tried it in its final version they found it finer and safer and the level of sensation high. In a word, they were won over; the Hot Rubber was made for them.
The next step was to bring the product to the people concerned. Bars and saunas, meeting-points for gays, were obvious distribution points. The first stage was to persuade the managers and owners to agree to sell Hot Rubbers in their establishments. After more than two years of effort it is now possible in certain bars to order "a beer with", and be served beer with two condoms. Some saunas make them available free of charge.
Constant efforts are exerted on the publicity front. Every month a new poster comes out, intended for bars and saunas. The regular renewals, adapted to the season of the year and sometimes very amusing, facilitate a wider and more personalized identification with and acceptance of the message and also provide a topic of conversation among the gays. Examples of the many posters produced in the last three years are shown in Fig. 3.
Effects of the campaign
In addition to observations of the reactions of the people concerned, some spot evaluations were carried out. A survey conducted in gay circles in Bern after one year of campaigning asked the question, "What is a Hot Rubber?"; 90% of those polled answered "a condom" or "the gay condom".
The trend of sales figures also speaks for itself (Fig. 4).
The product came on to the market in November 1985. In 1986, 125000 condoms were sold. The 1987 sales stabilized at around 300000. This levelling-off of sales may be accounted for by the fact that in the same year the national AIDS information and prevention campaign was getting under way. Major supermarket chains then began to sell products comparable in price and quality with the Hot Rubber. It was at last possible to purchase condoms anonymously, like milk or chocolate.
In summer 1987, the Lausanne Institute for Social and Preventive Medicine, on behalf of the Swiss Federal Office of Public Health, conducted a scientific survey of behavioural changes among homosexuals. Eight hundred questionnaires and 50 personal interviews were evaluated. Most of those questioned were promiscuous homosexuals, and the survey, although not truly representative, can be considered indicative of the real situation.
More than 50% of those questioned lived alone, 25% lived with a partner, and the remaining 20% considered themselves bisexual or were living with a woman.
Some 50% claimed not to have had anal intercourse in the three months preceding the survey; 30% said that they always used condoms during anal intercourse, 20% that they did not. Concerning the last group, it was not determined whether or not the contacts involved steady partners.
Eighty-five percent claimed to have changed their sexual behaviour; 75% said that they bought condoms and 66% stated that they consistently observed the safer sex rules.
On the basis of these data we may assume that one out of five homosexuals continues to be at risk. It is important to note that knowing a person with AIDS was associated with positive behaviour change, but it was not the only factor. We also found that men with many partners, independent of whether they knew anyone with AIDS, adopted safer sex practices more rapidly than other men at risk. It seems that all groups are familiar with the prevention message and appear to follow its rules. In saunas, unsafe sex is rarely practiced. in public toilets and parks it is more frequent.
Three problem groups remain:
• Bisexuals often do not think of themselves as homosexuals, and consider that a message addressed to homosexuals does not affect them. They were reached more effectively by the "STOP AIDS" campaigns aimed at the general public.
• Adolescent homosexuals, as they make their first tentative steps into the subculture, are too preoccupied to pay much attention to messages about preventing AIDS.
• Older homosexuals who do not easily find partners are more inclined to dismiss the warning "if it's with me it's with a rubber".
It appears that many gays who find difficulty accepting their homosexuality have problems in changing their sexual behaviour. Prevention efforts should therefore include improving the image of homosexuality and the climate within the gay community. We intend to initiate pilot projects towards this end, specifically targeted at these groups, particularly adolescents and older homosexuals.
The use of the existing structures of an established community-specifically bars and saunas-has certainly been conducive to individual acceptance of responsibility. Thus, instead of being panicked into deserting such places, the gay community has been given an opportunity to change its behaviour. Last but not least, it was self-proclaimed gays who took responsibility for informing their community, and this certainly contributed to the fact that the instructions on safer sex were accepted as preventive and not repressive.
Clearly the campaign has to continue, the object being to increase to 100% within a short time the percentage of condom users among homosexuals in Switzerland who practice anal intercourse. It should, however, be stressed that the Hot Rubber campaign is only part of the preventive work being carried out among that population. It is just one of the Swiss programmes being conducted under the slogan "STOP AIDS".