# Presentation: 304416

##           Public Perceptions and the HIV/AIDS Crisis:          “Getting the Message on Track”	Scott Gottlieb, MD	Resident Fellow, The American Enterprise Institute	Columnist, Forbes Magazine	Staff Writer, British Medical Journal

## History of Advertising in HIV/AIDSCurrent Ads Often Criticized

- Mixed Messages From Washington, Drug
- Industry Fuel Rising HIV Rates, Says AHF
- Los Angeles Times
- June 14, 2005

**Notes:**
AIDS Healthcare Foundation (AHF), the nation's largest AIDS organization with clinics in the US, Africa, Asia and Central America recently expressed disappointment at the news that the number of people living with HIV/AIDS in the United States has reached 1 million for the first time, according to data released recently by the Centers for Disease Control and Prevention (CDC) at a conference in Atlanta. And said prevention strategy in this country has failed. 

This warning came from Michael Weinstein, President of AIDS Healthcare Foundation (AHF). He blamed what he called ”mixed messages” from Washington DC on condoms and unsafe sex that have hampered effective prevention efforts and have contributed to an increase in HIV infections and lack of awareness of an individual's HIV status.

And he said responsibility also lies with drug companies, whose high-priced direct-to- consumer drug-advertising campaigns downplay the seriousness of HIV, as well as with the FDA that continues to allow this irresponsible corporate behavior to go unchecked. 

Finally, he said “lack of responsibility in the gay community must also be cited as a contributing factor -- one that has to change if we are to see a decrease in the rate of new HIV/AIDS infections in the coming years." 

AHF had previously asked companies to sign on to The AIDS Education Pledge committing to limit marketing of products and treatment for HIV and AIDS to help-seeking advertisements, which serve to educate consumers about the disease, inform them that a treatment is available, and then direct them to a health care professional.

## History of Advertising in HIV/AIDSCurrent Ads Often Criticized

- Abbott Laboratories has been cited by the **FDA** for a pair of **direct-to-consumer** promotional pieces that exaggerate the benefits of its HIV drug, Kaletra, while omitting significant risk information.An untitled letter issued by the agency's Division of Drug Marketing, **Advertising** and Communications (DDMAC) said an Abbott print advertisement and a restroom poster "overstate the effectiveness of Kaletra (lopinavir/ritonavir) and omit the indication and material risks associated with [the drug] in the treatment of HIV infection."According to the untitled letter, dated Oct. 29 but released by the agency earlier this week, the print ad and the poster contain chronologically ordered photographs over five years of a man in good health, with the caption "Where do you see yourself in 5 years? Talk to your doctor about Kaletra." After reviewing the ads, DDMAC concluded the promotions suggested that "patients taking Kaletra can expect to survive and be healthy for at least five years, and have undetectable HIV RNA [ribonucleic acid] levels and their disease under control at the end of that five-year period."

## History of Advertising in HIV/AIDSDTC in HIV/AIDS Falls Off

- Bristol-Myers Sustiva slipped to $600,000 in ad support from $710,000 in 2001, according to Competitive Media Reporting
- Glaxo Wellcome's Trizivir (a combination of previous brands Retrovir, Epivir and Ziagen) fell from nearly $1 million in 2001 to $216,000 in 2002
- POZ magazine has experienced a steady drop in direct-to-consumer HIV drug advertising every year since 1999, its strongest year, according to publisher and CEO Brad Peebles. By 2002, total DTC ad revenue was just half that of 1999, the magazine’s peak year
- Marketing costs for AIDS drugs tend to be lower because of their high demand and because advocates for AIDS patients rapidly spread information on new drugs

## History of Advertising in HIV/AIDSDTC in HIV/AIDS Falls Off

- 	Howard Buford, president of New York-based Prime Access, which has handled a number of drug company clients, says:
- 	"I've been in meetings regarding HIV medications and they were skittish of going forward with advertising to meet the demands of community groups. There was a fear of severe criticism, regardless of the direction they took the advertising."

**Notes:**
Become a less competitive market for DTC
Established regimens, most of the 
competition is in detailing and working with advocacy groups – warnings on this kind of promotion recently (Viread’s bizarre spectacle)
Reflected concern of FDA – Promotion shifting to communications with docs, unregulated, questionable legal authority
Less DTC now than in beginning, like cancer drugs
Genentech Never Does DTC
Evolution – Heavy Promotional ads to disease awareness (help seeking) to nothing
Question: Has this lowered awareness? 

## Public Health PromotionRole of Advertising

- In the two consumer surveys, FDA assessed the influence of advertising on attitudes toward prescription drugs, health-related behavior, and on aspects of the doctor-patient relationship.
- Among respondents who had seen a doctor with the past three months and remembered seeing an ad for a prescription drug, approximately half in 1999 and approximately 40 percent in 2002 said that an advertisement for a prescription drug had caused them to seek more information, for example, about the drug and their health.
- More than a quarter (27 percent) of survey respondents in 1999 and 18 percent in 2002 who had seen a doctor in the last three months said that an ad for a prescription drug had caused them to ask a doctor about a medical condition or illness that they had not talked to a doctor about before.
- The results of the two consumer surveys indicate that DTC can serve as stimulus for consumers to seek more information about their health and the drug product including the risks associated with the use of the drug.

## Public Health PromotionRole of Advertising

- The results of FDA’s survey of 500 physicians in the U.S. about DTC promotion found:
- Many physicians believe that DTC advertising can play a positive role in their interactions with their patients.   For example, most agreed that because their patients saw a DTC ad, he or she asked more thoughtful questions.
- Some physicians thought the ads made their patients more aware of possible treatments.
- Many physicians thought that DTC ads made their patients more involved in their health care.
- Forty percent of physicians believe that patients understood well the possible risks and negative effects of an advertised drug from the DTC ad alone.

## Literature on Advertising as an HIV/AIDS Prevention Strategy

**Paid advertising for AIDS prevention--would the ends justify the means?**
- Donovan RJ, Jason J, Gibbs DA, Kroger F
- Public Health Rep. 1991 Nov-Dec;106(6):645-51
- NAIEP, CDC, Atlanta, GA 30333
**Using fear appeals in advertising for AIDS prevention in the college-age population**
- LaTour MS, Pitts RE
- J Health Care Mark. 1989 Sep;9(3):5-14
**Entertainment-Education and HIV/AIDS Prevention: **
**A Field Experiment in Tanzania**
- Peter W. Vaughan, Everett M. Rogers, Arvind Singhal, Ramadhan M. Swalehe
- Journal of Health Communication, volume 5, Supplement 1 - January 1, 2000

**Notes:**
Paid advertising for AIDS prevention--would the ends justify the means?Donovan RJ, Jason J, Gibbs DA, Kroger F.NAIEP, CDC, Atlanta, GA 30333.An examination by the Centers for Disease Control and the Research Triangle Institute concluded that "hard-to-reach" populations could be reached with AIDS prevention messages through the broadcast and print media and that a study should be undertaken to assess whether paid placement of these messages could have an effect on HIV-related behaviors. 

The recommended target population for a study of paid advertising would be sexually active 18-24-year-old black urban dwellers. Its behavioral objectives would include abstinence and safer sex practices. For any evaluation of a paid advertising campaign to be valid, there would have to be extensive audience profiling, research into the development of the message, pretesting of the message, and involvement of the community. 

The proposed study would include measurement of various "dosage" levels of paid advertising, use of a no-intervention comparison group, and a novel data collection technique. 

Although a specific target group and specific messages would be involved, the evaluation would make a substantial contribution to resolving the broader issue of whether and how mass media should be used directly or indirectly to change or reinforce health-related behaviors

Using fear appeals in advertising for AIDS prevention in the college-age population.
LaTour MS, Pitts RE
J Health Care Mark. 1989 Sep;9(3):5-14	

A multiple-indicator model reveals the impact of AIDS prevention advertising on dimensions of arousal and subsequent cognitive impressions of the advertisement. Exploratory results obtained from a sample of college students indicate that levels of arousal and impressions of the advertisement vary according to emphasis on the deadly consequences of AIDS. These findings have strategic implications for addressing important target groups such as college students

Entertainment-Education and HIV/AIDS Prevention: A Field Experiment in Tanzania
Peter W. Vaughan, Everett M. Rogers, Arvind Singhal, Ramadhan M. Swalehe
Journal of Health Communication, volume 5, Supplement 1 - January 1, 2000

Entertainment-education is the process of designing and implementing an entertainment program to increase audience members' knowledge about a social issue, create more favorable attitudes, and change their overt behaviors regarding the social issue. 

The results of a field experiment in Tanzania to measure the effects of a long-running entertainment-education radio soap opera, Twende na Wakati (Let's Go with the Times), on knowledge, attitudes, and adoption of human immuno deficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) prevention behaviors were presented in this study.

The effects of the radio program in Tanzania include (1) a reduction in the number of sexual partners by both men and women, and (2) increased condom adoption. 

The radio soap opera influenced these behavioral variables through certain intervening variables, including (1) self-perception of risk of contracting HIV/AIDS, (2) self-efficacy with respect to preventing HIV/AIDS, (3) interpersonal communication about HIV/AIDS, and (4) identification with the primary characters in the radio soap opera.
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## Recent Public Efforts Have Turned Away from Prevention Message

**Top broadcasters join forces with UN on HIV/AIDS prevention**
- Twenty of the world's most powerful broadcasters and media conglomerates joined forces with humanitarian agencies to fight HIV/AIDS in a new initiative which UN Secretary-General, Kofi Annan, said had the potential to save "as many, if not more, lives than physicians.“
- "In the world of AIDS, silence is death," Annan told broadcasters at a meeting in New York on 15 January to launch the Global Media AIDS Initiative.
- The initiative — the first of its kind to be launched by the UN — is financed by the Bill and Melinda Gates Foundation and run jointly with the Kaiser Family Foundation, a US non-profit group that has been working with health agencies and media groups addressing the HIV/AIDS epidemic for more than a decade.
- The project aims to find ways in which the media can use their resources to raise awareness about HIV/AIDS and to help gather broader support in the fight against it.

## How can we get the message back on track?

## Leverage AdvertisingMake DTC a More Effective Tool

- Advertising promotes awareness – wants more speech, not less
- FDA doesn’t have authority over disease awareness ads, it’s more of a PSA if you don’t mention products
- It could be useful for DDMAC to develop guidance on the specific issue of HIV/AIDS – product specific ads
- Product advertising is down because of uncertainty in the community and regulatory environment – could affirmative statements from FDA (guidance) or Commission encourage more positive DTC
- Consensus document, looking at warning letters of the past, to make recommendations on how ads should look and sound

## Building on the Public Messages for a Broad-Based Prevention Campaign

**Leverage PR/Advertising to Promote Prevention – Learn from Successful Campaigns**
**ONDCP Provides one Recent Effective Model for Working with Popular Media – linking broadcast, print, and on-line communications**
**Pharma Companies Searching for a Positive Promotion Agenda, Providing Opportunity for Public/Private Partnerships**
**Ryan White Funding Should Focus on Treatment and Prevention, Including a Public Campaign for Preventing New Infections and Promoting Testing**

## Selected CampaignsMidwest AIDS Prevention Project 

**Notes:**
The Midwest AIDS Prevention Project (MAPP) is one of Michigan's largest non-profit community-based organizations whose mission is the prevention of HIV transmission through risk-reduction education and health promotion programs.  Incorporated in 1988, MAPP has provided thousands of safer sex work­shops, train­ings, media events, display tables and outreach projects.  Since its inception, MAPP has distrib­uted 300,000 AIDS education mate­rials and 500,000 condoms, reaching more than a quarter of a million people. 

MAPP has provided HIV prevention train­ings and original education materials to health de­partments and communi­ty groups nationwide, and has presented workshops to audiences at national conferences.  In addition, MAPP has participated in national research projects in collaboration with the National AIDS Fund, the Center for AIDS Intervention Research in Milwaukee, and the Centers for Disease Control and Prevention.

In 1996, MAPP collaborated with the HOPE Fund and the Community Foundation of Southeast Michigan in 1996 to create A.D.A.P.T., an innovative project to prevent health and safety problems that result from AOD abuse in the g/l/b/t community. The project used research-based methods developed by the Center for AIDS Intervention Research and the Medical College of Wisconsin to train popular leaders in the gay and lesbian community to promote healthier, safer behaviors to their friends and acquaintances.  Because these “opinion leaders” are well-liked and respected by others, their endorsement of risk-reduction behaviors can positively influence the wider gay community to adopt behaviors which reduce alcohol and substance abuse and high risk sexual activity.

In 1997, MAPP expanded the A.D.A.P.T. project by developing a media campaign alerting the gay/lesbian community about the dangers of alcohol and drug abuse.  This first-of-its-kind campaign in Michigan  (funded with a grant from the Michigan Department of Community Health's Substance Abuse Services) included targeted print advertising that was placed in gay/lesbian newspapers statewide.  MAPP also created targeted posters that were distributed to substance abuse centers, and gay/lesbian community centers, businesses and nightclubs.

## Selected CampaignsAd Council

**Notes:**
The Ad Council is a private, non-profit organization that marshals volunteer talent from the advertising and communications industries, the facilities of the media, and the resources of the business and non-profit communities to deliver critical messages to the American public. The Ad Council produces, distributes and promotes thousands of public service campaigns on behalf of non-profit organizations and government agencies in issue areas such as improving the quality of life for children, preventative health, education, community well being, environmental preservation and strengthening families.

As the AIDS epidemic began to sweep the nation in 1987, the Ad Council partnered with the American Foundation for AIDS Research and the National AIDS Network to develop an AIDS prevention campaign that would educate individuals about methods of protection and help inspire change in current behavior. At the time, the majority of Americans were aware of the existence and gravity of the AIDS virus, but many did not fully understand the facts about the disease and how it spreads.

Launched in September of 1988, just months before the first ever World AIDS Day on December 1, this groundbreaking campaign was the first in American advertising to use the word "condom." The campaign, featuring the tagline "Help stop AIDS. Use a condom," received the endorsement of then United States Surgeon General Dr. C. Everett Koop and continued until 1990.

These ads were effective. Unfortunately, in 2001, the Ad Council shifted the focus of its AIDS campaign from prevention through education to inspiring change through awareness with the launch of its current AIDS Awareness campaign in partnership with the United Nations Foundation. The campaign encourages Americans to get involved in the global effort to combat the AIDS epidemic by raising awareness of the havoc it has already created..

## Selected Campaigns NAPWA “National Testing Day”

- The National Association of People With AIDS (NAPWA) sponsors National AIDS Testing Day, which is June 27. A number of organizations support this
- Gilead, for example, will run a public service announcement in parts of the country where the incidence of HIV is rising (the Southern U.S., of note) to remind listeners of National AIDS Testing Day and that support is available
- This PSA doesn't include any information about Gilead or our products; it fits in with our commitment on a corporate level to HIV education
- The NAPWA website also describes a program, in partnership with the makers of an HIV testing kit, called the "Mayors Campaign Against HIV.“ http://www.napwa.org/hivtestinfo/index.html

## Selected CampaignsOffice of National Drug Control Policy

**Notes:**
In 1999 this media campaign, and related programming and surrounding activities were made possible by a unique collaboration among the Office of National Drug Control Policy (ONDCP), NBC Television, and AOL, arising from the messages of the National Youth Anti-Drug Media Campaign.

ONDCP's purchase of advertising required a pro bono public service match from the network. NBC's creative response included developing a special substance abuse-themed month for its popular Teen NBC (TNBC) line up. To promote this theme, TNBC aired one episode focusing on the dangers of substance use each Saturday morning during the month of February. 

TNBC producers developed the programming with the help of educators, psychiatrists, and other experts to ensure efficacy with today's young people. 

In addition, during the themed month, each substance use episode was accompanied by specially produced The More You Know public service announcements featuring stars from the TNBC line up.

At the time, the campaign was based on the Administration's National Drug Control Strategy and strategic communications objectives to target young people, parents, and adult influencers at the community level.

In Phase I, campaign messages were tested in 12 markets across the country. 

In Phase II, those messages were distributed nationwide. 

In Phase III, other elements of the campaign will be implemented, including the formation of partnerships with media, the entertainment and sports industries, and civic, professional, and community groups.

The media campaign was considered one of the largest and most complex social marketing efforts ever undertaken. 

## Pharma Companies Searching for a Positive Promotion Agenda

- PhRMA Code of Conduct
- Industry’s Own Moratoriums: Bristol’s Limits on Year-One Advertising

## Ryan White Funding Should Focus on Treatment and Prevention

- Current focus diverts money for general medical support for HIV infected patients
- Limited funds could have more impact on disease prevention by emphasizing virus suppression and prevention
- This would align the domestic goals with the President’s International agenda on HIV/AIDS