"Preaching abstinence wouldn’t sell many Calvin Kleins, and urging risk avoidance wouldn’t sell many Nikes," says Richard Marlink, executive director of the Harvard AIDS Institute. "Yet abstinence and risk avoidance are exactly how HIV prevention is being sold to young people - one of the groups at highest risk for infection."

Today one in four people newly infected with HIV in the United States is under the age of 22; one-half of all infections are in people under 25. Every hour, at least two Americans under 25 become infected with HIV. And the number of HIV-infected teenagers in the country doubles every 14 months.

To create new strategies to prevent HIV among young people, the Harvard AIDS Institute and the Center for AIDS Prevention Studies have launched Marketing HIV Prevention (MHP), a program that seeks to tap into the nation’s marketing expertise to convince young people to protect themselves against sexual transmission of HIV.

"Our choice is to deal honestly with the sexual realities of today’s young people or to risk losing them," Marlink says. "We’re hoping to incorporate marketing strategies that have been effective with young people into our prevention efforts. We need to use the expertise that sells so many designer jeans and athletic shoes to sell a more difficult product to young people - HIV prevention."

Reassessing the Messages

According to an MHP report on young people’s vulnerability to HIV, youth-oriented marketing, media, and health promotion strategies have added up to a dangerously mixed message: experiment and take risks - except when it actually comes to having sex. Then the message becomes even more muddled. Young people are told to be attractive and sexy, but not to have sex, or they may die.

In addition, HIV prevention strategies for young people are often poorly matched with the target population. Many youth-focused HIV prevention messages are fear based, even though young people tend to consider themselves invincible. In fact, young audiences usually dismiss HIV prevention messages that use scare tactics and overdramatization.

"So far, all we’ve done is jump out and yell ‘Boo!’ at these kids," says Thomas Coates, director of the Center for AIDS Prevention Studies. "We must do more than just try to scare them with our messages. We must convince them to pay attention and to change their behavior - so they can save their own lives."

In addition, HIV prevention messages often urge young people to avoid risk, when taking risks and disregarding advice are the very currency of youth. Preaching abstinence as the only acceptable option also tends to be ineffective in preventing HIV transmission - or even in preventing sexual activity. Research has shown that once young people become sexually active, the abstinence message loses its credibility. One study even found that a school-based, abstinence-only program actually increased the young people’s level of sexual activity.

The report concludes by calling for an emergency, targeted campaign to reach young people. This campaign should include such steps as expanding school-based sex education and condom availability; increasing government funding that targets adolescents, especially gay men and people of color; and urging prevention educators to use commercial marketing tools to convince young people to protect themselves against infection.

Listening to Young People

To complement the report, MHP organizers also conducted a qualitative research study based on in-depth personal interviews of young people. The researchers found that although those interviewed had been taught about how to prevent HIV infection, the prevention messages were failing to motivate safer sex behavior because they did not resonate. The young people admitted knowing that anyone can get HIV; they just didn’t believe it would be them.

For the interviewees, HIV was a topic of conversation, but often only on an abstract and impersonal level. Rarely had they inquired about a person’s HIV status prior to having sex, and many did not know whether their partners had been tested. Those who had discussed HIV with their sexual partners, however, said that television had played a pivotal role in prompting them to raise the subject. Story lines about HIV on television - notably Beverly Hills, 90210 and MTV programming - had triggered their thinking about getting tested for HIV. Movies, the music and clothing industries, and youth-oriented magazines also were powerful influences.

For the most part, however, those interviewed had found ways to place themselves outside the specter of risk. When safer sex messages were unclear or minimized the risk of certain behaviors or for certain population groups, many young people tended to apply the least threatening message to their own sexual encounters.

Relying on what they had learned about HIV prevention, the young people had developed a complex system of rationalizations to diminish their own sense of risk for HIV. When they could categorize themselves as being outside the high-risk definitions they had learned, they began to believe they were at little to no risk for infection.

The young people also believed that trust between sexual partners obviated the need for condoms. While they may have used condoms the first time they had sex with a new partner, condom usage tended to decrease as the relationships matured, which for some of the young people was within a week. If they insisted on condoms, they said, they would risk rejection by raising suspicions or insulting their partners.

Enlisting the Private Sector

In 1997, to explore strategies for closing the gap between knowledge and behavior change, MHP organizers hosted a brainstorming retreat with writers and producers of popular television shows, marketing executives from the retail and entertainment industries, youth-focused advertising experts, HIV prevention experts, and young people themselves. The retreat participants emphasized the role of the private sector in promoting sexual safety among youth. They also agreed to call upon the nation’s marketing experts to create compelling safer sex messages.

"The public and non-profit sectors cannot address HIV among youth alone," says Mario Cooper, MHP founder and a member of the Harvard AIDS Institute’s International Advisory Council. "Much of the expertise, resources, creativity, and access to communication channels needed to reach young people with powerful and effective messages lie in the private sector. Hollywood, Madison Avenue, and the music industry must step up to the plate. They cannot sell their products to our kids without taking responsibility."

"Marketers need to understand that HIV will kill far too many members of their target audience," adds retreat participant John Shea, creator of MTV’s Sex in the 90s. "They’re busy selling to 16- to 19-year-olds, without realizing that those kids may soon be dropping dead."

Retreat participants agreed that the key challenge to marketers of HIV prevention is to ensure that young people identify HIV as a personal threat - personal enough to take steps to protect themselves. The participants noted that no single message will effectively reach all young people. Successful HIV marketing campaigns will require listening to young people’s specific needs, acknowledging the important role that sex plays in their lives, and providing culturally appropriate, targeted messages. The private sector can successfully use its marketing savvy and media clout to promote HIV prevention among youth in the same way it targets young customers to buy merchandise. The advertising industry, for example, spends $1 billion each year to reach young consumers, producing annual teen expenditures of $65 billion in the United States. These marketing efforts ultimately do more than sell products; they play a pivotal role in the culture of adolescence in the 1990s.

Retreat participants called for joint private and public sector initiatives to create and implement effective strategies for promoting sexual safety among youth. They agreed that the most influential step would be to call upon network and cable television executives to accept condom commercials. Nearly all the major television networks have policies banning condom advertising, yet a Henry J. Kaiser Family Foundation survey found that 72 percent of American adults favor condom commercials on network television.

For condom use to become normalized in society, retreat participants said, condom companies must have the same access to television advertising that Nike, Coca-Cola, and other major products have. National networks and local television stations must not only remove their restrictions on condom advertising, but must also play condom commercials during prime time. In addition, network and studio producers and writers must integrate safer sex messages - including condom promotion - into television shows and movies that are popular with youth.

Retreat participants further suggested using brand philanthropy - in which an established brand name is associated with a particular social cause - to gain a greater degree of respectability in the youth market. They suggested encouraging corporations to weave HIV prevention messages into their marketing efforts and to exploit the power of popular brands - including franchise brands such as Beverly Hills, 90210 - to influence what young people consider cool.

"Messages that American corporations have used so well to get brands into people's heads can be used to help save young lives," says retreat participant Neal Baer, co-producer of the television drama ER.

Already retreat participants have taken steps as individuals. Todd Cunningham, director of research and planning at MTV, undertook a national survey on sexual risk-taking among youth. The study found that 87 percent of the 770 young people surveyed did not believe they were at risk for HIV infection. It also found that while 90 percent of the respondents said they had not engaged in any risky behaviors, 53 percent of those who were unmarried had not used a condom the last time they had sex.

Also following the retreat, Jessica Klein, executive producer of Beverly Hills, 90210, convinced producer Aaron Spelling of the need to work on a subliminal level, incorporating shots of condom wrappers into the sex scenes of future episodes of the program.

"We need to urge the key influencers of pop culture to deliver messages that safer sex is cool," Klein says. "All of us in Hollywood need to examine how we can take a proactive approach to preventing new HIV infections."

"This retreat was unprecedented in the history of HIV prevention because the public and private sectors came together to talk not about philanthropy, but about what they could do to complement each other’s HIV prevention efforts," MHP founder Cooper says. "The MHP program is an example of how we can combine knowledge and resources to change the way we promote HIV prevention among young people, for whom entertainment and consumer marketing are powerful communications tools."