Evaluation of the Impact of News Coverage of an HIV Multiclass Drug–Resistant Cluster in Seattle, Washington

Abstract

Objectives. In February 2007, Public Health–Seattle and King County issued a press release describing a cluster of multiclass drug–resistant HIV cases among men who had sex with men (MSM). We evaluated the effect of the press release among MSM in the Seattle area.

Methods. We administered a rapid assessment survey at venues where MSM congregate. Eligible participants were men who had sex with men in the past year, were older than 18 years, and were residents of western Washington State.

Results. Among 325 participants, 57% heard or saw messages related to the press release. Of these, 87% remembered 1 or more key points, but only 5% remembered key prevention messages. Ninety-eight percent of participants thought it was important for the health department to get the message out about drug-resistant HIV.

Conclusions. The press release was found to be a useful and well-received method to inform the public about an HIV drug–resistant cluster. Low retention and nonprominent coverage of key prevention messages suggests that health departments using press releases as a prevention tool need to carefully consider placement and emphasis of those messages in a press statement.

In January 2007, Public Health–Seattle and King County (PHSKC) identified 4 cases of multiclass drug–resistant (MDR) HIV among recently diagnosed, antiretroviral-naive men who have sex with men (MSM) with genetically similar strains of HIV-1.¹ The men had a transmitted strain of HIV that was resistant to 16 of 18 antiretrovirals tested and in all 3 drug classes tested. Additional analysis indicated a high degree of phylogenetic relatedness among the strains of HIV infecting these men. All of the men were diagnosed with HIV between December 2005 and December 2006 with indications of recent infection. The 4 men had a history of methamphetamine use and sex with multiple, mostly anonymous, male partners they met at various local venues and on the Internet.

On February 1, 2007, PHSKC issued a press release describing the MDR cluster, explaining that MDR HIV may be difficult to treat and recommending routine HIV testing for MSM, at least yearly and every 3 months for high-risk MSM. The decision to release a statement to the media was made, in part, because of the effectiveness of press releases as a method for disseminating health information to the public and specifically those most at risk.^2,3 The primary objectives of the press release were to (1) inform the public of a cluster of transmitted MDR HIV, (2) encourage people at risk for HIV to use condoms during sexual activity and not share drug-injecting equipment, (3) encourage MSM to get tested for HIV, and (4) remind HIV-infected patients to take medications on schedule and talk to their medical providers about drug resistance. Given these objectives, the press release also was considered to be a prevention intervention for MSM, focusing on raising awareness about HIV generally and MDR HIV specifically as well as promoting the adoption of protective behaviors.

Although press releases can be effective for disseminating information, studies of the effect of media campaigns, including press releases, on health-related behavior change have shown mixed results. Some have shown media campaigns to be fairly effective at influencing health-related knowledge and behavior,^4–7 whereas other studies have indicated that media campaigns alone are not effective tools for health interventions or fail to provide any long-term behavior change.^8–10 Furthermore, although a press release can draw media attention to an issue, the group issuing the press release cannot control the extent to which information in the release is disseminated or presented by the media.

To evaluate the press release as a prevention intervention for MSM, we used 2 methods: a review of the media coverage resulting from the press release and a rapid assessment survey of MSM in the area primarily covered by the press release. The review of media coverage assessed how many and what types of media picked up the press release and whether coverage included information about the cluster and the prevention messages. The objectives of the rapid assessment were to assess, among MSM, (1) awareness and recall of key messages in the press release and perception of the importance of media coverage; (2) attitudes about the health department releasing information about the MDR HIV cluster and well as attitudes about HIV testing, condom use and beliefs about risk; (3) recent HIV-related behaviors and future intent to engage in these behaviors; and (4) recent HIV testing history and future intent to test. In this article, we address the nature of the media coverage and the effect of the press release on awareness of HIV drug resistance, perception of the importance of media coverage, and intention to engage in HIV-related behaviors.

METHODS

Review of Media Coverage

To describe the media coverage in response to the press release, we first collected copies of stories related to the press release in print publications distributed in King County. To determine online sources of media that may have been available to MSM in King County, we conducted a Google search using the search string “Seattle HIV multiple drug resistance” and included online stories that were published before February 16, 2007, when the survey was initiated. We categorized articles as coming from the mainstream press (general interest publications distributed or sold in the King County area), gay or alternative press (gay-themed newspapers and free weekly publications distributed in the King County area), and online only (sources either published only online or published in online versions of publications that are not normally distributed or sold in the King County area). For articles that were both distributed in print in King County and available online, we evaluated and counted only the print copy of the article.

The identified media reports were reviewed by a technical writer and by an epidemiologist; each independently scored whether several key points of the press release were included in each article and, if included, whether the key points were emphasized (mentioned in the first half of the article). In cases of disagreement between the 2 scorers, a second epidemiologist reviewed the articles and made a final determination. The results are reported as the percentage of articles overall and in each category that mentioned a particular key point and the percentage of articles that emphasized those key points.

Rapid Assessment

To evaluate the effect of the press release among MSM, PHSKC, in collaboration with staff from the Centers for Disease Control and Prevention (CDC), developed a rapid assessment, called Swift. Eligible participants were men who had sex with men in the past year, aged at least 18 years, and residents of western Washington State. Interviewers conducted the surveys using handheld computers at venues in Seattle where MSM congregate, including bars, dance clubs, bathhouses, HIV clinics, MSM-related community events, and a gay-friendly coffee house. All interviews were conducted 2 to 3 weeks after the press release.

We used active, sequential recruitment to limit selection bias. Interviewers were trained to station themselves at a well-trafficked area at their designated venue. They were trained to intercept every second male that crossed an imaginary line to recruit him for the survey. In venues where most attendees were sitting or congregating in groups, interviewers recruited either all attendees or used the same sequential selection process, selecting every second male. Consent was provided orally, and eligible participants who completed the survey received a $5 gift certificate. Interviewers also provided referrals to PHSKC HIV testing sites located near the venues and contact information for the HIV/AIDS and sexually transmitted disease hotline.

To assess recall of key messages from the press release, we asked those respondents who remembered seeing or hearing something about MDR HIV to say what they remembered about the media report. We field coded the responses against a list of 10 key messages predetermined by the investigators. HIV testing was assessed by asking whether the participant had ever been tested, when was the most recent test, and the result. Sexual behaviors of interest included unprotected anal sex with a partner of discordant or unknown HIV status. We also asked about use of methamphetamine or sexual intercourse with a partner who had been using methamphetamine. Questions on HIV testing and current sexual behavior and methamphetamine referred to the 2 weeks before and the 2 weeks after the press release (30 days before the survey). Five-point Likert scales were used to measure intention to engage in these HIV-related behaviors in the next 30 days (“no chance at all” to “very likely”). Demographic information, including race, age, HIV status, zip code, and education level also were collected. Demographic characteristics were not collected for participants who were ineligible, refused to participate, or did not finish the survey.

Statistical analyses were conducted using SAS v.8.2 (SAS Institute, Cary, North Carolina). Differences by demographic characteristics in recall of press release, attitudes about the press release, behaviors, and intentions were compared using χ² and Fisher exact tests. P values less than .05 were considered to be statistically significant. Borderline significance was defined as P values of .05 through .09.

RESULTS

Media Coverage

We identified 18 publications that MSM in King County may have been exposed to: 3 articles in mainstream print sources, 4 in gay-themed or alternative sources, and 11 in online-only sources. All articles reported that MDR HIV was linked to methamphetamine use and to multiple partners (Table 1); less than half of all publications mentioned the 2 primary prevention messages (importance of condom use and of HIV testing), and no online article emphasized a prevention message.

TABLE 1.

Key Messages From a Press Release That Were Mentioned and Emphasized by Media Articles, by Publication Type: Swift Assessment, Seattle, Washington, February 2007

	MDR Linked to Methamphetamine Use, %		MDR Linked to Multiple Sex Partners, %		MDR Linked to Anonymous Partners, %		MDR More Expensive to Treat, %		Condom Use Recommended to Prevent, %		Important for MSM to Get Tested for HIV, %
Publication Type	Mentioned	Emphasized	Mentioned	Emphasized	Mentioned	Emphasized	Mentioned	Emphasized	Mentioned	Emphasized	Mentioned	Emphasized
All (n = 18)	100	100	100	85	92	92	15	15	23	23	46	0
Mainstream print (n = 3)	100	100	100	100	67	67	67	67	33	33	100	0
Gay/Alternative print (n = 4)	100	75	100	50	100	50	0	0	50	50	50	0
Online only (n = 11)	100	100	100	100	72	72	9	0	0	0	9	0

Note. MDR = multiclass drug resistance; MSM = men who have sex with men. Messages were considered to have been emphasized if the message appeared in the first half of the media article.

Rapid Assessment

Of 662 persons approached for the rapid assessment survey, 237 (36%) refused to participate, 93 (14%) were ineligible, and 7 (1%) were eligible but did not complete the survey; the remaining 325 (49%) agreed to participate and completed the survey and were the basis for this analysis. Most (78%) of the participants were interviewed at bars or dance clubs, followed by 10% at bathhouses, 5% at HIV clinics, and 6% at other venues. Table 2 describes the demographic characteristics of the participants.

TABLE 2.

Demographic Characteristics, Recall of Multiclass Drug–Resistant (MDR) HIV Cluster, HIV Testing Behavior, and Drug and Sexual Behavior of Eligible Participants: Swift Assessment, Seattle, Washington, February 2007

	Total Participants, No. (%)	Saw/Heard MDR HIV Cluster Message, %	Ever Tested for HIV,a %	Will HIV Test in Next 30 Days,b %	UAI with Discordant/Unknown Status Partner in Past 30 Days, %	UAI With Discordant/Unknown Status Partner Next 30 Days,b %	Methamphetamine Use by Self or Sex Partner, %	Methamphetamine Use by Self or Partner in Next 30 Days,b %
Number	325	186	313	96	22	45	17	23
Age group, y
18–24	36 (11)	47	86	50	0	11	3	6
25–34	121 (37)	53	98	32	7	12	6	5
35–44	112 (34)	60	98	25	7	13	6	1
≥ 45	56 (17)	68	96	20	9	20	2	7
Race/ethnicity
White	228 (70)	58	96	27	6	12	4	6
Black	10 (3)	80	100	50	0	10	20	30
Hispanic	13 (4)	46	100	23	0	15	0	8
Other/unknown	38 (12)	55	95	45	8	21	3	5
Multiple race	36 (11)	53	94	28	14	17	11	11
Education
Less than high school	6 (2)	17	67	0	0	0	17	33
High school graduate	33 (10)	39	97	24	6	21	12	12
More than high school	286 (88)	60	97	31	7	13	4	6
Residence
Seattle	237 (73)	59	97	29	6	14	5	7
King County, non-Seattle	37 (11)	65	97	35	11	11	3	5
Other western Washington	51 (16)	41	90	27	6	14	8	10
HIV status
Non infected	283 (87)	56	95	30	6	13	2	5
Infected	42 (13)	64	NA	NA	12	17	29	21

Note. UAI = unprotected anal intercourse; UI = unprotected intercourse, type not specified; NA = not applicable.

^aNon–HIV infected only.

^bOn the basis of Likert scale responses “somewhat likely” and “very likely.”

Awareness and Recall of Press Release

More than half (57%) of the 325 participants saw or heard messages related to the press release (Table 2). Participants with education beyond high school were significantly more likely than those with a high school education or less to report having seen or heard messages (60% vs 36%; P < .01). Older participants (> 34 years) were somewhat more likely than were younger participants to have seen or heard the messages (63% vs 52%; P = .05).

Most participants heard or saw information about the MDR cluster from mainstream newspapers (51%), followed by the Internet (41%), friends (33%), television (28%), alternative or gay-oriented newspaper (24%), radio (12%), or a flyer (10%). Retention of key points was highest among those who reported seeing or hearing messages through gay or mainstream newspapers (93% and 94%, respectively), television (91%), and the Internet (95%). When compared with those who reported seeing the message in mainstream newspapers, recall was lower among those who heard or saw the messages through flyers (P = .01) and borderline significantly lower for hearing about the cluster through the radio (P = .05) and friends (P = .06) compared with mainstream newspapers.

Of participants who reported seeing or hearing messages related to the press release, 87% remembered 1 or more key points (Table 3). The most common key points that participants remembered were that the cluster was made up of 4 gay men (57%), that the cluster was linked to methamphetamine use (31%), and that MDR may be hard to treat (25%). Only 5% of participants remembered that the media message encouraged using condoms or getting tested for HIV infection.

TABLE 3.

Recall of Key Messages From Multiclass Drug–Resistant (MDR) HIV Press Release, by HIV Status: Swift Assessment, Seattle, Washington, February 2007

	Non–HIV infected (n = 139), No. (%)	HIV Infected (n = 22), No. (%)
MDR HIV may be harder to treat	35 (25)	4 (18)
Cluster linked to methamphetamine use	44 (32)	7 (32)
Cluster linked to multiple partners	17 (12)	4 (18)
Cluster linked to anonymous partners	16 (12)	2 (9)
MDR HIV more expensive to treat	5 (4)	1 (5)
No evidence MDR HIV spread to Seattle from other city	2 (1)	0 (0)
May be ongoing transmission of MDR HIV	17 (12)	1 (5)
Use condoms to prevent MDR HIV	7 (5)	1 (5)
Cluster of 4 cases among gay men	86 (62)	8 (36)
Get tested for HIV	5 (4)	4 (18)

When asked whether participants thought it was important for the health department to get the message out about drug-resistant HIV, 98% thought it was somewhat to very important. Both HIV-infected respondents and non–HIV-infected respondents thought it was important to get the message out (95% vs 99%). Eighty-two percent of participants thought being infected with drug-resistant HIV would be a very serious problem, and 14% thought it would be somewhat of a serious problem. Among HIV-infected respondents, 50% were somewhat to very likely to have their doctor check their HIV resistance status in the next 30 days, with no difference between HIV-infected participants that heard or saw messages and those who did not.

Sexual Behavior and Methamphetamine Use

Of the 74% (n = 241) of participants who had sex in the 30 days before participation, the average number of male partners was 2.2. Of those who had sex in the past 30 days, 20% reported having sex with a partner of discordant or unknown HIV status. Having any sex partners of discordant or unknown HIV status was higher among HIV-infected participants compared with those who were HIV-uninfected or of unknown HIV status (P < .001), those aged 25 to 34 years compared with all other age groups (P = .002), and Black respondents compared with White respondents (P = .09). Among men who had a partner of discordant or unknown HIV status, 34% reported having unprotected anal sex with a discordant or unknown status partner. Half of the participants who had sex in the past 30 days had a least 1 first-time partner (someone they had sex with for the first time in the past 30 days).

Fourteen percent of participants responded that they were somewhat to very likely to engage in unprotected sex with a partner of unknown or discordant HIV serostatus in the next 30 days. Among participants who reported having unprotected anal sex with an unknown or discordant status partner in the past 30 days, 64% reported that they were somewhat to very likely to engage in unprotected sex with a partner of unknown or discordant status in the next 30 days. Of those intending to engage in unprotected sex, 56% heard or saw messages about the press release and 44% remembered key points; neither of these proportions was statistically significantly different from those not intending to engage in unprotected sex.

Approximately 5% of participants or participant's sex partners used methamphetamine before or during sex (Table 2). These proportions were highest among HIV-infected individuals (P < .001) and Black respondents compared with White respondents (P = .02). Seven percent of participants reported being somewhat to very likely to use methamphetamine or to have sex with a partner who uses methamphetamine before or during sex in the next 30 days, including approximately three quarters of participants who previously had experience with methamphetamine before or during sex. Among these men, 55% heard or saw messages about the MDR HIV cluster and remembered key points. No significant differences were found between those that heard or saw the information from the press release and intention to use or have sex with a partner who uses methamphetamine in the next 30 days.

HIV Testing

More than 95% of non–HIV-uninfected participants had ever been tested for HIV (Table 2) and 305 (94%) had tested in the past year. Testing was more common among participants 25 years or older (P < .001) and participants with a high school education or higher (P < .001). Approximately two thirds of participants who had not been tested in the past year had sex in the past 30 days, including 32% who had at least 1 first-time partner.

One third (34%) of non–HIV-infected participants reported that they were somewhat to very likely to get HIV tested in the next 30 days. Of those who did not intend to get tested, 26% had already been tested in the past 3 months, and 38% had been tested in the past 6 months. Of those intending to get HIV tested in the next 30 days, 49% heard or saw messages about the MDR HIV cluster and 87% of those remembered key points. No significant relation was found between status of having seen or hearing information related to the press release and intention to get HIV tested in the next 30 days.

DISCUSSION

The decision to release a public statement about the cluster of MDR HIV cases in Seattle was debated at length by PHSKC staff with input from local and national colleagues. Information about the cluster had already been released through local provider newsletters and reports, and some public health officials believed that sending a general press release to the public might be viewed as alarmist, create fear in the community, and contribute to stigma already surrounding the gay community. However, the obligation of health departments to inform the public of potential outbreaks and health risks often outweighs potential criticism from members of the affected community, especially when preventative messages need to reach those most at risk.^11,12 Providing health-related information through the media is a common component of most health education protocols in public health and a useful tool in providing health-related information to the public.^13–15 In 2005, the New York City Department of Health (NYCDOH) reported a single case of MDR HIV with rapid disease progression.^16,17 The case was widely publicized nationwide as a potentially new, deadlier strain of HIV. Although others with related drug-resistant strains were found, none of the other cases experienced rapid progression,¹⁸ and the rapid progression of the index case was not found to be related to the drug resistance. NYCDOH and the CDC were subsequently criticized for unnecessarily alarming the public and not emphasizing prevention messages.^19–22

The Swift assessment of the effect of the press release found that more than half of participants had seen or heard information related to the press release and that almost all the participants thought it was important for the health department to release information about HIV drug resistance. Retention of at least 1 key message was high. However, most of the recalled key points were related to the characteristics of the cluster, and very few recalled recommendations for condom use or HIV testing as key points. A number of factors might explain the low retention of prevention messages. First, the 2 key prevention messages were mentioned less often than were other key messages and were emphasized less often in the stories in which they were mentioned. The primary point the media likely found newsworthy from the press release was the information regarding the small cluster of 4 cases of transmitted MDR HIV.

Studies have suggested that coverage of health and medical news releases often includes insufficient information or exaggerated and sensationalized news reporting that can be misleading or obscure the intended message.^23–26 Also, the prevention messages were mentioned in the second half of the original press release; despite the health department's attention to the inclusion of and specific wording for prevention messages within the press release, it is possible that articles written in response to the press release mentioned the prevention messages later in the text because their authors followed the order of topics in the original press release. Media relations specialists in health departments may wish to consider ways to increase the chances of prominent placement of prevention messages, such as including information about prevention recommendations early in the press release or including reference to prevention messages in first-line media messages delivered by spokespersons.

Second, the participants were all MSM, a community well saturated with safe sex and HIV-testing messages. Perhaps participants assumed that we wanted to know about their retention of specific MDR HIV cluster facts, not prevention messages they may have heard routinely. Finally, mass media campaigns for prevention are most effective when the audience members perceive themselves as the target of the messages.²⁷ Many MSM may have read the initial report of the cluster and did not perceive themselves to be at risk based on the characteristics of the cluster and disregarded the subsequent prevention messages. For example, because such a small number of participants reported using methamphetamine, which was a key characteristic of the MDR cluster, many participants may have felt disassociated from the cluster and prevention messages.

Overall, a small proportion of participants in the Swift assessment had engaged in high-risk behaviors. This may indicate that the saturation of prevention messages among MSM noted earlier has been effective. It is notable, however, that somewhat higher proportions of participants had some intention to engage in high-risk behaviors than had engaged in these behaviors in the past 30 days (14% vs 7% for unprotected sex; 7% vs 5% for methamphetamine). These differences in past behavior and intention, multiple sex partners (average 2.2 among participants), and the partner change rate (half of participants had a first-time sex partner in the past 30 days) may result from uncertainty about predicting the future and the probability or uncertainty of risk in the future with new partners may be higher than what is known about past behaviors with different partners.

A high proportion of respondents had been tested for HIV in the preceding 12 months; this is in accordance with CDC guidelines about HIV testing among MSM.²⁸ To increase the effect of messages about adopting protective behaviors, it may be effective to focus counseling that occurs as part of HIV testing on risk behaviors.

The prevention component of this project was limited in the fact that the press release was a single, short-term media event and not a mass media campaign lasting for several weeks. Measuring behaviors or intentions after a brief media event is a challenge; another evaluation based on the rapid assessment data, accounting for attitudes and beliefs, also did not find significant associations between the press release and intentions.²⁹ One other limitation of this assessment was the inability to collect data on men who declined to participate. However, additional analysis has shown participant demographics to be similar to other studies of MSM in Seattle.²⁹

Based on the findings of this assessment, the press release was successful at informing the community about the MDR HIV cluster. The vast majority of participants thought it was important for PHSKC to make this information accessible to the public. We found that press releases are useful tools for providing public health and HIV-related news to the community, although prevention messages should be more prominent within the press release so that they are picked up more often in the media coverage. Although mass media campaigns have been shown to be a cost-effective prevention method,³⁰ further studies are needed to determine whether a single-event press release is an effective prevention method in absence of other methods or follow-up media event.