Messaging matters: achieving equity in the HIV response through public health communication

Abstract

Public health messages shape how the world understands the HIV epidemic. Considerable inequalities remain in HIV care continuum indicators by subpopulation and geography (eg, highest infection and mortality burden among men who have sex with men and people who live in sub-Saharan Africa). Health equity-focused approaches are necessary in this next decade to close gaps in the HIV epidemic. Between 1981 and 1989, HIV messages triggered fear and victim blaming, and highlighted behaviours of a few marginalised groups as deviant. Between 1990 and 1999, messages signalled that HIV was a growing challenge for the world and required multisector approaches that addressed structural drivers of inequality. Between 2000 and 2009, messages highlighted universal testing, while advances in HIV testing made these messages easier for individuals to respond to than in previous decades. Currently, messages signal that ending HIV is possible, people can live productive lives with HIV, and transmission to people without HIV can be eliminated. Public health messaging about the HIV epidemic has evolved substantially over the past 40 years. Future HIV messaging should be driven by health equity principles that include an increased representation of key populations in message design and dissemination, transparency of funding, and communicating any impact that campaigns have had on closing health inequalities.

Introduction

The USA became the initial focal point of the HIV epidemic when the disease emerged among men who have sex with men (MSM) in San Francisco, CA; southern California; and New York, NY, in the early 1980s. To date, approximately 32 million people have died of HIV-related complications and 75 million people are living with the virus, with most residing in low-income and middle-income countries (LMICs).¹ Decades of surveillance research has led to a shift from the population groups initially identified as being at risk for HIV (eg, people with haemophilia, people who inject drugs, and Haitian refugees) to a broader focus on members of key populations, including MSM, transgender people, sex workers, individuals involved with the criminal justice system, and people who inject drugs.² Although not explicitly identified among key populations, young people (aged 15–24 years) globally and adolescent girls and young adult women in LMICs are also overly represented among people living with HIV. Disproportionate burden of HIV among these populations reflect a long history of social–structural inequalities, including stigma, discrimination, scarcity of employment opportunities, poverty, incarceration, inadequate funding for HIV-related services, and gendered power imbalances in sexual relationships and society.

In the past four decades, a notable shift has occurred in the scientific and public health approach to ending the HIV epidemic. The days of separate models for HIV prevention and treatment are rapidly fading in favour of combination prevention packages: interventions addressing behavioural, social–structural, and biomedical drivers of disparities in outcomes along the HIV prevention and care continuum.³ However, the extent to which these approaches can be scaled up and adopted is contingent on effective health communication.

Health communication has an integral role in HIV prevention and treatment efforts.⁴ More than a collection of messages, initiatives, or campaigns intended to share ideas, health communication is a dynamic, multilevel social process that serves several key functions, including: providing information (eg, increasing HIV awareness), convincing people to change their beliefs or behaviours (eg, testing for HIV and eliminating high-risk behaviours), facilitating social connections or support (eg, peer support groups), and lending voice to shifting social or cultural norms (eg, promoting abstinence only vs comprehensive sex education or use of evidence-based HIV advocacy).^4–6 Although promising, health communication about HIV has not reached its full potential, which might be partially attributed to inadequate consideration of the complex inequitable social–structural factors and systems that contribute to disproportionately poor HIV-related outcomes among members of key populations. To address these limitations and to contribute to ending the HIV epidemic, public health messaging about HIV must incorporate health equity.

Health equity is the absence of unfair and avoidable differences in health among marginalised groups.⁷ Health equity is the ability for individuals to reach their full health potential and not be excluded from resources due to race or ethnicity, gender, socioeconomic status, sexual orientation, geographical location, or a combination of these social positions.⁷ Accordingly, health equity in communication about HIV should consider the influence of social–structural inequalities and systems on HIV-related vulnerabilities, and should place social justice at the forefront of messaging about HIV prevention and treatment.

1981–89: the emergence of HIV

During the early 1980s, HIV cases quickly rose among young MSM in the USA, and by 1983 the US Public Health Service declared that combating HIV was its top priority.

Initial public health messages about HIV were largely designed using fear-based appeals to shock and scare individuals at risk of the disease. For example, an Australian television advertisement created by a government agency to educate the public about the dangers of AIDS used a skeletal grim reaper throwing bowling balls into crowds of people who, once hit, dramatically fell to the ground.⁸ These highly stigmatising messages were later criticised for inciting panic, driving HIV inequities, and furthering misconceptions about HIV and people dying from AIDS.^9,10

This period also included the initiation of HIV criminalisation laws. In the USA, people with HIV were added to the immigration exclusion list and testing mandates for all visa applications were enforced. Similarly, in some Latin American, eastern European, and central Asian countries, public health messages disparaged particular migrant groups and promoted HIV-related travel restrictions, which controlled the entry, stay, or residence of people living with HIV.¹¹ Although these policies were positioned as ways to protect public health and to prevent HIV transmission, HIV-related travel and migration restrictions were shown to be discriminatory and ineffective, and to impede equitable access to HIV prevention and treatment.^9,11

Between 1987 and 1989, public health shifted to messages aimed at increasing awareness and knowledge about HIV among groups at risk. In the USA, the Centers for Disease Control and Prevention (CDC) disseminated information on HIV and risk reduction through its America Responds to AIDS initiative, which included promoting campaigns such as Humanizing AIDS and Preventing HIV Infection and AIDS: Taking the Next Steps, establishing a National AIDS Hotline and National AIDS Information Clearinghouse, and providing support to regional health departments for HIV counselling and testing. In Thailand, the National AIDS Program was launched, showing a strong political commitment to reducing HIV through aggressive messaging about HIV prevention and treatment. In later years, messaging about condom use, campaigns to reduce HIV-related stigma, free and mandatory testing services, and the inclusion of HIV control in all governing budgets became central to Thailand’s HIV programme and success in reducing HIV incidence.¹²

This period also introduced HIV activism and advocacy, which pressured the scientific and public health community to be responsive to the growing epidemic and to partner with activists. Mobilised by popular media images of people living with HIV, celebrity deaths, and growing accounts of the inhumane treatment of people dying from AIDS, activities led by HIV activists resulted in increased funding for HIV research, an increased number of educational campaigns, and improved access to developing treatments.¹³ A key message promoted during this decade was the expansion of harm reduction strategies, such as needle and syringe programmes. In the UK, needle and syringe programmes paired needle exchange with counselling on drug treatment, safe sex, and HIV testing. Similar efforts were launched by WHO to raise awareness about HIV (eg, World AIDS Day), to develop guidelines on HIV prevention (eg, increased access to condoms) and emerging therapeutics (eg, clinical trials for antiretroviral medications), and to promote a global response that recognised the humanity of individuals affected by HIV.¹⁴

Overall, public health messages of this decade promoted and stigmatised particular subgroups as the drivers of HIV transmission. Rather than contextualising HIV and related risk behaviours, communication about HIV described it as a disease of marginalised groups. Messaging strategies unintentionally fuelled stereotypes of MSM, people who inject drugs, and Haitian immigrants as hypersexual and irresponsible. These initial messages did not promote health equity and contributed to widening disparities in HIV on the basis of race, sexual orientation, socioeconomic status, and geography. During this decade, public health missed the opportunity to integrate equity in the emergent HIV funding, policy, and health promotion strategies used by public health agencies.

1990–99: a global public health challenge

The 1990s marked an increase in the number of people living with HIV and dying from AIDS. In the USA, racial and socioeconomic disparities began to emerge. The CDC reported that African Americans accounted for 49% of AIDS-related deaths in the USA, which was approximately 10 times higher than deaths among White people living with HIV.¹⁵ Towards the end of this decade in the USA, Black and Latinx MSM who were young (aged <35 years) and socioeconomically disadvantaged experienced a disproportionate burden of HIV. These sociodemographic shifts showed how social–structural factors, including poverty, structural disadvantage, stigma, and discrimination, heightened HIV vulnerabilities. Similar trends were evident globally. WHO estimated that there were between 13 million and 14 million people living with HIV worldwide, and that HIV prevalence was expected to reach between 30 million and 40 million by the end of the decade, with much of this burden concentrated in LMICs.¹⁶ Epidemics across many LMICs were concentrated within marginalised groups. In sub-Saharan Africa, women and girls were at considerable risk of HIV and acquired HIV at a young age (<25 years) partly due to few educational and economic opportunities, gender inequities, and social norms that restricted sexual decision making. Migration due to economic and political factors, limited access to HIV prevention and treatment resources, and poor health infrastructure also accelerated the HIV epidemic in this region.^17,18

Emergent innovations in HIV testing (eg, rapid blood tests and viral load diagnostic kits) and treatment resulted in shifts in public health messaging, and facilitated the scale-up of HIV testing.^19,20 Highly active antiretroviral therapy (ART) was also introduced as the new standard of HIV care. With advancing strategies in HIV testing and treatment, marked shifts in the sociodemographic profile of people acquiring HIV, and increased recognition of the failure of fear appeals and stigma as effective health communication tools, public health messaging around HIV prevention and treatment changed. Unlike the previous decade, the 1990s had an increasing number of targeted public service announcements and messages that heralded the importance of prevention of mother-to-child transmission, testing, and treatment. Despite more positive and inclusive messaging about HIV than in the 1980s, access to highly active ART remained scarce.⁴ In the USA, Black and Latinx individuals, and those who were socioeconomically disadvantaged continued to be at an increased risk of AIDS-related mortality.²¹ This period also marked an increase in HIV criminalisation laws, which criminalised the behaviours of people living with HIV.^11,22

Globally, HIV messaging in the 1990s promoted an increased awareness of HIV in LMICs. Partnerships among public health, activists, and private sector groups formed to create targeted communication strategies, including public service announcements, programmes, and concerts, to increase public education about HIV in LMICs. With the establishment of UNAIDS, there was a new emphasis on public health messages that were non-stigmatising, included communities and people most affected by HIV, and situated HIV as a human rights issue.²³ There was also an increased acceptance of and communication about World AIDS Day. In some countries globally, national HIV testing days were promoted as strategies to increase HIV testing and to reduce stigma.²⁰ These efforts also highlighted mounting inequalities, in which the high cost of HIV testing and treatment (ie, highly active ART) made them widely unavailable to people living with HIV in LMICs.

This period included an increase in campaigns promoting AIDS denialism—a major barrier to accessing HIV prevention and treatment—which was estimated to have killed 330 000–340 000 people in South Africa due to a government-level refusal to implement HIV treatment.²⁴ The Abstain, Be Faithful, or use Condoms approach was developed and used for HIV prevention in many LMICs. However, its implementation remains controversial due to its promotion of abstinence only sexual health education to young people; disregard for gender norms and inequities, in which abstinence, monogamy, and condom use were often not within a woman’s control; and focus on individual behaviours, without consideration for the social–structural factors that drive the HIV epidemic.^25,26 In partnership with religious and community organisations, the Ugandan Government implemented this approach through targeted media and programmes that promoted condom use and advocated for a cultural return to traditional practices of abstinence and faithfulness. This programme was credited with substantially decreasing HIV incidence and prevalence in Uganda, shifting cultural norms about sexual behaviour, and becoming a focal point for global HIV prevention.^25,26

The 1990s also saw a rise in grassroots social movements, HIV and AIDS support groups, and HIV activism organisations, which informed political and public health messaging about HIV.²⁷ For example, the Treatment Action Campaign in South Africa raised awareness about the availability of HIV treatment and challenged the government on its refusal to provide affordable highly active ART and to support prevention of mother-to-child transmission through highly active ART provision and accurate messaging. Similarly, in the USA, the Treatment Action Group was formed as an HIV activist organisation. The activities of these HIV and AIDS activist organisations, among others, promoted global solidarity and support for people living with HIV, lobbied for increased funding and research on HIV treatment, challenged messaging that stigmatised and promoted harmful myths about HIV transmission, and prompted partnerships with advocacy organisations and social justice movements.^6,27

Public health messaging in this decade evolved from portraying select marginalised groups as drivers of HIV transmission to more broad-based messaging aimed at the general population that promoted HIV testing and treatment. Disparities emerged as HIV disproportionately affected marginalised groups. Public health messaging acknowledged this new challenge, but largely overlooked the underlying social–structural drivers of these disparities.

2000–09: the leading cause of death among people aged 15–59 years

This decade saw a negligible decrease in the absolute number of new HIV infections globally, from an estimated 2·7 million in 2000 to an estimated 2·1 million in 2010, and a modest decrease in AIDS-related deaths, from 1·4 million to 1·1 million.¹ Notably, attributed to a rise in HIV among people who inject drugs, sex workers, and their sexual partners, HIV incidence increased in eastern Europe and central Asia. The burden of HIV was also highest among women aged 15–24 years and MSM of all age groups.²⁸ This era was marked by a growing trend to define HIV and AIDS outcomes based on CD4 cell counts.²⁹ Furthermore, late HIV diagnosis emerged as a global challenge in controlling HIV transmission. For example, health-care settings in Australia, Thailand, Uganda, and the USA reported high (>40%) rates of late HIV diagnoses.^30–33 However, a considerable shift in messaging promoted the promise of extended life expectancy from improved ART medications that had reduced toxicity, fewer side-effects, and easier combinations to improve adherence through fixed-dose combination pharmacotherapies.³⁴

Early in this decade, public health messages focused on universal access to HIV testing, early detection, and initiation of ART.^35,36 These messages aimed to convey that HIV could be prevented and that an aggressive public health response could halt the pending global epidemic.^20,37,38 Public health communication about HIV during this period largely targeted the general population, but some messages targeted Black women in the USA and young Black and Latinx adults in the USA (aged 15–29 years).³⁹ In the USA, prominent initiatives included HIV Stops with Me and Act Against AIDS, which focused on empowering people living with HIV, reinforced the benefits of viral suppression to quality of life, and addressed growing complacency among the general public about HIV only being a problem in LMICs. These messages were strengthened by clinical guidelines supporting opt-out testing, which promoted HIV testing as part of routine health screenings unless the patient requested not to be tested.⁴⁰ Opt-out testing guidelines were supported by innovations in HIV testing, including the first fingerprick rapid test and oral fluid test, which facilitated efforts to increase testing among marginalised populations.^41–43

Albeit less widespread, another initiative during this period was voluntary male medical circumcision (VMMC) for men and boys aged 15 years and older. In 2007, WHO recommended VMMC as a strategy to reduce HIV acquisition among heterosexually active men, especially in generalised epidemic settings.⁴⁴ This strategy also sought to reduce transmission among heterosexually active men and their female sexual partners, who benefited indirectly.⁴⁴ Messaging for VMMC was primarily promoted through community mobilisation events. The primary messages communicated through these events were that VMMC was affordable and safe. Messages also shifted away from the individual focus that had permeated HIV testing campaigns, towards a focus on prevention that benefited couples and families.⁴⁵ Although some of the VMMC messaging campaigns often failed to stimulate considerable demand for the procedure in adults, communication strategies that targeted adolescent boys were typically more successful, especially because they positioned the campaign to change social norms, which increased acceptability of VMMC.⁴⁶

This period also saw an increase in structural HIV prevention interventions, which called for an increased focus on reducing social vulnerability by altering social–structural factors (eg, economic conditions, stigma, and gender inequality) through government and private sector partnerships.^16,47–50 Support for structural interventions led to increased funding through the President’s Emergency Plan for AIDS Relief and the Bill and Melinda Gates Foundation.⁵¹ However, as funding through these initiatives increased, so did tensions between the funder (eg, the US Government and foundations) and local governments and non-governmental organisations, furthering challenges to implementing equitable approaches to HIV communication.

Addressing HIV stigma fuelled by discrimination of people living with HIV became increasingly visible in prevention messages.^52,53 Messages in support of structural interventions also called for the end of HIV stigma and discrimination, which was illustrated through speeches from global leaders. For example, Peter Piot, then executive director of UNAIDS, declared that stigma and discrimination were “the continuing challenge” to HIV and that the world needed a “renewed effort to combat stigma”.²³ Nelson Mandela’s speech at the International AIDS Society meeting in Durban, South Africa, urged a move from rhetoric to action to “banish stigma and discrimination, and ensure total inclusiveness within the struggle against AIDS; those who are infected with this terrible disease do not want stigma, they want love”.⁵⁴ Several campaigns were announced to address HIV stigma and discrimination, including Getting to Zero aimed at achieving zero new infections, zero discrimination, and zero AIDS-related deaths by 2015 (announced in 2010 and launched in 2011; figure 1A).⁵⁵ World AIDS Day themes (eg, Stigma and Discrimination and Live and Let Live!) also reflected this shift in communication focus (figure 1B).⁵⁶

Figure 1: Example UNAIDS campaign messages and World AIDS Day themes.

Examples include the 2011 Getting to Zero campaign (A) and the 2016 Hands Up for HIV Prevention theme (B). Credit: UNAIDS.

The 2000s marked an increase in messaging about HIV through media and entertainment. For example, MTV launched the Staying Alive Ignite global media campaign to raise HIV awareness among young people and to address social and cultural determinants of HIV. One approach included the television series MTV Shuga and its accompanying website with information on the series and on HIV prevention and treatment (figure 2).⁵⁷ Initially set in Kenya, this series included episodes on sexual health, HIV stigma, sexual concurrency, and gender inequity. This popular series reached 179 broadcasters worldwide, 719 million households, and 42 million people through social media.⁵⁷

Figure 2: Example MTV Shuga episode themes.

Scenes taken from MTV Shuga episodes on themes related to sexual health, HIV prevention and treatment, and gender inequity. Credit: The MTV Staying Alive Foundation and MTV Shuga.

Public health messaging during this decade targeted universal access to HIV testing. Reducing HIV stigma and discrimination and empowering people living with HIV were also prominent messaging themes. Despite multiple aggressive efforts, there were still substantial disparities in HIV prevention and treatment among key populations globally.^58–60 Although this period saw a slight increase in public health messages targeting vulnerable groups such as young women, the impact of these segmented approaches on reducing HIV inequalities remains unclear.

2010–21: biomedical prevention and treatment could end the HIV epidemic

30 years after the first cases of HIV were identified, the public health community announced two breakthroughs in biomedical HIV prevention and treatment: pre-exposure prophylaxis (PrEP) and treatment as prevention.

Between 2010 and 2011, the results of several clinical trials, including the iPrEx study⁶¹ with MSM and the Partners PrEP study⁶² with heterosexual couples who were serodiscordant for HIV-1, showed the efficacy of PrEP in preventing HIV. In 2012, the success of these trials led the US Food and Drug Administration to approve PrEP for HIV prevention among adults and, within 5 years, adolescents. The discovery and availability of PrEP made national and international news, with headlines such as “Can this pill end the AIDS epidemic?”⁶³ The CDC launched the Let’s Stop HIV Together campaign, which used public service announcements and social media to reduce stigma, but was revised to encourage people at very high risk of HIV to consider PrEP.⁶⁴ The pharmaceutical industry also promoted PrEP awareness and uptake through commercials, targeted social media campaigns, and direct solicitation to health-care providers.

Messaging to increase awareness seemed to be effective in providing information about PrEP.⁶⁵ However, data on PrEP uptake among members of key populations signalled shortcomings in messaging and access to PrEP. By the end of 2019, approximately 590 000 people worldwide had received PrEP at least once.⁶⁶ Despite the UNAIDS global target of 3 million people taking PrEP by 2020, including 90% of members of key populations, to date, fewer than 1 million people have taken PrEP at least once, including fewer than half of all sex workers and nearly a third of MSM and people who inject drugs.^65,67,68

Research regarding the social–structural drivers of disparities in PrEP uptake among key populations point to several potential causes, including barriers associated with cost, access, and power imbalances in sexual relationships.^67,69 Another key barrier, PrEP stigma, refers to the concern of potential and current PrEP users that if they use PrEP, others will assume that they have HIV or are intentionally engaging in high-risk sexual or drug-related behaviours, which are themselves highly stigmatised.⁷⁰ PrEP stigma might be an unintended consequence of previous PrEP messaging and related research and policy, which initially promoted and limited PrEP use to individuals at very high risk of HIV, and employed stigmatising language that implied that only people engaging in socially unacceptable sexual practices should use PrEP. Later health communication has since promoted PrEP use among the wider population. For example, in Thailand, the PrEP in the City campaign was developed in partial response to advocates who called for transgender women to be represented in PrEP campaigns and messages (figure 3). Despite this progress, it has been difficult to undo the damage caused by the messaging surrounding the initial promotion of the drug. Nevertheless, the late 2010s witnessed the rise of social media campaigns advocating for the adoption of PrEP, along with several social media-based interventions, such as #PrEP4Love, which is estimated to have reached over 40 million people.⁷¹

Figure 3: Example PrEP campaign messages.

Examples from Thailand (A) and South Africa (B). PrEP=pre-exposure prophylaxis. Credits: (A) Institute of HIV Research and Innovation, PrEP in the City 2020; (B) National Department of Health (South Africa).

The second major breakthrough of this decade occurred in 2011, when the results of the HPTN 052 study⁷² were reported. HPTN 052 was a randomised controlled trial conducted across nine countries that evaluated the effect of early versus delayed ART initiation among people living with HIV on HIV transmission to their stable, HIV-negative partner. Results provided conclusive evidence that initiating and adhering to ART when the immune system is relatively healthy reduced rates of sexual HIV transmission. In addition, when the individual living with HIV was virally suppressed, the risk of HIV transmission was eliminated. These findings, among others, led WHO to recommend that all people living with HIV initiate ART following diagnosis.⁷³ The rationale was that if all people living with HIV adhere to ART and attain viral suppression, they cannot transmit HIV to others (ie, treatment as prevention), effectively ending the HIV epidemic.

Despite these conclusive findings, messaging regarding the importance of treatment as prevention was slow to reach people living with HIV, and many were unaware or confused about its importance. The public health community was criticised for failing to clearly and consistently state that people living with HIV who have suppressed viraemia cannot transmit HIV to their sexual partners. Instead, vague or inconclusive language was used to communicate the protection that treatment as prevention offers people living with or at risk of HIV, with words or phrases such as “negligible”, “extremely low”, or “essentially no” to convey HIV transmission risk.^74,75 In response to this gap in health communication, the Prevention Access Campaign, a health equity and HIV advocacy initiative aimed at ending HIV and HIV-related stigma, launched the Undetectable=Untransmittable campaign (figure 4).⁷⁶ This campaign was designed to increase awareness about the social, sexual, and reproductive health options for people living with HIV and their sexual partners, to eliminate HIV stigma, to encourage individuals with HIV to initiate and adhere to ART, and to prompt public discourse to reduce barriers to engagement in HIV treatment. In 2017, advocates from the Undetectable=Untransmittable campaign representing 16 countries organised a press conference at the International AIDS Society Conference in Paris to promote the message to global leaders, calling for the acknowledgement that access to universal care is a right that all humans should have. Unfortunately, along with insufficient knowledge, acceptance, or understanding about the campaign, most people living with HIV (especially members of key populations) face inequitable barriers to the testing, treatment, and care required to attain and maintain suppressed viraemia, including HIV-related stigma, low health literacy, discrimination, and challenges with mental health and substance misuse.^74,75

Figure 4: Example Undetectable=Untransmittable campaign messages.

Examples from the USA (A, B), Ghana (C), and Vietnam (D, E). Credits: (A, B) AIDS Institute, New York State Department of Health, created by Better World Advertising; (C) Meeting Targets and Maintaining Epidemic Control (EpiC) project/Ghana/FHI360; (D, E) The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center.

Public health messaging in this decade has leveraged the momentum generated by PrEP and treatment as prevention. However, inequalities persisted as communication about these breakthroughs were, at times, inadequate. The success of messaging campaigns related to these two breakthroughs in reaching vulnerable populations, shifting social norms, or addressing the root causes of HIV disparities remains unknown.

Discussion

Ending HIV by 2030 is a goal for the global community that cannot be achieved without prioritising equity in HIV prevention and treatment through public health communication strategies. Evidence from the past 40 years indicates that scientific innovation, research, funding, activism, and policies are all central components of HIV messaging. Regardless of decade or strategy, disparate rates of HIV incidence and prevalence in key populations underscore the need for health equity to be a prominent feature of communication strategies. Notably, the communication strategies described in this Review show progress, especially in later decades (eg, the Undetectable=Untransmittable campaign), towards integrating health equity. Despite this progress, inequalities by gender, race, geographical location, and economic status persist in HIV care cascade outcomes. Guidance on how to implement and incorporate equity in public health communication about HIV prevention and treatment remains largely unknown. On the basis of findings in this Review and of our experience in engaging with key populations in HIV prevention and treatment, we suggest five principles for prioritising health equity in communication about HIV prevention and treatment that can also be applied across the three primary strategic priorities put forth in the Global AIDS Strategy 2021–2026.⁷⁷

First, health communication must incorporate health as a human right.^7,78 An example of this guidance is establishing multisector communication approaches that incorporate the scientific and lived experience evidence about how behavioural, social–structural, and biomedical factors influence multiple care continuum outcomes (eg, ART access and mortality). This strategy would provide an opportunity for health communication to move beyond only providing information to advocating for system-level changes that promote wellbeing through opportunity as a function of society. Additionally, integrating communication strategies with HIV programming and research will draw attention to the need to develop equitable environments through economic development, housing stability, and capacity building.

Second, to see a sustained shift in social norms, equity has to be enacted through regional and national laws and policies, and this approach should be reflected in public health messaging. Legislation upholding LGBT legal rights and decriminalisation of sex work should be part of revised HIV criminalisation laws to reflect advances in HIV prevention and treatment, which have turned a once fatal diagnosis into a chronic condition.²² Similarly, HIV messaging should be transparent in identifying the metrics and anticipated reductions in disparities that would result from the campaign.

Third, messages should explicitly name HIV stigma and discrimination as causal agents of HIV inequalities. Messaging campaigns could be accompanied by anti-stigma and discrimination toolkits designed to change the perception of specific key populations most affected by HIV within a specific context.⁷⁰ These toolkits could educate on how HIV-related stigma is internalised, how it manifests itself in everyday interactions, and the negative effects of discriminatory behaviours.⁷⁹

Fourth, public health messaging should not only endeavour to educate and raise awareness but also include promoting clinical guidelines and policies that reduce stigma and dismantle power structures that sustain discriminatory environments. Use of messaging about HIV prevention and treatment to address the drivers of HIV-related stigmas represents a promising opportunity to shift social norms and practices towards health equity, while empowering people living with or most vulnerable to HIV.⁷⁹

Fifth, sustained and genuine participatory approaches are needed to engage HIV-affected communities throughout the process of developing and disseminating messages about HIV prevention and treatment. Communication about HIV prevention and treatment might have unintended consequences for marginalised groups and communities, including increased stigma and decreased uptake of prevention and treatment interventions. Participatory approaches might be beneficial for preventing these unintended consequences and are effective in addressing the social–structural drivers of health inequalities.^80,81 Community-based participatory research provides guidance on how to engage in an assets-based participatory approach to HIV-related research, programme development and evaluation, interdisciplinary and multisector partnership, and messaging.⁸¹ Use of these types of approaches has the potential to increase the cultural relevance and effectiveness of communication. Additionally, with increasing use of social media and advancing technology over recent years, more innovative and inclusive participatory strategies, like crowdsourcing, have been used to engage marginalised groups in message creation and dissemination.^82,83 To sustain non-stigmatising health promotive environments and systems, the centring of key populations in communication about HIV needs to empower, be authentic, promote global solidarity, and provide the necessary support for programmes to address HIV stigma and discrimination. One notable example of this kind of strategy is the International AIDS Society Conference’s Global Village and sessions to centre and involve key populations through the arts, presentations, sharing sessions, protected space, and reduced or free admission.

This Review underscores that communication about HIV prevention and treatment will need to highlight how systems and institutions of power contribute to inequalities. In the early years of the epidemic, HIV messaging campaigns missed opportunities to adopt a health equity framework to address various inequities (eg, racism, sexism, and classism) that probably contributed to HIV stigma and discrimination and that allowed HIV disparities to persist over four decades. Moving forward, it is imperative for messages about HIV to focus on inequitable social processes, and not individuals, as the drivers of the epidemic. The public health community has an opportunity to learn from the past 40 years of messaging about HIV prevention and treatment, which largely focused on providing information, convincing people to change their beliefs or behaviours, and facilitating social connections or support. The next decade must advocate for and support sustainable and equitable solutions that shift social and cultural norms, as well as social movements that restore collective efficacy and community capacitance.

Search strategy and selection criteria.

We collaborated with a public health librarian (KN) to tailor our search strategy to the research question, while balancing specificity and sensitivity. We searched MEDLINE All (including the in-process and PubMed-not-MEDLINE sets) on Jan 15, 2021, with no date limit or language restrictions, using both controlled vocabulary and text word searches of multiple indexes (including title, author keywords, journal names, publication type, and the Ovid multipurpose keyword field, which includes abstracts). We retrieved three sets of papers published between the date of inception and Dec 1, 2020. First, we retrieved 223 HIV messaging papers with a health equity focus. Second, we retrieved 613 review papers, guideline papers, and reflection papers about HIV messaging (regardless of whether they mentioned specific campaigns). Third, on the basis of a list of significant HIV campaigns and messaging efforts (compiled by TT, TDR, and YR), we retrieved 243 articles that mentioned known campaigns. There was some overlap between the sets; in total, we retrieved 1057 records from the searches. The complete 57-line search history is available in a public Open Science Framework project at https://osf.io/59sr3/. Additional references from seminal reviews and articles were also searched to ensure that important contributions were not excluded.