HIV Prevention Messages Targeting Young
Latino Immigrant MSM
Rosa Solorio,1,2,3Pamela Norton-Shelpuk,4Mark Forehand,5
Marcos Martinez,6and Joel Aguirre1,6
1Department of Health Services, School of Public Health, University of Washington, 4333 Brooklyn Avenue NE,
Box 359455, Seattle, WA 98195, USA
2Department of Global Health, School of Public Health, University of Washington, Seattle, WA 98104, USA
3Social and Behavioral Prevention Core, Center for AIDS Research, University of Washington, Seattle, WA 98104-2499, USA
4Activate Brands, Denver, CO 80202, USA
5Foster School of Business, University of Washington, Seattle, WA 98105, USA
6Entre Hermanos, Seattle, WA 98122, USA
Correspondence should be addressed to Rosa Solorio; firstname.lastname@example.org
Received 12 February 2014; Accepted 30 March 2014; Published 17 April 2014
Academic Editor: Glenda Gray
Copyright © 2014 Rosa Solorio et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Young Latino immigrant men who have sex with men (MSM) are at risk for HIV and for delayed diagnosis. A need exists to
raise awareness about HIV prevention in this population, including the benefits of timely HIV testing. This project was developed
through collaboration between University of WA researchers and Entre Hermanos, a community-based organization serving Lati-
nos. Building from a community-based participatory research approach, the researchers developed a campaign that was executed
byActivate Brands,basedinDenver, Colorado.The authors(a)describe thedevelopment ofHIVprevention messages throughthe
integration of previously collected formative data; (b) describe the process of translating these messages into PSAs, including the
application of a marketing strategy; (c) describe testing the PSAs within the Latino MSM community; and (c) determine a set of
important factors to consider when developing HIV prevention messages for young Latino MSM who do not identify as gay.
In the United States, Latinos are disproportionately affected
by HIV infection and have an HIV diagnosis rate that is
three times that of non-Latino Whites . Late diagnosis is a
significant public health problem among Latino immigrants
in the United States. In the USA, Latinos are more likely
than other racial/ethnic groups to receive an AIDS diagnosis
within one year of testing positive for HIV . Given that
unrecognized HIV infections are one of the driving forces
of ongoing HIV transmission among populations [3, 4],
increasing screening is of upmost importance. Additionally,
individuals who are infected with HIV but are unaware of
their status may be more infectious than those receiving
treatment because of high viral loads [5–7]. It has been
estimated that unrecognized infections account for as much
in the USA . To bring HIV transmission under control,
universal voluntary HIV testing and access to treatment have
been proposed as important strategies.
Improvements in late HIV diagnoses have been achieved
among USA-born populations, in the past decade .
However, there has been no corresponding change among
immigrantpopulations.In places like Washington State, over
70% of Latino immigrants continue to be diagnosed late
. Previous studies report that Latino immigrants with low
levels of English proficiency who have resided in the USA for
less than five years are at an elevated risk for delayed HIV
diagnosis[9, 10]. It is thereforeessential forSpanishlanguage
interventions to be developed to address the HIV prevention
needs of the Spanish speaking population. The Affordable
Hindawi Publishing Corporation
AIDS Research and Treatment
Volume 2014, Article ID 353092, 12 pages
2 AIDS Research and Treatment
of the benefits of timely HIV testing; in addition, several
states provide access to HIV treatment for undocumented
immigrants through the Ryan White HIV/AIDS Program.
A need for research exists to identify culturally specific
ways to communicate with Latino immigrant MSM and
address their HIV prevention needs, including the use of
social media marketing to more effectively communicate the
benefits from timely HIV testing. Social media marketing is
and techniques to the analysis, planning, execution, and
evaluation of programs and has been recognized as a way
to influence the voluntary behavior of audiences to improve
their personal welfare . Social media marketing programs
integrate four components of the “marketing mix” (or 4 P’s):
(1) product—the bundle of benefits that derive from the
behavior; (2) price—reducing the cost of the behavior; (3)
place—the location, time, and setting in which the behav-
ior occurs; and (4) promotion—informing and persuading
individuals of the net benefit of the behavior . Social
marketing programs go beyond education and attempt to
increase the attractiveness of the behaviors and reduce the
barriers to behavior adoption .
It has been proposed that to promote behavior change,
education programs should be based on at-risk popula-
tions’ beliefs, emotions, and perceived barriers concerning
HIV/AIDS and should be able to address such psychosocial
needs through systematic and strategic formative evaluation
processes [13–15]. This is especially important in the case of
HIV/AIDS, due to HIV-related fear which causes maladap-
tive reactions such as denial, fatalism, and avoidance [15, 16].
and beliefs about HIV testing, has been conducted by the
authors of the current study ; in the context of social
media marketing, such formative research is considered
audience research. This formative research found that 35%
of the Latino MSM had never undergone testing. Moreover,
compared to testers, nontesters were more likely not to
identify as gay, to have sex with both men and women
(MSMW), to have less knowledge about HIV risks, and to
perceive their sexual behaviors as less risky and to deflect
HIV-related stigma . Testers tended to be men who self-
identify as being gay. Both groups believed that fear of a
positive result was the main barrier to testing, and this
belief superseded all others. Both testers and nontesters also
reported negative attitudes from family members towards
would be interpreted by family members as a confirmation
of being gay and/or of being promiscuous. In addition,
both groups believed that having Latino staff at HIV testing
sites hinders confidentiality and both groups also expressed
concerns about the financial cost of HIV testing.
this formative research to develop HIV prevention messages
to promote timely HIV testing and then to translate these
messages into Public Service Announcements (PSAs) as part
of a social media marketing campaign that will target young
Latino MSM Spanish speakers. Although the target audience
will be MSM who do not identify as gay, the messaging will
use language that does not alienate MSM who do identify
as gay. Such an approach may allow both groups to benefit
from the developed messages for the social media marketing
campaign. In summary, this paper (a) describes the develop-
ment of HIV prevention messages through the integration
of previously collected formative data; (b) describes the
application of a marketing strategy; (c) describes testing the
a set of important factors to consider when developing HIV
prevention messages for young Latino MSM who do not
a future social marketing campaign to promote HIV testing
among young Latino immigrant MSM.
To date, no social media marketing programs have
targeted young Latino immigrant MSM Spanish speakers
(of age 18–25) who do not identify as being gay with HIV
prevention messages in the USA. A recent Cochrane analysis
in developed countries identified only three such programs
. However, none of the aforementioned studies were
a randomized control trial. The authors recommend that
future social media marketing campaigns use more rigorous
designs in evaluating social media marketing interventions,
measure their long-term impact, and identify intervention
components that are most effective in reaching the target
population and changing behaviors. The CDC has recently
created a campaign that promotes HIV testing (http://
Latino gay and bisexual men that there are many reasons
for getting an HIV test and that everyone can play a role
in stopping the spread of HIV; this campaign’s outcomes are
currently under evaluation.
This project was developed through collaboration between
University of WA researchers and Entre Hermanos, a
community-based organization serving the Latino lesbian,
gay, bisexual, and transgender (LGBT) communityin Seattle,
WA. We used a community-based participatory research
(CBPR) approach  in conducting this research; this
involved the development of a genuine partnership between
the University of WA researchers and Entre Hermanos,
capacity building of community members in research, apply-
ing findings to benefit all partners, and long-term part-
nership commitments. Building from this CBPR approach,
the researchers developed a campaign that was executed
by Activate Brands, based in Denver, Colorado. We now
the preliminary formative research, describe the process of
describe importantfactors to consider when developing HIV
prevention messages for young Latino MSM.
2.1. Phase One: Development of HIV Prevention Messages
through the Integration of Previously Collected Formative
AIDS Research and Treatment3
Figure 1: Conceptual model of constructs influencing intentions to undergo HIV testing (adapted from the integrated model of behavior;
board script was developed to promote HIV testing. We used
the integrated model of behavior (IMB; Figure 1); [20–25] as
a framework in developing HIV prevention messages for the
storyboard script that address young Latino MSM Spanish
speakers attitudes, beliefs, norms, and self-efficacy towards
HIV testing; the messages developed reframed negative
attitudes and beliefs with positive ones. The ultimate goal of
The formative research  identified important areas
to address in the HIV prevention messages. The messages
were developed for young Latino immigrant MSM who do
not identify as gay (i.e., market segment). Important areas to
address were these young men’s beliefs and attitudes about
HIV risk, perceptions of sexual risk behaviors (i.e., tended to
(i.e., belief that HIV testing is only for promiscuous men or
gay men) as well as their self-efficacy towards HIV testing
(i.e., fear of undergoing testing because results might be
positive, fear of going to an HIV testing site alone without
any social support, and fear that their family members might
think that they are gay or promiscuous for seeking testing).
The newly developed messages were focused to promote
HIV testing. Table 1 describes the messages used in story-
board script, the rationale for reframing negatives attitudes,
beliefs, norms, and self-efficacy with positive ones, and the
IMB domain addressed. We systematically countered each
of the most prevalent negative perceptions regarding HIV
testing. The benefits of timely HIV testing (i.e., individuals
is best to defer HIV testing due to the fear of testing positive,
we focused on the fact that the majority of Latino MSM
who undergo HIV testing will test negative. To counter the
perception that a positive result means imminent death, we
reframed this belief by positioning HIV as a chronic disease
for which treatment exists and with which a person could
potentially live a normal lifespan. To counter the denial of
risk for HIV, we focused on the fact that MSM sometimes
have unprotected sex and therefore, in fact, are at risk. To
counter issues of self-efficacy (i.e., men fearing being judged
by family members simply for seeking testing) we countered
that the men’s health takes priority over the concerns of
other people; to further enhance feelings of self-efficacy, we
promoted getting social support from a trusted friend who
emphasized that the CDC has recommended HIV testing for
all people, including men and women .
ryboard script was tested with ten focus groups (푁 = 61).
of yielding information about MSM community norms with
regard to HIV testing. Latino MSM were recruited from
Entre Hermanos and through flyers posted at community
sites. Latino MSM community members were hired and
trained to recruit and facilitate focus groups and assist with
the interpretation of the qualitative data obtained. Facili-
tators for each group all had previous experience working
with Latino MSM. Written informed consent was obtained
from all participants. Focus groups lasted 90 minutes in
length. Each focus group was audiotaped and transcribed,
and all identifying information was removed from the final
transcript. Each focus group participant was paid $25 for
their participation. Entre Hermanos permitted project staff
to conduct the focus groups with clients of their organization
on site, in a private room. The University of WA Institutional
Review Board approved this study.
Eligible individuals were biologically male, of His-
panic/Latino descent, between the ages of 18 and 40 years
(with an average age of 25), Spanish speaking (monolingual),
and reporting a history of having sex with men in the past 12
or under the influence of drugs or alcohol at the time of
screening were excluded from study participation.
We used a grounded theory approach with open coding
to generate reactions to messages according to participant’s
experiences and perspectives . We used an iterative pro-
cess of questioning, analysis, and verification until saturation
was reached. A process of comparison between focus group
collection ceased when “saturation was reached” (themes
being repeated in successive focus group comments). After
2.1.1. Storyboard Script Testing with Focus Groups. The sto-
This approach allowed participantsto have discussions about
the HIV prevention messages with each other with the goal
4 AIDS Research and Treatment
Table 1: Reframing negative HIV testing attitudes, beliefs, and norms with positive ones.
Messages in storyboard script
Rationale for reframing negative beliefs, attitudes, and
norms with positive ones.
Young MSM need help in prioritizing their health over
the concerns of other people when contemplating HIV
This is the likely outcome for most young Latino MSM
testing for HIV and knowing this may deter them from
further delaying testing.
Many MSM are fatalistic and consider that a positive
result means that they are going to die very soon. This
statement contradicts that common belief.
Many Latino MSM are in denial about being at risk for
HIV; however, they need to understand that if they did
have unprotected sex, then they do need to get HIV
MSM need to know that they are better off knowing
their HIV status. They fear that family members and
friends will consider them promiscuous for seeking
Integrated model of behavior
Testing is beneficial for me. My life matters
I tested for HIV and my results are negative.
Positive belief about behavior
HIV is a chronic illness that can be treated
Countering negative beliefs
I did not think that I was at risk for HIV and
therefore did not think that there was a need
for testing; however, there were times when I
had not used protection (condoms).
What will my family say? What will my
friends say? My health is on the line and I
need to know my status.
Countering negative beliefs
My friend, Carlos, helped me out. He
accompanied me to the HIV testing site.
He calmed me down while I awaited my
Men need peer social support when seeking HIV
testing (i.e., to reduce stress and fear).
HIV testing is available at many places,
including medical clinics, emergency room,
hospitals, community-based organizations,
and HIV testing centers funded by public
Latino MSM have confidentiality concerns about Latino
staff at HIV testing centers (they fear that staff will
spread rumors about them for seeking testing); thus,
informing them of the multiple places one can go for
testing may increase their likelihood of identifying a
place where they may be more comfortable seeking
testing. We plan to promote multiple HIV testing sites,
including Entre Hermanos, Gay City, and other sites
that offer free
I test for HIV every 6 months.
The CDC recommends that everyone, man
or woman, of age 13–64 years, receive an
HIV test. Persons who remain at risk,
including men who have sex with men, are
advised to undergo HIV testing at least
I recommend HIV testing to all of my
friends. It is important to protect not just our
own health but also that of our community.
This statement targets everyone but ends by focusing
specifically on young Latino MSM. The MSM
recommended that everyone be targeted for HIV
testing; they do not want only MSM to be targeted,
especially because they are not the only ones at risk.
Latino MSM tend to express
the 10 focus groups, the participants no longer had any
new information to add to enhance the messages and all
participants considered the final messages developed to be
2.1.2. Selection of a Communications/Marketing Partner. At
the end of phase one, plans were made to select a marketing
firm to assist in the translation of developed HIV prevention
messages into public service announcements (PSAs) for a
media campaign to promote HIV testing. A search for local
and national marketing firms with experience working with
the Latino Spanish speaking populations was undertaken.
Three firms were identified and their experience working
with Latinos and proposed budgets were evaluated. Activate
Communications, a firm based in Denver, Colorado, was
2.2. Phase Two: Translation of HIV Prevention Messages
into Public Service Announcements (PSAs). Activate focuses
on interactive campaigns that help organizations formulate
and convey messages that explain the purpose behind their
brands. Using their proprietary “mood marketing tool”
(Figure 2) they create messages that produce positive change
in individuals as well as the community in which they reside.
Activate leveraged insights gathered from the previously
collected formative data  in developing concepts for
AIDS Research and Treatment5
Get out the tissue
Love and loss
Looking for love
Figure 2: Activate Mood Marketing Chart—Project Pepe.
the campaign. The formative data provided a format for
Activate to tap into the mood sentiment of young Latino
MSM who may not identify as being gay. The insights
gathered and the mood sentiment of these men led to the
development of a character that evokes the same emotion
they are experiencing towards their identity.
The character “Pepe” formed from the Mood Marketing
tool findings, social media outreach, and focus group testing;
all of these identified key aspects based on mood that
addressed why Latino immigrant MSM do not seek HIV
testing in a timely manner. The model for the Pepe campaign
who will help them receive access to confidential HIV testing
ultimate goal when this campaign is launched is for the com-
munity to see Pepe as an advocate who can provide positive
of life using culturally competent information in Spanish.
The focus of the campaign is to increase the number of
generated by these messages; we plan to present such moods
through social and mobile media to increase participation
and interest among young Latino MSM.
created that focused on four central themes: community,
empowerment, private life, and humor. The intent of these
developed messages was to help reduce cultural barriers to
testing and to encourage safe sex practices. The formative
research thus was used as a platform to create a culturally
relate to. Three PSAs had a male voice and one had a female
The resulting PSAs incorporated elements of each of
the marketing mix components (the 4P’s—product, price,
place, and promotion) to promote HIV testing. The for-
mative research provided a clear understanding of young
Latino men’s fears, concerns, and moods with regard to
HIV testing. We incorporated a marketing mix of the 4 P’s
to reduce the barriers (e.g., price) to HIV testing [28, 29];
Table 2 describes the marketing approach. The main barriers
previously identified included fear of testing HIV-positive
and associated stigma, lack of perceived benefit, cultural
factors, confidentiality concerns, and financial barriers .
by focusing on reducing the barriers and promoting the
benefits of testing (Table 2). The overall intervention (i.e., the
health and social services with an intent to keep testing as
anonymous as possible (i.e., place). This overall message was
then promoted through the use of peer models in the PSAs
The peer model promotes testing at multiple HIV testing
sites (i.e., place), including medical and nonmedical sites
and those within and outside of Latino communities. This
approach will allow men to choose a site that meets their
needs (i.e., this will reduce fears with regard to confi-
dentiality). In addition, some MSM fear being judged by
family/friends simply for seeking HIV testing (i.e., they fear
being labeled as promiscuous).These concerns are addressed
by focusing on the importance of MSM’s health over the
concerns of other people. Since the Latino men expressed
financial concerns about HIV testing, the developed mes-
sages promote free HIV testing at HIV testing sites.
we conducted four focus groups (푛 = 15) with Latino MSM
used an iterative process of questioning, analysis, and verifi-
cation until saturation was reached. A process of comparison
reached” (themes being repeated in successive focus group
campaign elements including photos, emoticons, logos, the
focus groups were digitally recorded, transcribed verbatim,
and imported into ATLAS.ti . All data were deidentified
to protect confidentiality. Eligibility criteria, recruitment
process, and data analysis mirrored those of the initial focus
groups, outlined above, the only exception being that the age
group for the PSA testing was 18–25 years.
To assess the content of the PSAs, we assessed mes-
sage comprehension, perceived impact of messaging, and
perceived impact on attitude strength. In addition, evalua-
tion questions measured pre- and post-quantified outcomes,
including using a 10-point scale for intentions to undergo
HIV testing in the next 3 months and IMB domain assess-
ments, including attitudes, beliefs, norms, and self-efficacy
towards HIV testing (see Supplementary Material available
online at http://dx.doi.org/10.1155/2014/353092).
targeted young MSM, of age 18–25, for PSA testing. We again
2.4. Phase Four: Dissemination of HIV Prevention Messages.
The PSAs were created for a mass media campaign that will
involve radio PSAs, a campaign website (http://tuamigopepe
.com/), social media outreach and a campaign awareness,
and reminder system using mobile technology and print
6 AIDS Research and Treatment
Table 2: Application of marketing principles: the 4P’s (product, place, price, and promotion).
The product is the intervention itself which promotes Latino men’s sexual health and offers HIV testing in an accepting
environment that provides social support and linkages to needed health services
Multiple HIV testing sites are promoted within and outside of Latino communities and these sites include medical and
nonmedical sites (i.e., local health care facilities, Gay City, and hospitals); this way MSM may identify HIV testing sites that
meet their needs
We used a marketing mix of the 4P’s to reduce the “price” of HIV testing (i.e., reduced the barriers to testing)
The peer model promotes the desired behavior (i.e., HIV testing)
15, 2014, and April 15, 2014. The PSAs are also incorporated
into campaign website. Evaluation of the media campaign is
3.1. Participant Characteristics. A total of 66 Latino immi-
grant men participated in the two sets of focus groups. Both
country. For phase one focus groups, the age ranged from 18
to 40 years with a media age of 25 years and over 60% of
the men reported a history of HIV testing; for phase three
focus groups, the age ranged from 18 to 25 years and 80%
had never been tested for HIV and, among the 20% who had
been tested, the testing had taken place more than 12 months
ago. All participants were monolingual Spanish speakers.
annual incomes below $20,000. Most of the participants had
resided in the USA for less than 5 years and had less than a
high school education. Although the majority of MSM (over
70%) self-identified as gay, several explained that their self-
are with (i.e., they may identify as gay when in the presence
of other gay friends but not when in the presence of family
members). All participants were residents of King County,
3.2. Final PSAs. The final PSAS developed were in Spanish
language (translated into English below). The PSAs focused
on four central themes: community, empowerment, private
life, and humor. Out of 8 PSAs developed (using two voices
foreach one),fourwere selected asbeing thebest onesby the
focus groups. The finalized PSAs are presented below.
Community. Hi, my name is Julia, and I am
dedicated to provide care and support to the men
in the community of King County who are seeking
a private, very rapid, and confidential option
to take a free HIV test. It is for them that we
have created Pepe, through which by just texting
CONOCEAPEPE to 99000, you will receive in
the privacy of your phone the information you
need to take that important step. Come on, we are
waiting for you—and remember that for Latino
young men, 90% of the time their results are good
atenci´ on y apoyo a los hombres de la comu-
nidad de King County que buscan una opci´ on
privada, muy r´ apida y confidencial para hacerse
una prueba gratuita del VIH. Es para ellos que
hemos creado a Pepe con el cual, a trav´ es de
tan s´ olo enviar el mensaje CONOCEAPEPE al
99000, recibir´ as en la privacidad de tu tel´ efono,
la informaci´ on que necesitas para dar ese impor-
tante pas´ o. Ac´ ercate, te esperamos—y recuerda
que para los hombres latinos j´ ovenes, el 90% de
las veces sus VIH resultados son buenas noticias.
Y t´ u, ¿ya conociste a Pepe? Averigua m´ as en
The preliminary research identified that Latino men
wanted “to be invited” to come in for testing and wanted
information about sites that offered free HIV testing. There-
fore, we developed the messages to be inviting and each was
services. In previous focus groups, the men had said:
instilling them with fear and without the use of
The peer model needs to invite others to undergo
People need to be invited for testing without
strange words...I’ve heard programs on the radio
say, undergo testing and you might live a better
that promote HIV testing and they say to undergo
testing before it’s too late but instead, they should
Due to the preliminary research indicating that the main
barrier to HIV testing is being fear of a positive result, we
considered it important to emphasize to participants that in
since this is consistent with the current epidemiology of HIV
groups, the participants particularly liked the statement,
“...over 90% of young Latinos who test for HIV will test
fact that such a task could be done anonymously.
negative.” Participants also liked the recommendation to go
to the campaign website for additional information and the
Empowerment. I consider myself a man sure of
what I am, what I feel and want. I take my health
and well-being seriously. That’s why I like talking
about the importance of getting tested for HIV.
AIDS Research and Treatment7
Thanks to Pepe, I took the test with total privacy,
confidentiality, and for free. I got the results in
only 20 minutes and with service in Spanish.
Now I feel even more confident. And you can too.
Just think that to have fear does not help...but
you, have you met Pepe? Text CONOCEAPEPE
(MEETPEPE) to 99000 and you too, get tested.
to have courage does. Besides, for Latino young
men, 90% of the time results are good news. And
que siento y quiero. Yo me tomo en serio mi salud
y bienestar. Por eso, me gusta hablar de la impor-
tancia de hacerse la prueba del VIH. Gracias a
Pepe, me hice la prueba con total privacidad,
confidencialidad y de manera gratuita. Tuve los
resultados en s´ olo 20 minutos, y adem´ as me
atendieron en espa˜ nol. Ahora me siento todav´ ıa
m´ as seguro. Y t´ u tambi´ en puedes. S´ olo piensa que
tener miedo, no ayuda...pero tener valor, s´ ı.
Adem´ as, para los hombres latinos j´ ovenes, el
90% de las veces los VIH resultados son buenas
Y t´ u, ¿ya conociste a Pepe? Env´ ıa el mensaje
CONOCEAPEPE al 99000 y t´ u tambi´ en hazte la
The focus group participants considered it important to
important to Latino men and thus the men recommended
that messages should increase awareness about multiple
places for HIV testing that offered confidential services.
The original script contained the statement, “I am proud
noting that not all Latino MSM self-identify as gay—and
among those who do, not all are “proud” to be gay. They
therefore felt that some MSM would not relate to this type
of message. This stimulated a lively discussion about the
statement “I am proud to be gay” among young Latino
MSM. Most men felt that being gay is no longer a negative
stereotype, as we now live in a more open-minded society:
who are gay...they may go to gay bars together,
Participants felt that, previously, more Latino men hid the
fact that they were gay, but now many more social networks
exist for gay men, and it was easier for gay men to find
other gay men like themselves. The men said that nowadays
there is increasing recognition about the wide spectrum of
self-identification among MSM, with some identifying as
gay and others as bisexual, transgender, or heterosexual. In
general, the men perceived that young people are growing
negate the fact that stigma remains associated with being an
“Someone may not be gay but they have friends
they live with gays.”
MSM and the men especially perceive a lack of acceptance
from family members:
Perhaps, some young Latino MSM want to be
like the messenger, open about being gay, but they
cannot because of what their family might say.
We [gays] perceive that family will reject us if we
come out, and even though we may identify with
being gay, we still feel lost and feel that we do
not belong anywhere. The issue is not just coming
out of the closet but how you identify yourself.
treat us if they find out, we prefer to not even
investigate the sexual identify inside ourselves.
The men also thought that if a young man is currently
“living in the closet,” the message about admitting that he is
gay might make him feel uncomfortable. The men expressed
a concern that the messenger sounded overly confident in
being gay and that men who did not feel secure about their
sexual orientation may not identify with him and therefore
may not absorb the rest of the message and may not text into
the campaign website to obtain more information.
Some participants felt that even if some young Latino
this in public. According to participants, many men who
identify as gay feel as if they live in two separate worlds: one
with other gay men, in which they feel free, and another with
family, in which they have to hide a portion of their identity.
A minority of men expressed the opinion that some young
Latino MSM who identify as gay may feel supported by a
message asserting “I am gay” because this message indicates
that he knows who he is, is comfortable with his identity, and
therefore got tested for HIV.
In general, the men wanted the message to be more
personable and for the tone to sound less “pushy” (i.e.,
to not tell them how to self-identify or how to feel). The
men liked hearing about the importance of being strong
and overcoming fear of testing. In the final iteration of the
message, the statement about being proud and being gay
was removed based on participant feedback. This was done
not identify as gay while still resonating with MSM who do
not identify as gay.
Private Life. I am one of those who keep things to
I prefer to do with my life. But there is something
that I find important, and that is to know what
happens with my body and my health. So I was
glad to know that I could get tested for HIV with
complete confidentiality, for free, and with service
in Spanish. Thanks to Pepe, I visited the X clinic
and in only 20 minutes I had the results in my
hands. And here is where the results will stay.
male Latinos we have something in our favor and
that is that 90% of the time, our results is good
8 AIDS Research and Treatment
news. Not everyone has to but you should know
it. And you, have you met Pepe? Text right now
CONOCEAPEPE (MEETPEPE) to 99000.
Yo soy de esos que se guardan las cosas. Al final,
no todo el mundo entiende lo que prefiero hacer
con mi vida. Pero hay algo que s´ ı encuentro
y mi salud. Por eso, me alegr´ o saber que pod´ ıa
hacerme la prueba del VIH con total confiden-
cialidad, de manera gratuita, y con atenci´ on en
espa˜ nol. Gracias a Pepe, visit´ e la cl´ ınica X y en
s´ olo 20 minutos tuve los resultados en mis manos.
Y aqu´ ı se quedan. An´ ımate t´ u tambi´ en—adem´ as,
favor y es que el 90% de las veces, nuestros
resultados son buenas noticias. No todos tienen
que saberlo pero t´ u s´ ı debes saberlo. Y t´ u, ¿ya
conociste a Pepe? Env´ ıa ahora mismo el mensaje
CONOCEAPEPE al 99000.
Most participants stated that they preferred to keep their
sexual orientation to themselves. Several reported that their
friends did not know that they were having sex with other
men and that they would not understand their behavior.
Many young Latino men expressed how difficult it was to
“come out” to friends and family about being gay and this
message was developed to reflect that.
When we tested this message with focus group, the
participants liked the story and felt that the message had
authenticity. The men especially liked that the messenger did
not have a perfect attitude (i.e., his voice sounded shaky and
timid and slightly depressed in the first half of the message
but then as he asserts that he cares about his health, his tone
changes to be more lively and confident) and that he was not
perfect in general, making him “more real” and easier for
other young Latino MSM to relate to him. Participants felt
that Latino men will identify with this message. They liked
was particularly authentic in its portrayal of a young Latino
man just “coming out”:
the only one who feels this way...there are other
way as I do [i.e., depressed].
[This message] makes you think, oh, I am not
people who have the same questions that I have
[i.e., about their sexuality] or who feel the same
The participants felt that this authenticity may influence
other Latino men to identify with the message. Furthermore,
the men appreciated that the messenger cared about his
health and liked his message about where to go to get tested
and the importance of knowing one’s HIV status
Participants were asked, “What could cause you to be
that if the message focused more on respecting one’s body
they might be more inclined to follow the messenger’s
advice. The men recommended removing the words from
the original message, “nobody should care about what I do”
(stated in reference to sexual behaviors), because they felt
such words have negative implications and are not consistent
with the outlook of young Latino MSM (the participants said
that young Latino MSM do care about what others think and
that they do need social support). The men recommended
that the messages should focus more on that fact that the
messenger underwent testing because his health matters to
him. The men also wanted the message to promote the idea
that those who undergo HIV testing are strong and felt that
the message should emphasize that the messenger does not
feel ashamed for undergoing HIV testing.
One man commented on the timid and shaky tone of
the message, stating that not all Latino men are timid and
wondering if this would promote untrue stereotypes about
Latino MSM. However, the majority of men disagreed and
with regard to their sexual orientation and therefore it would
be a good idea to have many different types of messages to
reach a broader audience.
Plus, you get the results in only 20 minutes. And
speaking of results, 90% of the time they are good
Humor. In the closet, out of the closet, who cares
right now and discover that taking a free HIV
test is easier and more private than you think.
news for Latino young men. Thank you Pepe...it’s
good you came into my life, friend. Find out more
Plus, you get the results in only 20 minutes. And
speaking of results, most of the time they are good
news for Latino young men. Thanks, Pepe...it’s
CONOCEAPEPE (MEETPEPE) to 99000 right
importaelcl´ oset...Env´ ıaahoramismoelmensaje
good you came into my life, friend. Find out more
at TuAmigoPepe.com. Have you met Pepe? Text
Dentro del cl´ oset, fuera del cl´ oset, a qui´ en le
unapruebagratuitadelVIHesm´ asf´ acilyprivado
de lo que te imaginas. Gracias, Pepe...qu´ e bueno
que llegaste a mi vida, amigo.. Averigua m´ as en
Pssss...¿ya conociste a Pepe? Env´ ıa ahora mismo
f´ acil y privado de lo que te imaginas. Adem´ as,
obtienes los resultados en s´ olo 20 minutos. Y
el mensaje TUAMIGOPEPE al 99000 y descubre
que hacerte una prueba gratuita del VIH es m´ as
hablando de resultados...la mayor´ ıa de las veces
son buenas noticias para los hombres latinos
j´ ovenes. Gracias, Pepe...qu´ e bueno que lle-
gaste a mi vida, amigo.. Averigua m´ as enTu-
AIDS Research and Treatment9
¿Ya conociste a Pepe? Env´ ıa ahora mismo el
mensaje CONOCEAPEPE al 99000.
Many participants had previously expressed that they
were still living “in the closet” and that their family members
Therefore this message was developed to be inclusive of all
men, whether they are “in the closet” or “out of the closet.”
When we tested this message with focus groups, the
men felt positive about this message and found it easy to
relate to, funny, friendly, and effective. Participants perceived
that many young Latino MSM would identify with this
message. The men considered this message inclusive of all
men, regardless of self-identification of sexual orientation:
“It does not matter at what phase you are in, in
is to be tested and to meet Pepe.”
The men liked how the message was inclusive of persons
“in the closet” or “out of the closet” and felt that message
targeted all MSM, regardless of whether they identified as
being gay. The men believed that such an inclusive message
would have a great impact on young Latino MSM.
While the majority of participants felt that all listeners to
this message would know what “closet” refers to, one man
wondered if young Latino MSM would understand the use
of this word:
what it means to be gay; but if a young man is
confused and is not at a point in their life where
they want to find out about themselves, they may
are part of the gay community, after several years,
you begin to understand this term (i.e., closet).
it may be hard to understand this term.
the way the story was structured. The men stated that this
message was one that they wanted to keep hearing:
“This young man is part of our circle. He sounds
way we would speak.”
the closet...under the closet” and the men recommended
All of these final PSAs were deemed effective at pro-
moting HIV testing by the focus groups. The majority of
participants reported having intentions towards HIV testing
in the next 3 months after hearing the PSAs. Using quan-
titative surveys to assess the domains from the IBM (i.e.,
beliefs, attitudes, norms, and self-efficacy), a general trend
was observed among the focus group participants towards
more positive attitudes, beliefs, norms, and self-efficacy.
The original message included words like “On top of
removing those words because they felt that the message
would be better stated in a simpler form.
3.2.1. Campaign Components
male voices and the participants selected the ones they liked
best. One message with a female voice and three messages
with male voices were selected out of 8 messages tested.
The female voice of Julia in the “Community” PSA was
selected because her voice sounded natural and friendly. Her
voice reminded participants of a community counselor. The
and recommended changing it; this voice was removed from
(2) Empowerment PSA Voice. Focus group participants also
described concerns with the voice in the “Empowerment”
in order to call attention from young Latino men about his
message. Their recommendations were followed in the final
(3) Private Life PSA Voice. In the “Private Life” PSA, the men
felt that the timidity and shakiness of the messenger’s voice
conferred authenticity to his message.
(4) Humor PSA Voice. The men liked the enthusiasm and the
youthfulness of the messenger’s voice in the “Humor” PSA.
Images. The men were shown nine photographs of young
Latino men. They were asked to pick the ones that they
thought would best promote HIV testing. A photograph of
two men hugging was the most preferred by the largest
proportion of participants. This photo represented warmth,
caring, social support, and trust. Other images that the
men liked included a photo of a young construction worker
because it depicted an ordinary young working-class man
and his face was easily recognized as Latino. Some men felt
that the construction worker’s face might invite a broader
audience (i.e., not just those who identify as being gay,
as some participants believed that the photo of two men
together implied that self-identification):
the photo of the construction worker could be of a
man who is gay or straight...he could be in or out
Emoticons. Various emoticons were also tested with the
focus groups. The preferred emoticon depicted a cell phone
image with a smiling face. None of the participants liked
the emoticons with mustaches and the group recommended
of the closet...he might have children.
10 AIDS Research and Treatment
removing those; the men said that they could not identify
with the mustache because it made the emoticon look older
than 25 years.
Logos. Various logos were tested with focus groups. The men
recommended that if the emoticon smiles then the campaign
logo should not smile.
Pepe’s Image and Name. The majority of participants sup-
ported the idea of including Pepe as a fictitious character.
one that looked more like a real man rather than an image
that was just made up. The participants like the name Pepe
because itisatraditionalLatinonameandeasyto remember.
The name Pepe is a play on words on the letter “P” (in
would be pronounced Pepe). We are using the name Pepe as
a code name for two Spanish words that begin with the letter
“P”, privacy and prevention (privacidad y prevencion).
Call to Action. The men approved of the call to action,“Text
CONOCEAPEPE” (Spanish for “Meet Pepe”).
Colors. Participants were shown photographs with various
background colors (potential formats for campaign poster
and website). The most popular formats were those with
red, blue, and green in the background. One man strongly
that one identified with being gay, and said that he would
be embarrassed to open a web page with such color. The
preferred color was blue. Most men approved of the use of
the color red and felt that this color is appreciated among
Latino culture because if reflects life and passion, but some
men argued against its use in an HIV campaign, stating that
although they like the color red, they did not think it was
appropriate for an HIV-related campaign (i.e., it might make
some think of danger or blood).
We developed HIV prevention messages that resonated
strongly with young Latino MSM. Our approach was
grounded in the integrated model of behavior [20–25] and
capitalized on a customized program that uses marketing
principles to reduce the barriers to HIV testing [28, 29]. The
HIV prevention messages developed (i.e., PSAs), targeting
Latino MSM key attitudes, beliefs, and norms toward HIV
testing, have the potential to influence these men’s intentions
and HIV testing behavior. To promote HIV testing, messages
focused on addressing the barriers (i.e., price) to testing by
reducing fear and stigma and addressing cultural factors.
In collaboration with Activate, four PSAs were developed
that were culturally tailored for Latino immigrant MSM
Spanish speakers and these focused on four central themes
(i.e., community, empowerment, private life, and humor) to
reduce fear and stigma related to HIV testing.
The preliminary formative research identified the costs
associated with HIV testing (price); identified the most
salient benefits of testing from the audience’s perspective
and used these benefits in the development of marketing
offers (product); and identified channels for product delivery
(place). Marketing segmentation is a marketing strategy
that involves dividing a broad target market into subsets
of consumers who have common needs and priorities. By
using attributes of the target audience such as demographics,
behaviors, beliefs/attitudes, segments (smaller, more homo-
Latino MSM who do not identify as gay); such an approach
will influence the final social marketing program design and
outcome. Finally, the product will be delivered (promotion)
to these segments through selected channels (e.g., mass
media, including radio PSAs, campaign website, and social
The feedback from the focus groups on the development
provides promising preliminary data for the development of
a mass media campaign to target Latino MSM with HIV
of theoretically based HIV prevention messages for Latino
MSM that may be used in social marketing campaigns to
there are limitations in the current study that need to be
discussed. First, the participants in this study tended to be
monolingual Spanish speakers of Mexican descent and the
majority had lived in the USA for less than 5 years; thus,
the findings presented here are from a group that appears to
have low levels of acculturation to US culture. Second while
the majority of the sample identified as being gay, many men
explained that such self-identification varies by the type of
group that they are with, with some only identifying as gay
when in the presence of other gay friends but not when in
the presence of family members. Thus, since the sample was
recruited from Entre Hermanos, a community-based agency
possible that many of the men who self-identified as being
gay may not do so at other places. Additionally, it is also
may not be comfortable seeking services at Entre Hermanos.
Thus, the type of men who are represented here may be a
group that is somewhere in the middle of the continuum of
self-identification with being gay. Current studies describe
various methodologies used in recruiting MSM who do not
cies, as done in our study, and snowball sampling [32–34].
Previous studies report that Latino immigrant MSM are
less likely to identify as being gay compared to Latino US-
Latino ancestries . Thus, future campaigns that target
Latino immigrant MSM of Mexican descent need to take
that target MSM who do not identify as gay; considering
that self-identification may be a continuum and such self-
identification may change over time, it would be important
for such campaigns to not alienate MSM who do not identify
AIDS Research and Treatment 11
interventions targeting young Latino MSM who do not
identify as gay. The next step of this research will involve
the incorporation of the developed PSAs into a mass media
radio PSAs, a campaign website (http://tuamigopepe.com/),
social media outreach, campaign awareness, and reminder
system using mobile technology and print materials. Once
these PSAs are tested in a pilot social marketing campaign
and shown to be effective at promoting HIV testing, they
may ultimately be used in radio, television, and social media
websites to promote HIV testing among young Latino MSM.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
This research was funded by NIMH R34 MH098740 (PI
Solorio, Rosa; Co-Is Holmes, King; Forehand, Mark; Mar-
 MMWR, “HIV/AIDS among hispanics—United States, 2001–
2005,” Morbidity and Mortality Weekly Report, vol. 56, no. 40,
pp. 1052–1057, 2007.
 N. E. Chen, J. E. Gallant, and K. R. Page, “A systematic review
of HIV/AIDS survival and delayed diagnosis among Hispanics
vol. 14, no. 1, pp. 65–81, 2012.
 H. F. Raymond, T. Bingham, and W. McFarland, “Locating
unrecognized HIV infections among men who have sex with
men: San Francisco and Los Angeles,” AIDS Education and
Prevention, vol. 20, no. 5, pp. 408–419, 2008.
 G. Marks, N. Crepaz, and R. S. Janssen, “Estimating sexual
 R. H. Gray, M. J. Wawer, R. Brookmeyer et al., “Probability of
HIV-1 transmission per coital act in monogamous, heterosex-
ual, HIV-1-discordant couples in Rakai, Uganda,” The Lancet,
vol. 357, no. 9263, pp. 1149–1153, 2001.
 S. Mannheimer, G. Friedland, J. Matts, C. Child, and M. Ches-
dicts biologic outcomes for human immunodeficiency virus-
infected persons in clinical trials,” Clinical Infectious Diseases,
vol. 34, no. 8, pp. 1115–1121, 2002.
 T. C. Porco, J. N. Martin, K. A. Page-Shafer et al., “Decline
in HIV infectivity following the introduction of highly active
antiretroviral therapy,” AIDS, vol. 18, no. 1, pp. 81–88, 2004.
 L. Saganic, J. Carr, M. R. Solorio, M. Courogen, T. Jaenicke,
and A. Duerr, “Comparing measures of late HIV diagnosis in
Washington state,” AIDS Research and Treatment, vol. 2012,
Article ID 182672, 8 pages, 2012.
 A. R. Wohl, J. Tejero, and D. M. Frye, “Factors associated
with late HIV testing for Latinos diagnosed with AIDS in Los
Angeles,” AIDS Care—Psychological and Socio-Medical Aspects
of AIDS/HIV, vol. 21, no. 9, pp. 1203–1210, 2009.
 V. Levy, D. Prentiss, G. Balmas et al., “Factors in the delayed
HIV presentation of immigrants in Northern California: impli-
cations for voluntary counseling and testing programs,” Journal
of Immigrant and Minority Health, vol. 9, no. 1, pp. 49–54, 2007.
 A. Andreasen, Marketing Social Change: Changing Behavior
to Promote Health, Social Development and the Environment,
Jossey-Bass, San Francisco, Calif, USA, 1995.
 E. W. Maibach, M. L. Rothchild, and W. D. Novelli, “Social
marketing,”inHealthBehavior and HealthEducation,K.Glanz,
Francisco, Calif, USA, 3rd edition, 2002.
 C. K. Atkin and V. Freimuth, “Formative evaluation research in
campaign design,” in Public Communication Campaigns, R. E.
Rice and C. K. Atkin, Eds., pp. 131–150, Sage, Newbury Park,
Calif, USA, 1989.
the Quality of Life, Sage, Newbury Park, Calif, USA, 2002.
 H. Cho and K. Witte, “Managing fear in public health cam-
paigns: a theory-based formative evaluation process,” Health
Promotion Practice, vol. 6, no. 4, pp. 482–490, 2005.
 K. Witte, “Putting the fear back into fear appeals: the extended
parallel process model,” Communications Monographs, vol. 59,
no. 4, pp. 329–349, 1992.
 M. R. Solorio, M. Forehand, and J. Simoni, “Attitudes towards
and beliefs about HIV testing among Latino immigrant MSM:
a comparison of testers and nontesters,” AIDS Research and
Treatment, vol. 2013, Article ID 563537, 10 pages, 2013.
 C. Wei, A. Herrick, H. F. Raymond, A. Anglemyer, A. Gerbase,
and S. M. Noar, “Social marketing interventions to increase
HIV/STI testing uptake among men who have sex with men
Systematic Reviews, no. 9, Article ID CD009337, 2011.
 N. Wallerstein and B. Duran, “Community-based participatory
of science and practice to improve health equity,” The American
Journal of Public Health, vol. 100, supplement 1, pp. S40–S46,
 I. Ajzen, “From intentions to actions: a theory of planned
approach: comment on Ogden (2003),” Health Psychology, vol.
23, no. 4, pp. 431–434, 2004.
 A. Bandura, “Self-efficacy: toward a unifying theory of behav-
ioral change,” Psychological Review, vol. 84, no. 2, pp. 191–215,
 A. Bandura, “Health promotion by social cognitive means,”
Health Education and Behavior,vol.31,no.2,pp.143–164,2004.
 M. Fishbein and I. Ajzen, “Theory-based behavior change
interventions: comments on Hobbis and Sutton,” Journal of
Health Psychology, vol. 10, no. 1, pp. 27–31, 2005.
 I. Rosenstock, V. Strecher, and M. Becker, “The health belief
ories and Methods of Behavioral Interventions, R. J. DiClemente
and J. L. Peterson, Eds., AIDS Prevention and Mental Health,
pp. 5–24, Plenum Press, New York, NY, USA, 1994.
 B. M. Branson, H. H. Handsfield, M. A. Lampe et al., “Revised
recommendations for HIV testing of adults, adolescents, and
12 AIDS Research and Treatment
pregnant women in health-care settings,” Morbidity and Mor-
tality Weekly Report, vol. 55, no. 14, pp. 1–17, 2006.
 A. Strauss and J. Corbin, Basics of Qualitative Research:
Grounded Theory Procedures and Techniques, Sage, Newbury
Park, Calif, USA, 1990.
 D. Peppers and M. Rogers, The One to One Future, Cur-
rency/Doubleday, New York, NY, USA, 1993.
 B. J. Pine, Mass Customization: The New Frontier in Business
Competition, HarvardBusiness Press,Boston,Mass,USA, 1993.
 T. Muhr, ATLAS.Ti 5.0, Version 5, ATLAS.ti Scientific Software
Development GmbH, Berlin, Germany, 2004, http://www.atlas
 A. M. Oster, C. H. Johnson, B. C. Le et al., “Trends in HIV
prevalence and HIV testing among young MSP: five United
States cities, 1994–2011,” AIDS and Behavior, vol. 18, no. 3,
supplement, pp. 237–247, 2014.
and M. M. Penha, “Latino gay and bisexual men’s relationships
with non-gay-identified men who have sex with men,” Journal
of Homosexuality, vol. 57, no. 8, pp. 1004–1021, 2010.
 H.A.Finlinson,H.M.Col´ on,R.R.Robles,andM.Soto,“Sexual
identity formation and AIDS prevention: an exploratory study
of non-gay-identified Puerto Rican MSM from working class
neighborhoods,” AIDS and Behavior, vol. 10, no. 5, pp. 531–539,
 J. K. Williams, G. E. Wyatt, J. Resell, J. Peterson, and A.
Asuan-O’Brien, “Psychosocial issues among gay- and non-
MSM,” Cultural Diversity and Ethnic Minority Psychology, vol.
10, no. 3, pp. 268–286, 2004.
 D. H. Chae and G. Ayala, “Sexual orientation and sexual
behavior among Latino and Asian Americans: implications for
unfair treatment and psychological distress,” The Free Library,