From Scene to Screen: The challenges and opportunities of commercial digital platforms for HIV community outreach

Introduction

It would be an overstatement to say that hook-up apps have been solely responsible for recent shifts in gay male sexual cultures. The increasing use of drugs during group sex parties (aka “chemsex”), for example, has as much to do with this culture’s long relationship with narcotics, and the ease of access to such drugs, as it does with the popularity of hook-up apps. Likewise, the popularity of contemporary social networking apps designed for gay and bisexual men should not obscure the much longer history of media use by this community. The back pages of gay magazines from the 1970s and 1980s, for instance, reveal a thriving trade in contact advertisements that included the solicitation of casual sexual partners and more long-term relationships (see Thorne & Coupland, 1998 and Hatala & Prehodka, 1996 for discussion).

At the same time, smartphone applications and mobile-optimized versions of more established dating and sex websites have had an impact on the sexual cultures of men who have sex with men (MSM). ¹ This enfolding of new digital platforms becomes intelligible when we recognize that a history of invisibility, prejudice, violence, and shame has ensured such cultures remain “flexible, transient and in some sense always virtual” (Mowlabocus, 2010, p. 11). Such flexibility has hitherto been required in order for sexually dissident folk to negotiate contexts of “compulsory heterosexuality” (Rich, 1981). Given such contexts, it is not difficult to see how and why gay, bisexual, and MSM men were well positioned to incorporate digital technologies into their practices of sex sourcing relatively early on in the history of domestic Internet access.

Numerous scholars (Campbell, 2004; Davis, Hart, Bolding, Sherrc, & Elford, 2006; Dean, 2009; McGlotten, 2013; McLelland, 2000; Mowlabocus, 2010; Race, 2010) have identified the initial and ongoing impact of digital and social media on the lives of gay, bisexual, and MSM men. Alongside research that celebrates the liberating potential of these platforms, hook-up apps and websites have also been the target of regular criticism and condemnation. Dean (2009) argues that such platforms destroy public sexual cultures, and that practices of digital searching mean we filter out difference and diversity, leading to the loss of a civic or public sexual culture. Arguing along the same lines, Rosser, West, and Weinmeyer (2008) have suggested that new forms of sexual/social media have been detrimental to the sense of a physically located gay community.

Alongside this mourning for “the good old days” of public sexual cultures, there is an ongoing concern that hook-up apps play a role in the transmission of HIV and other sexually transmitted infections (STIs). It would seem that barely a month goes by without a journalist suggesting that apps such as Grindr or Tinder are facilitating fast and easy sex, and that this is leading to a spike in transmission rates. These stories commonly reference studies such as Berry et al. (2008) and Rosser et al. (2009) who identify a link between aspects of digital cruising (such as the speed, efficiency, and access to sexual partner) and poor health outcomes.

While not disputing the research that underpins such scholarship, it is often the case that such findings are produced—and received—in a cultural vacuum that filters out the panoply of other factors that must be taken into account before pinning the blame on a sole cause. ² At the same time, it is all too easy to dismiss such concerns as moralistic and conservative. The homonormative (Duggan, 2002) framing that pervades such journalism often draws upon reservoirs of stereotypical representation that aligns gay male sexuality with disease and death.

Yet, the fact remains that hook-up apps and mobile sites are a key route for sourcing new sexual partners today. This fact alone means that those charged with supporting the health and wellbeing of MSM have to respond to this changing landscape. If, as will be discussed below, HIV and STI prevention work is based on a model of informing publics in the spaces where they interact, then hook-up apps and websites must surely be targeted as a site for disseminating information and offering support—whether diseases are being transmitted or not. Exactly what form that support and dissemination work takes is a key question; how should sexual health agencies respond to digital cultures of sexuality? What opportunities lie within these spaces? And what are the obstacles that such responses face?

In this article, we report on part of the Reaching Out Online (ROO) study, ³ which explored how and why hook-up apps and websites can become useful spaces for peer-led sexual health promotion. One of the strengths of this project was that it did not seek to develop new digital spaces for outreach (such as a bespoke website or app) but instead harnessed existing digital and social media services in order to work more effectively within a community of existing digital users. We begin our discussion by briefly mapping the terrain of community outreach work, identifying the role that such work has played in reducing the incidence of HIV and STI transmission in the United Kingdom. We then outline the development of an innovative outreach scheme designed for, and implemented across, a range of pre-existing commercial hook-up sites and applications. Drawing on ethnographic research and focus group interviews conducted with digital outreach workers, we document the potential that such a service has for supporting MSM in relation to their sexual health before considering what the challenges are to fully realizing that potential.

Throughout this article, our geographical point of reference is London and the South East, in the United Kingdom. Just as hook-up cultures differ across national contexts, so the epidemiological narratives of STIs shift according to geographical boundaries (see Gould [1993] for discussion). It is for this reason that we draw attention to the specificity of this study. However, we believe that our broad findings remain relevant across geographical borders. Finally, and in response to some of the moralizing journalism identified above, this article does not position hook-up apps and sex sites as harbingers of disease. Instead, and in the tradition of the very best practices of community health, the authors of this article recognize that as the sex sourcing practices of MSM change and evolve, so the health services that they may (or may not) rely on also need to develop in order that they continue to provide relevant and contextually appropriate services.

What Exactly Is Community Outreach?

The Terrence Higgins Trust (THT) is the longest running charity dedicated to HIV promotion and transmission/harm reduction in the United Kingdom. Named after one of the first people to die of AIDS in the United Kingdom, THT was formed in 1982 and has, from the very beginning, placed a strong emphasis on community outreach work. Five years before the British government began directly investing in HIV awareness campaigns, THT sought to inform and educate the gay community about the virus. While the charity has since gone on to work with a broad range of populations, it has its roots in the gay community, and from the outset, THT has worked within that community, often in the same spaces that men meet to drink, socialize, hook-up, party, cruise, and have sex. This form of localized intervention continues to be a key weapon in the charity’s fight against HIV and HIV stigma, and contemporary outreach activities include “bar blitzes,” ⁴ on-site screening at gay venues and events, rapid HIV tests in saunas, and “drop-in” services at local cruising grounds.

The UK National Health Service (NHS) defines community outreach as “activity undertaken in order to contact individuals or groups from particular target populations, who are not effectively contacted or reached by existing services or through traditional health channels” (NHS, 2011). These activities often seek to connect “hard to reach,” “disengaged,” or “invisible” populations with relevant health information and resources with the aim of increasing the health and wellbeing of specific, often marginalized, sub-populations. Consequently, this form of health promotion is deeply invested in understandings of the spaces that disenfranchised communities occupy and typically involves taking health promotion out of clinical settings and into the social, intimate, and even private spaces of groups and individuals in order to meet them on their “turf” (see Barry & Britt, 2002; Mills & Curtis, 2008; Needle et al., 2005; Rhodes, 1994).

As numerous studies have shown (Altman et al., 2012; Chan, Stoové, & Reidpath, 2008; Faugier & Sargeant, 1997; Herek, 1999), a fear of discrimination and of being judged can serve to frame the clinic (and clinicians) as a site of stigma and alienation for marginalized communities, especially when their behaviors and lifestyles do not align with (hetero)normative understandings of sexuality or sexual practice (see Emlet, 2006; McCann, 1999; Rose, 1994). By contrast, the types of “informal” education and knowledge transfer (as well as practical resources) that characterize a typical outreach activity have been central to the success of HIV prevention, particularly in the West (for further discussion, see Barry & Britt, 2002; Latkin, 1998; Mills & Curtis, 2008; Needle et al., 2005).

THT’s current outreach activities target the diverse groups and sub-groups of men that congregate under the umbrella term “MSM.” These include those across a range of self-identifying and “non-identifying” sexual identities; those in monogamous or open relationships; those who access “metropolitan” (Sinfield, 1999) gay culture including commercial bars and clubs; “party boys” who spend the weekend moving between clubs, parties, and saunas; non-defining or heterosexually identifying men who rely on “illegitimate” public sites (toilets, lay-bys, parks, and recreation grounds) to source sex; and those who are disenfranchised from commercial gay culture by virtue of their location, their (dis)ability, their financial situation, or their mental health.

In each instance, project workers plan, implement, and evaluate every outreach activity according to the identified needs of the target group. If THT is looking to support homeless gay men and provide them with testing facilities and condoms, then they know that such a service must be sited in a public space that these men feel comfortable accessing, and that this service will have more success if it also offers hot drinks and snacks. If THT is looking to engage with young men at a student club night, then the intervention strategy needs to be in keeping with the spirit of that club night—whether that involves health workers dressing up in fancy dress or giving out “freebies” such as lip salves or candy. In each instance, the key to a successful intervention is best summed up in the words of an experienced health worker who, during an interview for this project, stated that effective interventions were about “having the most impact on a particular group or community, with the least amount of disruption.”

NetReach: Community Health Promotion Goes Online

THT recognized that MSM were sourcing sex online relatively early, and by 2005, the charity was experimenting with using digital platforms for outreach activities. This early work was characterized as “maverick” by one health worker, who suggested that it was a game of “cat and mouse.” By using profiles to advertise sexual health support services, health workers were seen to be contravening conditions of use set out by commercial dating sites. As the NetReach profiles got taken down, workers set up new profiles under slightly different usernames and continued working until, once again, the profiles were deleted. This antagonistic relationship was finally resolved in 2010 when THT began entering into formal relationships with digital providers to deliver sexual health advice via chatrooms and messaging services.

Around the same time, the NetReach initiative broadened its scope to reflect the continued growth of MSM digital hook-up culture. Today, the service operates across 11 different social media platforms that cater to gay, bisexual, and MSM men. These platforms include websites that offer desktop and mobile access (such as Gaydar, BBRT, Recon, and Squirt) as well as services (including Grindr, Scruff, and Hornet) that utilize popular mobile operating systems such as Apple’s iOS and Google’s Android OS. NetReach is run out of regional offices across the United Kingdom and is coordinated from the charity’s head office in London. This localized approach has been central to conventional forms of community outreach and, as such, NetReach seeks to replicate the success of older activities by adhering to the core philosophy of such services, outlined above.

NetReach is innovative in that it refuses to build new digital platforms, relying instead on the community outreach ethos of taking resources, support, and information into the (digital) spaces that MSM use to meet one another. It is also unique in that it isn’t simply an “online” version of, or a digital replacement for, “offline” activities. This kind of division (reflecting an outmoded vision of an online/offline binary) refuses to acknowledge mounting empirical evidence (De Souza e Silva, 2006; Latour, Camacho-Hübner, & November, 2010; Zook, Dodge, Aoyama, & Townsend, 2004) that highlights the co-existence of digital and physical spaces, which overlap and “stack up” on top of one another in myriad ways.

As with other forms of outreach, NetReach activities are tailored to the spaces in which the outreach worker is operating, and the needs of the target audience. Interventions might, for instance, take the form of individual discussions, conducted via a private messenger service on a commercial dating website. This is typical of the kinds of interactions that take place on Gaydar, for instance. In other contexts, such as BBRT, the health promotion work might involve message board discussions around “hot topics” (such as post-exposure prophylaxis [PEP] ⁵ and pre-exposure prophylaxis [PrEP] ⁶ ). In yet other contexts, the intervention might exploit the geo-locative capabilities of a service such as Scruff in order to alert nearby men when testing services are running in the local area. In all cases, NetReach activities seek to forge a dialogue between outreach workers and the men who are on these hook-up services in order to foster honest and sex-positive conversations about sexual health, safer sex, harm reduction, and STI testing.

Thus far, NetReach has proven to be successful in developing such dialogue and in providing a space for men to talk frankly about their sexual practices and sexual anxieties. When interviewed for this research, outreach workers regularly identified the speed and depth of disclosure that occurs during NetReach interventions, stating that men typically disclose unsafe sexual behaviors far more easily, and far more quickly, when talking to workers via a web interface, than when compared to other forms of outreach:

[What do you think is the biggest advantage of online work?] Depth, honesty and the opportunity to really explore some of the issues . . . to get really into it, straight into it. (Ralph—Focus Group 1)

Similarly, NetReach was seen as a powerful resource for engaging difficult-to-reach populations, including those who might have hitherto felt marginalized by conventional health promotion discourse. One such example would be the work that THT has undertaken on websites such as BBRT, which are dedicated to bareback hook-ups ⁷ :

I genuinely think we are reaching some of those people. Some of the conversations I’ve had I’m like “right you exactly kind of, why we are doing this.” People that have er are taking lots of drugs and erm or erm are caught up in a cycle of behaviour and don’t want to keep doing it but find it hard to stop so want to talk to somebody about how to minimise risk and how to . . . I do think we are reaching some of that group. (Josh—Focus Group 2)

NetReach has allowed health workers to enter these digital spaces and undertake contextually relevant harm reduction work. This work involves providing health information that does not privilege condom use, while also signposting resources such as gay men’s health clinics and drug therapies. Together, these two strategies help to reduce anxieties about being judged when visiting clinics and enfranchise men who might otherwise feel that their sexual practices are incompatible with the services and advice of a health organization. As another worker explained, one of the advantages of undertaking outreach work in spaces dedicated to a particular sexual practice is that the information given out—and the framing of that information—can be “gated”:

it means we can say “we know you might see THT as being about promoting condoms and we do do that, but we respect the choices that you are making and we want to help you negotiate those choices in ways that take into account other options and opportunities for reducing the risk of STI transmission.” (Mike—Focus Group 2)

Thus, while community outreach operates in similar ways in digital and physical spaces, the specificity of certain digital environments offers opportunities to engage with niche populations on their own terms, and provide support that acknowledges the sexual practices and sexual choices of that community. NetReach also provides an opportunity to reach out to men who might be heavily involved in particular sexual cultures, but who might fall “under the radar” of traditional outreach. One such example was given during a focus group interview:

It’s interesting, thinking about Grindr, there’s big sex parties going on and stuff and those aren’t the people that would see THT out on the scene or be out on the scene. Grindr is probably one of the few kinds of places where we are visible to these men cos they’ll be using Grindr to find other guys to come round to their private parties. (Mike—Focus Group 2)

When journalists write about the “risks” of hook-up apps, it is often these kinds of parties that they allude to. Chillout parties, chemsex parties, and other forms of social-sexual gatherings have become a mainstay of urban gay male culture in the United Kingdom. Hook-up apps are central to the organization of these casual events and play a role in keeping them going. One research participant commented on the heavy use of apps and the constant messaging that occurred during these parties, suggesting that it was through apps that men learned about parties, were invited to different parties, and hooked up. This echoes Jensen’s (2015) statement that “social media are distinguished by their potential for many-to-many communication, drawing on and feeding into networks of one-to-one and one-to-many communication” (p. 1). Although those who are part of the chemsex and/or chillout party scenes may well also access physical commercial gay scene spaces, outreach through apps enables real-time interventions to take place. Once more, the emphasis is not on curbing sexual activity or counseling men against making “wrong decisions.” Instead, THT NetReach workers answer questions, offer advice and provide support when asked for it, and (as happens regularly) give information on how to access (for instance) PEP.

Navigating Code(s): (Commercial) Challenges to Online Outreach

As successful as NetReach is, digital outreach is not without its problems or limitations. Many outreach workers in the study cited difficulties in trying to “read” a client’s situation without the help of visual aids or cues as the biggest drawback. Indeed, communicating digitally in the written form also facilitates the creation of records of conversations that could be kept by users and/or rapidly shared online. This created an added pressure for workers, who were regularly seen spending a great deal of time and energy preparing carefully worded responses to questions. Despite some of these drawbacks, NetReach is already proving to be a powerful resource for HIV community outreach work particularly to access those meeting for sex through digital networks in “real-time.” Arguably, however, its potential has yet to be fully realized. Whether this potential can be reached depends on several factors. In the final section of this article, we sketch out three key challenges that face NetReach—and similar initiatives.

Conclusion

In September 2014, and reflecting both their ongoing commitment to technological innovation, and through such innovation, to meeting the needs of their client base, THT began trialing a new outreach scheme that targets men who may not be accessing traditional commercial physical venues, and particularly those involved in high-risk sexual practices involving sex using recreational drugs (“chem sex”) and intravenous drug use. “Slamming”—the practice of injecting traditionally methamphetamine (crystal meth) or, more recently, mephedrone—has become an increasing concern among gay health professionals working in urban centers such as London.

Slamming forms part of the broader “chem sex” sexual culture that involves marathon sex parties, lasting days at a time and which employ pharmaceutical technologies (Gamma Hydroxybutyrate [GHB], mephedrone, and methamphetamine) and digital technologies to engineer and maintain these parties. While the former enhances stamina, libido, and sexual performance, the latter provides a means of connecting men, and recruiting people in to the party. These parties are not “visible” if one’s understanding of the urban landscape is limited to the physical environs of the city, but are highly visible on the apps and social media websites that MSM use. Community outreach models that focus solely on physically located venues and spaces of interaction risk overlooking these urban, yet digitally maintained, networks of casual and anonymous sexual interactions.

The Luber team operates in London and maintains a presence on popular mobile platforms such as Grindr in order to promote a highly localized condom and safer drug use resource delivery service. Recognizing that these platforms are central to this emerging subculture, and that this subculture represents an ideal opportunity for HIV and STI transmission, the Luber team navigate through the densely populated city on bicycles in the evening and at weekends, using the apps to connect with men online and, when given the opportunity to do so, delivering harm reduction materials—and advice—into the hands of men at the point at which they are looking for sexual partners and may be about to engage in high-risk practices.

While facilitating very targeted and tailored harm reduction work, Luber also provides a way to (re)invest in some of the more traditional aspects of community-focused, peer support outreach into the online sphere, allowing workers to physically re-connect with their clients, and use more traditional communication skills (such as banter and body language) to achieve positive outcomes.

The fact that the Luber scheme does not have a formal partnership with the platforms it uses to reach out to service users demonstrates the challenging relationship that continues to exist between digital commercial platforms designed for gay and bisexual men, the sexual cultures and environments that these men create and negotiate in cities and towns across the United Kingdom, and the services set up to support harm reduction and risk negotiation. Alongside NetReach, the scheme also illustrates the levels of digital and physical enmeshment involved in gay and bisexual men’s sexual practice. There is no doubt that sexual health community outreach services must operate across digital and physical environments, while seeking to recognize both the specificity of each site, and the ways in which these sites merge and stack up in order to create new networked spaces of sexual connection.

If community outreach that targets MSM sexual health is to remain relevant and of use to those it seeks to support, it must navigate this enmeshed terrain, while recognizing that new rules, new codes of conduct, and new relationships with commercial service providers must be developed. Such recognition (and the subsequent [re]training of community health workers that it invariably engenders) is vital to the success of future intervention services and, by extension, the sustainability of online outreach for sexual health. Meanwhile, the authors of this article call upon commercial platform developers (and platform providers) to recognize their corporate responsibilities and support organizations such as THT in their work by providing better service integration for community outreach and, in turn, recognizing the role that they are playing within urban (and suburban/rural) gay men’s sexual cultures.