"The complex interplay between stigmatisation of homosexuality and the onward effect of this on self-esteem, mental health and sexual behaviour mean that MSM are a hard-to-reach group for delivering effective and sustained health education and prevention communication."

This European Centre for Disease Prevention and Control (ECDC) guide provides an overview of approaches on how to design communication programmes and interventions that are designed for men who have sex with men (MSM). It offers guidance for developing communication strategies to promote a culture of lower risk behaviour, supporting MSM to make decisions that reduce their risk of HIV, sexually transmitted infection (STI), and viral hepatitis transmission. It should be considered as a supplement to the more comprehensive ECDC guidance issued in 2015, entitled HIV and sexually transmitted infection prevention among men who have sex with men [PDF], and may be used to complement the health promotion section of this document. Written for public health professionals, policymakers, and HIV prevention practitioners, "Communication Strategies for the Prevention of HIV, STI and Hepatitis among MSM in Europe" is intended as a practical tool for selecting and locally adapting appropriate communication interventions to a variety of contexts in the European Union and European Economic Area.

The content of this guide is derived from a review of current interventions, scientific and implementation research, and grey literature, as well as collective practical experience and expert consensus. (This systematic review of the literature identified a number of key measures that should be considered for inclusion in national and sub-national public health programmes in Europe, such as: Promote and deliver vaccination to protect against hepatitis A and B in line with the national vaccination recommendations, and carefully assess vaccination for human papilloma virus (HPV) of boys during early adolescence.) The guide includes sample prevention messages for MSM, planning concepts, and examples on how to implement and evaluate communication strategies and prevention campaigns. Chapter 1 provides a brief introduction into the topic and how to use this guide. Chapter 2 summarises topics such as HIV and STI prevention among MSM, the epidemiology of HIV and STI, the vulnerability of MSM as a risk group, and the need for targeted communication strategies. "To be effective, these principles and messages will need to be adapted to the local context based on the knowledge of the target group and the social norms surrounding it."

Chapter 3 outlines 5 principles for effective prevention messages:

1. Use accurate, complete, and current information - "For example, communicating the risk of HIV transmission in absolute terms ('condomless sex can lead to HIV infection') is sufficient as an initial prevention message, but once this message is established, MSM will require detailed and differentiated information about the relative risk of their sexual behaviour, e.g. 'condomless sex is riskier in some situations than others, depending on factors such as...'."
2. Build trust between the recipient and the sender - e.g., "Trust can be built by adopting an affirmative stance toward MSM's right to a fulfilling sexual life, rather than defining MSM or their behaviour as a problem. Trust needs time to develop and requires many interactions over time. Communicating challenging, controversial messages at the beginning of a trust-building period is probably premature..."
3. Promote self-respect and empowerment - "This concept relies on MSM taking charge of prevention actions collectively and individually, with the goal to empower MSM networks and tackle stigmatisation and discrimination."
4. Take a participatory approach - "Ensuring the participation of MSM in all aspects of the communication strategy through community-centred, dialogic and participatory approaches can alleviate negative responses....The prevention strategy as a whole is often characterised by a well-structured partnership between experts, government organisations, NGOs and advocacy groups, including the meaningful participation of people living with HIV (PLHIV) at all levels. Many of the staff members and volunteers of those partners are usually MSM themselves..."
5. Use acceptable language and imagery - "When communicating about sex and sexual health with MSM as the target group, vocabulary and language should be in synch with the situational context....When communicating HIV and STI prevention messages to MSM, the best way to identify the most appropriate language and imagery is to collect information directly from MSM..."

Chapter 4 explores major barriers to delivering effective communication strategies. These include: structural barriers to communication, such as hostile political environments that downplay the existence of MSM and promote discrimination and exclusion, and individual barriers to communication, such as unintended effects of fear-based communication ("Arousing fear may increase awareness; but it is not an effective means of effecting sexual behaviour change."). An overview of prevention messages for MSM is presented in Chapter 5. This section presents a catalogue of the main communication topics for HIV, STI, and viral hepatitis prevention. It contains phrases and slogans that can be used for evidence-based messages that can be part of communication plans seeking to reach MSM. Public health professionals, policymakers, and HIV prevention practitioners can draw from this catalogue of stock phrases but should make sure that the final wording has been adapted to the local context. Messages were written in plain English and in neutral language. Examples from different European contexts illustrate how messages can be adapted locally. Specific guidance is offered, such as: "Information about a health problem or risk is best combined with a 'call to action'. This means offering a concrete and practical way to solve the problem or reduce the risk (e.g. 'Get your free condoms from...', 'Make an appointment today by calling 555-1234'). For the target group to successfully implement the call to action, messages need to be practical and match the lived experience of MSM. Effective messages emphasise respect, support and build on established social norms, such as the principle of equal responsibility for protecting one's own health..."

The last chapter presents a toolkit for the planning, implementation, and evaluation of communication programmes and interventions that reach out to MSM. It includes, for example, a template for campaign objectives, help on how to select effective communication channels, guidance on how to choose the most appropriate materials for dissemination, and a framework for monitoring and evaluating (M&E) campaigns (including indicators). Some of the areas covered are mass advertising, printed and online information materials, outreach work, community debate, one-to-one or small group communication/peer education, and social media and smartphone applications (ECDC organised a meeting in February 2015 on 'Understanding the impact of smart phone applications on MSM sexual health and STI/HIV prevention in Europe'; key takeaways from the meting are listed on page 38, with a link to the meeting report). The final sections of Chapter 6 on M&E include suggestions such as: "Graphical representations can often communicate quantitative results more effectively, while a selection of quotations can be used to link the themes emerging from qualitative data back to the lived experience of the respondents. Given the need for constant change and innovation in developing communication interventions, it is useful to feed evaluation results directly into the planning process for future interventions."