The big disconnect. Bob Leahy on how HIV prevention messaging, doctors and researchers interpret risk for us – and why their messages don’t always match the way we deal with risk in our everyday lives.
A lot has been written about how we process risk lately – how we take risks all the time based on a calculation of what we know, what might happen, and what are the likely chances of that happening.
It’s being increasingly pointed out that we make risk calculations every time we cross the road or board an airplane. So do people who cross Niagara Falls on a tightrope. So do people who have sex, with or without condoms.
The HIV landscape is changing around us, so that talking about risk has never been hotter. In part that reflects our ability to treat HIV often quite successfully. Often routine suppression of viral load, the Swiss statement and then HPTN 052 which followed have all necessitated thinking about the risk of transmission, and how that risk is processed and communicated, for instance. Things are different now.
The concept that we all take risks, everyday in our lives and “is sex any different?” is being widely talked about. Here’s what one of our writers, Michael Bouldin, said recently ”It’s not that we don’t know what constitutes risky behavior; it’s that it’s simply not possible to always avoid it, or in a given moment even desirable. Walking a red light can get you killed; it can also get you to a job interview on time.”
Megan DePutter, another PositiveLite.com writer and the Poz Prevention coordinator at an Ontario ASO, recently developed this theme further: “The risk of an accident likely trumps the risk of acquiring HIV by unprotected sex. The number of car accidents per year far exceeds HIV infections, yet people get into their cars every day, buckle their seatbelt as a matter of harm reduction, and go ahead with their day without thinking, calculating, or questioning these risks, let alone judging others who also put themselves at risk by being on the road. But many of these HIV negative car drivers would not carry this same approach to sero-discordant sex, even though it could be argued that a car accident could potentially have worse consequences than HIV acquisition and that missing out on a great love or even great sex would be a tremendous loss.”
Knowing what the risk is.
The recognition that we all take risks and why is HIV any different – has until recently seldom been reflected in HIV prevention messaging, and has arguably been its biggest failing. But let’s be clear. We sexual health “consumers” DO need to know if there is a risk and, better still, what that risk is. In fact let’s talk odds, let’s talk percentages, let’s talk probabilities. Whether we also need to know - or be told - HOW to process that risk, e.g. “wear a condom every time” is a moot point. Perhaps a more effective approach is talk about choices, as some service providers are doing. More on that later.
But choices are at the heart of every sexual deed, aren’t they?.Sometimes we make them in advance – carry a condom in our pocket and use it, come what may. Sometimes they are made in the heat of the moment. Sex is a messy business, not at all rational when it comes down to it and whatever factual information we have and decisions made about how we will act on it, all this can of course, be tossed aside when the lights go out.
Sometimes decisions to take risk can become more deliberate. Tim Dean in his book “Unlimited Intimacy, Reflections on the Subculture of Barebacking” says of the decision-making process in the barebacking subculture ”after two decades of safe-sex education, erotic sex among gay men has become organized and deliberate, not just accidental.”
There is of course much literature to suggest that at least a little bit of risk taking is a good thing in life. Goethe said “The dangers of life are infinite, and among them is safety.” General Patton, of all people said “Take calculated risks. That is quite different from being rash.” And let’s hear from T. S. Elliott “Only those who will risk going too far can possibly find out how far it is possible to go.” So clearly risk is part of our culture, and in many circumstances, lauded.
Against this propensity for us all to take risk in some form or another we have a panoply of interventions designed so that we don’t. Let’s look first at the traditional approach to HIV prevention, for instance, which seems to maximize risk and thus maximize the need for precautions. Where does that approach come from? Here’s what one HIV specialist thinks about “maximalist precautions” and why he recommends them. Bernard Hirschel, Head of HIV, Geneva University Hospital said this. "Recommending safer sex . . practices for all HIV- infected patients, even those with (an undetectable viral load) is indeed advisable. Imagine, as is likely, these recommendations are not followed. Then, if something bad happens, the onus is on the patient. As physicians, we should always try to shift responsibility for mishaps to our patients, and one of the means of doing so is issuing maximalist precautions. It makes our practice so much easier.
One hopes he is being flippant or sarcastic or both, but I don’t think he is. The truth is the practice of medicine inevitability involves liability issues. That fact is seldom talked about or expressed in writing but the idea of "maximalist precautions” underlies almost everything about how medicine, including sexual heath interventions, is practiced today.
Again, we do need to know the worst that can happen. If there is a remote possibility, a “significant risk” or even a likelihood of harm to ourselves or others, we need to hear about that, for sure.
Researchers sometimes goes beyond the facts to provide warnings which also reflect a “maximalist precautions” approach to their findings. For example, look at my article on levels of the HIV virus in men’s semen in PositiveLite.com here. This is how the risk was described in a recent study I quoted there. “Low seminal HIV titers could potentially pose a transmission risk in MSM, who are highly susceptible to HIV infection. . . Until more information on transmission risk in MSM is available,” the authors write, “it would be prudent to advise sexually active HIV-infected MSM to use condoms and other risk-reduction strategies throughout all stages of HIV regardless of treatment status.”
One could pose the question “Is it the role of research to tell people what to do? “ Or is it to provide factual information on which people – service providers and sexual health information consumers - can make their own decisions. Similarly, is it the role of ASOs and other sexual health service providers to tell people what to do, or to provide information so that those who consult them can make informed choices?
In the past, of course, we’ve been told what to do A LOT. Here are some examples.
Trojan Commercial: "Use a condom every Time"
(US) National HIV/STI Control & Prevention Program: "Use a Condom Every Time"
FDA 2010 Brochure “A person who takes part in risky sexual behavior should always use a condom.”
www.positive.org: “Always use a condom. If you're going to suck your partner's dick (blowjob), put a condom on it first.”
Messaging like this, with its inherent failure to recognize the realities of human behaviours, or how and why we process risk, runs the risk of undermining credibility.
This maximalist approach - always do all that you can to protect yourself, all the time - is inevitably starting to wear thin. Increasingly, service providers are recognizing that messaging has to be much more nuanced, recognizing risk is about the choices we make in life – and in the bedroom . In the gay men’s sexual health movement, for example, the concept of resiliency brought to the fore by Amy Herrick et al in Resilience as an Untapped Resource in Behavioral Intervention Design for Gay Men is being built on. In particular prevention messages building on gay men’s perceived strengths, which include the ability to make informed choices, are becoming increasingly common.
An example of that approach can be seen in thesexyouwant.ca resource from Ontario’s Gay Men’s Sexual Health Alliance. Their website says this. “We talk about condoms, and also how to reduce your risk in other ways. . . . We just give you the facts and let you make your own decisions. We all accept different levels of risk every day, and that’s okay. What matters is that we have enough information to be comfortable with the risks we take.”
In any event, we appear to be moving in the right direction. But just how much do we know about how, when and why we take risks? Search on the net and you’ll find some research on that, but much less on why we take risks - sometimes quite big risks - when it comes to sexual behaviour, when we might otherwise be risk – averse, for instance. There is even less research relating to specific populations. So clearly more needs to be done there to make prevention work solidly founded on a knowledge of complex human behaviors.
But ultimately, whatever we do can be thwarted and its healthy, I think , to recognize that. Humans take risks, period. And as Denis Waitley said "Life is inherently risky. There is only one big risk you should avoid at all costs, and that is the risk of doing nothing."
- Bob Leahy - Contributing Editor, PositiveLite
Tell us what do you think?