Risk Appraisal and HIV Prevention

Drawing heavily on traditional public health approaches ­ which have, in turn, drawn heavily on deeply rooted American values about human sexuality ­ HIV prevention, particularly for gay men, has consistently focused on the elimination of risk and relied on the provision of information to accomplish this goal. In the early 1980s, we assumed that this approach would stop the epidemic, and in the context of what seemed to be a short-term health emergency, this approach made sense. Indeed, many gay men heeded the message by adopting significant changes in sexual practice, including what was, for many, the radical solution of temporary abstinence.

As the epidemic of HIV seroconversion continued through the 1980s and into the 1990s, it became increasingly apparent that such short-term approaches were falling far short of risk elimination. While many AIDS educators had difficulty believing that informed gay men were continuing to expose themselves or others to HIV, there was substantial evidence as early as 1988 that one-third of San Francisco’s gay men reported engaging in unprotected anal sex. From the perspective of risk elimination and public health traditions, such behavior could be interpreted only as the product of continued ignorance, substance-induced impairment, malice, or psychopathology. But the evidence ­ which demonstrates that these factors have had only a relatively small influence ­ supports a more complex explanation. Gay male attitudes toward sexual behavior ­ particularly oral sex ­ illustrate the distinctions between risk elimination and harm reduction and the role of risk appraisal in HIV prevention not only for gay men, but also for people who participate in other HIV-related risk behaviors.

Risk Elimination versus Harm Reduction

The message from gay men should have been clear: the forbidden “exchange of body fluids” was not only a medical issue, but one laden with psychological meanings. Men were attaching importance to unprotected sex within relationships ­ and sometimes outside of them ­ as evidenced in the practice of “negotiated safety” (a process by which partners test and re-test to confirm that they are seronegative and then make agreements about sex outside the relationship in order to enable themselves to participate safely in unprotected sexual activities within their relationship). Men were almost universally eschewing the use of condoms for oral sex, despite suggestions from many prevention educators that unprotected oral sex “might be risky.” In other words, even as it was becoming widely accepted that prevention, rather than treatment, offered the only hope for controlling the epidemic, gay men were being motivated by feelings about trust, intimacy, and sexual communication to practice harm-reduction rather than risk-elimination approaches.

Harm reduction, by definition, is not intended to completely eliminate new infections, but gay men’s first decade of attempted harm reduction has resulted in an unfortunate and probably unnecessary rate of seroconversion, high even by the standards of harm reduction. Because this harm reduction effort has been almost completely unsupported by the public health establishment, gay men have had to fend for themselves in ignorance of facts and approaches that could have facilitated this effort. Unfortunately, many educators have used the results of this flawed harm-reduction effort to justify the retrenchment and redoubling of risk-elimination approaches; and they have expended little or no effort to understand why gay men had resoundingly rejected risk-elimination in the first place.

Appraising Risk

In our daily lives, we attempt to completely eliminate risk only for activities upon which we place little or no value. For activities we do value, we routinely exercise harm-reduction approaches by weighing the relative value of the activity and the costs of taking the risks involved against the potential costs of not taking the risk. For example, a vast majority of Americans drive or ride in automobiles despite the knowledge that approximately 45,000 people ­ close to the entire American death toll of the Vietnam War ­ will be killed annually. We value mobility and all that it provides, and we experience a lack of mobility as too costly to eliminate “reasonably” conducted automobile travel from our lives. We attain this level of reasonableness by exercising harm-reduction: safety engineering for automobiles, careful road design, and the exercise of personal responsibility in when and how we drive.

Our behaviors ­ as opposed to our public statements ­ suggest that we similarly value sexual expression, including aspects of sexuality that express relationship, intimacy, and trust. But most of our AIDS prevention work to date, rooted in the assumptions of risk-elimination, has defined “safe” sexual expression in ways that large numbers of gay men are demonstrably finding unreasonable.  Contrary to our relatively broad acceptance of the necessity of vaginal sex for heterosexuals ­ billions of dollars spent on developing contraceptive methods to allow vaginal sex without condoms or pregnancy ­ we have consistently told gay men to use condoms or abstain from anal sex. Despite a paucity of significant evidence for oral HIV transmission ­ and a huge body of data suggesting that oral sex is an extremely low-risk activity – prevention organizations have persisted in instructing gay men to take precautions routinely ­ to “Suck Latex” ­ when engaging in oral sex. Many of the same gay educators who propose unprotected sex within a mutually monogamous relationship (that is, negotiated safety) as the “most effective” prevention solution for heterosexuals, have said that for gay men it may tantamount to “negotiated danger.”

Such unreasonable prescriptions often reflect an authentic concern for the welfare of gay men and a belief that prevention should “err on the safe side.” Unfortunately, these prescriptions also express erotophobic and homophobic values, unclarified feelings about sexuality, risk, and life, and deeply held American beliefs that it is more important to pursue longevity than quality of life. Many gay men internalize these values and, at least publicly, collude with the messages they inspire.

The United States is now almost alone among industrialized nations in advocating HIV risk-elimination. This approach conforms to a traditional reluctance to accept the costs of any “socially unproductive” activity, particularly if it is experienced as sexual, sensual, or “indulgent.” Thus, it is the rare gay man in the United States who would not feel more comfortable dying in an automobile accident ­ preferably while commuting to a respected job ­ than by contracting HIV through sexual intimacy. And it is the rare HIV counselor who would not feel similarly about those whom they have counseled. What is excluded from such formulae is the huge human cost of lives subjected to social expectations that distort or deny an individual’s feelings.

Risk elimination must, by its very nature, provide guidelines rather than assist in a clarification of personal values. In asserting that no risk is, could be, or ought to be acceptable for a given behavior, risk elimination is predicated on a set of values that is imposed on a population ­ values assumed on behalf of all people ­ and not on an individual’s beliefs. If the behavior in question is something about which people are already acculturated to feel ambivalence, shame, or guilt, most will publicly voice compliance, even as they retreat, sometimes subconsciously, into personal, often ineffective, harm-reduction alternatives. While unprotected anal sex has become the single most stigmatized behavior in the public rhetoric of gay communities, it is widely practiced, a fact evidenced by current levels of new seroconversions. This unfortunate result is a predictable and intelligible consequence of depriving gay men of the accurate information, education, and counseling that are necessary components for authentic and lasting risk reduction. It is only with such assistance that gay men could possibly make informed, conscious decisions about balancing the potential costs of taking risks with the costs of avoiding them, and consider effective harm-reduction alternatives when the psychological costs of risk elimination are too high.

Currently, gay men are in the same predicament in which we would all find ourselves if health authorities decided that automobile travel over 25 miles per hour was unacceptably risky and prohibited it rather than educating the driving population about how to reduce risk while taking advantage of the reasonable and often desirable alternative of traveling at higher speeds. The results of such a prohibition ­ an unnecessarily large highway death toll as uneducated drivers flaunted the unreasonably low speed limit ­ would indicate not the need for more vigorous enforcement of a 25-mile-per-hour limit, but rather, the need to reexamine the conflict between personal and social values. As with gay men and sexual risk, the idea that the “speeders” were acting solely out of incompetence or noncompliance would miss an important point about health promotion and about human life and its potential enrichment through mobility and interpersonal intercourse.

Client-Centered Education

In May 1994, the Centers for Disease Control and Prevention (CDC) released new guidelines describing “client-centered” counseling for HIV antibody test site clients. Aware that purely information-based prevention was falling short of expectations, the CDC hoped to address some of the more complex individual issues ­ including so-called “psychosocial issues” ­ contributing to new infections. But this change of approach, and the relatively broad guidelines issued in support of it, have left many counselors in a quandary about exactly what client-centered counseling is and how it might be implemented.

Much of this quandary is a product of public health’s traditionally assumed values and purposes, which cannot be part of a client-centered approach. Client-centered approaches must, by definition, account for and respect the values, purposes, motivations, and individual needs of each client. The assumption of risk-elimination, without regard to the individual’s experience of the risks and benefits involved, cannot be part of a client-centered approach.  It is only through a client-centered approach, itself, that it might be clear that the client wished to avoid risk at any and all cost. Client-centered counseling is, by definition, a harm reduction approach, for it helps the client weigh his or her personal values against potential risks. Most clients accept risk for activities that they value and societal insistence on risk-elimination results only in the underreporting of “risky” activity.

Unfortunately, counselors may not be able to easily determine a client’s wishes because, among other reasons, clients themselves are often not clear about their feelings and values. Oral sex is a good example of an unclearly and inconsistently presented “risk” activity, and it is practiced without protection by a large majority of gay men. A risk-elimination approach would dictate that a client who reports having “a lot of unprotected oral sex” be advised to stop this practice or use condoms consistently when having oral sex, and that he be assisted in adopting these behaviors. In contrast, a client-centered approach would examine the obvious contradictions of a client doing “a lot of” something he fears may have lethal consequences. For example, a counselor might seek to support a client in clarifying his feelings and values: “It’s normal for people to take some risks to do things that are important to them.  It might be useful for you to consider how important unprotected oral sex is to you and, given this, whether you are willing to make the sacrifices necessary to achieve “complete safety,” a goal that suggests abstinence. How do you feel about this?”

Such a line of inquiry, when successful, will reveal much that is pertinent to prevention, including perhaps the client’s perception that sex, particularly homosexual sex, is not supposed to be important to him. Alternately, some clients will discover that they experience their sexual relations as unsatisfying and perhaps compulsive. And still others will find that they have not distinguished between different kinds of sexual contact, their feelings about each, and the relative importance of each in their lives. Connected to these insights, counselor and client will discover many related issues, including problems communicating about sex, confusions about relationships, and conflicted interpersonal issues.

All of these clarifications are crucial to prevention because they provide a foundation upon which an individual may begin to clarify the role and meanings of sexuality in his life, the potential risks he is willing to incur for his sexuality, and the personal costs of not taking those risks. In recognizing and respecting the complexity and range of individual values, rather than assuming absolute points of unacceptable risk, client-centered counseling thus naturally expresses a harm-reduction, rather than risk-elimination, approach.

Conclusion

While many counselors and educators, particularly those trained in traditional public health models, may find client-centered approaches to prevention unfamiliar, they will usually find them effective in practice. By clarifying pertinent feelings and values, clients are in a position to make better-informed, more considered, and more consistent decisions about risk.

Such beneficial results, however, require providers to discover and sustain attention to their own values and the extent to which those values influence interactions with clients. A counselor who has strong personal feelings about the importance or unimportance of his or her own sexuality, who is anxious or aversive to any risk, or who wishes to “save clients from themselves” must carefully examine the ways in which such feelings can distort or defeat a truly client-centered approach. In the end, counselors must authentically respect their clients, their values, and their efforts to create a life that is rich and satisfying enough to be worth protecting from unknown, unnecessary, or unintended risk.