July 19, 2012
I've never really heard people ask this question -- strange in itself when it looks like every question about HIV has been asked, and written about, often -- whether people living with HIV are inherently different. I'm talking about more prone to taking risks and thus more susceptible to becoming infected. Sure, we know all about vulnerable populations, social determinants of health and all that, which are often fingered as the culprits in HIV infections. But let's face it; the reality is that many, many people from vulnerable populations and with ALL the social determinants of health looking pretty good DON'T get infected. So what is different about the ones who do?
What's different about me too? Me, the ex-banker, me the semi-privileged white guy. Why did I get infected?
Who knows? But there are so many me's out there -- people of privilege with HIV -- that it's perhaps naïve to suggest that those social determinants of heath are all that's going on, all that's driving the epidemic. So pouring millions into addressing the social determinants of health, while producing very desirable collateral benefits, will never, ever end the epidemic. It's the plain truth that some of those, perhaps in large numbers, whose social safety nets are firmly in place are still going to get infected one way or another.
It all boils down to this: whatever our backgrounds, whatever our socio-economic status, we take risks. It's natural -- some would say admirable -- behaviour. It's just that some do it more than others. Me, I guess, included.
Bad luck can't be ignored of course, and I'd wager that's a big factor in many an infection. But I'd wager too (us risk takers do a lot of wagering, no?) that a certain propensity for risk taking is an even bigger factor. Which raises the question "do people with HIV have an attitude towards risk-taking that sets us apart from our negative brothers and sisters?"
It's kind of an impolite thought, so we seldom go there. But surely it's a proposition worth looking into. It's the case, after all, that if you are HIV-positive your past life has probably been marked either by taking one big risk or, much more likely, a whole series of risks. Risks perhaps that negative people would never think of taking.
This may be uncomfortable territory to ask, but what else suggests that we poz folks are a nation of risk takers? Well, a lot of us smoke for one, three times the national average. Some will suggest reasons for that -- self medication, for instance -- but smoking is nevertheless surely a continuation of the risky behaviour that got us positive in the first place. Ditto the use of street drugs -- we use them more than the general population, an activity that may risk health and certainly risks exposure to the legal system. Many of us aren't all that treatment-adherent either and that is as risky as hell.
There are potential reasons for all these risky behaviours, of course, and more than a few of them bounce right back to the social determinants of health. But can we avoid also looking at us -- what makes us tick as persons? Maybe we are just less averse to taking risks than most people?
If there is even a chance that this is a viable hypothesis, maybe -- just maybe -- researchers should be looking at that. Our relative propensity to take risks (or not) is not a hard one to measure. But I've seen nothing in the literature about it.
Why is this even important? It's becoming increasingly clear, I think, that how we all process risk is an issue destined to be at the heart of future prevention efforts. Or at least it should be, because even if treatment as prevention holds sway, we will still need to look at a variety of other techniques to stem the epidemic, and behavioural interventions will remain important. I'd wager (here we go again with the wagering -- see what I mean?) that HIV education and awareness won't have legs; most people -- even the young -- know about HIV now, know about condoms, know how to use them. Most too are to some degree committed to using them when they consider themselves at risk of infection. Strikes me we now need to go one step further, to look at what happens to those best intentions that see those condoms left unused, usually in the heat of the moment, And at the heart of those situations where best intentions get tossed aside is our approach to risk. Which brings me back to our original point -- we all process risk individually.
Me, I wouldn't classify myself as a risk-taker, in fact my career in the bank -- it was boring by the way -- was in risk management, of all things. But clearly I am, or I wouldn't be poz. Interesting too that while I don't have much money, I like gambling. My partner and I go to the penny slots quite often -- and enjoy it, risking a few dollars for the sake of a good time. Sound familiar?
Of course you can't talk about our propensity for taking risks without acknowledging we all do it, poz or neg. You've crossed the road, haven't you? Been in a plane, eaten too many French fries for your own good? It's part of life.
PositiveLite.com writer Michael Bouldin said it best in an article for the site: "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."
So really it's all a question of degree. We take risks every day. I'm just suspecting many of us pozzies have been prepared to take it one step further, because that's the way we are. Maybe, just maybe, we are wired that way.
Ok. Shoot me down. I can risk that. But you knew that already ...