Special issue on: HIV/AIDS risk in the fourth decade

“Risk is our business … ”

—James T. Kirk, “Return to Tomorrow”

In the fourth decade of HIV/AIDS, the concept of risk continues to be an essential component of HIV/AIDS service provision. Across many disciplines and perspectives, risk appears to be a concept with considerable use, importance, and relevance. Yet the critical reflection and construction of risk appear to be as elusive as the concept is popular. As Michael Power notes, “risk ‘talk’ [is] all around us” (Power, 2004, p. 9). Only somewhat recently have related health professionals published thoughtful inquiries into the construction, meaning, consequences, and implications of risk in medicine and other related heath fields (e.g., Chamberlain, 2015; Beyrer & Karim, 2013; Baral, Logie, Grosso, Wirtz, & Beyrer, 2013; Brennan et al., 2012). There appears to be no central definition of risk in the most recent entries in the Encyclopedia of Social Work, nor does there appear to have been a recent special issue or discussion of “risk” in U.S. social work journals. However, the British Journal of Social Work published a special issue on the concept of risk and social work in 2010 (Volume 40, Issue 4). Affirming the importance of the concept of risk, the editors suggested the special issue be used “neither to solve nor eliminate the problem of ‘risk’ in social work, but to stimulate critical and creative reflection and practice” (Warner and Sharland, 2010, pp. 1045). To this end, the current array of articles in this issue reflect our commitment to publish and share strong, salient research findings related to the notion and experience of risk in HIV/AIDS within the context of social work and social services. As readers of this issue will discover, the notion of risk is global, and essential for prevention, care, and treatment. The concept of risk also incorporates space, gender, race, class, place, time, and social, political, and economic contexts (Land & Prabhughate, 2012; Pellowski, Kalichman, Matthews, & Adler, 2013).

In “Risk factors for HIV among Zambian street youth,” Tyler, Handema, Schmitz, Phiri, Wood, and Olson examine multiple levels of social influence on HIV infection among 250 street youths in Zambia. The article illustrates the challenges of intervention under multiple pandemics of HIV, poor health care, and drug use (Wyatt et al., 2013). Nearly 35 years ago, we discovered that the old public health/psychology/social work prevention “faux-quation” of Knowledge_Change + Attitude_Change = Behavior_Change (also memorably known as KA = B) was parsimonious, succinct, and nearly always false, regardless of population (hence the subsequently almost comparably memorable “KA ≠ B”). The results from the Tyler et al. study show that little has changed in 35 years. The majority of youth in the study correctly understand what behaviors increase their risk for HIV, yet still hold many misconceptions about HIV/AIDS. Additionally, youth who are homeless and those who report drug misuse by parents were much more likely than their counterparts to be HIV positive (Chen, Voisin, & Jacobson, 2016; Voisin, Hong, & King, 2012; Voisin, Tan, & DiClemente, 2013).

Homelessness and other structural proxies continue to be associated with increased risk for HIV infection particularly among urban residents in the United States (Gant, Gant, Song, Willis, & Johnson, 2014). Bowen and Mitchell examine “Homelessness and residential instability as covariates of HIV risk behavior among residents of single room occupancy housing” for a sample of low-income residents living in single room occupancy (SRO) buildings in Chicago. Previously, homelessness was associated with recent illicit drug use while self-identifying as homeless was associated with having multiple sexual partners. The study findings suggest that residential stability and housing histories vary considerably among SRO residents. Bowen and Mitchell also observe the importance of using precise definitions of housing as a structural determinant of health in helping to understand the relationship between housing histories and stability with HIV risk (Gant et al., 2014). In an interesting observation, funding for SRO housing opportunities (along with General Assistance funding) was eliminated in the state of Michigan in 1991 (Danziger & Kossoudji, 1994). However, given the increasing rates of HIV prevalence after the elimination and closure of thousands of SRO hotels in the city of Detroit, the elimination and closure of SROs appears to have done absolutely nothing to reduce HIV prevalence in Detroit (Michigan Department of Community Health, 2014; Beyrer & Karin, 2013, p. 163).

The concept of cognitive reserve suggests that people can maintain normal or optimal thinking processes as the brain experiences deterioration due to HIV-related complications. These complications include the following HIV-associated neurocognitive disorders (HAND):

• HIV-associated dementia (reported in 40% of people living with HIV);

• HIV-associated mild neurocognitive disorder (reported in 25% of those living with HIV);

• HIV-associated neurocognitive impairment (reported in 70% of those living with HIV).

With increasing numbers of people living with HIV, and the reality that highly active antiretroviral therapy very rarely, if ever, moderates the impact of HIV across the blood brain barrier, HAND remains common among people living with HIV (Volberding et al., 2010).

Employment—when possible—is widely cited as an efficient, “neuroprotective” method of shoring up cognitive reserve in persons living with HIV. In “The neuroprotective influence of employment on cognitive reserve: Implications for an aging HIV population” Vance, Cody, Nicholson, McManus, Stavrinos, Hoenig, and Fazeli describe several ways that employment, parallel employment, and alternative non-employment activities can be neuroprotective of cognitive reserve and cognitive functioning for adults with HIV. Implications for practice and research are provided, particularly since the observations may also be applicable to other clinical populations where the notion of cognitive reserve is salient and significant.

In “HIV-transmission-related risk behavior in HIV+ African American men: Exploring biological, psychological, cognitive, and social factors” researchers Arentoft, van Dyk, Thames, Thaler, Sayegh, and Hinkin search for individually based factors associated with HIV-transmission-related risk behavior among HIV+ African American men. A binary logistic regression shows that individuals under age 50 with clinically-elevated masochism scores, current substance abuse/dependence, and higher sensation-seeking are more likely to report recent risk behavior. The authors note that reducing substance use, addressing self-defeating attitudes, and improving self-control may be avenues for future prevention and intervention research among HIV+ African American men engaging in HIV-transmission-related risk behavior.

In “Relationship dynamics and challenges of safer sex in a HIV serodiscordant couple in India: A case review from the positive Jeevan Saathi study” Patel, Hennink, Yount, Wingood, Kosambiya, McCarty, and Windle present a somber, richly dense case study of the spectrum of high HIV risk behaviors by both members of a serodiscordant couple in India. There are no easy answers in this case study as the researchers present the factors that contribute to the structure, engagement, and ambiguous consequences of escalating HIV risk in this married serodiscordant couple. These factors include changes in spousal roles, history of unresolved child sexual abuse, unfulfilled sexual desire, unprotected sex with extramarital partners, intimate partner violence, and inconsistent condom use with marital partners. The researchers encourage early and ongoing counseling interventions by trained counselors for serodiscordant couples. The future trajectory of that couple—and others, however, is far from sanguine.

The work of the Arentoft and Patel research teams does not diminish the importance of larger structural factors but enhances the pernicious mediating (impacting process) and moderating (impacting outcome) effects of structural determinants of health (Baral et al., 2013). Even if some subset of structural factors were assiduously addressed, people are still social creatures and will engage in risky behaviors according to local social norms, mores, and values (Brennan et al., 2012; Land, 2015a, 2015b; Land & Linsk, 2013). Additionally, the personal perception, construction, and execution of a continuum of risky behavior will continue to depend on how the individual constructs his or her reality in response to a cascade of social and structural determinants of health (Mason, Sultzman, & Berger, 2014). Even in this era of medicalized AIDS and AIDS cures, clinical casework still has a provocative provenance (e.g., Mason, Vasquez, & Mason, 2014). Directly responsive to these last observations is the article that concludes this special issue on HIV risk. Hardré and Crowson’s “Measurable, malleable and contributory: Toward a motivational framework for reducing risk of HIV/AIDS” generates a compelling theoretical model generated from Lisrel software analyses of survey responses of over 6,500 youth living in challenging communities in Kenya and Tanzania. Twelve variables in four categories (abstinence effort, self-efficacy, future intentions, and success expectations) account for between 46–65% of respondent variation. The model discusses the ways in which youth try to make sense of their abilities to engage in behavioral changes within the structural and social determinants of health. Hopefully, this model will lead to more sophisticated understanding of behavior changes in the context of health determinants, and pave the way for comparable theoretical work with other groups across other relevant identities (e.g., age, sexual orientation, ethnicity, and gender expression) and in other societies.

It appears the deceptively simple word or term “risk” will continue to be complicated in any glossary of HIV care, prevention, and treatment for the foreseeable future. As long as that continues to be the case, indeed, risk will continue to define our work in HIV/AIDS for years to come. In a very real sense, risk is our business. Risk is the business of social work.