Cad. Saúde Púb lic a, Rio d e Jane iro , 15(Sup. 2):93-105, 1999
General populat ion and HIV prevention:
f rom risk to action
Po p ulaç ão g e ral e p re ve nç ão d a infe c ç ão
p e lo HIV: d o risc o p ara a aç ão
1 Ce n t re de Re c h e rc h e M é d e c i n e , M a lad ie et Scien ces S o cia les (CERM ES), Ce n t re N at ion al d e l a Re c h e rch e S cien t ifi qu e – C E R M E S ,1 8 2 ,b o u l e va rd d e l a Vi l l e t t e ,7 5 0 1 9 , Pa r i s , Fra n c e . p a i c h e l e @ ex t . j u s s i e u . f r
Ge n e v i è ve Pai ch eler 1
Abst ract Sin ce k n ow led ge a bo u t AID S t ra n sm issi o n n ow a p p ea rs t o be v e ry go od , m a n y o b-s e rv erb-s a re b-su rp rib-sed t h a t m ore p eop le d o n ot p ra ct ice b eh av ior, lik e b-sa fer b-sex , d eb-sign ed t o m in i-m i z e risk of con t ra ctin g t h e disea se. St i l l ,p reviou s stu dies h av e n ot sh ow n th at t h ere is a direct lin k bet w een k n ow led ge a n d beh a vior. New m od els, based on p eop le’s con cret e ex p e r i e n c e s ,a re th ere f o re n e e d e d . Th e goa l of th is qu a litat iv e re s e a rc h , ba sed on 61 in -d ep t h in t erv i ew s con d u ct ed in Fra n c e , is to describe h ow p eop le u n d erst a n d t h e th reat of AIDS an d h ow t h ey fa ce th e risk of tra n s m i s s i o n in t h eir sex live s . In ord er t o u n d ersta n d p re ve n t i ve act ion s, w e m u st st u d y h ow in form at ion is in -t e r p re-ted an d h ow k n ow ledge is in -tegra -t e d , so -th a -t p eop le p erc e i v e gen eral or p erson a l risk . We m u s-t a lso sp ecify t h e w ay in w h ich p eo p le dist in gu ish bet w een a sp ects of risk p ercep t ion an d vu ln era b i li t y ; feellin gs of p erson a l con t ro l , con stru cted on th e baslis of soclial ex p e r li e n c e s ;c h a ra cterlistlics of slitu -a t i o n s ; -a n d fin -ally, t he dyn -am ics of -action . Th e p rop osed risk m -an -agem en t m od el -a ccou n ts for th ese d i verse factors in elu cida tin g t he grea t div ersit y of a ction s re p o rt e d . This dyn a m ic, n on -lin ea r m od el is d esign ed t o ca p tu re both th e im p act of p erc e p t i ve an d cogn itive elem en ts on act ion an d vice ve r s a . Key words Healt h Ed u c a t i o n ; H I V; Ac q u i red Im m u n od eficien cy Sy n d ro m e ; Sex Be h a v i o r ; R i s k
Cad. Saúde Púb lica , Rio d e Jane iro , 15(Sup. 2):93-105, 1999
I n t ro d u c t i o n
Th e fe a r t h a t AIDS in s p ire s d o e s n o t d ire c t l y lea d to p re ve n t i ve b e h avior. It see m s th at p eo -p le h a ve go o d kn owle d ge a b ou t h ow t h e viru s s p re ad s b u t n u m e r ou s KABP (kn ow l e d g e , a tt i-t u d e s, b e lie fs, a n d p ra ci-tice s) si-t u d ie s h a ve e s-t a b lis h e d n o d ire cs-t lin k b e s-t we e n in fo r m a s-t i o n a n d a ct io n (Pe r u ga & Ce l e n t a n o, 1993). T h e s e st u d ie s we re la rgely in sp ire d b y th e He alt h Belief Mo d e l (Ro sen sto ck, 1974), wh ich e sta b lish -e s a d ir-e c t a n d ra t io n a l c o n n -e ct io n b -e t w-e -e n k n o w le d ge a n d p ra ct ice w h e n a n in d ivid u al fe e ls t ru ly c o n c e rn e d b y a h e a lt h t h re a t . T h i s m od el h as b een wid ely criticized (O’Brien , 1 9 8 9 ; Fe e & Kr i e g e r, 1993; Bl o o r, 1995a , 1995b ) a n d a l t e rn a t i ve m o d e ls h a ve b e e n p r o p o s e d . Fo r e x a m p l e , t h e t h e o r y o f re a s on e d a ct io n in t e -g ra t e s so c ia l n o rm s a n d p r e s s u re s an d m ake s a d ist in ct io n b e t w e e n in t e n t io n a n d a ct io n ( Fish b e in & Ajze n , 1975). H owe ve r, t h is th e o ry re m a in s a m o d e l o f in d ivid u a l d e cis io n -m a kin g an d p roves to b e a p oo r p red icto r o f h ea lt h -relate d b eh avio r. In o rd er to ove rcom e t h e d efi-cien cies in th e se m o d e ls an d fin d ad eq u a te e x-p la n a t io n s fo r th e ch an ge s in b e h avio r t h at a re o b s e rve d , we m ust a d a p t a n e w fra m e o f re f e r-e n c r-e. In str-e a d of t r yin g to im p o sr-e p rr-e c o n c r-e i vr-e d m o d e ls o n t o kn o wle d ge an d p ra c t i c e , a p h e -n o m e -n o lo gica l a p p ro a c h , wh ic h st u d ie s h ow p e o p le in t e gra t e t h e t h re at of AID S a n d wh a t t h ey a ctu a lly d o a b o u t it, sh o u ld b e a d o p te d .
Th e e m e r ge n c e o f a n e p id e m ic a n d le t h a l illn ess ra ise s th e q u e st io n o f m ean in g a n d u n -d e rs t a n -d in g. Th e p u b lic h a s t o -d o m o re t h a n sim p ly a ssim ilat e n e c e ssa ry an d su ffic ie n t in -f o rm at io n in ord er to pra ct ice a p p ro p r ia te p re-ve n t i re-ve b eh avio r. Co n f ro n t e d wit h u n cert a i n t y a n d a p le t h o ra o f in fo rm a t io n fro m d ive r s e s o u rc e s, la yp e r so n s e n ga ge in in t e n se a ctivity o f so rtin g an d in te rpret at io n , a s th ey a re f o rc e d t o s it u a t e t h e m s e lve s in t e r m s o f t h e d a n ge r (Wa rwick et al., 1988). Pe rce ivin g risk at a so ci-e t al lci-e vci-e l d o ci-e s n o t n ci-e cci-e ss ar ily im p ly p ci-e rc ci-e i v-in g risk t o on e se lf, alth o u gh risk m a n a gem en t d o e s d e p e n d o n m o d a lit ie s o f in d ivid u a l ri s k p e rc e p t io n , a n d also, o f co u r se , o n t h e o b je ct i ve m a rgin o f a cct io n a llowe d b y c o n cre ct e s ict -u a t i o n s.
Ris k is a m o d e rn wa y o f u n d e r st a n d in g p a th o logica l d a n ger as a n om n ip resen t an d in -va s i ve sa n ita ry th re at to b oth p o p u latio n s a n d in d ivid u als (Arm s t ro n g, 1993). Howe ve r, it d oe s n o t p r o vid e a cle a re r vie w o f t h e d a n ge r in -vo l ved n or a p recise evalu ation of it (Dou glas & Wi l d a v s k y, 1982). A p o lyse m ou s a n d co n tra d i c-t o r y n o c-t io n (Ha ye s, 1992), ic-t d e sign a c-t e s b o c-t h e x t e rn a l facto rs, over wh ich n o con t rol is p
ossib le a n d co n d it io n s c o n sid e re d u n d e r t h e co n -t rol o f in d ivid u als, su ch as p a-th oge n ic l i f e s -t y l e s. Fu rt h e rm o re , t h e co n ce p t o f risk im p lie s a p ro cess t ha t o b e ys laws b a sed o n lon g se ries of o b s e r va t i o n s, fro m wh ic h it is p a r a d ox i c a l l y p ossib le t o in d ivid u a lly iso lat e on ese lf.
It h a s b e com e ve ry co m m o n t o u se t h e e x-p re ss io n “r isky b e h a vio r” in t h e d o m a in of h e a lt h t o re fe r t o t h e p o t e n t ia l c o n t rol t h a t in -d ivi-d u a ls co u l-d h a ve ove r th e ir h e a lt h ( Je f f e r y, 1989). Ac c o rd in g t o t h is lo gic, so m e p e o p le , wh ile p er fect ly co n scio u s o f th e con seq u e n ce s o f t h e ir a ct io n , d is re g a rd t h e sa n it a ry t h re a t a n d vo l u n t a rily p u t t h e m s e lve s in a sit u a t io n t h a t t h re a t e n s t h e ir h e a lt h . “ Se l f - c o n t rol i s t h e re f o re a p re requ isit e fo r h ea lt h . La ck of self c o n t ro l , of w h ich det ect a ble sym p t om s in clu de form s o f beh a v i ora l , p sych o logi ca l a n d co gn i -t i v e o rga n iz a -t ion , is con seq u en -t ly a n ‘ i l l n e s s’ p reced in g t h e p h ysi ca l a i lm en t ”( Gre c o, 1993: 161). If p e o p le ge t ill, it is c o n s id e re d t o b e t h rou gh weakn ess o r ch oice. Yet, to ch o ose, o n e m u st h a ve a cle ar a n d ob jective vision of th e al-t e rn a al-t i ve s a n d co n s e q u e n ce s a s so c ia al-t e d wial-t h t h e d e c is io n s in vo l ve d . Th is im p lie s s h ift in g f ro m t h e d o m a in o f “r isky b e h a vio r ” t o “ri s k p e rc e p t i o n”. To re a lly b e re s p o n s i b l e, d o es o n e n o t h a ve t o b e ca p a b le o f e va lu a t in g d a n ge r wit h fu ll kn o wle d ge o f it s o rigin so a s t o b e ab le t o m ake th e m o st ju d icio u s ch o ices p o ssi-b le ? Ca n we e xp e ct a re lia ssi-b le e va lu a t io n fro m ep id e m io lo gist s? Pro b a b ly n o t , sin ce t h ey, like a ll re s e a rc h e r s, h a ve a sp e cific vie w o f t h e p h e n o m e n o n a n d ch o o se a m o n g t h e lim it e d am o u n t o f in fo r m a t ion t h a t c a n b e ga t h e re d a n d p roc e sse d . Ep id e m iolo gic a l s t u d ie s fu n c -tion m o re as a n or m a lizin g t ech n iq ue. “Th e ra-t i o n a l i z ed m a ra-t h em a ra-t i ca l logic a n d rh era-t ori c of th e disco u rse of ep id em iology serves t o obscu re m o ra l ju d gm en t s a bo u t in d iv idu a ls’o r g ro u p s’ b e h a v i o r”( Lu p t o n , 1995:67).
Cad. Saúd e Púb lic a, Rio d e Jane iro , 15(Sup. 2):93-105, 1999 o f reaso n o r ca lcu la t ion of risk an y m o re ra t i
o-n al t h ao-n relyio-n g o o-n ch ao-n ce, m yst e r y, or m ale v-o le n ce ? Scie n c e d v-o e s n v-o t cv-o n t rib u t e t v-o t h e id en t ifica tion o f m o re co n crete th re a t s, th e iso -la t io n of real d an ge rs, wh ose ca u se s a re ob je c-t i vely id e n c-tified , gu a ran c-tee d b y c-th e a u c-th or ic-t y of e x p e rim en ts a n d t he o r y (Dou gla s & Wi l d a v s k y, 1982). Ap p a re n t scie n t ific o b jec t ivit y d o e s n o t a l l ow u s to e scap e t h e fa ct th a t , in a n y so cie t y:
“risk -t a k in g a n d risk a ve r s i o n , s h a red con fi-den ce an d sh a red fea rs, a re p a rt of t h e d ia logu e on h ow t o best orga n iz e socia l re l a t i o n s”( D o u -gla s & Wi l d a v s k y, 1982:8).
Th e in d ivid u a lis t ic vision o f risk h a s b e e n t h e o b je c t o f n u m e ro u s crit iq u e s (Blo o r e t a l., 1992). Th is p o sit ivist ic vision m isin t erp ret s t h e social, cu lt u ra l, m o ra l, a n d p o litical d im e n sio n o f r isk, e sp e c ia lly a s it re la t e s t o h e a lt h (Lu p -t o n , 1993; Ga b e , 1995). I-t a ssu m es -t h a -t if in d i-vid ua ls o r scien tific e va lu at o rs d o n ot h ave a c-cess to th e tru th ab ou t give n ri s k s, it is b ecau se t h e in st ru m e n t s o f e va lu a t ion a re fla we d . Ra tio n al an d calcu la te d p e rcep tion is still con sid -e r-e d p o ssib l-e . Y-e t , a ll p rob ab ilist ic -eva l u a t i o n s o f e ve n t s a re m a d e in a co n t e xt o f u n c ert a i n t y, a co n d it io n wh ic h ce r t ain in d ivid u als t ole ra t e a n d m a n a ge b e t t e r t h a n o t h e rs. Th e se e va l u a tio n s le n d t h e m s e lve s t o d iffe re n t sim p lifica t io n s a n d t ra n s l a t i o n s. Pe rc e n t a ge s a re t ra n s la t e d in t o o rd in a l m e asu re s a n d d iscre t e ca t e g o ri e s, wh ich a re sim p lifie d a n d e asie r t o co n -c e p t u a l i ze a n d a-c t u p o n (Pa rs o n s & At k i n s o n , 1992). Fo r layp erso n s, risk ca n on ly b e in te gra t-e d if it is tran slatt-e d in t o th t-e t t-erm s o f su b jt-ectivt-e, l i ve d e xp e ri e n c e . It is im p o ssib le t o re q u i re t h e m t o vie w t h e m s e lve s a n d th e e ve n t s t h a t affect t h e m wit h th e d e t a ch e d p e rsp e ctive o f a d e m o g ra p h ic stat ist icia n .
Risk is on ly on e a n gle o f a p rism th a t allow s p eo p le to u n d erstan d t h e p ro b le m at ic o f AIDS. Th e co n s t r u ct io n o f la y kn owle d ge o f t h is ill-n es s o p e ra t e s o ill-n d iffe re ill-n t re gist e rs t h a t c oe xist w it h a c e rt a in in d e p e n d e n c e, e ve n co n tra -d ict io n . Gl o b a l l y, it is p o ssib le t o -d ist in gu ish b e t we en t w o leve ls o f so cio -co gn itive p ro c e s se s : t h se rse p rse sse n t a t io n s o f illn se s s o r o f ill p se o -p le an d th e -p e rce-p tion of r isk (Pa i c h e l e r, 1 9 9 4 ) . Th e le ve l o f re p re s e n t a t io n s d o e s n o t s e e m t o b e sp e cific t o AIDS. Ra t h e r, we fin d , in d iscu s-sio n of t h is illn e ss, m e t ap h o rs t h at ch a ra c t e r-i ze all r-illn e sse s, o r a ll ser r-iou s r-illn e sse s, a s t h e y h a ve b e e n d e s c r ib e d fo r d e ca d e s (He rz l i c h , 1969; So n t a g, 1978). Pe rce p t io n o f r is k is d e -ve lo p e d a c co r d in g t o t h re e r e gis t e r s o f va r ia b le fo r m s o f p e rc e i ve d vu ln e ria b ilit y – c ia t ia -s t ro p h e , -so c ia l vu ln e ra b i l i t y, a n d corp o ra l vu ln e rab ilit y – a ln d h a s a cle a r im p a c t o ln p re ve ln -t i ve a c-t io n s.
In ord e r t o u n d e rst a n d h ow p eo ple d eve l o p AIDS pre ve n t i ve a ction s, seve ra l p la n s of in ve s-t iga s-t ion m u ss-t b e ars-t i c u l a s-t e d :
• co n s id e r wh ic h in fo rm a t io n , fr o m a m o n g t h at w h ich is d iffu se d – in clu d in g in fo rm a t i o n a im e d a t p r e ve n t io n – is m o st like ly t o in flu -e n c-e a ct ion ;
• a cco u n t fo r p rocesse s of in t erp ret at ion a n d i n t e g ration of kn owled ge b ot h on an in d ivid ua l a n d co llect ive leve l ;
• d e m o n s t ra t e h ow th e se p roce sses a llow for t h e e la b o ra t io n o f ge n e ra l a n d p e rso n a l r i s k p e rc e p t i o n ;
• in a n alyzin g a ction , d istin gu ish b etween el-e m el-e n t s rel-e la t el-e d t o risk p el-e rcel-e p t io n an d fel-eel-e lin gs o f vu ln era b i l i t y, sen se o f person al con trol b a s e d o n socia l e xp e ri e n c e, ch ara c t e rist ics o f th e sit -u a t io n , an d fin a lly, act -u al d yn am ics of a ct io n .
Th is article will focu s on th e last two asp ects.
M e t h o d s
Si x t y-o n e in -d ep th in t ervie ws of a p p rox i m a t e l y o n e an d a h a lf h o u rs we re co n d u ct ed . Th e in i-t ia l in s i-t ru c i-t ion s as ke d re sp o n d e n i-t s: “Ca n yo u t e ll m e wh a t t h e wo rd “A I D S” e vo ke s fo r yo u ? ” Th is t yp e o f in t e rvie w m e t h o d o lo gy p ro v i d e s in d ivid u a ls a ce rt a in la t it u d e o f e xp re ss io n so t h a t t h e y h a ve t h e o p p o r t u n it y t o t h e o ri ze – m o re o r le ss n a ive ly – a b o u t t h e ir own e xp e r i-e n ci-e s an d co n ci-e p t io n s. Th is a llows th i-em sp aci-e in wh ich t o e la b o ra t e a d isc o u r se th a t , u n d e r ot h er co n d it ion s, wo u ld p ro b a b ly n o t h a ve t h e o p p o rt u n it y t o e m er ge in t h e sam e t er m s. T h e i n t e rv i e we r fo cu ses o n t h e re s p o n d e n t s’ wo rd s a n d s tyle s o f re a s o n in g, s tr ict ly fo llo ws t h e s t ru c t u r e o f t h e a rgu m e n t , an d h e lp s t h e re -sp on d e n ts exp re ss th e m se lve s a n d m a ke se n se o f t h eir re a so n in g an d a ct io n s. In th is wa y, t h e i n t e r vie w is c o n c e p tu a lize d a s a n a ct o f d isco u rse in wh ich t wo in t e r lo cu t o rs jo in t ly c o n -s t r u ct m e a n in g in t h e ir in t e ra c t ion (Mi -s h l e r, 1 9 8 6 ) .
Sin ce th is m e th o d im p lie s a lim it ed sam p le s i ze , t h e go a l is o b vio u s ly n o t r e p re s e n t a t i ve -n e ss b u t d iversit y i-n t erm s o f sp ecific va ri a b l e s t h a t b e a r u p on t h e p ro b le m a t ic a t h a n d . T h e d i versity o f th e sam p le a cco u n ts for t he f o l l ow -in g va r i a b l e s:
• Ge n d e r : 30 m e n , 31 wo m e n .
• Age : t h re e gro u p s co n ce n t ra te d aro u n d 20, 30, an d 40 ye a rs o f a ge (N = 20, 21, a n d 20, re -s p e c t i ve l y.
Cad . Saúd e Púb lic a, Rio de Jane iro , 15(Sup. 2):93-105, 1999
cit ie s o u tsid e of Pa ris d ivid e d in t o t wo re g i o n s o f d iffe re n t e p id e m io lo gic al p re va le n c e a n d p ro f i l e s, N = 24.
• fa m ily st at u s : m a r ri a g e , d ivo rc e, co h a b it a-tio n , st a b le o r u n st ab le re l a t i o n s h i p , p re s e n c e o r a b sen ce of ch ild re n , a ge o f ch ild re n .
With two e xcep t io n s (on e gay m a n a n d o n e b isexu a l m an ), th e p eo p le in t erv i e wed p re s e n t-e d t h t-e m st-elvt-e s as h t-ett-e ro s t-e x u a l s.
Th e in t erviews we re an alyzed on a th em a tic ( s y n c h ron ic) level, an d accord in g to th e lo gic of t h e a rgu m e n ta tion . An a ut om a tic lexical an a ly-sis was con d u cte d u sin g two p ro g ra m s: ALC E S-TE a n d H YPERBASE. A d ia ch r on ic a n alysis o f a ct io n s re p o rt e d a n d t h e ir d e t e rm in a n t s wa s p e rf o rm ed fo r e a ch in t erv i e w.
F i n d i n g s
I) Perceiving Risk
• Risk Perception O bstacles
In o rd er to e va lu a t e risk, p e o p le u se d ive rse res o u rc e res, in clu d in g a cc e resres t o in fo rm a t io n , o b s e rvat io n , an d expe ri e n c e. Yet ava ilab ility o f in -f o rm a t io n is im p er -fe ct , e it h e r b ec a u se c ert a i n i n f o rm a tion d o es n ot exist, it d oes n o t circ u l a t e o u t sid e o f a s m a ll c irc le o f sp e cia lis t s, o r b e -cau se it is t ain te d with u n ce rt a i n t y. In ad d it io n , o b s e r va t io n a n d e xp e r ie n c e a re gro u n d e d in in e vit a b ly p a r t ia l a n d b ias e d p e r sp e c t ive s. Am on g th e gen e ra l p op u lat io n t od ay in Fra n c e, t h e m a jo rit y o f in d ivid u a ls h a ve n o t h a d t h e o p p o rt u n it y t o p e rson ally kn ow som e o n e wit h H I V. T h e re we re 45,204 cu m u la t e d ca s e s o f AIDS on Se pte m b er 30, 1996, an d ap p rox im a t e-ly 120,000 H IV- p o s i t i ve p e o p le, o u t o f so m e 60 m illion re sid e n ts (H IV/ Aid s Su rveilla n ce in Eu -ro p e , 1996). Ye t s u c h a n e xp e r ie n c e s e r ve s t o g re at ly in cre a s e p e o p le’s se n s e o f risk, le ad in g s o m e t o o ve re s t im a t e it , e ve n t h ou gh it d o e s n o t p re c lu d e p e o p le’s t e n d e n cie s t o d ist an c e t h e m s e l ve s from it . If we ad d to th ese con sid er-a t io n s t h e fer-a ct t h er-a t sys t e m er-a t ic d e vier-a t ion s er-a re p r o d u ce d b y “ h e u ri s t i c s” t h a t a llo w fo r r i s k c o m p r e h e n sio n , e s p e c ia lly c o n ce rn in g re p re s e n t a t i ven e ss a n d a va ila b ilit y ( T ve rsky & Ka h -n e m a -n , 1974), we se e t h a t a c or re ct t h e o re t i c e va lu a t io n is ve r y im p r o b a b l e. In ad d it io n ,
“ch a n ce is com m on ly view ed as a self-corre c t i n g p rocess in w h ich a d evia tion in on e direct ion in -d u ces a -deviation in th e op p osite -d irect ion to re-s t o re t h e eq u ilib riu m ”( T ve r sky & Ka h n e m a n , 1974:1125). Pe op le a re th u s a m a ze d b y ch an ce s u r p rise s like co n t a m in a t io n d u r in g t h e fir st se xu a l re lat io n wit h so m e o n e wh o is HIV- p o s
i-t i ve o r, i-t h e op p osii-te : ab sen ce o f in fe ci-tio n a fi-t e r a lo n g h ist o ry of co n t a ct . “Im a gin e th a t I sleep w it h som eo n e w h o h as AIDS. I d on’t k n ow if I’l l syst em a t ica lly be H IV- p o s i t i v e a ft er o n e a ct” (sin ce t h e re ar e fe w cit a t io n s fro m t h e in t e r -vie ws a n d t h ey we re ch osen for th eir e xe m p l a ry c h a ra c t e r, t h e y a re p re sen t ed a n o n ym o u s l y, in i t a l i c s ) . “W e’v e seen w om en w h o h a d got t en AIDS in on e w a y or a n ot h er, w h o liv ed w i t h th eir h u sban ds, w h o h ad n orm a l sex live s , a n d th e h u sba n d s n ev er got it .”In a d d it io n , a s with t h e c o n s u m p t io n o f t o b a cc o o r a lc o h o l, t h e co n se q u e n c e s co n n e c t e d t o e a ch e ve n t se e m le s s p ro b a b le b e ca u s e t h e y a re s e p a ra t e d in t i m e. “ It ’s a bit lik e w h en som eon e tells you :‘y o u s m o k e ,y o u’re goin g to get can cer in t w en ty, t h i r-ty or fort y yea rs,’i t ’s so fa r off. . .”
Bu t e ve n if t h e p re vale n ce ra t e in Fr an ce is o n e o f t h e h igh e st in Eu ro p e, AIDS rem ain s a n u n rea l, fa r-off t h rea t. Not h a vin g a cce ssib le ex-am p le s o f in fe ct io n m a ke s it ve r y a b s t ra c t .
“T h e re’s a lo t of t a lk a bou t AIDS , b u t sin ce w e d o n’t k n ow m a n y p eop le a rou n d u s w h o h ave it, w e sa y: ‘t h a t w on ’t h a p p en t o m e , a n d , s h e’s t w en t y yea rs old , s h e’s lik e m e, w h y w o u ld sh e h a ve AIDS?’. ‘ N ot k n ow in g p eop le w h o h a v e t h e illn ess or w h o a re HIV- p o s i t i ve ,i t ’s n ot re a l ,i t’s ve ry a bst ra c t , a n art istic blu r. . .’“
K n ow in g so m e o n e w h o is in fe ct e d a llo w s o n e t o re a l i ze t h e p re se n ce o f risk fo r o n e s e lf. Ye t , t h is d o e s n o t a lwa ys e lim in a t e co n t ra d i c -t io n s: “We a re a ll a t ri sk ,”sa id a wo m an in t e r-v i e we d , d e sp it e a n ea rlier re m a r k: “I k n ow th a t w o m en h a v e it . Am on g t h e p eop le I k n ow, o n l y m en h a ve it a n d it ’s t ru e th a t , for th em , i t’s con -n ect ed t o t h eir h om osex u a l a ct iv i t y. N ow i t ’s a h o r ror t h at can also to u ch m e.”
Sin ce risk is exp resse d in te rm s of p ro b a b i l-i t l-i e s, ce r t a l-in p e op le t h l-in k t h a t kn owle d ge o f ra t e s o f in fe c t io n o r e p id e m io lo gic a l d a t a a re n e c e s s a r y fo r a go o d e valu at io n o f r isk. Ye t th e se se em to b e e ith er in d ecisive or d istort e d . Peo p le a re p a rt icu la rly su sp icio u s of in fo r m a -t io n circu la -t e d b y -t h e m e d ia , e sp e cially in -t h e l ower cla ss (Paich ele r & Qu em in , 1994a). “T h e y t a lk t o u s a bou t AID S, a bou t t h e da n ger, b u t w e d o n’t k n ow w h a t w e sh ou ld d o, besid es p ro t e c t o u r s e l ve s , of cou rse. W h a t is t h e p ro p o rt ion o f dru g a d d ict s w h o h av e AIDS? W h o a re t h e p eo -p le w h o are m o st a ffect ed? W h ich a ges? Te e n s ? We’d lik e m ore d et ails a n d p ercen t a ges so a s t o k n ow w h ich p eop le a re m ost lik ely to h a ve it...”
Cad . Saúde Púb lic a, Rio de Jane iro , 15(Sup. 2):93-105, 1999 su ch . Co m p u t a tion al p rob le m s see m to b e fu ll
o f m e a n in g an d c o n t in u ally p u s h e d as id e.
“Th ey say th at th ey w an t to tell u s, yet w e liv e in a cou n t ry w h ere in fo rm a t i on ci rcu la t es a p r i-o ri. . . Th ey t ell m e t h a t t h ere a re 300,000 p eo p le w it h AIDS , bu t m a ybe t h ere a re a ct u a lly on ly 1 0 0 , 0 0 0 . . . It ’s p ossible th at t h ere are on e m illion a n d th ey don ’t w an t u s t o p an ic or th a t th ere are 100,000 a n d t h ey w a n t u s t o be ca re f u l .”Fo r s o m e, th e p re ss an d t h e gove rn m e n t con tri b u t e to t h e circu la tio n o f fa lse figu re s. The p roo f th a t t he y a re false lie s in t h e la ck of co h ere n c e. “We sh o u ld t ry t o get som e rea l st a t ist ics, som e re a l d a t a , som e tru e figu re s . Ma ybe t h e on es th ey give u s a re t ru e, b u t I d ou bt it beca u se on e da y t h ey g i v e u s on e figu re , th e n ex t an ot h er, so w e n eve r k n ow exa ct ly w h ere w e a re .”
It rem a in s ve ry d ifficult fo r m o st to eva l u a t e p erson al risk th rou gh a p ro b a b ilistic lo gic. T h i s is e ith e r b e cau se p e o p le d o n ot th in k t h at th e y h a ve e n o u gh o r re liab le e n o u gh in fo r m a t i o n ; b e ca u se n o n e o f th e ir a cq u a in t an ce s a re e xp e -rie n cin g t h e t h re a t first -h a n d , wh ich w o u ld m a ke it se e m m o re co n c re t e ; o r b e ca u se ru l e s a b o u t large n u m b ers h a ve lit tle u se for m an ag-in g e ve ryd ay life.
Pe rc e p t io n o f p e r s o n a l r is k is e la b o r a t e d le ss a c co rd in g t o sta tist ica l d at a t h a n in t er m s o f o n e’s ow n fe e lin gs o f vu ln e ra b ilit y a n d t h e p o ssib ilit y o f p ro te ct io n from d a n ge r. Do u gla s & Ca l ve z’s (1990) a n a lys is d ist in gu is h e s t wo f o r m s o f in d ivid u a l p r o te ct io n : “c o r p o ra l en -v e l o p e”an d “so cia l en v e l o p e”. A t h ird re g i s t e r s h o u ld b e a d d e d t o t h is a n a ly sis , t h a t o f t h e c a t a s t ro p h e , w h e n p ro t e c t io n b e c o m e s im -p o s s i b l e.
• C a t a s t rophe and the impossibility of pro t e c t i o n
In t h is first r e g i s t e r, d a n ge r is d r a m a t i ze d , e s -p ecially in th e low er class wh e re th e a va i l a b i l i-ty of in form a t io n is re d u ce d . The risk o f AIDS is f re q u en t ly p re sen te d , n o t ab ly in t h e m a ss m e -d ia , an -d p erc e i ve-d as a cata strop h e : a ti-d al w a ve th a t p ro g resses rap id ly an d re ach e s “e ve ryo n e” wit h o u t d isc rim in a t io n o r a n y p ar t icu la r re a -son . “ It ’s m ore t h a n a n illn ess, i t ’s a fa t alit y, i t ’s lik e a p la gu e fro m Egyp t t h a t h a s f allen ou t o f th e sk y. . . All of a su dd en , i t ’s an in credible sw ord of Da m o c l e s , th at m ak es th e p ossibilit y of dyin g p ressin g again , w ith ou t a n y solu tion or a n sw er.”
Th is d isco u rse evo kes t h e arb it ra ry, t h e u n co n t ro l l a b l e, an d b lin d lu ck. It is clea r t h at th e cat a s t ro p h e re gist e r b lo cks ra t io n a l u n d e rst an d -in g o f th e illn e ss. “Th is illn ess, i t’s lik e a lo tt ery, b eca u se it ca n h a p p en t o a n yon e... It ’s li k e a w h eel of fo rt u n e or m isfort u n e .”
Disco u rse s d evelo p ed accord in g t o t h e cat-a s t ro p h e re gist e r d r cat-a w o n n a r ra t i ve st h a t a re d e p l oye d in t wo d om a in s: ca ta st ro p h e - s c e n a r-ios an d r u m o r s. Th ese sto ries ser ve to in te rpre t e ve n t s b y c o n s t ru c t in g a ca u sa l p a t t e r n , t e m -p o ra l se q u e n c e s, b y -p ro vid in g im a ge s wh e n a b s t ract re f e re n ces are la ckin g, a n d by p ro d u cin g fee lcin g an d em o tio n s (Sarb cin , 1986; Po l k i n -h o rn e, 1988).
• Ca t a s t ro p h e - s c e n a r i o s, o f wh ich t h e re a re m u lt ip le ve r s i o n s, sh ow, in an a m b igu ou s way, t h a t it is p o ssib le fo r a ch ain of h igh ly im p ro b -a b le e ve n t s t o le -a d t o -a n in fe ct io n . Th e y -a re u su a lly c o n s t ru ct e d a c co rd in g t o t h e s a m e m o d e l: t h e in e vit a b le re c e p tio n o f i n f e c t e d b l o o d f ro m a n o t h e r u n kn own c o n t a m in a t in g p erso n . “ Im agin e I h a ve AIDS a n d I scra tch m y-s e l f, in fa ct , I’m bleedin g. I en joy a d rin k , g e t t i n g it a ll ov er t h e gla ss a n d t h e gu y beh in d t h e b a r com es t o p ick u p th e glasses. He h im self ju st cu t h im self cu t t in g lem on t o p u t in Perri er d rin k s. He t a k es t h e gla ss a n d h e get s i t [t h e viru s ].”
Th e s e im a ge s c o n firm t h a t AIDS s t rike s in a b lin d an d u n p re d ict a b le wa y.
• Ru m o r sa re a w ay o f e xp lain in g ele m en t s o f t h e illn e s s’ a p p a rit io n t h a t a re n ot a cc ou n t e d for b y a p p ro ve d fa c t s (Pa ich e le r & Qu e m i n , 1994b ). Th e y se e k t o e s t a b lis h t h e c au se s a n d t h o se “re s p o n s i b l e” fo r t h e ge n e sis o f t h e ill-n e s s. Th e y a re u su a lly iill-n fo rm e d b y iill-n t e gra t e d n o rm s, e s p e cia lly in Fra n c e , a b o u t t o le r a n c e an d n o n -d iscr im in a t io n , cen tral t h e m es in m e-d ia cam p aign s. T h e re are two kin e-d s of ru m o r s : • Peo p le t ra n s f o rm ve rifie d in fo rm at io n in t o ru m o r s, d em o n stratin g a social h yp er- v i g il a n c e. Th e fa ct th a t ce rta in gro u p s, n am e ly gays, we re d e sign a te d , is con sid e re d in d ica t ive o f a la b e lin g p ro ce ss t h a t m u st b e d e n o u n c e d a n d re -je ct e d . Th is d e sign a t io n o f “fa lse ly a ccu se d ” is b e l i e ved to m a sk t h o se wh o are rea lly re s p o n s i-b l e . “I t h i n k t h a t p eop le t ried t o b la m e t h e Bla ck s b eca u se t h ey w ere bla ck , h o m o s ex u a l s b eca u se t h ey w ere h o m osex u a l . . . Dru g ad d ict s a l s o, b e c a u s e , of cou rse dru g add icts are m ean ... I believ e t h a t p eo p le w a n t ed t o d iscred it t h ese g ro u p s .”
• O t h e r kin d s o f ru m o rs d ra w o n e rro n e o u s i n f o rm a t io n . Th e y a t t rib u t e AIDS t o b lu n d e r s o f s cie n ce t h a t a re u n fo r t u n a t e b e ca u s e t h e y t ra n s f o r m t h e n at u r al or d e r, o r t o vo l u n t a r y a n d d e st r u c t i ve a ct io n like b io lo gica l w ar f a re . Th is is a wa y o f d ra win g fr o m a r e p e rt o i re o f p e o p le p la u s ib ly re sp on sib le fo r t h e d iffu sio n o f t h e illn e ss : Am e ri c a n s, Na z i s, in d u s t ry, e t c.
Cad. Saúde Púb lica , Rio de Jane iro , 15(Sup . 2):93- 105, 1999
p u r p o s e , t h a t ’s ev en d eep er. Bu t , I’d ra t h er n ot t h in k a b ou t t h a t beca u se i t ’s cra z y.”Ru m o r s , wh ich re ly m o re o n c o n je ct u re t h a n c e r t a i n t y, a re ch a ra c t e ri ze d b y a c u m u la t ive d is co u r s e t h a t t o le ra t e s co n t ra d ic t io n . All p o ssib le h yp ot h e se s a re im agin e d an d ret a in e d , a n d co n -vict io n gat h ers s tre n gt h fro m th e so cial re a l i t y o f a d isco u rs e t h a t re i n f o rc e s it se lf a s it circ u -l a t e s.
Th e se t wo typ e s o f n a rrat io n , c a t ast ro p h e s c e n a r io s a n d r u m o r s, a re im p o r t an t for u n -d e rst an -d in g p h e n o m e n a o f in t e rp re t a t i o n . “Tellin g st ori e s” is a wa y o f ela b o rat in g re a s o n s fo r a ct ion s, in fe r rin g a n d re so lvin g p r o b l e m s, re ve alin g ca u se a n d e ffec t, crea tin g im a ge s fo r a f f ro n t in g a r b it ra r y a n d o p a q u e m e a n in gs , p rod u cin g d ram a tic feelin gs a n d e m ot io n s, b a-sica lly forcin g o n e se lf t o u n d erst a n d .
• P o rous bodies and individual vulnerability
Th e e vo ca t io n o f b o d ily flu id s – b lo o d , s aliva , s p e r m , o r va gin a l flu id s – o c cu rs in a n e m o -t io n a lly a n d s ym b o lic ally c h a rge d la n gu a ge ( Ro zin & Fa llo n , 1987). Th is in t erven tion of th e sym b o lic p la ces t h e d iscou r se of th e b o d y a n d b o d ily p r od u c t s in a s o cia l d im e n sio n . Si m u l-t a n e o u s l y, l-t h ese d isc o u rse s re fle cl-t l-t h e d o m a in o f b e lie fs a n d t h e fu n d a m e n t a l a m b igu it y b e -t ween d o u b -t a n d u n cer-t a in -t y -th a -t -t he y exp re s s. Th e e xp re s s io n o f t h e sym b o lic is n e ve r n e u t ral. It e vo kes stro n g im a ge s, fee lin gs, an d co m -m i t -m e n t s. Th e e vo ca t io n o f b o d ily flu id s c a n n o t o p e ra t e in d e p e n d e n t ly o f a visio n o f t h e wo rld , o f s yst e m s o f p re s c r ib e d b e h a vio r a n d i n t e rd i c t i o n s, o r fo u n d a t io n s o f a so c ia l a n d c o r p o ra l id e n tity, n or can it fu n ctio n se p a ra t e l y f rom t he powe rfu l e m o tion s a sso cia te d with it.
Th e b od ily p ro d u c ts with wh ich t h e m e a n s o f t ra n sm ission a re a sso cia te d are a t t h e h e ar t o f n o t io n s o f p o llu t io n a n d p u r it y a n d t h e ir c o r r e sp o n d in g m o ra l o rd e rs (D o u gla s, 1967; Ro zin e t a l., 1992). Th e se n o t io n s e n ge n d e r classifica t ion s t ha t a re at th e cen t er of world vi-s i o n vi-s. “ . . . (Po l l u t i o n p ow ers) p u n ish a sym bolic b reak in g o f t h a t w h ich is n ot lik ely to occu r ex cep t w h ere t h e lin es of st ru ct u re , cosm ic or so -c i a l ,a re -clearly d efin ed(...) A p ollu t in g p erson is a lw a ys in t h e w ro n g . He h a s d ev elop ed so m e w ron g con d it ion o r sim p ly crossed som e lin e w h ich sh ou ld n o t h a v e b een crossed a n d t h is d i sp la cem en t u n lea sh es d a n ger fo r som eon e e l s e” ( D o u g l a s, 1967/ 1996:136). Dis co u r se on b od ily flu id s is also a d iscou rse ab ou t th e wo rld a n d n a t u ra l o r d e r w h e re d a n ge r a r ise s wh e n t h in gs a re n ot in t h eir p la ce.
Th e n o tio n o f p o llu tio n is co n n e cte d with a glo b a l visio n of co n ta gio n t h a t a p p lies to m ore
t h a n ju st illn e s s. It c o n c e r n s a ll kin d s of c o n -ta cts with ot h er p eo p le, su b s-tan ces, o r ob je ct s. It assu m es th a t em an atio n d isen gages fro m t h e b od y a n d ca n a ct at a d is t a n ce. In t h is wa y, a ll co n ta ct is p o t e n t ia lly d a n ge ro u s b u t so m e , su ch a s th ose con n ect ed to b od ily ‘e n t ry ro u t e s’, m o re t ha n ot h e rs. “We sh ou ld exp ect th e orifices of t h e bod y t o sym boliz e its sp ecially vu ln era b l e p o i n t s . Ma tt er issu in g from th em ... by sim p ly is-su in g fort h (h a s) t ra v ersed th e bou n da ry of th e b o d y” (Do u gla s, 1996:145).
Discou rse ab ou t tran sm ission , wh ich e vo k e s t h e p o ss ib le im p lica t ion o f d iffe re n t flu id a n d b od ily ve c t o rs (b lo o d , s p e r m , vagin a l flu id s, s a l i va ), is fu n d am en t a lly a d isco u rse a b o u t th e “b od ily en ve l o p e”, t h e p orosit y a n d vu ln e ra b i ity o f t h e b o d y. It is a r ticu la t e d a ro u n d t h e fo l-l o win g c e n t r a l-l q u e s t io n : h ow co u l-ld t h e viru s p e n e t ra t e m y b o d y ? It is t h e re f o re n e c e ss a r y t o id e n t ify b o t h t h e “ve c t o r s” a n d t h e “e n t r y ro u t e s”. It is well kn own t h at t h e re a re t wo p ri n -cip al ve ct ors (se xua l a n d b lo o d -re late d ) b u t t he sexu a l t ra n sm issio n is p o o rly u n d e rst o o d . Ju s t as p e o p le h ave d ifficu lt y asso cia tin g se xu al re -lat io n s wit h d a n ge r, it is d ifficu lt fo r t h e m t o im agin e h ow th e viru s cou ld b e p assed from on e se xu al p artn e r t o an o th e r, n ot ab ly from wom e n to m en . “I t ota lly k n ow th at it is sex u ally t ra n s-m i t t e d , bu t I can’t is-m agin e h ow it h ap p en s.”T h e t ra n s la t io n fro m a b st ra c t ve ct o rs t o co n cre t e an d p ra ct ica l rea lit y is n ot an ea sy o pe ra t i o n .
Cad. Saúd e Púb lic a, Rio d e Jane iro , 15(Sup. 2):93-105, 1999 n or ext e rio r. “ Eve ry k in d of cu t, a n yt h in g op en ,
is a da n ger.”
Po p u la r re a so n in g a m p lifie s s c ie n t ific in -c e rt i t u d e. Ce rt a in n o t io n s t h a t a re e lab o ra t e d in a re s e a rc h e r’s office a re e asily n ot tra n sp o s e d in p o p u la r wisd o m . Th is is p articu la rly t h e case fo r th e n o t io n o f “t h e o re t ica l ri s k” in vo l v i n g t ran sm ission t hro u gh saliva . An in te r vie w cit a-t io n e xp res ses w e ll a-t h e a m b igu ia-t y a-t h a a-t ch a ra c-t e ri ze s c-t h e d isc o u rse su r ro u n d in g sa liva : “Ap -p a re n t l y, i t i s n o t t ra n sm it t ed t h rou gh sa liva . Ap p a ren t ly t h a t ’s cert a i n .”In sit u at io n s o f u n -c e rta in t y -co n -ce rn in g th e q u e st ion o f t ra n s m i s-sio n , p e o p le p r e fe r t o t a ke a sid e . Ul t i m a t e l y, th e d e cisio n is b a se d o n b e lie fs t h a t p ro f o u n d -ly in fo rm eve ryd a y life. “I w a n t t o th in k t h at be-ca u se I p refer to believe in t h a t. If it ’s n ot t ru e, i f t ra n sm ission ca n occu r th rou gh sa liva or sw ea t, h u m a n it y is doom ed.”
• T h reat to groups and social vulnerability
Pro t e c t io n b y vir t u e o f b e lo n gin g t o a p a rt i c -u la r s o c ial gr o -u p is s o m e t im e s c h a ra c t e ri ze d b y a s t r u c t u re d a n d va lu e d c o m m u n it y id e n -t i -t y a n d , m o s-t o f-t e n , b y a “c o u n -t e r- i d e n -t i -t y ” i n wh ich p eo p le a ttr ib u te ch a ra c t e r istics a n d a c-t ion s c-t o c-t h e m se lve s c-t h a c-t e xclu d e c-t h e m fro m g ro up s “c o n c e rn e d” by AIDS. Wh en co m m u n i-t y c o h e sio n is we a k a n d i-t h e re f o re co n i-t r i b u i-t e s litt le or n o th in g t o stru c t u rin g id e n tity o r gu id in g a ction , it is n o t p erc e i ve d a s p ro t e c t i ve. Be -ca u se o f th is, so cia l p ro t e ct io n is o ft e n lim it e d to th e fa m ily o r clo se fri e n d s.
Pe rce pt io n of r isk h e re is gro u n d ed in s o c i a l i d e n t i t i e s, a sso cia t e d w it h s o c ia l c a t e gor i e s wh o se vu ln e r a b ilit y is o b vio u s b e ca u se t h o s e wit h in t h e m a re p e rc e i ve d a s livin g o u t sid e o f or e ve n t ra n s g re ssin g n o rm s (Cra w f o rd , 1994; Sch iller e t al., 1994). Ep id em iologica l d iscou rse s a b ou t “risk gro u p s” rrse ap p rse ar h rse rrse in an o b -viou sly co n t ra d i c t o r y fo rm sin ce p eo p le sim u lt a n e o u s ly a d h e re lt o lt h e n or m lt h a lt “AIDS con -c e r n s e ve r yo n e”. “AID S st a rt ed in Am e r i c a : i t w as ju st ga ys w h o got it. It didn’t scare p eop le; i t on ly tou ch ed on e ca t egory of p eop le. A f t e rw a rd s , t h ey sa y it w a s t h e d ru g a d d i ct s w it h syrin ges. An d t h en , n ow , I k n ow t h a t i t ca n st rik e o t h er p e o p l e ,e ven th ou gh t he on ly p eop le t h at I k n ow w h o h a v e AIDS a rou n d m e a re h om osex u a ls or dru g a dd ict s.”
Co n f o r m it y is e xp e rie n ce d a s p ro t e c t i ve a n d d e via n ce as exp o su re t o d a n ge r. To b e a n d b e h a ve “like e ve ryo n e e lse” is co n tra st e d wit h id e n t it ie s a n d a c t io n s o f p a rt icu la r gro u p s.
“Righ t n ow , if you beh a v e n o rm ally, e v en if you a re in th e p resen ce of so m eon e w h o is HIV- p o s i-t i ve , I d on’i-t see h ow you can h a ve ii-t.”Re s t ri c t i n g
AIDS to p articu lar gro u p s a llow s p e op le to fu r-t h e r re a s s u re r-th e m se lve s r-t h a r-t r-t h e se gro u p s a re clo se d off, wh ich is m ore th e case for ga ys t h an for u sers of in je ctab le d ru g s. T h u s, th e im age o f t h e b is e xu al cr y s t a l l i ze s in d isc e rn ib le d an ge r.
“A sin gle h om osex u a l , w h o t a k es risk s, w h o t ak es n o p re c a u t i o n s , h e kn ow s w ha t h e’s d oin g, bu t h e o n ly in vo l v es h im self a n d h is p a rt n e r. Bu t I rea lly t h in k t h a t gu ys w h o a re bi sex u a l , w h o h a v e w iv es a n d k i d s, a re a w fu l.”Bl u r re d ca t e -g o ri e s , fu zzy b o u n d a r i e s, o ve r st e p p e d lim it s , b o th in te rm s of id en tity an d social b o d y: t h re a t e m e rge s wh e n t h e wo rld o rd e r is sh aken .
II) M anaging Risk
• Aspects of risk management
Ma n a gin g t h e ris k o f s e xu a l t ra n sm is sio n o f AIDS va r ie s d ep en d in g o n wh et h er on e is m a le o r fe m a le, you n g or o ld , a n d wh e th e r on e live s in a fin an cia lly a n d p ro fession ally sta b le wo rld o r o n e in wh ich p re c a rio u sn e ss is a n o m -n i p re se -n t t h re a t . Ac t io -n s re p o r t e d d u r i-n g t h e i n t e rvie ws form a ve r y co m p o sit e p a le t te. Se ve ra l fact o rs co n vve rgve t o con t rib u t ve t o p ar t i c u -la r co n figu rat io n s a t an y give n m o m en t . T h e s e in clu d e : re p re se n t a t io n s o f th e b od y; id e n t it y; fe e lin gs o f vu ln e r a b i l i t y, s e cu r i t y, o r e ffic a cy; p o sitio n in a sexu a l tra j e c t o ry; r isk p erc e p t i o n ; s u b j e c t i ve d ista n ce fro m t h e illn e ss; e th ica l ori-e n t a t i o n s, ori-e t c. Kn owlori-e d gori-e p rob a b ly a lso in t ori-e r-ve n e s, b u t in d ire c t l y. On t h e o t h e r h a n d , t h e c o n n e ct io n b e t we e n risk p e rce p t io n a n d b e -h a vio r se em s m u c-h cle are r (Pa i c -h e l e r, 1996).
In d ivid u a l a n d in t e ra c t i ve st ra t e gie s co m -b in e t o co m p o se a co m p le x c olle ct io n o f r i s k m a n a ge m e n t m e t h o d s. On t h e o n e h a n d , t h e d i ve rsity o f action s d e p e n d s on risk p erc e p t i o n a n d th e co n st rain t s a n d re s o u rce s o f t h e situ a -t io n . On -th e o -th e r h an d , -t h e fe elin g o f secu ri -t y u lt im a t ely p rovid ed b y t h e se st ra te gie s c a n b e lin ked to kn ow l e d g e, bu t it is also associated with a visio n o f t h e wo rld a n d o f o n e se lf a n d w it h a con ception of on e’s self efficacy (Ba n d u ra, 1992). Typ e s o f r isk m an age m e n t ca n b e d iffere n -t ia -t e d in -to -th ree ca-t e go rie s: p re ve n -t i ve, fo cu s-in g o n co n d o m u se a n d n ecessarily s-in tera c t i ve ; p ro t e c t i ve, p ri o rit izin g in d ivid u a l fo rm s o f ri s k m a n a ge m e n t like a b st in e n c e, wait in g, s e le c-t ion o f p a rc-tn er s; o r m ixed , co m b in in g con d o m u s e wit h o t h e r fo rm s o f p ro t e ct io n d e p e n d in g o n th e situ a tio n s a n d in t e ra c t i ve cap acitie s.
Cad. Saúd e Púb lica, Rio d e Jane iro , 15(Sup. 2):93-105, 1999
Th is feelin g of secu rityd oe s n o t o n ly d ep en d on t h e a ct io n s p e rf o r m e d . It is a lso a sso cia t e d with t h e ir risk p erc e p t i o n, which is in form ed by fe e lin gs o f p e rso n a l o r so c ia l vu ln e ra b i l i t y, in t u rn lin ke d t o earlie r e xp er i e n c e s. Th is pe rc e p t io n co n d it io n s w h e t h e r on e fe e ls o n e is c o n t ro llin g t h e ris k. Still, a ct io n s a re n ot o n ly d e -p e n d en t on -p e rc e -p t i o n s, b u t a re a lso su b o rd i-n a t e d t o t h e c o i-n st ra ii-n t s a i-n d re s o u rce s t h a t c h a ra c t e ri ze t h e sp e c ific s it u a t io n s in wh ic h t h ey t a ke p la ce. Fe e lin gs o f se cu ri t y, wh ich ca n e ffe ct vu ln e ra b ility a n d r isk m a n a ge m en t, va ry in st re n gt h d e p e n d in g o n t h e in t e n sit y o f t h e p e rce p t io n o f r is k a n d t h e p o ss ib ilit ie s t h at a g i ven act ion will b e m ore o r less ad e q u a te. T h e c o m p o n e n t s of r isk m a n a ge m e n t fo rm a d y-n am ic syst e m iy-n wh ich a ll o f t h e e le m e y-n t s a re in con st an t in t era ctio n (se e Fi g u re 1).
• Examples of ways to manage risk
Fi ve e xe m p la r y ca se s w ill b e p r e se n t e d h e re . Th e first co n sist s o f a ra t io n a l w a y of u s in g a co n d o m , in fo rm ed by a b a lan ce d p erce pt io n of
risk. Two o th er ca ses d e m o n strate co n d om u se t h a t , w h ile s yst e m a t ic, is n o n -r at io n a l, e it h e r b eca u se it is sit u at ed in a co n te xt of d ra m a t i z a tio n o r b eca u se soc ial vu ln era b ilit y is e xa gger -a t e d . In t h e fo u r t h c-a s e, p e o p le d isp e n se wit h u sin g co n d om s b eca use th ey fe el se cu re with in t h e ir s oc ia l c irc l e. Fi n a l l y, t h e d o m in a t e d a n d d e p e n d e n t ca s e, wh ich is ch a ra c t e r ist ic o f wo m en , illu stra te s t h a t p re ven t ion n egot ia tio n is n o t a lwa ys p ossib le.
• C o n t rol, eff i c a c y, securit y
Wh en p re ve n t i ve a ct io n s p ri o ri t i ze syst e m a t ic co n d om use, t h e y sh o u ld crea te a fe elin g of se -c u rit y a n d m a st e ry a llow in g for t h e d issip a tio n of a n xie t y. Th is is e m b le m a t ic o f t h e ra t i o n a l a p p ro ach e n visio n ed in p re ven t io n ca m p a ign s, c h a ra c t e ri ze d b y a m e a su re d a n d re a s o n a b l e c o n t ro l o f r isk. Th e fe e lin g o f vu ln e ra b ilit y is m o d e ra t e d a n d c o n d o m u s e is c o n s id e re d t o b e b o t h s im p le a n d su re. It a llows o n e t o b ot h d e a l w it h r is k a n d c o n t in u e t o h a ve a d ive r s i fie d se xua lity, in wh ich a ll kin d s o f sexu al re l a
-F i g u re 1
Co mp o ne nts o f risk manag e m e nt.
P e rc e p tio n o f mo re o r le ss c o n t ro llab le risk
F o rms o f vulne rab ility: to tal (c atastro p he ), b o dily and / o r so c ial
Strate g ie s o f risk m anag e m e nt: - p re v e n t i o n
- p ro t e c t i o n - mixe d
Variab le fe e ling o f se curity i n f o rme d b y actio n
Cad. Saúde Púb lic a, Rio d e Jane iro , 15(Sup . 2):93-105, 1999 t io n s ca n b e e n visio n e d wit h o u t h a vin g t o ask
wh e t h e r o r n o t o n e’s p a rt n e r is H IV- p o s i t i ve. We sh ou ld st re ss t h a t t h is kin d of t r a n q u il ra -tio n alit y is q u it e ra re.
Sa ra h , a 20-ye a r-o ld , m id d le -cla s s co lle ge st u d e n t , p r ais e s t h e re a ct io n t o t h e th r e a t of AIDS, even t h ou gh sh e says sh e ha s n o id e a h ow AIDS is se xu ally t ran sm it ted : “Th e on ly t h in g t o do righ t n ow is t o b e ca re f u l , t o u se a con dom ,”
in t h a t t h e gro u p wit h w h ich s h e id e n t ifie s, yo u n g p e o p le , d a t e a lo t o f p e o p le a n d fr e q u en tly ch an ge p ar t n e r s. Un like b lo od t ra n s f u -s i o n -s, w h ich are im p o -s-sib le t o con t ro l, p e o p le “c h o o s e” wh et h e r o r n ot t o t a ke risks in se xu a l re l a t i o n s. Howe ve r, sh e d e p lo re s th e n e ce ssit y o f h a vin g t o n e go t ia t e, so m e t im e s fir m l y, t h e u se of con d om s with “b oy s”wh o a re “ i n c a p a b l e o f t a k i n g i t ou t of t h ei r p ock et .”Th is give s h e r t h e im p re s sio n o f b e in g “ f o rced t o fi gh t a ll o f th e tim e.”Con d o m s favor sh are d re s p o n s i b i l i t y a n d exch an ge b e cau se it ta kes two to use t h e m , an d u sa ge a llo ws o n e t o a cc e p t on e’s p ar t n e r
e ven if h e/sh e is in fect ed .In th is wa y, Sa rah is a n exam p le o f rea son e d p re ven t ion a s sp e cified in m ed ia ca m p a ign s. Howe ve r, h e r d et erm i n a t i o n is n o t in fa llib le . Like o t h e r re gu la r c o n d o m -u s e r s, sh e a d m it s th a t sh e so m etim es “l e t ’s h er-self go,”wan t in g t o “forget abou t AIDS,” : “s o m e-t im es e-t h ere are la p ses.”Wh ile h er risk m a n a ge -m e n t s t ra t e gy is c o n s ist e n t wit h t h e co n ce p t , p ra is e d b y t h e m a ss m e d ia , o f sa fer sex, h e r “ l a p s e s” d e m o n st ra t e we ll t h e lim it s o f t h is f o r m o f risk m a n a ge m e n t a n d t h e a sso c ia te d fe e lin g o f se cu ri t y. Th is fe elin g can le a d t o ri s k d ist an cin g. Co m p a ra b le fin d in gs e m e rge in t h e h o m o s e xu al p o p u la t ion p ra ct icin g s a fe r se x (Sch ilt z & Ad a m , 1995).
• Dramatizing the risk and re i n f o rced s e c u r i t y
Syst e m a t ic co n d om u se d o e s n o t a lwa ys m it i-gat e t he un ce rt ain ty co n n ect ed t o t h e visio n of AIDS a s a n e xc e s s i ve a n d u n c on t ro lla b le d is-e a s is-e. All fo r m s o f p ro t is-e ct io n p rovis-e a s in s u ffi-cien t as b o d ily an d / o r so cia l “e n ve l o p e s” se em f ra g i l e. Di s t ru st tow a rd s all p ote n t ia l p artn ers is g rea t. Con d om s a re u sed b u t th is d oes n ot lessen t h e fe ar o f in it ia t in g co n t a ct wit h H IV- p o s i t i ve p e o p l e . Pe r so n s in u n st a b le a n d fra il s it u a tio n s sh ow th is d ram at iza tion , like Mu riel, a 3 2 -ye a r-old cop y w ri t e r, wh o h a s ju st gon e th ro u g h b rea kin g o ff a lon g a n d sta b le re l a t i o n s h i p .
Sh e u se s a d isco u rse t a in t e d wit h c at a st ro -p h e b eca u se “n o on e is sh elt ere d ”a n d it’s “a bit lik e a lottery,”a “ Ru ssian ro u l e t t e .”Sh e live s in a m ilie u wh e re se ve ra l p e o p le h ave t h e vir u s, p e o p le o f h e r a ge, e xc l u s i ve ly m e n , a ll h o m o
-sexu al. Sh e com p lain s ab ou t th e u n cert ain ty o f a vailab le fact s: “T h e re’s a lw ays som eth in g th at’s n ot clea r, e ven in th e p h a rm acy p a m p h let s. Yo u rea d t h em a n d sa y in t h e en d : you sh ou ld ju st st o p h a v in g sex en t i re l y.”Th e illn e s s c au se s
“p s y c h o s e s .” ‘T h e re w i ll a lw a ys be p orou s ru b-b ers t h a t let th in gs th ro u g h ,”so t h a t o n e o f h er f rie n d s t old h e r t h a t it’s b e t t e r t o u se t wo c o n -d o m s, o n e o n t op o f t h e o t h er, a p ro sp e ct th at s t r ike s h e r as in t o le ra b l e . Wh e n re fle c t in g o n t h e r is k lin ke d t o s e xu a l p ra ct ic e s o t h e r t h an p e n e t ra t io n , s h e wo n d e rs if it is n e ce ss a r y t o
“p u t ru bbers on yo u r t o n gu e t o k iss”a n d co n -clu d e s t h a t “w e ca n’t be su re of a n yt h i n g a n y-m o re .”In a n y c a s e , sh e r e fu se s t o u se a co n -d o m -d u r in g fe lla t io a n -d wo n -d e rs if sh e is n o t t a kin g a risk in so d oin g. In ad d it io n t o cu m u la t in g p ro t e c t i ve b e h a vio r, sh e p e rf o r m s fre q u e n t m ed ica l te st s for a grea te r se n se of se cu -ri t y. Th e e xa m p le o f Mu r ie l d e m on st ra t e s h ow co n d o m s ca n p ro te ct wit h o u t n e ce ssa rily p ro -vid in g a fee lin g o f se cu ri t y.
• P rotection in an uncertain world
Co n d o m u se ca n b e co n sid ere d co n st it u t ive of ta kin g in itiative in an u n certa in world , in w h i c h it is fo o lish t o b e lie ve an d h a ve co n fid e n c e in o t h e r s. On e ca n on ly co u n t o n on eself in facin g t h is d a n gero u s wo rld . Th is p o sitio n ap p ea rs t o b e c h a ra c t e r is t ic m o s t ly o f t h e wo rkin g c la s s. Usin g a co n d o m is t h u s p re se n t e d a s a n a b -s o lu t e im p e ra t i ve t o wh ich n o e xce p t io n -s a re p o s s i b l e, b u t th is d oe s n o t m ea n t h a t o n e fe els s u fficie n t ly p ro t e c t e d . Livin g in an u n ce rt a i n wo rld p ro d u c e s, a s Ho g g a rt (1957) d escr i b e s, a h a b it u s in wh ich p e o p le cre a t e islan d s o f co n -t ro l a n d sm a ll s -t re -t c h e s of lib e r -t y, in a w o r ld d o m in a t e d b y o t h e r p e o p le a n d o u t s id e cir -c u m s t a n -c e s. Th is life se e m s risky e n o u gh a l-read y so t ha t on e d oes n ot t ake ad d ition a l ri s k s u n n e c e s s a ri l y.
Ro d o lp h , a n u n e m p loye d 19-ye a r-o ld , e x-e m p lifix-e s t h is st ra t x-e gy o f r isk a d ap t a t io n . Hi s world is filled with d a n ge r, o f wh ich AIDS is on -ly o n e in ca rn at io n of e ve ryd ay m is e ry. He h a s t o co u n t p ri m a rily o n h im s e lf t o u se wh at e ve r m e a s u re o f c o n t ro l h e ca n , e ve n re l a t i ve, o ve r t h e c o u rse o f e ve n t s. Usin g a co n d o m is a n
a-Cad. Saúde Púb lica , Rio de Jane iro , 15(Sup . 2):93-105, 1999
son in g p reced e s as fo llows: fa ce d with a n eve n -t u a li-ty -th a-t is se riou s a n d co s-t ly, h e op -ts for -th e b e h avio r t h a t a s su re s t h e m o st se cu r it y p o ssib l e . In t h e e ve n t t h a t h e d id n o t h ave a co n -d o m , h e w ou l-d go w it h o u t t h e se xu a l in t e r-c o u r s e . “T h a t ’s w h a t ’s sca ry, d yi n g b eca u se of t h a t , for a stu p id m ista k e, beca u se on e da y you d i d n’t p u t on a con d om .”Still, life is rou gh in “a ro t t en w orl d .”Co n d o m s p r ot e c t , b u t n o t fro m e ve r yt h in g. Th ey a re n o t in fa llib le. Eve n wh e n h e sleep s wit h a girl with a con d om , h e st ill h a s
“a sligh t re g re t” : “I h op e t h a t t h ere isn’t a h ole, t h a t t h e ru b ber h a sn ’t t o rn .”Wh e n t h e se n t im en t of d an ger is stron g, it’s n ot p ossib le to en -t ru s-t -t h is o b je c-t w i-t h o n e’s life wi-t h o u -t fe e lin g s o m e u n e a s in e ss: “ It ’s n ot re l i a b l e , i t ’s on ly p l a s t i c .”
Pre ven t io n strate gies ce n t ere d on con d o m s a re co m m o n , b u t t h e y ca n h a ve se ve ra l sh o rt -c o m in gs re l a t i ve t o e m b le m a ti-c ra t i o n a l i t y. As t h e a b ove ca se s d e m o n st r a t e d , t h is m a n age -m e n t is n o t n e c e s sa r ily gro u n d e d in a cc u ra t e k n ow l e d g e, a ju st an d m e asu re d visio n of ri s k , n or is it wit h ou t co n tra d i c t i o n s. It ca n a lso op -e ra t -e in o b s cu rit y o r in p a n ic. Wh -e n ris k is -e x-a g g e rx-a t e d , th e n ee d fo r p ro t ec t io n cx-an x-a p p e x-a r h ighly im p era t i ve t o so m e.
• Social Pro t e c t i o n
Wh e n on e’s so cia l m ilie u is re a s s u rin g, st a yin g w ith in it p re s e rves on e from d a n ge r. First o f all, t h is d icta t es a void in g a n y p o ssib le re l a t i o n s h i p w it h s o m e o n e wh o is H IV p o s i t i ve (Ma t i c k a -Ty n d a l e , 1992), wh ich c o u ld o n ly h a p p e n in u n u su a l sit u at io n s. Avo i d a n c eco n st it u te s o n e d im en sio n of th e sexu a l re s t r i c t i o nth at cha ra c-t e ri ze s c-t h e se sc-trac-te gies: avo id in g e n cou n c-t ers in c e r tain p lace s (esp e cially b a rs a n d n igh t club s), in ce rt a in c ircu m st a n ce s wh e re so cia l co n t r o l is d im in ish e d , with certa in c a t e g o r i e sof p eo p le (e sse n t ia lly d ru g a d d ict s, b ise xu als, t h o se wh o h a ve se x wit h se ve ra l p a r t n e r s, a n d p ro s t it u ite s), wh o are con sid e re d d a n ge ro u s. Ca it e g o -rizin g p e op le a n d p lace s is a way o f se p a ra t i n g t h e fa m ilia r, kn ow n , n o rm a l, re a s s u r in g, a n d w o r t hy o f co n fid e n ce fro m t h e worri s o m e, fo r-e ign , stra n g r-e , a n d ab n orm a l .
Twe n t y- ye a r-o ld Te re n c e , wh o is fro m a p rivile ged b ackgro u n d , cat ego rica lly refu se s t o u s e a co n d o m . “I d o n’t lik e h a v i n g sex u n d er c e l l o p h a n e , a n d I p refer t o a b st a i n f rom sex w i t h som eo n e w h om I con sid er t o be a t risk .”
H e is c o m fo r t e d b y t h e fa ct t h a t h e o n ly fre -q u e n t s a “m i l i e u ”t h at h e“k n ow s ,”h a s “t ra d i -t io n a l a ss o c i a -t i o n s”wit h p e o p le h e’s“k n ow n si n ce k i n d erga rt e n . . . in t h e sa m e circ l e ,”i n which h e fee ls in tegrat ed , su p p o rt ed , an d re a
s-s u re d . He n e ve r go e s-s a lo n e t o s-s u ch p la ce s-s o f p e rd it io n a s n igh t c lu b s. Gi ve n “t h e sli gh t est d o u b t ,”h e wo u ld a b st ain a n d “t a k e h is d i s-t a n c e”b e ca u se “t h e re is n o p o in t i n m a k in g l ov e”u n d e r su c h con d it io n s; h e co u ld n o t e n -j oy it . For h im , as for m a n y ot h ers, t he n ecessi-t y o f p re ve n ecessi-t io n is lim iecessi-t e d ecessi-t o ecessi-t h os e wh o h a ve se x wit h la rge n u m b ers of d ifferen t p ar t n e r s. In a d d it io n , h e t h in ks h e ca n t ru st a p p e a ra n c e s :
“Th e w a y som eon e loo k s giv es you a good id ea of th e p eop le th ey fre q u e n t .”On t he oth e r h an d , p a ra d ox i c a l l y, s im p ly e n jo yin g a re l a t i o n s h i p wit h so m e o n e m a ke s an y kin d o f p re c a u t i o n u n n e c e s s a r y. “ If you ’re w i t h som eon e you lik e, w i t h w h om you w a n t t o sp en d t im e a n d m a k e l ove , th a t m ea n s you tru st h er.”
Avoid a n ce st ra t e g i e s, wh e re co n d o m u se is d e n i g ra t e d a n d re je ct e d , a re co m m on a m o n g p eo p le wh o d o n o t h a ve a sta b le p a rt n e r, o ft e n h a ve co n sid e rab le s o cia l a n d cu lt u ra l ca p it a l, a n d t h in k t h e y ca n c o n t ro l risk w it h st ra t e g i e s th at a re far from ju stifyin g t h e ir fee lin g o f secu -rity a n d ce rt a i n t y.
• Dependence and b r i c o l a g e: women and contro l
Cad. Saúde Púb lic a, Rio de Jane iro , 15(Sup . 2):93-105, 1999 Fo r T h é r è s e, a 38-ye a r-o ld sin gle se cre t a r y
wh o co n sid e rs h er se lf “t h e ep it om e of t h e n on -i n f o r m e d ,”d a n ger is b o th o m n ip resen t a n d u n -c o n t ro l l a b l e. AIDS is a re al “t h re a t ,”a “c o n c e r n,” b e ca u s e sh e kn ows t h a t sh e h a s t a ke n risks in h e r “v e ry d isp ersed ”se x life . Sh e d o e s n o t h a ve t h e co m fo rt of “th e con fiden ce of a sta b le re l a-t i o n s h i p.”“W e can k n ow w h a a-t p reca u a-t ion s w e sh ou ld t a k e, bu t t h a t d oesn’t m ean w e ca n a ct on t h em . Th in gs d on’t a lw ays w ork o u t w it h ou t a h it ch .”Sh e sa ys sh e u su a lly h a s co n d o m s o n h e r, b u t t h a t “som et i m es t h i n gs h a p p en t oo f a s t ,”a n d s h e d o e s n o t a lwa ys “p a y a t ten t ion .”
Wh a t b o t h e rs h e r m o st is t h a t o n e h a s t o u s e th em “in t h e v e ry begin n in g,”d u rin g th e u n ce r-t a in a n d u n d e r-t e r m in e d m om e n r-t of a m o ro u s con q u e st . De s i re is t h wa rte d w h e n calcu la t io n a n d p la n n in g t ake ove r t h a t wh ic h o n e wo u ld like t o co n sid e r u n p re d ict a b le or im p r ov i s e d .
“ It ’s d efin it ely t ru e t h a t ju st bein g rea d y t o a n -ticip at e in t h at w ay m ak es you less in to it... Yo u h a ve t o th in k a bou t th ose k in d s of t h in gs ca lm -l y, bu t t h a t a -lm o st -lea d s you t o ren o u n ce a -lt o-g e t h e r.”In a d d it ion , con d om s “lim it th e ro m p,”
p a rt icu la r ly fe lla t io : “if i t ’s w i t h a co n do m , I w o n’t d o it.”Sin ce th e t est h as t o b e “p e rf o r m e d a ga in ev e ry d ay,”th e on ly “re m e d y”wo u ld b e fi-d e l i t y, b u t t h a t is n ot a fi-d a p t e fi-d t o h e r sexu al ac-t i v i ac-t y, b e cau se sh e is n o ac-t p ar ac-t o f “a st a ble cou p l e .” “We’re a lw a ys rea d y t o d o w it h ou t con -d o m s ,”sh e sa ys, re ve rsin g a co m m o n s lo ga n . Sh e h ate s t o h a ve to d e m a n d th e m so m et im e s, w h ic h le a d s h e r t o c on sid e r t h a t h e r love rs d o n o t p ra ct ic e p re ve n t ion a n d t h a t t h e y “c o u l d get st u ff a n d t h en t ran sm it it .”Fo r h e r, d a n ge r is e ve ry w h e re, am o n g h er p rob ab ly im p ru d e n t l ove r s, in d iffe re n t co n ta c t s a n d d ive r se p ra c-t i c e s. Sh e c-t r ie s c-t o h a n g o n c-t o c a c-t e go ri z a c-t i o n t h a t p rove s n o t t o b e ve ry re a s s u rin g: “as lon g as so m eon e isn ’t a ju n k ie or a h om osex u a l ,y o u th in k th at h e’s a lread y less at risk , bu t t h at’s n o t t r u e .”Sin c e h e r love rs wo u ld o n ly s a y “w h a t t h ey w a n t t o sa y,”so t h a t sh e ca n n o t t ru s t t h e m , s h e t h in ks sh e h a s t o “d o a ll sh e ca n ”– u s e co n d o m s o r ab st a in – b u t d o e s n o t re a l l y d o t h is. “ In fa ct , t h e w h ole t h in g for m e bo ils d ow n to th is: absta in or tak e th e risk .”
An o t h e r e xa m p le o f d e p e n d e n t fe m in in e s t ra t egie s in vo l ves wo m en wh o a re in vo l ve d in s e riou s re l a t i o n s h i p s, d o u b t t h e ir p a rt n e r’s fid e l i t y, b u t re fu s e t o je o p a rfid i z e t h e ir re l a t i o n -sh ip s by ad d ressin g t h e q u e stio n d ire c t l y. No t e t h a t m o re wo m e n d o u b t t h e fid e lit y o f t h e ir p a r t n e r t h a n m e n , wh o t e n d t o fe e l e xt re m e l y p rote ct ed wh en th ey a re in vo l ve d in seriou s re -l a t i o n s h i p s. T h u s , 20-ye a r-o -ld Co r rin e d ra g s h e r co m p a n io n t o give b lo o d so a s t o a ss u r e h e rse lf of h is se rological st at u s. Ju l i e, a 38-ye a
r-o ld d e s ign e r, is lr-o ya l t r-o h e r a p p are n t ly fickle c o m p a n io n . Be ca u se o f t h is, sh e p ro t e c t s t h e fa m ilia l p e ac e b y re gu la rly ve r ifyin g h e r ow n s e ro logical sta tu s.
C o n c l u s i o n
Cad . Saúde Púb lic a, Rio de Jane iro , 15(Sup. 2):93-105, 1999
R e f e re n c e s
A R M S T RONG, D., 1993. Pu b lic h e alt h sp a ce s a n d t h e f a b r icat io n of ide n t it y. S o c i o l o gy, 27:393-410. B LOOR, M., 1995a . Th e Sociology of HIV Tra n s m i s s i o n.
Lo n d o n : Sa g e.
B LOOR, M., 1995b. A u ser’s gu id e to con trast in g t h e o -rie s o f H IV- r e la t e d ris k b e h a vio u r. In : M e d i c i n e , H ealt h an d Ri sk ( J. Ga b e, e d .), p p . 19- 30, Ox-f o rd / Ca m b rid ge: Bl a c k we ll Pu b l i s h e r s.
B LOOR, M.; Mc K E G A N EY, N.; FINLAY, A. & B A R N A R D, M., 1992. Th e in a p p ro p riat e n e ss o f p syc h o - s o c i a l m o d e ls o f r isk b e h a vio u r t o u n d e rst a n d in g H IV-re la te d r isk b e h a vio u r a m o n g Gl a s g ow m a le p ro s-t i s-t u s-t e s. AIDS Ca re, 4:131-137.
BAN D U RA, A., 1992. A so c ia l c o gn it ive a p p ro a c h o f t h e e xe rc ise o f co n t ro l ove r AID S in fe c t io n . In :
Ad olescen ts an d A IDS: A Ge n e rat ion in Je o p a rd y
(R. J. Di Clem e n te , e d .), p p . 86-116, Lo n d on : Sa g e . CAM PBELL, C. A., 1995. M ale ge n d e r role s a n d se xu -a l i t y: Im p lic-a tion s fo r wom en’s AID S risk -a n d p re-ve n tio n . Social Scien ce an d M e d i c i n e ,4 1 : 1 9 7 - 2 1 0 . C A ROVA N O, K., 1991. Mo re t h an m o th e rs a n d w h o re s : Red efin in g th e AID S p re ve n t io n n e ed s of wo m en .
In tern a tion a l Jou rn al of H ealt h Se rv i c e s, 21:131-1 4 2 .
C R AW F O R D, R., 1994. Th e b o u n d a rie s o f t h e self a n d t h e u n h e a lt h y o t h er : Re fle c t io n s o n h e a lt h , cu l-t u re a n d AIDS. Soci al Scien ce a n d M e d i c i n e, 38: 1 3 4 7 - 1 3 6 5 .
D O U G LAS, M ., 1996. Pu rit y a n d Da n g e r : An An a l y -si s of t h e Con cep t of Pollu tion a n d Ta b o o.Ha r -m o n d s w o rt h / Mid dle se x: Pen gu in Bo o k s. D O U G LAS, M., 1992. Risk an d Bl a m e : Essa ys i n Cu
l-t u ral Th eories. Lo n d on / New Yo rk: Ro u t l e d g e. D O U G LAS, M . & CALVEZ, M ., 199 0. Th e se lf a s r i s k
-t a k e r: A cu l-t u ral -t h e o ry o f co n -t a gio n in re la-t io n -t o AIDS. Sociological Re v i ew, 38:445-464.
D O U G LAS, M. & W I L D AV S K Y, A., 1982. Risk an d Cu l-t u re .Be r ke le y/ Lo s An ge les: Un i ve rsit y o f Ca l i f o r-n ia Pre s s.
FEE, E. & KRIEGER, N., 1993. Un d e r st a n d in g AID S: Hi s t o r ic a l in t e rp re t a t io n s a n d t h e lim it s o f b io -m ed ical in d ivid u alis-m . Am erica n Jou rn al of Pu b -lic He a l t h, 10:1477- 1486.
FISHBEIN , M . & AJZEN , I., 1975. Be l i e f, At t i t u d e , In -ten t ion a n d Be h a v i o r : An In t rod u ct ion t o T h eory an d Re s e a rc h .Rea d in g: Ad d i s o n - We s l e y. GABE, J., 1995. He a lt h , m ed icin e a n d r is k: Th e n e ed
for a so cio lo gica l a p p r oa ch . In : M e d i c i n e , He a l t h an d Ri sk( J. Ga b e , e d .), p p . 1 18, Oxfo rd / Ca m -b ridge : Bl a c k we ll Pu -b l i s h e r s.
G R E CO, M ., 199 3. Ps ych o s o m a t ic su b je ct s a n d t h e “d u t y of t h e will”: Perso n al age n cy wit h in m ed ical ra t i o n a l i t y. Econ om y an d Society, 22:357-372.
H AYES, M. V., 1992. On t h e ep ist e m o lo gy o f risk: La n -g u a -g e, lo -gic an d soc ia l scie n c e. Social Scien ce a n d Me d i c i n e, 35:401-407.
HIV/ AID S S U RV E I L LAN CE IN EU RO PE, 1996. Qu a r-t e rly Re p o rr-t, 61:3.
H O G G A RT, R., 1957. Th e Uses of Li t e ra c y. Lo n d o n : Ch a tt o & Wi n d u s.
H O L LA N D, J.; RO M A ZA N O G LU, C.; SCOTT, S.; SHARPE , S. & THOMSON, R., 1990. Sex, gen d er a n d p owe r : Yo u n g w o m en ’s sexu a lity in t h e sh a d ow o f AIDS.
S o c i o l o gy of Health an d Il l n e s s,12: 336-350. HERZLICH , C., 1969. San té et M a l a d i e . An alyse d ’ u n e
Rep résén tation Sociale.Pa ris: Mo u t o n .
J E F F E RY, R. W., 1989. Risk be h avio rs a n d h e alth : Co n -t ra s-t in g in d ivid u a l a n d p o p u la -t io n p e rsp e c-t ive s.
Am erican Ps y c h o l o g i s t, 44:1194-1202.
K I P PAX, S.; CRAW F O R D, J.; WA L D B Y, C. & BEN TO N , P., 1990. Wo m e n n e gocia t in g h et e ro s ex: Im p l i c a-t ion s fo r HIV p re ve n a-t io n . Wo m e n’s Stu d i es In t e r-n atior-n al Fo r u m, 13:533-542.
KRIEGER, N. & MARG O, G. ,1990. Wo m e n a n d AID S: In t ro d u ct io n t o “Se ct io n o n AIDS: Th e p o lit ics o f s u rv i va l”. In tern ation al Jou rn al of Health Se rv i c e s, 2 0 : 5 8 3 - 5 8 8 .
LU P TON, D., 1993. Ris k a s m o r a l d a n ge r : T h e so c ia l a n d p o litica l fu n ct io n s o f risk d isco u r se in p u b lic h e a lth . In t ern at ion a l Jou rn al of H ea lt h Se rv i c e s ,
2 3 : 4 2 5 - 4 3 5 .
LU P TON , D., 1995. Th e Im p e ra t i v e of He a l t h ; Pu b l i c Health an d th e Regu lated Bo d y. Lon do n : Sa g e . M AT I C K A - TYN D ALE, E., 1992. So cia l co n st ru ct io n o f
H IV t ra n sm issio n a n d p re ve n t io n a m o n g h e t er o-sexu a l a d u lts. Social Pro b l e m s, 39:238-252. MISHLER, E. G., 1986. Re s e a rch In t e rv i ew i n g :C o n t ex t
a n d N a r ra t i v e. Ca m b rid ge : Ha r va rd Un i ve r s i t y Pre s s.
O’BRIEN, B. J., 1989. AIDS a n d su b je c tive r isk a sse ss-m e n t : A crit ica l re v i e w. Health Po l i c y, 1 3 : 2 1 3 - 2 2 4 . PAICH ELER, G., 1994. Le Pu bli c Face à la Men ace d u Si d a . Vo l . I : In terp réta ti on d es Con n aissan ces et Pri se d e Con scien ce d u Risqu e. Pa r is : Age n ce Na -t io n a le d e Re c h e rch e su r le Si d a .
PAICH ELER, G., 1996. Le Pu b li c Face à la M en a ce d u Si d a . Vo l . I I : G é rer le Ri squ e. Pa r is: Age n c e Na -tion a le d e Re c h e rc h e su r le Sid a.
PAIC HELER, G. & QUEM IN , A., 1 994a . Ac t io n s d e p r é ve n t io n d u Sid a e t p u b lic : Pro lé go m è n e s à la r é ce p t io n e t à l’in t e rp r é t a t io n d e s d is co u rs d e co m m u n ica tion d e m a sse . Di scou rs Social/Social Di s c o u r s, 3-4:47-67.
PAICHELER, G. & QU E M I N , A., 1994b . Un e in t o le -ra n ce d iffu se : Le s ru m e u r s s u r l’ o rigin e d u Si d a .
Scien ces Sociales et San té, 12:41-72.
A c k n o w l e d g m e n t s
Cad. Saúd e Púb lic a, Rio d e Jane iro , 15(Sup. 2):93-105, 1999
PARSONS, E. & ATKINSON , P., 1992. La y co n st ru c t i o n o f ge n e t ic ris k. S o c i o l o gy of H ealth a n d Il l n e s s, 14:437-455.
PE RUGA, A. & CELEN TA N O, D. D., 1993. Co r re la te s o f AID S kn o wle d ge in sa m p le s o f th e ge n e ra l p o p u -la tion . Social Scien ce an d M e d i c i n e, 3 6 : 5 0 9 - 5 2 4 . POLKINH ORNE, D. E., 1988. N a r ra t i ve Kn ow in g a n d
th e Hu m a n Sci en ces.A l b a n y: St a t e Un i ve r sit y o f Ne w Yo rk Pre s s.
RO S E N S TOCK, I. M ., 1974 . Th e He a lt h Be lie f Mo d e l a n d p re ve n t i ve h e a lt h b e h a vio r. H ea lt h Ed u c a -tion Mo n o g ra p h s, 2: 354-386.
ROZIN , P. & FA L LO N, A., 1987. A p e rsp e ct ive o n d is-gu st. Psych ological Re v i ew, 94:23-41.
RO ZIN, P.; M ARKWITH , M. & NEM ERO F F, C., 1992. Mo ra l con ta gio n a n d fe a r o f AIDS. Jou rn al of Ap-p lied Social Ps y c h o l o gy, 22:1081-1092.
SARBIN, T. R., 198 6. T h e Storied N a t u re of Hu m a n C o n d u c t. Ne w Yo rk: Pre a g e r.
SCHILLER, N. G., CRY S TAL, S. & LEWELLEN, D., 1994. Risky b u sin ess: Th e cu lt u ral co n st ru ct io n o f AIDS ris k gro u p s. Soci al Scie n ce an d M e d i c i n e, 38: 1 3 3 7 - 1 3 4 6 .
S C H I LTZ, M. A. & AD AM, P., 1995. Les H o m o s ex u e l s Face au Si d a : En qu ête 1993 su r les M od es d e Vie et les Gestion s du Risqu e. Pa ris: Age n ce Nat io n a le d e Re c h e rch e su r le Sid a .
S O N TAG, S., 1978. Illn ess as Me t a p h o r. Lo n d o n : Pe n -gu in Bo o k s.
TV E R S K Y, A. & KAH N EM AN , D., 1974. Ju d gm en t u n -d e r u n ce r t a i n t y: He u ri st ic s a n -d b ia se s. S c i e n c e, 1 8 5 : 1 1 2 4 - 1 1 3 1 .
WA L D B Y, C.; KIP PAX, S. & CRAW F O R D, J., 1993. Re -s e a rch n ote : He t e ro-sexu a l m e n a n d “-sa fe -sex” pra c-t i c e. S o c i o l o gy of Health an d Il l n e s s, 15:246-256. WA RWICK, I.; AG G L E TON , P. & H OM ANS, H ., 1988.
