We asked three people about the challenges of explaining risk to their clients and patients.
What are the major challenges in communicating risk?
The overarching challenge is how to communicate risk without confusing or discouraging people.
One challenge is trying to communicate risk without putting a number on it. The public often wants risk to be communicated as a percentage (such as 2%) or a ratio (such as a 1 in 50 probability of HIV transmission). However, it's very difficult to communicate risk as a number and these ratios can easily be misunderstood. For example, a person could understand this ratio to mean that they can have anal sex without a condom 50 times before they get HIV when, in fact, they could be the guy who does it once and gets HIV or the guy who does it 600 times and doesn't get HIV.
Another challenge is how to communicate the many variables that need to be considered, such as the viral load of the HIV-positive partner, whether either partner has sexually transmitted infections (STIs), the window period, how often someone is getting tested, and how much one partner trusts the other(s). All these things can affect transmission significantly but are not easily measured or quantified. The information is complicated and can discourage someone from trying to reduce their risk.
What are the limitations of current approaches to communicating risk?
Most current models for communicating risk group activities into "low-risk" and "high-risk" categories. For example, unprotected oral sex and protected anal sex are normally considered low-risk and all unprotected anal sex is assigned to the high-risk category. However, at the Health Initiative for Men, we don't think this approach is nuanced enough to reflect the recent research or the complex and exciting sex lives of gay men. Gay guys know that risk is more than just "low" or "high" and that other variables can influence their risk of HIV transmission. We feel that this approach doesn't give guys a lot of options to choose from to reduce their risk. Not all guys are able, or want, to reduce their risk by engaging in "low-risk" activities and not all unprotected anal sex is the same.
What are your solutions?
At HIM we have developed a risk communication model that includes a risk calculator -- it can be found on our "Do the Math: Calculate Your Risk" website. We opted to expand the "low-risk" and "high-risk" model to include more categories, including "no or very low," "low," "moderate," "high" and "very high" risk. The model uses several factors to assess risk, including the type of sex they are having (oral or anal), the position they are assuming (top or bottom), the HIV status of both partners (poz, neg or unknown) and whether condoms are used. Using the statistics from the ManCount survey, we felt that these were the variables that gay men were most commonly using to make decisions and also those that people know the most about.
This approach gives gay men more options to reduce their risk. Instead of simply telling people that all unprotected anal sex is high-risk, we opted to say that it is more risky than oral sex and protected anal sex, but less risky if you are a top or with a same-status partner.
Our model doesn't provide numbers, but it is based on absolute risk percentages calculated in a mathematical modelling study titled "Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use" (Varghese et al 2001), published in the journal Sexually Transmitted Diseases. The numbers in this study informed our "Do the Math" model and were used to assign different activities to a risk category.
We didn't provide the numbers from this study in our model because we don't feel that communicating risk as percentages and ratios is the most effective way of translating probability information to the average gay guy. Even those of us who are well versed in statistics can struggle to understand them, specifically the difference between absolute risk and relative risk and how the two can interact. You can look at the numbers but the more you look into all the factors used to calculate them, the more you realize how far from reality they are and how they have little meaning in the "real world."
What are the limitations of your approach?
The main weakness of our model is its simplicity. Although it is more nuanced than other models, it doesn't consider factors such as antiretroviral treatment, acute HIV infection, STIs, dates of testing, and trust. These factors were difficult to integrate into the calculator for various reasons.
In the case of viral load, there are still gaps in the research, particularly among gay men, and the messages are different depending on the context (for example for poz guys vs. neg guys, gay guys who go the bathhouse vs. guys in monogamous serodiscordant relationships). Since these factors need a more detailed explanation and there is no simple message that applies to everyone, they are discussed at length in the text on the website but were not integrated into our risk calculator.
In the end, the risk calculator was a bit of a compromise. We asked ourselves "Do we want to get something out there or produce nothing because it's too complicated?" We opted to take on the challenge and start a community dialogue about risk.
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