Since 1985, voluntary HIV antibody testing has served as the cornerstone of HIV prevention efforts in the United States. HIV positives detected through testing can clearly benefit from early medical intervention. However, the effect of testing on the risk behaviors of the roughly 98% of test clients receiving negative results is unclear. While most studies show that testing has a marginal effect on behavior change, several suggest that a negative HIV test result can actually increase risk behavior. Two variables that directly influence the behavioral impact of testing -- test counseling process and the client's initial motivations for testing -- are poorly understood.
This dissertation aims to improve the practice of HIV test counseling. I examine the symbolic and practical meanings of the test for counselors and clients through an analysis of the process of test counseling. Data was collected during four years of participant observation as a test counselor, and through audio recordings of thirty test sessions, forty interviews with counselors and clients, and 200 questionnaires.
Two theoretical questions guide the research. How does talk about sex during the test session affects the clients' subjectivity? How does periodic testing function to manage guilt over risk behaviors? To answer these questions I use analogies with confession and interrogation as practiced in legal, religious, and twelve-step recovery contexts. The comparison of HIV test counseling with other confessional practices offered several new perspectives to explain many puzzling aspects of testing behavior.
For example, counselors often express frustration over the large proportion of low or no-risk clients who test frequently. I show how routine HIV testing by couples has enabled serial monogamy without condoms to become a common safer sex strategy. Like confession rituals, HIV testing anoints new relationships by providing a "clean slate" from past partners. Clients labeled "the worried well," are clients with an obsessive compulsive disorder manifested in frequent testing and paralyzing guilt over past risks. This problem can be understood through analogies with the "disease of scruple," a phenomenon documented by priests centuries ago in confession manuals. Much like annual sacramental confession, test counseling can generate anxieties that can only be allayed through periodic testing. Theories of confession also shed light on power relations within the counseling session. I analyze transcripts of test sessions to show how the clients' avowals of contrition serve to alter the balance of power and limit the scope of the counseling session in providing insight into the meaning of risk behaviors and the test.
Through an ethnography of the Berkeley
Free Clinic's collective
management process, I demonstrate how the
organizational structure of a
test site can influence counselor training
and practice. I conclude with
a description of ways I used my findings to
develop new risk assessment
forms, counseling techniques, and innovative
counselor training materials
available through an interactive web
page.
In the introduction I position myself in relation to the problem, the field site and my interdisciplinary method. I describe the advantages and difficulties of studying one's own work site. I offer a number of vignettes from my training and counseling sessions to introduce the reader to the connections between confession, sexuality, and biopower.
Chapter two begins with an analysis of media coverage of Magic Johnson's 1991 public disclosure as key turning point in the response to the epidemic. Johnson's disclosure is used to demonstrate the articulation of voluntary HIV testing with confession, and what Cindy Patton has termed the "national safe sex pedagogy." I analyze HIV prevention efforts as a struggle between two approaches to prevention. The confessional model is based on individual testing, monogamy, and the interrogation of partners. The community model is based on universal safer sex precautions and grass roots community organizing. I demonstrate the role of HIV testing as it influenced the struggle between the confessional and community approaches to prevention.
Chapter three introduces the Berkeley Free Clinic's HIV Prevention Section Collective which runs the Anonymous Test Site every Sunday evening. My data for this chapter is derived from four years of participant observation and interviews with counselors and clinic workers. I describe the culture of the volunteer collective to and how it's non-hierarchical organizational structure impacts the training methods and counseling practices. To historically situate the test site's evolution since 1989, I describe the complex web of knowledge, funding, and expertise that has linked the Gay Men's Health Collective, the Pacific Center, a commercial sex club, the University, and the Berkeley Public Health Department.
In chapter six I begin by providing a historical overview of sacramental confession ritual and its relationship to sexuality, the self, and power. I then examine a number of analogies between sacramental confession and HIV test counseling in order to provide a heuristic perspectives on the reasons behind puzzling testing behaviors. I compare test counseling and sacramental discourse on periodization, absolution, contrition, monogamy, guilt, scrupulosity, transgression, and addiction. I conclude with a critique of new confessional interfaces such as home testing, phone counseling, and cyber confessions that do away with the face-to-face interaction.
Chapter seven examines the strategic role of confessions in test counseling interaction. I begin by analyzing the risk assessment process as a ritual of moral inventory that constructs a juridical and confessional context for test counseling. I demonstrate the utility of conversation analysis as a method for understanding the interactional rules of counseling. Through a close reading of three counselor's reactions to clients' expressions of contrition for past risky behavior I evaluate the strategic use of accounts, justifications, and silence by counselors and clients.
In chapter four I examine how work-load and institutional constraints function to limit the scope of test counseling. Data from this chapter will be derived from test session transcripts and counselor interviews. I describe the evolution of models of test counseling from "information provision" to "client centered." I employ symbolic interactionist frameworks of "role formats" and "emotion work" to describe counselors' strategies in coping with both "difficult" and "routine" clients. I analyze the assumptions about behavior change and sexuality that shape the counselor's concept of their role in HIV prevention. I review behavioral studies of test counseling that focus narrowly on quantitative outcome measures, to argue the importance of interaction, emotion, and symbolic ritual practice for an understanding of HIV prevention. By comparing the ways that counselors deal with common topical and practical issues , I discuss the interactional consequences of different styles and approaches.
In chapter seven, I follow the trajectory of "client's reason for testing" during the test session through its transformation into surveillance data for the state office of AIDS in Sacramento. Because people's reasons for testing resist empirical analysis, I approached it from various perspectives using different sources of data. These included (1) a waiting room questionnaire, (2) a content analysis of the risk assessment forms, (3) transcripts of test sessions, (4) interviews with test clients, and (5) participant observation of clients as a counselor and of counselors at post shift meetings. In chapter seven I begin with an analysis of the questionnaire and risk assessment form data, followed by an line by line analysis of the reason for testing discussion of two sessions to show how the client's reason for testing is constructed during the test session.
The assumption that risk reduction or even
risk factors
are the primary motivations for testing has obscured the
fact that testing
is often used as a warrant, an indulgence for
"risky" behaviors.
Ironically, routine testing encourages
people to test in order to account
for risk behaviors which were
justified by the previous test. In chapter
eight I analyze data collected
in interviews with test clients and through
participant observation as a
counselor and situate these within the litterature
on the problematic
relationship between heterosex and condom use. An examination
of the
socio-cultural and psychological context of testing reveals that
the
majority of testing is not about risk per se but about negotiating and
managing the formation and development of sexual relationships.
Chapter nine describes how I have used the findings of this study to improve my own counseling technique. I suggest ways to incorporate the principles of harm reduction, counselor evaluation, new counseling forms, post shift discussions, and off-shift continuing education into existing counseling and testing programs. I describe a web site I developed to allow community based organizations to share counseling and outreach materials and expertise.
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