Most counsellors initiate their risk assessment counselling by launching a discussion about reasons for testing. Counsellors usually start by producing an open-ended question such as ‘What brings you in for an HIV test?’ Although this form of questioning can elicit the client's description of risk behaviour (Kinnell 2001), it does not attribute a reason to a specific risk exposure. While the form of the question asks for a ‘reason’ for the decision to get tested, it does not presuppose a specific risk or concern. This initial question is often used as a gateway to a discussion of risk, and counsellors often follow it with more focused questions about risk exposure. The reason for testing question thus serves as an avenue into the more specific discussion of risk.
As Table 1 shows, a majority of the clients responded to the reason for testing question by indicating that it was a routine course of action. While ‘routine testing’ is a bona fide reason for getting the test, the clients often designed their responses in ways that suggest that they did not treat it as such. They presented routine testing in such a way as to show that it departed from what the counsellor's question was asking for.
For instance, in example (1) below, the counsellor formulates a wh-question that asks for a reason for testing (line 1). At line 2, the client delays his answer with ‘tch uh:’, which indicates an orientation to his response as less than optimal (Pomerantz 1984). The client's subsequent use of ‘just’ both shows that the test is no more than a routine one, thus mitigating his decision, and, simultaneously, displays an understanding of the question as searching for a specific concern which his answer will disappoint. In this way he asserts that his decision to test is not driven by a specific concern. His use of the term ‘regular upkeep’ suggests a ‘health maintenance’ approach to the issue, and this is consonant with the test site's website which depicts HIV testing using images drawn from car maintenance
The counsellor, however, does not acknowledge this response (line 3), thereby treating it as incomplete and inviting elaboration. However, the client continues by re-completing his response without further elaboration (line 4). At line 5, the counsellor produces an acknowledgement, ‘okay,’, which is again hearable as inviting elaboration; but the client again re-completes his previous turn without elaboration (line 7). There is thus a tacit stand-off between the counsellor and the client, in which the counsellor tacitly invites and the client resists, any move beyond the ‘routine’ as the client's account for testing. This is brought to a close when the counsellor explicitly asks about risk (line 8).
Thus, while the reason for testing question can be and is being answered with routine testing, it is treated as potentially in search of something else. The client displays his understanding of the question as searching for more by minimising the nature of his testing and continuing to take the turn after the lack of uptake (line 3) and the equivocal uptake (line 5) by the counsellor. Despite this understanding of the question, the client presents routine testing as the only reason. Thereby, the client portrays himself as a reasonable person who gets tested on a regular basis, rather than in response to every particular incident or in a panic-struck fashion.
Example (2) shows a similar pattern. The counsellor elicits a reason for testing (lines 1–3). At line 4, the client begins with ‘oh:,’ which sets aside the issue implicitly raised by the question that there is a specific reason, potentially some risk incident or concern (cf. Heritage 1998). The client continues by constructing the routine nature of his testing. His use of ‘usually’ and specification of the frequency of testing ‘every- (.) six months or so’ (line 4) show that his current testing is one of such calendric, habitual events.
The counsellor does not acknowledge the client's response immediately. After 0.4 seconds (line 5), he produces ‘okay,’, which possibly invites elaboration from the client (line 6). The client expands his previous response at lines 7–9. He builds his approach to testing as a routine by invoking a relationship in the distant past. He then elaborates his current test as part of a routine by continuing ‘it's just habit tuh go and get tested every six months’ (lines 8–9). Again, the ‘just’ works to minimise the significance of the decision to get tested. The characterisation of testing as ‘habit’ conveys that testing is not done as a matter of any particular concern but rather gets done regardless of what goes on. In this way, the client portrays himself as a sensible and responsible person who takes care of himself on a regular basis.
In these examples, clients present their reasonableness in seeking HIV testing. Reasonableness is portrayed through the normality of testing: a reasonable and responsible person gets tested relatively regularly, tends to avoid risky behaviours, and takes care of their HIV health on a routine basis regardless of life events (cf. Lupton et al. 1995, Sheon 1999). By constructing the routine nature of their testing, clients engage in presenting what kind of person they are.
Disclaiming and downgrading risk
Because clients present themselves as reasonable and responsible people in managing their HIV status during the reason for testing discussion, counsellors have the burden of constructing a rationale for the counselling they are mandated to perform. They often pursue this goal by probing for a specific risk or concern, and by developing more focused questions about risk. Clients, however, do not readily identify or admit to a particular incident in response. Rather, they disclaim or downgrade their risk.
Consider example (3). In response to the reason for testing question (line 1), the client implies that he usually tests at least annually (line 3). The counsellor produces ‘okay¿’ (line 4) and invites elaboration from the client. At line 6, the client re-completes the turn without adding further information, thus treating his previous response as complete. However, the counsellor does not treat the client's response as adequate. He re-elicits the reason for testing (1->). This time, the counsellor does not formulate an open-ended question (cf. line 1), but instead offers two, more specific alternatives.
He first produces a question of ‘do you normally te:st’ (line 7). Although the client's previous turn implies that he gets tested on a regular basis, the counsellor does not treat it as established and makes it subject to (dis)confirm. As an alternative, the counsellor produces a yes-no question that focuses on ‘something:’ that led the client to get tested (lines 8–10). This question is designed to look for a particular risk. First, its format prefers a ‘yes’ answer, that is, that there has been something that caused some concerns (Boyd and Heritage 2006). Secondly, its description of ‘something:’ conveys some doing or incident that prompted HIV testing and implies a particular risk exposure. Thus the counsellor reformulates the open-ended question about the reason for testing (line 1) into a more focused search for risk.
At lines 11–13, the client designs his answer as a response to the latter yes-no question. He produces a ‘no’ answer and continues with ‘nothing in particular:’ (line 11), thus disconfirming any particular risk that made him get tested. The client also re-presents testing as a normal practice, ‘it's been a year so I've – I need to know’ (line 13). He thus invokes his annual testing cycle as a sufficient account for the reason for testing, and blocks the risk-focused line of inquiry that the counsellor was pursuing.
About two minutes later in the session, the counsellor again asks for the reason for testing while completing a risk assessment form (example (4)). He makes another search for risk in a more specific way. At lines 1–4, the counsellor asks for confirmation about the client's reason for testing as a matter of putting it in the form. The client confirms it immediately (line 5). However, in overlap with the client's confirmation, the counsellor again checks whether the test is not related to some particular concerns (2->), such as ‘risk exposure::’ (line 4) or ‘new relationship’ (line 6). Although this utterance is designed with a preference to a ‘no’ response, the counsellor still solicits in a more specific way whether there has been some risk or other concern that prompted the testing.
In response, the client acknowledges risk but disqualifies it as a concern or reason for testing (2=>). The client first produces ‘there's always some: (1.2) ex:posure: r:isk’ (lines 9–10). He characterises his risk as a general fact of existence, and not particular to him or a situation. After acknowledging this general risk, the client produces a contrastive marker, ‘but’ (line 12). He thus projects and implies that he does not have a particular risk that prompted testing.
The counsellor, however, makes another attempt (3->). While displaying an understanding of the absence of a particular risk by using a ‘no’ preferring turn, the counsellor probes for risk again. This time he formulates descriptions that convey risk in particular, such as ‘great alarm’ and ‘gosh’ (line 13). The counsellor thus seeks to establish a particular risk that prompted testing. The client again disconfirms a specific risk (3=>). By producing ‘nothing out of thuh -ordinary’ (line 17), he admits having had ordinary, general risks but not one that made him get tested out of a particular concern. At lines 17–19, the client evidences an absence of risk-related concern with ‘no like medical condition is making me go::’. He thus elaborates on the absence of a risk-related concern in getting the test. The counsellor finally terminates the probe (line 22), and accounts for the fact that he has engaged in an extended, and fruitless, search for risk (lines 22–27).
Thus, the counsellor does not treat routine testing as an adequate reason for testing. He rather probes for a particular risk in identifying a reason for testing, and gets more and more specific in doing so. However, the client persistently presents the routine nature of his testing and disclaims a specific risk or concern. This shows conflicting orientations between the parties in approaching the reason for testing discussion.
The following example was introduced in (1) above. Like example (4), the counsellor directs the interaction towards a more specific discussion of risk behaviours after the client establishes his testing as part of a routine (lines 2–7). For instance at line 8, the counsellor launches a question that elicits a discussion of risk. The client delays his response substantially. He first delays for 0.8 seconds (line 9). Then he initiates a repair, ‘My risks?’ (line 10) and projects an upcoming rejection of the topic (Pomerantz 1984). When starting to produce his response after another delay of 0.6 seconds (line 11), the client delays yet again with ‘uh:m’, 0.4 seconds, and ‘tlk’ (line 12). All these delays indicate the client's trouble in producing the response.
Finally, the client begins his response with self-assessment, ‘I've been pretty good lately’ (line 12). He not only shows that he has been conscious of and attentive to his sexual behaviours, but also implies that he does not have a particular risk-related problem. At lines 15–17, the client continues by acknowledging a general risk. He displays his awareness of risk but does not treat the risk as particular to himself or as particularly significant.
When the client's response is complete (line 21), the counsellor gets more specific in eliciting risk (2->). The counsellor produces a question that presupposes an identifiable exposure to risk, and seeks to locate such a specific risk incident. The client delays his response with ‘tch ~hhhhh u(h)h::m’ and locates a risk incident, ‘probably a month ago’ (2=>).
At line 27, the counsellor elicits a telling about the identified incident. In response, the client provides only a minimal description of the experience by formulating short phrases rather than a narrative or even a sentence (3=>). Note that his description is limited to the type of sex he had. In addition, the client downgrades his risk. He qualifies his barebacking by minimising it with ‘just little’ (line 29). He further minimises its risk with ‘no load taking’ (line 29), suggesting that he was careful not to let his partner(s) ejaculate inside him. In this way, he also demonstrates his knowledge of risk reduction strategies. Thus, the client provides only minimal information on his risk behaviour while downplaying its significance. Note, however, that the counsellor focuses on the client's sexual positioning which is directly related to the client's level of risk (line 34). The counsellor thus develops a risk-focused line of inquiry throughout the turns, while the client persistently presents himself as one who is in control of his HIV risks.
‘Sandwiching’ risk: displaying knowledgeability and control
A few clients in our dataset brought up specific risks when discussing a reason for testing. An interesting pattern in which they did so was to present risk within the context of routine testing. Clients commonly presented their testing as part of a routine, discussed a specific risk, and re-presented their testing as part of a routine and not as a response to the said risk. In this way, clients ‘sandwiched’ their discussion of risk within the normality of testing and exempted it from being heard as the reason for testing.
Consider example (6). In response to the question about reason for testing (lines 1–2), the client produces ‘N::no:’ and presents his testing as part of a routine (line 3). Then the client continues with a discussion of risk (->). He explains his self-assessment, ‘pretty low risk’, in terms of his limiting his sexual activity to oral sex. In this way, the client not only displays his knowledgeability about what type of sex constitutes high vs. low risk, but also demonstrates his control over his risk of HIV exposure.
Then the client continues by re-establishing the normality of testing (line 5). He displays that his testing is not particularly related to risk, while at the same time avoiding being viewed as someone who is ‘paranoid’ about HIV status (cf. Sheon 1999). First, with the use of ‘anyway’ (line 5), the client shows that his testing is not related to the risk. Secondly, by describing his testing as a norm despite the low risk, the client displays himself as being vigilant in managing his HIV status. He thus packages the discussion of risk within the context of his responsibility and routine care.
Finally, example (7) is another instance of the ‘sandwich’ pattern. In response to the reason for testing question (line 1), the client first implies the routine nature of his testing (line 2). Then the client introduces a risk in a past relationship (line 4). When discussing the risk (lines 4–11), the client focuses on the quality of relationship in terms of rationality, consensus, and trust. First, by producing ‘I: made that decision: with them:’ (line 6), the client describes the risk behaviour as a joint, knowing decision rather than as a mistake or a concern that prompted testing. Secondly, in providing an account for that decision, the client characterises himself and his partners as equally risk-averse. He describes himself as ‘a real picky person’ and ‘anal’, and his partners as ‘a:s anal as I am’ (lines 7–9). Through these characterisations, the client establishes his own lack of risk, which is again confirmed by the choosiness of his partners in selecting him as a partner. Thirdly, the client claims that ‘the trust level between myself a:nd those partner:s was: very high’ (lines 9–10). The invocation of a trusting relationship provides an additional account for his risk behaviour. Thus, the client justifies his unprotected sex and describes the risk as a consensual decision based on trust.
After this description, the client provides an upshot. He first constructs the reason for testing in terms of an absence of relationships (lines 13–14). Then the client establishes his testing as part of a routine (line 15). After ‘sandwiching’ the risk in this manner, the client continues by acknowledging, although downgrading, a concern about the unprotected sex (lines 17–19). He then explicitly exempts it from being treated as the main reason for testing (line 20), thus again ‘sandwiching’ his concern about the risk. The client disavows his risk as a main concern related to the decision to get the test, and displays his control over managing his HIV status.