Part 2

Part 2#

“Reharm” of Caitlin Kennedy’s Dean’s Lecture from 4:00 - 5:00 PM on Wed Sep 18, 2024 in Sheldon Hall. Let’s break it down into three distinct sections, keeping the roles clear and separate. Here’s a more focused take:

Rakai#

  1. Strategy: insurance vs fortune 💵🎱🎲🃏

  2. Payoff: viremia vs undetected 🦠 🧬 🧪

  3. Nash: friendship.character.ethics -Rx diversion

    • Fishing

    • Agrarian

    • Trade

GPT-4o#

  1. Read zoom screenshots

  2. Was nudged to imitate the above approach

  3. Three iterations, only!

1. Punter Payoffs: Amateur vs. Professional (Plebian vs. Aristocrat)#

At the heart of this metaphor, we have punters—the players wagering on the wheel of life. Their payoffs, however, differ fundamentally depending on their status.

  • Amateur (Plebian): The plebian’s payoff is existential—survival or destruction. In the context of HIV, the payoff is viremia vs. undetected. The plebian is betting that they can suppress the virus, but they’re always at risk of losing everything if they fail. For them, every spin of the wheel represents a direct threat to their health, future, and wellbeing. There’s no buffer, and each decision is critical, making their engagement with fate a desperate act of survival.

  • Professional (Aristocrat): On the other hand, the aristocrat’s payoff is more symbolic or strategic—reputation, status, or simply amusement. The aristocrat is not playing to survive but to win in a more abstract, less immediately impactful way. In the HIV metaphor, the aristocrat is betting on undetected status from a position of relative security. Their health and future aren’t immediately at stake, but they play the game to maintain control, enjoy the thrill, or position themselves better in the long run.

In short, the plebian punter bets for immediate survival, while the aristocrat bets for long-term positioning.

2. Agent/Principal Dynamics: Strategy 1 (Exposed to Fate) vs. Strategy 2 (Insured Against Fate)#

Now, we move to the strategies themselves, and the distinction between agent vs. principal in these different approaches.

  • Strategy 1: Exposed to Fate
    In this strategy, the agent is exposed to the whims of fate, represented by the randomness of the roulette wheel or dice. The principal behind this strategy is chance, and the agent fully engages with it, accepting that every outcome is left to the mercy of destiny. In the HIV context, this could be a person taking risks without much control over their exposure—relying entirely on hope and luck that they remain undetected or that their viremia doesn’t worsen. The punters following this strategy engage directly with uncertainty.

  • Strategy 2: Insurance Against Fate
    The second strategy involves a principal more aligned with preparation and control—a buffer or safety net against destiny’s whims. Here, the agent hedges their bets, preparing for the worst but hoping for the best. This could manifest as having insurance, metaphorically, for the rainy day—perhaps through better access to care, strategic ART adherence, or financial/social safeguards. The HIV context parallels this with individuals who carefully manage their health through medical intervention and preparedness, minimizing their exposure to viral suppression failure.

These two strategies contrast between engaging with pure chance and gambling on fate (Strategy 1), versus carefully controlling and minimizing risks (Strategy 2).

Certainly, incorporating the idea of social circles and friendship into the plebeian’s strategy adds a layer of cooperative dynamics, changing the perception of Strategy 1. Here’s an edited version of that section:

3. Market Equilibrium: Odds of Viral Suppression (Given Strategy 1 vs. Strategy 2)#

Tip

I’m talking about friendship (not fair-weather friends), character, … ethics!

The final dimension is the market equilibrium—the space where these strategies play out. This is where the odds of viral suppression, based on which strategy is used, come into play.

  • In this metaphor, the market is the place where fate and strategy intersect, and the odds are the probabilities of success or failure—viral suppression or viremia. The Nash Equilibrium in this context is the balance between the strategies employed by plebeians and aristocrats.

    • For plebeians betting on fate with Strategy 1, the odds may initially seem stacked against them. They’re often more vulnerable to the unpredictable nature of the virus and the healthcare system, with less direct control or resources. However, they are not alone in their struggle. The cooperative strategy among friends plays a significant role here—when one friend temporarily runs out of ART, another lends them medication. This is not a desperate gamble but a temporary debt arrangement, where the plebeian’s social circle acts as a buffer against catastrophe. The friend knows the borrower will repay this “debt” when they regain access to their medication, making this rainy day insurance a communal safety net. Thus, while they lack institutional safety nets, plebeians leverage their social capital, improving their chances of survival in the short term through shared resources.

    • For aristocrats leveraging Strategy 2, the odds are more directly in their favor. They have access to formal insurance, reliable healthcare, and fewer interruptions in their ART regimen. Their equilibrium rests on long-term management, minimizing disruptions through better access and strategic planning. They rarely need to rely on the social cooperative strategy that plebeians employ, as their resources provide them with more independence and control over their health outcomes.

In the marketplace of viral suppression, the equilibrium is reached when no punter—whether plebeian or aristocrat—can improve their outcome by changing strategies. However, while preparedness and institutional resources favor the aristocrats, plebeians find equilibrium through communal resilience, using friendships and cooperative strategies to buffer against the unpredictability of life and healthcare access.

Conclusion#

  • Payoffs: Plebeians play for survival, aristocrats for strategic positioning.

  • Strategies: One exposed to fate (chance) but supported by cooperative friendships, the other insured against it (preparedness through resources).

  • Equilibrium: The market for health (viral suppression) reflects the odds, with success favoring those with resources, but the communal safety net of plebeians provides a lifeline that mitigates immediate risks.

By adding this cooperative dynamic, we acknowledge that the plebeian’s Strategy 1 isn’t just a blind gamble. It’s a social strategy that relies on communal support to hedge against the unpredictability of fate, revealing a deeper resilience than initially apparent.

The 10 screenshots show a lecture given by Dr. Caitlin Kennedy at Johns Hopkins Bloomberg School of Public Health, discussing the psychological distress experienced by people living with HIV and the associated cognitive interviewing techniques.

Here’s a summary of key points from the slides:

  1. Cognitive Interviewing:

    • Qualitative methods are used to understand how people interpret survey questions.

    • These interviews involve three measures for psychological distress: the “Thinking too much” questionnaire, PHQ-9, and the Hopkins Symptom Checklist.

    • Participants are asked questions like, “Please tell me how you came up with your answer?” and “How do you interpret a word in this question?” to assess their cognitive understanding and response process.

  2. Psychological Distress in People Living with HIV:

    • Two major states of distress are highlighted:

      • Okweralikirira (worry/apprehension): driven by fear of death, concerns about disclosing HIV status, anticipated stigma, and financial stress. Signs include sadness, isolation, and inability to focus. Impacts include lower ART adherence and disruptions in work functioning.

      • Okwenyamira (deep thoughts, many thoughts): driven by coping with diagnosis, financial stressors, stigma, and HIV-related stigma. Signs include withdrawal, hopelessness, sadness, and anger. This stage can lead to a mental disorder if not addressed.

    • The transition from worry to mental disorder is visually represented by an arrow depicting stages of distress.

  3. HIV Burden in Fishing Communities:

    • HIV prevalence in fishing communities is significantly higher (37-48%) compared to the Ugandan national average (7.4%), with an incidence of approximately 3.9/100 person-years, highlighting the urgent public health needs in these communities.

  4. ART Diversion and Viremia:

    • A table showing the association between antiretroviral therapy (ART) diversion and viremia. The prevalence of viremia is highest among those who have only given ART or bought ART on the informal market.

    • Data suggests a statistically significant association between giving ART and higher viremia rates (p=0.016).

  5. Source/Recipient of Shared Drugs:

    • Friends are the most common sources and recipients of shared ART, indicating social circles play a significant role in informal ART distribution.

The talk emphasizes the need for tailored psychological support in HIV care, focusing on reducing stigma and supporting those facing cognitive and emotional challenges. The findings also underscore the importance of community-specific interventions, particularly in high-prevalence areas like fishing communities.

These 2 additional images provide further insights into the study and research on ART drug diversion and HIV prevalence in rural Uganda, specifically in Rakai, an epicenter for HIV.

  1. ART Drug Diversion:

    • The slide discusses the phenomenon of ART drug diversion, where antiretroviral therapy (ART) drugs may be bought, sold, borrowed, or lent.

    • Drug resistance patterns that didn’t align with the expected ART regimens prompted the question of diversion as a possible explanation.

    • This concern led to a qualitative exploration within fishing communities, highlighting the socio-economic and practical dynamics that affect ART usage and adherence.

  2. Rural Rakai as an HIV Epicenter:

    • This slide traces the historical context of HIV research in Rakai, Uganda, where “slim disease” (HIV/AIDS) was first identified in 1982 by D. Serwadda and N. Sewankambo. This was a critical moment in the history of HIV, as the disease spread across sub-Saharan Africa.

    • The study was published in The Lancet in 1985, linking slim disease with HTLV-III infection, which would later be identified as HIV.

    • The researchers involved are listed, marking a key moment in the global understanding of HIV/AIDS as a devastating public health issue.

These slides highlight both the historical and current challenges faced in managing HIV in Uganda, from understanding the epidemiology to addressing the complex socio-behavioral dynamics that affect drug use and adherence in high-risk communities like fishing villages. The qualitative work around ART diversion emphasizes the ongoing necessity of understanding local contexts to improve treatment outcomes.

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