Knight Rod, Small Will, Pakula Basia, Thomson Kimberly, Shoveller Jean
Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, Canada.
BMC Med Ethics. 2014 Jul 3;15:54. doi: 10.1186/1472-6939-15-54.
Despite the evidence showing the promise of HIV treatment as prevention (TasP) in reducing HIV incidence, a variety of ethical questions surrounding the implementation and "scaling up" of TasP have been articulated by a variety of stakeholders including scientists, community activists and government officials. Given the high profile and potential promise of TasP in combatting the global HIV epidemic, an explicit and transparent research priority-setting process is critical to inform ongoing ethical discussions pertaining to TasP.
We drew on the Arksey and O'Malley framework for conducting scoping review studies as well as systematic approaches to identifying empirical and theoretical gaps within ethical discussions pertaining to population-level intervention implementation and scale up. We searched the health science database PubMed to identify relevant peer-reviewed articles on ethical and implementation issues pertaining to TasP. We included English language articles that were published after 2009 (i.e., after the emergence of causal evidence within this field) by using search terms related to TasP. Given the tendency for much of the criticism and support of TasP to occur outside the peer-reviewed literature, we also included grey literature in order to provide a more exhaustive representation of how the ethical discussions pertaining to TasP have and are currently taking place. To identify the grey literature, we systematically searched a set of search engines, databases, and related webpages for keywords pertaining to TasP.
Three dominant themes emerged in our analysis with respect to the ethical questions pertaining to TasP implementation and scale-up: (a) balancing individual- and population-level interests; (b) power relations within clinical practice and competing resource demands within health care systems; (c) effectiveness considerations and socio-structural contexts of HIV treatment experiences within broader implementation contexts.
Ongoing research and normative deliberation is required in order to successfully and ethically scale-up TasP within the continuum of HIV care models. Based on the results of this scoping review, we identify several ethical and implementation dimensions that hold promise for informing the process of scaling up TasP and that could benefit from new research.
尽管有证据表明艾滋病治疗即预防（TasP）在降低艾滋病发病率方面具有前景，但包括科学家、社区活动家及政府官员在内的各类利益相关者提出了围绕TasP实施及“扩大规模”的一系列伦理问题。鉴于TasP在抗击全球艾滋病流行方面备受瞩目且颇具潜力，一个明确且透明的研究重点设定过程对于为有关TasP的持续伦理讨论提供信息至关重要。
我们借鉴了阿克西和奥马利进行范围综述研究的框架以及系统方法，以识别与人群层面干预实施及扩大规模相关的伦理讨论中的实证和理论差距。我们检索了健康科学数据库PubMed，以识别有关TasP伦理及实施问题的相关同行评审文章。我们纳入了2009年之后发表的英文文章（即该领域出现因果证据之后），使用了与TasP相关的检索词。鉴于对TasP的许多批评和支持倾向于出现在同行评审文献之外，我们还纳入了灰色文献，以便更详尽地呈现有关TasP的伦理讨论过去及当前的开展情况。为识别灰色文献，我们系统地在一组搜索引擎、数据库及相关网页中搜索与TasP相关的关键词。
在我们关于TasP实施及扩大规模的伦理问题分析中出现了三个主要主题：（a）平衡个人和人群层面的利益；（b）临床实践中的权力关系以及医疗保健系统内相互竞争的资源需求；（c）在更广泛的实施背景下，艾滋病治疗经验的有效性考量及社会结构背景。
为了在艾滋病护理模式的连续统一体中成功且符合伦理地扩大TasP规模，需要持续的研究和规范性审议。基于本范围综述的结果，我们确定了几个伦理和实施层面，它们有望为扩大TasP规模的过程提供信息，并且可能受益于新的研究。
