Johns David Merritt, Bayer Ronald, Fairchild Amy L
Center for the History and Ethics of Public Health, Mailman School of Public Health, Columbia University.
Milbank Q. 2016 Mar;94(1):126-62. doi: 10.1111/1468-0009.12183.
In situations of scientific uncertainty, public health interventions, such as counseling for HIV infection, sometimes must be implemented before obtaining evidence of efficacy. The history of HIV counseling and testing, which served as the cornerstone of HIV prevention efforts at the US Centers for Disease Control and Prevention (CDC) for a quarter of a century, illustrates the influence of institutional resistance on public health decision making and the challenge of de-implementing well-established programs.
In 1985, amid uncertainty about the accuracy of the new test for HIV, public health officials at the Centers for Disease Control and Prevention (CDC) and AIDS activists agreed that counseling should always be provided both before and after testing to ensure that patients were tested voluntarily and understood the meaning of their results. As the "exceptionalist" perspective that framed HIV in the early years began to recede, the purpose of HIV test counseling shifted over the next 30 years from emphasizing consent, to providing information, to encouraging behavioral change. With this increasing emphasis on prevention, HIV test counseling faced mounting doubts about whether it "worked." The CDC finally discontinued its preferred test counseling approach in October 2014.
Drawing on key informant interviews with current and former CDC officials, behavioral scientists, AIDS activists, and others, along with archival material, news reports, and scientific and governmental publications, we examined the origins, development, and decline of the CDC's "counseling and testing" paradigm for HIV prevention.
Disagreements within the CDC emerged by the 1990s over whether test counseling could be justified on the basis of efficacy and cost. Resistance to the prospect of policy change by supporters of test counseling in the CDC, gay activists for whom counseling carried important ethical and symbolic meanings, and community organizations dependent on federal funding made it difficult for the CDC to de-implement the practice.
Analyses of changes in public health policy that emphasize the impact of research evidence produced in experimental or epidemiological inquiries may overlook key social and political factors involving resistance to deimplementation that powerfully shape the relationship between science and policy.
在科学存在不确定性的情况下,有时必须在获得疗效证据之前实施公共卫生干预措施,例如针对艾滋病毒感染的咨询。长达四分之一世纪以来一直作为美国疾病控制与预防中心(CDC)艾滋病毒预防工作基石的艾滋病毒咨询与检测历史,说明了机构阻力对公共卫生决策的影响以及取消既定项目所面临的挑战。
1985年,在对艾滋病毒新检测方法的准确性存在不确定性的情况下,疾病控制与预防中心(CDC)的公共卫生官员和艾滋病活动家一致认为,检测前后都应始终提供咨询,以确保患者自愿接受检测并理解检测结果的含义。随着早年将艾滋病毒视为“特殊情况”的观点开始消退,艾滋病毒检测咨询的目的在接下来的30年里从强调同意,转变为提供信息,再转变为鼓励行为改变。随着对预防的日益重视,艾滋病毒检测咨询面临着它是否“有效”的越来越多的质疑。CDC最终在2014年10月停止了其首选的检测咨询方法。
通过对现任和前任CDC官员、行为科学家、艾滋病活动家及其他人员进行关键信息访谈,并结合档案材料、新闻报道以及科学和政府出版物,我们研究了CDC用于艾滋病毒预防的“咨询与检测”模式的起源、发展和衰落。
到20世纪90年代,CDC内部就检测咨询是否能基于疗效和成本得到合理证明产生了分歧。CDC中检测咨询的支持者、认为咨询具有重要伦理和象征意义的同性恋活动家以及依赖联邦资金的社区组织对政策改变前景的抵制,使得CDC难以取消这种做法。
对公共卫生政策变化的分析若强调实验或流行病学调查中产生的研究证据的影响,可能会忽略涉及抵制取消实施的关键社会和政治因素,而这些因素有力地塑造了科学与政策之间的关系。