Routine HIV Testing Among Adolescents and the Shifting Culture of AIDS

描述（由申请人提供）：自20世纪80年代初艾滋病在美国流行以来，对艾滋病的临床认识和治疗以及与艾滋病有关的公共文化都发生了重要变化。其中一些变化反映在疾病预防控制中心最新的艾滋病毒检测建议中。建议建议所有13至64岁的患者都要接受检测；将同意检测纳入患者对医疗护理的一般同意；除非患者选择退出，否则艾滋病毒检测必须定期进行。虽然这些建议是对现有预防规划的补充，但它们代表了艾滋病毒预防活动重点的重要转变。他们为迄今为止美国青少年中最大规模的艾滋病预防干预奠定了基础。拟议研究的目的是审查青少年如何接受新的建议，以及他们的保健提供者如何执行这些建议。在巴尔的摩的医疗机构中，提供常规检测的临时措施（尽管根据国家的强制要求，需要提供单独的同意书）为评估这一点提供了机会。新的建议反映了文化上的转变，即认为艾滋病是一种慢性但可控制的疾病，不再是“特殊的”。重要的是要了解青少年和他们的护理提供者如何回应这些建议所体现的关于艾滋病毒的新思想。这一点尤其重要，因为这些建议的有效性不仅取决于它们促进检测的能力，而且取决于它们对检测结果产生一系列反应的能力，包括青少年对性伴侣的识别、参与护理和改变行为以减少艾滋病毒风险。青少年医疗提供者是文化掮客。诊所提出的艾滋病毒不再是“特殊”的观点，与青少年社会中对这种疾病的其他文化观点形成了竞争，例如将艾滋病毒视为死刑的观念；艾滋病毒是一种只有特定人群才会感染的疾病；或艾滋病病毒是政府针对特定种族或民族的阴谋。我们建议研究两个青少年患者群体——一个是非裔美国人，一个西班牙裔美国人——如何在诊所内外应对不断变化的艾滋病文化。我们建议使用三种不同但相互关联的方法来做到这一点：患者调查；与青少年卫生保健提供者进行重大事件访谈；以及对青少年患者子样本的人种学访谈。人种学访谈将对三组青少年进行：来诊所寻求艾滋病毒检测的青少年；那些不寻求检查，但在作为常规护理的一部分提供检查时接受检查的人；以及那些拒绝接受艾滋病毒检测的人。这些层次的理解将为新的测试建议的实施提供信息，并突出为使建议实现其既定目标而需要解决的文化影响的实施障碍。

DESCRIPTION (provided by applicant): There have been important shifts in the clinical understanding and treatment of HIV/AIDS and in public culture as it relates to HIV/AIDS since the epidemic began in the US in the early 1980s. Some of these shifts are reflected in the latest HIV testing recommendations from the CDC. The recommendations suggest that all patients between 13 and 64 be tested; that consent for testing be incorporated into patients' general consent for medical care; and that HIV testing be routinely conducted unless patients 'opt-out.' Though conceived as a supplement to existing prevention programs, the recommendations represent an important shift in the focus of HIV prevention activities. They set the stage for what could be the largest-scale HIV prevention intervention among adolescents in the US to date. The objective of the proposed study is to examine how the new recommendations might be received by adolescents and might be implemented by their health care providers. Interim measures to offer routine testing (though with a separate consent form as mandated by the state) in health care facilities in Baltimore provide an opportunity to assess this. The new recommendations reflect cultural shifts toward a view of HIV as a chronic but manageable disease that is no longer `special.' It is important to understand how adolescents and their care providers respond to the new ideas about HIV that these recommendations embody. This is particularly the case since the effectiveness of the recommendations is premised not only on their ability to promote testing, but on their ability to engender a chain of responses to a test result including adolescents' identification of sexual partners, engagement in care, and change in behaviors to reduce HIV risk. Adolescent medicine providers are cultural brokers. The idea introduced in the clinic that HIV is no longer `special' competes with other cultural views of the disease prevalent in adolescents' social worlds, such as notions about HIV as a death sentence; HIV as a disease that only certain kinds of people get; or HIV as a government plot against people of a particular race or ethnicity. We propose to examine how two adolescent patient populations - one African-American and one Hispanic - negotiate the shifting culture of HIV both inside the clinic and outside of it. We propose to use three distinct, but interrelated, methodological approaches to do this: a patient survey; critical incident interviews with adolescent health care providers; and ethnographic interviews with a sub-sample of adolescent patients. Ethnographic interviews will be conducted with three groups of adolescents: those who come to the clinic seeking an HIV test; those who do not seek a test but who accept one when it is offered as a routine part of care; and those who refuse the offer of an HIV test. These layers of understanding will inform the implementation of the new testing recommendations and highlight culturally inflected barriers to implementation that need to be addressed in order for the recommendations to attain their stated objectives.