When Science and Values Collide: Recalling the Lessons of Evidence-Based HIV Prevention

AIDS Behav DOI 10.1007/s10461-017-1861-z GUEST EDITORIAL When Science and Values Collide: Recalling the Lessons of Evidence-Based HIV Prevention Ronald O. Valdiserri1 • Robert A. Bonacci2 • David R. Holtgrave1  Springer Science+Business Media, LLC 2017 Although terminology espousing ‘‘evidence-based’’ approaches to the practice of medicine and of public health is a relatively recent contribution to the scientific lexicon [1, 2], recognition of the importance of basing actions to improve health outcomes on sound evidence, rather than relying on subjective beliefs and long-standing traditions, extends back centuries. Nearly 400 years ago, Sir Francis Bacon, often acknowledged as the father of inductive reasoning and a major proponent of the scientific method, cautioned that ‘‘confirming and rendering inveterate’’ past errors was ‘‘more hurtful’’ than ‘‘searching after the truth’’ [3]. Rather than stagnate, Bacon affirmed that the arts and sciences must evolve and that they ‘‘should resound…with new works and advances’’ [3]. New information, whether arising from emerging trends in HIV incidence, qualitative observations acquired from community stakeholders or demonstration projects evaluating innovative prevention strategies, has resulted in successive improvements in our response to combatting HIV. A retrospective review of HIV prevention efforts in the United States provides ample evidence of how advances in behavioral and biomedical science have driven improvements in the content and focus of HIV prevention efforts over the past decades [4]. Consider early efforts to decrease the sexual transmission of HIV that relied primarily on the provision of basic information about the mechanics of HIV transmission, usually delivered in a & Ronald O. Valdiserri 1 Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2 Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA didactic manner (so called ‘‘AIDS 101’’ education). Compare those initial prevention responses to subsequent approaches, informed by theory and evidence, that tested interventions based on theoretically derived models of behavior change, delivered by engaging the social networks of vulnerable populations [5]. Or reckon how randomized controlled trials have demonstrated the efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV infection among men who have sex with men [6] as well as heterosexual men and women [7]; if brought to scale and provided in tandem with other effective HIV prevention methods, there is little doubt that PrEP could substantially reduce the number of new HIV infections among at-risk populations [8]. For those of us who focus our research, teaching and practice on effective, evidence-based strategies to prevent HIV infection and its negative sequelae, there is no question that an ever-expanding knowledge base across a variety of scientific and technical disciplines has the potential to continually improve health outcomes for populations at risk for or living with HIV. But knowledge doesn’t exist in a void and we cannot ignore the fact that subjective experiences and opinions, including values and belief systems, can radically alter the way that knowledge is gathered, interpreted and subsequently acted upon. The history of HIV prevention includes notable examples of scientifically sound, evidence-based prevention approaches that have been minimized—or in some instances, even sidelined—because of strong, countervailing negative attitudes and values. Access to sterile injection equipment for people who inject drugs (PWID) is perhaps the most obvious example. Despite cumulative evidence of HIV prevention effectiveness, concerns about the appearance of endorsing or promoting the practice of substance use have resulted in legislative bans against the use of 123 AIDS Behav federal funds to support access to sterile injection equipment as a necessary component of comprehensive HIV prevention among PWID [4, 9]. It took an outbreak of HIV in rural Indiana in 2015, among persons sharing syringes to inject the prescription opioid oxymorphone [10, 11], to induce Congress to pass a partial repeal of the ban prohibiting the use of federal funds to support needle and syringe exchange programs [9] (federal funds still cannot be used to purchase sterile needles and syringes, but can be used to support other programmatic components of needle exchange programs—in areas that can document that they’re experiencing or are at risk for an outbreak of viral hepatitis or HIV related to injection drug use). A look at early efforts to promote safer sexual behaviors among gay and other men who have sex with men (MSM) provides additional documentation of how evidence and values can clash, to the detriment of health outcomes. Years prior to the onset of AIDS in America, several accepted theories of human behavior change recognized the importance of social influence on the adoption of new behaviors and posited that the credibility of both the message and the messenger could affect the success of efforts to modify behaviors [12]. In terms of reaching sexually active MSM with information about how to prevent the transmission of HIV, extant theoretical constructs should logically have directed prevention specialists to talk frankly about the range of human sexual practices—in language that would be understood, and accepted, by the very individuals for whom the information was intended. Instead, during those early years, structural stigma against homosexuality—which was widespread and in many instances supported by state laws—restricted the ways in which prevention messages were communicated to at-risk communities. In fact, it wasn’t until 2003, some 22 years after AIDS was first reported, that the U.S. Supreme Court ruled that criminalizing intimate sexual contact between two consenting adults of the same sex was unconstitutional—overturning previous rulings that had upheld state laws on sodomy [13]. Negative values about homosexuality (and, for that matter, injection drug use) may help explain the Congressional Office of Technology’s (OTA) 1985 finding that federal efforts to educate high risk groups about AIDS was left ‘‘largely up to the leadership of the groups themselves’’ and that ‘‘brochures designed by gay organizations have provided much more explicit and practical advice on the relative safety of various sexual practices’’ than those developed by the US Public Health Service [14]. OTA opined that ‘‘one reason’’ for organized public health’s failure to provide adequate risk reduction information to MSM and PWID might be because ‘‘providing advice on preventive practices may be viewed as condoning bisexuality, homosexuality, or intravenous drug abuse’’ [14]. 123 OTA’s supposition gained further credibility some 2 years later when the U.S. Congress passed an amendment that prohibited the use of federal funds for any AIDS educa (...truncated)