哈佛大学法学院临床教授就“归零”和Pepfar的成功进行了问答-新东方前途出国

　　15年后，与罗伯特·格林沃尔德就“归零”和Pepfar的成功进行了问答

　　By Kaitlyn Dowling, October 22, 2019

　　作者：Kaitlyn Dowling，2019年10月22日

　　“Getting to zero”—what Harvard Professors Ingrid Katz and Ashish Jha describe as “end[ing] transmission of [HIV] and control[ing] the epidemic in the United States within the next 10 years”¬—will take a suite of tools to achieve, according Robert Greenwald, a clinical professor at Harvard Law School and the faculty director of the Law School’s Center for Health Law and Policy Innovation (CHLPI). Greenwald has been a leader in the field of health law for more than 25 years and is currently serving as co-chair of the Federal Chronic Illness & Disability Partnership and the HIV Health Care Access Working Group.

　　哈佛大学法学院临床教授、法律系主任罗伯特·格林沃尔德表示，哈佛大学教授英格丽德·卡茨和阿希什·贾哈所说的“在未来10年内结束[艾滋病]的传播并控制美国的流行病”将需要一套工具来实现。学校卫生法律与政策创新中心。格林沃尔德在卫生法领域担任了超过25年的领 导者，目前担任联邦慢性病与残疾伙伴关系和艾滋病毒保健准入工作组的联合主席。 在线咨询

　　On October 7, the Harvard Global Health Institute, the Harvard University Center for AIDS Research, the Center for Health Law Policy and Innovation at Harvard Law School, and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School hosted “15 Years of PEPFAR,” a full-day conference looking back on the uncertain early days of the epidemic, the successes of President George W. Bush’s President’s Emergency Fund for Aids Relief, and opportunities for the future.

　　10月7日，哈佛全球健康研究所、哈佛大学艾滋病研究中心、哈佛法学院卫生法律政策与创新中心、哈佛法学院Petrie Flom卫生法律政策、生物技术和生物伦理学中心举办了“15年PEPFAR，“一个全天的会议回顾了艾滋病流行初期不确定的日子，小布什总统的艾滋病紧急救援基金取得的成功，以及未来的机遇。

　　Kaitlyn Dowling, communications associate at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, sat down with Greenwald to discuss PEPFAR’s impact at home in the United States, policy barriers to “getting to zero,” and ways to address the epidemic head-on. The following interview has been edited for length and clarity.

　　Petrie Flom卫生法律政策、生物技术和生物伦理学中心的通信助理Kaitlyn Dowling与Greenwald坐下来讨论了PEPFAR在美国国内的影响、实现“归零”的政策障碍，以及如何迎头应对这一流行病。以下采访内容经过编辑，以确保篇幅和清晰度。

　　Kaitlyn Dowling: Your work focuses on domestic HIV care and prevention efforts. How do you see your work relating to what’s happening globally with such efforts?

　　Kaitlyn Dowling：您的工作重点是家庭艾滋病毒护理和预防工作你如何看待你的工作与这些努力在全球发生的事情有关？

　　Robert Greenwald: The U.S. and global efforts to end the HIV epidemic face many of the same challenges. To start, I think we all recognize the critical role that biomedical treatments play in any getting to zero plan. Successfully engaging all people living with HIV in antiretroviral therapy is a significant first step, as treatment leads to viral suppression which promotes individual health and eliminates the risk of transmitting HIV. We also recognize the critical role that Pre Exposure Prophylaxis (or PrEP) plays in preventing HIV transmission.

　　罗伯特·格林沃尔德：美国和全球为结束艾滋病疫情所做的努力面临着许多同样的挑战首先，我认为我们都认识到生物医学治疗在任何归零计划中所起的关键作用成功地让所有艾滋病毒感染者参与抗逆转录病毒治疗是重要的第一步，因为治疗会导致病毒抑制，从而促进个人健康并消除传播艾滋病毒的风险我们也认识到暴露前预防（或PREP）在预防HIV传播中的关键作用。 在线咨询

　　Yet, biomedical interventions alone will not get us to zero. A successful ending the epidemic plan must also address the political, economic and social conditions that often drive the HIV pandemic. While both the U.S. and PEPFAR countries are confronting similar issues, the specific challenges often vary by country and region.

　　然而，单靠生物医学干预并不能使我们达到零成功结束这一流行病计划还必须解决经常导致艾滋病毒流行的政治、经济和社会条件虽然美国和PEPFAR国家都面临着类似的问题，但具体挑战往往因国家和地区而异。

　　Dowling: Since the beginning of the epidemic in the early eighties, many norms have shifted within American government, in particular the problem of partisan gridlock in Congress. How has that impacted your work and the work of other activists, policy makers, and public health officials?

　　道林：自80年代初开始流行以来，美国政府内部的许多准则都发生了转变，特别是国会中的党派僵局问题这对你的工作以及其他活动家、政策制定者和公共卫生官员的工作有何影响？

　　Greenwald: Partisan gridlock certainly has an impact on the role that Congress plays in ending the epidemic. Thankfully, our current Congress appears, to some extent, to continue bipartisan support for both domestic and global HIV funding. On the other hand, the expectation that Congress will pass any meaningful, substantive legislation is low.

　　格林沃尔德：党派僵局当然会影响到国会在结束这场流行病方面所扮演的角色。值得庆幸的是，本届国会似乎在某种程度上继续为国内和全球艾滋病毒基金提供两党支持。另一方面，人们对国会通过任何有意义的实质性立法的期望很低。

　　Domestically, gridlock is good news for people living with HIV, at least as compared to before the 2018 mid-term elections in the U.S. Then, Republicans controlled both the legislative and the executive branches of government, and their health law and policy agenda was largely focused on repealing the Affordable Care (ACA) and restructuring our health and public health systems.

　　在国内，僵局对艾滋病毒携带者来说是个好消息，至少与2018年美国中期选举前相比。当时，共和党控制着政府的立法和行政部门，他们的卫生法律和政策议程主要集中在废除负担得起的医疗（aca）和重组我们的卫生和公共卫生系统。

　　If this agenda had succeeded, over 20 million people would have lost their health insurance coverage and we would have returned to a time when many people living with HIV were excluded from public and private health insurance systems.

　　如果这一议程成功，将有2 000多万人失去医疗保险，我们将回到许多艾滋病毒感染者被排除在公共和私人医疗保险制度之外的时代。

　　Thankfully that didn’t happen, and as a result of the ACA’s Medicaid expansion and other reforms, the rates of uninsured people living with HIV has declined by over 50% in most of the states that expanded Medicaid. That’s a tremendous gain in health care coverage, and as a result we’ve seen the U.S. go from about 25% of people living with HIV virally suppressed to about 54% in 2019. So, I’ll take gridlock over the prior political landscape.

　　谢天谢地，这并没有发生，而且由于aca扩大医疗补助计划和其他改革，在大多数扩大医疗补助计划的州，未参保的hiv感染者的比率下降了50%以上。这是医疗保障覆盖率的巨大增长，因此我们看到美国艾滋病病毒感染者的比例从约25%上升到2019年的约54%所以，我会在先前的政治局面上陷入僵局。 在线咨询

　　Dowling: What are your thoughts on President Trump’s Ending the Epidemic program?

　　道林：你对特朗普总统结束疫情计划有何看法？

　　Greenwald: I agree with the Trump Administration that an important focus of the plan must be on improving access to biomedical interventions. I also agree that Phase One of the plan should focus on geographic hotspots, the 48 counties with the highest number of new diagnoses. Additionally, it is important that the Administration recognizes the rural epidemic in the Southeast, U.S., where health inequities are greatest and outcomes are far below the national average, by including seven states in the Southeast as geographic hotspots.

　　格林沃尔德：我同意特朗普政府的观点，即该计划的一个重要重点必须是改善获得生物医学干预的机会我也同意计划的第一阶段应该把重点放在地理热点地区，即新诊断病例最多的48个县。此外，重要的是，政府要认识到美国东南部的农村流行病，那里的卫生不平等现象最严重，结果远远低于全国平均水平，东南部有7个州被列为地理热点。

　　With that said, I have concerns that there is insufficient funding for the plan to succeed, that the plan is substantively too limited, and that there are serious disconnects between the Administration’s ending the HIV epidemic plan and its broader health policy agenda.

　　尽管如此，我仍担心该计划成功所需的资金不足，该计划在实质上过于有限，以及政府结束艾滋病毒流行计划与其更广泛的卫生政策议程之间存在严重脱节。

　　The Administration is promoting new regulations that would undermine our public and private health insurance systems and reverse the gains we have made in recent years, by supporting the sale of Association Health Plans and other forms of “junk insurance” that were largely prohibited under the ACA. These plans operate outside of mandates that prohibit insurers from denying health insurance based upon pre-existing conditions, or from ignoring the coverage of essential health benefits and consumer protections. In addition, the Administration’s attacks on immigrant communities, transgender and gender non-binary people, and women seeking sexual and reproductive health care services have been relentless.

　　政府正在推行新的法规，通过支持销售协会健康保险计划和其他形式的“垃圾保险”，破坏我们的公共和私人健康保险体系，扭转我们近年来取得的成果，而这些都是《反腐败法》基本禁止的。这些计划超出了禁止保险公司基于预先存在的条件而拒绝健康保险的任务，或者忽略了基本健康福利和消费者保护的覆盖范围。此外，政府对移民社区、变性人和非双性恋者以及寻求性和生殖保健服务的妇女的攻击也十分无情。

　　These policies, and many others proposed by the Administration, clearly undermine access to effective HIV care and prevention services. Despite biomedical advances, we will not end the HIV epidemic in the US, and elsewhere, until we end policies that threaten the health and well-being of all people living with HIV.

　　这些政策以及行政当局提出的许多其他政策，显然损害了获得有效艾滋病毒护理和预防服务的机会。尽管在生物医学方面取得了进展，但在我们结束威胁所有艾滋病毒携带者健康和福祉的政策之前，我们不会结束美国和其他地方的艾滋病毒流行。

　　Dowling: You’ve describe several of the challenges that the U.S. faces in getting to zero. Have there been any successful efforts to address these challenges?

　　道林：您描述了美国在实现零排放方面面临的几个挑战是否有任何成功的努力来应对这些挑战？

　　Greenwald: There are many examples of successful efforts to address the challenges we face in current health and public health law and policy. I will focus on some of the litigation successes, but it is important to note that community mobilization and advocacy have also been successful in protecting and promoting sound health and public health.

　　格林沃尔德：有许多成功的例子可以说明，我们正在努力应对当前卫生和公共卫生法律和政策中面临的挑战。我将重点介绍一些诉讼成功的案例，但必须指出的是，社区动员和宣传在保护和促进健康和公共卫生方面也取得了成功。 在线咨询

　　As to litigation, a federal district court judge has struck down the Trump Administration’s approval of Medicaid work requirements in the first three cases to challenge them in our courts, finding that the Administration’s approval of such requirements reflected an arbitrary and capricious disregard for the primary purpose of the Medicaid program, which is to provide medical assistance to state residents.

　　在诉讼方面，一名联邦地区法院法官驳回了特朗普政府在前三起案件中对医疗补助工作要求的批准，向我们的法院提出质疑，政府对这些要求的批准反映了对医疗补助计划主要目的的任意和反复无常的漠视，该计划的主要目的是向州居民提供医疗援助。

　　Earlier this year, a federal district court judge invalidated the Trump Administration rule that encouraged insurers to offer Association Health Plans, a major form of “junk insurance” that I had mentioned earlier, saying the rule relied on a tortured reading of what the ACA allowed.

　　今年早些时候，一名联邦地区法院法官宣布特朗普政府鼓励保险公司提供协会健康计划的规定无效，这是我早些时候提到的一种主要形式的“垃圾保险”，他说，这项规定依赖于对ACA允许的内容的严刑拷打解读。

　　Most recently, at the intersection of the opioid, HIV and HCV epidemics, a federal district court judge in Pennsylvania ruled that safe injection sites do not violate the Controlled Substances Act, allowing for the development of public health programs that can dramatically reduce opioid related deaths and the transmission of infectious diseases.

　　最近，在阿片类药物、艾滋病毒和丙型肝炎流行的交叉点，宾夕法尼亚州的一名联邦地区法院法官裁定，安全注射点不违反《管制物质法》，允许制定公共卫生方案，大大减少阿片类药物相关死亡和传染病的传播。

　　These are just a few examples of how litigation has worked to defend against efforts that undermine ending the HIV epidemic goals.

　　这些只是一些例子，说明了诉讼是如何为那些破坏结束艾滋病毒流行目标的努力辩护的。 在线咨询

　　Dowling: We’ve talked a lot about challenges to “getting to zero” in the United States, but where do you see hope for the future? Where do you think we’ll see successes?

　　道林：我们谈了很多关于美国“归零”的挑战，但你认为未来的希望在哪里你认为我们会在哪里看到成功？

　　Greenwald: I think we are at a crossroad in deciding the future direction of this country. I’m not sure what will happen in upcoming elections, but I believe that they will determine whether we have federal officials who support strong national standards in sound health and public health law and policy. In this past decade, we have made some great progress. We’ve seen this country make strides in moving away from disability-based health care financing and delivery systems toward systems that are focused on prevention, early intervention and value. I would like to think that we will move forward in a positive way and build on these successes, so that we have systems in place that truly respect the health, well-being and dignity of all people living in the United States.

　　格林沃尔德：我认为我们正处在决定这个国家未来发展方向的十字路口。我不确定在即将到来的选举中会发生什么，但我相信，他们将决定我们是否有联邦官员在健全的卫生和公共卫生法律和政策方面支持强有力的国家标准。在过去的十年里，我们取得了很大的进步我们看到这个国家在从以残疾为基础的医疗保健筹资和提供系统向注重预防、早期干预和价值的系统迈进我想，我们将以积极的方式向前迈进，并在这些成功的基础上再接再厉，以便我们建立起真正尊重生活在美国的所有人的健康、福祉和尊严的制度。