Health care innovations from policy to practice: A case study of a rapid HIV testing trial in general practice

Abstract

The UK National Guidelines on HIV Testing 2008 recommended that adults in areas where more than 2/1000 people were living with HIV be considered for an HIV test at the point of registration with general practice. The RHIVA2 trial of rapid HIV testing in primary care implemented and evaluated this recommendation across 20 general practices in a single UK borough using a pragmatic cluster randomised controlled trial (RCT) design. This trial, and the policy that underpinned it, reflected two more general developments: first, the move towards population screening to detect and treat disease in early and latent stages and second, the emergence of ‘pragmatic’ clinical trials that seek to account for complexity and measure interventions in their context of use. This interdisciplinary case study uses multiple methods and theoretical frames to explore what happened in the RHIVA2 trial at both an empirical and a theoretical level. Sub-studies reveal how the trial was justified, enacted and became meaningful as a policy, as a trial, and as an intervention in the lives of patients. My analyses show that two operating logics informed the justification and enactment of the trial and patterned patient and provider experiences. The first, the logic of normalisation for HIV aims to treat HIV infection as a medical condition ‘like any other’. This logic emphasises general practice as a site of increased value and position in HIV management and as a space where population screening can be undertaken. Second, the logic of the pragmatic trial aims to measure interventions in the ‘real world’ but is revealed to produce unintended effects, raising questions about the claims of such trials to generalisability and reproducibility. This thesis demonstrates how contrasting versions of the research event (‘multiplicity’) can be produced through different modes of inquiry, raising questions about the tension between situated and generalisable findings.