Introduction to HIV and Ethics
Amy Lynn Payne, BA
Tete: MSF center for HIV vertical transmission programme
Principles of Medical Ethics
• Nonmaleficence- “Above all, do no harm”
• Beneficence- Act only to provide a benefit
• Autonomy - Act in accord with the will of the individual
• Utility– Act in a way to bring about the greatest benefit and the least harm
Ethical Issues
• Confidentiality• Research• Distributive Justice• Testing • Public Health (individual autonomy vs. interest of
the public)• Needle Exchange (Prevention and public values)
Distributive Justice
• Principle of Equality-to each the same• Principle of Effort-to each according to his
or her effort• Principle of Contribution-to each according
to contribution• Principle of Need-to each according to her
or his needs
Confidentiality
• Importance of Health Care Provider-Patient Relationship
• Stigma associated with HIV status
• Confidentiality ≠ anonymity
Clinical Research
• Grassroots movement changing research ideals
• Conflict between researcher and physician
• Therapeutic obligation
• Placebo use = Withholding treatment
• Equipoise
Changes in Research due to HIV
• Large grass roots movement– ACTUP
• Move to include new treatment exclusive arm
Language and Public Perceptions
• Compliance to adherence
• Patient to subject to participant
Distribution of Health Care Resources
• Huge gap between developing and developed nations
• Access to specialists, testing, and tertiary care facilities
• Controversy over cost highlighting the lack of accord between pharmaceutical industry and public health goals.
Fatal Imbalance: Research and Development of New Therapies
• 10% of research goes to test therapies that effect 90% of the world
• Diseases that effect the poor, particularly tropical diseases, attract very little attention from the pharmaceutical and research community
AIDS in Africa• 2.4 million (est.) dead in 2002
• 29.4 million (est.) infected
Villagers in Masogo, Kenya attend a funeral for a suspected AIDS victim.
Perinatal Transmission
• Transmission from mother to fetus approx. 25% baseline in the absence of ARV.
• 076 ACTG protocol, AZT monotherapy, dropped rates to about 8%.
• Modified 076 protocol tested in developing world reduced rates to about 11%
• Triple ARV reduces transmission to >2%
Perinatal Transmission: Breast-Feeding
• WHO estimates 10-20% transmission rate through breast-feeding.
• Prevention thought problematic in developing countries– Conflict with promotion of breast-feeding– Lack of access to formula– Safe supplies of water– Social stigma associated with formula use
Perinatal Transmission Studies in Developing Countries
• 16 studies in developing countries-15 using placebo controls
• Modified 076 protocol-cheaper and simpler• Placebo controls = withholding therapy?• When is it nonexploitative to accept lower
standards of care?• Consent issues?• “Reasonable availability”
Substance Abuse and HIV
• Needle exchange programs:– Politically unpopular?– Public Health necessity?– NIMBY– Endorsing/Accepting drug use
Reaching at-risk populations
• Prison populations thought to be at risk due to in house use of drugs and risky sexual practices
• European and Australian prison systems set up needle exchange programs
• American prisons rarely keep (or admit) numbers on in house transmission of HIV
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