Introduction to HIV and Ethics

1
Introduction to HIV and Ethics

• Amy Lynn Payne, BA

Tete MSF center for HIV vertical transmission
programme
2
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

3
Ethical Issues

• Confidentiality
• Research
• Distributive Justice
• Testing
• Public Health (individual autonomy vs. interest
  of the public)
• Needle Exchange (Prevention and public values)

4
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

5
Confidentiality

• Importance of Health Care Provider-Patient
  Relationship
• Stigma associated with HIV status
• Confidentiality ? anonymity

6
Clinical Research

• Grassroots movement changing research ideals
• Conflict between researcher and physician
• Therapeutic obligation
• Placebo use Withholding treatment
• Equipoise

7
Changes in Research due to HIV

• Large grass roots movement
• ACTUP
• Move to include new treatment exclusive arm

8
Language and Public Perceptions

• Compliance to adherence
• Patient to subject to participant

9
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.

10
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

11
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.
12
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 gt2

13
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

14
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

15
Substance Abuse and HIV

• Needle exchange programs
• Politically unpopular?
• Public Health necessity?
• NIMBY
• Endorsing/Accepting drug use

16
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