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