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 >2%

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