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Chapter 12: Epidemic! AIDS and HIV. Introduction. “HIV” stands for “human immunodeficiency virus” which is the cause of AIDS (“acquired immunological deficiency syndrome”). The number who have died from AIDS since the epidemic began in the late 1970s is estimated to be around 30 million .
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Introduction • “HIV” stands for “human immunodeficiency virus” which is the cause of AIDS (“acquired immunological deficiency syndrome”). The number who have died from AIDS since the epidemic began in the late 1970s is estimated to be around 30 million. • While advances in HIV/AIDS research have improved our understanding of both the virus and the disease, and while medical treatments have allowed certain HIV positive patients to live longer, there is still no cure.
Introduction • In addition, while the dangers of AIDS has become more widely known, AIDS continues to spread, particularly in Africa. • The AIDS epidemic raises a number of ethical questions that have appeared in other chapters. But those questions gain special urgency because of the scale of the AIDS epidemic and the potential consequences if it is not brought under control.
Ethical questions Among those questions are following: • HIV is typically spread through sexual contact. • Is its wrong for someone infected with HIV to fail to inform a potential sexual partner about his HIV status? • Should failing to do so be a criminal offense?
Ethical questions B. Medical professionals such as doctors and therapists may, as part of their practices, learn that an HIV patient of theirs has had sexual relations with others but failed to inform them of his disease beforehand. • It is typically understood that such professionals have an ethical obligation to keep information about their patients confidential. But in this case, the patient’s sexual partners are at risk of contracting the virus themselves. • Do medical professional have a duty to breach confidentiality and warn those partners of the potential risk? • The reading “Lethal Sex: Conditions of Disclosure in Counseling Sexually Active Clients with HIV” by Elliot Cohen addresses this issue.
Ethical questions C. Epidemiological models suggest that an intensive program of HIV testing and immediate treatment with antiviral drugs could reduce the rate of HIV transmission to such a low level that AIDS would virtually disappear within a decade. • Such a program would be expensive and everyone would have to be tested in the absence of any signs of the disease. Those testing positive would have to agree to be treated with drugs with unpleasant side effects that can become toxic after prolonged use. • To what extent can we violate individual autonomy to protect the health of others in the society?
Ethical questions D. Given the risks that HIV positive individuals can pose to others, one way to reduce that risk is to create a mandatory AIDS registry. Laws already permit public health officials to register those infected with tuberculosis. • Why should HIV be treated any differently?
Ethical questions E. Sub-Saharan Africa is the worse AIDS region in the world but also one of the poorest making it especially difficult for the region to deal with the epidemic. Of the roughly 34 million people in the world with AIDS, 23 million are in Africa. • Efforts to find cheap and effective medical treatment have led to ethical disputes over how the effectiveness of proposed treatments should be assessed. • The section “Testing AIDS Drugs in the Third World” examines the disagreements that arose over the use of placebos in testing the effectiveness of a non-standard dose of the drug zidovudine (ZDV) to reduce transmission of AIDS from mother to child.
Ethical questions • Since a standard dose of the drug had already been shown to be effective in US trials, was it ethical to employ a placebo on African research subjects? • The readings in Section 2, “Human Rights and Maternal-Fetal HIV Transmission Prevention Trials in Africa” and “We’re Trying to Help Our Sickest People, Not Exploit Them” address this question.
Ethical issues F. Another ethical issue related to the testing of AIDS treatments concerns how demanding the test standards should be given the fact that death is an almost inevitable outcome of the disease and given the fact that AIDS has become so widespread. • Shouldn’t possible therapies be made more quickly available with such high stakes, even if they are not as fully tested as might be ideal? • The reading “Aids Activism and the Democratization of Medicine: What is the Lesson” takes up this issue.
Scope of the epidemic The numbers in the table to the right speak for themselves
Reading: Lethal Sex: Conditions of Disclosure in Counseling Sexually Active Clients with HIVElliot D. Cohen • Elliot Cohen argues that although effective psychological counseling requires that a client trust the counselor, this trust has a moral limit. • Drawing on Kantian and utilitarian notions, Cohen argues that if a counselor learns that an HIV-positive client is sexually active with an uninformed third person, the counselor has a duty to make sure the person is warned of the risk. • Cohen distinguishes cases of Type 1 (a specific sexual partner) from those of Type 2 (multiple and anonymous partners) and spells out when breaking confidentiality is morally permitted and when it is morally required.
Reading: Aids Activism And The Democratization Of Medicine: What Is The Lesson?James R. Grove • Grove reviews the background of the search for an effective drug to treat AIDS. AIDS activists, Grove points out, were impatient with the standard, scientific way of testing new drugs. • Because people with AIDS were dying by the hundreds, the activists pushed the FDA to accept a new model for drug testing, one in which people would be treated with drugs some believed might be effective. • Animal studies would not be required, nor would testing for safety and side-effects need to be done before the drugs was used.
Reading: Aids Activism And The Democratization Of Medicine: What Is The Lesson?James R. Grove • Grove points out that AIDS activists were also unwilling to accept that AIDS could not be cured, even though cures did not exist for other viral diseases like polio. • AIDS activists insisted that the disease be dealt with in new ways, but Grove asks, should the approach advocated by AIDS activists he followed in the future and with respect to other diseases.
Reading: Human Rights and Maternal–Fetal HIV Transmission Prevention Trials in AfricaGeorge J. Annas and Michael A. Grodin • George Annas and Michael Grodin argue that unless a therapy which is being tested in an “impoverished” country will actually be made available to those needing it in that country, research subjects are being exploited to benefit developed countries. • The mere possibility that the therapy will be feasible for use in the impoverished country is not enough to justify the testing.
Reading: Human Rights and Maternal–Fetal HIV Transmission Prevention Trials in AfricaGeorge J. Annas and Michael A. Grodin • Nor is the fact that scientists from that country are involved; nor is the existence of a professional consensus favoring the testing. • Even when the testing is justified, research subjects must not be drawn from the most vulnerable groups and informed consent of participants is required.
We’re Trying to Help Our Sickest People, Not Exploit ThemDanstanBagenda and PhilippaMusoke-Mudido • The authors respond to critics of the clinical trials in Africa involving comparing the effectiveness of new therapies with placebos in preventing the transmission of HIV from mothers to their infants. • The authors argue that such factors as cost, nutrition, social practices, culture, and environmental circumstances make it inappropriate to compare testing in developed countries with testing in Africa.
We’re Trying to Help Our Sickest People, Not Exploit ThemDanstanBagenda and PhilippaMusoke-Mudido • Also, women enrolled in the trials received intensive education and individual counseling, and were given a consent form written in their local language and explaining their potential risks and chances of getting a placebo. • Only after their questions and concerns were addressed by counselors were they asked to sign. The authors express skepticism about those who claim to speak on behalf of Africa yet have never worked with its people.
Section 3: Origin of the AIDS Virus • One approach to finding a cure for AIDS is trying to establish the origins of HIV. It is known that African chimpanzees are sometimes infected with a virus very similar to HIV called “Simian immunodeficiency virus” (SIV). • Some have argued that HIV may have originated from SIV and then mutated into its current form. The simian virus might have been transmitted to humans by an exposure to chimpanzee blood as the result of slaughtering chimpanzees for meat (“bush meat”). • An alternative account of how transmission might have taken place is discussed in the reading for this section “Investigating the Origin of AIDS: Some Ethical Dimensions”.
Reading: Investigating the Origin of AIDS: Some Ethical DimensionsBrian Martin • Brian Martin argues that a theory linking the origin of the AIDS virus with polio vaccines used in Africa in the late 1950s should be investigated. • Despite the risk of diverting funds from preventing the spread of AIDS and discouraging vaccinations for other diseases, we might learn something to help us combat AIDS. • Also, such an investigation would sensitize scientists to the potential dangers of vaccination practices, xenotransplantation, and genetic engineering that involve combining genes from different species.
Reading: Investigating the Origin of AIDS: Some Ethical DimensionsBrian Martin • Martin argues that even if the polio vaccines are found to be responsible for causing the AIDS virus, individual scientists should not be blamed. • However, scientists should not file lawsuits against those who say they are responsible for AIDS, because the damaging effect of this on research would be too great. • Finally, Martin argues that science should investigate even an unorthodox theory if the combination of its implications and its chance of being correct is sufficiently great—as it is in the case of the origin of the AIDS virus from contaminated vaccines.
