Chapter 12: Epidemic! AIDS and HIV

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14 déc. 2012 (il y a 9 années et 1 mois)

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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
.



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:


A.
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

Section 1: Responsibility and
Confidentiality


.

Reading: Lethal Sex: Conditions of Disclosure in
Counseling Sexually Active Clients with HIV

Elliot 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.


Section 2: AIDS Trials in Africa

Reading: Human Rights and Maternal

Fetal HIV
Transmission Prevention Trials in Africa

George 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 Africa

George 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
Them

Danstan

Bagenda

and
Philippa

Musoke
-
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
Them

Danstan

Bagenda

and
Philippa

Musoke
-
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
Dimensions

Brian 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
Dimensions

Brian 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.