The practice of HIV‐infected physicians who perform seriously invasive procedures calls for professional guidance to protect patient safety and the privacy of infected physicians.

An Institute of Medical Ethics working party argues that an ethically desirable relationship of mutual empowerment between patient and clinician is more likely to be achieved if patients understand the ground rules of medical confidentiality. It identifies and illustrates ambiguities in the General Medical Council's guidance on AIDS and confidentiality, and relates this to the practice of different doctors and specialties. Matters might be clarified, it suggests, by identifying moral factors which tend to recur in medical decisions about maintaining or (...) breaching confidentiality. The working party argues that two such factors are particularly important: the patient's need to exercise informed choice and the doctor's primary responsibility to his or her own patients. (shrink)

The paper advances a consequence-based argument in support of the American Medical Association's policy that a physician may not ethically refuse to treat a person with HIV solely because the patient is seropositive. A limited number of alternative arguments, both in support of and in opposition to this policy are also considered, but are found wanting. The paper then concludes with a discussion of some of the other obstacles to quality health care that persons with HIV must often confront.

Ford, Norman There has been some confusion in the media over what Pope Benedict XVI meant by his comments on the use of condoms. He was discussing acts of sexual intercourse performed by male prostitutes in relation to HIV (human immune deficiency virus) infection in reply to a question put to him during an interview with Peter Seewald. The Vatican spokesman Fr Lombardi SJ said the Pope 'had confirmed to him that the example was valid in the case of all (...) prostitutes. The point of the example, he said, "was not the sex of the prostitute but the process of growing awareness of the risk [to] the life of the other person".' He was not referring to married couples nor contraception but the prevention of HIV infection from acts of prostitution. (shrink)

The AIDS epidemic calls for an ethical analysis of conflicting obligations surrounding HIV-infected psychiatric patients and confidentiality, as well as issues that go beyond confidentiality. Although laws pertaining to HIV infection have been enacted in a number of states, these statutes leave much discretion to health professionals. The ethical principle known as "the harm principle" can permit disclosure of confidential information and detention or isolation of psychiatric patients who pose a threat of infecting other patients. From an ethical point of (...) view, however, the circumstances under which traditional protections may be weakened or abandoned remain limited. (shrink)

Since testing for HIV infection became possible in 1985, testing of pregnant women has been conducted primarily on a voluntary, ‘opt-in’ basis. Faden, Geller and Powers, Bayer, Wilfert, and McKenna, among others, have suggested that with the development of more reliable testing and more effective therapy to reduce maternal-fetal transmission, testing should become either routine with ‘opt-out’ provisions or mandatory. We ask, in the light of the new rapid tests for HIV, such as OraQuick, and the development of antiretroviral treatment (...) that can reduce maternal-fetal transmission rates to <2%, whether that time is now. Illustrating our argument with cases from the United States (US), Kenya, Peru, and an undocumented Mexican worker in the US, we show that when testing is accompanied by assured multi-drug therapy for the mother, the argument for opt-out or mandatory testing for HIV in pregnancy is strong, but that it is problematic where testing is accompanied by adverse events such as spousal abuse or by inadequate intrapartum or follow-up treatment. The difference is not a ‘double standard’, but reflects the presence of conflicts between the health interests of the mother and the fetus – conflicts that would be abrogated by the assurance of adequate, continuing multi-drug therapy. In light of these conflicts, where they still occur, careful processes of informed consent are appropriate, rather than opt-out or mandatory testing. (shrink)

The diagnosis of HIV infection is the point of entry for treatment and prevention services, yet many infected persons in both developed and developing countries remain undiagnosed. To reduce the number of undiagnosed infections, a variety of expanded testing policies have been recommended, including opt-out testing. This testing model assumes that in populations of increased HIV prevalence, voluntary testing should be offered to all patients seen in healthcare settings and performed unless patients specifically decline. While this approach raises ethical (...) issues concerning “voluntariness”, access to care, and stigma, the potential benefits of opt-out testing far outweigh its potential adverse effects. (shrink)

An increasing number of HIV-infected patients require surgical care. Many surgeons, regardless of their venue of practice, would prefer not to treat HIV-infected patients.1 The reasons for this attitude differ from individual to individual but include the fear of contracting an incurable fatal illness, a desire to avoid interaction with homosexuals and intravenous drug users, and fears that occupationally acquired HIV infection would result in restriction of clinical privileges and loss of income.2,3 At the same time, many individuals, institutions, and (...) professional organizations have affirmed the obligation of all healthcare workers, including surgeons, to care for patients without regard to their HIV status.4-6 This article explores the nature of this obligation from the perspective of a clinical surgeon working in an inner city hospital. (shrink)

Multiple drug resistant strains of HIV and continuing difficulties with vaccine development highlight the importance of psychologi- cal interventions which aim to in uence the psychosocial and emo- tional factors empirically demonstrated to be significant predictors of immunity, illness progression and AIDS mortality in seropositive persons. Such data have profound implications for psychological interventions designed to modify psychosocial factors predictive of enhanced risk of exposure to HIV as well as the neuroendocrine and immune mechanisms mediating the impact of such factors (...) on disease progression. Many of these factors can be construed as unconscious mental ones, and psychoanalytic self-psychology may be a useful framework for conceptualizing psychic and immune de- fence as well as bodily and self-integration in HIV infection. Al- though further prospective studies and cross-cultural validation of research are necessary, existing data suggest that psychoanalytic insights may be useful both in therapeutic interventions and evaluative research which would require an underlying epistemology of the complementarity of mind and matter. (shrink)

In 1991, the CDC recommended that health care workers (HCWs) infectedwith HIV or HBV (HbeAg positive) should be reviewed by an expert paneland should inform patients of their serologic status before engaging inexposure-prone procedures. The CDC, in light of the existing scientificuncertainty about the risk of transmission, issued cautiousrecommendations. However, considerable evidence has emerged since 1991suggesting that we should reform national policy. The data demonstratesthat risks of transmission of infection in the health care setting areexceedingly low. Current policy, moreover, does (...) not improve patientsafety. At the same time, implementation of current national policy atthe local level poses significant human rights burdens on HCWs.Consequently, national policy should be changed to ensure patient safetywhile protecting the human rights of HCWs. This article proposes a newnational policy, including: (1) a program to prevent bloodborne pathogentransmission; (2) a responsibility placed on infected HCWs to promotetheir own health and well-being and to assure patient safety; (3) adiscontinuation of expert review panels and special restrictions forexposure-prone procedures; (4) a discontinuation of mandatorydisclosure of a HCW's inflection status; and (5) the imposition ofpractice restrictions if a HCW is unable to practice safely because of aphysical or mental impairment or failure to follow careful infectioncontrol techniques. A new national policy, focused on management of theworkplace environment and injury prevention, would achieve high levelsof patient safety without discrimination and invasion of privacy. (shrink)

All international codes of research ethics and virtually all national legislation and regulation in the field of research involving human subjects project an attitude of protectionism. Written with the aim of avoiding a repetition of atrocities like those committed by the Nazi physician-researchers, calamities like the thalidomide experience, or ethical violations like those of the Tuskegee syphilis study, their dominant concerns are the protection of individuals from injury and from exploitation. In recent years, however, society's perception of clinical research has (...) shifted dramatically. Now, largely as a consequence of the efforts of the AIDS activists, clinical research is widely perceived as benign and beneficial. Although this shift in attitude has resulted in some important improvements in research policies and practices, this new perception is just as wrong-headed as was the earlier excessive protectionism. It is necessary to maintain a balanced perspective; our policies should encourage the conduct of ethical research while maintaining the vigilance necessary to safeguard the rights and welfare of the subjects. (shrink)

A mathematical model of the dynamics of the immune system is considered to illustrate the effect of its response to HIV infection, i.e. on viral growth and on T-cell dynamics. The specific immune response is measured by the levels of cytotoxic lymphocytes in a human body. The existence and stability analyses are performed for infected steady state and uninfected steady state. In order to keep infection under control, roles of drug therapies are analyzed in the presence of efficient immune response. (...) Numerical simulations are computed and exhibited to illustrate the support of the immune system to drug therapies, so as to ensure the decay of infection and to maintain the level of healthy cells. (shrink)

The aim of this study was to evaluate terminal care among hospitalized children who died of HIV/AIDS. The design was a retrospective.

The aim of this study was to evaluate terminal care among hospitalized children who died of HIV/AIDS. The design was a retrospective chart review of the terminal hospitalization. The setting was a public, secondary and tertiary children's hospital in Cape Town, South Africa (SA). The patients included a consecutive series of in‐patient deaths from HIV‐related causes. The main outcome measures included: documentation of do not resuscitate (DNR) orders and comfort care plans, intensity of diagnostic and therapeutic interventions in last 24 (...) hours of life, and presence of pain and distress in last 48 hours of life. The results are based on the review of 165 out of 167 in‐patient deaths. Of those, 79% of patients died in general wards. Median age and length of stay were 4 months and 6 days respectively. A total of 84% of patients had a DNR order. DNR orders appeared simultaneously in only 41% of medical and nursing notes. Only 44% of patients had a comfort care plan. Pain and distress in the last 48 hours was documented in 55% of patients who died in the general wards. Respiratory symptomatology and painful skin conditions accounted for most discomfort. Half (36/72) the patients with pain and distress, including 16 with a comfort care plan, received no analgesia. Conclusions drawn found that, despite clinical uncertainty, doctors made tough end of life decisions that included DNR orders and comfort care plans. The lower rate of comfort care plans suggests doctors had difficulty making the transition from curative to palliative care. Many comfort care plans were incoherent and included interventions unlikely to promote patients' comfort. In light of the HIV/AIDS pandemic in SA, reforms are needed to integrate palliative care within mainstream hospital medicine. However, without adequate human resources including trained interpreters, doctors and nurses will struggle to deliver optimal terminal care in acute hospitals. (shrink)

The epidemic of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) has led to many ethical problems. Most studies have focused on the ethical issues faced by nurses who provide care to persons with AIDS (PWA), rather than the ethical issues faced by PWAs themselves. The purpose of this study, therefore, was to explore the ethical issues faced by five HIV/AIDS-infected African-American women. An analysis of interview data revealed that these women deal with four broad categories of ethical issues: (...) diagnosis; disclosure; treatment by, and of, others; and future pregnancies. The results of this study provide an initial description of the ethical issues faced by HIV/AIDS-infected African-American women, and begin to lay the foundation necessary for nurses appropriately to facilitate and support their decisions. (shrink)

A commentary on “Time to Decriminalize HIV Status,” from the September‐October 2013 issue.

The maternal‐fetal HIV transmission trials, conducted in developing countries in the 1990s, undoubtedly generated one of the most intense, high profile controversies in international research ethics. They sparked off a prolonged acrimonious and public debate and deeply divided the scientific community. They also provided an impetus for the revision of the Declaration of Helsinki – the most widely known guideline for international research. In this paper, I provide a brief summary of the context, outline the arguments for and against the (...) controversial use of placebo controls, and focus on particular areas that I believe merit further discussion or clarification. On balance, I argue that the researchers failed in their duties to protect the best interests of their research subjects, and to promote distributive justice. I discuss the difficulties of obtaining valid consent in this research context, and argue that it is unethical to inform women of their HIV status without at least offering them prophylactic treatment for their unborn children. A global view of justice, which endorses international equity, cannot be squared with international research guidelines that allow ‘local conditions’ to define the scope of duty to the control group. Finally, I suggest that the heated debate reflects a tension, if not an outright war, between two conflicting meta‐ethical systems, or incommensurable paradigms, that underpin scientific research involving human subjects. (shrink)

On March 9, 1993, in the first ruling of its kind, the Maryland Court of Appeals declared that physicians and hospitals may be sued for failing to inform patients of a practitioner’s human immunodeficiency virus status. What is more significant, these suits may be pursued even in instances when the physician has followed universal precautions and the patient did not contract the virus that causes acquired immunodeficiency syndrome. The Maryland court addressed two central questions in Faya v. Almaraz. First, do (...) HIV-infected physicians have a legal duty to inform their patients of their HIV status? And, second, can patients recover damages for fear induced by a physician’s conduct? While one finds numerous precedents that authorize actions to recover damages based purely on fear of disease and emotional distress, the Faya court’s holdings on the issue significantly expand the scope of potential liability. Moreover, the court’s analysis of the informed consent and HIV-infected physician issue is incomplete, inconsistent, and represents an unjustified and unwise departure from traditional informed consent theory. It, and its progeny, may have widespread and dire repercussions. (shrink)

The ethical issues in conducting research on preventing HIV infection are among the most complex of any area of human subjects research. This article is an update of a 1987 article that addressed potential conflicts between research design and ethics with respect to AIDS prevention among injecting drug users. The present article reviews current ethical issues that arise in the design and conduct of HIV/AIDS prevention research focused on injecting drug users.

The HIV/AIDS epidemic has placed increasing demands on limited paediatric intensive care services in developing countries. The decision to admit HIV infected children with Pneumocystis carinii pneumonia into the paediatric intensive care unit has to be made on the best available evidence of outcome and the ethical principles guiding appropriate use of scarce resources. The difficulty in confirming the diagnosis of HIV infection and PCP in infancy, issues around HIV counselling, and the variance in the outcome of HIV infected children (...) with PCP admitted to the PICU in African studies compound this process. Pragmatic decision making will require evaluation of at least three ethical questions: are there clinical and moral reasons for admitting HIV positive children with PCP to the PICU, should more resources be committed to caring for HIV children who require the PICU, and how can we morally choose candidates for the PICU? Those working in the PICU in HIV endemic regions need to make difficult personal decisions on effective triage of admissions of HIV infected children with PCP based on individual case presentation, availability of resources, and applicable ethical principles. (shrink)

The old literature on whether medical confidentiality may be breached to warn a spouse of a risk of contracting syphilis from his/her partner — a deep and rich literature — has become relevant once again in the context of HIV infection and AIDS. This paper examines the reasoning and method employed in: the Catholic approach centered around the patient's (property) right to the secret; a (generic) model of justice, utilizing minimal principles of non-aggression and restitution; and an approach involving the (...) elimination of unstable alternatives: the view that public health officials, but not the spouse, may/must be notified; and, that maintaining that the physician is at liberty to disclose but is not obliged to do so. The theory and method behind confidentiality turns out to be deeper than you might have anticipated. (shrink)

Aim To explore the way people living with HIV and healthcare providers in Togo judge the priority of HIV-infected patients regarding the allocation of antiretroviral drugs. Method From June to September 2015, 200 adults living with HIV and 121 healthcare providers living in Togo were recruited for the study. They were presented with stories of a few lines depicting the situation of an HIV-infected patient and were instructed to judge the extent to which the patient should be given priority for (...) antiretroviral drugs. The stories were composed by systematically varying the levels of four factors: the severity of HIV infection, the financial situation of the patient, the patient's family responsibilities and the time elapsed since the first consultation. Results Five clusters were identified: 65% of the participants expressed the view that patients who are poor and severely sick should be treated as a priority, 13% prioritised treatment of patients who are poor and parents of small children, 12% expressed the view that the poor should be treated as a priority, 4% preferred that the sickest be treated as a priority and 6% wanted all patients to get treatment. Conclusions WHO's guideline regarding antiretroviral therapy allocation currently in use in many African countries does not reflect the preferences of Togolese people living with HIV. For most HIV-infected patients in Togo, patients who cannot get treatment on their own should be treated as a priority. (shrink)

HIV remission clinical researchers are increasingly seeking study participants who are diagnosed and treated during acute HIV infection—the brief period between infection and the point when the body creates detectable HIV antibodies. This earliest stage of infection is often marked by flu-like illness and may be an especially tumultuous period of confusion, guilt, anger, and uncertainty. Such experiences may present added ethical challenges for HIV research recruitment, participation, and retention. The purpose of this paper is to identify potential ethical challenges (...) associated with involving acutely diagnosed people living with HIV in remission research and considerations for how to mitigate them. We identify three domains of potential ethical concern for clinicians, researchers, and ethics committee members to consider: 1) Recruitment and informed consent; (2) Transmission risks and partner protection; and (3) Ancillary and continuing care. We discuss each of these domains with the aim of inspiring further work to advance the ethical conduct of HIV remission research. For example, experiences of confusion and uncertainty regarding illness and diagnosis during acute HIV infection may complicate informed consent procedures in studies that seek to recruit directly after diagnosis. To address this, it may be appropriate to use staged re-consent procedures or comprehension assessment. Responsible conduct of research requires a broad understanding of acute HIV infection that encompasses its biomedical, psychological, social, and behavioral dimensions. We argue that the lived experience of acute HIV infection may introduce ethical concerns that researchers and reviewers should address during study design and ethical approval. (shrink)

Since the beginning of the AIDS epidemic, the proportion of AIDS cases among women has continued to rise. Women constituted 23 percent of the AIDS cases reported to the Centers for Disease Control and Prevention in 1995, and 81 percent of these women were of childbearing age. It was not until 1991, however, that epidemiological studies of women were initiated. By comparison, the representation of HIV-infected women in clinical trials gradually has grown. Undoubtedly, a consequence of the increased numbers of (...) women in clinical and epidemiological research is the earlier identification of and more appropriate treatments for HIV-related syndromes when women present in the clinical setting. Despite this expanded focus on women, however, clear information to guide the treatment of HIV-infected women who are pregnant is still lagging behind. (shrink)

Since the beginning of the AIDS epidemic, the proportion of AIDS cases among women has continued to rise. Women constituted 23 percent of the AIDS cases reported to the Centers for Disease Control and Prevention in 1995, and 81 percent of these women were of childbearing age. It was not until 1991, however, that epidemiological studies of women were initiated. By comparison, the representation of HIV-infected women in clinical trials gradually has grown. Undoubtedly, a consequence of the increased numbers of (...) women in clinical and epidemiological research is the earlier identification of and more appropriate treatments for HIV-related syndromes when women present in the clinical setting. Despite this expanded focus on women, however, clear information to guide the treatment of HIV-infected women who are pregnant is still lagging behind. (shrink)