With the advent of new AIDS treatment initiatives such as the World Health Organization's “3 by 5” program and the United States' “President's Emergency Plan for AIDS Relief,” the ethical questions about AIDS care in the developing world have changed. No longer are they fundamentally about the conduct of research; now, we must turn our attention to developing treatment programs. In particular, we must think about how to spread limited treatment resources among the vast reservoir of (...) people who need them. (shrink)

With a global commitment to scaling up AIDS care and treatment in resource-poor settings for some of the most HIV-affected countries in Africa, availability of antiretroviral treatment is no longer the principal obstacle to expanding access to treatment. A shortage of trained healthcare personnel to initiate treatment and manage patients represents a more challenging barrier to offering life-saving treatment to all patients in need. Physician-centered treatment policies accentuate this challenge. Despite evidence that task shifting for nurse-centered (...) class='Hi'>AIDS patient care is effective and can alleviate severe physician shortages that currently obstruct treatment scale-up, political commitment and policy action to support task shifting models of care has been slow to absent. In this paper we review the evidence in support of task shifting for AIDS treatment in Africa and argue that continued policy inaction amounts to unwarranted healthcare rationing and as such is ethically untenable. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Closing the Gaps in Pediatric HIV/AIDS Care, One Step at a TimeLisa V. Adams, Helga Naburi, Goodluck Lyatuu, Paul Palumbo, and C. Fordham von ReynFatuma's* doctors were completely perplexed. It was 2003 and she had returned to the DARDAR clinic in her hometown of Dar es Salaam, Tanzania three times that week with vague complaints of various pains and aches. Her doctors were considering whether these symptoms (...) were due to the initiation of her recent treatment with antiretroviral medications for her HIV infection or related to the last administration of the investigational tuberculosis (TB) vaccine that the DARDAR Health Study was evaluating. Fatuma's doctor, Dr. Lillian Mtei, consulted with Dartmouth's chief of Infectious Disease, Dr. Ford von Reyn, who happened to be in Dar that week on a site visit. Neither physician could determine the basis for her symptoms. Dr. Mtei returned to the exam room once more and this time emerged with the answer: Fatuma had just learned that her three year old daughter was HIV-infected, likely contracted from Fatuma during or shortly after she gave birth to her daughter. Fatuma believed that her HIV diagnosis was a death sentence for her daughter since antiretroviral therapy was not widely available for children.Dr. von Reyn, Dartmouth's lead clinical researcher in Africa and a father, knew too well the harsh reality of inequities in a resource-limited country. He turned to Dr. Mtei and said decidedly, "we need to do something about this."Thus the DARDAR Pediatric Program was born.Pediatric HIV: A Neglected DiseaseThe need for HIV treatment among children in Tanzania, as in most of sub-Saharan Africa, is compelling. At the end of 2009, approximately 160,000 children aged zero to fourteen in Tanzania were living with HIV (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2011). Even with successful roll out of prevention of mother to child transmission programs in Tanzania, there were nearly 29,000 perinatal infections in 2009. As of December 2010, only 18% of these were enrolled in HIV treatment programs (UNAIDS, 2011; World Health Organization [WHO], 2011). Without antiretroviral therapy (ART), one-half of HIV-infected children will die before their second birthday. Since clinical research to determine efficacy and safety of new medical treatments is conducted almost exclusively in adults, provision of new medical treatments to [End Page 75] children always lags behind advances for adults. Furthermore, children are often underrepresented in programs for antiretroviral drugs for the following reasons: 1) they are not prioritized for care; 2) facilities lack infant diagnostic capabilities; 3) there is limited pediatric HIV training and consequently, a shortage of pediatric providers; and 4) pediatric antiretroviral formulations are frequently unavailable. The unacceptable delays in pediatric HIV drug development and treatment access led the international organization Drugs for Neglected Diseases initiative to publish an editorial in which they referred to pediatric HIV as a "neglected disease" (Lallemant, Chang, Cohen, & Pecoul, 2011).The Tip of the Iceberg: More than Just MedicinesWith a grant from the New York-based Foundation for the Treatment of Children with AIDS, the DARDAR Pediatric Program, a joint collaboration between Geisel School of Medicine at Dartmouth and Muhimbili University of Health and Allied Sciences, began seeing patients in May 2006. It was the first dedicated pediatric HIV Care and Treatment Center in Tanzania and operates in accordance with Tanzania's National AIDS Control Programme's guidance. Testing for both children and infants (the latter of which requires a more sophisticated assay) is available.The day the clinic opened we celebrated this collaborative effort that would provide HIV-infected children in Dar es Salaam access to antiretroviral treatment. One of our first patients was a six-year-old boy whose mother, like Fatuma, was a participant in our TB vaccine trial. She had been advised to bring her son to us for HIV screening. Her son looked healthy so she was surprised and understandably distraught when his test results indicated that not only was he HIV-infected, but his CD4 percentage was very low. His mother was reluctant to have him started on antiretrovirals given his general appearance and young age—and that he was... (shrink)

Despite global acknowledgement of HIV/AIDS reaching pandemic proportions with 37.8 million people living with the infection, progress towards developing effective international responses to curb its spread has been slow. The focus of current debate tends to focus on the medical treatment and prevention of HIV/AIDS, leading to emphasis being placed on the rapid increase in HIV infection as well as opportunistic diseases such as tuberculosis and malaria. The traditional view of responding to these challenges has been probing the (...) high cost factors associated with antiretroviral treatment and burgeoning medical care needs. This article argues that these responses are limited in their effect as they have a narrow, medical focus. This article presents a broader perspective. It investigates the implications of HIV/AIDS to the goals of national sustainable development using theoretical standpoints provided by reflexive modernization, namely, the concepts of risk and reflexive judgement. Attention is given to those regions of the world—Africa and Asia—where HIV/AIDS are acute policy issues. (shrink)

BackgroundAfrica continues to bear a disproportionate share of the global HIV/AIDS, tuberculosis (TB) and malaria burden. The development and distribution of safe, effective and affordable vaccines is critical to reduce these epidemics. However, conducting HIV/AIDS, TB, and/or malaria vaccine trials simultaneously in developing countries, or in populations affected by all three diseases, is likely to result in numerous ethical challenges.MethodsIn order to explore convergent ethical issues in HIV/AIDS, TB and malaria vaccine trials in Africa, the Ethics, (...) Law and Human Rights Collaborating Centre of the WHO/UNAIDS African AIDS Vaccine Programme hosted a consultation on the Convergent Ethical Issues in HIV/AIDS, TB and Malaria Vaccine Trials in Africa in Durban, South Africa on the 10-11 February 2009.ResultsKey cross cutting ethical issues were prioritized during the consultation as community engagement; ancillary care obligations; care and treatment; informed consent; and resource sharing.ConclusionThe consultation revealed that while there have been few attempts to find convergence on ethical issues between HIV/AIDS, TB and malaria vaccine trial fields to date, there is much common ground and scope for convergence work between stakeholders in the three fields. (shrink)

This article examines bioethics in Tanzania, particularly in relation to the HIV/AIDS epidemic for the following reasons: First, not only is HIV/AIDS the most alarming health problem in most parts of Africa, but the complexity of issues involved in medical and research ethics clearly illustrates the various levels of problems that bioethics—more precisely, both professional medical ethics and research ethics—faces in a poor, developing country. The article defends uniformity in the general, international bioethical guidelines but calls for (...) wider discussion in their applicability in different economic and social conditions by claiming that in the present debates the issues of distributive justice, culture, and individual professional judgment have been tangled together in a manner that tends to justify double standards in practice. To avoid this confusion there is a need to find a more coherent approach to bioethics that brings together the normative requirements set by international guidelines, national policy planning, social ethics, and professional medical ethics. a. (shrink)

The current training model being used in higher education advocates the acquisition of competences aimed at providing students with all-round training that will enable them to tackle their future work responsibilities effectively. This encompasses a number of different competences, most notably the transversal kind, especially in view of the important role they play in shaping the profile of any professional individual. The active learning methods applied to group work have shown to be the most suitable for achieving these competences. From (...) this perspective, and considering their relevance, we present the results of a study that addresses the perceptions held by students from Education Degrees regarding the extent to which transversal competences are acquired by implementing active learning methods. The students perceive group work as a dynamic that teaches them how to be more self-critical and committed to group-oriented tasks, thus encouraging communication skills, personal relationships and motivation. However, a lesser degree of acquisition has been recorded in other equally important competences. As such, it is necessary to promote these learning methods from the start, carefully designing and planning the curriculum structure as well as the tasks to be performed in order to avoid any negative implications that may arise. (shrink)

Keeping the diagnosis of a client confidential is one of the cornerstones of professional practice. In the case of a diagnosis such as HIV/AIDS, however, the ethics of this action may be challenged. Such a decision has a range of negative effects, for example, the blaming of others, supporting the denial of the client, and complicating the health education and care of the patient. It is suggested that the four ethical principles should be used to explore the ethics (...) of such decisions, and that professional regulatory bodies and organizations should support professionals in situations where the client’s sexual partner is informed against the wishes of the client. (shrink)

BackgroundThe issue of stigma is very important in the battle against HIV/aids in Africa since it may affect patient attendance at healthcare centres for obtaining antiretroviral medications and regular medical check-ups. Stigmatization creates an unnecessary culture of secrecy and silence based on ignorance and fear of victimization. This study was designed to determine if there is external stigmatization of people living with HIV and AIDS by health care workers at a tertiary hospital in KwaZulu-Natal province, South (...) Africa. The study investigated the impact of knowledge of HIV/aids by HCWs on treatment of patients, as well as the comfort level and attitude of HCWs when rendering care to PLWHA.MethodsA descriptive cross sectional study was designed to collect data using an anonymous self-administered structured questionnaire from 334 HCWs. The study was conducted in clinical departments of a large multidisciplinary 922-bed tertiary care teaching hospital in Durban, KZN.ResultsOverall HCWs had an above average knowledge about HIV/aids although some gaps in knowledge were identified. Tests of statistical significance showed that there was association between level of education and knowledge of HIV/aids ; occupation and knowledge of HIV/aids ; and gender and knowledge of HIV/aids. Test for comfort level was only significant for gender, with males showing more comfort and empathy when dealing with PLWHA. The study also revealed that patients were sometimes tested for HIV without informed consent before surgery, due to fear of being infected, and there was some gossiping about patients' HIV status by HCWs, thereby compromising patient confidentiality. The majority of HCWs showed a willingness to report incidents of stigmatization and discrimination to higher authorities, for better monitoring and control.ConclusionsAlthough knowledge, attitude and comfort level of HCWs taking care of PLWHA was above average, enforcement of existing antidiscrimination laws and continuing education in medical ethics and healthcare law, would greatly improve the performance of HCWs taking care of PLWHAs. More psychological support and counselling should be provided to HCWs, to further reduce the impact of stigmatization and discrimination against PLWHA. (shrink)

Acquired Immune Deficiency Syndrome (AIDS) is an emotive subject, particularly in southern Africa. Among those who have been directly affected by the disease, or who perceive themselves to be personally at risk, talking about AIDS inevitably arouses strong emotions - amongst them fear, distress, loss and anger. Conventionally, human geography research has avoided engagement with such emotions. Although the ideal of the detached observer has been roundly critiqued, the emphasis in methodological literature on 'doing no harm' has (...) led even qualitative researchers to avoid difficult emotional encounters. Nonetheless, research is inevitably shaped by emotions, not least those of the researchers themselves. In this paper, we examine the role of emotions in the research process through our experiences of researching the lives of young AIDS migrants in Malawi and Lesotho. We explore how the context of the research gave rise to the production of particular emotions, and how, in response, we shaped the research, presenting a research agenda focused more on migration than AIDS. This example reveals a tension between universalised ethics expressed through ethical research guidelines that demand informed consent, and ethics of care, sensitive to emotional context. It also demonstrates how dualistic distinctions between reason and emotion, justice and care, global and local are unhelpful in interpreting the ethics of research practice. (shrink)

Awareness, care and preventative action regarding HIV/aids, and those affected by it, is growing in the evangelical Christian Community in French-speaking Sub-Saharan Africa. Yet, even though the issues seem to be addressed through teaching and preaching in the churches, the real issues, questions and struggles of the people are not discussed. This article describes some of the most important outcomes of a qualitative research in this people group, looking at the values and beliefs around sexuality and community (...) and what impact they have on current HIV/aids prevention practices and strategies. This description highlights the seeming discrepancy between people’s values and their daily lives, the role community can play – as both a community of grace and a countercultural yet contextually relevant community, and the role of leaders, grass-root communities and partnership processes in strategy development. This article argues for a contextual relevant approach in which the specific evangelical worldview is encountered as a possible strength, rather than a problem. (shrink)

The author reviews various conceptions of autonomy to show that humans are actually not autonomous, strictly speaking. He argues for a need to rethink the personal autonomy approaches to HIV testing in sub-Saharan Africa (SSA) countries. HIV/AIDS has remained a leading cause of disease burden in SSA. It is important to bring this disease burden under control, especially given the availability of current effective antiretroviral regimens in low- and middle-income countries. In most SSA countries the ethic or value (...) of personal autonomy or self-determination is promoted as primary in HIV testing decision-making. SSA policymakers have an ontological and moral duty to adopt HIV testing policies that reflect human and medical realities, relationships, local contexts, and respect human rights for both individuals and others who are affected by HIV in society. Without rethinking the value of autonomy in HIV testing decision-making, the article cautions that attainment of the Sustainable Development Goal (SDG) 3 and the UNAIDS fast-track strategy that explicitly call to end the epidemic by 2030 will not be feasible for SSA. (shrink)

Like many African countries, Botswana is adversely affected by HIV and AIDS. However, from the onset of the epidemic there was an inimical expectation, both internally and externally, that the country would effectively address the problem. The paper posits that this expectation was a partial result of the halo effect emanating from Botswana's successful history on many social, economic, and political fronts. However, whilst the country's HIV and AIDS strategy is one of the success stories of the African (...) continent insofar as the state's commitment is concerned, it is afflicted by ethical impediments that continue to negatively impact the effectiveness of related policies and programmes. The paper examines the loopholes in the Botswana Government's HIV and AIDS response from the perspective of missed opportunities for addressing relevant ethical issues. These include anomalies regarding the lack of targeted sexual health and wellness programmes for prison inmates, sex workers, and sexual minorities. Strategies requiring urgent attention are concerned with provision of HIV prevention, treatment, and care for these populations. The authors contend that inclusive policies, legislation, and programmes to achieve a holistic and ethical response to the epidemic are urgently needed to harmonise the halo effect of Botswana's otherwise positive stance in relation to HIV and AIDS in Africa. (shrink)

The practice of pastoral care (cura animarum) over the ages has been informed and influenced by the need to develop creative ways (interventions) to respond to people’s contextual challenges. These approaches have been well documented. However, the history, developments and emerging pastoral care practices in Africa have not been documented. This article, by way of a survey, considers the pastoral care approaches that emerged in Africa from the period when Christianity was introduced to the continent. (...) It addresses three interlinked questions. Firstly, to what extent has pastoral care approaches and practices in Africa been influenced by the African context and developments? Secondly, to what extent has the context and the emerging pastoral care approaches in Africa been discerned from historical developments and documented? Thirdly, what links can be drawn between pastoral care practices in Africa and its historical as well as cultural context? In answering these questions, the article retrieves pastoral care developments in Africa by discerning pastoral care during the periods of Christianity in Africa. The notion of cura animarum as ‘soul care’, referring to care for the whole person (holistic care, i.e., nephesh care) from a Christian spiritual perspective, will be employed as a framework. The assumption guiding the article is that pastoral care practices and approaches in Africa have arisen as responses to the contextual realities being experienced at the interface of Christianity and the African people. These realities arose and persist to this day as a struggle to relate, apply and live out an authentic African Christian life to cope with life in a meaningful way. It concludes by suggesting ways on how pastoral care in Africa should be practiced in the current period and going forward. (shrink)

The duty to help our fellows is not the same,and not stringent in the same way as thefamiliar duties to refrain from violence toothers, and to be honest. In general, beinghelpful to others is commendable, and to beheld up as a virtue. Only in cases wherereciprocity is possible and likely may we speakof anything stronger along this line. Moreover,the case of AIDS in Africa is furthercomplicated by the fact that it is easilypreventable by readily understandable behavioralterations. However, there (...) are certainpossible spin-offs, especially from mutation,which can happen when, as with AIDS, there aremillions of cases. So we in the west have somefurther, reason for concern and action thansheer good will. What can be done is especiallydifficult because of cultural factors of majororder. Serious investigation of how,nevertheless, to get the message across isclearly in order. Otherwise, we cannot and, asa nation, should not, try to do much more. (shrink)

The role of churches in primary health care delivery in Africa's poor contexts is widely acknowledged. Discussion of churches' work in health largely focuses on the spiritual side and tends to downplay the practical side. A clear challenge and gap in the role of churches in primary health delivery is the lack of clear models and approaches to determine the efficacy of the interventions. Hence, the role of churches as a player in the delivery of primary health (...) class='Hi'>care needs examination. This paper examines the role of church-driven primary health care, using a practical case study of the health work of the Salvation Army in East Africa. It outlines the primary health services rendered by the Salvation Army and deduces five models that emerged from the work of the various implementing churches in delivering primary health care. The article proceeds from an analysis of the meaning of primary health care and how churches are historically and currently positioned to contribute to primary health care. The article demonstrates that, viewed from a primary health care delivery perspective, churches in Africa play a critical practical contribution further to a spiritual role. From a practical theology perspective, the paper provides insight into how churches could operate in communities within the interface of church and health spaces. However, the church's role and function is organic and differs in every community. (shrink)

The debate over how to best guide HIV-infected mothers in resource-poor settings on infant feeding is more than two decades old. Globally, breastfeeding is responsible for approximately 300,000 HIV infections per year, while at the same time, UNICEF estimates that not breastfeeding (formula feeding with contaminated water) is responsible for 1.5 million child deaths per year. The largest burden of these infections and deaths occur in Sub-Saharan Africa. Using this region as an example of the burden faced more generally (...) in other resource-poor settings, we contrast the evolution of the clinical standard of care for infant feeding with HIV-infected mothers in high-income countries to the current international clinical guidelines for HIV-infected mothers and infant feeding in resource-poor settings. While the international guidelines of exclusive breastfeeding for a 6-month period seem to offer the least-worst strategy for reducing mother-to-child transmission of HIV during infancy while conferring some immunity through breastfeeding post-6 months, we argue that the impact of the policy on mothers and healthcare workers on the ground is not well understood. The harm reduction approach on the level of health policy translates into a complicated, painful moral dilemma for HIV-positive mothers and those offering them guidance on infant feeding. We argue that the underlying socio-economic disparities that continue to fuel the need for a harm reduction policy on infant feeding and the harm to women and children justify: (1) that higher priority be given to solving the infant feeding dilemma with improved data on safe feeding alternatives, and (2) support of innovative, community-driven solutions that address the particular economic and cultural challenges that continue to result in HIV-transmission to children within these communities. (shrink)

BackgroundThe issue of stigma is very important in the battle against HIV/aids in Africa since it may affect patient attendance at healthcare centres for obtaining antiretroviral medications and regular medical check-ups. Stigmatization creates an unnecessary culture of secrecy and silence based on ignorance and fear of victimization. This study was designed to determine if there is external stigmatization of people living with HIV and AIDS by health care workers at a tertiary hospital in KwaZulu-Natal province, South (...) Africa. The study investigated the impact of knowledge of HIV/aids by HCWs on treatment of patients, as well as the comfort level and attitude of HCWs when rendering care to PLWHA.MethodsA descriptive cross sectional study was designed to collect data using an anonymous self-administered structured questionnaire from 334 HCWs. The study was conducted in clinical departments of a large multidisciplinary 922-bed tertiary care teaching hospital in Durban, KZN.ResultsOverall HCWs had an above average knowledge about HIV/aids although some gaps in knowledge were identified. Tests of statistical significance showed that there was association between level of education and knowledge of HIV/aids ; occupation and knowledge of HIV/aids ; and gender and knowledge of HIV/aids. Test for comfort level was only significant for gender, with males showing more comfort and empathy when dealing with PLWHA. The study also revealed that patients were sometimes tested for HIV without informed consent before surgery, due to fear of being infected, and there was some gossiping about patients' HIV status by HCWs, thereby compromising patient confidentiality. The majority of HCWs showed a willingness to report incidents of stigmatization and discrimination to higher authorities, for better monitoring and control.ConclusionsAlthough knowledge, attitude and comfort level of HCWs taking care of PLWHA was above average, enforcement of existing antidiscrimination laws and continuing education in medical ethics and healthcare law, would greatly improve the performance of HCWs taking care of PLWHAs. More psychological support and counselling should be provided to HCWs, to further reduce the impact of stigmatization and discrimination against PLWHA. (shrink)

ABSTRACTIt has been estimated that more than 80% of people in Africa use traditional medicine . With the HIV/AIDS epidemic claiming many lives in Africa, the majority of people affected rely on TM mainly because it is relatively affordable and available to the poor populations who cannot afford orthodox medicine. Whereas orthodox medicine is practiced under stringent regulations and ethical guidelines emanating from The Nuremburg Code,1 African TM seems to be exempt from such scrutiny. Although recently there (...) have been calls for TM to be incorporated into the health care system, less emphasis has been placed on ethical and regulatory issues.In this paper, an overview of the use of African TM in general, and for HIV/AIDS in particular, is given, followed by a look at: the relative laxity in the application of ethical standards and regulatory requirements with regards to TM; the importance of research on TM in order to improve and demystify its therapeutic qualities; the need to tailor‐make intellectual property laws to protect traditional knowledge and biodiversity. A framework of partnerships involving traditional healers’ associations, scientists, policy makers, patients, community leaders, members of the communities, and funding organizations is suggested as a possible method to tackle these issues. It is hoped that this paper will stimulate objective and constructive debate that could enhance the protection of patients’ welfare. (shrink)

AIDS in the Twenty‐First Century: Disease and Globalization, by Tony Barnett and Alan Whiteside. New York: Palgrave Macmillan. 2002. 416 pp. US$19.95 The Moral Economy of AIDS in South Africa, by Nicoli Nattrass. Cambridge, UK: Cambridge University Press. 2004. 222 pp. US$30.00.

The situation and human rights of people living with HIV and AIDS were explored through focus groups in five African countries (Lesotho, Malawi, South Africa, Swaziland and Tanzania). A descriptive qualitative research design was used. The 251 informants were people living with HIV and AIDS, and nurse managers and nurse clinicians from urban and rural settings. NVivo™ software was used to identify specific incidents related to human rights, which were compared with the Universal Declaration of Human Rights. (...) The findings revealed that the human rights of people living with HIV and AIDS were violated in a variety of ways, including denial of access to adequate or no health care/services, and denial of home care, termination or refusal of employment, and denial of the right to earn an income, produce food or obtain loans. The informants living with HIV and AIDS were also abused verbally and physically. Country governments and health professionals need to address these issues to ensure the human rights of all people. (shrink)

In few other areas of bioethical inquiry exists as close a connection between bioethical professional advice and policy development as is the case with HIV and AIDS. Historically, the reasons for this have much to do with one of the groups initially affected most severely by HIV and AIDS, namely well-educated middle-class gay men in developed countries. This particular group of people, highly sophisticated and used to political activism in its pursuit of civil rights-related objectives, engaged the medical (...) profession as well as regulatory agencies such as the US Food and Drug Administration, and legislators (more so in the USA than in other countries) in a number of bioethically interesting policy areas. Many of the controversies of the times were framed as civil rights and/or ethical disputes. The initial areas of concern and inquiry focused on: informed consent to HIV testing and trial participation, the confidentiality of HIV test results, access to trials as a means of access to experimental drugs, the length of time it took to get an experimental drug to the market approval stage, and end-of-life decision-making. This line-up of issues explains why AIDS has become such an interesting topic for bioethicists. Bioethicists concerned about the traditional breadand- butter themes of medical ethics themes of the doctor - patient relationship (e.g., Daniels, 1991; Boyd, 1992), as well as bioethicists more concerned about policy and regulatory issues in the drug research and approval process (e.g., Edgar & Rothman, 1990; Salisbury & Schechter, 1990), found research topics worthy of vigorous pursuit. No surprise, then, that HIV/AIDS led to a probably unprecedented number of books and articles in professional journals (Manuel et al., 1990). HIV/AIDS has become a permanent fixture in all major mainstream bioethics textbooks (e.g., Kuhse & Singer, 1998; Arras & Steinbock, 1999). Reference series in medicine, ethics and law provide for dedicated volumes on AIDS.1 Even specialist bioethics textbooks, for instance those directed at dentistry students, carry chapters on HIV/AIDS (Ozar & Sokol, 2002). 128 Udo Schuklenk AIDS, designated by the medical profession a pandemic lives up to its classification. It did not stop at the borders of developed countries. As one would expect of a primarily sexually transmitted illness in the age of globalisation, it spread rapidly across the globe. Indeed, in many countries it has become one of the main causes of death, as in sub- Saharan Africa (Shisana & Simbayi, 2002). Dramatic increases in the number of AIDS cases are predicted for many Eastern European countries as well as for the two most populous nations on earth, India and China. Some of the HIV/AIDS-related bioethical and policy issues of concern to developed countries remain the same for developing countries. However, in ethically important ways they are dwarfed by concerns over drug prices, intellectual property rights, and affordable access to essential AIDS drugs for the impoverished masses of infected people in such countries. Of increasing importance have become ethical issues pertaining to the ever-growing research industry associated with clinical trials undertaken in developing countries. Indeed, major funding initiatives both in the USA and UK have brought clinical research in developing countries into focus. Some have questioned whether this attention is appropriate, considering other bioethical problems of arguably greater importance to developing countries (Chadwick & Schuklenk, 2003). Standards of clinical care in a study, and after a trial has concluded, as well as community benefits and access to the trial regime after the trial’s conclusion remain contentious issues. It is worth noting that more often than not it was an AIDS-related trial or policy decision that led to a great deal of bioethical analysis, yet the issues discussed almost always have ramifications far beyond AIDS. For instance, decisions about the question of what (if any) standards of care failures in preventive trials (of HIV vaccines or microbicides) ought to receive have important implications for non-AIDS prevention trials. (shrink)

China’s role as an emerging aid provider and the concept of a social plan in Africa has led to polarised responses in the West. Several say that this “productivist” strategy is much less determined by the concepts of citizenship, legal, social rights, and much more regarding building functions. The purpose of this study is to examine whether the welfare and social policy ideas that characterize Chinese aid in Africa are influencing traditional donors and becoming global. The article utilised (...) a qualitative study that has two main components. First, a comprehensive content analysis of over 50 key Sino-African, Chinese and Western policy documents from 2000 (since cooperation between Beijing and African countries first became institutionalised). Second, there were semi-structured interviews with Chinese, African and Western stakeholders in Addis Ababa, (Ethiopia), who was directly involved in the relationship between China and Africa and related development issues. The result of documentation and interview analyses show that there are currently significant differences between Chinese and Western approaches. China has made much stronger and more explicit links between development aid and economic activity than most Western donors. The aid is usually implemented through specific projects rather than broader programs or policies. (shrink)

Sub-Saharan Africa bears the brunt of the HIV epidemic, which is fueled by the many ethical, social, and political complexities that make up Africa. In turn, the pandemic has also caused many ethical, social, and political complexities that Africa now grapples with. Being infected with HIV is highly complex and challenging. Regrettably, gender inequality is still pervasive in Africa. The response by African leaders to the pandemic has been, on the whole, shamefully lethargic. For Africa (...) to win its war against HIV/AIDS, a paradigm shift is required from the perspective of its socio-political context. What is called for is positive political will that will address all aspects of the social determinants of AIDS. What is also required is that Ubuntu is embraced meaningfully. (shrink)

At the core of democracy is the idea that governments must be systematically responsive to the desires and interests of citizens as expressed through the electoral process which is the principal mechanism of democratic accountability as it is through this process that politicians are called to account by a sovereign electorate with powers to sanction them. The effectiveness of the process depends on the viability of democratic institutions and the citizens' engagement, political sophistication and access to information, which in turn (...) impact on political contestability and transparency. Ensuring accountability is difficult enough if there is only one elected sovereign in a particular space. It becomes profoundly more complex when two sovereigns act upon the same space but are accountable to different constituencies and when the power of one of the two sovereigns is likely to impinge on the accountability of the other. In this paper I consider the problem of accountability in African democracies that are heavily dependent on aid from richer democracies. Concentrating on aid as a constraint on accountability in no way suggests it is the only culprit in this respect. There are many other factors that impinge on accountability at the national level. Indeed it is the interplay with and at times the connivance of local and external factors that have undermined accountability in Africa The internal factors include the lack of transparency of national governments and the "smoke and mirrors" political practices that come along with it; the undemocratic mores of the political class ; the contradictory political affiliations of voters reflecting conflicting ideological, ethnic or clientelistic loyalties that undermines the collective action required to ensure accountability; the institutional barriers to free and fair elections; the strange behavior of legislatures that have weakened themselves by ceding more powers to the executive etc. Each of these has been subject of analysis in the literature on democracy in AfricaI will argue that although many donors have invested considerable resources in support of democratization, they have also, simultaneously, proceeded to circumscribe the reach and competence of democratic institutions and their accountability to the citizenry in aid-receiving countries. Even as they swear by democracy, part of the aid establishment is still preoccupied with finding ways and means of insulating aid from the encumbrances of democratic politics in recipient countries by creating what have been aptly termed "authoritarian enclaves" . I will also suggest that the notion of accountability in developing countries, especially the aid-dependent ones, is best understood not only in the context of democratization but also in the context of the much more fraught aid/donor relationship. Aid, by its very nature, involves power relations that go beyond the adage "who pays the piper, calls the tune". Any exercise of power necessitates and creates its own institutions. Aid giving and receiving often set in motion a whole range of asymmetrical relationships that may take on lives of their own. In such a context, preoccupation with accountability is driven at least as much by ideas about the relationship between the donors and the aid recipient countries as by the inherent meaning of democracy…. (shrink)

This article argues that the challenge and need for relevant ministry models is critical for effective Christian ministry and pastoral ministry as practical life ministry. It establishes an Adamic Christological model as a paradigm that provides a practical effective ministerial approach in Africa, particularly within the context of pastoral care and healing. This framework reveals Christ’s complete identification with African Christians in their contextual sufferings as the New Adam without compromising authentic gospel reality. In employing the Adamic Christological (...) framework as the anchor for African pastoral and healing ministry, a model for African Christians’ daily response to their various contextual sufferings is constructed. This responsive model bridges the gap between the ascension of Christ and the interim period of Christianity by instituting God’s ongoing personal presence in believers’ suffering through the Holy Spirit (pneumatology) as an encouraging and comforting reality that should enable Christians to cope in their suffering. It is argued that this Adamic Christological framework provides a practical theological model that contributes to healing and hope in pastoral care through practical knowing that impacts and imparts meaning in life. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Broken Bodies and Healing Communities: The Challenge of HIV and AIDS in the South African ContextEmily Reimer-BarryBroken Bodies and Healing Communities: The Challenge of HIV and AIDS in the South African Context Edited by Neville Richardson Pietermaritzburg, South Africa: Cluster Publications, 2009. 209 pp. $12.00.The township of Mpophomeni, like many communities in South Africa, has been tragically devastated by HIV/AIDS. Christian churches in (...) the region have responded to this ongoing crisis in a variety of ways. In this collection of essays, edited by Neville Richardson, a team of international scholars from various subfields has combined ethnography and qualitative research with theology, with the goal of understanding how Christian churches have responded to the needs of the people of Mpophomeni. This book is the result of a two-year collaborative research project. The title of the book alerts the reader to two major themes of the unfolding narrative: the reality of brokenness, suffering, and sin (individual, interpersonal, social, and ecclesial) and the goal of healing (again, individual, interpersonal, social, and ecclesial). The ten chapters, individually authored, are divided thematically into three sections: Part 1, “Healing and Community: Perspectives from Zulu Culture and Religion”; Part 2, “Caring, Healing and Faith Communities”; and Part 3, “Caring and Community: Training in a Hospital Setting.” As perhaps expected, the authors’ conclusions remain ambivalent. James R. Cochrane explains: “Religion per se is not innocent of breaking bodies, which should always stand as a warning to us. But religion per se is also the source of healing; indeed, in some ways it is all about healing or wholeness, in relation to the sacred” (115). Churches in Mpophomeni have been “protective spaces” (11), “bridging communities” (91), and “broken bodies” that remember and re-member “the broken body of Jesus” (145–51). But communities are also in flux (101) and are sources of discourse that stigmatizes and shames (172).The book presents clearly argued and compelling essays that work independently and could be read or adopted for class as individual essays. The authors approach some of the same difficult questions from different vantage points, methodological foundations, and subdisciplines. For example, in the first two chapters Sidsel Roalkvam and Jone Salomonsen describe the many social problems in Mpophomeni, including poverty, unemployment, gender inequalities, sexual violence, drug and alcohol addiction, and criminal violence. But their [End Page 225] ethnographic research uncovers some of the rituals of healing that help the community to cope, including the practice of communal “strong prayer” (11–15), and uMemulo rite of passage for girls (23–37).However, I wish there were more coherent conversation between the authors of each individual essay. While Richardson explains that the research was collaborative “not only in terms of interaction between the researchers and the community but also among the researchers themselves” (ix), this collaboration between the researchers is not obvious to the reader in the final format of the book. Perhaps another book format would have more fruitfully conveyed this collaborative stance (for example, the inclusion of responses to each chapter or the addition of a roundtable discussion chapter or coauthored chapters).The ethnographic data presented in the third section is particularly rich and challenging for theology, but the authors could have spent more time unpacking, contextualizing, and analyzing the included quotations from patient–chaplain conversations. If, for example, the story of a thirty-three-year-old HIV+ man who allegedly raped a fifteen-year-old girl to give her “a good lesson for her life” so that she will not dress provocatively is “very characteristic of the material” in the study (203–5), much more needs to be said to explain how pastoral care interventions can address the stated “gender inequalities and the drastically different roles of men and women resulting in the vulnerable position of women” (206).The book is a must-read for scholars working on HIV/AIDS and Christian ethics. It could also provide supplemental readings for an undergraduate or graduate course in this area. [End Page 226]Emily Reimer-BarryUniversity of San DiegoCopyright © 2012 Society of Christian Ethics... (shrink)

The HIV/AIDS epidemic is increasingly a diseaseof the disadvantaged, a destroyer of nations,and a threat to global security and well-being.But this need not be so: the world has thescientific knowledge, technologicalinnovations, and financial resources tosignificantly reduce the spread and sufferingcaused by the disease. This paper argues thatthe wealthy nations of the world, led by theUnited States, have a moral obligation to offermuch greater assistance to developing countrieswhere the epidemic is most severe. UsingZimbabwe as a case study, this essay examinesthe (...) immediate and underlying factors behind theepidemic in order to make realistic andaffordable policy recommendations that includenew investments in global health care, debtrelief, and long-term economic development. Bydemonstrating our ability to dramaticallyaffect the future course and consequences ofthis unprecedented epidemic, the paperconcludes that greater action is not only inthe interest of public health, but is also amoral imperative. By investing the necessaryresources to improve public health and toreduce global poverty, we promote and extendthe fundamental rights and values that weprofess to hold dear. (shrink)

BackgroundThe prevention of HIV remains an ongoing global concern. The safety and welfare of participants in these trials are imperative. Research Ethics Committees (RECs) review all reports of serious adverse events, adverse events and social harms arising in the course of such trials. There is little guidance for RECs on how to respond appropriately to social harm reports.MethodologyThis paper reviews the literature on social harms in HIV prevention trials and offers suggestions for RECs on how to respond appropriately to such (...) reports.ResultsThis review confirms that social harms are reported in clinical trials in South Africa and that specific guidance on managing these is minimal.ConclusionSocial harms in South African HIV prevention trials need to be more systematically researched so that ethical evidence‐based prevention, care and treatment strategies can be developed. This review makes specific suggestions for further research on social harms that can inform further consultations to develop more specific guidance for stakeholders on appropriate responses to such social harms. Such future work may also inform future versions of relevant local and international ethics guidance on HIV prevention trials. (shrink)

The aim of this study is to undertake an in-depth conceptual and ethical analysis of African philosophy of sex and the HIV/AIDS epidemic in Africa by taking the Oromo of Ethiopia as an example. The continent with just 10% of the world’s population is home to over 70% of the world’s HIV/AIDS infection. HIV/AIDS is a social, economic, demographic and moral problem as well as a health care issue. Some scholars hypothesise that the unique nature (...) of African sexuality, sexual promiscuity, the prevalence of other ailments, and the unique nature of the viral subtypes (known as clades) are the major reasons for Africa’s AIDS prevalence. However, there is little substance to their hypotheses. As of today there is no sound explanation for the prevalence of HIV/AIDS in Africa. So far the HIVintervention has largely focused on behaviours, systems and structures which are visible without fully taking into account culture, values, norms and traditions which are invisible but have a strong influence on visible aspects of individual behaviours and societal structures. Thus, this issue requires further research into people’s philosophy of sex and indigenous moral values. This study and the contributions of many scholars have shown that Africans have a diverse spectrum of sexual behaviour ranging from the very restrictive to the permissive. Although some ethnic groups have developed a profound philosophy of ex that can curb the expansion of HIV/AIDS, there have been some sexual and religious norms and expectations in Africa that have contributed to the rapid spread of HIV/AIDS. Social, economical, and political forces have also shaped the HIV/AIDS epidemic. This paper thus suggests that global fight against HIV/AIDS should go beyond a narrow focus on the behavioural and biological, and consider broader structural and underlying factors such as poverty, homelessness, widespread sex work, rural to urban migration, instability, a high rate of unemployment, unequal gender relations, harmful traditional practice and global injustice that have facilitated the spread of HIV/AIDS. African governments should involve the local people and civil society organisations in the fight against HIV/AIDS by using a wide range of participatory methodologies and culturally sensitive advocacy strategies. This study thus suggests that a multi-faceted approach is needed to deal with the challenges of the 21st century and address the HIV/AIDS epidemic in our world. This study relies on literature review, interviews and personal observation. (shrink)

The aim of this study is to undertake an in-depth conceptual and ethical analysis of African philosophy of sex and the HIV/AIDS epidemic in Africa by taking the Oromo of Ethiopia as an example. The continent with just 10% of the world’s population is home to over 70% of the world’s HIV/AIDS infection. HIV/AIDS is a social, economic, demographic and moral problem as well as a health care issue. Some scholars hypothesise that the unique nature (...) of African sexuality, sexual promiscuity, the prevalence of other ailments, and the unique nature of the viral subtypes (known as clades) are the major reasons for Africa’s AIDS prevalence. However, there is little substance to their hypotheses. As of today there is no sound explanation for the prevalence of HIV/AIDS in Africa. So far the HIVintervention has largely focused on behaviours, systems and structures which are visible without fully taking into account culture, values, norms and traditions which are invisible but have a strong influence on visible aspects of individual behaviours and societal structures. Thus, this issue requires further research into people’s philosophy of sex and indigenous moral values. This study and the contributions of many scholars have shown that Africans have a diverse spectrum of sexual behaviour ranging from the very restrictive to the permissive. Although some ethnic groups have developed a profound philosophy of ex that can curb the expansion of HIV/AIDS, there have been some sexual and religious norms and expectations in Africa that have contributed to the rapid spread of HIV/AIDS. Social, economical, and political forces have also shaped the HIV/AIDS epidemic. This paper thus suggests that global fight against HIV/AIDS should go beyond a narrow focus on the behavioural and biological, and consider broader structural and underlying factors such as poverty, homelessness, widespread sex work, rural to urban migration, instability, a high rate of unemployment, unequal gender relations, harmful traditional practice and global injustice that have facilitated the spread of HIV/AIDS. African governments should involve the local people and civil society organisations in the fight against HIV/AIDS by using a wide range of participatory methodologies and culturally sensitive advocacy strategies. This study thus suggests that a multi-faceted approach is needed to deal with the challenges of the 21st century and address the HIV/AIDS epidemic in our world. This study relies on literature review, interviews and personal observation. (shrink)

This paper discusses how to apply a collective decision model of the principle of voluntary informed consent in African communitarian culture, in a culturally sensitive way, in order to protect research candidates from potential exploitations and abuses. Dismissing cultural and ethical skepticism surrounding the global application of the principle of voluntary informed consent, the paper ultimately concludes that international collaboration on diagnostic and therapeutic medical research in Africa, especially HIV vaccine trials, is a moral imperative.

Objective: Ethical guidelines are designed to ensure benefits, protection and respect of participants in clinical research. Clinical trials must now be registered on open-access databases and provide details on ethical considerations. This systematic survey aimed to determine the extent to which recently registered clinical trials report the use of standard of care and post-trial obligations in trial registries, and whether trial characteristics vary according to setting. Methods: We selected global randomized trials registered on http://www.clinicaltrials.gov and http://www.controlled-trials.com. We searched for (...) intervention trials of HIV/AIDS, malaria, and tuberculosis from 9 October 2004, the date of the most recent version of the Helsinki Declaration, to 10 April 2007. Results: We collected data from 312 trials. Fifty-eight percent (58%, 95% CI = 53 to 64) of trial protocols report informed consent. Fifty-eight percent (58%, 95% CI = 53 to 64) of trials report active controls. Almost no trials (1%, 95% CI = 0.5 to 3) mention post-trial provisions. Most trials measure surrogate outcomes. Twenty percent (20%, 95% CI = 16 to 25) of trials measure patient-important outcomes, such as death; and the odds that these outcomes are in a low income country are five times greater than for a developed country (odds ratio (OR) 5.03, 95% CI = 2.70 to 9.35, p = < 0.001). Pharmaceutical companies are involved in 28% (CI = 23 to 33) of trials and measure surrogate outcomes more often than nonpharmaceutical companies (OR 2.45, 95% CI = 1.18 to 5.09, p = 0.31). Conclusion: We found a large discrepancy in the quality of reporting and approaches used in trials in developing settings compared to wealthier settings. (shrink)

Proper conduct of an AIDS vaccine trial in Africa must be informed not only by the epidemiology and biology of HIV infection in African settings, but also by the ethical norms and cultural constraints prevailing in African settings.

Health systems in Africa have been widely studied in the social sciences. Several aspects have been addressed in particular: the provision of and access to care, working conditions, the human resources crisis, and patient–provider relations, for example. In this respect, the idea of an “attitude problem,” with health-care providers offering different services for different patients, has been suggested. Recently, researchers have studied the impact of global health initiatives on local health systems, mainly in the fight against HIV/ (...) class='Hi'>aids. Others have explored why some health issues have attracted more attention than others. Despite this wealth of studies, one point remains insufficiently addressed: the materiality of care and its impact on interactions within hospital settings. In this article, I consider the heuristic value of the uses of a maternity ward in a resource-limited country to understand health workers’ so-called attitude problem, specifically, the tension characteristic of patient–provider interactions. I suggest that this tension is related to a continuous process of translation and anticipation to adapt the maternity ward’s space to everyday activities. Drawing on Akrich’s description of technical objects, and Lussault’s pragmatics of space, I attempt to show that in this context, care is also an art of tinkering with unpredictable bodies in unstable hospitals’ spaces. (shrink)

The response to the HIV/AIDS pandemic in Africa has so far ignored important traditional African values and attitudes toward disease and commerce. These values and attitudes are significantly different from the libertarian, market-driven, profit-oriented values and practices of important sectors of the Western world. To deal with this epidemic, the world should consider respect for, and possibly even adoption of those African values, which provide for people in genuine need, irrespective of their ability to pay. HIV/AIDS vaccine (...) research indigenous to Africa is also not always taken seriously, and struggles to find adequate funding for such research within or outside of the continent have been extremely difficult. A better appreciation of knowledge systems and values indigenous to the African experience is important in the fight against the HIV/AIDS pandemic. (shrink)

The challenges of dealing with disclosure of HIV status cause frustration to health care providers and counselors. This frustration follows from the already known high risk to the third party on one hand and our ethical obligation to “respect persons” in terms of privacy and confidentiality on the other side. Given the stubbornly low rates of voluntary disclosure (partner notification) among couples, however, it is quite tempting to suggest a paradigm of routine third party disclosure to identifiable sexual partners (...) by health care providers. This might be the lesser of the two evils and might give better public health outcomes in the fight against HIV/AIDS in Sub-Saharan Africa. (shrink)

AIDS in the Twenty‐First Century: Disease and Globalization, by Tony Barnett and Alan Whiteside. New York: Palgrave Macmillan. 2002. 416 pp. US$19.95 (paperback) The Moral Economy of AIDS in South Africa, by Nicoli Nattrass. Cambridge, UK: Cambridge University Press. 2004. 222 pp. US$30.00 (paperback).

Oftentimes, we have been informed that democracy is the best form of government possible. In African politics, this view has mostly been adopted and pursued as true. Surprisingly, democracy has mostly failed as a system in most parts of the continent—with most democratic governments undermining the mandates of the citizens who are supposed to have placed them in power, and also escalating the already spiralling decline of the continent through bad leadership and corruption. In this article, and with Nigeria as (...) the primary case study, I offer explanations regarding why democracy fails in most African countries. Specifically, I argue that mass miseducation and false self‐interestedness are the main culprits that limit the success of democracy in Africa. I further propose that democracy in Africa can only be salvaged when there is proper moral ideology guiding the informal education of citizens, when citizens are offered proper quality formal education that would grant them the necessary skills and aid them to make informed decisions, and when citizens take a turn from false self‐interestedness to true self‐interestedness (which is fealty to collective interests). (shrink)

HIV/AIDS strikes with the greatest frequency in sub-Saharan Africa, a region lacking resources to deal with this epidemic. To keep millions more people from dying, wealthy countries must provide more help. Yet deeply ingrained biases may distance the sick from those who could provide far more aid. One such prejudice is viewing disease as punishment for sin. This 'punishment theory of disease" ascribes moral blame to those who get sick or those with special relations to them. Religious versions (...) hold that God punishes them in order to castigate, encourage virtue, warn, rehabilitate, or maintain some cosmic order. Its various religious and secular forms are untenable; they lack cogency, risk blaming people unjustly, and jeopardize compassionate care for people. These views are not only irrational but also dangerous because they influence policies and cost lives. We need to cooperate and respond as befits this global public-health disaster and not engage in the misguided and bad faith activity of dividing the world into the blameworthy and blameless. (shrink)