In Lesotho, the risk of mother-to-child-transmission (MTCT) of HIV is substantial; women of childbearing age have a high HIV prevalence rate (26·4%), low knowledge of HIV status and a total fertility rate of 3·5 births per woman. An effective means of preventing MTCT is to reduce unwanted fertility. This paper examines the unmet need for contraception to limit and space births among HIV-positive women in Lesotho aged 15–49 years, using the 2004 Lesotho Demographic and Health Survey. HIV- (...) class='Hi'>positive women have their need for contraception unmet in almost one-third of cases, and multivariate analysis reveals this unmet need is most likely amongst the poor and amongst those not approving of family planning. Urgent action is needed to lower the level of unmet need and reduce MTCT. A constructive strategy is to improve access to family planning for all women in Lesotho, irrespective of HIV status, and, more specifically, integrate family planning with MTCT prevention and voluntary counselling and testing services. Copyright © Cambridge University Press 2008. (shrink)

The aim of this study was to investigate the association between temperament and social support and the level of quantitatively rated PTSD symptoms in a sample of HIV+ and HIV/aids men and women. A total of 310 men and women, including 182 HIV+ and 128 HIV/aids, were studied. Social support was assessed with the Berlin Social Support Scales. Temperament was assessed with the Formal Characteristics of Behaviour - Temperament Inventory. Intensity of PTSD symptoms was assessed with the PTSDF. (...) The best predictors of intensity of PTSD symptoms in HIV+ participants were support seeking and sensory sensitivity. Support seeking was positively associated, and sensory sensitivity was negatively associated with intensity of PTSD symptoms. (shrink)

Analisa-se a relação entre religião, sexualidade e família de pessoas soropositivas para o HIV. O objetivo foi verificar a repercussão da constatação de que um dos (ou ambos) cônjuges é portador do HIV, nas representações e na configuração de suas famílias, tendo por base um possível ideário religioso subjacente às identidades de gênero masculina e feminina, bem como das formas de exercício da sexualidade que tal identidade de gênero comporta. Realizou-se uma pesquisa qualitativa. Os participantes foram mulheres e homens que (...) vivem ou viveram maritalmente, podendo essa relação se dar ou ter se dado entre pessoas do sexo oposto ou pessoas do mesmo sexo, selecionados em uma instituição de apoio a soropositivos e a seus familiares. Todos os participantes soropositivos da referida instituição foram convidados a responder um questionário composto por nove perguntas abertas relacionadas à temática em foco. A análise dos dados permitiu a percepção de que embora haja uma forte incidência do ideário religioso sobre família e sexualidade para aquela população, o foco principal desse ideário não está nas representações das configurações de família, e sim enquanto elemento desencadeador de preconceito em relação ao soropositivo tanto no espaço familiar quanto para além dele. Palavras-chave : Religião. Sexualidade. Família. Soropositividade.This article examines the relationship between religion, sexuality and family of HIV seropositive individuals. It aims to verify the repercussion of finding that one of ( or both ) spouses is HIV positive , within the representations and configuration of their families , based on a possible religious ideas underlying to gender identities male and female , as well as to the exercise of sexuality that such gender identity entails. For this purpose, a qualitative survey was conducted. Participants were men and women who live or have lived in a marital status, and this relationship has occurred or took place between members of the opposite sex or same sex, selected in an institution to support HIV positive and their families. All seropositive participants of the mentioned institution were asked to answer a questionnaire composed of nine open questions related to the subject in focus. Data analysis allowed the perception that although there is a strong incidence of religious ideas about family and sexuality for that population, the main focus of this notion is not within the representations of family structures, but within the triggering element of prejudice towards HIV-positive both in the family space and beyond. Keywords : Religion. Sexuality. Family. Seropositivity. (shrink)

Client-provider relationships have significant effects on how individuals comprehend their life situation during chronic disease and illness. Yet, little is known about how frontline health care providers (HCPs) influence client’s identity formation through meaning-making with clients such as HIV-positive women living in poverty. This requires ethical consideration of the meanings made between clients and providers about client’s health and well-being, both individually and in the larger society. Health care providers (N = 15) and married women living with (...) HIV (N = 33) in north-central India engaged in separate intensive interviews providing narrative data which were analysed using a conceptual framework crossing Lipsky’s street-level bureaucracy theory (Lipsky 2010) with meaning-making processes. HCPs and women construct meanings of women’s role as caregivers that impact women’s sense of identity, health, and well-being. Findings indicate that despite being well-intentioned, HCPs inadvertently reinforce rigid gender norms and convey that women’s worth is tied to their familial caregiving role. HCPs’ discretionary advocacy may also reinforce societal images of women as incapable and needy, thereby harming them more generally. Attention to the gender-sensitive training of HIV health care providers may assure that discretion is ethically interrogated to promote gender equity and enhance women’s access to social welfare services. (shrink)

Summary Recent research has highlighted the risk of HIV infection for married teenage women compared with their unmarried counterparts (Clark, 2004). This study assesses whether a relationship exists, for women who have completed their adolescence (age 20–29 years), between HIV status with age at first marriage and the length of time between first sex and first marriage. Multivariate analysis utilizing the nationally representative 2004 Cameroon Demographic and Health Survey shows that late-marrying women and those with a longer (...) period of pre-marital sex have the highest risk of HIV. Although women in urban areas overall marry later than their rural counterparts, the positive relationship between age at marriage and HIV risk is stronger in rural areas. The higher wealth status and greater number of lifetime sexual partners of late-marrying women contribute to their higher HIV risk. Given that the age at first marriage and the gap between first marriage and first sex have increased in recent years, focusing preventive efforts on late-marrying women will be of much importance in reducing HIV prevalence among females. (shrink)

This qualitative cross-sectional survey, undertaken in the antenatal booking clinics of a hospital in central London, explores pregnant women’s responses to routine HIV testing, examines their reasons for declining or accepting the test, and assesses how far their responses fulfil standard criteria for informed consent. Of the 32 women interviewed, only 10 participants were prepared for HIV testing at their booking interview. None of the women viewed themselves as being particularly at risk for HIV infection. The minority (...) of the participants who declined testing differed from those who accepted, by interpreting test acceptance as risky behaviour, privileging the negative outcomes of HIV positivity and expressing an inability to cope with these, should they occur. Troublingly, only a minority of women had a broad understanding of the rationale for the test, and none fulfilled the standard criteria for informed consent. This study suggests that, although routine screening combined with professional recommendation may be successful in increasing uptake, this may be at the cost of eroding informed consent. Protecting third parties from a preventable disease may outweigh the moral duty of respecting autonomy, enshrined in Western bioethical tradition. Nevertheless, such a policy should be made transparent, debated in the public domain and negotiated with women seeking antenatal care. (shrink)

Background: Confidentiality lies at the core of medical ethics and is the cornerstone for developing and keeping a trusting relationship between nurses and patients. In the wake of the HIV epidemic, there has been a heightened focus on confidentiality in healthcare contexts. Nurses’ follow-up of HIV-positive women and their susceptible HIV-exposed children has proved to be challenging in this regard, but the ethical dilemmas concerning confidentiality that emerge in the process of ensuring HIV-free survival of the third party (...) – the child – have attracted limited attention. Objective: The study explores challenges of confidentiality linked to a third party in nurse–patient relationships in a rural Tanzanian HIV/AIDS context. Study context: The study was carried out in rural and semi-urban settings of Tanzania where the population is largely agro-pastoral, the formal educational level is low and poverty is rife. The HIV prevalence of 1.5% is low compared to the national prevalence of 5.1%. Methods: Data were collected during 9 months of ethnographic fieldwork and consisted of participant observation in clinical settings and during home visits combined with in-depth interviews. The main categories of informants were nurses employed in prevention of mother-to-child transmission of HIV programmes and HIV-positive women enrolled in these programmes. Ethical considerations: Based on information about the study aims, all informants consented to participate. Ethical approval was granted by ethics review boards in Tanzania and Norway. Findings and discussion: The material indicates a delicate balance between the nurses’ attempt to secure the HIV-free survival of the babies and the mothers’ desire to preserve confidentiality. Profound confidentiality-related dilemmas emerged in actual practice, and indications of a lack of thorough consideration of the implication of a patient’s restricted disclosure came to light during follow-up of the HIV-positive women and the third party – the child who is at risk of HIV infection through mother’s milk. World Health Organization’s substantial focus on infant survival (Millennium Development Goal-4) and the strong calls for disclosure among the HIV-positive are reflected on in the discussion. (shrink)

In most countries in Africa, the epidemiologic profile of HIV/AIDS is significantly different from that of the USA or Europe. Women in Africa are as likely to be HIV positive as men, while young women are significantly more likely to be HIV positive than young men. How can health research in Africa be made more responsive and relevant to women’s health needs? And how would a human rights perspective change the conduct of biomedical and social (...) scientific research on gender and HIV/ AIDS in Africa? The application of a human rights framework to HIV/AIDS typically has focused on social justice issues employing national and international legal structures to legislate and advocate for HIV positive persons. This essay, however, offers some broad considerations of the links between the health of African women, biomedical and social scientific research, HIV/AIDS, research ethics, and the human rights movement. (shrink)

Half of the 33.2 million people living with HIV today are women. Yet, responses to the epidemic are not adequately meeting the needs of women. This article critically evaluates how prevention of mother-to-child transmission (PMTCT) programs, the principal framework under which women's health is currently addressed in the global response to AIDS, have tended to focus on the prevention of HIV transmission from HIV-positive women to their infants. This paper concludes that more than ten years (...) after their inception, PMTCT programs still do not successfully ensure the adequate treatment, care and support of HIV-infected women. Of particular concern is the continued widespread use of single-dose nevirapine despite World Health Organization recommendations to employ more effective combination therapies that do not potentially jeopardize women's future treatment outcomes. In response, the article calls for a more comprehensive approach that places women's health needs at the centre of AIDS responses. This is critical in settings where the pandemic is generalized and there is a push to greatly expand PMTCT programs, as a more effective and equitable way of meeting the needs of women in the context of HIV. Without such a comprehensive approach, women will continue to be impacted disproportionately by the pandemic, and current strategies for prevention, including PMTCT, and treatment will not be as effective and responsive as they need to be. (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)

In this article we investigate the way in which viral load assays are used to assess the viruses of Human Immunodeficiency Virus (HIV)-positive pregnant women who are cared for in an HIV-specialist antenatal clinic in London. One of the viral load assays has been made more sensitive to subtypes of the virus that are considered to be local, possibly reading the viruses of those who have ‘foreign’ subtypes as undetectable. Consequently, the patient might not be offered the kind (...) of care needed to prevent transmission of HIV, as her body is not recognised as sufficiently debilitated. Thus, being identified as a debilitated body in this setting facilitates the prevention of vertical transmission of HIV and the management of the HIV-positive pregnant patient's virus. Further to this, we argue that in our example, having a debilitated body as constructed by the viral load assay is thus a ‘privilege’ that is accorded to HIV-positive persons depending on the geographic origin of their virus. Using Karen Barad's agential realism, we argue that the manner in which HIV is read through the viral load assay constructs a specific woman/foetus/hiv phenomenon. The specificity of this phenomenon directly impacts on the course of care, opening up or foreclosing the possibility of her child having a future free from HIV. (shrink)

It has been almost 20 years since the field of bioethics was galvanized by a controversial series of multinational AZT trials employing placebo controls on pregnant HIV-positive women in the developing world even though a standard of care existed in the sponsor countries. The trove of ethical investigations that followed was thoughtful and challenging, yet an important and problematic methodological assumption was left unexplored. In this article, I revisit the famous “double standard of care” case study in order (...) to offer novel consideration of the placebo orthodoxy that underlies much of the ethical debate. This majority view found in medical research is that placebo-controlled trials are methodologically superior to comparative trials that use active controls. I challenge this orthodoxy and argue that lives were unnecessarily lost in these trials as a result. Furthermore, current HIV research on vaccines and microbicides is now poised to repeat the error of subscribing to the placebo orthodoxy. (shrink)

SEXUALITY, BETWEEN SPEECH AND STAGES IN LIFE, OF HIV-INFECTED SUBJECTS AIDS, that union between death and sexuality, makes the latter non-representable and has deeply modified the world of sexual imagination. The article seeks to show how the emergence of HIV has re-defined the current norm within individuals’ sexuality and then goes on to analyse the different stages HIV positive subjects have to confront as they go through life, with the need to re-organise their sexuality ; it then evokes the (...) transgressive aspect of sexuality for some sectors of the population and, finally, gives HIV positive women the opportunity to speak out on how they come to grips with their bodies in relation to partners – soiled bodies henceforth disentitled, deprived of pleasure. HIV infection has the effect of sowing confusion between the different registers such as death, life and sex, and causes in the subject feelings of shame and guilt : so many effects that the therapist has to take on board to render the feeling that they exist in full to the subject. (shrink)

BackgroundPrevention of mother to child transmission of HIV remains a key public health priority in most developing countries. The provider Initiated Opt – Out Prenatal HIV Screening Approach, recommended by the World Health Organization lately has been adopted and translated into policy in most Sub – Saharan African countries. To better ascertain the ethical reasons for or against the use of this approach, we carried out a literature review of the ethics literature.MethodsPapers published in English and French Languages between 1990 (...) and 2015 from the following data bases were searched: Pubmed, Cochrane literature, Embase, Cinhal, Web of Science and Google Scholar. After screening from 302 identified relevant articles, 21 articles were retained for the critical review.DiscussionMost authors considered this approach ethically justifiable due to its potential benefits to the mother, foetus and society. The breaching of respect for autonomy was considered acceptable on the grounds of libertarian paternalism. Most authors considered the Opt - Out approach to be less stigmatizing than the Opt - In. The main arguments against the Opt - Out approach were: non respect of patient autonomy, informed consent becoming a meaningless concept and the HIV test becoming compulsory, risk of losing trust in health care providers, neglect of social and psychological implications of doing an HIV test, risk of aggravation of stigma if all tested patients are not properly cared for and neglect of sociocultural peculiarities.ConclusionsThe Opt – Out approach could be counterproductive in case gender sensitive issues within the various sociocultural representations are neglected, and actions to offer holistic care to all women who shall potentially test positive for HIV were not effectively ascertained. The Provider Initiated Opt – Out Prenatal HIV Screening option remains ethically acceptable, but deserves caution, active monitoring and evaluation within the translation of this approach into to practice. (shrink)

Cass Sunstein and Richard Thaler's proposal that social and legal institutions should steer individuals toward some options and away from others-a stance they dub "libertarian paternalism"-has provoked much high-level discussion in both academic and policy settings. Sunstein and Thaler believe that steering, or "nudging," individuals is easier to justify than the bans or mandates that traditional paternalism involves. -/- This Article considers the connection between libertarian paternalism and the regulation of reproductive choice. I first discuss the use of nudges to (...) discourage women from exercising their right to choose an abortion, or from becoming or remaining pregnant. I then argue that reproductive choice cases illustrate the limitations of libertarian paternalism. Where choices are politicized or intimate, as reproductive choices often are, nudges become not much easier to justify than traditional mandates or prohibitions. Even beyond the context of reproductive choice, it is not obvious how much easier nudges are to justify than bans or mandates. -/- Part I of this Article briefly introduces Sunstein and Thaler's libertarian paternalism. Part II then turns to the context of reproductive choice. Part II.A reviews restrictions on the right to choose an abortion-particularly post-Casey regulations such as waiting periods, requirements that women receive certain types of information, and requirements that women undergo ultrasound-that pitch themselves as steering choice without entirely closing off the right to choose an abortion. This distinction between nudges and prohibitions echoes Sunstein and Thaler's proposals, but works to subordinate women's choices to the judgment of (often male) experts and administrators-hence my term "libertarian patriarchalism." Part II.B reviews efforts to nudge women-particularly teenagers, HIV-positive women, and others thought to be unsuitable mothers-to avoid pregnancy. -/- Part III considers the normative implications of nudging reproductive decisions. In Part III.A, I argue that the political nature of reproductive choices presents a problem for nudges. I do so by considering a parallel with voting rights. Empirical research shows that voters are more likely to choose the candidate listed first on the ballot. Yet we do not empower the administrator in charge of ballot design to choose a default rule that nudges individuals toward the candidate he sincerely believes would promote choosers' welfare. Given the political nature of reproductive choices, a policymaker's attempting to nudge reproductive decisionmaking in the direction he prefers-or indeed in any direction-fails to show adequate respect for the chooser's agency. In Part III.B, I offer an argument that targets the use of nudges in the context of pregnancy. Finally, in Part III.C, I argue that nudges do not merely add choices to an existing menu, but change the substantive choices available to individuals and thereby impose more-than-trivial costs on them. I conclude by exploring the implications of my arguments for nudges more generally. (shrink)

The 2015 judgment of the Namibia Supreme Court in Government of the Republic of Namibia v LM and Others set an important precedent on informed consent in a case involving the coercive sterilisation of HIV-positive women. This article analyses the reasoning and factual narratives of the judgment by applying Neil Manson and Onora O’Neill’s approach to informed consent as a communicative process. This is done in an effort to understand the practical import of the judgment in the particular (...) context of resource constrained public healthcare facilities through which many women in southern Africa access reproductive healthcare. While the judgment affirms certain established tenets in informed consent to surgical procedures, aspects of the reasoning in context demand more particularised applications of what it means for a patient to have capacity and to be informed, and to appropriately accommodate the disruptive role of power dynamics in the communicative process. (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)

Behavior change is the only available means of curtailing new HIV infections in South Africa. This study investigated the relationship between sexual risk taking and attitudes to AIDS precautions. The participants were about 25% white, about 30% colored/mixed blood and 45% black in their second year in polytechnics (413 females and 402 males). Participants responded to the 40-item HIV-related knowledge, attitudes and behaviors. Data indicated that young women showed more positive attitudes to AIDS precautions than young men (reflecting (...) in part the stereotypic negative attitudes of young men toward condoms). In general, most males and females were found to have less knowledge about HIV transmission and less favorable attitudes toward safe sex behavior than their counterparts in the west. Also young men with more partners expressed more fatalistic attitudes toward AIDS. The possibility that a finergrained multivariate analysis of attitudes to AIDS and safe-sex behaviour is something that needs to be taken seriously in future research, however. (shrink)

A growing and substantial body of research suggests that female sex workers play a disproportionately large role in the transmission of HIV in many parts of the world, and they are often referred to as core groups by epidemiologists, mathematical modellers, clinicians and policymakers. Male sex workers, by contrast, have received little attention and it is not known whether it is helpful to conceptualize them as a core group. This paper draws upon ethnographic research documenting social and sexual networks in (...) London and looks at the position of five male sex workers within a network comprising 193 men and seven women (as well as 1378 anonymous sexual contacts and 780 commercial contacts). In so doing, it suggests that there is no evidence to show that male sex workers are more or less likely to acquire or transmit HIV in the course of commercial sex compared with other types of sexual relationships. In addition, men engaging in non-commercial sex all reported having unprotected sex in a variety of contexts and relationships and there is no evidence to suggest that men who are not sex workers play less of a role in the transmission of HIV. In short, these data suggest that it would be inappropriate to conceptualize male sex workers as a core group. This is not to suggest that public policy should continue to overlook male sex workers. New and inventive approaches are required to reach out to a vulnerable but diverse group of men, selling sex for a variety of reasons; even if these men are no more vulnerable to acquiring and/or transmitting HIV than other men and women that form part of their network. (shrink)

This book was inspired originally by the debates at the turn of the century about placebo controlled trials of antiretrovirals in HIV positive pregnant women in developing countries. Moving forward from this one limited example, the book includes several additional controversial cases of clinical research conducted in developing countries, and asks probing philosophical questions about the ethics of such trials. All clinical research by its very nature uses people to acquire generalizable knowledge to help future people. But what (...) sorts of "use" are morally permissible? What is it to exploit people? Suppose that a trial conducted in a developing country would not be ethically permissible in the developed world. Can we automatically conclude from this that the trial is unethical, that some sort of morally problematic double standard is in operation? Or might the differences in the two settings justify differences in trial design? This collection of philosophical essays examines these important questions about what exploitation is and when clinical research counts as exploitative. -/- "This is an outstanding contribution to the growing literature on the ethics of research with human subjects and a fine example of what bioethics can offer at its best. Anyone with a serious interest in these issues will need to read this book from start to finish." -Daniel Wikler, Harvard School of Public Health "This book contributes significantly to the literature on exploitation in clinical research conducted in the developing world."--Patricia Marshall, Case Western Reserve University . (shrink)

BackgroundHIV prevention research in resource-limited countries is associated with a variety of ethical dilemmas. Key amongst these is the question of what constitutes an appropriate standard of health care (SoC) for participants in HIV prevention trials. This paper describes a community-focused approach to develop a locally-appropriate SoC in the context of a phase III vaginal microbicide trial in Mwanza City, northwest Tanzania.MethodsA mobile community-based sexual and reproductive health service for women working as informal food vendors or in traditional and (...) modern bars, restaurants, hotels and guesthouses has been established in 10 city wards. Wards were divided into geographical clusters and community representatives elected at cluster and ward level. A city-level Community Advisory Committee (CAC) with representatives from each ward has been established. Workshops and community meetings at ward and city-level have explored project-related concerns using tools adapted from participatory learning and action techniques e.g. chapati diagrams, pair-wise ranking. Secondary stakeholders representing local public-sector and non-governmental health and social care providers have formed a trial Stakeholders' Advisory Group (SAG), which includes two CAC representatives.ResultsKey recommendations from participatory community workshops, CAC and SAG meetings conducted in the first year of the trial relate to the quality and range of clinic services provided at study clinics as well as broader standard of care issues. Recommendations have included streamlining clinic services to reduce waiting times, expanding services to include the children and spouses of participants and providing care for common local conditions such as malaria. Participants, community representatives and stakeholders felt there was an ethical obligation to ensure effective access to antiretroviral drugs and to provide supportive community-based care for women identified as HIV positive during the trial. This obligation includes ensuring sustainable, post-trial access to these services. Post-trial access to an effective vaginal microbicide was also felt to be a moral imperative.ConclusionParticipatory methodologies enabled effective partnerships between researchers, participant representatives and community stakeholders to be developed and facilitated local dialogue and consensus on what constitutes a locally-appropriate standard of care in the context of a vaginal microbicide trial in this setting.Trial registrationCurrent Controlled Trials ISRCTN64716212. (shrink)

Recently a number of AIDS/AZT research studies, carried out by U.S. universities, have come under intense ethical scrutiny. In these studies, control groups of HIV-positive pregnant women were being given a placebo rather than AZT. Such research protocols would be illegal if practiced in the U.S. I examine a number of lamentable ethical lapses in the studies, and conclude that at least some of these ethical problems are traceable to a troubling contradiction between differing international codes of ethics. (...) In a word, some international codes mandate that all research subjects (including control groups) receive the best standard of care available in the country sponsoring the research, while others suggest that providing only a “Iocal” standard of care is ethically appropriate. I argue that these two ethical mandates cannot both be satisfied, and that host country populations will remain subject to exploitation unless this contradiction is resolved. (shrink)

This article focuses on the ways that sexual risk behaviors are related to race, class, and gender among low-income, culturally diverse women in South Florida. Data concerning sexual risk and gender are presented in terms of race and class variations. Results indicate that, in general, these women have a high degree of knowledge about acquired immune deficiency syndrome, a quite contemporary awareness of women's gendered subordination, and a lack of trust in heterosexual relationships. Attitudes, beliefs, and knowledge, (...) however, are not translated into sexual behaviors with men partners that would reduce their vulnerability to infection with the human immunodeficiency virus. The data indicate that race is a major factor that places women into an underclass position. Consequently, without socioeconomic resources, gendered behaviors have a direct influence on sexual risk. Multivariate analyses indicate that those women who are sex workers are significantly more likely to negotiate safe sex with clients than with main partners. The research not only challenges mainstream thinking about race, class, and gender but also provides overdue information on the vulnerability of women to HIV infection. (shrink)

The processing of sensitive information in the health field is subject to rigorous standards that guarantee the protection of information confidentiality. Recently, the Italian Data Protection Authority (Garante per la Protezione dei Dati Personali) stated their formal opinion on a standard procedure in dental offices involving the submission of a questionnaire that includes the patient's health status. HIV infection status is included on the form. The Authority has stated that all health data collection must be in accordance with the current (...) Italian normative framework for personal data protection and respect the patient's freedom. This freedom allows the patient to decide, in a conscious and responsible way, whether to share health information with health personnel without experiencing any prejudice in the provision of healthcare requested. Moreover, data collection must be relevant and cannot exceed the principles of treatment goals with reference to the specific care of the concerned person. However, the need for recording information regarding HIV infection at the first appointment, regardless of the clinical intervention or therapeutic plan that needs to be conducted, should not alter the standard protection measures of the healthcare staff. In fact, these measures are adopted for every patient. (shrink)

This article examines HIV-positive patients’ experiences of treatments within a context characterized by the multiplicity of opinions expressed both by specialists and the public domain. It is based upon a survey of 63 patients encountered in a Paris hospital. The authors demonstrate the contrasts between these patients in terms of two main dimensions: the degree of the patients’ proximity to specialist knowledge, and the level of homogeneousness that the patients attribute to medical know-how. At the point where these two (...) dimensions meet, the article distinguishes between three forms of patient attitude towards treatment; in other words, three ways of simultaneously positioning oneself with regard to the media, associations, doctors and family circles/entourage: resorting to exteriority; self-integration into biomedical institutions; arranging heterogeneous actors. It analyses the transformations relating to the main experience profiles highlighted by sociological studies of other pathologies. (shrink)

This study’s objectives were: (1) to describe and explore the ethical dilemmas surrounding the HIV-positive person in the workplace in South Africa; and (2) to describe the Rational Interaction for Moral Sensitivity (RIMS) approach as a possible mechanism for solving these ethical dilemmas. A qualitative, exploratory and descriptive research design was used. The target populations were HIV-positive employees and occupational health nurses working for a South African company. Data collected through individual HIV-positive employee interviews and occupational health (...) nurse workgroups were analysed. The ethical dilemmas were conceptualized and described within the theoretical framework of the principles of ethics, namely, autonomy, beneficence, justice and confidentiality. To elicit a solution to the dilemmas, the data were recontextualized using the RIMS approach, a group decision-making strategy designed for the business environment. (shrink)

Religion and spirituality seem to be very important for HIV-positive patients believers. Indeed, a recurring number of studies show strong correlations between religiosity/spirituality of individuals and different dimensions of health. The majority of these studies show most positive associations of religiosity/spirituality to physical health through reducing emotional distress, reduced rates of depression, greater optimism, better psychological adjustment, better preservation of CD4 cells, better control of viral load. The objective of this research is to understand the nature of the (...) relationship between religiosity and emotional health among HIV-positive patients, migrants from sub-Saharan Africa. Religiosity, the frequency of depressive episodes and subjective health 81 asymptomatic HIV patients regularly followed, were evaluated. Regression models and mediation, backed by a resampling procedure were tested. From mediation analyzes, the results show that through the mediating effect of subjective health, religiosity explains a decrease in the number of depressive episodes in people with HIV migrants from sub-Saharan Africa. (shrink)

Global debates in approaches to HIV/AIDS control have recently moved away from a uniformly strong human rights-based focus. Public health utilitarianism has become increasingly important in shaping national and international policies. However, potentially contradictory imperatives may require reconciliation of individual reproductive and other human rights with public health objectives. Current reproductive health guidelines remain largely nonprescriptive on the advisability of pregnancy amongst HIV-positive couples, mainly relying on effective counselling to enable autonomous decision-making by clients. Yet, health care provider values (...) and attitudes may substantially impact on the effectiveness of nonprescriptive guidelines, particularly where social norms and stereotypes regarding childbearing are powerful, and where providers are subjected to dual loyalty pressures, with potentially adverse impacts on rights of service users. Data from a study of user experiences and perceptions of reproductive and HIV/AIDS services are used to illustrate a rights analysis of how reproductive health policy should integrate a rights perspective into the way services engage with HIV-positive persons and their reproductive choices. The analysis draws on recognised tools developed to evaluate health policies for their human rights impacts and on a model developed for health equity research in South Africa to argue for greater recognition of agency on the part of persons affected by HIV/AIDS in the development and content of policies on reproductive choices. We conclude by proposing strategies that are based upon a synergy between human rights and public health approaches to policy on reproductive health choices for persons with HIV/AIDS. (shrink)

The world’s first living donor liver transplant from an HIV-positive mother to her HIV-negative child, performed by our team in Johannesburg, South Africa (SA) in 2017, was necessitated by disease profile and health system challenges. In our country, we have a major shortage of donor organs, which compels us to consider innovative solutions to save lives. Simultaneously, the transition of the HIV pandemic, from a death sentence to a chronic illness with excellent survival on treatment required us to rethink (...) our policies regarding HIV infection and living donor liver transplantation. Although HIV infection in the donor is internationally considered an absolute contraindication for transplant to an HIV-negative recipient, there have been a very small number of unintentional transplants from HIV-positive deceased donors to HIV-negative recipients. These transplant recipients do well on antiretroviral medication and their graft survival is not compromised. We have had a number of HIV-positive parents in our setting express a desire to be living liver donors for their critically ill children. Declining these parents as living donors has become increasingly unjustifiable given the very small deceased donor pool in SA; and because many of these parents are virally suppressed and would otherwise fulfil our eligibility criteria as living donors. This paper discusses the evolution of HIV and transplantation in SA, highlights some of the primary ethical considerations for us when embarking on this case and considers the new ethical issues that have arisen since we undertook this transplant. (shrink)

Thirty-four states criminalize HIV in some way, whether by mandating disclosure of one’s HIV status to all sexual partners or by deeming the saliva of HIV-positive persons a “deadly weapon.” In this paper, we argue that HIV-specific criminal laws are rooted in historical prejudice against HIV-positive persons as a class. While purporting to promote public health goals, these laws instead legally sanction discrimination against a class of persons.

The purpose of this article is to describe and reflect ethical challenges in a grounded theory study on the dynamics of hope in HIV-positive adults and their significant others. It concentrates on the justification of a research problem, sensitive research and the relationship between the researcher and the participants in data collection. The basis of ethically sound nursing research on the dynamics of hope in these two vulnerable groups lies in the relationship between the researcher and the participant. However, (...) it is also obvious that the content, the process, the methods used and the ethics of the study cannot be divorced from this relationship. In conducting grounded theory research on the dynamics of hope in this research population, the researcher has to consider the surrounding world, that is, the reality in which these people live in hope or despair. (shrink)

In the decade following hepatitis B vaccine’s 1981 approval, U.S. health officials issued evolving guidelines on who should receive the vaccine: first, gay men, injection drug users, and healthcare workers; later, hepatitis B-positive women’s children; and later still, all newborns. States laws that mandated the vaccine for all children were quietly accepted in the 1990s; in the 2000s, however, popular anti-vaccine sentiment targeted the shot as an emblem of immunization policy excesses. Shifting attitudes toward the vaccine in this (...) period were informed by hepatitis B’s changing popular image, legible in textual and visual representations of the infection from the 1980s through the 1990s. Notably, the outbreak of AIDS, the advent of genetically engineered pharmaceuticals, and a Democratic push for health reform shaped and reshaped hepatitis B’s public image. Hepatitis B thus became, in turn, an AIDS-like scourge; proof of a new era of pharmaceuticals; a threat from which all American children had a right to be protected; and a cancer-causing infection spread by teenage lifestyles. The metamorphosis of the infection’s image was reflected in evolving policy recommendations regarding who should receive the vaccine in the 1980s, and was key to securing broad uptake of the vaccine in the 1990s. (shrink)

Robert Veatch has proposed a model of the doctor-patient relationship that has as its foundation the sharing of values between the doctor and the patient. This paper uses qualitative research conducted with six doctors involved in the long term, specialised care of HIV positive patients in South Australia to explore the practical application of Veatch’s value sharing model in that setting. The research found that the doctors in this study linked “values” with sexual identity such that they defined value (...) sharing, in part, as a shared set of values and beliefs about sexual identity and practices. They voluntarily identified themselves as either homosexual or heterosexual and they regarded the relation between their own sexual identity and that of their patients as important for the provision of quality care. None of the doctors thought that value sharing, in the way they defined it, was essential to the clinical relationship, but the homosexual doctors attributed a greater degree of importance to it than their heterosexual colleagues. (shrink)

ABSTRACT Do physicians and nurses have an obligation to treat patients who are HIV‐positive? Although an initial review of the possible sources of such an obligation yields equivocal results, a closer examination reveals a clear obligation to treat. The current risk of job‐caused HIV‐infection is not sufficient to warrant a refusal to treat. This is so because there exist rationally justified, general social, as well as specific peer expectations, that health care professionals treat HIV‐positive patients. These expectations impose (...) moral obligations on doctors and nurses. Moreover there is no sound libertarian argument entitling doctors and nurses to refuse to treat HIV‐positive patients. A morally appropriate identification with his or her role would disincline a health care professional to refuse treatment to an HIV‐positive patient. The likely source of such refusal is occupational alienation and an irrational reaction to AIDS symbolism. (shrink)

The question of the moral acceptability of infertility treatment to HIV positive persons raises a number of interesting ethical points regarding the responsibility of the infertility specialist for the outcome of his or her actions. The analysis of the physician’s responsibility is conducted within the framework of accomplice liability. The physician is a collaborator in the parental project of the principals—that is, the intentional parents. Both causal contribution and intention are considered as elements of complicity. It is concluded that (...) a two per cent risk of vertical transmission when the woman is HIV positive is insufficient to blame the infertility specialist who helps her to conceive. Helping an infertile HIV positive infertile couple to have a child does not constitute reckless behaviour. When the couple is fertile, infertility treatment is directed at risk reduction and falls under the physician’s obligation to act in the best interests of his patients. (shrink)

On April 3, 1995, the Fourth Circuit upheld the right of a Maryland hospital to terminate a surgeon who was HIV-positive ). A resident in the University of Maryland Neurosurgical Training Program was dismissed when hospital administrators learned of his infection with HIV. The resident, known as Dr. Doe, claimed that his termination violated federal laws protecting persons with disabilities. The court upheld the hospital's actions as lawful and affirmed the trial court's grant of summary judgment for the hospital.Dr. (...) Doe charged that his dismissal from the training program violated the Rehabilitation Act and the Americans with Disabilities Act. (shrink)

Therapeutic reactivity among psychology trainees was ascertained by their response to 10 clinical vignettes depicting clients with HIV who are sexually active with uninformed partners. This construct accounts for the relative change in decisions to maintain the confidentiality of clients who acknowledge safe versus unsafe sexual behavior. As anticipated, an analysis of variance revealed a significant main effect for safety and a significant 3-way interaction. Subsequent analyses revealed that trainees exhibit the highest level of therapeutic reactivity toward heterosexual male clients, (...) and the lowest reactive stance toward heterosexual female clients. Although the decisional pattern evidenced toward heterosexuals seems congruent with epidemiological estimates of risk, the decisions toward lesbians and gay males appear more likely a function of bias. The ethical implications of these findings are discussed. (shrink)