Ethical dimention of hiv

Ethical Dimension of HIV/AIDS

Najibullah Safi, MD, MSc. HPMPhD Candidates (Health Management)

Tuesday, April 11, 2023 Ethical dimensions of HIV/AIDS 2

Presentation outline

• Introduction (what is ethics, why is it important)

• General principles • Ethical dimensions of HIV/AIDS in clinical

practice and research • Codes and policies for research ethics• Conclusion


What is ethics?

• It comes from the Greek word “ethos”, which mean character

• Dictionary meaning:– The moral principles governing or influencing

conduct (OXFORD) – اخالق – علم جمع صورت به اخالق اصول

(Babylon)– In Arabic اخالقیات


What is ethics? cont…

• Moral philosophy – defining or recommending the concept of right and wrong

• Ethics has to do with:– Feelings (e.g. right and wrong) – Law requirement– Standard of behavior society accepts – Religious beliefs (character traits of the human

and virtuous physician are already embedded in the Qur’an and Sunna)


What is ethics? cont…

• At a more fundamental level, ethics is the method by which we categorize our values and pursue them – Do we pursue our own happiness, or do we

scarifies ourselves to a great cause • Hippocratic Oath:– … “first of all, do not harm”…


Ethics in epidemiology

• Ethics is a branch of philosophy that deals with distinction between right and wrong – the moral consequences of human action

• The ethical principles in epidemiological practice and research includes: – informed consent– Confidentiality – Respect for human rights and – Scientific integrity


Why is ethics important?

• Required for human life• Means of deciding on a course of action• Without ethics – no way to work towards goal


General ethical principles

• Respect for person– Autonomy – Protection of persons with impaired or diminished

autonomy • Beneficence – Maximize benefits and minimize harms

• Nonmaleficence (do not harm)• Justice (equitable distribution of both burden

and benefits)


Ethical Dimension of HIV/AIDS 1. Clinical Ethics


• Protection of HIV related medical records• Exceptions may exist (e.g. HIV/AIDS cases

should be reported to Public Health Authorities in USA)– Benefits to public health to outweigh the risk to

individuals– Health care providers may also disclose a patient’s

HIV infection to person at risk of infection• Prevent serious harm to an identifiable person• No other effective means of achieving goal• The breach of confidentiality is minimized

Confidentiality


Informed consent for testing

• Blood test do not require extensive informed consent discussion (minimal risk, only implied consent)

• However, in early epidemics of HIV/AIDS– Serious psychosocial risks (e.g. rejection by family,

discrimination in employment)– Specific procedures (e.g. pretest counseling,

specific informed consent)


Exceptions to informed consent

• HIV test without consent – Significant exposure to emergency response

workers or health workers – Testing of prisoners– Persons accused of sex crimes – Mandatory HIV testing of newborns (indirectly

reveals maternal HIV status)


Exceptions to informed consent • Prenatal HIV testing (all pregnant women be tested for

HIV as a routine part of prenatal care in US)• May raise several concerns– Acceptability – Women may not realize that they have option to

decline testing – Caregivers may forget the psychosocial risk of

testing – Routine testing may undermine prevention efforts– May affect adherence to the norms of pretest

counseling and informed consent in other contexts


End of life issues

• End-of-life care in HIV infection in US has become less prominent – as the availability of highly active antiretroviral therapy prolonged survival

• In developing countries palliative care focuses on relief from suffering (pain, psychosocial issues)– Ongoing efforts to reduce the price of ARV, permitting

production of generic version, provisions of funds


Ethical Dimension of HIV/AIDS 2. Research Ethics


General principles

• Helsinki Declaration of1964 focuses on: – Privacy and integrity of individuals protected– Adequate informed consent – Research for valid scientific benefits – Accepted scientific principles – Benefits outweigh risks– Protect control group– Individual wellbeing vs. needs of science and

society


Research design

• People accept risks and inconvenience to advance knowledge and to benefits others

• Sufficiently rigorous that the results will be valid and generalizable

• Meet ethical obligations • Adequate sample size• Appropriate end point (study outcome) • RCTs – require preliminary lab and animal

research


Informed consent

• Informed consent might be affected by– Personal expectation– Individual benefits vs. generalizable knowledge – Inadequate understanding of experiment vs. research– Randomization – Patients inclination to follow the advice of their health

care providers– Patients trust in health care providers – Over estimation of the benefits by health care

providers


Vulnerable participants

• Vulnerability is defined by categories, in US includes:– Children, prisoners, pregnant women, mentally

disabled person, economically and educationally disadvantage persons, homosexuals, injecting drug users, minorities

• Vulnerable groups require special protection from research risks


Conflict of interest

• Some conflicting interest are inherent in research such as:– Gain prestige, grants, promotion, publication– This interest may conflict sometimes with the best

interest of participants– It is an accepted element of research and

acknowledged • Some interest e.g. financial interest may create

ethical problems– Overestimate the benefits, underestimate the risks


Special issues in vaccine research

• Good animal model does not exist• HIV is highly variable and undergoes rapid

mutation• Little information on protection against HIV• Misbelieve of protection from the vaccine, may

increase high risk behavior • Participants should have access to appropriate

risk reduction counseling • Appropriate monitoring


Special issues in vaccine research cont…

• Risk to participants – May not participate in future trials, less

effectiveness of vaccine may produced in the future– Positive reaction to HIV antibody tests (may limit

travels and eligibility for certain jobs)• Early phase clinical trials should take place in

sponsor countries• Placebo-controlled vaccine trials are ethically

acceptable


Codes and Policies for Research Ethics


Codes and Policies for Research Ethics

• Honesty• Objectivity • Integrity• Carefulness• Openness• Respect for Intellectual Property • Confidentiality • Human subject protection


Codes and Policies for Research Ethics cont…

• Responsible publication• Responsible mentoring• Respect for colleagues• Social responsibility• Non-discrimination• Competence• Legality• Animal care


Conclusion

• Muslim Physician and the ethics of medicine: the Muslim physician, guided by Qur’an and Sunna (two primary sources of Islamic Law), will possess the necessary character traits of a good physician. This in turn, will lead to a healthy physician-patient relationship and will safeguard the profession of medicine.


References Materials

1. International ethical guidelines for epidemiological studies 2. Responsible Conduct of Research, 2nd ed. (New York: Oxford

University Press) - Shamoo A and Resnik D. 2009. 3. Ethical dimension of HIV/AIDS, Leslie E. Wolf et all, University of

California San Francisco4. Guidance on Ethics and Equitable access to HIV Treatment and

Care, WHO, UNAIDS 20045. The Muslim physician and Ethics of Medicine , Thalia A. Arawai,

PhD, JIMA: Volum 42, 2010, page 111-1166. The Ethics of Muslim Physician and the Legacy of Mohammad

Thalia A. Arawai, PhD, JIMA: Volum 43, 2011, page 35 - 38 ,(ص)


Thanks, any questi on or comments?

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Ethical dimention of hiv