Ethical dimention of hiv

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  • 2nd Exception – HIV Positive Health Care Providers – who perform exposure-prone invasive procedures (expert review – may required to inform patients about their HIV status)
  • In majority of stats still specific procedures are in place for testing – counseling, nature of the test, risk and benefits, prevention of transmission, confidentiality of the results, voluntary nature of the test, availability of anonymous testing
  • Situation is different in developing countries – high cost of ART (prophylaxis) – may help in inform decision e.g. breastfeeding – may expose women to physical harm, loss of job and housing
  • International research
  • Ethical dimention of hiv

    1. 1. Ethical Dimension of HIV/AIDS Najibullah Safi, MD, MSc. HPM PhD Candidates (Health Management)
    2. 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• ConclusionMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 2
    3. 3. What is ethics?• It comes from the Greek word “ethos”, which mean character• Dictionary meaning: – The moral principles governing or influencing conduct (OXFORD) – – (Babylon) – In ArabicMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 3
    4. 4. 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)Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 4
    5. 5. 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”…Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 5
    6. 6. 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 integrityMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 6
    7. 7. Why is ethics important?• Required for human life• Means of deciding on a course of action• Without ethics – no way to work towards goalMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 7
    8. 8. 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)Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 8
    9. 9. Ethical Dimension of HIV/AIDS 1. Clinical EthicsMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 9
    10. 10. Confidentiality• 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 minimizedMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 10
    11. 11. 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)Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 11
    12. 12. 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)Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 12
    13. 13. 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 contextsMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 13
    14. 14. 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 fundsMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 14
    15. 15. Ethical Dimension of HIV/AIDS 2. Research EthicsMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 15
    16. 16. 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 societyMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 16
    17. 17. 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 researchMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 17
    18. 18. 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 providersMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 18
    19. 19. 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 risksMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 19
    20. 20. 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 risksMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 20
    21. 21. 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 monitoringMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 21
    22. 22. 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 acceptableMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 22
    23. 23. Codes and Policies for Research EthicsMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 23
    24. 24. Codes and Policies for Research Ethics• Honesty• Objectivity• Integrity• Carefulness• Openness• Respect for Intellectual Property• Confidentiality• Human subject protectionMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 24
    25. 25. Codes and Policies for Research Ethics cont…• Responsible publication• Responsible mentoring• Respect for colleagues• Social responsibility• Non-discrimination• Competence• Legality• Animal careMonday, March 11, 2013 Ethical dimensions of HIV/AIDS 25
    26. 26. 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.Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 26
    27. 27. References Materials1. International ethical guidelines for epidemiological studies2. 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 - 38Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 27
    28. 28. Monday, March 11, 2013 Ethical dimensions of HIV/AIDS 28

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