Science and ethics of human immunodeficiency virus/acquired immunodeficiency syndrome controversies in Africa

Abstract

Abstract:The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in Africa has raised important ethical issues for both researchers and clinicians. The most notorious controversy has been related to the zidovudine (AZT) trials in Africa in the late 1990s, in which the control groups were given a placebo rather than an effective drug to prevent vertical transmission. This raised concerns in the sponsoring country about exploitation of subjects, injustice and an ethical double standard between donor countries and resource-poor settings. However, the real double standard is between clinical practice standards in Western versus African countries, which must be addressed as part of the increasing global inequity of wealth both between countries and also within countries. There are important limitations to ethical declarations, principles and guidelines on their own without contextual ethical reasoning. The focus on research ethics with the HIV epidemic has led to a relative neglect of ethical issues in clinical practice. Although the scientific advances in HIV/AIDS have changed the ethical issues since the 1990s, there has also been progress in the bioethics of HIV/AIDS in terms of ethical review capability by local committees as well as in exposure to ethical issues by clinicians and researchers in Africa. However, serious concerns remain about the overregulation of research by bureaucratic agencies which could discourage African research on specifically African health issues. There is also a need for African academic institutions and researchers to progressively improve their research capacity with the assistance of research funders and donor agencies.

Clinical Ethics in HIV/AIDS Prevention, Care, and Research

“…The stigma associated with the sexual practices and illicit drug use through which HIV is commonly transmitted highlighted this ethical issue early in the pandemic (Pinching et al 2000). Clinicians worldwide recognized an essential link between maintaining confidentiality and controlling the spread of infection: at-risk individuals were unlikely to seek diagnostic testing or counseling on preventing transmission if they feared disclosure of their infection or personal behaviors (Bayer 2003;Brewster 2011). Because confidentiality was particularly central to the effective delivery of HIV services before ARV treatment became available, early AIDS-related law in the United States prohibited caregivers from disclosing a patient's HIV status without his or her consent.…”

Teaching Research Ethics on Clinical Trials to Multidisciplinary and International Trainees in Global Infectious Disease Research

“…Through group deliberations of case studies trainees were able to identify areas of variation in the process of obtaining informed consent in North America, Africa and other global research environments. They were further able to interpret the challenges of maintaining informed consent from individuals and communities and how to engage with problems of obtaining meaningful informed consent in cross-cultural and cross-national studies [8,9].…”

African fluid bolus study: Implications for practice

“…Many seem to imply that because the bolus groups had a higher mortality, the excess deaths prove that the study was unethical, ignoring that this was an unexpected outcome and that the study still reduced mortality from the expected 15%, which was why the committee opted to increase the sample size. As I have pointed out in the context of HIV research in Africa, it is facile to use ethics for grandstanding declarations, but true ethical decision making must be based upon ethical reasoning in the context in which the study is carried out 18 . In my view, the FEAST study demonstrated the highest ethical standard of research.…”

“…As I have pointed out in the context of HIV research in Africa, it is facile to use ethics for grandstanding declarations, but true ethical decision making must be based upon ethical reasoning in the context in which the study is carried out. 18 In my view, the FEAST study demonstrated the highest ethical standard of research.…”