AIDS Care and Treatment in Sub-Saharan Africa: Implementation Ethics

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Within the contradiction lies the hope.--Bertolt Brecht

As the global response to the AIDS pandemic evolves, bioethics must keep pace. With each new phase, bioethical problem fields emerge, accumulate, and interact. In the mid-1990s, the AIDS crisis in the developing world burst onto the bioethics scene in the context of HIV prevention research. Placebo-controlled efficacy trials in Uganda on the use of AZT (zidovudine) to prevent mother-to-child HIV transmission gave rise to heated accusations of exploitation and ethical double standards. (1) This led to a vigorous debate on the Helsinki Declarations requirement that the benefits, risks, burdens, and effectiveness of a new method be tested against those of the best current prophylactic, diagnostic, and therapeutic practices, (2) which led to general debates about biomedical research in the developing world, global health inequities, and injustice. (3) Despite talk of an international consensus to the effect that the wording of the Helsinki requirement (found in Paragraph 29) should be "best attainable" treatment, not "best current" treatment, the controversy continues. (4) In fact, so much attention has been devoted to the standard of care in clinical trials that sometimes people living with HIV/AIDS in the developing world seem significant to developed world bioethicists only when they are the subjects of externally funded research. (5)

As the response to the AIDS crisis has evolved, however, bioethics has been forced to move with the times. In 2001, small-scale programs in Haiti and elsewhere demonstrated that antiretroviral treatment could be effectively delivered in resource-poor settings. (6) Activists who had been calling for AIDS treatment programs in the developing world responded by pressuring pharmaceutical companies to lower their prices and petitioning governments to allow for the import or domestic production of generic antiretroviral drugs. Bioethical attention therefore shifted from a research context to an activism and public policy context. The ethical ideal of the "treatment movement" is to mobilize resources to treat millions who are already infected with HIV and will almost certainly die of AIDS (in stark contrast to more privileged societies, where antiretroviral treatment is generally the standard of care). But this global treatment ideal has not gone unchallenged. Some argue that prevention is a more cost-effective response to the AIDS epidemic than treatment. (7) Others fear a strong focus on treatment could divert human and financial resources from other serious diseases afflicting low-income countries, such as malaria and tuberculosis. Still others argue that national AIDS treatment programs are more expensive and difficult to manage than small-scale projects, and if the financial and logistical challenges are not met, then patients may not adhere to treatment well, and drug-resistant strains of HIV could become more widespread. (8)

The focus then changed yet again. In September 2003, the director-general of the WHO and the executive director of UNAIDS declared the lack of access to AIDS treatment in the developing world a global health emergency. In response, the WHO and UNMDS launched the "3 by 5" initiative--treat three million by 2005. U.S. President George W. Bush announced in 2003 that the U.S. government would devote $15 billion to AIDS prevention, treatment, and care in the developing world through the President's new Emergency Plan For AIDS Relief (PEPFAR). With these and other new AIDS treatment program initiatives, the bioethical framework changed from "Should AIDS treatment programs should be initiated in the developing world?" to "How can these new programs be carried out in ethically sound ways?" We might call this implementation ethics in contrast to research ethics. Implementation ethics poses the question, What ethical issues are raised by the implementation of AIDS treatment programs in developing world contexts? …