Correspondence and reprint requests: Dale M. Needham, 18 Ilderbrook Circle, PO Box 266, Ilderton, Ontario N0M 2A0, Canada.
Katherine Nyirenda, the first woman in Zambia to publicly declare her HIV positive status, is no stranger to Canadians and others interested in the HIV/AIDS pandemic. Her story has been told elsewhere (1)-(2) and in July 1996 she told this story in person at the XIth International Conference on AIDS in Vancouver. (3)
Katherine is a 24-year-old unmarried mother of two sons, Simon and Darlington, one and three years old, respectively. Katherine knew of her HIV status two years before the birth of her first son and as an AIDS educator in Zambia she appreciated the implications of her pregnancies and HIV status. Currently, Katherine is in good health. Her children are young and active; however, Simon has had frequent illnesses requiring short-term hospitalization. Living as an average Zambian, Katherine has no access to HIV treatment. She accepts this without much thought, but should she?
A Humanitarian Cause, But Not the Reality
The theme of the XIth International Conference on AIDS--One World, One Hope--reflects a global humanitarian response to HIV/AIDS. However, the latest advances in HIV/AIDS research create little hope for Katherine and 13 million others living with the disease in Africa (4): the cost of new anti-HIV combination therapy is well beyond the means of most infected Africans. Thus, although these drugs may increase hope in resource-rich countries, they further widen the gap in hope throughout the world.
Do we have an obligation to more equitably distribute this hope of HIV treatment between resource-rich and resource-poor countries? This is an enormous ethical issue that, for the purpose of this essay, I will narrow to specific questions. In this paper, the term resource-poor refers to the low per capita gross national product of many African countries such as Zambia.
Simon, A Case of Preventable HIV Infection?
Katherine's youngest son, Simon, has been ill frequently. Is Simon HIV positive? Katherine does not know. She does know, however, that an approximately 30% chance exists of maternal-infant (vertical) HIV transmission in Africa, said to be higher than in the resource-rich setting. (5) She also knows that, based on research with HIV-positive mothers in the resource-rich world, zidovudine (AZT) reduces the rate of vertical HIV transmission by two-thirds, from approximately 25% to 8%. (6)
At present, Katherine and virtually all other women who are part of the HIV/AIDS pandemic in sub-Saharan Africa do not have access to AZT. To put this barrier to treatment into perspective, the cost of two 100 milligram AZT capsules is greater than the annual per capita health budget of most African countries. (5) If Katherine wanted to buy the medication, her entire month's salary would purchase only four days supply of AZT. Of course, this would mean that Katherine would have AZT, but not food or lodging for the entire month.
Just Another Gap, or Exploitation of Africans?
So Simon and one million HIV-infected children in sub-Saharan Africa (4) are deprived of AZT's benefits in reducing the risk of vertical transmission. This barrier to HIV treatment raises an important ethical issue. Africans account for more than 65% of global HIV prevalence, (4) and research in Africa by resource-rich countries has contributed significantly to our understanding of HIV/AIDS, with only a modest cost. (7) For example, this research in Africa has included many studies on vertical HIV transmission. (7) In return for the benefits from this research, do resource-rich countries have an obligation to the population they use as research subjects? Specifically, do resource-rich countries have an obligation to subsidize AZT in order to reduce vertical HIV transmission?
Evidence for the Obligation to Share Benefits
The Nuremberg Code and Helsinki Declaration provide the basic ethical principles that guide research on human subjects. …