HIV / AIDS : Social and Ethical Issues: Medical Journal Armed Forces India

[Guest guest]

HIV/AIDS : Social and Ethical Issues

Col Zile Singh*, Lt Col A Banerjee+

Medical Journal Armed Forces India. [MJAFI] 2004 Apr; 60(2): 107-108

*Professor and Head, +Associate Professor, Department of Preventive

and Social Medicine, Armed Forces Medical College, Pune - 411 040.

The social issues associated with AIDS can be understood in two ways.

Firstly, they may refer to the social determinants of the pandemic.

Secondly, they relate to the social impact of the pandemic. Ethical

questions present some of the most vexing problems associated with

HIV infection [1]. Ethics cannot be considered in a vacuum. The

social context dictates how the principles of ethics are applied and

interpreted.

Spread of HIV is linked to certain patterns of human behaviour.

Hence, it has both biological and socio-cultural determinants. Any

attempt to control its spread must take into account the complex

social, cultural, economic and environmental factors in which the

disease is embedded. India has a large migrant population. Rapid

urbanization coupled with poor housing facilities in city areas

leads to migrant labours staying away from families. Illiteracy and

poor awareness exposes them to high risk behaviour. Occupational

groups such as truck drivers are especially vulnerable.

Mass uprooting of people by ethnic conflicts may also be related to

an increased incidence of HIV infection. In a study among drug users

[2], it was found that 80% of the respondents, many of whom migrated

following ethnic clash, reported having sex with non-regular

partners. Two-thirds of these respondents reported sex in exchange

for money or drugs.

The unequal status of women in most societies also makes them

vulnerable to HIV infection. Gender inequities preclude the women on

insisting the male to wear a condom even when she suspects him of hig

hrisk behaviour. In many parts of the world, commercial sex is an

important source of HIV infection. Even if commercial sex workers

(CSWs) are willing to adopt safer sex practices, their clients may

object [3]. Thus, for promotion of condom use, AIDS prevention

programmes should target not only CSWs, but their clients as well.

Interventions aimed at establishing safe sexual practices among CSWs

have shown remarkable results.

In Thailand, the decline in new infections has been very marked and

attributed to universal condom use by CSWs

[4]. The `Sonargachi'project in Kolkata red-light area has

demonstrated that such interventions are possible in India also [5].

Successful targeted intervention projects in Kolkata have kept the

HIV prevalence at a low level among sex workers. Participation of sex

workers in programme planning and the resultant empowerment were the

key elements of these interventions along with condom promotion, STD

management and clinic services for clients as well as sex workers.

The other targeted groups in and around the city were the fishermen,

migrant labourers and truck drivers.

The first case of HIV seropositivity in an intravenous drug user

(IDU)was detected in Manipur in 1989.

Subsequently, within a decade, 44.7% of IDUs were found to be

positive for HIV in Manipur. Injectable drug abuse is rapidly

spreading in India and has been found to be prevalent in North East

India, Maharashtra, Tamil Nadu, Punjab, Chandigarh, Delhi and other

metropolitan cities. IDUs also often indulge in various sex related

risk behaviours. Condom use is also low in the group[6].

At the family level, an adult with AIDS will severely compromise

household resources as the functional capacity to work is reduced,

medical expenditures increase and the income of both the infected

individual and those who care for that person is lost. Reduced income

in turn threatens food supply, the ability to pay for the education

or health of surviving family members.

The entire social fabric of the family is potentially disrupted. The

effects of HIV/AIDS multiply far beyond the infected individual. In

the long run, it has the potential to affect whole sectors of the

economy and societies as resources will be required for increasing

number of people living with HIV/AIDS and for the care of increasing

number of orphans.

The four pillars of medical ethics are autonomy, no nmaleficience,

beneficience and justice [1]. These are general guidelines, which

leave room for interpretation and judgement in specific cases. Many

of the ethical issues that confront us in the context of AIDS are not

new. However, the AIDS pandemic has given a sharp focus to issues

such as confidentiality, discrimination, access to health care,

prenatal testing/abortion and the conduct of clinical/vaccine

trials.

The ethical issues relating to confidentiality and partner

notification within the context of HIV infection are complex. The

right of the individual to confidentiality can be in conflict with

the right of the partner to be protected from the risk of infection.

Confidentiality is essential to prevent discrimination. On the other

hand, the seriousness of the threat to the health of unsuspecting

third parties resulted in the debate on informing people at risk,

also known as `partner notification'. The National AIDS Control

Guidelines for HIV counselling encourages motivation of the HIV

positive person to disclose his/her status to the sex partner.

The Supreme Court of India has ruled on the issue of the right to

confidentiality of subjects with HIV infection and the breach of

confidentiality in order to protect the health of third parties [7].

The opinion of the court is that the right to privacy and

confidentiality is not absolute.

This right may be lawfully restricted in situations where third

parties are at risk. According to the National AIDS Control

Organization (NACO) policy, no person is to be tested for HIV without

voluntary consent. The NACO policy rules out any mandatory testing

for HIV. It encourages voluntary HIV testing with appropriate pre-and

post-test counselling. Ideally, the disclosure of HIV status of the

person should not in any way affect his rights to employment,

position at the workplace, right to medical care and other

fundamental rights.

Unfortunately, one of the biggest problems faced by HIV positive

person is stigma. People, even doctors, are sometimes afraid of

dealing with HIV positive persons leading to discrimination in

medical

care.

This stigma can prevent people from being tested. It can result in

individuals unknowingly transmitting HIV. HIV positive women should

have complete choice to make decisions about pregnancy and

childbirth.

There should be no forcible abortion or even sterilization. Proper

counselling should be given to pregnant women to enable her to decide

whether to continue or terminate the pregnancy.

Even the selection of study sites for clinical and vaccine trials are

fraught with ethical complications. Sometimes, researchers have

chosen developing countries for such trials to avoid the ethical

constraints faced in the developed world [8]. The highest ethical

standards must be upheld when collecting behavioural or biological

data on sexually transmitted infections, including HIV/AIDS. Because

of the stigma and human rights issues around HIV/AIDS, study

participants may experience psychological, social, physical or

economic harm, even when precautions are taken. Data collection

protocols or procedures should include an explicit description of

the measures that will be taken to protect the subjects. Both the

Indian Council of Medical Research (ICMR) and the Central Drugs

Standard Organization have established guidelines for biomedical and

clinical research in India [9,10].

The global burden of HIV infection in the years to come will be borne

overwhelmingly by people in developing countries. Increasingly,

inequalities of gender, race and wealth will dictate the course of

the pandemic, with infection rates increasing among the vulnerable

groups.

Social and economic dependenc will be the major determinants of the

future course of the HIV/AIDS pandemic.

Input from social research field is urgently needed for planning and

evaluation of AIDS prevention programs. Social, behavioural and legal

research will improve understanding of the dynamics of the pandemic

and its impact. It will translate into public health and societal

action for fostering understanding of the intricate relationships

between the individual, public health and society. It will also help

in resolving some of the complex social and ethical issues.

References

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4thed. AIDS. Etiology, Diagnosis, Treatment and Prevention.

Lippincort-Raven, 1977;633-42.

2. Panda S, Bijoya L, Sadhana Devi N et al. Interface between drug

use and sex work in Manipur. The National Med Jour India 2001;14:209-

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3. Helman CG. Medical anthropology and global health. In : Helman CG,

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HIV/AIDS pandemic, Jul 1996;5-6.

5. Jana S, Bandopadhyay N, Mukherjee S et al. STD/HIV intervention

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6. Sharma S. Overview of injection drug abuse and HIV/AIDS in India.

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7. Abraham S, Prasad J, ph A, KS. Confidentiality, partner

notification and HIV infection : Issues related to community health

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8. Mirken B. AIDS Vaccine. The ethical and social issues. Bulletin of

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Summer/autumn 2002;6-8.

9. ICMR. Ethical Guidelines for biomedical research on human

subjects. ICMR, New Delhi 2000;1-101.

10. CDSCO. Good clinical practices - guidelines for clinical trials

on pharmaceutical products in India. Directorate General of Health

Services. Ministry of Health and Family Welfare, Government of India,

New Delhi. 2001;1-132.

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