Transcript AIDS etická problematika

2014
Marek Vácha
Deník Metro, 20/11/2012
Metro Journal: „Big Discovery. The
Scientists can destroy a HIV
bacteria.“
AIDS
BIOLOGY AND ETHICS
A woman comes at 10 week of pregnancy for
prenatal care. She has a history of STDs such as
gonorrhea.
 You offer HIV testing, which the patient refuses,
as a routne part of prenatal care.
 She returns at 14 and 18 weeks of pregnancy but
is still refusing because of anxiety that she may
be positive.
 You inform tha patient that there are medications
that can reduce transmission from mother to
child to less than 2 %.
 She persist in her refusal.
 What should you do now?


Although there are medications to prevent
transmission of HIV to the fetus during pregnancy,
you cannot compel mandatory testing of pregnangt
women.
• in Czech rep. the test is routine and mandatory, women are not
even asked
The woman has the right to refuse testing as well as
to refuse antiretrovirals.
 If the woman is found to be HIV-positive you cannot
mandate the use of antiretrovirals even though they
are safe and effective in preventing transmission of
the virus from mother to child.
 The autonomy of the mother legally outweighs the
safety of the fetus.

The Case of the Infected Spouse
 The following fictionalized case is based on an actual
incident.


1982: After moving to Honolulu, Wilma and Andrew Long visit
your office and ask you to be their family physician. They have
been your patients ever since.
1988: Six years later the two decide to separate. Wilma leaves
for the Mainland, occasionally sending you a postcard. Though
you do not see her professionally, you still think of yourself as
her doctor
The Case of the Infected Spouse


1990: Andrew comes in and says that he has embarked upon a
more sophisticated social life. He has been hearing about some
new sexually transmitted deseases and wants to be tested.
Testing reveals that he is positive for the AIDS virus, and he
receives appropriate counseling.
1991: Visiting your office for a checkup, Andrew tells you
Wilma is returning to Hawaii for reconciliation with him. She
arrives that afternoon and will be staying at the Moana Hotel.
Despite your best efforts to persuade him, Andrew leaves
without giving you assurance that he will tell Wilma about his
infection or protect her against becoming infected
The Case of the Infected Spouse
 Do you take steps to see that Wilma is warned?

Kipnis, K., A Defense of Unqualified Medical Confidentiality. The American Journal of Bioethics 6, no. 2 (2006): 7 - 18
Solution
Counseling the patient to notify his partners voluntarily.
If the patient is unwilling to notify their partners the next
step is to notify the Department of Health to start the
process of contact tracing.
The health department interviews the patient and attempts
to construct a list of partners in order to notify them
1.
2.
3.
1.
this is a voluntary process and there is neither a penalty nor criminal
threat of prosecution if the patient chooses not to comply.
The health department then sends notice to the partner that
there is a health-related issue to discuss and the partner is
notified in person of their potential exposure to HIV.
4.
1.
The name of the source patient is never revealed to the partner and the
confidentality of the original partner is maintained.
Solution
If the patient is unwilling to disclose the means of his
contacts you cannot compel him to do so.


There is no incarceration or criminal penalty for not disclosing
these names.
If a patient will not notify his partners and you have
certain knowledge of the partner at risk, you have legal
immunity to carry out the notification yourself.




now (2014) you have even legal duty!
There is a legal protection if you do notify the partner, but it is
(not) mandatory for you to do so.
No one has ever been successfully prosecuted for violating a
patient´s confidentiality if it is to warn another person who is at
risk.
You have a patient in your clinic who is accompanied
by her boyfriend
 She is clearly having unprotected sex because she is
pregnant.
 When you ask if her boyfriend knows her HIV status
she says, „Of course not – he might leave me if I told
him.“
 You strongly encourage her to tell him her HIV status
 On a subsequent visit, when you ask her if she has
notified her partner she says „Not yet.“
 You know the boyfriend because he accompanies
her to the office visits.
 What should you do?


You have legal immunity if you notify the partner.
• At this point either you can ask the health department to
notify the partner or you may do it yourself
• if the partner were to seroconvert for HIV and you did not
make sure he was notified you would be legally liable
because you did not follow your duty to warn.
• this is similar to having a psychiatric patient who told you
he was going to harm someone.

Although you have a duty to maintain the
confidentiality of the patient, you also have a
duty to inform the person at risk.
Dr. I
 Dr. I was vaguely disturbed by something about the
slim, handsome young man who was in his
examining room because of an unstable knee. The
knee, however, had unequivocal indications for
surgical repair of three ligaments. It could probably
be done by arthroscopy but might require an open
procedure. The patient agreed to the procedure and
it was scheduled. Dr. I asked him to provide a blood
sample for routine laboratory tests. He also
scheduled a preoperative chest X-ray. After the
patient left, Dr. I added an HIV test to the laboratory
request.
Dr. I
 Dr. I was anxious about blood-borne infections and
was glad he had gotten his hepatitis B shots. The day
before a planned surgery, the patient´s laboratory
and radiology reports came back. His blood cell
count showed reduced lymophocytes. The HIV test
was positive. To make matters even more perplexing,
the radiologists reported a lung infiltrate that
suggests tuberculosis.
 Dr. I wondered about what to tell his patient and
what to do about the surgery.
Solution
 Dr. I erred when he obtained a potentially
lifechanging tests and did not inform his patient and
obtain consent.
 He probably realized this when the result returned.
 At that point, the ethical imperatives for Dr. I are





to ascertain whether the patient knows his HIV status
to explain why the patient was tested for HIV
to disclose the results of that test and the chest radiograph
to defer the scheduled operation until it is safe and desirable
for the patient to proceed
to determine whether the patient has another doctor who can
capably address his infectious diseases
http://www.unaids.org/en/media/unaids/contentassets/documents/e
pidemiology/2013/gr2013/201309_epi_core_en.pdf
HIV AND AIDS IN NUMBERS
1986 - 2001
AIDS prevalence rate
1986 – 2001
among adults age 15 - 45
Over 90 % of HIV infected
people live in the poor
countries of the Southern
Hemisphere.
Two-third of these in subSaharan Africa alone.
2002
AIDS
 till 2002 42 millions of deaths on the whole
2004
AIDS
2004
 HIV has so far infected more than 60 milion people
 20 million have already died
 Joint United Nations Programme on HIV/AIDS
estimates that by 2020 the AIDS epidemic will have
claimed a totaly of nearly 90 million lives
 According to WHO, AIDS is now responsible for about
5 % of all deaths worldwide
 cancer 12 %, heart attacks 12 % , strokes 9%, lower
respiratory tract infections 7 %
 tuberculosis 3 %, malaria 2 %, car accidents 2 %, homicides
1%
 roughly 8000 people die of the disease every day
AIDS 2004: USA
 As of December 2004, an estimated
944,306 persons had received a diagnosis
of AIDS, and of these, 529,113 (56%) had
died
Sub-Saharan Africa
2004
 average prevalence among adults there is
9%
 Botswana 39 %
 Zimbabwe 34 %
 Swaziland 33 %
 Lesotho 31 %
 the AIDS epidemic has cut the average life
expectancy from 62 to 47.
2008
2008
 over 7400 new HIV infection a day
 more than 97% are in low- and middle-
income coutries
 about 1200 are in children under 15 years of
age
 about 6200 are in adults
2009
The number of people living with HIV rose from around 8 million in 1990 to 34 million by the end of
2010. The overall growth of the epidemic has stabilised in recent years. The annual number of new
HIV infections has steadily declined and due to the significant increase in people
receiving antiretroviral therapy, the number of AIDS-related deaths has also declined.
Since the beginning of the epidemic, nearly 30 million people have died from AIDS-related causes
http://www.avert.org/worldstats.htm
2010
Estimate
Range
People living with HIV/AIDS in 2010
34 million
31.6-35.2 million
Proportion of adults living with HIV/AIDS in
2010 who were women (%)
50
47-53
3.4 million
3.0-3.8 million
2.7 million
2.4-2.9 million
390,000
340,000-450,000
1.8 million
1.6-1.9 million
Children living with HIV/AIDS in 2010
People newly infected with HIV in 2010
Children newly infected with HIV in 2010
AIDS deaths in 2010
http://www.avert.org/worldstats.htm
 In 2010, about 68% of all people living
with HIV resided in sub-Saharan Africa, a
region with only 12% of the global
population
2011 - 2012
2011
2012
2012
 the population affected by the disease has
extended to all groups
 from „high-risk groups“ to „high-risk
behaviours“
 The number of AIDS-related deaths
declined by nearly one-third in subSaharan Africa between 2005 and 2011.
 The Caribbean experienced declines in AIDS-
related deaths of 48% between 2005 and 2011
and Oceania 41%.
 However two regions experienced significant
increases in AIDS-related deaths; Eastern
Europe and Central Asia (21%) and the Middle
East and North Africa (17%).
Cost of AIDS
 when one considers personal medical
costs, direct costs of research, and
indirect costs such as education,
screening, and potential productivity
losses,
 the disease carries a yearly price tag of
over $ 8 billion
http://www.unaids.org/en/media/unaids/contentassets/documents/e
pidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf
WORLD 2013
CZECH REPUBLIC: 31/12/2013
BIOLOGY OF HIV
AIDS
 1981: On June 5,
the Centers for
Disese Control
(CDC) Mortality
and Morbidity
Report listed an
unusual outbreak
of opportunistic
infections such
as Pneumocystis
carinii
pneumonia
among gay men
 "gay cancer"
T-lymocyte infected by HIV (blue)
History
 GRID - gay-related immune disorder
 july 1981
 108 cases reported, 43 individuas had died
 1982: Acquired Immunodeficiency
Syndrome becomes the term used by the
CDC to describe thr unusual outbreak of
opportunistic infection
 1984: Virus HIV is identified by a team of
French scientists
 1987: FDA approves AZT
(azidothymidine), the first antiviral agent to
treat AIDS
 AIDS began as a mutant virus that was iked
up from a species of African monkey and
transferred to humans by way of bites
 It was then transmitted among the African
population via direct mucous to mucous
contact, through semen and perhaps blood
exchange
 From Africa, the disease spread to Haiti, and
was later carried to the United States,
probably by homosexual males

(Edge, R.S., Groves, J.R., (2007) Ethics of Health Care. A Guide for Clinical Practice, 3rd ed.
Thomson Delmar Learning, NY,USA, p.284)
 2008
 Luc Montagnier received a
Nobel prize
Harald zur Hausen
Born 1936
German Cancer
Research Center,
Heidelberg, Germany
Françoise BarréSinoussi
Born 1947
Institut Pasteur,
Paris, France
Luc Montagnier
Born 1932
World Foundation for
AIDS Research and
Prevention,
Paris, France
AIDS
HIV
Immune Response - Overview
Life
cycle
Δ 32 CCR5
Δ 32 CCR5
 9 % Europeans have CCR5-Δ 32
 deletion 32 bp in coreceptor CCR5 coding
gene
 HIV can not „land“ on this cell and a patient is
therefore immune
 0 % Africans has this deletion
 CCR5-Δ 32 allele is common in northern
Europe and declines dramatically in
frequency to both south and east
Evoluce viru HIV
Resistance proti
léku 3TC začíná
téměř ihned po
aplikaci a za několik
týdnů dosahuje
původní úrovně
AIDS and Cancer
 In AIDS, the human immunodeficiency
virus (HIV) promotes development of an
otherwise rare cancer called Kaposi´s
sarcoma by destroying the immune
system, thereby permitting a secondary
infection with a human herpes virus (HHV8) that has a direct carcinogenic action.
Origin of HIV
 the last common ancestor of the group M
HIV – 1 viruses lived in 1930s
 this common ancestor could, in principle, have
lived in either a chimpanzee or a human
RT-PCR: NEW KIND OF TEST
 because
the sequence of the RNA
genome of HIV is known, RT-PCR can be
used to amplify, and thus detect, HIV RNA
in blood or tissue sample
uses the enzyme reverse transcriptase (RT) in
combination with PCR and gel electrophoresis
 in this example, samples containing mRNAs from
six embryonic stages of hummingbird

1.
2.
3.
cDNA synthesis is carried out by incubating the mRNAs
with reverse transcriptase and other necessary
components
PCR amplification of the sample is performed using
primers specific to the hummingbird β-globin gene
Gel electrophoresis will reveal amplified DNA products
only in samples that contained mRNA transcribed from
the β-globin gene
Result: the mRNA for
this gene is first
expressed at the stage
2 and continues to be
expressed through
stage 6
2014
AIDS
ETHICS
Ethical Problems
 Do health care practitioners have a duty to treat?
 What is an acceptable risk for health care




professionals?
Should the patient be warned if the health care
practitioner is HIV positive?
Should the practitioner be warned of the patient
is HIV positive?
Should infected practitioners be allowed to
continue practice?
What is the meaning of confidentiality when it
comes to AIDS, and who should be told?
 It is ethically unacceptable to refuse to
treat HIV or take care of HIV-positive
patients simply because they are HIVpositive.
2006: change
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
 CDC changed its recommendation about HIV
screening for patients in health care settings
 the recommendations moved away from
specific, explicit informed consent, usually in
written form, to general, implicit consent as
part of the acceptance of medical care.
 previous policies required specific disclosure of
information and a decision to accept or refuse
testing.
 specific, explicit consent would still be expected in
nonclinical settings
2006: change
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
 For patients in all health-care settings
 HIV screening is recommended for patients in all
health-care settings after the patient is notified that
testing will be performed unless the patient declines
(opt-out screening).
 Persons at high risk for HIV infection should be
screened for HIV at least annually.
 Separate written consent for HIV testing should not be
required; general consent for medical care should be
considered sufficient to encompass consent for HIV
testing.
 Prevention counseling should not be required with HIV
diagnostic testing or as part of HIV screening programs
in health-care settings.
2006: change
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
 For pregnant women
 HIV screening should be included in the routine
panel of prenatal screening tests for all pregnant
women.
 HIV screening is recommended after the patient is
notified that testing will be performed unless the
patient declines (opt-out screening).
 Separate written consent for HIV testing should
not be required; general consent for medical care
should be considered sufficient to encompass
consent for HIV testing.
 Repeat screening in the third trimester is
recommended in certain jurisdictions with elevated
rates of HIV infection among pregnant women.
Transmission
 heterosexual sex
 homosexual sex
 oral sex
 needle sharing
 transfusion
with
product
 childbirth
 breast feeding
contaminated
boold
Spreading
 sexual
intercourse (both homo and
heterosexual) (in ČR 84% cases)
 blood-to-blood
contact
–
blood
transfusion, needle sharing among drog
abusers etc.
 from pregnant woman to a fetus (cca 20 –
30% pregnancies)
 BTW we see how useful organ a placenta is!)
 much higher number is via breast-feeding
(HIV+ women must not feed their babies)
Succes in preventing programme in
Thailand
and Ivory Coast
New infections among men who have
sex with men in Amsterdam
1991 – 2000
It appears that the introduction of effective
long-term drug therepies, which for
some individuals have at least
temporalily transformed HIV into a
manageable chronic illness, may also
have prompted an increase in risky
sexual behavior.
"Breaking the Chain"
 clean needle exchange
 provision of free condoms fro high school
students
 screening prospective blood donor
 testing of blood supplies
 abstinence in high-risk situation
Reagan Administration:
„conservative“ approach
 no sex before marriage
 faithfullness in marriage
 no drugs
Clinton Administration:
„pragmatic“ approach
 HIV is not transmissed by sexual
intercourse, byt by unprotected sexual
intercourse
 condom
 throwaway needles
Bushova administrativa 2004 2008
 ABC program
 abstinence
 be faithful
 condoms
CASE REPORTS
HIV+ HEALTH-CARE WORKER
HIV+ Health-care worker
 There is no duty on the part of an HIV
positive health-care worker to inform his
patients of his HIV status.
 An HIV-positive physician who practices
high-risk surgical and obstetric procedures
is expected to maintain precautions to
protect the patietns from transmission.
Dr. Acer Case
 Dr. David J. Acer, a Florida dentist,
infected six of his patients with the AIDS
virus.
 Fifty-seven other health-care
professionals have told the authorities that
they are H.I.V.-positive; 19,000 of their
patients have been tested. Not one has
caught the virus from medical treatment.
Dr. Acer Case
 But no one expected the example to be such
an anomaly - one dentist with six cases
versus 57 professionals with no cases.
 Before he died of AIDS in 1990, Dr. Acer
wrote an open letter to his patients saying:
 "I am a gentle man, and I would never
intentionally expose anyone to this disease. I
have cared for people all my life, and to infect
anyone with this disease would be contrary
to everything I have stood for."
 it is far more likely that the practitioner will
be infected by the patient than the other
way around.
 100 health care providers had contracted
the disease from patients (2007).

Edge, R.S., Groves, J.R., (2007) Ethics of Health Care. A Guide for Clinical Practice, 3rd ed.
Thomson Delmar Learning, NY,USA,p. 288
A
32-year-old pregnant woman comes to
your prenatal clinic. She has a history of
syphilis and gonorrhea in the past but her
VDRL/RPR is negative now. An HIV test is
offered as a routine part of her prenatal
evaluation as well as because of the history
of previous STDs. You explain to her the
importance of the test for her baby´s wellbeing. She refuses the test when offered.
 What should you do?
1.
2.
3.
4.
5.
6.
No test+. she has the right to refuse
PCR RNA viral load testing as an
alternative
Consent for HIV testing is not needed in
pregnancy because it is to protect the
health of the baby.
Add the test to the other toutine tests that
are to be drawn
Administer empiric antiretroviral therapy
to prevent perinatal transmission
HIV testing is now part of routine prenatal
care and no specific consent is needed.
 You
have a patient who is an HIV-positive
physician. He has recently found out that
he is HIV-positive. He is very concerned
about confidentiality and you are the only
one who knows he is HIV-positive. He
asks you who you are legally obligated to
inform.
 What should you tell him?
1.
2.
3.
4.
5.
6.
7.
His insurance company
State government
His patients
His patients, only if he performs a
procedure such as surgery where
transmission canoccur
No one without his direct written consent
His employer
The hospital human resources department
1.
2.
3.
4.
5.
6.
7.
His insurance company
State government
His patients
His patients, only if he performs a
procedure such as surgery where
transmission canoccur
No one without his direct written consent
His employer
The hospital human resources department
 patients
with HIV have a right to privacy
as long as they are not putting others at
risk
 you have no mandatory obligation to
inform the state, his insurance, his
employer
 you and the patient do not have a
mandatory obligation to inform his
patients of his HIV status even if he is a
surgeon
 If
the automatic right to know the HIV
statsu of the patient does not exists, the
the patient does not automatically have
the right to know the HIV status of the
physician.
 It works both ways.
 You
have an HIV-positive patient in the
office. You aks her if she has informed
her partner that she is HIV-positiev. She
has repeatedly resisted your attempts to
have her inform the partner. She is
pregnant with his child. The partner is in
the waiting eoom and you ave met him
many times.
 What should you do?
1.
2.
3.
4.
Inform the partner now.
Respect her confidentiality
Refer your patient to another physician
who is comfortable with her wishes.
Tell the partner to practice safe sex
from now on but don´t tell him her HIV
status
1.
2.
3.
4.
Inform the partner now.
Respect her confidentiality
Refer your patient to another physician
who is comfortable with her wishes.
Tell the partner to practice safe sex
from now on but don´t tell him her HIV
status
 You
have full legal protection if you
inform the partner.
 The safety of an innocent person is
always more important that privacy.
 You are not legally mandated to inform
the partner directly but you are protected
if you do so.
 You definitely are liable if the patient´s
partner seroconverts and you did not tell
him he was at risk even though you knew
 This
is a version of the Tarasoff case in
psychiatry
 if you know that harm may occur, but you
do nothing, then you are liable.
 If partner notification is going to occur,
you must inform the patient that you will
inform the partner.