6 курс / Кардиология / Kartikeyan_HIV and AIDS-Basic Elements and Properties

severe preterm birth (less than 34 weeks gestation), and small for gestational age at birth, and increase CD4, CD8, and CD3 counts. The effect on MTCT is yet to be determined in this study (Tanzania Vitamin and HIV Infection Trial Team, 1998).

22.6.2 – Mode of Delivery

Many studies have revealed that caesarean section was associated with a reduction in MTCT. A meta-analysis of prospective follow-up studies has shown that elective caesarean section reduced the risk of MTCT by more than 50 per cent, after adjusting for ARV therapy, birth weight, and stage of maternal infection (International Perinatal HIV Group, 1999). The use of elective caesarean section must take into account the risk of maternal morbidity and mortality, the availability of safe operating facilities, and the accessibility of maternal services for women in future pregnancies (UNAIDS/WHO, 1999).

22.6.3 – Vaginal Cleansing

It is hypothesised that the use of antiseptics (chlorhexidine or benzalkonium chloride) during labour and delivery could reduce the intrapartum transmission of HIV-1. The advantages are its low cost, other potential health benefits for the mother, its feasibility in most health care settings, and ability to implement without HIV testing (UNAIDS/WHO, 1999). Microbicides are anti-HIV substances that could reduce the risk of HIV infection and other STIs during vaginal or anal intercourse. Use of these products can be controlled by women without the need for cooperation from their male partners or without their partners’ knowledge. Success of vaginal cleansing with microbicides depends on women remembering to use them correctly and consistently during each act of coitus. Microbicides can be incorporated in gels, foams, creams, thin films, or vaginal pessaries. The possible mechanisms of action include immobilising the virus, creating a barrier between the virus and epithelial cells, and preventing HIV from reproducing and establishing infection after it has entered the body. So far, no anti-HIV microbicide has been approved. Microbicides closest to approval are Carraguard, cellulose sulphate gel (also being studied as a contraceptive), PRO 2000 Gel, BufferGel, and Savvy (Fact Sheet 157, 2006).

22.6.4 – Modification of Infant Feeding Practices

Potential modifications of infant feeding include:

(a)Complete avoidance of breastfeeding

(b)Avoiding breastfeeding in the presence of breast abscesses or cracked nipples

(c)Early cessation of breastfeeding

(d)Pasteurisation of breast milk (Newell et al., 1997; Kuhn & Stein, 1997)

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(d)If the baby has no symptoms of HIV-related diseases, all the vaccines (live and killed) are to be given, as per the national schedule. If the baby is symptomatic, all the vaccines except live vaccines should be given as per the national schedule (NACO, Training Manual for Doctors).

22.6.7– Antiretroviral Therapy

Long-Course Zidovudine Therapy: The use of long-course ZDV in pregnancy was recommended as the standard of care in Europe, United States, Brazil, and Thailand, and the introduction of this regimen has resulted in a dramatic reduction in rates of transmission. This regimen is based on Paediatric AIDS Clinical Trials Group (PACTG) trial, in which asymptomatic pregnant women in a non-breastfeeding population participated. The women are given ZDV orally (100 mg five times daily), after 14th week of pregnancy, and intravenously during labour. The infants receive oral doses of 2 mg per kg body weight, four times daily for 6 weeks (UNAIDS/WHO, 1999). Although viral resistance to ZDV monotherapy has been reported, it is not common, and there are concerns about using this regimen in any subsequent pregnancy (Srinivas et al., 1996; Eastman et al., 1998). Recent reports of ZDV toxicity in mice have renewed concern about the long-term effects of the drug (UNAIDS/WHO, 1999). This regimen is not feasible in developing countries because it is difficult to monitor blood parameters, drug reactions, intravenous infusions during delivery, and the treatment of the infant for 6 weeks. Women in developing countries have a higher prevalence of anaemia, which is aggravated by ARV therapy. Access to voluntary testing and counselling is poor in these countries (UNAIDS/WHO, 1999).

Short-Course Zidovudine Therapy: The regimen consists of ZDV during the antenatal period only. ZDV is given orally in a dose of 300 mg twice daily from 36th week of pregnancy to onset of labour and 300 mg every 3 hours from onset of labour until delivery. Randomised short-course ZDV trials have been conducted in Thailand and African countries, where all the participants were advised not to breastfeed and were provided with infant formula foods (UNAIDS/WHO, 1999).

Combination Therapy: Recent recommendations advise the use of a three-drug combination therapy, but with rapid advances in ARV therapy, such recommendations can change frequently. The long-term follow-up of the PETRA trial, which is coordinated by UNAIDS, is going on in predominantly breastfeeding populations in several African countries. Interim results at 6 weeks of age of the infant suggest that the lowest risk of transmission was seen with the following regimen – ZDV and lamivudine (3TC) from 36th week of pregnancy and during labour for the mother; and for 1 week post-partum for mother and child (UNAIDS/WHO, 1999).

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CHAPTER 23

HUMAN RIGHTS, LEGAL, AND ETHICAL ISSUES

Abstract

In general, laws are not in tune with rapidly changing needs of the society. Legal ambiguities, contradictions, and prohibitions hinder health and educational programmes such as family life and sex education. Obsolete laws ought to be reformed and new laws enacted, to facilitate provision of care and support services for HIVinfected individuals. In most countries, medical treatment is legally viewed as an interference with the patient’s body. Informed consent must be obtained from a mentally competent patient, over a stipulated age, before any treatment is administered. In view of the HIV epidemic, an increasing number of countries have enacted laws that prevent health care personnel from disclosing patient-related information acquired in the course of their duties. Modern medical management uses a team approach that requires rapid transfer of patient-related information between members of a team, which amplifies the risk of breach of confidentiality.

– Collaborative studies between developed and developing countries could give the impression of experimentation on the population of resource-poor countries by a developed country and could invite allegations of exploitation. Debates on this issue led to the revised Helsinki declaration of 2000, but the issue is still unresolved.

– In voluntary euthanasia, a doctor or other person acts directly to end a suffering person’s life when the person specifically requests death. In physician-assisted suicide (PAS), a doctor provides the means and information necessary for a person to commit suicide. In some states of Australia, euthanasia is legal under specified circumstances and as per Australian law, it is not a crime to attempt or to commit suicide. Holland was the first country in the world, followed by Belgium, to legalise both PAS and physician-unassisted euthanasia. In January 2006, the US Supreme Court upheld State of Oregon’s 8-year old Death with Dignity Act. In most countries of the world including India, euthanasia is illegal.

Key Words

Confidentiality, Declaration of Helsinki, Disclosure, Euthanasia, Informed consent, Partner counselling, Physician-assisted suicide, Privacy, Secrecy, Shared confidentiality

23.1 – CONCEPTS

1.Confidentiality: It is an ethical and/or legal duty of the health care professionals, not to disclose to anyone else, without prior informed consent of the client, any personal, physiological and psychological information that was

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8.Epidemiological studies, socio-behavioral studies and clinical trials of drugs, vaccines, microbicidal agents – standard of care, accessibility, affordability, post-trial benefits, equity, and sustainability of interventions.

23.3 – ETHICS IN PUBLIC EDUCATION

The response to the HIV epidemic ought to be mature and not impulsive, as in a panic situation. Allaying irrational public reaction while avoiding social or psychological harm to infected persons and those at high risk is the key to halting the spread of any epidemic. In view of public apprehensions without knowledge of facts, public education would be the best antidote, for fear is bred in the unknown (Vas & de Souza, 1991).

The HIV epidemic in India, which was restricted mainly to high-risk groups in the 1990s has started spreading to unsuspecting groups in rural populations, which includes women and children. India accounts for 10 and 65 per cent of the total burden of HIV-positive persons in the world and South and South-East Asia, respectively. Given such a scenario, it is still being debated whether educationists and counsellors should break taboos about discussing sexual behaviour. This raises issues pertaining to human rights, ethics, and the law (Muthuswamy, 2005).

IEC campaigns for the general population will promote tolerance, understanding, and reduce fear, stigma, and discrimination. Involvement of HIVinfected persons, politicians and noted personalities may help in changing public attitudes (UNAIDS/WHO, 2000).

Education campaigns need to include sensitisation of health care providers, employers, police, and members of the legal profession in attitudes of non-discrimination, acceptance, principles of confidentiality, and informed consent. This is a priority since HIV-infected individuals usually face discrimination at the hands of these very professionals (UNAIDS/WHO, 2000). Non-discriminatory practices are to be promoted in the workplace (UNAIDS/ WHO, 2000).

23.3.1 – Conflicts of Interest

Conflicts of interest may influence HIV-related activities. Public health experts would like to know the prevalence of HIV infection. An individual client would be jittery when called upon to submit to HIV testing. Sex workers may feel that HIV testing may increase social stigma and affect their earnings. An educator may want to promote correct scientific information regarding sex, sexuality, and sexual behaviour but may be opposed by self-appointed “protectors” of morals and other vested interests having imaginary fears about increase in promiscuity (Vas & de Souza, 1991). The mass media can play a positive role by reporting on the HIV epidemic in a non-partisan, non-sensational, responsible, and nondiscriminatory manner.

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