AIDS Care and Treatment in Sub-Saharan Africa: Implementation Ethics (Acquired Immunodeficiency Syndrome) (Cover Story‪)‬

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)