Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa.

Strategies for HIV prevention among infants, children, and adolescents have evolved significantly over the past 20 years. These include the global scale-up of simplified multidrug HIV regimens for pregnant women, leading to impressive reductions in new child HIV infections. However, significant gaps remain, especially in high HIV-burden sub-Saharan African countries. For example, many pregnant women living with HIV (WLHIV) are unable to access and sustain HIV testing and treatment partly due to low agency and harmful gender norms. Among pregnant WLHIV, adolescent girls face an additional layer of societal and health-system barriers in accessing care for themselves and their exposed infants. Legal and structural barriers limit access to HIV prevention-related sexual and reproductive health services among high-risk adolescents, including girls and young men who have sex with men. Key ethical issues underlying HIV prevention gaps for infants, children, and adolescents prevail. This narrative review explores these issues and highlights counter-measures for programming and policy, including gender empowerment, improving access to and appropriateness of critical health services, rights-based policy and legislation, closing research gaps, and considering the values and preferences of young people for HIV prevention and treatment services.

A qualitative study on the voluntariness of counselling and testing for HIV amongst antenatal clinic attendees: do women have a choice?

BACKGROUND: Mother-to-child transmission (MTCT) of the Human Immunodeficiency -Virus (HIV) is a serious public health problem, contributing up to 90% of childhood HIV infections. In Tanzania, the prevention-of-mother-to-child-transmission (PMTCT) feature of the HIV programme was rolled out in 2000. The components of PMTCT include counselling and HIV testing directed at antenatal clinic attendees. It is through the process of Provider Initiated Counseling and Testing (PITC) that counselling is offered participant confidentiality and voluntariness are upheld and valid consent obtained. The objective of the study was to explore antenatal clinic attendees' experiences of the concept of voluntariness vis- a- vis the implementation of prior counseling and subsequent testing for HIV under the PITC as part of their antenatal care. METHODS: In-depth interviews were conducted with17 antenatal clinic attendees and 6 nursing officers working at the Muhimbili National Hospital (MNH) antenatal clinic. The study data were analyzed using qualitative content analysis. RESULTS: Antenatal clinic attendees' accounts suggested that counselling and testing for HIV during pregnancy was voluntary, and that knowledge of their HIV status led them to access appropriate treatment for both mother and her newborn baby. They reported feeling no pressure from nursing officers, and gave verbal consent to undergo the HIV test. However, some antenatal clinic attendees reported pressure from their partners to test for HIV. Healthcare providers were thus faced with a dilemma of disclosure/ nondisclosure when dealing with discordant couples. CONCLUSION: Antenatal clinic attendees at MNH undertook the PITC for HIV voluntarily. This was enhanced by their prior knowledge of HIV, the need to prevent mother- to- child transmission of HIV, and the effectiveness of the voluntary policy implemented by nursing officers.

Mitochondrial Replacement Techniques: Who are the Potential Users and will they Benefit?

In February 2015 the UK became the first country to legalise high-profile mitochondrial replacement techniques (MRTs), which involve the creation of offspring using genetic material from three individuals. The aim of these new cell reconstruction techniques is to prevent the transmission of maternally inherited mitochondrial disorders to biological offspring. During the UK debates, MRTs were often positioned as a straightforward and unique solution for the 'eradication' of mitochondrial disorders, enabling hundreds of women to have a healthy, biologically-related child. However, many questions regarding future applications and potential users remain. Drawing on a current qualitative study on reproductive choices in the context of mitochondrial disorders, this article illustrates how the potential limitations of MRTs have been obscured in public debates by contrasting the claims made about the future beneficiaries with insights from families affected by mitochondrial disorders and medical experts. The analysis illuminates the complex choices with which families and individuals affected by mitochondrial disorders are faced, which have thus far remained invisible. An argument is presented for improved information for the public as well as an intensification of critical empirical research around the complex and specific needs of future beneficiaries of new reproductive biotechnologies.

Inequality and ethics in paediatric HIV remission research: From Mississippi to South Africa and back.

In 2013, physician-researchers announced that a baby in Mississippi had been 'functionally cured' of HIV [Persaud, D., Gay, H., Ziemniak, C. F., Chen, Y. H., Piatak, M., Chun, T.-W., … Luzuriaga, K. (2013b, March). Functional HIV cure after very early ART of an infected infant. Paper presented at the 20th conference on retroviruses and opportunistic infections, Atlanta, GA]. Though the child later developed a detectable viral load, the case remains unprecedented, and trials to build on the findings are planned [National Institute of Allergy and Infectious Diseases. (2014). 'Mississippi baby' now has detectable HIV, researchers find. Retrieved from http://www.niaid.nih.gov/news/newsreleases/2014/pages/mississippibabyhiv.aspx ]. Whether addressing HIV 'cure' or 'remission', scrutiny of this case has focused largely on scientific questions, with only introductory attention to ethics. The social inequalities and gaps in care that made the discovery possible - and their ethical implications for paediatric HIV remission - have gone largely unexamined. This paper describes structural inequalities surrounding the 'Mississippi baby' case and a parallel case in South Africa, where proof-of-concept studies are in the early stages. We argue that an ethical programme of research into infant HIV remission ought to be 'structurally competent', and recommend that paediatric remission studies consider including a research component focused on social protection and barriers to care.

'Hey everybody, don't get pregnant': Zika, WHO and an ethical framework for advising.

WHO recently issued new guidance on the prevention of sexual transmission of Zika virus. The updated guidance states that '[c]ountry health programmes should ensure that… [i]n order to prevent adverse pregnancy and fetal outcomes, men and women of reproductive age, living in areas where local transmission of Zika virus is known to occur, be correctly informed and oriented to consider delaying pregnancy'. While the media has reported this advice as WHO telling couples in Zika-affected regions to avoid pregnancy, WHO states that they are not doing that. In an interview with the New York Times, a spokesperson from WHO stated, 'it's important to understand that this is not WHO saying, "Hey everybody, don't get pregnant." It's that they should be advised about this, so they themselves can make the final decision'. In this statement, the WHO's spokesperson distinguishes between actively directing individuals to delay pregnancy and advising them, which is portrayed as a merely informative act that facilitates but does not direct an individual's final decision. This paper proposes that advising should not be understood as a purely informational and non-directive act. The choices that agencies make in what advice to offer and to whom to offer the advice are ethical choices with practical implications. We will thus lay out a framework for considering the ethical issues that arise in the context of advising and demonstrate how it can be used to evaluate the WHO guidance.

Boundaries of confidentiality in nursing care for mother and child in HIV programmes.

BACKGROUND: Confidentiality lies at the core of medical ethics and is the cornerstone for developing and keeping a trusting relationship between nurses and patients. In the wake of the HIV epidemic, there has been a heightened focus on confidentiality in healthcare contexts. Nurses' follow-up of HIV-positive women and their susceptible HIV-exposed children has proved to be challenging in this regard, but the ethical dilemmas concerning confidentiality that emerge in the process of ensuring HIV-free survival of the third party - the child - have attracted limited attention. OBJECTIVE: The study explores challenges of confidentiality linked to a third party in nurse-patient relationships in a rural Tanzanian HIV/AIDS context. STUDY CONTEXT: The study was carried out in rural and semi-urban settings of Tanzania where the population is largely agro-pastoral, the formal educational level is low and poverty is rife. The HIV prevalence of 1.5% is low compared to the national prevalence of 5.1%. METHODS: Data were collected during 9 months of ethnographic fieldwork and consisted of participant observation in clinical settings and during home visits combined with in-depth interviews. The main categories of informants were nurses employed in prevention of mother-to-child transmission of HIV programmes and HIV-positive women enrolled in these programmes. ETHICAL CONSIDERATIONS: Based on information about the study aims, all informants consented to participate. Ethical approval was granted by ethics review boards in Tanzania and Norway. FINDINGS AND DISCUSSION: The material indicates a delicate balance between the nurses' attempt to secure the HIV-free survival of the babies and the mothers' desire to preserve confidentiality. Profound confidentiality-related dilemmas emerged in actual practice, and indications of a lack of thorough consideration of the implication of a patient's restricted disclosure came to light during follow-up of the HIV-positive women and the third party - the child who is at risk of HIV infection through mother's milk. World Health Organization's substantial focus on infant survival (Millennium Development Goal-4) and the strong calls for disclosure among the HIV-positive are reflected on in the discussion.

Ethical issues surrounding the provider initiated opt--Out prenatal HIV screening practice in Sub-Saharan Africa: a literature review.

BACKGROUND: Prevention of mother to child transmission of HIV remains a key public health priority in most developing countries. The provider Initiated Opt - Out Prenatal HIV Screening Approach, recommended by the World Health Organization (WHO) lately has been adopted and translated into policy in most Sub - Saharan African countries. To better ascertain the ethical reasons for or against the use of this approach, we carried out a literature review of the ethics literature. METHODS: Papers published in English and French Languages between 1990 and 2015 from the following data bases were searched: Pubmed, Cochrane literature, Embase, Cinhal, Web of Science and Google Scholar. After screening from 302 identified relevant articles, 21 articles were retained for the critical review. DISCUSSION: Most authors considered this approach ethically justifiable due to its potential benefits to the mother, foetus and society (Beneficence). The breaching of respect for autonomy was considered acceptable on the grounds of libertarian paternalism. Most authors considered the Opt - Out approach to be less stigmatizing than the Opt - In. The main arguments against the Opt - Out approach were: non respect of patient autonomy, informed consent becoming a meaningless concept and the HIV test becoming compulsory, risk of losing trust in health care providers, neglect of social and psychological implications of doing an HIV test, risk of aggravation of stigma if all tested patients are not properly cared for and neglect of sociocultural peculiarities. CONCLUSIONS: The Opt - Out approach could be counterproductive in case gender sensitive issues within the various sociocultural representations are neglected, and actions to offer holistic care to all women who shall potentially test positive for HIV were not effectively ascertained. The Provider Initiated Opt - Out Prenatal HIV Screening option remains ethically acceptable, but deserves caution, active monitoring and evaluation within the translation of this approach into to practice.

When courts intervene: public health, legal and ethical issues surrounding HIV, pregnant women, and newborn infants.

Ninety-three percent of pediatric AIDS cases are the result of perinatal HIV transmission, a disease that is almost entirely preventable with early intervention, which reduces the risk of perinatal HIV infection from 25% to <2%. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend routine HIV testing of all pregnant women and at-risk newborn infants. When pregnant women decline HIV testing and/or treatment, public health, legal, and ethical dilemmas can result. Federal courts consistently uphold a woman's right to refuse medical testing and treatment, even though it may benefit her fetus/newborn infant. Federal courts also reliably respect the rights of parents to make health care decisions for their newborn infants, which may include declining medical testing and treatment. Confusing the issue of HIV testing and treatment, however, is the fact that there is no definitive United States Supreme Court ruling on the issue. State laws and standards vary widely and serve as guiding principles for practicing clinicians, who must be vigilant of ongoing legal challenges and changes in the states in which they practice. We present a case of an HIV-positive pregnant woman who declined treatment and then testing or treatment of her newborn infant. Ultimately, the legal system intervened. Given the rarity of such cases, we use this as a primer for the practicing clinician to highlight the public health, legal, and ethical issues surrounding prenatal and newborn infant HIV testing and treatment in the United States, including summarizing key state-to-state regulatory differences.

[HIV disclosure in polygamous settings in Senegal]. / Partager l'information sur son statut sérologique VIH dans un contexte de polygamie au Sénégal.

In Senegal, where HIV prevalence is less than 1% and stigma remains important, 40% of marriages are polygamic. The purpose of this article is to describe and analyze the motivations, benefits and constraints related to HIV disclosure, and to explore specific situations related to polygamy. Data were collected through qualitative research based on in-depth repeated interviews on the experience of antiretroviral therapy and its social effects, conducted over a period of 10 years with people on antiretroviral treatment and their caregivers. Health professionals encourage people to disclose their HIV status, especially in certain circumstances such as preventing mother-to-child transmission of HIV. Nevertheless they are aware of the social risks for some patients, particularly women. Some health workers insist on disclosure, while others do not interfere with women who do not disclose to their partner, while highlighting their ethical dilemma. Interviews trace the changing attitudes of caregivers regarding disclosure. The majority of married women begin by sharing their HIV status with their mother, waiting for her to confirm that the contamination is not due to immoral behavior and to participate in implementing a strategy to maintain secrecy. In polygamous households, women try to disclose to their partner, keeping the secret beyond the couple. Some women fear disclosure by their husbands to co-spouses, whose attitudes can be very diverse: some stories relate collective rejection from the household; sometimes disclosure is made in a progressive way following the hierarchy of positions of each person in the household; another person reported the solidarity shown by her co-spouses who kept her HIV status a secret outside the household. The article shows the diversity of situations and their dynamics regarding both disclosure practices and their social effects.

Separate goals, converging priorities: on the ethics of treatment as prevention.

Recent evidence confirming that the administration of antiretroviral drugs (ARVs) to HIV-infected persons may effectively reduce their risk of transmission has revived the discussion about priority setting in the fight against HIV/AIDS. The fact that the very same drugs can be used both for treatment purposes and for preventive purposes (Treatment as Prevention) has been seen as paradigm-shifting and taken to spark a new controversy: In a context of scarce resources, should the allocation of ARVs be prioritized based on the goal of providing treatment, or on the goal of preventing the spread of the HIV epidemic? Contributions to this discussion tend to assume that treatment and prevention constitute two divergent goals that entail conflicting priorities. We challenge that assumption on the basis of both conceptual and empirical examination. We argue that, as far as the provision of ARVs to HIV-infected persons is concerned, the goals of treatment and prevention do not entail conflicting priorities; to the contrary, they dictate converging strategies for the optimal allocation of ARVs. In light of the current evidence, the concept of Treatment as Prevention can indeed be seen as paradigm-shifting, yet in a novel way: Rather than extending the tension between the goals of treatment and prevention to the level of drug-allocation, it dissolves this tension by providing a rationale for a unified strategy for allocating ARVs.

Canadian HIV Pregnancy Planning Guidelines: No. 278, June 2012.

OBJECTIVE: Four main clinical issues need to be considered for HIV-positive individuals and couples with respect to pregnancy planning and counselling: (1) pre-conceptional health; (2) transmission from mother to infant, which has been significantly reduced by combined antiretroviral therapy; (3) transmission between partners during conception, which requires different prevention and treatment strategies depending on the status and needs of those involved; and (4) management of infertility issues. The objective of the Canadian HIV Pregnancy Planning Guidelines is to provide clinical information and recommendations for health care providers to assist HIV-positive individuals and couples with their fertility and pregnancy planning decisions. These guidelines are evidence- and community-based and flexible, and they take into account diverse and intersecting local/population needs and the social determinants of health. OUTCOMES: Intended outcomes are (1) reduction of risk of vertical transmission and horizontal transmission of HIV, (2) improvement of maternal and infant health outcomes in the presence of HIV, (3) reduction of the stigma associated with pregnancy and HIV, and (4) increased access to pregnancy planning and fertility services. EVIDENCE: PubMed and Medline were searched for articles published in English or French to December 20, 2010, using the following terms: "HIV" and "pregnancy" or "pregnancy planning" or "fertility" or "reproduction" or "infertility" or "parenthood" or "insemination" or "artificial insemination" or "sperm washing" or "IVF" or "ICSI" or "IUI." Other search terms included "HIV" and 'horizontal transmission" or "sexual transmission" or "serodiscordant." The following conference databases were also searched: Conference on Retroviruses and Opportunistic Infections, International AIDS Conference, International AIDS Society, Interscience Conference on Antimicrobial Agents and Chemotherapy, the Canadian Association of HIV/AIDS Research, and the Ontario HIV Treatment Network Research Conference. Finally, a hand search of key journals and conferences was performed, and references of retrieved articles were reviewed for additional citations. Subsequently, abstracts were categorized according to their primary topic (based on an outline of the guidelines) into table format with the following headings: author, title, study purpose, participants, results and general comments. Finally, experts in the field were consulted for their opinions as to whether any articles were missed. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table) and through use of the Appraisal of Guidelines Research and Evaluation instrument for the development of clinical guidelines. SPONSORS: The Society of Obstetricians and Gynecologists of Canada, Women and HIV Research Program, Women's College Research Institute, Women's College Hospital, University of Toronto, Abbott Laboratories Canada, the Ontario HIV Treatment Network, the Canadian Institutes of Health Research, and the Canadian HIV Trials Network.

Estrategias para la reducción de la transmisión vertical del virus de inmunodeficiencia humana (VIH) y su relación con Enfermería / Estratégias para redução da transmissão vertical do vírus da imunodeficiência humana (HIV) e sua relação com a Enfermagem

Introducción: Cerca del 40% de las personas infectadas por el vírus VIH son mujeres, feminización de la epidemia, ocurriendo de esta forma un aumento de casos de niños infectados a través de la TV. Objetivos: Identificar las estrategias utilizadas en el proceso de investigación diagnóstica de la gestante y la importancia del enfermero en este proceso. Material y Métodos: Se trata de una revisión bibliográfica en bases de datos virtuales. Resultados y Discusión: Se encontraron 56 publicaciones, de las cuales tras realizar una lectura exploratoria de sus resúmenes, fueron seleccionados 17 artículos que contienen el tema propuesto. Se establecieron las siguientes estrategias: evaluación y educación sexual del VIH, que consiste en la realización de exámenes gratuitos y consejos a las gestantes antes y después del test. Yen la adhesión a la terapia anti-retroviral, indicada para las gestantes seropositivas, percibimos que hay una gran dificultad en la continuidad del tratamiento, sin embargo los factores deben ser investigados individualmente. En estas estrategias el enfermero tiene un papel significativo en su ejecución.. Consideraciones finales: Son varios los desafios encontrados, siendo necesaria la constante actualización para la asistencia de enfermería, constituyendo la aplicación de acciones y de informaciones científicas un objetivo de la prevención y tratamiento para la disminución de la TV (AU)

Introduction: About 40% of people infected with HIV are women, called the feminization of the epidemic, in this way an increase occurs in cases among children infected through TV. Objectives: To identify the strategies used in the diagnostic investigation of pregnancy and the importance of nurses in the process. Methods: This is a bibliographic survey on the database software. Results and Discussion: There were 56 publications, of which after reading the exploratory summaries, 17 articles were selected covering the proposed topic. The following strategies were raised: HIV testing and counseling, which consists of free testing and counseling and examinations of pregnant women before and after the test. Joining the antiretroviral therapy, given to the women who are pregnant and HIV positive, we realize that continuation of the treatment is very difficult, however the factors must be investigated individually. In both the strategies the nurse has in a significant role to play in the implementation of treatment. Final considerations: There are several challenges encountered, there is a constant need to update the assistance of nursing and the implementation of actions and scientific information with the objective of prevention and treatment is aimed at the reduction of TV (AU)

Introdução: Cerca de 40% das pessoas infectadas pelo vírus HIV são mulheres, denominando a feminização da epidemia, ocorrendo desta forma um aumento de casos de crianças infectadas através da TV. Objetivos: Identificar as estratégias utilizadas no processo de investigação diagnóstica da gestante e a importância do enfermeiro nesse processo. Material e Métodos: Trata-se de um levantamento bibliográfico em base de dados virtuais. Resultados e Discussão: Foram encontradas 56 publicações, dos quais após realizada uma leitura exploratória de seus resumos, foram selecionados 17 artigos que abrangem o tema proposto. Foram levantadas as seguintes estratégias: testagem e aconselhamento do HIV, que consiste na realização de exames gratuitos e aconselhamento das gestantes antes e após o teste. E a adesão à terapia anti-retroviral, indicada para as gestantes soropositivas, percebemos que há uma grande dificuldade na continuidade do tratamento, no entanto os fatores devem ser investigados individualmente. Sendo que em ambas as estratégias o enfermeiro encontra-se em um papel significativo para execução das mesmas. Considerações finais: São vários os desafios encontrados, sendo necessária a constante atualização para a assistência de enfermagem, constituindo a aplicação de ações e de informações científicas com objetivo da prevenção e tratamento visando a diminuição da TV (AU)

Human immunodeficiency virus and infertility treatment.

Human immunodeficiency virus is a serious but manageable chronic disease that affects persons of reproductive age, many of whom express a desire for biologic parenthood. This document is a revision of the original document of the same name, published in 2002 and reviewed in 2006.

From PMTCT to a more comprehensive AIDS response for women: a much-needed shift.

Half of the 33.2 million people living with HIV today are women. Yet, responses to the epidemic are not adequately meeting the needs of women. This article critically evaluates how prevention of mother-to-child transmission (PMTCT) programs, the principal framework under which women's health is currently addressed in the global response to AIDS, have tended to focus on the prevention of HIV transmission from HIV-positive women to their infants. This paper concludes that more than ten years after their inception, PMTCT programs still do not successfully ensure the adequate treatment, care and support of HIV-infected women. Of particular concern is the continued widespread use of single-dose nevirapine despite World Health Organization recommendations to employ more effective combination therapies that do not potentially jeopardize women's future treatment outcomes. In response, the article calls for a more comprehensive approach that places women's health needs at the centre of AIDS responses. This is critical in settings where the pandemic is generalized and there is a push to greatly expand PMTCT programs, as a more effective and equitable way of meeting the needs of women in the context of HIV. Without such a comprehensive approach, women will continue to be impacted disproportionately by the pandemic, and current strategies for prevention, including PMTCT, and treatment will not be as effective and responsive as they need to be.

Should ART be offered to HIV-serodiscordant and HIV-seroconcordant couples: an ethical discussion?

Increasingly, fertility clinics are offering their services to human immunodeficiency virus (HIV)-serodiscordant couples where the woman is seropositive. In the case of HIV-seroconcordant couples, there remains a general reluctance to provide treatment. This attitude to seroconcordant couples is reminiscent of that once widely held towards serodiscordant couples when the risk of vertical transmission rates in pregnant women was greater than 1-2%. Due to recent advances in HIV clinical care and assisted reproduction technique (ART) procedures directed at reducing the risk of viral transmission during gamete transfer, where good healthcare is available, the current risk rate has fallen to 1-2%. This article deals with the ethical arguments of those who remain opposed to offering HIV-serodiscordant and HIV-seroconcordant couples access to ART. Until these arguments have been addressed, clinics providing ART to such couples cannot be assured that their practices are ethical.