HIV / AIDS: Social and Ethical Issues: Editorial

Editorial
HIV / AIDS : Social and Ethical Issues

Col Zile Singh*, Lt Col A Banerjee+
MJAFI 2004; 60 : 107-108

Key Words : HIV/AIDS; Ethics; Social
T he social issues associated with AIDS can be

understood in two ways. Firstly, they may refer to
the social determinants of the pandemic. Secondly, they
[4]. The ‘Sonargachi’project in Kolkata red-light area
has demonstrated that such interventions are possible in
India also [5]. Successful targeted intervention projects
relate to the social impact of the pandemic. Ethical in Kolkata have kept the HIV prevalence at a low level
questions present some of the most vexing problems among sex workers. Participation of sex workers in
associated with HIV infection [1]. Ethics cannot be programme planning and the resultant empowerment
considered in a vacuum. The social context dictates how were the key elements of these interventions along with
the principles of ethics are applied and interpreted. condom promotion, STD management and clinic services
Spread of HIV is linked to certain patterns of human for clients as well as sex workers. The other targeted
behaviour. Hence, it has both biological and socio-cultural groups in and around the city were the fishermen, migrant
determinants. Any attempt to control its spread must labourers and truck drivers.
take into account the complex social, cultural, economic The first case of HIV seropositivity in an intravenous
and environmental factors in which the disease is drug user (IDU) was detected in Manipur in 1989.
embedded. India has a large migrant population. Rapid Subsequently, within a decade, 44.7% of IDUs were
urbanization coupled with poor housing facilities in city found to be positive for HIV in Manipur. Injectable drug
areas leads to migrant labours staying away from abuse is rapidly spreading in India and has been found
families. Illiteracy and poor awareness exposes them to to be prevalent in North East India, Maharashtra, Tamil
high risk behaviour. Occupational groups such as truck Nadu, Punjab, Chandigarh, Delhi and other metropolitan
drivers are especially vulnerable. cities. IDUs also often indulge in various sex related
Mass uprooting of people by ethnic conflicts may also risk behaviours. Condom use is also low in the group[6].
be related to an increased incidence of HIV infection. At the family level, an adult with AIDS will severely
In a study among drug users [2], it was found that 80% compromise household resources as the functional
of the respondents, many of whom migrated following capacity to work is reduced, medical expenditures
ethnic clash, reported having sex with non-regular increase and the income of both the infected individual
partners. Two-thirds of these respondents reported sex and those who care for that person is lost. Reduced
in exchange for money or drugs. income in turn threatens food supply, the ability to pay
The unequal status of women in most societies also for the education or health of surviving family members.
makes them vulnerable to HIV infection. Gender The entire social fabric of the family is potentially
inequities preclude the women on insisting the male to disrupted.
wear a condom even when she suspects him of high- The effects of HIV/AIDS multiply far beyond the
risk behaviour. In many parts of the world, commercial infected individual. In the long run, it has the potential to
sex is an important source of HIV infection. Even if affect whole sectors of the economy and societies as
commercial sex workers (CSWs) are willing to adopt resources will be required for increasing number of
safer sex practices, their clients may object [3]. Thus, people living with HIV/AIDS and for the care of
for promotion of condom use, AIDS prevention increasing number of orphans.
programmes should target not only CSWs, but their The four pillars of medical ethics are autonomy,
clients as well. nonmaleficience, beneficience and justice [1]. These are
Interventions aimed at establishing safe sexual general guidelines, which leave room for interpretation
practices among CSWs have shown remarkable results. and judgement in specific cases. Many of the ethical
In Thailand, the decline in new infections has been very issues that confront us in the context of AIDS are not
marked and attributed to universal condom use by CSWs new. However, the AIDS pandemic has given a sharp
*
Professor and Head, +Associate Professor, Department of Preventive and Social Medicine, Armed Forces Medical College, Pune - 411 040.
108 Singh and Banerjee
focus to issues such as confidentiality, discrimination, taken. Data collection protocols or procedures should
access to health care, prenatal testing/abortion and the include an explicit description of the measures that will
conduct of clinical/vaccine trials. be taken to protect the subjects. Both the Indian Council
The ethical issues relating to confidentiality and of Medical Research (ICMR) and the Central Drugs
partner notification within the context of HIV infection Standard Organization have established guidelines for
are complex. The right of the individual to confidentiality biomedical and clinical research in India [9,10].
can be in conflict with the right of the partner to be The global burden of HIV infection in the years to
protected from the risk of infection. Confidentiality is come will be borne overwhelmingly by people in
essential to prevent discrimination. On the other hand, developing countries. Increasingly, inequalities of gender,
the seriousness of the threat to the health of unsuspecting race and wealth will dictate the course of the pandemic,
third parties resulted in the debate on informing people with infection rates increasing among the vulnerable
at risk, also known as ‘partner notification’. The National groups. Social and economic dependenc will be the
AIDS Control Guidelines for HIV counselling major determinants of the future course of the HIV/
encourages motivation of the HIV positive person to AIDS pandemic.
disclose his/her status to the sex partner. Input from social research field is urgently needed
The Supreme Court of India has ruled on the issue of for planning and evaluation of AIDS prevention
the right to confidentiality of subjects with HIV infection programs. Social, behavioural and legal research will
and the breach of confidentiality in order to protect the improve understanding of the dynamics of the pandemic
health of third parties [7]. The opinion of the court is and its impact. It will translate into public health and
that the right to privacy and confidentiality is not absolute. societal action for fostering understanding of the intricate
This right may be lawfully restricted in situations where relationships between the individual, public health and
third parties are at risk. society. It will also help in resolving some of the complex
According to the National AIDS Control Organization social and ethical issues.
(NACO) policy, no person is to be tested for HIV without References
voluntary consent. The NACO policy rules out any 1. Grady C. Human immunodeficiency disease; ethical
mandatory testing for HIV. It encourages voluntary HIV considerations for clinicians. In : DeVita Jr V T, Hellman S,
testing with appropriate pre-and post-test counselling. Rosenberg SA, editors, 4 thed. AIDS. Etiology, Diagnosis,
Treatment and Prevention. Lippincort-Raven, 1977;633-42.
Ideally, the disclosure of HIV status of the person
2. Panda S, Bijoya L, Sadhana Devi N et al. Interface between
should not in any way affect his rights to employment, drug use and sex work in Manipur. The National Med Jour
position at the workplace, right to medical care and other India 2001;14:209-11.
fundamental rights. Unfortunately, one of the biggest 3. Helman CG. Medical anthropology and global health. In :
problems faced by HIV positive person is stigma. People, Helman CG, editor, 3 rd ed. Culture, Health and Illness.
even doctors, are sometimes afraid of dealing with HIV Butterworth Heinemann. 1997;339-83.
4. AIDSCAP. Francois-Xavier Baynoud Centre, Harvard School
positive persons leading to discrimination in medical care. of Public Health UNAIDS. Final report of the status and trends
This stigma can prevent people from being tested. It of the global HIV/AIDS pandemic, Jul 1996;5-6.
can result in individuals unknowingly transmitting HIV. 5. Jana S, Bandopadhyay N, Mukherjee S et al. STD/HIV
HIV positive women should have complete choice to intervention with sex workers in West Bengal. India. AIDS
1998;12(Suppl B);S101-S108.
make decisions about pregnancy and childbirth. There
6. Sharma S. Overview of injection drug abuse and HIV/AIDS in
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7. Abraham S, Prasad J, Joseph A, Jacob KS. Confidentiality,
Even the selection of study sites for clinical and partner notification and HIV infection : Issues related to
vaccine trials are fraught with ethical complications. community health programmes. The National Med Jour of
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physical or economic harm, even when precautions are
MJAFI, Vol. 60, No. 2, 2004

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Editorial

HIV / AIDS : Social and Ethical Issues

MJAFI 2004; 60 : 107-108

T he social issues associated with AIDS can be

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