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Treatment as Prevention: Protecting patient autonomy

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The difference between TB and HIV is that TB is a communicable disease. It can be spread by close contact, rapidly. HIV can not be spread by close contact, only through the exchange of body fluids and even then it is kind of shaky. Very bad comparison. I can tell you didn't think that one out too much.

June 27, 2011

Joseph Sonnabend

Dr Ostrow is right to point out that there can be difficulties in balancing public health needs with individual rights. In western democracies at least, individual freedoms have only been limited in situations where the harms otherwise done to others would be considerable. Surely the refusal of a healthier HIV positive individual to receive treatment does not fall in such a category.

June 9, 2011

David Ostrow

While Joseph Sonnabend has consistently raised important ethical issues throughout the course of the AIDS/HIV epidemics, and his current piece raises very important issues pertaining to individual autonomy and freedom from coercion in the rush to "treatment as prevention," it seems IMHO that these principles as ABSOLUTE or adhered to in the real world of public health as Joseph contends. Although he is absolutely right that it can be a slippery slope towards unethical practices whenever we try to rationalize our way around any of the Beaumont principles, I can think of plenty of situations in which this is done in the cause of the "common good" without leading to gross disregard for individual autonomy and beneficence (just as we can point to examples, usually in fascist or other totalitarian societies that start with the assumption that (some) individuals/groups are not as deserving of human rights as the majority/ruling class are). For example, observed treatment and even quarantine of persons with active Tb are certainly forms of coerced treatment that we have come to accept as necessary for the halt of spread of treatment resistant Tb, particularly among the most vulnerable groups of persons with immunodeficiency, malnutrition, homelessness, etc. Would this be an acceptable exception to absolute individual autonomy and non-coerced treatment? If an individual suspected of spreading syphilis or another treatable STI through epidemiological case finding who refuses treatment be forced to have treatment or face quarantine, as many existing public health statutes permit? One could argue that treatment for syphilis or GC or Chlamydia is clearly established to be beneficial for such a person, but absolute individual autonomy could also be used to argue that it is still up to that individual whether to decide whether or not they undergo what might seem to them to be painful or unnecessary treatment. I don't raise these issues to raise objections to Dr. Sonnabend's very important arguments against coerced treatment, but rather to hopefully point out that there will always be points of conflict between what medical ethicists believe are absolute principles and what public health authorities feel are strong imperatives whenever new prevention technologies emerge without a complete understanding of all the cost-benefit considerations that include individual vs. societal benefits and costs. And that is clearly where we are right now with "treatment as prevention," as Dr. Sonnabend himself points out. David O David G Ostrow, MD, PhD

June 8, 2011


Shooting the HIV+ would end the epidemic, too. I am worried about the ethical issues in "test & treat." Since AZT, AIDS care has been marked by a cycle of strategies that have ultimately been proven to be bad theory: two that come to mind are the eradication of the virus from the body or treatment interruptions. We do not yet understand the natural history of HAART, and most clinicians cannot honestly separate long-term effects of infection from drug toxicities, which have become ever more problematic and risky. Given what we know about side effects and long-term drug resistance, aren't we asking a select group of individuals to possibly trade away huge quality of life issues on some vague assurance of prevention?

June 8, 2011


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