I. PUBLIC HEALTH ISSUES

At the conclusion of Plagues and People, a magisterial account of epidemics and their impact on history, William McNeill asserts, "Infectious disease, which antedates the emergence of humankind, will last as long as humanity itself and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history" (McNeill, p. 291). In the mid-1970s, this observation seemed overdrawn, especially in relation to economically advanced societies, where chronic diseases had displaced infectious threats to communal well-being. Yet just five years later, McNeill's comment seemed prescient.

In June 1981, the first cases of what would ultimately be called acquired immunodeficiency syndrome (AIDS) were reported by the U. S. Centers for Disease Control (CDC). Within three years of the first CDC report, human immunodeficiency virus (HIV), the viral agent responsible for AIDS, was identified. Although those who were infected could experience a long disease-free state—50 percent remained symptom-free for up to ten years—in the end the virus attacked the immune system, resulting in a series of ultimately fatal opportunistic disorders. By the beginning of the twenty-first century, it was estimated that approximately 900,000 Americans and more than 42 million people worldwide were infected. Although found on every continent, AIDS had made its most stunning impact on Africa. Projections by the World Health Organization (WHO) forecast a grim picture, with catastrophic spread of HIV in Asia and the former Soviet Union.

Exceptionalism and the Ethics of Testing, Reporting, and Partner Notification

In the early and mid-1980s, at the outset of the American encounter with AIDS, it was necessary to face a set of fundamental questions: Did the history of responses to lethal infectious diseases provide lessons about how best to contain the spread of HIV? Should the policies developed to control sexually transmitted diseases or other communicable conditions be applied to AIDS? If AIDS were not to be so treated, what would justify such differential policies?

To understand the importance of these questions, it is necessary to recall that conventional approaches to public health threats typically provided a warrant, when deemed appropriate, for mandating compulsory examination and screening, breaching the confidentiality of the clinical relationship by reporting to public health registries the names of those diagnosed with "dangerous diseases," imposing treatment, and in the most extreme cases, confining persons through the power of quarantine. To be sure, many aspects of this public health tradition, forged at the outset of the twentieth century, had been modulated over the decades, in part because of changes in the patterns of morbidity and mortality.

Nevertheless, it was the specter of the historically coercive aspects of the public health tradition that most concerned proponents of civil liberties and advocates of gay rights and bioethics as they considered the potential direction of public health policy in the presence of AIDS, a disease that so disproportionately affected disfavored groups—gay men, drug users, the poor in minority communities. In place of the conventional approach to public health threats, there emerged an alternative view—broadly defined as exceptionalism (Bayer, 1991)—that took as its starting point the need to craft policies that were persuasive rather than coercive, which viewed the protection of the rights of those who were infected as integral rather than as antagonistic to the goals of disease prevention. For those who advanced this new perspective, privacy and confidentiality were to be accorded great importance. In all, the goal was to avoid measures and practices that might be counterproductive, which might "drive the epidemic underground" by inspiring fear and distrust rather than fostering engagement between public health officials and those most at risk. How the exceptionalist perspective with its commitment to noncoercive approaches to HIV affected policy is most clearly illustrated in the debates over HIV testing, reporting of HIV, and partner notification efforts.

HIV TESTING. From the moment of its introduction in 1985, the HIV test became the subject of intense debate. Fear that those identified as having HIV might be subject to discrimination and stigma; concern about how the diagnosis of HIV infection, in the absence of effective therapy, could produce unbearable psychological burdens; and a belief that testing had little to do with behavioral change led AIDS activists generally, and gay leaders specifically, to adopt a posture of hostility and/or skepticism regarding the test. On the other hand, many public health officials believed that the identification of infected persons could play a crucial role in fostering behavioral change. Out of their confrontations emerged a broad consensus that, except in a very few well-defined circumstances, people should be tested only with their informed, voluntary, and specific consent (Bayer, 1989).

Much of the early discussion of HIV testing occurred in the context of extreme therapeutic limits. And indeed in the epidemic's early years the primary function of testing was as an adjunct to prevention efforts. By 1990, as a result of clinical developments—the belief that treatment with zidovudine (also known as azidothymidine, or AZT) could delay the onset of symptomatic AIDS and the recognition of the importance of primary prophylaxis against Pneumocystis carinii pneumonia—the medical significance of identifying those with early HIV disease had become clear. Consequently, the clinical and political context—involving a wide range of constituencies—of the debate about testing underwent a fundamental change (Bayer, Levine, and Wolf). Gay organizations began to urge homosexual and bisexual men to have their antibody status determined under confidential or anonymous conditions. Physicians pressed for AIDS to be incorporated into the medical mainstream and for the HIV-antibody test to be treated like other blood tests—that is, given with the presumed consent of the patient.

Pressure to shift the paradigm of testing away from the exacting standard of informed consent was especially pronounced in the case of pregnant women and newborns (Bayer, 1995). Diagnostic progress was to make it possible to determine whether HIV-positive newborns were truly infected soon after birth, and the improved prospects of clinical management were to make such determinations for infected infants appear all the more critical. So it is not surprising that pediatricians became increasingly impatient with the strict regimen of explicit and specific consent that surrounded the testing of newborns for HIV (Hegearty and Abrams)—all the more so because routine and unconsented testing of newborns for inborn errors of metabolism such as phenylketonuria was mandated in virtually every state and had provoked little ethical objection.

In 1994 a research study discovered that the administration of zidovudine during pregnancy could reduce the rate of maternal–fetal HIV transmission by two-thirds (to about 8%) (Connor, Sperling, and Gelber). In the aftermath of that finding, pressure mounted to ensure that infected women were identified early in pregnancy. In 1996 the American Medical Association's House of Delegates passed a resolution calling for mandatory testing of pregnant women (Shelton). Even the Institute of Medicine, which early in the epidemic had opposed testing policies that abrogated the privacy rights of pregnant women, was by the end of the 1990s to endorse routine testing on the basis of an informed right of refusal, a much less exacting standard than specific informed consent (Institute of Medicine).

In other contexts as well, the retreat from the exacting standard of specific informed consent with pretest counseling has taken the form of efforts to integrate HIV testing into clinical practice where standards of presumed consent prevail.

REPORTING OF HIV. A course similar to that which occurred with testing characterized the debate surrounding case reporting for HIV infection. Given the profound stigma that surrounded AIDS in the epidemic's first years, and the extent to which individuals with or at risk for HIV feared the social consequences of having their diagnoses made public, it is not surprising that confidentiality of AIDS-related information assumed great salience. From the pragmatic perspective of the public health officials, it was crucial to preserve confidentiality as a way of assuring that those at risk would come forward for testing and counseling (Institute of Medicine). Others objected on grounds of principle. Privacy was a value that should not be lightly set aside.

But however central were the claims of privacy and the duty to protect confidentiality, they were not absolutes. One of the conventionally accepted limits to those claims occurred when individuals with infectious diseases were reported by name to confidential public health registries. It was thus not surprising that despite concerns about privacy, little opposition existed in the epidemic's first years to making AIDS cases reportable by name (Bayer, 1989). The acceptance of AIDS case reporting requirements was facilitated by the well-established record of state health departments in protecting such records from unwarranted disclosure.

With the inception of HIV testing, however, debate emerged about whether the names of all infected persons, regardless of whether they had received an AIDS diagnosis, should be reported. Activists who accepted AIDS case reporting opposed HIV reporting because of heightened concerns about privacy, confidentiality, and discrimination. For them the potential public health benefits of reporting were too limited and the burden on those who would be the subject of reporting too great to justify an abrogation of privacy.

While many public health officials, especially those who came from states with large AIDS caseloads, opposed HIV reporting because of its potential effect on the willingness of people to seek testing and counseling, some public health officials did become strong advocates of such reporting. In their arguments in favor of such reporting, they sought to underscore the extent to which the public health benefits of HIV reporting would be similar to those that followed from more broadly conceived reporting requirements, such as those that applied to syphilis, tuberculosis, and AIDS itself (Vernon).

As therapeutic advances began to emerge in the late 1980s, and as the logic of distinguishing between HIV and AIDS became increasingly difficult to sustain, fissures began to appear in the relatively broad and solid alliance against named HIV reporting. At the end of November 1990, the CDC declared its support for HIV reporting, which it asserted could "enhance the ability of local, state and national agencies to project the level of required resources" for care and prevention services (CDC, 1990, p. 861). The House of Delegates of the American Medical Association also endorsed the reporting of names (Bayer, 1999).

Central to the argument for HIV name reporting was the assertion that AIDS case reporting captured an epidemic that was as much as a decade old and that an accurate picture of the incidence and prevalence of HIV infection—especially in light of the impact of treatment—required a surveillance system based on HIV case reporting.

At the end of 1999, in the face of lingering opposition from most AIDS activists, the CDC finally proposed that all states put in place an HIV reporting system. And while it left open the possibility of reliance on unique identifiers that met strict performance criteria, it was clear that the use of names was viewed as preferable (CDC, 1999). Remarkably, of those states that adopted HIV case surveillance after the publication of the CDC's recommendations, virtually all adopted coded systems. By 2002 only one state—Georgia—had not adopted some form of HIV reporting.

PARTNER NOTIFICATION. In the controversy over partner notification the limits of privacy were also encountered. What emerged as a source of contention in the first decade of the epidemic was the extent to which the protection of identifiable third parties who had been or were currently placed at risk for HIV by already infected individuals provided a warrant for public health interventions. This was not a new issue; it had been confronted in the context of psychiatry in the so-called Tarasoff doctrine (from the mid-1970s court case, Tarasoff v. Regents of the University of California), which held that physicians who knew that their patients were about to inflict serious harm on other identifiable individuals had a duty to act to warn or protect. While opinions differed about the wisdom of such efforts, there was little principled objection to breaching confidentiality under such circumstances.

Thus in the mid-to late 1980s, when many AIDS activists argued that the principle of confidentiality had to be inviolable, and when public health officials were loath to endorse legislative mandates requiring third party notification, many ethicists suggested that protection of unsuspecting sexual partners took precedence over privacy. In 1988 the American Medical Association's House of Delegates embraced the duty to warn.

Some states sought to meet the challenge of endangered third parties by enacting statutes that secured a "privilege to disclose." Under such laws physicians could, if they chose, breach confidentiality to warn unsuspecting individuals but would not be held liable if they failed to do so.

The depth of antagonism to public health interventions in matters of sexual intimacy was further demonstrated by the deep suspicion of contact tracing programs, under which public health officials would notify those who had been placed at risk without divulging the identity of the individual who had imposed the risk. Such efforts were typically voluntary and relied on the willingness of index patients to provide the names of their contacts.

Despite the four decades of experience with contact tracing, efforts to undertake such public health interventions in the context of AIDS met with fierce resistance in the first years of the epidemic. Opposition by gay leaders and civil liberties groups had a profound impact on the response of public health officials, especially in states with relatively large numbers of AIDS cases, where contact tracing efforts remained all but moribund (Bayer, 1989). In part the opposition was fueled by the fact that throughout most of the 1980s, no therapy could be offered to asymptomatic infected individuals. Thus, the role of contact tracing in the context of HIV infection differed radically from its role in the context of other sexually transmitted diseases. In the latter case, effective treatments could be offered to notified partners. Once cured, such individuals would no longer pose a threat of transmission. In the case of HIV, nothing could be offered other than information about possible exposure.

Public health officials saw in such information an opportunity to target efforts to foster behavioral changes among individuals still engaging in high-risk behavior—behavior that could place both the individual contacted and future partners at risk; for such officials, this was reason enough to undertake the process. For opponents of contact tracing, the very effort to reach out to such individuals represented a profound intrusion on privacy with little or no compensating benefit. The task of behavioral change, they asserted, could be achieved more effectively and efficiently through community-based HIV prevention efforts (Bayer and Toomey).

Early misapprehensions about the extent to which public health officials typically relied on overt coercion in the process of contact tracing, and the degree to which confidentiality might be compromised, had by the end of the 1980s all but vanished. With such concerns allayed, many gay leaders had come to recognize that partner notification, in fact, could be a "useful tool" in efforts to control AIDS (Schram). The debate began to shift to one centered on relative efficacy (APHA). That dispute was informed by questions that had already surfaced about the usefulness of contact tracing in the control of syphilis in populations where individuals had large numbers of sexual partners, many of whom were anonymous (Andrus et al.).

In short, by the early 1990s the exceptionalism of the first years of the AIDS epidemic began to fade and a process of normalization had set in.

Public Health and Clinical Research

The HIV epidemic provided the circumstances for the emergence of a broad and potent political movement that sought to reshape radically the conditions under which research was undertaken. Brought into question were the role of the randomized clinical trial, the importance of placebo controls, the centrality of academic research institutions, the dominance of scientists over subjects, the sharp distinction between research and therapy, and the protectionist ethos of The Belmont Report (the landmark formulation of research ethics published in 1979 by the U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research). Although scholars concerned with the methodological demands of sound research and ethicists committed to the protection of research subjects played a crucial role in the ensuing discussions, both as defenders of the received wisdom and as critics, the debate was largely driven by the articulate demands of those most threatened by AIDS (Epstein). Most prominent were groups such as the People with AIDS Coalition and ACT UP, organizations made up primarily of white, gay men. They were joined by community-based physicians who identified closely with the plight of their patients.

What was so stunning—disconcertingly so to some, exciting to others—was the rhythm of challenge and response. Rather than the careful exchange of academic arguments, there was the mobilization of disruptive and effective political protest. Most remarkable was the core demand. As Carol Levine noted in 1988, "The shortage of proven therapeutic alternatives for AIDS and the belief that trials are, in and of themselves, beneficial have led to the claim that people have a right to be research subjects. This is the exact opposite of the tradition started with Nuremberg—that people have a right not to be research subjects" (Levine, p.172). That striking reversal resulted in a rejection of the model of research conducted at remote academic centers, with restrictive (protective) standards of access and strict adherence to the "gold standard" of the randomized clinical trial.

Having blurred the distinction between research and treatment—expressed forcefully through the slogan "A Drug Trial Is Health Care Too"—those insistent on radical reform sought to open wide the points of entry to new "therapeutic" agents both within and outside of clinical trials; they demanded that the paternalistic ethical warrant for the protection of the vulnerable from research be replaced by an ethical regime informed by respect for the autonomous choice of potential subjects who could weigh, for themselves, the potential risks and benefits of new treatments for HIV infection. Moreover, the revisionists demanded a basic reconceptualization of the relationship between researchers and subjects. In place of protocols imposed from above, they proposed a more egalitarian and democratic model in which negotiation would replace a scientific authority. Indeed, research "subjects" were now thought of as "participants." Furthermore, the role of the carefully controlled clinical trial as providing protection against the wide-scale use of drugs whose safety and efficacy had not been proven no longer commanded unquestioned respect (Bayer, 1990).

The new perspective did not go without challenge, of course. Some were concerned that the proposed regime would make all but impossible the conduct of research so crucial to the needs of those with HIV/AIDS ("Parallel Track," 1989), while others feared that desperate individuals would, in the absence of the now discredited (paternalistic) ethos, be subject to deception (Annas).

The AIDS-inspired challenge to the ethics of research was not restricted to issues within the United States. Just as the protective regime surrounding research in the United States was a product of a history of abuse, efforts to enunciate ethical standards for the conduct of research in Third World nations was shaped by a history of exploitation, a history characterized by investigations on the poor designed to serve the interests of the privileged. Central to those efforts was the belief that the ethical principles first encountered in industrialized nations had direct bearing on the norms that should govern research in very different settings (IJsselmuiden and Faden). Such universalism took as a given the need to assume that insights regarding cultural differences not serve as the basis for moral relativism.

Just as individual informed consent was the first principle of the ethics of research in advanced industrial nations, it was at the heart of the codes designed to guide research in the poorest nations. To preclude exploitation, international consensus also existed on the extent to which it was critical that research be responsive to the health needs and priorities of the community in which it is to be carried out (CIOMS). What would remain a matter of uncertainty, however, was whether the needs of the poorest and the requirement of responsiveness could justify research that would be unacceptable in the richest nations—whether the principle of universalism could accommodate research in Burundi that would be prohibited in Brooklyn.

That was the issue that would animate a furious international debate occasioned by the 1994 finding that AZT administered to infected women in the second and third trimesters and to their infants for six weeks could reduce by two-thirds the rate of mother-to-child HIV transmission (Connor, Sperling, and Gelber). Although superficially a conflict over a technical matter involving research design—the role of placebos—the dispute touched on the deepest questions of what ethical conduct meant in a world characterized by great inequalities and profound inequities.

Given the burden of pediatric AIDS in Africa and Asia, it was a matter of some urgency that trials begin to determine whether radically cheaper alternatives to the standard regimen could achieve at least some measure of reduced maternal–fetal HIV transmission. In June 1994 a special consultation of the World Health Organization (WHO) considered the challenge and called for the launching of studies to achieve that goal. The consultation made clear its conclusion that placebo-controlled trials—trials in which a comparison is made between an inert substance and the potentially active agent—"offer the best option for obtaining rapid and scientifically valid results."

There was no question that a placebo-controlled trial would have been considered unethical in the United States or any other advanced industrial nation. No trial that denied access to the effective standard, or to an intervention thought to hold the promise of being at least as effective as, if not more effective than, the prevailing standard of care, would have satisfied the requirements of ethical review. The question posed by the furious controversy that unfolded was whether it was ethical to conduct such a trial in a poor country. In 1997 the New England Journal of Medicine gave its answer unambiguously: "Only when there is no known effective treatment is it ethical to compare a potential new treatment with a placebo. When effective treatment exists, a placebo may not be used. Instead, subjects in the control group of the study must receive the best known treatment" (Angell, p. 847).

Given this premise, the Journal rejected as irrelevant the fact that healthcare available in most Third World countries provided nothing like healthcare available in industrialized countries. Citing for authority the Declaration of Helsinki—the international code of research ethics adapted by the World Medical Association in 1964—the editorial noted that control groups had to be provided with the best current therapy, not simply that which was available locally. "The shift in wording between 'best' and 'local' may be slight, but the implications are profound. Acceptance of this ethical relativism could result in widespread exploitation of vulnerable Third World populations for research programs that could not be carried out in the sponsor country" (Angell, p. 848).

Those who rejected the Journal 's viewpoint made clear that placebo-controlled trials were dictated by the urgency of the situation. Only placebo-controlled trials could provide "definitive," "clear," "firm" answers about which interventions worked, thus allowing governments to make "A sound judgment about the appropriateness and financial feasibility of providing the intervention" (Varmus and Satcher, p.1004). The failure to employ a placebo would have made it difficult to clearly determine whether the affordable but less effective intervention was better than no intervention at all. In short, they concluded that placebos were crucial to policymakers required to make relatively costly decisions under conditions marked by profound poverty and scarce public health resources (Varmus and Satcher).

Paralleling the debates over maternal–fetal transmission of HIV were those that surfaced over the ethics of AIDS vaccine trials. In this case the focus was on those research participants who might become infected with HIV during a trial. On the one hand there were those who argued that such individuals be provided with optimal care—the retroviral therapy available in the developed countries. On the other hand there were those who asserted that care should reflect that which was consistent with what was available in the host nation (Bayer, 2000). So divisive was this controversy that the Joint United Nations Programme on HIV/AIDS (UNAIDS) could not come to an agreement on the appropriate ethical norm and indeed had to settle for a procedural rather than substantive solution, a solution that focused on how to reach acceptable agreement rather than one that put forth a standard to guide such deliberations (UNAIDS).

Thus were the issues joined. These controversies ultimately provoked an international effort to consider ethical standards of research in the Third World. The World Medical Association undertook a series of consultations on the revision of the Declaration of Helsinki; the Council for International Organizations of Medical Sciences (CIOMS) did so as well. Finally, within the United States, which funded much of the international research that had been subject to scrutiny, the National Bioethics Advisory Commission took up the issue of studies in poor nations.

Whereas those who saw in any effort to craft "flexible" standards that reflected the uniquely pressing context of international poverty and inequality the treacherous embrace of moral relativism, their opponents persisted in arguing that a failure to consider the context of investigation was a failure of moral understanding. Principles could be universal; their application could not be rigid. (Singer and Benatar; Benatar and Singer).

Securing Access to Care

In the first years of the epidemic there was little that medicine could offer those with HIV. Indeed, that was the context within which AIDS activists struggled to increase access to experimental trials. As the prospects for clinical intervention improved, first with the use of prophylactic treatment to prevent Pneumocystis carinii pneumonia and other opportunistic infections and then with AZT, the first widely prescribed antiretroviral agent, it was inevitable that the inequities of the U.S. healthcare system would be encountered.

Some who needed treatment had private insurance—although they frequently faced efforts on the part of their insurers to deny them coverage for their HIV-related conditions; those who were poor or who became impoverished because of their disease could qualify for Medicaid; but many remained unprotected (Green and Arno). To meet the needs of the latter group, special programs were developed. The federal government, through the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, directed significant sums to localities to provide medical services. Among the initiatives under the act was the AIDS Drug Assistance Program (ADAP), designed to pay for AIDS-related medicines. Like the End Stage Renal Disease Program that assured access to dialysis and transplantation regardless of the ability to pay, these AIDS programs left untouched the basic patterns of medical inequality.

When the protease inhibitors emerged in the mid-1990s and combination antiretroviral therapy became the standard of care, the system was strained to the limits. Medication costs alone for those receiving care could range from $10,000 to $15,000 per year (Deeks et al.). A 1996 review of dramatically improved therapeutic prospects added the caveat that the new achievements were important "at least for those socioeconomically privileged" (Richman, p.1887). ADAP experienced persistent shortfalls in funding. When that was the case, it was necessary to resort to a host of rationing strategies (Henry J. Kaiser Family Foundation). At one point, nearly half of the ADAP programs limited access to protease inhibitors (Carton).

The remarkable advances in therapeutics have provided a critical element in the argument that the exceptionalism of the epidemic's early years is no longer appropriate. It is therefore a remarkable paradox that the very same achievements have set the stage for challenging the exceptionalist programs that seek to ensure—however inadequately—access to those same treatments. These expressions of disquiet must be understood, at least in part, as a reflection of concern that the American AIDS epidemic may no longer be seen as immediately threatening, that the unique services for those with HIV would be vulnerable unless they were embedded in a broader system of a just healthcare system.

On an international plane the prospect of effective antiretroviral treatment would pose challenges vaster by many orders of magnitude. What justification was there for a system of pricing that made the cost of drugs beyond the reach of the desperate? Could markets ever respond to need where effective demand was nil? Could the monopoly confirmed by patent rights be compatible with a response dictated by claims of the dying? Was the treaty on intellectual property rights, incorporated into the World Trade Organization's international regime, a barrier to survival in context of the AIDS epidemic? What moral obligation did the wealthiest nations have to the poorest to provide the resources necessary to purchase the new lifesaving agents and build the medical infrastructure necessary for their appropriate administration? Was there any reason to believe that a global community that permitted millions to die each year from treatable and preventable diseases such as tuberculosis and malaria would respond differently in the face of AIDS?

AIDS activists ultimately seized on this issue and began an international campaign to confront the pharmaceutical industry. What might have seemed an utterly quixotic undertaking would ultimately, however, take on worldwide dimensions linking protesters in the United States, France, and South Africa (Berkman), institutional proponents of global health such as the World Health Organization, and a sympathetic public. By the end of the 1990s the pharmaceutical industry was placed on the defensive, perceived as protecting narrow self-interest when the lives of millions were at stake. Against the claims that high prices were necessary to fuel the engine of research, and that patent protections were crucial to spurring investments in drug investigations, those who sought to turn the terms of discourse asserted that urgency demanded that the barriers to drug access tumble.

Ultimately, under pressure from generic drug manufacturers, prices began to fall, and pharmaceutical firms began to accept the notion of differential or equity pricing.

As prices began to fall, it became ever more apparent that even if drugs were to be provided at cost, even if the principle of equity pricing were to guide sales, even if nations pursued the option of compulsory licensing and parallel imports, the cost of providing antiretroviral therapy was simply beyond the reach of the poorest and most HIV-burdened nations. And even if drugs could be paid for, the necessity of a medical infrastructure that could offer and monitor the use of drugs in a way that was attentive to the needs of individual patients and the risks to public health from drug resistance would require huge investments. This was the context within which a remarkable movement would take shape to create a massive funding effort to respond to the threat of AIDS.

The moral urgency of AIDS treatment was amplified by United Nations Secretary General Kofi Annan, who called for a global trust fund that would spend $7 to $10 billion a year over an extended period to face the threat to the world's poorest people. Most striking was his assertion that the care that had for so long eluded men, women, and children in the less-developed nations was a matter of moral right. Everyone who was infected should have access to medicine and medical care. That was a moral imperative. What was the unfortunate had become the unfair; inequality had become inequity (Bayer, 2002).

Conclusion

This discussion began with an analysis of ethical and policy issues that emerged in the United States as it confronted the AIDS epidemic. These issues were commonly addressed in other economically advanced nations bounded by the liberal tradition, even when the resolution of the controversies that surfaced took on divergent forms.

No ethical analysis of the challenges posed by AIDS will ever again be sufficient if it is restricted to the challenges faced in wealthy developed nations. Indeed, increasingly the analysis will need to be driven by the complexities of an epidemic in the world's poorest nations. Older concerns rooted in a focus on the need to protect the privacy rights of individuals will inevitably be overshadowed by new concerns about global equity.

ronald bayer (1995)

revised by author

SEE ALSO: Confidentiality; Epidemics; Healthcare Resources, Allocation of; Homosexuality; Human Dignity; Human Rights; Life, Quality of; Public Health;Sexual Identity; and other AIDS subentries

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