PHILIPPINE WOMENS UNIVERSITY

GRADUATE SCHOOL OF NURSING

MASTER OF ARTS IN NURSING







LEGAL PROBLEMS IN NURSING




TERM PAPER

ON

ETHICAL ISSUES ON AIDS
(Acquired Immunodeficiency Syndrome)












PREPARED BY:

LYKA MAE A. VILLANUEVA, RN








In just three decades, over 30 million people have died of AIDS, and 34 million more have been
infected with HIV (Levine, 2012). Globally, the HIV/AIDS epidemic has presented unique health
challenges to populations, including a host of ethical and moral issues related to human life and dignity.
The disease has most affected the vulnerable groups of people in the world often leading to stigma and
discrimination.
Although it is considered that nowadays there is adequate knowledge about transmission of
HIV, published figures show an increase in the number of HIV positive people and individuals suffering
from AIDS.
The increase in cases detected might be due to the reduction of information given to the
general population. Healthcare professionals including nurses have significant responsibility for
providing information about the transmission of HIV and for developing a strategic health programs to
reduce that transmission.

BASIC FACTS ABOUT HIV/AIDS
What is AIDS? AIDS stands for acquired immunodeficiency syndromea pattern of infections
which follows infection by the human immunodeficiency virus, or HIV, which attacks and destroys
certain white blood cells that are essential to the bodys immune system.
When HIV infects a cell, it combines with that cells genetic material and may lie inactive for
years. Most people infected with HIV are still healthy and can live for years with no symptoms or with
only minor illnesses. They are infected with HIV, but they do not have AIDS.
After a variable period of time, the virus becomes activated and then leads progressively to the
serious infections and other conditions that characterize AIDS. Although there are treatments that can
extend life, AIDS is a fatal disease.
Persons who are HIV-positive are both infected and infectious for life. Even when they look and
feel healthy, they can transmit the virus to others.

WHAT IS HIV?
The human immunodeficiency virus, or HIV, attacks the bodys immune system. By weakening
the bodys defenses against diseases, HIV makes the body vulnerable to a number of potentially life-
threatening infections and cancers. HIV can be transmitted from one person to another.
HIV spreads through three major routes:
Unprotected sex (vaginal, anal, oral) carries a risk of HIV transmission because it brings
semen and vaginal secretions directly into contact with exposed mucous membranes, through
which HIV can enter the body. Unprotected anal and vaginal sex has a high risk of transmission;
the risk is lower for oral sex;
Blood including through transfusions of unscreened blood, sharing of injecting
equipment (not just needles), organ transplants, and blood products;
Mother to child or from an infected woman to her child during pregnancy, delivery and
breastfeeding.
An HIV-positive person is someone who has HIV and HIV-negative means that a person does
not have HIV.

FROM HIV TO AIDS
Individuals with HIV are infected for life and are at risk of dying from opportunistic infections
caused by the weakening of their immune system. Treatment with antiretroviral drugs, where they are
available, can slow the progression of HIV, and this means there is room for hope for a condition that
was once considered a death sentence. Appropriate and timely medication for opportunistic
infections can substantially prolong the life of someone with HIV. In individuals who do not get
antiretroviral therapy, the time between infection with HIV and the development of the serious illnesses
that define AIDS is around eight years, and most patients do not survive much more than two years after
the onset of AIDS without appropriate medical interventions.
From January 1984 to May 2007, there were 2,857 HIV cases reported in the country (HIV/AIDS
Registry, Department of Health, 2007). However, the actual figure may be several thousands more. It is
believed that the Philippines has the potential to face an AIDS epidemic because of its burgeoning sex
industry, changing patterns of sexual behavior (particularly among the young people), relatively high
rates of other sexually transmitted infections, non-use or infrequent use of condoms, low general
awareness of HIV/AIDS, and highly mobile populationfactors and conditions which are conducive to
the potential spread of HIV. However, because of stigma and discrimination against people with HIV,
many people are reluctant to be tested and those that know they have HIV may not disclose the fact to
their partners or to health practitioners.
Although there is a debate regarding the actual number of people living with HIV, the extent of
HIV infection is probably under-reportedin fact, the epidemic appears to be hidden and steadily
growing. Most Filipinos infected with HIV are aged 15-49, inarguably the most productive sector of the
labor force. This means that there may be many
Filipinos in their most productive age who are living with HIV without even knowing it, and
possibly passing the virus on to others.

OVERVIEW OF ETHICAL PRINCIPLE
There are three widely recognized principles in bioethics that apply in taking care of patients
with AIDS/HIV: respect for persons, beneficence, and justice. Respect for persons entails respecting the
decisions of autonomous persons and protecting persons who lack decision making capacity and
therefore are not autonomous. It also imposes an obligation to treat persons with respect by
maintaining confidences and keeping promises. Beneficence imposes a positive obligation to act in the
best interests of patients or research participants. It often is understood to require that the risks of
research be minimized and that the risks be acceptable in light of the potential benefits of research.
Finally, justice requires that people be treated fairly. It is often understood to require that benefits and
burdens be distributed fairly within society.

Ethical Issues on Confidentiality
In the United States, all medical information generally is considered confidential and protected
under the law. Because of the sensitivity of HIV-related information, many states in the U.S. have
adopted laws that provide additional protection to HIV-related medical records. For example, in many
states, HIV information may not be disclosed based on a general release of medical information-specific
authorization for release of HIV-related information must be obtained.
Exceptions to the legal and ethical obligation to maintain the confidentiality of HIV-related
information exist. For example, health care providers in the U.S. have a duty to report HIV infections and
AIDS cases to public health authorities. The benefits to the public health of this reporting are felt to
outweigh the risk to individuals. Reporting of AIDS cases has always included the patient's name and
other identifying information. Although reporting of HIV infections initially was not done by name, there
has been a recent and controversial movement in the U.S. toward name-based reporting of HIV
infection. The debate over name-based reporting has focused on the need for more accurate
epidemiological information regarding the spread of the epidemic-especially as antiretroviral therapies
have proven successful in delaying progression to AIDS-versus concerns about deterring testing and the
risk of discrimination. The Centers for Disease Control and Prevention (CDC) has made specific
recommendations for keeping reporting confidential. However, because HIV testing carries the risk of
discrimination if confidentiality is breached, the CDC and commentators on this issue have
recommended that anonymous testing, from which name reporting is not possible, continue to be
offered.
Health care providers may also be permitted to disclose a patient's HIV infection to persons at
risk of infection without legal penalty. In some states, such as California, a health care provider may not
warn sexual or drug-using partners of infected patients without first informing the patient of the
intended disclosure. This exception to confidentiality is justified on the grounds that (a) breaching
confidentiality will help prevent serious harm to an identifiable person, (b) there is no other effective
means to achieving the goal, and (c) the breach of confidentiality is minimized.
Another exception to the general rule of confidentiality of HIV-related information concerns
HIV-infected health care workers. U.S. government policy has recommended that HIV-infected health
care workers who perform exposure-prone invasive procedures have their cases reviewed by an expert
panel, which will decide whether they may continue to perform such procedures and whether they must
inform patients of their infection. States are required to adopt this policy or its "equivalent." Because
the government has taken a flexible view on "equivalency," there is wide variation in state law and not
all states require disclosure of HIV infection by health care workers. Those who favor the federal policy
argue that disclosure of health care worker HIV infection is necessary to meet the obligation of informed
consent. They also argue that the health care workers' obligations to act in patients' best interests also
mandate disclosure of HIV infection and, in some cases, restrictions on clinical activities. Those who are
against the federal policy argue that such disclosure or restrictions are inappropriate because they
violate health care workers' privacy and because the risks to health care workers, for example from
discrimination, far outweigh the benefits to patients, given that the risk of infection from a seropositive
health care worker is very small. Some have suggested that the federal policy should be revised in light
of the data demonstrating that the risks of transmission in the health care setting are exceedingly low.
In the Philippines, "Anonymous Testing" is also being practiced. This refers to an HIV testing
procedure whereby the individual being tested does not reveal his/her true identity. An identifying
number or symbol is used to substitute for the name and allows the laboratory conducting the test and
the person on whom the test is conducted to match the test results with the identifying number or
symbol.
It is included in the Philippine REPUBLIC ACT NO. 8504, also known as the Philippine AIDS
Prevention and Control Act of 1998, that strict confidentiality must be observe in handling of all
medical information, particularly the identity and status of persons with HIV. It is also mandated that
any person with HIV is obliged to disclose his/her HIV status and health condition to his/her spouse or
sexual partner at the earliest opportune time.
However, medical confidentiality has an exemption when complying with reportorial
requirements in conjunction with the AIDSWATCH programs. It is a comprehensive HIV/AIDS monitoring
program under the Department of Health which determines and monitors the magnitude and
progression of HIV infection in the Philippines, and for the purpose of evaluating the adequacy and
efficacy of the countermeasures being employed.

Ethical Issues on Informed Consent for HIV Testing
Because the physical risks are minimal, blood tests in the U.S. typically do not require extensive
informed consent discussions, and consent often is implied rather than explicit. However, early in the
AIDS epidemic, HIV testing was recognized as different from other blood tests because it presented
serious psychosocial risks, such as rejection by family; discrimination in employment; and/or restricted
or no access to health care, insurance, and housing. Moreover, because there was no proven treatment
at that time, the benefits of early diagnosis to individual patients were uncertain. In recognition of these
circumstances and to encourage testing, special procedures were adopted for obtaining consent for an
HIV test, such as pretest counseling and specific informed consent.
For the most part, these special requirements remain in effect. Nearly one-fifth of states require
pretest counseling, and many of these specify the information that must be covered, including the
nature of the test, the risks and benefits of testing, how to prevent transmission, and the confidentiality
of HIV test results. The pretest counseling requirement typically is in addition to any requirements for
informed consent. The majority of states require specific informed consent to HIV testing, and many of
these require that consent be written. In addition, a number of these states specify the information that
must be conveyed during the informed consent process, including information about the nature of the
test, the nature of the illness caused by HIV, risk behaviors and prevention measures, the confidentiality
of test results, reporting requirements and other circumstances under which test results may be
disclosed, the voluntary nature of the test, the ability to withdraw consent, and the availability of
anonymous testing. Some of these states require that written information also be provided during the
consent process.
Some states permit HIV testing without informed consent under specified circumstances. For
example, many states permit testing of patients without permission after a significant exposure to
emergency response workers or health care workers occurs, although permission generally must be
sought. In addition, some states permit the testing of prisoners and persons accused of sex crimes.
Connecticut and New York also require mandatory HIV testing of newborns, which indirectly reveals
maternal HIV status.
In the Philippines, there is no compulsory HIV testing allowed. However, the State encourages
voluntary testing for individuals with a high risk for contracting HIV, provided that written informed
consent must first be obtained. Such consent shall be obtained from the person concerned if he/she is
of legal age or from the parents or legal guardian in the case of a minor or a mentally incapacitated
individual. Lawful consent to HIV testing of a donated human body, organ, tissue, or blood shall be
considered as having been given when a person volunteers or freely agrees to donate his/her blood,
organ, or tissue for transfusion, transplantation, or research.

Research Ethics on HIV/ AIDS
Research with human participants raises ethical concerns because people accept risks and
inconveniences primarily to advance scientific knowledge and to benefit others. Although some research
offers the prospect of direct benefit to research participants, most research does not.
It is unethical to expose subjects to the risks of participating in a research study unless the
design is sufficiently rigorous that the results will be valid and generalizable. The expectations of
potential research participants may complicate obtaining informed consent in the research context.
Although the goal of research is to test a hypothesis and develop generalizable knowledge, many
participants enter research studies to benefit personally. Many participants also do not understand
randomization and expect that decisions about which intervention they receive will be based on their
individual clinical needs. Some of these misconceptions may arise because patients apply their own
experience with health care providers, who have an ethical obligation to place patients' interests first,
with to the research setting, which must take responsibility for the scientific and logistical aspects of the
research as well as the interests of the individual participant. Because of such hopes and
misconceptions, patients may misinterpret the information given to them about the study.
The role of health care providers in research may contribute to participants' misunderstanding.
Health care providers exert considerable power in their relationships with patients, and patients are
inclined to follow their health care providers' advice. Patients often understand offers to participate in
research as recommendations for their care. Patients also may agree to participate in research if their
health care providers ask because they want to please their providers or fear that the quality of their
care will be negatively affected if they refuse. In addition, patients' trust in their health care providers,
medical institutions, and the research enterprise may lead them to agree to participate in research
without critically reviewing information about the trial. Health care providers themselves frequently
overestimate the benefits of experimental interventions and participation in clinical trials.
Some people may be at greater risk from research and are considered vulnerable. They require
special protection from research risks. Vulnerability is particularly important in the context of HIV-
related research. Those infected with HIV may be medically vulnerable because of their infection. In
addition, homosexuals, injection drug users, minorities, and women, who, for various reasons, may be at
higher risk of HIV infection, are more likely to be socially and economically vulnerable because of
historical attitudes and discrimination. Accordingly, investigators conducting HIV-related research must
pay particular attention to vulnerability and take steps to protect potentially vulnerable research
participants.

End-of-Life Issues
Early in the U.S. epidemic, before antiretroviral therapy was developed and shown to be
effective, HIV infection often quickly progressed to a terminal illness. However, because the availability
of highly active antiretroviral therapy has prolonged survival, end-of-life care in HIV infection has
become a less prominent issue in the U.S. However, in the developing world, where antiretroviral
therapy is generally not available, palliative care, which focuses on relief from suffering, is the only
tenable goal. Severe resource constraints may render it difficult to provide palliative measures such as
opioids for pain control. Under those circumstances, care may be limited to psychosocial support and
helping patients make plans for such practical issues as burial and child custody and support. This focus
will need to change as highly active antiretroviral therapy becomes increasingly available in developing
countries. There have been many efforts to make HIV medications more available to the developing
world by pressuring pharmaceutical manufacturers to reduce prices, permitting production of generic
versions of effective therapies, and providing funds for drug purchases.

CONCLUSION
As health care providers, it is the duty of nurses to educate and disseminate information
regarding HIV/AIDS as part of the delivery of health services. It is considered a civic duty of health
providers to make available to the public such information necessary to control the spread of HIV/AIDS
and to correct common misconceptions about this disease. The health workers must take into
consideration the HIV-related ethical issues such as confidentiality, informed consent and the duty to
provide treatment when caring for HIV/AIDS patients. It is also their duty to observe the ethics of
medical practice and abide by the laws of his/her country that advocate for the protection of patients
rights. They must ensure protection of patients in the process of testing, care and treatment. HIV/AIDS
patients must not be discriminated against the right to life. This right ensures that patients can be able
to access health treatment and they cannot be refused emergency medical treatment just on the basis
of their HIV status.


REFERENCES:

Reyes, M. 2011. National Ethical Guidelines for Health Research



Levine, J. July 2012. HIV and the Law: Risks, Rights & Health



Managing HIV/AIDS in the Workplace: Employers Handbook For Action, 2008


http://www.ilo.org/wcmsp5/groups/public/@ed_protect/@protrav/@ilo_aids/documents/legaldocume
nt/wcms_117536.pdf