Breast milk transmission: Dankwart Wittenberg
Advocacy and vaccines: Tony Nelson
Research Ethics: David Brewster

D.F. Wittenberg, E.A.S. Nelson, J.A. Walker-Smith, D.R. Brewster.

Commonwealth Heads of Government met in Durban in 1999. Paragraph 55 of their Communique relates to HIV/AIDS, which is seen as a key Commonwealth health priority. "Heads of Government expressed grave concern over the devastating social and economic impact of HIV/AIDS, particularly in sub-Saharan Africa. They agreed that this constituted a Global Emergency, and pledged personally to lead the fight against HIV/AIDS within their countries and internationally. They urged all sectors in government, international agencies and the private sector to co-operate in increased efforts to tackle the problem, with greater priority given to research into new methods of prevention, the development of an effective vaccine and effective ways of making affordable drugs for the treatment of HIV/AIDS accessible to the affected population." As children with HIV/AIDS commonly present with the symptoms of diarrhoea and malnutrition it is important for CAPGAN to develop a formal response to Paragraph 55, including a plan of action. In developing this response the following need to be considered: vertical transmission is responsible for most HIV infections in children; the problem of mother-to-child transmission during delivery can be alleviated by the use of cheap anti-retrovirals; these drugs are not currently available for the majority of mothers with HIV infection; transmission of infection from mother to infant through breastmilk has generated uncertainty and debate; exclusive breastfeeding may have lower risk of transmission than partial breastfeeding; not breastfeeding may result in stigmatisation; what should be the recommended method of infant feeding in poor countries with high rates of HIV infection; the development of an efficacious and affordable HIV vaccine remains the only hope of controlling the HIV epidemic in the long term; ethics guidelines on HIV research may prevent important vaccine and other studies from being undertaken in poor developing countries. In developing a CAPGAN response to Paragraph 55, this session will focus on following groupings: 1) Introduction: Short situation analysis, impact on health indicators; 2) Breast milk transmission and implications for feeding; 3) Gut disease and impact on nutrition. 4) Advocacy, funding and vaccine research; 5) Research ethics.

David Brewster. Northern Territory Clinical School, Darwin, Australia

Should research studies on HIV transmission or treatment be allowed to compare a new treatment to placebo in countries where anti-retroviral treatment of HIV is not affordable? The declaration of Helsinki of the World Medical Association states clearly that "in any medical study, every patient - including those of a control group, if any – should be assured of the best proven diagnostic and therapeutic method." Because of inequities in medical practice between rich and poor countries, some have sought to revise this by adding "the best proven diagnostic, prophylactic or therapeutic method that would otherwise be available to him or her".

There is general agreement that studies of a new arthritis or asthma drug should not be compared to placebo but to existing therapy, since that is the question which the clinician wants answered. Armchair ethicists in the developed world would like to insist on absolutism in global ethical standards for medical research, so would stop some studies of great relevance to developing world practice. Perhaps it is the growing disparity in health resources between rich and poor countries which is unethical rather than medical research carried out in poor countries. One gets the impression that many of the vociferous opponents of relativism in ethical standards are more concerned about the loss of research revenue to the donor country than alleged exploitation of poor subjects. Although the latter has definitely occurred, poor people are nevertheless capable of deciding whether to participate in a research project and local ethical committee’s can surely judge what research is relevant to local medical practice.