Some Middle Ground by Lydia Karch

In thinking about potential replacements for animal testing, it seems as though stem cell research offers a promising alternative: pre-clinical trial drug tests could be performed on human tissue in a lab, obviating the need for any live animal involvement whatsoever. Lab-grown human tissue might even offer a better testing ground for drug side effects than animals, as human and animal biologies (and subsequent reactions to drugs) differ significantly and not always in predictable ways. However, due to the use of embryonic stem cells, stem cell research is almost impossible to separate from abortion and the question of when life begins. If life begins at the moment of fertilization, what does it mean to swap out an animal life for an embryonic cell? I pose this question mostly because I stumbled upon an entire page devoted to the question of abortion and animal rights on the Animal Liberation Front’s webpage. Are animal rights activists required to support and defend abortion pro-life activists? And if so, where does that leave the question of drug testing prior to clinical trials?

Pro-life and animal rights activists are both (broadly speaking) concerned with protecting life and preventing sentient pain. The latter does not seem like it would matter much to a stem cell, but the question of fetal pain is almost inextricably linked to abortion law and policy in the United States. In 2010, Nebraska passed a ban on abortions after 20 weeks based on evidence that a fetus may experience and respond to pain at that point, a direct challenge of the Roe v. Wade (1973) prohibition of abortion bans prior to fetal viability. Scientific consensus on the question of fetal pain is hard to come by, as various published studies can be cited to defend different positions. If fetal pain bans can be used to chip away at Roe v. Wade’s authority, they may very well be the key to achieving the pro-life movement’s major goal: overturning Roe v. Wade altogether. And in that sense, I find it interesting that both pro-life and animal rights activists focus on the experience of pain as a crucial criterion for an action’s moral wrongness, because researchers and doctors looking for more powerful ARVs or an HIV vaccine are also seeking to avert pain, as are women seeking an abortion. So whose pain matters more? Is there a scale, to measure and compare and contrast different experiences of pain? Or is pain in and of itself a wrong, regardless of the amount? But how to avert one pain without causing another?

The question of protecting life is slightly more problematic, as the question of when life begins is likely to affect a person’s perception of animal rights and the pro-life movement. If life begins at the moment of fertilization, then an embryonic stem cell has the same life value as a rhesus macaque, and the question is no longer a question: animal rights activists, as defenders of all life, are obligated to defend both an embryo and a macaque. But if life does not begin at the moment of fertilization, where does that put embryonic stem cells? Again, this question has more relevance in context of American abortion debates. If any abortion is wrong because it necessarily ends a life and potentially also causes pain, then animal rights activists and the pro-life movement have nearly identical agendas. Which really only causes a problem in terms of stem cell research, leading back to my original question: is stem cell research truly a viable alternative to animal research? Or does the American pro-life movement undercut the possibility of using stem cells to avoid animal testing? And if it does, what alternative exists that will allow all interested parties to protect life and avert pain (as they define both of those things)? Where is the middle ground?




The Financial and Ethical Tug-of-War by Soraya Chanyasubkit

I dislike tug-of-war. It’s rope burns, straining muscles and feet, and interminable, futile exertion of energy . And this is what is happening now with HIV/AIDS – a complex, constant power struggle.  This week’s articles addressed the “right” distribution of funds for HIV/AIDS prevention, ethical use of animal testing, and “progress” of an HIV vaccine. It truly shows how difficult it is to proceed in stopping this elusive and powerful virus. Let the tug-of-war games begin.

Round 1: HIV vs. Malaria – HIV is dangerous in its immediate, unobvious symptology and long latency period (~10 years). It is not as obvious as malaria in its prevention and treatment. And resources should be dedicated to continually fight against it. But having read Owen Barder’s blog, I realize that funds need to be re-evaluated and redistributed. Like many others students have mentioned before in this blog and in class, setting a price on a person’s life seems heartless, but we’re working with a finite financial source here. If it means re-allocating funds from HIV prevention to buy mosquito nets, so be it. I feel it is more important to analyze the country/region’s profile rather than picking and choosing diseases. Yet, Ethiopia has an HIV problem, but they also have more immediate infectious diseases running rampant through a variety of vectors: insects, water, microbes, etc. HIV should be a concern, but not necessarily a priority. What was most disturbing was the fact people consciously tried to become infected due to the resources and benefits that are available to HIV-infected patients, that’s defeating the entire system of treatment/prevention. It’s similar to how people would commit petty crime during the winters so that they can have a better place to sleep in jail than outside.

Round 2: Animal rights vs. Human rights – As a Neuroscience major, I’ve read countless scientific articles using animal subjects – rats, mice, voles, macaques, etc. This isn’t an HIV/AIDS specific issue, but prevalent in the science community as a whole. I understand where the animal advocates are coming from, but are we supposed to jump right in to human testing and clinical trials? “Oh, we aren’t sure what a good dosage is, what possible side effects there are, what level of toxicity this is, and we can’t test it on anything, so we’ll inject it into a human.” I know that the biology of different animals mean different outcomes but at least it’s a gauge, a rough estimate, of how the drug might work. I feel the animal activists are doing more harm than good when they vandalize laboratories. Rather than destroying work (and thereby invalidating the animal’s sacrifice in the first place), they would work with scientists to ensure compliance to animal safety regulation and ethics. I personally have not done research with animals, but my friends have. He performed surgeries on mice to observe neuromuscular junctions, and while he was training of course there were a couple casualties along the way. But what else could he do?

Round 3: Vaccine vs. Mother Nature – It’s kind of disheartening, the level of progress that has been made, or rather, not made. It’s also mind-boggling how extensive clinical trials are, just the initial number of people who are enrolled to the final talley. I am becoming more and more unsure of a veritable vaccine for HIV and maybe the funding can be put to better use elsewhere.

Non-Lethal Development Advocacy by Daniel Hougendobler

In the Owen Abroad blog post entitled “The lethal effects of development advocacy,” the author argues that, because development funding is limited, advocacy for particular development goals creates harm by diverting money into those projects that have the loudest advocates rather than into those which will provide the greatest benefit.  While I agree completely with his concern over the skewing of development resources, I disagree with several of the conclusions he draws.

I would agree with the author’s assessment that global development money is not being optimally distributed.  While working in Rwanda, I saw a similar skewing of resources towards HIV/AIDS.  While the 15-49 prevalence is less than 3% (, the great majority of resources I encountered were devoted primarily to combatting HIV/AIDS.  But, does it follow that the disease-specific advocacy is creating fewer resources for other diseases?  I would argue that this is where the author gets it wrong.

Take the example of PEPFAR.  It seems unlikely that the extraordinary level of bi-partisan support and spending would have been politically feasible had the target simply been health spending based on evidence.  PEPFAR is an excellent example of how specific development advocacy can actually increase the size of the overall development pie.   Moreover, funding for a single disease has the chance to positively impact overall health for multiple diseases. Even single-issue funding can strengthen health systems, create and support sustainable supply chains, and improve infrastructure.

The author also neglects the increasing importance of private donors to global development.  Even if the proportion of government aid is set (and I believe PEPFAR proves otherwise), that argument can certainly not be made for private donations.  Development advocacy in these cases is essential.

I would next like to address each of the author’s suggested solutions in turn.  I strongly agree with his first suggestion that “we should be much more rigorous and systematic about defining and measuring results from aid.”  This is already being implemented.  There is a move toward creating more rigorous and meaningful indicators from PEPFAR, the Global Fund, the Gates Foundation, and other major players.  This trend also incorporates the author’s fourth point about increasing transparency.

Although I agree that earmarking aid often leads to poor results, I also believe that this requires reliable indicators.  Moreover, I strongly believe that for political reasons there are situations in which the option is between earmarked aid and no aid at all.

I strongly disagree with the author’s third suggestion that global funds should be closed or merged.  If the goal is to stop waste, I believe that the global fund concept has been extraordinarily beneficial to increasing efficiencies and preventing useless duplication and poor coordination.  Merging funds risks creating unfocused behemoths that would become mired in bureaucracy.

I perhaps disagree most strongly with the author’s last point.  Based on my experiences, the last thing that is needed in the development world is more scorn and opprobrium.  While it is “anti-social” to ask that an important health issue be defunded to make room for your own, it is natural and healthy to focus on a single issue and advocate for more resources for it.

As an alternative to the author’s suggestions, I would make two of my own.  First, rather than the “scorn and opprobrium” the author advocates, I would suggest increased alliances between NGO’s and other aid recipients.  Those involved in HIV/AIDS should be working with their colleagues working in Malaria, Dengue and safe water to find ways that they can collaborate to benefit all these conditions simultaneously.  Perhaps the health workers who provide ART can also give out water tablets and mosquito nets.  Perhaps health worker training programs in Malaria can incorporate HIV/AIDS monitoring as well.  Ultimately, I believe this will net better results and be healthier for the community than the author’s “scorn and opprobrium” approach, which will burn bridges and punish individuals for their natural, humanitarian instincts.

Second, those in the development community should focus on solutions that that create capacity and improve health overall.  If an organization receives an HIV/AIDS grant, it should not simply hire the best doctors to the detriment of other health needs.  Rather it should create a program to train more health workers and strengthen the health system to benefit everyone.  Ultimately, global health, properly conceived and implemented, is not a zero-sum game.  Each intervention should improve both be able to improve overall healthcare capacity.

Week Four: Queen, Hagen, and Robinson

This week Edward Queen from the Center for Ethcis talked about the ethics involved in making decisions as to where development resources should go. He asked students to respond to the following blog:

Kimberley Hagen from the School of Public Health (and one of our co-conveners) discussed the ethics of animal testing in relation to HIV/AIDS drugs and vaccines. She asked students to look at: generally and more specifically:

Lastly, Harriet Robinson (Emeritus from the School of Medicine) discussed her experiences with vaccine development asked students to read:

  • Buchbinder, Susan et al. “ Efficacy assessment of a cell mediated immunity HIV-1 vaccine (the Step Study): a double-blind, randomized, placebo-controlled, test of concept trial.”  Lancet 2008; 372: 1881-93.
  • Rerks-Ngarm, Supachi, et al. “Vaccination with ALVAC and AIDSVAX to Prevent HIV-1 Infection in Thailand.” The New England Journal of Medicine. Volume 361. No. 23. December 3, 2009. 2209-2220.


Reflections from Gallant, Resch, and Hongaro by Hannah-Alise Rogers

I learned a lot by reading these three articles, because most of the research that I have done on HIV is based in the social sciences rather than the natural sciences. It was interesting to read the different studies and compare this more “factual” style of writing to the work done in the social sicences. While reading these three articles, I was reminded of articles that I have read within feminist epistemology studies. Epistemology is basically the study of knowledge (sounds repetitive, I know) and it looks at how and why we know what we know. Many feminists, Donna Haraway being one of the most well-known, argue that “knowledge” about a certain subject is culturally situated. In other words, “truth” is not natural or found a certain source, be the source scientific or otherwise. Feminist scholars such as Marsha Rosengarten (2004) and Susan Craddock (2000) have argued that what we know about HIV is part of a situated knowledge that is culturally flexible. Craddock argues that the institution of medicine produces a certain discourse about HIV which impacts studies of the virus or certain “vulnerable groups” (and I hate this term) that are affected by it, and it also affects the image of the person/groups of people who we see as being infected with HIV. I was reminded of Rosengarten and Craddock’s work as I was reading these articles.

One thing that caught my attention me about the articles by Resch and Hongaro was the heavy focus on economics. It almost seemed like these two studies were being performed less for the purpose of providing ART (Resch) or for providing palliative care (Hongaro), and more for the purpose of saving money. I understand that fiscal considerations are of paramount importance when trying to coordinate methods of prevention and treatment, but when Resch et al. suggests that current distribution levels of ART in lower and middle-income countries should be monitored and not increased too drastically because economic returns are thus less likely, I found this to be a little heartless. Are we treating people for HIV disease because if we don’t it’s costing money, or are we treating them because as human beings they have a right to be healthy? Furthermore, I find it upsetting that all of the resasons that this team suggests for increasing access to ART are discussed in monetary terms. For example, the team argues that more people should be put on ARV therapy because this would restore a large percentage of labor productivity and save more money from going into orphanages. Pardon me, but this seems a little ridiculous. Why are other reasons, like putting more patients on ARV therapy will help patients to feel better and will decrease the prevalence of HIV in the community not the first things on the list?! Are we caring for people – people with a human right to enjoy their health – or are we doing research? Are we serving these people, or are we doing economic surveys and writing papers about how to save money?

Uniting Parts of a Whole to Combat HIV by Megan Murphy

Gallant’s Essential Components of Effective HIV Care article dovetails nicely with class conversations facilitated by Dr. Gene Farber last week wherein he (and his assigned reading) underscored the importance of addressing the multifactorial needs of HIV/AIDS patients. The introductory discourse of this week’s article reinforces the idea that anti-retroviral therapy (ART) and proper case management have revolutionized HIV care, but that the continuation and frequent quality monitoring of integrated care will be paramount as care providers tackle new and existing cases of HIV. The article puts forth as the goals of HIV care, “earlier and greater engagement in care, effective viral control, improved immune state, near-normal life expectancy, enhanced quality of life, and prevention of HIV transmission,” and identifies as the per-patient leaders to execute these goals an HIV expert, a care coordinator (often a qualified nurse), a clinical pharmacist, and “a range of other specialists” including but not limited to providers of mental health and substance abuse treatment. This thorough and interdisciplinary outline prompted my wondering what the “best” bench research team would be for creating an effective HIV vaccine.

Collaborative efforts absolutely exist in the current molecular research of HIV, but a single scientist–or even on a larger scale, a single lab–can mire him/herself in the understanding of one protein or one pathway or one phenomenon so as to prevent synthesizing that knowledge in the context of other proteins or other pathways or other phenomena. HIV encodes nine genes, but my dissertation research examines only one of them in isolation, env. Invariably, HIV’s genes affect each other, and I’ve received questions to this effect when giving talks: “While all of this is going on in env, what’s happening in gag?” and I have to answer, “I don’t know,” or “We haven’t looked into that.” It has taken almost two years of active research for me to define a single neutralizing antibody target in a single subtype A HIV-1 patient from Kigali, Rwanda, and while this knowledge is valuable and can now be compared against the other subtypes to pinpoint shared viral vulnerabilities, the scope of my project is admittedly infinitesimal. Reading about integrated care made me desirous of more crosstalk among scientists from the different branches of HIV research.

Where Gallant et al. proposed a feasible and united but somewhat abstract plan, Resch et al. and Hongoro et al. expounded on concrete instances of current or pilot treatment infrastructures. The most significant commonality between these two latter articles was providing sound economic evidence that such implemented programs possess tangible (and often monetary) merit. Would treating patients in need of palliative care at home, frequently immersed in the comfort of a family environment, reduce costs as compared with those accrued during comparable hospital stays? According to the N’Doro South African study in Hongoro et al., yes. This echoes similar results collected in Spain, Italy, the United States, and the United Kingdom. Will efforts sponsored by the Global Fund to Fight AIDS, Tuberculosis, and Malaria to treat 3.5 million people across 98 countries with ART be proven worthwhile? In terms of “restored labor productivity amongst workers with AIDS, orphan care expenditures avoided because parents remain alive on ART, and delayed end-of-life care costs associated with death from AIDS,” the answer was a resounding yes. Overall, Resch and Hongoro examined the financial benefits attached to specific HIV intervention strategies. To some, their analyses may have appeared callous, but such studies are incredibly important because they inform policymakers and potential government, public, or private funders that representative programs are positively impacting the epidemic.

Antiretroviral Therapy and Risk – a problem of communication? by Luke Reimer

The development of antiretroviral therapies (AVT) in the 1990s transformed HIV/AIDS from a terminal illness to a chronic disease.  Today there exist dozens of drugs that target different phases of the retrovirus lifecycle, inhibiting the replication of the HIV-1 virus.  AVT lowers viral loads, increases CD4 counts, and reduces the probability of clinical and transmission events over time. In HIV patients under treatment life expectancy actually approaches that of unaffected individuals (Sigham, et al. 2010). The importance of adherence is therefore paramount to health and to the transmission of the virus. Two of this week’s readings introduce research into links between AVT adherence and risk taking behavior.  The first study (Holsted, et al. 2011) shows that group motivational interviewing promotes adherence and reduces risk-taking behaviors. A second study by the same group (2011) shows that adherence and risk taking behaviors closely correlate to one another in HIV patients. A third reading (Cohen, et al. 2011) determined that early initiation of ACT can prevent HIV-1 infection. Taken together, these papers indicate the importance of understanding and adjusting behaviors (risk taking and adherence specifically) for future progress towards preventing and treating HIV/AIDS.

A piece of data I found surprising was the extent of patient non-adherence to AVT. In her two studies Holsted reported that only 74.2 and 74.6 percent of prescribed doses were taken (and only 58.9 percent taken on schedule). Cohen reported similar levels of adherence; in two study groups 79 and 74 percent of patients adhered to the regimen of 95% of doses taken. In these studies, then, one in five patients was unreliable in taking their medications. To me this seems a remarkably high number. Not only does low adherence heighten the risk of a transmission or clinical event, it also raises the possibility of new multiple-drug-resistant virus strains.  Meanwhile, the benefits of ACT are plainly demonstrable. What I take away from these numbers is that, as Felicia Guest said in Monday’s discussion, behaviors are very difficult to change. It also seems that impressing patients with the meaning of risk is also a significant clinical challenge.

If adjusting behavior, then, is critical to making next steps in fighting and controlling HIV/AIDS, a major obstacle might be the difficulty of communicating risk and its implications. Risk, after all, is a quantified abstraction, usually appearing as a probability. How does a patient know how to make meaning of a percentage or number, and then to apply it to life decisions? Particularly when risk accumulates over many years (or an entire lifetime), it may be very hard to understand the consequences of a behavior or decision in terms of risk.  Perhaps if care providers were better able to communicate the meaning and implications of risk, progress could be made towards adjusting behaviors such as adherence. I look forward to learning more about how these kinds of conversations are developed between patient and care providor.