Paying Attention to "Water": A Pragmatic Ethics Argument for Returning Results from HIV Tests Performed During Population-Based Surveys in Sub-Saharan Africa 公开

Arenson, Michael David (2012)

Permanent URL: https://etd.library.emory.edu/concern/etds/9880vr80g?locale=zh
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Abstract

Abstract

This thesis argues for the development of a new HIV surveillance approach that better accounts for the current landscape of the HIV epidemic in sub-Saharan Africa. Today, one major driver of the HIV epidemic worldwide are people that do not know their HIV status. The method of surveillance commonly used in sub-Saharan Africa, called Unlinked Anonymous Testing (UAT), tests participants for HIV but does not return their results. Instead a referral voucher is provided for free Voluntary Counseling and Testing (VCT) where one can get counseled, tested for HIV (again), and if eligible, receive treatment. Simply referring survey participants to VCT, however, is ethically inadequate because of the barriers to VCT services (e.g. stigma). Instead, it is argued, one ethical approach would be to link the HIV tests performed during population-based surveys with home-based VCT. After many ethics consultations in the past, UAT was defended as the most ethical form of HIV surveillance. However as circumstances have shifted in sub-Saharan Africa, so have the ethical implications of not returning HIV test results obtained during population-based surveys.

When viewed through a pragmatic ethics lens, specifically through that of D. Micah Hester's Community as Healing [1], an argument is made that UAT has become an old habit (i.e. a habituation). In order to create new habits of surveillance, I argue, public health must pay more attention to the "softer," more intangible dimensions of the HIV epidemic in sub-Saharan Africa (i.e. behaviors and attitudes), and more broadly, to the ethics of public health. By doing so, public health creates new - and as Hester describes it - "intelligent" habits of HIV surveillance that better balance the population's need for accurate public health data with each community member's moral claim to information that could benefit their health (i.e. results of their HIV test) among other things (e.g. equitable access to VCT). Thus, Community as Healing accounts for public health's primary purpose of protecting populations, in addition to its ultimate goal of healing each individual within the population.

Table of Contents

Table of Contents

ABBREVIATIONS AND DEFINITIONS................................................................... 1

CHAPTER 1: SWIMMING IN PUBLIC HEALTH WATER .............................................. 2 CHAPTER 2: SURVEILLANCE AS "WATER" ............................................... .............. 6 Controversy Surrounding Unlinked Anonymous Testing (UAT).................................7 Global Response to UAT....................................................................................11 Improved Therapeutic Prospects and Concern Over UAT in America........................14 Surveillance: Research vs. Non-Research............................................................19

The Conversation on the Ethics of HIV Surveillance Practices in sub-Saharan Africa...21

Public Health Ethics..........................................................................................26 Columbia Consultation in Response to Debate Over Ethics of HIV Surveillance..........30 Conclusion......................................................................................................34 CHAPTER 3: RETURNING RESULTS AS "WATER" .................................................... 36 Sense of Urgency..............................................................................................39 The Utility of HIV Testing and Counseling (HTC)....................................................41 Kenya AIDS Indicator Survey (KAIS)....................................................................43 Home-Based VCT..............................................................................................45 Behavior as "Water"...........................................................................................48 The "T" in HTC: Testing for the Purpose of Improving HIV Status Awareness.............51 Counseling as Education.....................................................................................54 Pitfalls of Using Treatment as Prevention and The Softer Side of HIV Prevention.........56 Conclusion........................................................................................................60 CHAPTER 4: COMMUNITY AS HEALING AND HEALING THE COMMUNITY....................63 Pragmatism Justified..........................................................................................67 Moral and Social Psychology................................................................................70 Criticisms of Frameworks....................................................................................72 Introduction to Community as Healing...................................................................75 Habits of Intelligence; Habits of Surveillance..........................................................79 Habits of Morality, Moral Imagination, and Moral Artistry.........................................80 Social Products...................................................................................................84 Returning Results and Engaging the Community.....................................................87 Community as Healing.........................................................................................89 Healing the Community........................................................................................92 Conclusion.........................................................................................................94 BIBLIOGRAPHY...................................................................................................96 Non-Printed Sources...........................................................................................108 APPENDIX: FIGURES AND TABLES ............................................... .......................... 109 Figure 1............................................................................................................109 Figure 2............................................................................................................109 Table 1.............................................................................................................110 Table 2.............................................................................................................110 Figure 3............................................................................................................110 Figure 4............................................................................................................111 Figure 5.............................................................................................................111 Figure 6............................................................................................................112

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