28 Stories of Aids in Africa

• 28 Stories Of Aids In Africa Pdf Map For Kids

by Stephanie Nolen

Portobello £12.99, pp408

Stephanie Nolen was already known for her work as the Globe and Mail’s Africa correspondent, ranging from the effects of war on women and children, to Stephen Lewis’ fight to end AIDS in Africa, when she published 28 Stories of AIDS in Africa in 2007. 28 is Nolen’s attempt to reflect the 28 million Africans who had HIV in 2007. AIDS and Business in Southern Africa At the conference, Professor Alan Whiteside of the University of Natal gave an overview of the AIDS epidemic, which is currently centered in sub-Saharan Africa.

This may not, at first glance, seem like an appealing book: 28 true stories of people in Africa who have HIV/Aids or have been touched by it - that's one story for each million of the estimated 28 million people infected in Africa. But in fact, it is both brilliant and enraging, and contains accounts of some extraordinary people doing courageous things to fight the epidemic which go a long way to counter other stories of hopelessness, ignorance and corrupt or inept government.

Stephanie Nolen is an award-winning Canadian journalist who has lived in Africa for six years. The way Aids was ravaging the continent became clear to her while she was covering the crises in Uganda and Sudan and the aftermath of conflict in Sierra Leone and Rwanda. Her work in those areas brought her into contact with agencies such as Medecins Sans Frontieres - one of the few organisations trying to bring antiretroviral drugs and other treatments to HIV/Aids sufferers.

In the developed world, pregnant women carrying the virus are given a simple treatment in labour, along with their baby, and discouraged from breastfeeding. This lowers the risk of transferring the virus to about 2 per cent. In Africa, fewer than 10 per cent of pregnant African women get such interventions and, unlike here, almost none are tested for HIV; 700,000 HIV-positive babies are born every year, and most die before the age of five.

Then, of course, there is the dispute between Aids campaigners and the drugs firms that oppose generic antiretroviral treatments; the reluctance of governments such as Thabo Mbeki's to accept that HIV is sexually transmitted, or that ARVs can diminish the impact of the virus; and the fact that long-distance truckers in Rwanda and Uganda believe that they need to have regular unprotected sex to stay healthy.

Thankfully, there are some stories that stop you from totally giving up on humanity - from the tireless doctors who treat Aids patients to the campaigners who refuse to buy their own medication until it is freely available to all. Christine Amisi, for example, left the safety of a UN compound to continue her work as a nurse for MSF, risking her life in order to ensure that her patients got supplies of drugs. Nelson Mandela took on his own successor, Mbeki, when he realised that South African policy on the disease was causing thousands of unnecessary deaths, including that of his own son. Dr James Orbinski, who was president of MSF when the organisation was awarded the Nobel Peace Prize in 1999, says of the book: 'Read. Weep. Rage. And above all else - like those people described in this book - find the courage to do.'

This is a call to arms, to a battle that we should all have been fighting for a very long time.

HIV Research in Africa
A Series of Paradoxes

The pandemic outbreak of Human Immunodeficiency Virus (HIV) in Africa has generated worldwide interest in expanding clinical trials of HIV vaccines in developing countries. Since an infectious disease like HIV does not respect national borders, these studies have sparked international debate over the appropriate ethics for research in different countries and different continents. Specifically, questions have arisen regarding how American researchers conduct studies in Africa. This controversy stems from the fact that HIV research on human subjects affects the economic and social welfare of the populations under study. HIV’s economic and ethical issues are inseparable. Therefore, researchers and regulators are attempting to balance ethical imperatives against cultural, social, and economic realities, but complex paradoxes continue to puzzle researchers choosing between policies of universalism and policies of local particularism within the developing world.

Advocates of universalism believe that differences between countries should not prevent researchers from performing studies that adhere to globally-accepted ethical standards for clinical research. Those who support local particularism contend that the disparity between developed and developing countries should be taken into account when conducting HIV trials. This paper will suggest that researchers need to follow international rules that consider the inherent differences between the developing world and the developed world. Ethical research must be tailored to the specific needs of the communities under study and must be fully responsive to the economic, medical, and social contexts of those communities. This paper will first explain why any major clinical trial is difficult to design and execute in the hopes of generating useful but ethically sound information. Next, there will be a breakdown of the different arguments for and against the use of expensive treatments in the developing world. The conclusion will discuss political and social concerns that arise in response to the application of vaccine study results, especially when the countries under study are too poor to afford a day’s worth of medicine. Essentially, HIV vaccine trials should be conducted with the highest standard of care currently available.

HIV In Today’s World

Rates of disease and death related to HIV are increasing dramatically, but the available treatments for HIV are inadequate. Although Acquired Immunodeficiency Syndrome (AIDS) was unknown in 1980, it has grown explosively in the last twenty years. HIV is now the most critical incurable infection in the world.1 The burden of disease has been greatest in the poorest countries, where more than 90% of all HIV infections in children occur.2 In fact, AIDS is the leading cause of death in Africa, which is home to two-thirds of people living with AIDS or HIV,3 and despite intense national and international efforts to control the HIV pandemic, more than 16,000 HIV infections occur each day.4 Current treatments do not lead to a cure but, at best, slow the progression of the disease. The most effective treatment, antiretroviral medication, is complicated to administer, can cause serious side effects, requires close medical monitoring, and is extremely costly.5 These logistical and economic barriers make treatment inaccessible for many populations, creating a sense of urgency to develop a globally accessible HIV preventive vaccine to stop the epidemic.

The Developing World: A Promising Yet Controversial Site in the Search for a Cure

Although clinical trials of HIV vaccines began ten years ago in the U.S. and Europe, an increasing number of trials are now being conducted in developing countries. A number of factors make developing world countries attractive to researchers. First, trials need to be conducted in populations with a high incidence of new HIV infections in order to produce valid and timely results. Second, research in Africa is easier to perform due to its pervasive poverty, endemic diseases, and inadequate health care systems.6 These factors affect both the ease of performing trials and the selection of trials that can potentially benefit the populations of the countries under study. In the absence of health care, virtually any offer of medical assistance will be accepted as “better than nothing.”7 Third, the genetic variability of HIV requires that candidate vaccines be tested in different areas of the world where different strains are present.8 There are other, questionable incentives for carrying out studies in Africa: lower risks of litigation, less stringent ethical review, and populations prepared to cooperate with almost any study that appears curative in nature.9 As regulations at home become more restrictive and funding for studies abroad increases, research in the developing world looks relatively attractive.

Ethical Questions Surround Researchers

As the world enters the third decade of the HIV epidemic, it is clear that developing an effective study of HIV presents a formidable challenge in the forum of ethical behavior. First, there is the question of how to interpret ethical guidelines across international borders. If requested by local governments, should U.S. researchers perform experiments abroad using methods that would be considered substandard in the U.S.? Second, there is the issue of how to apply ethical guidelines to the unique economic situations in each country. Is the standard of care different in different places? Does it matter if local populations will not be able to afford the treatment under study? Each of these questions demonstrates how global social injustice and economic disparity influence the debate over ethical research.

The rising prevalence of HIV spurs researchers to conduct studies that are scientifically acceptable but ethically questionable. When studies are conducted across national and cultural boundaries, there is a greater potential for exploitation in research. The degree of access to health care, the economic situation, and the social norms of experimental populations can lead to potentially unfair trials on African populations for the scientific benefit of those who are better off. Researchers conducting HIV studies overseas should guard against the potential for exploiting the less fortunate citizens of developing countries.

Unfortunately, this can be difficult to do. A major struggle originates from the fact that researchers must maintain universal ethical standards while also considering the local standards of ethics in the developing world. Ideally, the way to prevent exploitation of a research population is to insist that informed consent be obtained. However, most Africans have not socially accepted the concept of informed consent.10 It is difficult to ensure informed consent in cultures which may not accord individual self-determination the same importance as Western societies. This also raises the issue of whether some ethical standards fail to be culturally sensitive and relevant. Consider the Western policy of counseling before testing. It implies that a patient is able to hold and maintain views independent of the doctor’s, and it usually assumes some educational sophistication. In Nairobi, such relationships are unusual between patient and doctor.11 Additionally, there is a great shortage of trained counselors in Africa, which means that some patients will not be fully counseled on the details of the study. Even if they are, consent, important though it is, is not enough protection because of the asymmetry in knowledge and authority between researchers and subjects in developing countries.12 However, these studies can still provide benefits to the participants and the researchers, so the lack of counseling does not necessarily mean that research should be stopped on ethical grounds. One major concern is that, by defining some problems as ethical rather than cultural or developmental, international funding agencies may erect unnecessary barriers to research.

Researchers often have a difficult time ensuring that the subjects’ participation is truly voluntary. If expensive and sophisticated treatment is provided in a context where no treatment is generally available, this may constitute undue inducement to participate in a trial.13 In populations lacking access to even basic care, individuals may view participation in any research study as beneficial, even when it includes placebos. Therefore, the ethical standard of informed consent does not ensure that a study is acceptable according to universally held principles. These are just two examples of the dilemmas that researchers face, but they reflect the complicated decisions that researchers must make when testing drugs in the developing world.

Zidovudine: Potential Panacea or Divisive Marker?

Recent trials on HIV-infected women in Africa highlight the current debate on international research and offer some solutions. A series of studies called the AIDS Clinical Trials Group Protocol 076 led to a major breakthrough in the search for a way to interrupt the transmission of HIV from mother to infant.14 During pregnancy and labor, a special regimen involving zido-vudine, which is the generic name of the drug AZT, reduced the incidence of HIV infection of infants by two-thirds.15 The regimen is so effective that it has become the standard of care in the United States and in other developed countries.

However, the treatment has a number of disadvantages for women in developing countries. First, it requires women to go through early HIV testing and counseling. Women must also comply with a lengthy oral and intravenous course of therapy, submit to expensive treatment of the antiretroviral drug, and refrain from breastfeeding.16 These requirements are extremely problematic because the incidence of maternal-infant transmission of HIV is greatest in countries where women have limited access to prenatal care. These women also depend on breast-feeding to protect their babies from many diseases besides HIV. Furthermore, both mother and infant must be carefully monitored for any adverse effects from the drug. Zidovudine has a very powerful impact on the body, and its safety is unknown in countries with a high rate of malnutrition and generally poor public health. Side effects may include anemia, headaches, dizziness, skin rashes, generalized weakness, stomach pain, muscle aches, fever or sweating.17 Although zidovudine is clearly the most effective therapy, it continues to be non-curative, complex to administer and monitor, and extremely expensive.18

Thus although zidovudine is a standard treatment in the developed, it is rarely used in developing countries. At more than $800 per patient, it is too expensive for widespread use.19 For example, in Malawi, the cost of zidovudine for one HIV-infected mother and her child is more than 600 times the annual per capita allocation for health care.20 Consequently, there is an urgent need to develop a more practical and affordable intervention to reduce the vertical transmission of HIV from mother to infant. Worldwide health organizations have called for studies of alternative regimens which could be used in developing countries, observing that the logistical issues and costs preclude the widespread application of the zidovudine regimen. The scientific community has responded by carrying out trials of several promising regimens that are recognized as candidates for widespread delivery in poor countries.

Methodological Dilemmas

In these new trials, the ethical debate centers on the question of whether to use zidovudine or a placebo as the standard control. A number of researchers propose giving placebos to the control group instead of zidovudine, because if the expensive zido-vudine regimen were used as a control, it would be unlikely that the treatment could be successfully applied in developing countries. Even in studies suggesting the addition of a zidovudine group to compare with a placebo control group and an experimental group, there will still be a number of people who will not receive the best-known treatment. At first glance, it may seem that unscrupulous researchers are simply using subjects in Africa for their own profit. But in fact, it is more complicated than that. The issue is not whether zidovudine would be affordable for the very limited number of research subjects: pharmaceutical companies can easily afford to pay for their subjects’ care during experiments. In essence, the debate arises over whether research should be measured against treatment known to be effective even if it is unattainable for the general population, or against the level of potentially ineffective treatment that meets the local standard. Paradoxical conflicts emerge when researchers need to choose between applying universal international guidelines and recognizing region-specific principles.

Best Treatment or Practical Treatment?

Researchers are pressured to generate useful scientific data while still providing the most beneficial information to African countries. A simple approach to these studies, then, would be to use a placebo instead of zidovudine as the control treatment. This would provide rapid and reliable information, as scientists would be able to determine the true effectiveness of a new regimen as compared to non-treatment. Because treatment needs to be both efficient and affordable for Africans, using a placebo for a control would help researchers know what works best within the social and economic contexts of the regions under study. However, failing to provide the best-known treatment violates commonly held ethical standards. The difficulty is in choosing between applying strict universal standards or allowing for region-specific guidelines that may go against basic ethics. The paradox arises when emphasizing economically viable treatments means acknowledging a global double standard.

Researchers make a strong case for using a placebo over a best alternative treatment. One important dilemma about the use of ziduvodine is whether HIV vaccine trials provide vital information for use by the sponsoring country, the country being tested, or possibly by both. On one hand, using zidovudine as the control treatment is definitely useful for worldwide knowledge. But, since zidovudine is too expensive to administer in countries of the developing world, using it as a control treatment means that developed countries create tests that are used for their own benefit. Harold Varmus, speaking for the National Institute of Health, and David Satcher, speaking for the Center of Disease Control and Prevention (CDC), both address this. They wrote in the New England Journal of Medicine that “trials that make use of impoverished populations to test drugs for use solely in developed countries violate our most basic understanding of ethical behavior.”21 It would be wrong to export research that could not ethically be carried out in the United States to countries more desperate for research benefits. Avenues for exploitation are opened when the research results that intend to benefit local populations are imported into treatment regimens in the United States, raising the question of why these trials were not performed in the United States in the first place. Unless the tested regimens will actually be made available to the impoverished nations, developed countries are simply exploiting them in order to use the knowledge gained from the clinical trials for their own benefit. Consequently, the challenge to developed countries is to improve the health of people in developing countries by delivering drugs that are both effective and affordable to them. Ethics and basic human rights require not a thin promise, but a real plan as to how the intervention will actually be delivered.

In fact, there are ongoing discussions to clarify the wording in the guidelines mandating the best-proven treatment in clinical trials. The Helsinki Declaration of the World Health Organization (1964) is one of the most influential sets of international ethics guidelines. It requires control groups to receive the best treatment currently available anywhere, not just the locally feasible one. Some people have recommended revising the Helsinki document by changing “best proven treatment” to “appropriate treatment.”22 They believe that this would help clarify the dilemma of what to do when the best-proven treatment is unclear, especially when economic and social differences hinder researchers from practically implementing the best-proven treatment. They also point out that placing emphasis on testing the “best methods” distracts researchers from exploring economically viable treatments. To provide additional support, an organ of the United Nations coordinating AIDS efforts, called UNAIDS, is also actively addressing bioethical issues. One council member agreed that it “really is important that ethics evolve, and guidelines should never be rigid.”23 UNAIDS will continue to hold a series of meetings with health officials from around the world, hearing views on such questions as whether changing the recommendation to “appropriate treatment” would work.

Therefore, experts advocating local particularism justify the use of a placebo or some other substandard care to identify treatment that is both effective and affordable. The inclusion of placebo controls will result in the most rapid, accurate, and reliable comparisons between the intervention being studied and the local standard of care. Marcia Angell, editor of the New England Journal of Medicine, asserts that the directors of the National Institutes of Health (NIH) and the CDC, organizations which sponsor the studies, are of the opinion that “women in the Third World would not receive antiretroviral treatment anyway, so investigators are simply observing what would happen to the subjects’ infants if there were no study.”24 Indeed, Dr. Varmus and Dr. Satcher argue that the use of a placebo control is ethically acceptable, since assignment to the placebo group would “not carry a risk beyond that associated with standard practice.”25 They strongly contend that HIV trials conducted with placebos do not violate any human rights because treatment is practically unavailable in an impoverished place like Africa. Since the American standard of care is simply not feasible in the developing world, placebo trials are useful to countries of the developing world when the studies apply region-specific knowledge to benefit the populations.

On the other hand, there are several reasons to use zidovudine over a placebo. First, trials that replace zidovudine with a placebo (or some other substandard treatment) would be considered unethical and even illegal in the United States or any other nation with high ethical standards and strict governmental guidelines. In fact, Marcia Angell states, “only when there is no known effective treatment is it ethical to compare a potential new treatment with a placebo. . . . Instead, subjects in the control group of the study must receive the best known treatment.”26 She bases her argument on the Helsinki Declaration, which requires control groups to receive the best treatment currently available anywhere. It states, “in research on man, the interest of science and society should never take precedence over considerations related to the well-being of the subject,” and, “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.”27 These guidelines must be followed, since clinical studies involving human participants are subject to strict review. By this argument, researchers should administer the treatment that has been proven the most effective, regardless of high costs or impossible application to the rest of the population.

Second, although in theory it is unfair that zidovudine cannot be made widely available to AIDS patients in developing countries, that is the reality that these patients face. When developed countries perform research on subjects in developing countries, the central issue at stake is exploitation. Yet, a health official in Uganda wrote the following to the director of the NIH regarding concerns that HIV vertical transmission trials in his country were exploitative: “It is not NIH conducting studies in Uganda but Ugandans conducting their study on people for the good of their people with the support of the NIH.”28 If governments and researchers in a specific country believe that zidovudine should be used in place of a placebo, even though they know they will never be able to distribute zidovudine to their people, international researchers should err on the side of the government. Even if it seems unethical that advanced treatments are not being administered to the general population, at least the results of research that uses zidovudine will be practically implemented and will fit local realities because they will say something about the actual drug that is being tested.

Third, using zidovudine is of value for the sponsoring country, especially when an experimental drug is shown to be effective. For example, if the research reveals equally effective regimens, they will surely be implemented in the developed world and will save thousands of lives. From the Epidemiological Research Unit in Denmark, Aaby et al. wrote a group letter reacting to an editorial article in The Lancet29 asserting, “many would judge these inequalities to be offensive to our ethical systems that hold all human lives to be of equal value, but nonetheless the profound injustice in the global distribution of health resources is ugly but real.”30 Aaby and colleagues effectively point out the fact that there are unalterable differences in the global distribution of health resources between countries. Thus, the same condition may be treated in a different way in various countries, which means that the outlook for those living in the poorest countries is substantially worse than for those in wealthier countries. Differences between treatments should not be looked upon as unethical, however, since it is impractical to apply universal standards to drastically different circumstances.

But even if the best possible treatment is not feasible for everyone in a poor country, research with potential benefits should not be cut short. Zidovudine would be good for at least the voluntary participants of the study, and maybe even for a fraction of the population. Philip Phanuphak of the Red Cross Society in Thailand (also a site of HIV vaccine trials) supports this argument by pointing out that at least half of the subjects ? those receiving active treatment of zidovudine ? will probably benefit.31 Researchers ought to be pragmatic in helping as many people as possible. By using zidovudine rather than a placebo, some people will be treated, regardless of the number of other people who will go untreated.

Another paradox arises when one considers the differences between international fairness and local fairness in administering treatment. When researchers do not provide zidovudine, it seems like they are taking advantage of global inequalities in health care. In effect, any controversy over placebo-controlled trials is a dispute over applying ethical principles in radically different economic conditions. It is the social context of undistributed wealth and resources that both mandates these studies and, at the same time, renders them so troubling. And while researchers cannot justify placebo controls in a vertical transmission trial in the United States, the realities of health care resources in San Francisco, USA, are vastly different from those in Nairobi, Kenya. Obviously, differences between developed and developing countries make it hard to determine what is appropriate and ethical when conducting research in the developing world.

Foreign-funded research has gone on for many years in Kenya and has always involved “international” ethical standards. Peter Lurie and Sidney Wolfe support this universal application of ethics, stating that “to claim that acceptable standards of care are shaped only by local conditions is to confuse optimal medical care with the quality of the local health care infrastructure.”32 Trials using substandard treatment (i.e. placebos) would not be approved in the United States because of strict governmental guidelines. Thus, to apply only the local standard of care creates an incentive to find research subjects with the least access to health care instead of focusing on research that will best serve those in need. Researchers need to realize that human rights are universal and cannot be compromised solely on the basis of beliefs or practices of any one country or group.

Social Equality in Drug Studies

Providing the special regimen to a few research subjects means that these inequalities become local problems for African countries. In turn, this side illustrates social tensions within countries of the developing world. Currently, many African leaders oppose the zidovudine treatment because of impractical costs. In South Africa, President Thabo Mbeki does not want to his country to participate in the latest HIV vaccine trials because even if the treatment can significantly reduce mother-to-child transmission at birth, that treatment will not be affordable for many poor women in Africa.33 African leaders such as Mbeki address the fact that it is impractical to adapt the scientific knowledge and technology of the First World to the developing world. The reality is that the unique circumstances of countries render direct transfer inappropriate and ineffective. Surely, a pragmatic approach should be adopted in which available resources are used to the fullest and solutions are found to specifically help African problems. The challenge is how to make the best-proven and most applicable regimens available to people in developing countries.

The social side effects of research on local African populations must also be considered when analyzing the ethics of vaccine trials. Those infected with HIV have experienced stigma, marginalization, and discrimination in many forms, and African volunteers participating in HIV vaccine trials may be falsely identified as HIV-positive simply through their association with a trial, or by developing falsely positive antibody tests as a result of receiving candidate vaccines.34 Furthermore, the African population is vulnerable due to region-specific factors like inadequate protection of human rights, limited availability of health care and treatment options, and insufficient formal experience in reviewing the proposed research.35 Thus, the risk of social and psychological harm is substantial for human subjects participating in vaccine research in Africa. Researchers need to adopt wholly new ethical standards for Africa because of the unique social consequences of HIV infection.

Conclusion

Ethical paradoxes arise when countries with relatively high levels of economic development initiate, design, or fund research conducted in countries that are relatively less developed. Developing world testing of new regimens brings to light the ambiguities in international guidelines, creating headaches for researchers and policy makers alike. AIDS in the developing world is reaching crisis proportions, and in a rush to develop new drugs to treat AIDS, many researchers have sidestepped medical standards that apply to developed countries and have used the dire social and economic situations in developing countries to justify their actions. Although a compelling argument can be made that subjects in Africa and elsewhere would not be able to afford zidovudine anyway, researchers should not use that as an excuse to conduct ethically questionable trials. The fact that these subjects live in developing countries does not make them any less worthy of high medical standards during research trials.

Permitting trials to continue without offering control groups the best available treatment sets a dangerous precedent of capitalizing on the disadvantaged situation of people in the developing world. The Helsinki Declaration exists for precisely this reason: to ensure that economic factors do not cause researchers to determine that certain humans are less worthy of effective treatment for their illnesses. Even if using a placebo more accurately simulates the real alternative to treatment that subjects face (which, in countries that cannot afford costly drugs like zidovudine, is usually no treatment at all), that alternative is well known, and need not be simulated any longer. Researchers know that the only alternative to treatment is eventual death, and any new drug that might delay death, or at least ease a patient’s suffering during life, is worthy of use. In light of this, ziduvodine should be used instead of a placebo because it does not detract from findings about the new drugs being developed, and it at least gives some AIDS patients the chance for life. Only with ethically sensitive research practices can the developed world avoid exploiting the less fortunate citizens of developing countries.

Amanda Silverio is a junior majoring in Human Biology with a focus on health and human performance. She hopes to enter medical school within the next few years, but in the meantime she is working on an Honors research project in immunology. In her spare time, Amanda enjoys tutoring at a local elementary school and volunteering at a student-run medical clinic that serves the surrounding community.

Endnotes

1 Guenter D., Esparza J., Macklin R. “Ethical Considerations in International HIV Vaccine Trials.” Journal of Medical Ethics. February 2000;26(1):37.

2 Perinatal HIV Intervention Research in Developing Countries Workshop Participants. “Science, Ethics, and the Future of Research into Maternal Infant Transmission of HIV-1.”The Lancet. March 6, 1999;353(9155):832.

3 Guenter D., Esparza J., Macklin R. p. 37.

4 Ibid p. 37.

5 Ibid p. 37.

6 Varmus H., Satcher D. “Ethical Complexities of Conducting Research in Developing Countries.” New England Journal of Medicine. October 2, 1997;337(14):1003.

7 Annas G., Grodin M. “Human Rights and Maternal-Fetal HIV Transmission Prevention Trials in Africa.”American Journal of Public Health. April 1998;88(4):562.

8 Guenter D., Esparza J., Macklin R. p. 38.

9 Bayer R. “The Debate over Maternal-Fetal HIV Transmission Prevention Trials in Africa, Asia, and the Caribbean: Racist Exploitation or Exploitation of Racism?” American Journal of Public Health. April 1998;88(4):567.

10 Annas G., Grodin M. p. 562.

11 Bayer R. p. 568.

12 Angell M. “The Ethics of Clinical Research in the Third World.” [editorial]. New England Journal of Medicine. September 18, 1997;337(12):847.

13 Guenter D., Esparza J., Macklin R. p. 41.

14 Cohen J. “AIDS Researchers Look to Africa for New Insights.” Science. February 11, 2000;287(5455):942.

15 Kahn J., Mastroianni A. “Innocents Abroad?”Minnesota Medicine. July 1999;82:28.

16 Varmus H., Satcher D. p. 1004.

17 http://www.aidsinfonyc.org/network/access/drugs/zido.html

18 Guenter D., Esparza J., Macklin R. p. 41.

19 Varmus H., Satcher D. p. 1004.

20 Ibid p. 1004.

21 Ibid p. 1003.

22 Guenter D., Esparza J., Macklin R. p. 41.

28 Stories Of Aids In Africa Pdf Map For Kids

23 Karim S. “Placebo Controls in HIV Perinatal Transmission Trials: A South African’s Viewpoint.” American Journal of Public Health. April 1998;88(4):566.

24 Angell M. p. 847.

25 Varmus H., Satcher D. p. 1004.

26 Angell M. p. 847.

27 Ibid p. 847.

28Varmus H., Satcher D. p. 1005.

29 Editorial. “The Ethics Industry.” The Lancet. 1997;350:897.

30 Aaby P, et al. “Ethics of HIV Trials.” [letter]. The Lancet. November 22, 1997;350(9090):1546.

31 Phanuphak P. “Ethical Issues in Studies in Thailand of the Vertical Transmission of HIV.” New England Journal of Medicine. March 19, 1998;338(12):834.

32 Kahn J., Mastroianni A. p. 28-9. see also Lurie P., Wolfe S. “Unethical Trials of Interventions to Reduce Perinatal Transmission of HIV in Developing Countries.” New England Journal of Medicine. September 18, 1997;337(12):855.

33 Cohen J. p. 942.

34 Guenter D., Esparza J., Macklin R. p. 38.

35 Ibid p. 39.