The trouble with Public Health: HIV/AIDS in Canada as a case in point

Here's my latest Editorial from the February issue of Bioethics

It has been known among HIV/AIDS specialists for many years that infected people are for all practical intent and purposes unable to transmit the virus on to their sex partners, provided they consistently take anti-HIV medicines that render the amount of the virus in their bloodstream undetectable. Common sense would have suggested that Public Health authorities should have acted on this knowledge and ensured that it is deployed in such a way that it contributes toward the maximisation of desirable public health objectives, in this case, obviously the reduction in number of new infections. Public Health agencies should have revamped existing policies demanding that infected people disclose their HIV status to their sex partners to no disclosure required where ‘your viral load is undetectable for 12 months’ or some such figure. This would have dramatically increased the attractiveness of getting tested, of getting infected people discovered in a more timely fashion, getting them treated in a more timely fashion, and ultimately getting their viral load to undetectable in a more timely fashion. The predictable result of this policy change: A significant reduction in new HIV infections. Common sense and Public Health are sadly all too often residing in different realities.

Nothing of this sort occurred during the last few years. HIV infected people with undetectable viral loads were prosecuted for not disclosing their status. Public Health agencies, when given a chance, would disclose their HIV status to their sex partners. The contact tracing Public Health surveillance machine remained in overdrive in countries such as Canada. About 200 carriers of the virus were prosecuted over the years in that country alone. None of this served the public health objective just outlined, and none of this was evidence driven. Rather, it was driven by views on HIV/AIDS that may have had a place in the 1980s to early 1990s when AIDS was considered as a serious public health concern. Today, with negligibly low new infections rates, it is worth asking why HIV remains high on the agenda of Public Health agencies. HIV is clearly not a public health concern in Canada and most other countries of the global north. My suspicion is that the threat of prosecution serves purposes unrelated to HIV, they serve to control consenting adults’ sexual behaviours.

Much is made of the fact that an estimated 1:5 Canadians who are infected with the virus are unaware of their infection. What is typically not mentioned by the same Public Health officials is that they have gone out of their way to make it difficult for Canadians who are HIV infected to find out about their infection. Because the contact tracing government Public Health agencies want to know about each infected Canadian, by name and address, they cannot permit people at risk to test themselves with tests they can conveniently buy down south in the United States in every pharmacy. Unsurprisingly, a different government agency, the drug approval regulator Health Canada, has swung into action and threatened people with prosecution who import and resell reliable, US FDA approved, HIV self-tests into Canada, lest they would find out whether they are infected and Public Health not having their names and addresses on their records. You might not be surprised to learn that while STI testing and treatment is ostensibly free and anonymous at the country's Public Health agencies, in reality patients must show their provincial health insurance cards or else they are out of luck if they carry an STI but fail to provide the said card. The UK's NHS unsurprisingly manages public health in a manner somewhat more focused on infection control than administration.

It is no surprise then that in a country where government surveillance has been prioritised over and at the same time conflated with public health, people at risk of HIV infections remain reluctant to get tested. They have no reason to trust Public Health to act in a timely fashion in response to evidence.

In late 2017, Canada's federal government noticed after much studying what has been known for years about HIV transmission risk and undetectable viral loads. Both federal and provincial justice ministers appear to be finally acting in response to the existing evidence. Prosecutions of HIV infected people with undetectable viral loads who do not disclose their status to their sex partners are likely to be a thing of the past in that country.1

The main lesson I am suggesting we take away from this episode of HIV/AIDS prevention in Canada is to ask that Public Health agencies' policies should be held to public health outcomes, otherwise they serve no purpose. The cavalier approach to civil liberties taken not only by Canada's Public Health agencies, one that was not evidence based for many years, must be replaced by a policy approach based transparently on the latest scientific evidence. A golden rule in most public health ethics documents is that limitations on civil rights (in this case ownership of one's confidential health information) must be justified by significant benefits in public health outcomes, i.e., the public interest. HIV disclosure policies executed by Public Health agencies have failed this test for a very long time. Public Health agencies in Canada in particular have lost trust and support among people at risk of HIV infection because they lost sight of public health outcomes while focusing on Public Health administration and control. A paradigmatic case of how not to implement efficient infection control policies.

Footnote

1. 1
   Harris, K. (2017, December 1). Liberals want to limit prosecutions of people who do not reveal status to sex partners. CBC NEWS. Retrieved from http://www.cbc.ca/news/politics/liberals-hiv-criminalization-1.4428395

AIDS and Medical Aid in Dying - are there lessons to be learned?

Canadians debate currently where to draw the line in the sand in terms of eligibility criteria for medical aid in dying. The federal government is determined to push thru a bill that is uncontroversially unconstitutional by limiting access to terminally ill patients.

Today the Globe and Mail (a paper that supports our government's restrictive approach to medical aid in dying) published an unusually thoughtful commentary by Konrad Yakabuski in support (you won't be surprised to hear) of said restrictive approach.

Yakabuski and I have something in common, something important. We both lived thru the early years of the HIV/AIDS epidemic, we both lost loved ones to the disease. Yakabuski mentions that his brother and several friends of his died of the ravages of AIDS, 'with dignity, the old-fashioned way'. Yakakuski's main point (a very reasonable point) is that eventually treatments for HIV infection came about that permit HIV infected individuals today to live basically healthy lives. If medical aid in dying would have been available to them, some HIV infected patients may have chosen to end their lives prematurely, however, if they had decided to stick it out, they might have been able to hang on for long enough to benefit from the life preserving drug regimes that exist today. He then makes the same claim about anti-depressants (arguably he is terribly mistaken on that frontier, but that's unimportant for the purpose of his broader point, it doesn't rely on him being right on that count).

Well, I'm a gay man who has seen very many of his friends succumb to HIV infection in the same years that Yakabuski writes about, and I disagree entirely with his argument and his policy recommendations. You won't be able to see this response in the Globe and Mail, unfortunately, because the paper has been reduced to a propaganda vehicle for a restrictive assisted dying regime.

There has been some debate both among medical ethics people, but certainly also among HIV infected people about medical aid in dying, in the 1980s. One leading bioethics journal, the Hastings Center Report, published many years back a piece by my friend, the late Michael Callen, entitled 'If I have AIDS, then let me die now.' Michael had, of course, no intention whatsoever, to die on AIDS. In fact, years after he published his commentary he wrote a book called Surviving AIDS. Eventually he succumbed to the disease, shortly before life-preserving treatment regimes came onto the market. I have lost far too many friends like Michael.

But I digress, let's return to Yakabuski's commentary. Why would educated AIDS activists, like Michael, have written a commentary for a mainstream medical ethics journal in which they argued that they should be able to receive medical aid in dying when they thought their time had come? Simply put, it was about self-determination. Something maligned by Canadian anti-choice activists as 'autonomy fundamentalism' (not Yakabuski's words!). It was a choice for Michael to make for himself, not for me, not for government, it was his call to make.

The problem with timelines in this context is that we can never know whether, if at all, and when a successful treatment for a particular ailment comes onto the market. Yakabuski briefly mentions the horrible deterioration in health and quality of life HIV infected people in those days experienced. It was worse than that, they had seen friends and lovers wither away, they knew what was coming their way. It's all nice and well to describe this withering away as 'dignified and old-fashioned', but frankly, for many of these young people who died during those years there was nothing dignified about their dying, and no amount of hand-holding and caring would have made their disintegrating lives any more dignified. I am deeply troubled about the euphemisms Yakabuski deploys to describe what was actually happening in our community. I also have no doubt that that is how he subjectively experienced or remembers his brother's death. It is not an experience that is representative of how dying of HIV was experienced by many, if not most, of those who died in those years.

The question then, surely, is whether these patients were entitled to call it a day when they decided they had enough, or whether the state had any right (as the Liberal government's legislation proposes) to force them to stick around and deny them access to medical aid in dying on the ground that some drug might come about. My answer: Of course they were entitled to make those choices and see those choices respected and supported. That the state would think it has a role to play in forcing such patients to stick around no matter what, or commit suicide by some gruesome means, is just mind boggling.

HIV is different to depression, of course, in that it was actually an illness where death would have been reasonably foreseeable, so HIV patients arguably would have met the standard set out in the restrictive government draft legislation of bill C14.

I have published a year ago with Suzanne van de Vathorst a lengthy piece on treatment resistant depression and medical aid in dying. May be take a minute or two to read it. It's available here. The same link will also take you to published responses, including one or two making Yakabuski's case, as well as our considered response to those arguments. The article also supplies hard data on the actual large scale failure of available treatment modalities that Yakabuski glosses over in his piece. The argument here is the same as above, if a patient is competent at the time of decision-making and he or she does not consider their lives worth living, and available treatment options have been exhausted, we as a society have no right whatsoever to force such people to stick around in the hope that some treatment might come about during their lifetime. It's a decision only such patients can make for themselves. Whatever they decide, they deserve our support.

Future Infectious Catastrophic Disease Outbreaks: Ethics of Emergency Access to Unregistered Medical Interventions and Clinical Trial Designs

The mass media excitement about Ebola has receded. The 2014-2015 West African outbreak has been brought under control not thanks to the deployment of successful treatment regimes, because there are none that are known to work. I participated recently in an international meeting of experts debating the ethical and methodological issues pertaining to trial designs for emerging infectious diseases like Ebola. It was both astounding and also immensely frustrating that to a large extent the controversies that exercised the minds of the delegates of this meeting exercised the minds of many an AIDS activist and clinical trials’ expert prior to the advent of highly active antiretroviral therapy, a good quarter of a century ago.[1] [2]Are placebo controls an ethically defensible methodological tool when patients face a terminal illness? Different alternative trial designs involving placebo controls, adaptive trial designs, and multi-stage approaches involving active controls were discussed during the meeting. The heated nature of some of these debates reminded me strongly of the passion that was on display during the early HIV trials. It turns out, despite decades of informed debate about these issues, a number of significant normative questions have not been settled.

A cluster of difficult ethical questions that engendered justifiably a lot of debate has to do with the use of placebo controls in trials involving patients facing a very high mortality risk (some in excess of 90%) and a fast-acting infection resulting in the death of these patient within 2-8 days after admission to a treatment centre. This scenario mirrors the sobering reality faced by a subset of Ebola Virus Disease patients. This issue was already highly contentious during the early HIV trials, and then patients and clinical investigators were faced with a virus that was nowhere near as fast-acting as the Ebola virus. The ethical conflict that arises here is this: We know that those randomized into the placebo arm face the same greater-than-90%-risk of death within a few days as those who receive the standard of care treatment. In some trial design the placebo control arm could be identical to the gold standard of (unsuccessful) clinical care provided in a particular clinical setting. Given that those who are randomized into the arm featuring the unregistered medical intervention might do better, or might do worse, or might do roughly as badly as those in the placebo control arm, the ethical question remains whether a trial design featuring a placebo control is ethically justifiable, given the almost certainty of imminent death faced by those randomized into the placebo arm. During the meeting I alluded to earlier a fairly contentious debate arose also over the question of whether trials producing less reliable results than placebo controlled trials might be acceptable under such circumstances.

What exacerbates the ethical challenges for those who undertake such trials is that their trial participants are arguably not true volunteers. Their – dying - trial participants are not given the opportunity to choose between participating in the placebo controlled randomized trial versus accessing the unregistered medical intervention on their own volition outside the trial process. It is perfectly conceivable that some patients might choose to participate in such trials in order to facilitate the development of a successful intervention capable of helping future patients like them. Or they might accept that there exists true clinical equipoise between the trial arms and they might be volunteering to be randomized under such circumstances. In the absence of alternative access routes to the unregistered medical intervention, we can never be certain that the patients agreeing to be randomized are not simply responding to what constitutes a coercive offer.

Clinical investigators colluding in this process, and arguably benefiting from it, are not absolved of their ethical responsibilities because they did not create the regulatory frameworks that gave rise to the problem. It is true that they did not create the regulatory framework under which they operate, but they undoubtedly benefit from its existence. We could respond to this kind of argument by pointing to the societal need for sound trial designs and the detrimental impact of permitting patients to access unregistered medical interventions outside the clinical trials’ system. The likely impact of permitting patients access, as a senior biostatistician attending the workshop rightly pointed out to me, would be a significant slowing-down in the trial recruitment process. Some trials might never be able to recruit sufficient patients, because most patients might be voting with their feet and opt to take their chances with the unregistered medical intervention. Surely that is not quite what is in the best interest of any society battling an emerging infectious disease such as Ebola. Does this justify coercing dying people into particular trial designs? I do not think so, but this is a contentious issue where reasonable, well-informed people can justifiably differ. A WHO panel looking at this question argued that while it would be ethically defensible to offer emergency access to unregistered medical interventions to Ebola patients, this should be subject to that emergency access not slowing down trial recruitment.[3] The panelists (not featuring a single expert or disease survivor from the affected countries) took a policy line here that mirrors US regulations. Other countries, including Canada and South Africa do not make this a threshold condition for emergency access. As it is with these sorts of panels, the advice it rendered on this controversial topic is not actually reasoned for, so policy makers and regulators as well as patient rights advocates aiming to balance the competing interests of access versus trial recruitment in a fair manner will be left wondering about the ethical reasons for this policy stance taken by the WHO panel, assuming there are any.

There are other ethical issues that arise in this context: Some experimental agents existed at the time only in insufficient quantities, for instance ZMapp, an unregistered medical intervention composed of monoclonal antibodies, was only available in very limited quantities. In light of this situation, is it acceptable to prioritize patients in comparable clinical circumstances who are willing to be randomized in a placebo controlled trial over patients clamoring for direct emergency access, given that the available quantities of this unregistered medical intervention would have been used up in the placebo controlled trial?

And here is another difficult question: While the AIDS activists of days gone by were highly educated about their disease and about the available unregistered medical interventions considered for expanded access programs, this is not quite the case with regard to the average West African Ebola patient. These patients were unlikely able to provide valid first person informed consent, because they were unable to demonstrate a reasonable person understanding of what was known about the unregistered medical intervention, about their options and so on and so forth. This is the case both because of educational limitations as well as disease progression. Are short-cuts to informed consent ethically justifiable under such circumstances? Given that time is of the essence and proxy consent might not be feasible due to family members being deceased or in a far-away village, are our informed consent requirements reasonable under such emergency circumstances?

The WHO panel suggests that evidence from nun-human primate experiments might be sufficient to justify offering a particular unregistered medical intervention for emergency access. Is that an ethically justifiable stance, given the high mortality rate and fast-acting nature of the infection?

Let me leave you with a final difficult question to ponder: Imagine you were running a medical NGO providing access to unregistered medical interventions to patients you care for in your emergency medical centre. By some fluke your unregistered medical intervention permits some of your patients to survive, but that survival comes at a high price, debilitating after-effects of the Ebola virus as well as of the unregistered medical intervention. Given concerns about your patients’ capacity to provide valid informed consent, should you accept responsibility for the patients’ future care and upkeep, given the lack of state infrastructure to assist these patients? If you accept responsibility for their care, say, by taking out an insurance package from some provider for them, you will expend a fair amount of donor monies on these patients (potentially for decades) that you cannot use to assist patients also facing life-threatening illnesses in other parts of the world. In other words, you face another ethical challenge, a resource allocation challenge. How should that medical NGO go about addressing this challenge?

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[1] U Schuklenk, C Lowry. 2009. Terminal illness and access to Phase 1 experimental agents, surgeries and devices: reviewing the ethical arguments. British Medical Bulletin 89: 7-22.

[2] U Schuklenk, C Hogan. 1996. Patient access to experimental drugs and AIDS clinical trial designs: ethical issues. Cambridge Quarterly of Health Care Ethics 5: 400-409.

[3] WHO. 2014. Ethical considerations for the use of unregistered interventions for Ebola virus disease.  WHO: Geneva 2014: p. 5.

Globe and Mail misleads about HIV/AIDS legal basics and vaccine research

Hmm, the Globe and Mail newspaper, Canada's only paper that comes reasonably close to being a national quality outlet, decided to contribute to today's World AIDS Day by offering a list of nine things we should know about HIV.  Good idea, questionable execution.

Under point five the paper informs us in the subheading going with point five (out of nine)

'5. In Canada, it’s is illegal for HIV-positive people to have sex without disclosing their status.'

Except... it isn't actually illegal for HIV-positive people to have sex without disclosing their status. As the journalist responsible for the list notes in the paragraph right under the subheading,
'A more recent Supreme Court ruling stated that a person living with HIV does not have to disclose their status before having vaginal sex if a condom is used and the person has a low viral load.'

That's actually the case. Canadians who happen to be HIV-positive, have an undetectable viral load and use condom during sexual intercourse are not under a legal obligation to disclose their HIV-status to their sex partners.

Important lesson. Make sure to scan more than just the subheadings of the Globe and Mail.

The journalist writing up the nine point list of random 'facts' made up another 'fact' altogether:

'8. The first and only preventative HIV vaccine is being developed in Ontario, but it still has a way to go.'

Reality check:  lots of preventative vaccine candidates are being tested in clinical trials. They pretty much all flamed out to date without doing much. The Globe and Mail journalist responsible for the nine point list links this particular 'fact' to a 2013 article in a business paper alerting readers to the fact that a team at Western University succeeded in testing their vaccine candidate in a phase 1 clinical trial. Phase 1 clinical trials only test for toxicity, no more. So, the long and short of it is that nothing much is being 'developed' on the preventative vaccine front in Ontario. Here's the Globe and Mail take on this: 'Preliminary clinical trial results appear positive but there are still many hurdles to overcome, including manufacturing and regulatory approval.' That's a funny way of looking at a vaccine candidate that has - according to the report the Globe and Mail article uses as reference - barely emanated from phase 1. If you think that manufacturing and regulatory approval are the relevant hurdles to take when it hasn't been established that the agent actually works as a preventative agent, you might want to reconsider your investment strategies as far as pharmaceutical companies are concerned.

This hyping of clinical research in the absence of firm evidence seems to become standard journalistic operating procedure in this country, ever since experimental agents were randomly promoted to Ebola vaccines by eager journalists across the country.

Check out the Globe and Mail piece, some of the other 'facts' seems suspicious, too, but I don't have the time to fact-check this particular list of 'facts' in detail.

In Saskatchewan, where the prevalence rate is three times the national average, a person is infected even more frequently.. A person is infected with HIV in Canada every three hours.

In Saskatchewan, where the prevalence rate is three times the national average, a person is infected even more frequently.

Public Health Arguments and Civil Rights Protections

For some time now gay civil rights (aka gay rights) activists have argued that same sex relationships and conduct should be decriminalized because evidence shows that in societies that don't do so there is a higher prevalence of HIV among gay men.

Let there be no doubt, the latter claim of fact is true. There is a fairly substantial body of social science evidence demonstrating that. Opponents of gay rights typically point to that higher prevalence - even in societies that have decriminalized - to bolster their opposition. They usually argue that if their society decriminalized same sexual relationships  (aka buggery, to use that lovely colonial phrase invented by the Brits) even more folks would engage in that high risk behaviour and things would get worse on the HIV fronts. That isn't true, demonstrably so. This will have little impact on these campaigners' messaging, because they're god people. Their opposition to homosexuality is driven by religious convictions plus almost certainly deep-seated other psychological issues. After all, these are the same people that like equating pedophilia and homosexuality. Evidence for that claim is also difficult to come by. There's a method to this madness though, and it's a successful madness. Whole countries (Jamaica and Uganda are just two examples) these days are in the thrall of moral panics when it comes to the matter of homosexuality.

Now, gay rights activists have resorted to engaging in similarly flawed arguments to further their political objectives. To be fair, unlike god people they at least have some evidence on their side (i.e. homosexuality isn't pedophilia, criminalization leads to higher HIV prevalence). However, none of that creates a case for gay rights. At least it shouldn't. Civil rights cannot be contingent on non-immutable characteristics. What if it turned out to be the case that decriminalization of homosexuality led to higher HIV prevalence? Should one then join god people and their campaigns? Civil rights case closed? Obviously not. The case for civil rights cannot be based on public health arguments.

The case for civil rights protections is always and necessarily so based on individuals' liberty entitlements to live their lives as they see fit, as far as self-regarding actions are concerned, on privacy rights, their right to associate with whoever consenting adult(s) they see fit, their entitlement to see their needs treated equally to comparable needs that led to rights heterosexual people enjoy, and a gaggle of other related arguments. None of these arguments are contingent on the truth or otherwise of particular public health matters. After all, where would one go once it was possible to eradicate HIV with a simple pill being taken, or once a working preventative vaccine existed? Too bad for gay rights then? I think not.

That's not to say that opponents of gay rights should not be called on their lies and deception. However, by turning their arguments on their head no case is made for gay rights either.

Addendum: 12:29pm, July 25, 2014 EST.

Of course, it is true that civil rights protections also extend to certain kinds of choices (e.g. religion) as well as other not immutable characteristics such as language. I stuck to immutable because that case is easier to make and it applies to homosexuality.

HIV Health Promotion Ethics and Pre-Exposure Prophylaxis

A lot has changed since the early days of HIV/AIDS. In the not so good old days an HIV infection pretty much constituted the end of the road for those infected. Most infected people died of one or another infection a healthy immune system would have been able to cope with. The public health messaging at the time was unequivocal: protect yourself and others by using condoms every time you have sex with someone whose HIV status is unknown to you. The ethical rationale for this was predicated on ideas such as Dan Beauchamp’s. He wrote, ‘public health should advocate a counter-ethics for protecting the public’s health, one articulated in a different tradition of justice and one designed to give the highest priority to minimizing death and disability.’[1] Libertarians such as the gay philosopher Richard D. Mohr didn’t buy into this story, questioning even whether the idea of ‘public health’ was intelligible to begin with.[2] He wasn’t the only critic of public health promotion campaigns. Patricia Illingworth warned more than two decades ago that AIDS health promotion campaigns could be hazardous to our autonomy.[3] She argued, persuasively to my mind, that many health promotion campaigns are manipulative and so they undermine autonomous decision-making by competent adults.

I cannot help but wonder whether we have come full-circle on this issue. Today we have medicines available that effectively control HIV. AIDS is so rendered a chronic manageable illness. These medicines have a truly remarkable side-effect. They are capable of rendering people with HIV infection, who take them, non-infectious for all practical intent and purposes.[4] Indeed, medication has come on the market offering something called pre-exposure prophylaxis. The idea here is basically that perfectly healthy people with a fairly high risk of contracting HIV take this medication to prevent the virus from taking hold in case they get exposed to it.

There are all sorts of ethical issues that arise in the context of the proposition that healthy people should take drugs to prevent a future infection that might never happen to them in the first place, at a cost of thousands of dollars per year per non-patient. Still, epidemiological modeling suggests that this strategy could end the HIV pandemic in a generation or two. You can see why: If infected people take drugs that render them non-infectious and everyone at high risk for contracting the virus took the same class of drugs as a prophylactic against an infection, eventually new infections would decrease very significantly. In the absence of a preventive vaccine this might be our best shot at beating the virus.

The courts have not quite caught up with this new reality. HIV infected individuals with undetectable viral load, who have unsafe sex without telling their partners, still risk prosecution in many countries. But what about the public health promotion industrial complex’s response? Has it modified its campaigning on the issue? It turns out, the strongest condemnation of pre-exposure prophylaxis came from public health promotion people. They were primarily concerned that people in groups at high risk for HIV infection might take the medication and engage in unsafe sex.  There is a mindset at work that we might be better off threatening people with HIV sufficiently to scare them into having safe sex. Telling them the truth and risking that some might decide to take drugs efficiently protecting them against HIV in order to engage in unsafe sex doesn’t seem an option. Why would otherwise sensible people hold such views?  Well, they are concerned that a rise in unsafe sex could lead to people acquiring other sexually transmissible illnesses.[5] 
Even if that was true, surely any health care system ought to strive toward reducing the number of people with a serious infection such as HIV even if that meant accepting a higher number of people with mostly treatable infections such as syphilis, gonorrhea and the like. Bizarrely the suggestion has also been made that if gay men stopped using condoms courtesy of the risk-reduction the pre-exposure prophylaxis affords them, they would eventually be as sloppy with the medication itself.  It goes without saying that there is zero evidence to support this contention. As to the increased risk-taking alluded to a moment ago, available research suggests that pre-exposure prophylaxis goes hand-in-hand with only a slight increase in the likelihood of reduced condom use    .[6]

There’s also the usual rhetoric of ‘reckless’ behavior, which ignores that a decision to have unsafe sex can be a carefully considered choice. It is not that safe sex is a cost neutral activity. Surely there is a reason for why most people do not use condoms consistently.[7] Patricia Illingworth wrote an illuminating monograph defending the right of gay men and others to make such choices.[8]  

It seems Illingworth and Mohr had a point when they warned about the capacity of public health promotion activities to harm individual autonomy. To campaign against HIV pre-exposure prophylaxis in order to ensure that gay men don’t make safe sex related choices health promotion people disagree with seems ethically deeply problematic. Their task would surely be to persuade potentially risk taking people not do do so by outlining what risks, other than HIV, they would run if they did what they are contemplating doing. To use the threat of an HIV infection as a means to achieve other objectives, namely to reduce the incidence of other sexually transmitted illnesses, is a non-starter.

UDO SCHUKLENK

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[1] As quoted in Patricia Illingworth. 1990. AIDS and the Good Society. London: Routledge, p. 48.

[2] Richard D. Mohr. 1987. AIDS, Gays and State Coercion. Bioethics 1(1): 35-50.

[3] Patricia Illingworth. 1991. Warning: AIDS Health Promotion Programs May Be Hazardous to Your Autonomy. In: Christine Overall and William P. Zion. (eds). Perspectives on AIDS: Ethical and Social Issues. Toronto: Oxford University Press, pp. 138-154.

[4] Gus Cairns. 2014. No-one with an undetectable viral load, gay or heterosexual, transmits HIV in first two years of PARTNER study. March 04. http://www.aidsmap.com/No-one-with-an-undetectable-viral-load-gay-or-heterosexual-transmits-HIV-in-first-two-years-of-PARTNER-study/page/2832748 [accessed March 05, 2014]

[5] For a bioethical version of this concern see Richard M. Weinmeyer. 2014. Truvada no substitute for responsible sex. February 14 .Bioethics Forum http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=6777&blogid=140 [Accessed March 04, 2014]
[6] Martin Holt, Dean A. Murphy, Denton Callander et al. 2012. Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men. Sexually Transmitted Infections 88: 258-263.

[7] L.A. Scott-Sheldon, K.L. Marsh, B.T. Johnson and D.E. Glasford. 2006. Condoms + pleasure = safer sex? A missing addend in the safer sex message. AIDS Care 18:750-4

[8] Patricia Illingworth. 1990. AIDS and the Good Society. London: Routledge