By Holly A. Taylor, PhD, MPH,

As a co-author of “Research into a functional cure for HIV in neonates, the need for ethical foresight”, I fully support efforts to anticipate and consider the ethical challenges investigators may face in developing and conducting trials to seek a functional cure for neonates.  That said, I would like to step back a bit from this paper and note a bigger, related ethical concern.  Two facts about the Mississippi Baby case identify holes in our current health care system.  First, we have known for almost 20 years that providing pregnant women with HIV access to antiretroviral therapy can radically reduce the number of infants born with HIV.  Data published by the Centers for Disease Control and Prevention in 2011 shows the estimated numbers of AIDS cases in children <13 years of age, by year of diagnosis, 1992–2009— 50 states and the District of Columbia.  The slope of this line is testament to one of the clear success stories in the prevention of HIV infection.

Child AIDS Diagnoses by year graph

The mother of the Mississippi Baby did not access antiretroviral treatment during her pregnancy.  Her failure to access to treatment is likely multi-layered.  If she had accessed prenatal care she would have likely been counseled to be tested for HIV and when found positive referred to treatment for herself.  Our goal should be to minimize any barriers the mother of the Mississippi Baby encountered in accessing health care.

The search for a functional cure is a laudable goal and will likely have wide application outside the US, but our goal here in the US ought to be to facilitate the identification and treatment of HIV pregnant women to minimize the number of infants exposed to the risks and uncertainty of combination antiretroviral therapy after birth.  When found, a functional cure approach will be a fail-safe rather than first-line prevention for infants born in the US.

Second, the mother and infant were lost to follow-up.  Again, the reasons for this are likely multi-layered but our goal, again, ought to be to minimize any barriers to care the mother and Mississippi baby may have encountered.  I would go as far to say that our obligation to follow the baby was even higher than usual given that she received a novel treatment.

I am not faulting the providers involved in the care of the Mississippi Mom and baby (one of whom is a co-author on this paper), but our general failure to commit ourselves to the demands of social justice – that we attend to health inequities and the “densely woven patterns systematic disadvantage” that may limit the ability of individuals and populations to flourish. (Powers and Faden 2006)

holly_taylorHolly A. Taylor, PhD, MPH is currently Associate Professor in the Department of Health Policy and Management, Bloomberg School of Public Health and a Core Faculty member of the Johns Hopkins Berman Institute of Bioethics

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