Haire Bridget, Kaldor John
The Kirby Institute for infection and immunity in society, UNSW Australia, Sydney, New South Wales, Australia.
J Med Ethics. 2015 Dec;41(12):982-6. doi: 10.1136/medethics-2014-102122. Epub 2015 Sep 29.
Evidence that treating people with HIV early in infection prevents transmission to sexual partners has reframed HIV prevention paradigms. The resulting emphasis on HIV testing as part of prevention strategies has rekindled the debate as to whether laws that criminalise HIV transmission are counterproductive to the human rights-based public health response. It also raises normative questions about what constitutes 'safe(r) sex' if a person with HIV has undetectable viral load, which has significant implications for sexual practice and health promotion. This paper discusses a recent high-profile Australian case where HIV transmission or exposure has been prosecuted, and considers how the interpretation of law in these instances impacts on HIV prevention paradigms. In addition, we consider the implications of an evolving medical understanding of HIV transmission, and particularly the ability to determine infectiousness through viral load tests, for laws that relate to HIV exposure (as distinct from transmission) offences. We conclude that defensible laws must relate to appreciable risk. Given the evidence that the transmissibility of HIV is reduced to negligible level where viral load is suppressed, this needs to be recognised in the framing, implementation and enforcement of the law. In addition, normative concepts of 'safe(r) sex' need to be expanded to include sex that is 'protected' by means of the positive person being virally suppressed. In jurisdictions where use of a condom has previously mitigated the duty of the person with HIV to disclose to a partner, this might logically also apply to sex that is 'protected' by undetectable viral load.
早期治疗艾滋病毒感染者可防止将病毒传播给性伴侣，这一证据重塑了艾滋病预防模式。作为预防策略的一部分，对艾滋病毒检测的重视重新引发了一场辩论，即那些将艾滋病毒传播定为刑事犯罪的法律是否会对基于人权的公共卫生应对措施产生适得其反的效果。这也引发了一些规范性问题，即如果艾滋病毒感染者的病毒载量检测不到，那么什么才构成“更安全的性行为”，这对性行为和健康促进具有重大影响。本文讨论了澳大利亚最近一起备受瞩目的艾滋病毒传播或暴露被起诉的案件，并思考在这些情况下法律的解释如何影响艾滋病预防模式。此外，我们考虑了对艾滋病毒传播的医学理解不断演变的影响，特别是通过病毒载量检测来确定传染性的能力，对与艾滋病毒暴露（与传播不同）犯罪相关的法律的影响。我们得出结论，合理的法律必须与明显的风险相关。鉴于有证据表明，在病毒载量得到抑制的情况下，艾滋病毒的传播性会降低到可忽略不计的水平，这一点在法律的制定、实施和执行中都需要得到认可。此外，“更安全的性行为”的规范性概念需要扩大，以包括通过病毒被抑制的阳性感染者进行“保护”的性行为。在以前使用避孕套减轻了艾滋病毒感染者向伴侣披露病情责任的司法管辖区，这在逻辑上可能也适用于通过检测不到的病毒载量进行“保护”的性行为。
