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The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in Africa has raised important ethical issues for both researchers and clinicians. The most notorious controversy has been related to the zidovudine (AZT) trials in Africa in the late 1990s, in which the control groups were given a placebo rather than an effective drug to prevent vertical transmission. This raised concerns in the sponsoring country about exploitation of subjects, injustice and an ethical double standard between donor countries and resource-poor settings. However, the real double standard is between clinical practice standards in Western versus African countries, which must be addressed as part of the increasing global inequity of wealth both between countries and also within countries. There are important limitations to ethical declarations, principles and guidelines on their own without contextual ethical reasoning. The focus on research ethics with the HIV epidemic has led to a relative neglect of ethical issues in clinical practice. Although the scientific advances in HIV/AIDS have changed the ethical issues since the 1990s, there has also been progress in the bioethics of HIV/AIDS in terms of ethical review capability by local committees as well as in exposure to ethical issues by clinicians and researchers in Africa. However, serious concerns remain about the overregulation of research by bureaucratic agencies which could discourage African research on specifically African health issues. There is also a need for African academic institutions and researchers to progressively improve their research capacity with the assistance of research funders and donor agencies. [ABSTRACT FROM AUTHOR]

The Fluid Expansion as Supportive Therapy (FEAST) trial in an African setting without intensive care facilities found that bolus fluid therapy for severe infections (including malaria and viral infections) resulted in a significantly higher mortality than those not given a bolus. This was a high-quality study of 3170 children with 48 h mortality as the primary outcome. Despite the different setting and diseases than in a developed country context, it could be argued that this study calls into question the wisdom of bolus fluid regimes for sepsis, and perhaps even the concept of 'compensated shock' in the Advanced Paediatric Life Support protocol. Some have tried to attack the ethics of the study, but this is unjustified. The implications for paediatric practice in Africa are that intravenous fluids need to be monitored more closely, and the practice of giving boluses to every 'query septic infant and child' needs to be examined more critically. [ABSTRACT FROM AUTHOR]