Evelyne Shuster
"Prevention and treatment of HIV/AIDS in Africa: Who gets it, who decides and what are the options?"

One of the many policy and ethics problems facing Africans and their governments is how best to introduce antiretroviral drug treatment for HIV positive and AIDS patients, now that funds reaching into the billions of dollars to pay for these drugs are becoming available. It has already been suggested that new drug treatment should preferentially focus on the next generation of Africans, thereby excluding those currently ill patients, the rationale being that preferentially targeting the young may help ensure the country's survival. Policies of exclusion are humanly and socially difficult to implement, and governments that adopt such policies would have to explain and defend their decisions to their citizens. A decision may also be to make antiretroviral drugs immediately available to everyone (which is, of course, not possible, although failing to acknowledge that rationing is taking place may be politically viable in the short run). But without analysis and debate about public policy, people will make arbitrary decisions about access to treatment. A rationing scheme is needed in each African country to decide which patients or groups of patients get access to antiretroviral drug treatment now as a first priority, and which groups will get it later. For example, should rationing strategy targets women of childbearing age and their children, skilled workers, poor people or core transmitters such as sex workers or truck drivers? Rationing (and priority setting) is not value neutral. Choices impact differently on a population and have different social and economic consequences depending on the adopted goals, both short and long-term. Who decides who gets treatment first, and on what basis, are critical issues. Four approaches to rationing scarce medical resources have been identified: the market (which favors those who want treatment and can pay for it), a lottery (first-come, first served), the customary (physicians -based decisions) and selection by committee method. Are there lessons to be learned from these various approaches, and can they be applied to the roll out of HIV/AIDS antiretroviral drug treatment in African countries?