Approaches to rationing antiretroviral treatment: ethical and equity implications

This article, from the Bulletin of the World Health Organization (WHO), explores the ethical dilemmas about who should receive antiretroviral treatment (ART) on publicly subsidised programmes. The article specifically looks at the eligibility and targeting criteria at different points of scale-up in ART programmes in Mexico, Senegal, Thailand and Uganda. Findings reveal that two sets of core technical criteria have been applied: clinical eligibility criteria and adherence criteria. Other factors used to determine priorities included: prevention-driven criteria; social and economic benefits of keeping certain subgroups healthier, longer; ethical arguments for groups such as children or vulnerable populations; financial factors, such as the ability to pay; and waiting lists.

The authors highlight how decisions about who should qualify for ART should reflect societal values. Stakeholder consultations and debate about explicit criteria are needed to inform policy makers and to create support and consensus around policies. However, while community based rationing may work well in pilot schemes, it is unlikely to be workable as treatment is scaled up. It is therefore critical that scale-up strategies consider rationing criteria from the outset. Public debate and consensus are essential for sustainable ART programmes, as is ongoing monitoring to ensure that policies are reaching those they are targeting and achieving societal objectives. [adapted from author]