Scaling Up Treatment for the Global AIDS Pandemic Challenges and Opportunities (2005) / Chapter Skim
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Appendix D: Human Ethical Issues Arising in ARV Scale-Up in Resource Constrained Settings
Appendix D: Human Ethical Issues Arising in ARV Scale-Up in Resource Constrained Settings
Pages 279-291
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From page 279... ...
It is then that con flicts are laid bare between on the one hand, those values by which society determined the beneficiaries of the distributions and the perimeters of scarcity, and on the other hand, those humanistic moral values which prize life and well being. In such conflicts, at such junctures, societies confront the tragic choice (Calabresi and Bobbit, 1978)
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From page 280... ...
In a span of about two years, mainly due to pressure from human rights and civil society organizations, we have seen the initiation of new programs such as The Global Fund to Fight AIDS, Tuberculosis, and Malaria, the United States Presidential Emergency Plan for AIDS Relief (United States Aid ) , and the World Health Organization's Three by Five Program, which aims to treat three million people in five years (WHO, 2003b)
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From page 281... ...
. Therefore, to maximize the benefits of ARV drug regimens, countries have to urgently make concrete plans to scale up their treatment programs, establish or strengthen their national drug procurement and distribution policies, develop quality control mechanisms, and engage in the relevant operational research.
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From page 282... ...
, and among nations and/or international donor agencies. As scale-up programs progress, new ethical questions continue to emerge.
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From page 283... ...
In the real world, countries and institutions are already setting up treatment eligibility criteria based on a variety of factors and ethical principles. For example: Technical Criteria: The World Health Organization has recommended using medical criteria (disease progression)
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From page 284... ...
Some countries ravaged by war and political instability might make the argument that, before any national treatment program can be implemented, infected military and security personnel should be treated so that they can maintain the civil order necessary for scale-up programs. Countries like Kenya argue that there are certain groups that merit special consideration for treatment, such as victims of rape, people who became infected during vaccine trials or through administration of infected blood, HIV/AIDS orphans, and infected pregnant women.
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From page 285... ...
Unfortunately, this program has been fraught with problems such as a weak political commitment to tuberculosis control, funding gaps, low access to treatment due to poor infrastructure in new settlements, and limited involvement of communities in tuberculosis control. Consequently, the program has not been able to meet its target goals and Zimbabwean health officials are struggling to meet organizational requirements needed to continue administering the program.
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From page 286... ...
Safeguards have to be put in place to prevent such losses to public programs. In summary therefore, the cost and logistical requirements for delivering, administering, monitoring, and evaluating treatment programs constitute a major obstacle to the implementation of ARV therapy in resource constrained settings.
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From page 287... ...
Because of the sensitivity of the information being gathered including patient records, privacy safeguards will have to be built into the systems. Without a systematic approach to learning by doing, there is a great danger that programs may end up not only wasting limited life-saving resources, but also perpetuating potentially harmful health care practices-an ethically unacceptable state of affairs.
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From page 288... ...
.The above hypothetical case does not suggest that donors should stop funding AIDS programs; rather, donors need to explore how their programs can have synergy with other programs addressing other health and welfare needs and, more broadly, how funding for HIV/AIDS can improve health care infrastructure and development in the long-term. Approaches to expand access to ARV treatment should simultaneously strengthen health systems, interact with treatment, prevention, and health care services, and reach vulnerable groups (McCoy and Loewenson, 2004)
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From page 289... ...
In that spirit, I believe that ethical decisions should be made in real time and should be further refined by a process of ongoing deliberation that is informed by, and informs, ongoing ARV treatment efforts. On the question of allocation of treatment, I think it is necessary for donors and international aid agencies involved in providing resources for ARV scale up to engage with recipient countries to establish a minimum entry criterion grounded in internationally recognized human rights.
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From page 290... ...
Even if a decision makes moral sense, it may be difficult or impossible to implement it on the ground. I strongly believe that making concrete attempts to anticipate and address ethical problems will make for more effective and equitable programs, as will a commitment to reconsidering and refining these ethical hurdles as the programs progress.
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From page 291... ...
2000. Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa.
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