Academic journal article The Hastings Center Report

The Vital Importance of Implementation Ethics

Academic journal article The Hastings Center Report

The Vital Importance of Implementation Ethics

Article excerpt

Stuart Rennie and Frieda Behets's article, "AIDS Care and Treatment in Sub-Saharan Africa: Implementation Ethics," is a landmark work that highlights the particular ethical challenges of rationing AIDS therapy in this part of the world. They ask, "What ethical issues are raised by the implementation of AIDS treatment programs in developing world contexts?"

South Africa--the world's most HIV-infected country--may be a useful starting point to answer this question because it offers an example of how not to ration and implement an antiretroviral (ARV) drug program. More than 800,000 HIV infected individuals there meet the WHO-recommended threshold requirements for treatment. Despite this alarming statistic and the vast resources South Africa has at its disposal, the government has been slow to roll out ARVs. South Africa's president, Thabo Mbeki, has squandered valuable time openly questioning the link between HIV and AIDS, and its health minister, Manto Tshabalala-Msimang, has repeatedly labeled ARVs "toxic" while championing natural remedies such as beetroot, lemon, garlic, olive, and the African sweet potato in the fight against the pandemic. Anecdotal reports suggest her stance sows confusion and deters enrollment in ARV programs where capacity to absorb additional patients exists. Not surprisingly, the government is being blamed for mismanaging implementation of ARVs.

Despite these missteps, treatment of HIV-positive individuals can be maximized in a resource-constrained setting if the treatment program utilizes a drug regimen that meets three criteria. First, it must be inexpensive, which allows a greater number of needy individuals therapy. Second, it should be administered in a single dose, which facilitates adherence. And finally, it should require minimal monitoring, which results in lower laboratory-related oversight costs. Efavirenz, an established ARV drug, meets these criteria. It is also compatible with tuberculosis treatment--an important factor in sub-Saharan Africa, where up to 70 percent of HIV-positive patients are infected with tuberculosis. Efavirenz has accordingly become the backbone of first-line, highly active antiretroviral therapy (HAART) regimens in many resource-constrained settings, favored over nevirapine, another commonly-used anti-HIV drug. But prescribing efavirenz as part of a first-line HAART regimen raises ethical concerns.

Clinical reports suggest efavirenz may be harmful to fetuses. …

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