11/17

My research paper actually focused on the ethics of clinical trials in HIV prevention, so the authors' casual dismissal of the subject was somewhat abrupt, in my opinion. However, their focus on treatment rather than prevention at this stage is a realistic perspective. Rationing has been accepted by bioethicists as an inevitability in HIV treatment, but how to implement it is obviously not an easy task. Recognizing that all rationing programs are politically, not simply medically, motivated. Preexisting social and economic disparities in this case have the possibility of being either minimized or further increased. Many disenfranchised propulsions are arguably more at risk for acquiring the infection, especially in developing countries. But the political inner workings of many NGOs and government-funded initiatives such as PEPFAR can often withhold treatment to those who need it as much as they help. PEPFAR appears to distribute aid either arbitrarily or based on political factors, skipping over clearly desperate countries like Zimbabwe because there is no derived political benefit from doing so. Rationing decisions on a lower level of bureaucracy are equally capable of altering the equity of treatment options, based on social standing, ethnic group, or often distance from treatment centers (establishment of "islands of treatment").
I was interested and alarmed by the authors' description of the disparity between developing an adequate healthcare infrastructure, limiting the brain drain and increasing the 'absorptive capacity' of these countries, and their ability to receive the IMF grants that are necessary to decrease the poverty level that causes healthcare disparities in the first place.
Ranking the "who" of treatment priorities is another interesting discussion treated in this article. Selecting pregnant women is a good idea as a means of preventing mother to child transmission, but is highly exclusive as a criterion. Selecting skilled workers is likely to improve human capital resources, which could by aiding the economy in turn help to improve treatment infrastructure overall, but this excludes most of the vulnerable populations in any society (women, children, etc.) Selecting sex workers may be a good means of eliminating one important vector of transmission, but this excludes the people who many would call the 'innocent victims' of HIV transmission.
Finally, the authors suggest that in treating AIDS comes the opportunity to expose and work to eliminate preexisting socioeconomic disparities, human rights violations, and basic inequalities in the developing world. In improving access to treatment, granting one of the most basic human rights and enabling previously vulnerable populations a more level playing field, the AIDS epidemic has the potential to have some positive effects.

Katie Nelson