Stuart Rennie and Frieda Behet’s report on implementation ethics reveals a multitude of dilemmas surrounding decision-making for AIDS treatment plans. While they mainly focus on the inevitable need to allot AIDS treatment in Sub-Saharan Africa, they first present opposition against treatment as the primary method for combating HIV/AIDS. Three areas question whether or not treatment is the best solution: first, prevention advocates cite cost-efficacy, arguing that prevention is better than treatment in this regard; second, some worry that intense focus on HIV/AIDS treatment will distract from other diseases, such as malaria and TB, that are also detrimental in developing countries; and third, there is the issue of small scale treatment vs. large-scale treatment: some worry that large-scale treatment plans - those that would be government funded – are more difficult to manage both financially and logistically, increasing the difficulty of adherence.
After establishing their focus on treatment implementation plans, Rennie and Behet provide further problems within providing treatment and the necessity for rationing. They underscore this inevitability with a variety of statistics and reasons, but the issue of what ‘treatment’ means is the most interesting. They point out how people seem to use this term loosely, without a clear definition of what they mean. Often, they say, people refer to ART and access to drugs when they use the word ‘treatment.’ However, we must broaden our meaning of this term, in order for ARVs to actually be successful in treating HIV/AIDS. This means that ‘treatment’ must include everything a person needs to successfully benefit from ART: medical personnel, a sufficient number of clinics so that every person is ‘close’ to one, a reliable drug supply to clinics/hospitals, diagnostic tests and monitoring equipment in clinics/hospitals, VCT and follow-up, counseling services, clean water, food, vitamins, etc. All of these factors further complicate the ability to provide wide-scale treatment plans – hence their argument that rationing is and will be necessary.
They continue the report by illuminating injustices within current programs that are supposed to help initiate and sustains AIDS treatment plans, (PEPFAR) as well as those that are supposed to help boost the economies of developing countries (IMF). These problems show that injustices exist at even the levels that we would expect the least from, and that these policies are, in many cases, actually a barrier to the implementation of treatment plans, such as in Uganda.
They conclude the report with two choices that have to be made: site selection (where treatment plans should be initiated) and who selection (within these sites, exactly who should receive treatment). They then discuss ‘fair process,’ a loose procedure for fairly making these two choices. By the end of the report, Rennie and Brehet have done a thorough job of identifying the obstacles one will encounter and the decisions that will have to be made in any treatment plan. They seem to conclude that someone will have to make these choices, and that no matter what someone decides, at least one group of people will be unhappy. But, as they say, ‘inequitable treatment programs are better than none at all.’ Plus, widespread, total coverage has to start off somewhere.
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