Thursday, September 28, 2006

South Africa: Allocation of resources

South Africa has the highest number of people living with HIV in Africa, and rivals only India for the most in the world.

Activists have long pushed for – and had great success – demanding greater access for everyone to antiretroviral drugs in South Africa. But the question is still sometimes raised – how can a scarce resource (antiretroviral drugs) be ethically and most effectively distributed?

As shown by recent reports on the KwaZulu-Natal Province by David P. Wilson, James Kahn, and Sally M. Blower in the Proceedings of the National Academy of Sciences and by Prof Gita Ramjee of the Medical Research Council of South Africa, there are different priorities that could guide allocation strategies.

The article in the PNAS focuses on the urban-rural divide. Using a model that predicted the consequences of three drug allocation strategies in different areas between 2004 and 2008, the researchers argue that the most effective strategy for preventing additional cases of HIV infection would be to prioritize distribution to urban populations. The authors acknowledged the ethical problems in such a strategy, but stated that given an opportunity to treat 500,000 people by 2008, “if the government health policy officials in KwaZulu-Natal wish to apply the utilitarian principle (and minimize the epidemic), our results show that they should allocate all drugs to Durban”.

The biggest problem with the study is that it only looks at preventing infections through 2008. Imagine if we did the same study with a global perspective in 1990 and only looked at infection through 1992. What would our conclusions have been – only to focus programs in Western countries and ignore Asia, Eastern Europe and Africa because they would prevent fewer cases? Didn’t we make that mistake once already?

The Medical Research Council’s study on KwaZulu-Natal focuses on women and revealed alarming HIV prevalence ranging from 38 to 66 percent. The social factors that cause this prevalence are timeless and bridge the urban-rural divide. MRC cites as factors the taboos surrounding sex and promiscuity and the treatment of boys as “demigods…exempt from apology for unfaithfulness”. The existence of AIDS is routinely denied and women are often forced to engage in unprotected sex.

MRC’s research adds complexity to the discussion of allocation strategies. While perhaps treating only people in urban areas would yield fewer infections in the short term, it would do nothing to lower the stigma surrounding AIDS or empower women economically or in their relationships. These social factors stretch across the urban-rural divide and will continue to be a driving force behind AIDS unless tackled directly.

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