AEGiS-15IAC: Which patients first? Setting priorities for antiretroviral therapy where resources are limited.

15th International AIDS Conference

Bangkok, Thailand - July 11-16, 2004

Which patients first? Setting priorities for antiretroviral therapy where resources are limited.

Int Conf AIDS 2004 Jul 11-16; 15:(abstract no. WeOrB1277)

McGough LJ, Reynolds SJ, Quinn TC, Zenilman J
Johns Hopkins University, Baltimore, United States

BACKGROUND: The availability of limited funds from international agencies for the purchase of antiretroviral (ARV) treatment in developing countries presents challenges and opportunities, especially in prioritizing who should receive therapy. Our objective was to examine historical precedents of allocation of scarce medical resources in cases where demand for life-saving therapy exceeded supply.

METHODS: We evaluated the following 4 medical discoveries in case study format: the discovery of insulin for diabetes in 1922, the release of penicillin in 1943, the development of chronic hemodialysis programs in 1961, and current allocation of liver transplants. We critically reviewed the published, peer-reviewed literature, in order to identify the key determinants of resource allocation decisions. We then evaluated these decisions within an ethical framework.

RESULTS: For insulin, there was no overall allocation system, which gave de facto priority to patients with strong political and family ties. Penicillin allocation was conducted by a centralized committee using defined clinical criteria. The development of clinical criteria maximized efficacy, but did not satisfy public demand for accountability and equal access. Dialysis was allocated based on social and clinical criteria. The inclusion of social criteria undermined goals of equal access to treatment. Liver transplants are based on clinical criteria that prioritize urgency rather than efficacy. Conclusion Policymakers will need to balance considerations of equity, efficacy, urgency, and accountability when deciding whether to prioritize the following factors for ARV treatment: clinical stage, adherence criteria, mode of acquisition, and geographic area. The development of specific clinical criteria, public input into the selection process, and the protection of equal rights within a local constitutional framework will optimize the process of patient selection.

Keywords: AEGIS, Health Resources, Resource Allocation, Developing Countries, Health Services Accessibility, Financial Management, Patient Selection, Social Responsibility, Humans, therapy, economics, ethics

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WeOrB1277