Ethics and health

Ethics and equitable access to treatment and care for HIV/AIDS

The fact that the need for ART exceeds the current ability to deliver it means that some will receive treatment and others will die. Such a situation poses serious ethical issues for the governments, international agencies, nongovernmental organizations, institutions and health care workers working to scale up access to ART.

The most compelling of these ethical dilemmas involve choices that will affect the life and death of millions of people. Equitable access for women and for poor, vulnerable, and marginalized populations has to be ensured. However, other serious ethical concerns surround the potential diversion of resources from other health and social needs, as well as the possible effects of vertically-implemented ART programmes on fragile health systems, communities and families.  

Scaling up in an ethical and equitable way
November 2004
WHO headquarters

Building on the work of an international consultation, the Department of Ethics, Trade, Human Rights, and Health Law has led the development of a document entitled "Guidance on ethics and equitable access to HIV treatment and care". It is intended to raise awareness of the ethical issues and to help with the planning and implementation of the scaling-up of ART and other HIV-related treatment and care programmes in a way that is ethically acceptable, fair, and benefits health systems in general.

The guidance document includes a set of 9 concrete measures identified by WHO and UNAIDS that can be taken in countries and communities to promote fairness in scaling up HIV care. These recommendations are that countries:

  • Scale up HIV treatment and care, as it is an ethics and human rights imperative
  • Establish broadly representative ethics advisory bodies
  • Create opportunities for public dialogue on equitable access to HIV treatment and care
  • Develop policies for scaling up HIV treatment that are firmly based in human rights and ethical principles
  • Identify vulnerable, marginalized or other potentially underserved populations
  • Consider the need for special policies and outreach programmes to prioritize these groups and to overcome barriers to their accessing care
  • Establish a fair process for setting priorities in the distribution of HIV treatment
  • Define or adopt a set of five to seven measurable indicators to monitor the fairness of HIV treatment scale up at the national and community level.
  • Use monitoring and evaluation data to ensure that HIV programmes are producing equitable results.

Box 1: Steps to equitable access - the policy cycle at a glance (From Guidance on ethics and equitable access to HIV treatment and care)

WHO/UNAIDS international consultation on equitable access to treatment and care for HIV/AIDS
26-27 January 2004
WHO headquarters

In an effort to help ensure the ethical and equitable distribution of treatment and care for persons living with HIV, WHO and UNAIDS convened an international consultation on Equitable Access to Treatment and Care for HIV/AIDS, held 26-27 January 2004 at WHO headquarters.

The objectives of the meeting were as follows:

  • To elucidate issues of ethics and equity that might arise in the course of implementation and scaling up of ART programmes.
  • To lay the groundwork for the formulation of guidance to help governments and other bodies to implement ART programmes in an ethical and equitable manner.
  • To consider indicators by which equity in implementation and distribution can be monitored.
The participants at the consultation included treatment providers, physicians and other health care workers; ethicists, lawyers and human rights advocates; and representatives of governments, international agencies, nongovernmental organizations, academia, and groups of people living with HIV/AIDS.
These participants considered three background papers at the meeting:

Designing an Equitable Strategy for Allocating Antiretroviral Treatments
February 2005
A. Capron, A. Reis

In a commentary invited by PLOS Medicine on a recent study in which David Wilson and Sally Blower (University of California Los Angeles) offer a mathematical model for equitably allocating the limited supply of antiretrovirals among sites that provide HIV treatment, Alex Capron and Andreas Reis place the Wilson-Blower model, and related technical approaches, into a broader understanding of equity and discuss the methods needed to respect human rights obligations and ethical norms. (Capron AM, Reis A (2005) Designing an equitable strategy for allocating antiretroviral treatments. PLoS Med 2(3): e69.)

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