Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Efficiency, Equity, and Reality

Background: Rationing of access to antiretroviral therapy already exists in sub-Saharan Africa and will intensify as national treatment programs develop. The number of people who are medically eligible for therapy will far exceed the human, infrastructural, and financial resources available, making rationing of public treatment services inevitable. Methods: We identified 15 criteria by which antiretroviral therapy could be rationed in African countries and analyzed the resulting rationing systems across 5 domains: clinical effectiveness, implementation feasibility, cost, economic efficiency, and social equity. Findings: Rationing can be explicit or implicit. Access to treatment can be explicitly targeted to priority subpopulations such as mothers of newborns, skilled workers, students, or poor people. Explicit conditions can also be set that cause differential access, such as residence in a designated geographic area, co-payment, access to testing, or a demonstrated commitment to adhere to therapy. Implicit rationing on the basis of first-come, first-served or queuing will arise when no explicit system is enforced; implicit systems almost always allow a high degree of queue-jumping by the elite. There is a direct tradeoff between economic efficiency and social equity. Interpretation: Rationing is inevitable in most countries for some period of time. Without deliberate social policy decisions, implicit rationing systems that are neither efficient nor equitable will prevail. Governments that make deliberate choices, and then explain and defend those choices to their constituencies, are more likely to achieve a socially desirable outcome from the large investments now being made than are those that allow queuing and queue-jumping to dominate.

Children Affected by AIDS: A Review of the Literature on Orphaned and Vulnerable Children

This paper presents a systematic review of the literature pertaining to orphans and vulnerable children in sub-Saharan Africa, with a particular focus on research in countries heavily impacted by HIV/AIDS. Despite study and data limitations, the literature provides evidence of growing orphan-based disparities, difficulties within households providing care, and insufficient capacity among social services. Still, additional research is urgently needed, including better OVC surveillance methods, qualitative data than answers persisting questions, the inclusion of more useful indicators in national household surveys, and longitudinal studies to determine the mechanisms by which parental HIV status and death impacts children, caregiving impacts households, and the orphan epidemic impacts communities and social systems.