Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Choices and Consequences

I n the past three years, expanding access to antiretroviral therapy (ART) for HIV/AIDS has become a global objective and a national priority for many countries in sub-Saharan Africa. Large-scale treatment programs have been launched in countries spanning the continent from Lesotho to Ghana, paid for by domestic funds mobilized by African governments and by international donor contributions. While these funds, which reach into the billions of dollars, will pay for ART for many thousands of HIV-positive Africans, there is almost no chance that African countries will have the human, infrastructural, or fi nancial resources to treat everyone who is in need. National plans for treatment rollout typically call for a specifi c number of patients to initiate therapy within the fi rst one or two years of the program. Though the target patient numbers are extremely ambitious—often requiring a 10-fold expansion of services over a two-year period—they still represent a minority of those who are eligible for antiretrovirals on even the most conservative medical grounds. Table 1 indicates the demand for and supply of ART in several African countries and globally, based on starting ART at a CD4 count of 200 cells/µl or an AIDS-defi ning illness. The message of Table 1 is clear: rationing of ART is already occurring and will persist for many years to come. The question facing African governments and societies is not whether to ration ART, but how to do so in a way that maximizes social welfare, now and in the future. Inevitably, the social and economic consequences of rationing a scarce and valuable resource—treatment for a life-threatening illness—will vary widely depending on the rationing system chosen. In a previous article [1], we argued that the chances of achieving a socially desirable outcome from the global intervention now being launched will be higher if an open public-policy debate is conducted and policies are selected that make transparent the trade-offs inherent in any rationing system. We also identifi ed a number of possible rationing systems and proposed several criteria that could be used to select among them. In this paper, we examine these issues in more detail and use an expanded set of criteria to evaluate several rationing systems that already exist in sub-Saharan Africa. In economic terms, any policy or practice that restricts consumption of a good is a rationing system [2]. A rationing system restricts demand for a scarce resource so that …