Decision maker priorities for providing antiretroviral therapy in HIV-infected South Africans: A qualitative assessment

Abstract

In resource-limited settings, successful HIV treatment scale-up has been tempered by reports of funding shortfalls. We aimed to determine the priorities, including ethical considerations, of decision makers for HIV antiretroviral programs. We conducted qualitative interviews with 12 decision makers, identified using purposive sampling. Respondents engaged in one-on-one, semi-structured interviews. We developed an interview guide to direct questions about key priorities and motivations for decision making about HIV antiretroviral programs. We evaluated textual data from the interviews to identify themes. Among 12 respondents, 10 (83%) lived and worked in South Africa. Respondents came from Western Cape, Gauteng, and KwaZulu-Natal provinces and worked primarily in urban settings. The respondents supported prioritizing individual patients based on treatment adherence, pregnancy status to prevent maternal-to-child HIV transmission and/or orphans, and severity of illness. However, priorities based on severity of illness varied, with first-come/first-serve, prioritization of the most severely ill, and prioritization of the least severely ill discussed. Respondents opposed prioritizing based on patient socioeconomic characteristics. Other priorities included the number of persons receiving treatment; how treated patients are distributed in the population (e.g., urban/rural); and treatment policy (e.g., number of antiretroviral regimens). Motivations included humanitarian concerns; personal responsibility for individual patients; and clinical outcomes (e.g., patient-level morbidity/mortality, saving lives) and/or social outcomes (e.g., restoring patients as functional family members). Decision makers have a wide range of priorities for antiretroviral provision in South Africa, and the motivations underlying these priorities suggest at times conflicting ethical considerations for providing HIV treatment when resources are limited.

Keywords:

• HIV
• HIV/AIDS
• antiretroviral therapy
• antiretroviral priorities
• ethics
• South Africa
• qualitative interviews

Acknowledgements

We extend deep thanks to the study participants for giving their time and sharing with us their on-the-ground experiences in HIV treatment provision and policy in South Africa. We also acknowledge with great appreciation comments from Milton C. Weinstein, PhD, and Sue J. Goldie, MD, MPH, on earlier drafts.

This work was supported in part by the Fogarty International Center (D43 TW000018); National Institute of Allergy and Infectious Diseases (T32 AI007433 and R01 AI058736); National Institute on Drug Abuse (R01 DA015612); Graduate Society Merit Award and Graduate Society Summer Fellowship, Graduate School of Arts and Sciences, Harvard University; and Project on Justice, Welfare and Economics, Weatherhead Center for International Affairs, Harvard University. The funding sources played no role in the study, including study design; collection, analysis, and/or interpretation of data; the writing of the manuscript; and the decision to submit the manuscript for publication.