health system functioning, maternal and child health, prevention and treatment of infectious conditions other than HIV, injury prevention and care, mental health, and chronic conditions such as cancer and cardiovascular disease. Likewise, governments and donors have ethical obligations to address the full range of pressing global health needs, which can represent competing moral claims on limited resources. At the same time, HIV/AIDS may be exceptional in that the disease usually strikes individuals at the prime of their lives for working, having children, and supporting families. Issues of the ethical allocation of health resources between HIV/AIDS and other health needs is beyond the scope of this study. Those issues aside, however, the prevalence of HIV/AIDS is expected to increase for the forseeable future (see Chapter 2 and Appendix A). Therefore, significant resources will need to be dedicated to combating the epidemic (IOM, 2005), and this chapter addresses ethical issues regarding the utilization of those resources.

The starting point for the discussion is the expectation that needs for HIV/AIDS prevention, treatment, and care will vastly exceed the resources available to meet those needs in resource-constrained African countries where the projected long-term burden of HIV/AIDS is very high. The combination of “high prevalence, low incomes, and heavy dependence on external assistance” in many African countries is of particular concern (Project HOPE, 2009; Haacker, 2009). Within the sphere of HIV/AIDS, many competing claims on resources will continue to arise: between subpopulations of persons who need antiretroviral treatment (e.g., in some circumstances, between those requiring their first treatment regimen and those requiring second- and third-line regimens); between subpopulations of persons who need preventive interventions; and among efforts to provide ART, HIV/AIDS care, and preventive interventions (see Chapter 2 for a discussion of these trade-offs). Such trade-offs are and will continue to be a reality, and the ways in which policy makers and others weigh them and their consequences are at the heart of this ethical inquiry. Whatever the outcome of the decisions made regarding the allocation of resources in the context of HIV/AIDS in Africa, those decisions will make an enormous difference in the lives of large numbers of people living with HIV/AIDS.

This chapter first reviews existing principles for ethical decisions in health care that have been promulgated by international organizations. The subsequent section examines how an ethical decision-making capacity for HIV/AIDS policy and programming can be developed in Africa.


This section examines in turn the levels of decision making in the allocation of health resources; key moral imperatives; the concept of equal moral status; and international covenants, codes, and declarations on ethics.

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