To Have or Have Not

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Science  29 Sep 2006:
Vol. 313, Issue 5795, pp. 1855
DOI: 10.1126/science.313.5795.1855a

The rollout of antiretroviral therapy during 2004–2008 in South Africa brings with it severe ethical dilemmas regarding the allocation of drugs, because supply will outstrip need. Incorporating data from KwaZulu-Natal in a spatially explicit mathematical model, Wilson et al. have applied the government's allocation strategy in three scenarios to predict the consequences of different choices.

The modeling reveals clearly that for preventing transmission, the most effective strategy is to concentrate all of the doses (for half a million people living with HIV) in Durban, where HIV prevalence is 13%. This will have the effect of preventing 15,000 infections by 2008, minimizing the transmission of drug resistance, and preventing the greatest number of deaths. But this choice is not egalitarian, and the intent of antiretroviral therapy is treatment and not prevention. However, if the drug allocation were split between urban and rural areas (just over half of the KwaZulu-Natal population is rural, with an HIV prevalence of 9%), its effectiveness for HIV prevention would be reduced by about a third to a half, not just because the rural population is dispersed but also because the rural health infrastructure is relatively weak and because distribution and clinical monitoring will not be so effective. — CA

Proc. Natl. Acad. Sci. U.S.A. 103, 14228 (2006)

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