There are fundamental medical ethical questions that apply to treatment of HIV in the context of a global epidemic. Who has the right to decide what health care and what treatment should be provided to an individual, a community, or entire country? Who determines when health care is rationed, if ever, and on what basis?
The 2012 International AIDS Society Conference in Washington, DC will address many of the issues that have prevented the global HIV epidemic from being controlled. But with over 30 drugs and combination of drugs to treat HIV a priority must be given to being certain that all individuals have equal access to life-saving treatment. Paradoxically, one of the major obstacles to the ethical treatment of all HIV infected individuals is the very organization that purports to represent the world health community—WHO. Their guidelines for treatment of HIV-infected individuals fall dangerously behind the recent evidence based US revision of treatment guidelines by clinical experts that clearly state that all HIV-infected individuals should be treated with antiretroviral drugs.
Guidelines are frequently misinterpreted and can, if not understood, morph into rules. Physicians consult treatment guidelines to determine the best treatment to provide to their patients. However, it is they, not the WHO, who are responsible for the ethical treatment of their patients. Unfortunately WHO guidelines have been interpreted as rules. This is troubling especially since guidelines, such as those published by WHO are not revised in a timely manner to accommodate new evidence based research and are often adjusted downward to accommodate countries with poor economies. Ministries of Health then use the guidelines to justify their failure to invest in the health of their own peoples and prevent physicians from providing standard of care even when treatment is available.
History shows that this is not a new issue in the HIV epidemic. The first CDC guidelines for diagnosis of AIDS included a listing of clinical diagnoses that were associated with AIDS but excluded some of the diagnoses that were specific to women such as vaginal candidiasis. Not many people realized that what was behind this exclusion was an economic concern—if vaginal candidiasis were to be included in the diagnosis of AIDS, it would vastly expand the number of individuals eligible for health care and treatment and would stress the US Medicaid system. Teresa McGovern, a lawyer, who founded the HIV Law Project to provide legal representation to low income HIV-infected individual, especially women who were not receiving equal access to health care, successfully argued in 1997 that that the CDC guideline should include gender specific issues and complications that women were experiencing. The guidelines were changed and are an example of the misuse of public health guidelines for rationing access to treatment.
That was 15 years ago. We are now confronted with a similar situation when WHO guidelines result in denial of standard of care to millions of HIV-infected individuals. Not only is it inappropriate to use guidelines for rationing healthcare but the concept that a single guideline can apply to all countries is misguided. There are many countries that could provide standard of care for their peoples and should not be prevented from doing so by guidelines that attempt to accommodate all national economies and thus recommend inferior care.
Treat All HIV infected individuals should now be the standard of care.
For further information and an opportunity to urge WHO to change their guidelines go to www.treatall.org