At AIDS conference, little word of hard choices

BANGKOK -- Throughout the five days of the 15th International AIDS Conference, one haunting question has lurked off-stage: who will decide which AIDS patients can stay alive longer and which must die sooner.

Treatment for children with AIDS seen lacking in poor countries. A16.

In the coming months, as the life-extending antiretroviral drugs begin to expand into many areas of sub-Saharan Africa and Asia for the first time, the supply will cover just a fraction of those who need the medicine, AIDS specialists said yesterday.

That means the challenge ahead will be to ration the available treatment, and, like doctors operating in triage, choose between those who get antiretroviral therapy in the poor world, and those who won't -- often a life-or-death decision.

But few here among the 20,000 participants talked openly about this dilemma -- including vexing issues such as whether nurses and teachers should get priority over other workers, or mothers over single women. Fewer than a half-dozen seminars out of several hundred touched on the issue.

''Rationing drugs already is occurring," said Jonathon Simon, director of the Center for International Health and Development at Boston University, who presented a paper on the topic. ''A public debate may lead to a better outcome, but we didn't have that."

Now, an estimated 440,000 people with HIV and AIDS receive antiretroviral treatment in developing countries, or roughly 7 percent of those who need the medication. The drugs are widely available in rich countries.

Soon, though, that global number receiving treatment is expected to increase fairly significantly, in large part due to major new funding from the Bush administration and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as from increased technical assistance from the World Health Organization and UNAIDS to countries.

Much of that increase will come in a handful of countries that have stronger health systems and teams of workers trained to oversee the antiretroviral therapy. But for many other countries in sub-Saharan Africa, which accounts for about 70 percent of the world's 38 million people living with HIV, the numbers of those who can be treated will be limited by the health system's ability to serve them.

''In Zambia, for instance, and in many countries, even if they accomplish everything they want in their AIDS treatment program, that still is a fraction of the true numbers of people with AIDS who need the drugs," Simon said.

He suggested that many people in public health are uncomfortable with the question; others, he said, are so focused on scaling up programs that they are not looking years ahead.

But at the end of one corridor at the conference, Arachu Castro, an instructor in medical anthropology at Harvard Medical School, didn't duck the question. She and Simon dove into a debate as streams of people flowed around them.

''The situation now is that it allows certain people to jump ahead in the line, and that creates inequities," Simon said. ''Countries should decide on their priorities. Do they give preferred access to mothers? To teachers and nurses? You got to have a public debate."

He said many countries may draw upon economic models to determine who should be in the front of the line for treatment. ''If you bring people back from death's door, what happens to their productivity afterward? If you have them on disability, that may not be a public good."

''Do you start with teachers, do you start with mothers?" Simon asked.

Castro replied: ''It should not be a cultural decision. It should be a clinical decision. It's first come, first served, and then you have to expand it rapidly."

Said Simon: ''But maybe a country really needs to save its teachers. Its classrooms are overcrowded. And maybe the poor are not employable. Perhaps you look at the experience of teachers, health workers, policemen, and you choose based on public good."

''How do you define public good?" Castro said. ''To let the poor die?"

''Well, if you don't define it, the elite will jump the queue," Simon said.

Some countries in sub-Saharan Africa are quietly talking about imposing qualification restrictions on a national level. One immediate factor is cost. Several countries, say AIDS treatment doctors, are considering limiting the funds for treatment to first-line drugs, and not second-line medicines, used for patients who develop resistances to the original drugs.

In one study presented Wednesday on health clinics that provide drugs to prevent mother-to-child transmission of the virus, Columbia University found that a lack of a single standard on who could enroll in the program resulted in wide-ranging rules on patient eligibility.

Nine of 12 clinics required that patients live close to the hospital, but the definitions of proximity differed widely. Three sites recommended the mothers make a commitment to have safer sex.

Speaker Michael Kelly, a retired priest and educator from Lusaka, Zambia, decried the lack of debate at the conference. Instead of giving his opinion, he raised questions.

''What criteria are we to use to select the people to get the drugs? Who are they going to be?" he asked. ''According to what standards can some people act as God?"

John Donnelly can be reached at donnelly@globe.com