aDepartment of Emergency Medicine
bDepartment of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA.
Correspondence to Dr. Ethan Cowan, MD, MS, Jacobi Medical Center, Department of Emergency Medicine, 1400 Pelham Parkway South, Building 6, Room 1B25, Bronx, NY 10461, USA. Tel: +1 718 918 3050; fax: +1 718 918 7459; e-mail: firstname.lastname@example.org
Received 9 March, 2013
Accepted 14 May, 2013
We read with interest Singh's  article in AIDS, ‘Antiretroviral resource allocation for HIV prevention’. Singh presents a blistering critic of our article in Health Affairs wherein we conclude that, ‘given financial constraints, it would be unethical to divert antiretroviral drugs from treatment to prevention ’. He argues that our conclusions are short sighted and flawed, and that ‘Denying ARV provision for prevention efforts is unethical and a transgression of human rights ’.
With respect to ethics, Singh  writes, ‘The principles of stewardship, responsibility, harm prevention, solidarity, and compassion dictate that authorities have a duty to protect the interests of all people, particularly the most vulnerable’. He further notes that, ‘the prioritarian principle holds that resources must be directed to the least advantaged members or groups in society,’ and that ‘the principles of urgent need and duty of rescue dictate that those at high risk of HIV infection and who are unable to protect themselves from infection must be provided with relevant interventions to prevent or mitigate their chance of being infected ’.
We contend that the principles mentioned do little to differentiate who should be given priority for antiretroviral (ARVs): those in need of drugs for treatment or for prevention. The difficulty lies not with the principles but in determining who should be considered most vulnerable and most in need. Singh contends that one group most in need are young women in sub-Saharan Africa who are disproportionately affected by the HIV epidemic and are particularly vulnerable because they are typically unable to prevent becoming HIV infected by insisting that their partners use condoms.
Although we do not disagree that this population is vulnerable, we argue that they are neither the most vulnerable, nor do they have the greatest immediate need for ARVs. It is difficult to see how uninfected individuals, regardless of their vulnerability, can claim a greater need than infected persons who would surely die without treatment. We also note that, at the present time, evidence supporting the use of ARV for prevention in young heterosexual women has not been firmly established . WHO has called for demonstration projects on efficacy of preexposure prophylaxis for prevention, not a roll-out for the general population . Even if ARVs for prevention become a standard for heterosexual women, this preventive method will have little impact if HIV testing programs have not been scaled up or women are afraid to come forward for testing.
Singh's second justification for diverting ARVs from treatment to prevention utilizes the language of human rights. He notes that the International Covenant on Economic, Social and Cultural Rights introduces the concept of a state's ‘minimum core obligation’ in respect to its citizens and ‘if a country is experiencing stubborn or rising HIV prevalence, this could be indicative of that setting not meeting its minimum core obligations in relation to HIV management ’. He contends that meeting this minimum core obligation in settings with vulnerable individuals who may be unable to access existing interventions obligates governments to provide ARVs for both treatment and prevention.
However, the human rights argument is no more persuasive than the argument using ethical principles. Whether the analysis proceeds in terms of human rights or ethical principles, the dilemma remains the same: whose rights take precedence? The rights of infected people who cannot access treatment because available drugs are being used for prevention are surely violated to the same degree, if not more, than those who do not have access to ARVs for prevention. Furthermore, if individuals lack access to existing preventive interventions due to social, cultural or legal factors, as Singh declares, then these factors need to be addressed before introducing ARVs for prevention. To do otherwise would limit the benefit of ARVs for prevention to groups that already have access, and are therefore less likely to be vulnerable, at high risk or in urgent need.
Lastly, Singh  states that ‘Framing ARV resource allocation as a treatment versus prevention dichotomy is simplistic and counter-productive’. Although framing the issue as a black and white choice between treatment and prevention may be somewhat artificial, we do not believe it is counter-productive. The stark contrast between treatment and prevention will definitely arise when governments, communities and nongovernmental organizations make resource allocation decisions. It is better to frame these choices in as clear a manner as possible to illustrate the ethical issues.
Conflicts of interest
There are no conflicts of interest.
1. Singh J. Antiretroviral resource allocation for HIV prevention
2. Macklin R, Cowan E. Given financial constraints, it would be unethical to divert antiretroviral drugs from treatment to prevention
. Health Aff (Millwood)
3. Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, Kapiga S, et al. Preexposure Prophylaxis for HIV Infection among African Women
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4. World Health OrganizationGuidance on Pre-Exposure Oral Prophylaxis (PrEP) for Serodiscordant Couples, Men and Transgender Women Who Have Sex with Men at High Risk of HIV: Recommendations for Use in the Context of Demonstration Projects
. 2012; Geneva:World Health Organization, Available at: http://apps.who.int/iris/bitstream/10665/75188/1/9789241503884_eng.pdf. [Accessed 1 June 2012].