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The Problem Of Uncontrolled HIV Spreading in Cularkistan

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Cularkistan has a weak health system. There is only one national hospital, that operates substantially below international standards. There are community health workers and a clinic for every 25,000 people but workers are not usually well trained. Aid is needed, and the United States government has decided to provide Cularkistan with anti-retroviral medication (ARV) designed to curb the tide of HIV among adults. The total number of adults who could benefit from this medication currently is 20,000 with an estimated 10,000 more being diagnosed with HIV each year. The United States has agreed to provide enough life-saving medication to treat those already on treatment (currently none) and an additional 5,000 people each year, over the course of 5 years. This totals to 25,000 people who will receive treatment. It is also important to note that treatment outside of what the government will provide is not possible. Decisions need to be made on who receives treatment and who does not. This proposal involves guidance on how this should be done. To decide who should and should not receive this medication, some background information is necessary. Without HIV treatment, life expectancy is related to how quickly your CD4 count drops and how low it gets. Your CD4 is essentially a snapshot of how well your immune system is functioning. For some, counts drop to a dangerous level within a few years of infection, while others can go 5-10 years or longer before needing treatment. Without close monitoring of these counts, it’s impossible to tell who is going to last longer than others. This monitoring will likely be implausible due to the scarcity of hospitals and trained medical professionals. It will be assumed that most people infected with HIV have the risk of dying sooner rather than later. The antiretroviral drugs that will be administered do not kill or cure the virus, but they do slow it down and prevent continuous growth. When the virus is slowed down, so is the HIV disease.

A study funded by the National Institutes of Health has confirmed that treating HIV- positive people with ARV drugs reduces the risk of transmitting the virus to HIV- negative sexual partners by 96% for heterosexual interactions. This is important because the epidemic of HIV in Cularkistant has been mostly driven by unprotected heterosexual sex. The prevalence has reached 6% among adults in 2014. While education and economic status are not indicators for this disease, factors that may increase risks of HIV include participating in high-risk behaviors, living in cities, and being female. One ethical violation that may present itself during this time is associated with politics. The president is up for re-election in three months and is from an area with high rates of HIV. This could sway his decision-making skills for who receives treatment. An argument may be made that those living in the city where the party’s electoral base is located should receive treatment. This would keep the voters happy and help guarantee a win for re-election to continue the good work of treating HIV. But, a counter point could be made that the current president of Cularkistant is not specifically giving these drugs, they are coming from an outside source (PREFAR) and can be sent to the country through any leader. The president should not base allocations on political gain (if you vote for me, you will receive an ARV). It is important that the president take an outsider’s opinion into consideration because it has the possibility of being less biased than an opinion of someone like the president who is close to the people of Cularkistant.

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Rationing will be inevitable due to the need being limitless and resources being limited. The principle of “to each to maximize overall quality-adjusted life years” should be taken into consideration during this rationing. This involves two steps; selecting outcome measures that adjust life-years for quality, and then allocating them to maximize quality-adjusted life years. Specific characteristics that would impact getting the medication or not will include; age, health not including HIV diagnosis, profession, location, and impact on society. Deciding who receives this drug should be focused on benefiting society as a whole. First, female sex workers and truck drivers should be treated. The prevalence among these groups are the highest of any other profession. These two groups of people also have greater opportunities to spread the disease once infected. Sex workers can spread HIV to many partners, and truck drivers can spread it to many locations. Because ARV’s prevent (for the most part) transmission, this will aid in stopping the problem at its core. Where people live will also impact if they are going to be medicated. Because there are not any medical professionals trained in ARV’s right now, it would be more efficient to train individuals and supply resources if they are based in densely populated cities, rather than trying to get trained personal and supplies out to more secluded, rural areas. It is also known that most people diagnosed with HIV live in cities, so more people will be able to receive treatment more efficiently, and with much less travel.

Health not including the HIV diagnosis should also be taken into consideration. If the individual has another pre-disposition that could also kill them, or the HIV disease has progressed to the point where months are left, allocating resources towards them would not be productive.

The ages of people being treated should be within 18-40. These years are generally child-bearing years and mother-to-child transmission of HIV during pregnancy, childbirth, or breastfeeding is common. Giving medication to individuals around these ages would help stop HIV from spreading through generations. This age span is also when society is going to benefit most from active participation; an unemployed 89-year-old with HIV who does not leave her home is much less useful to society than a 32-year-old doctor who volunteers at a homeless shelter twice a week. With the decision that persons aged 18-40, living in cities, in good health, starting with sex workers and truck drivers will be treated, the duty is now for the president to inform the people of Cularkistan that the ARV is available and specify who it is for.

Four characteristics of fair processes related to allocation need to be made known to the people of Cularkistan by the president. They are; oversight by a legitimate institution, transparent decision making, reasoning according to information and principles that all can accept as relevant, and procedures for appealing and revising individual decisions. There also needs to be a way for meaningful public engagement to occur to identify unanticipated needs and obtain public support. The United States Government, a legitimate institution, is overseeing the implementation of these drugs into Cularkistan society through the PEPFAR program. The decision making for who is getting these drugs should be provided, the main reason being to help nip the problem at its bud in treating those who readily spread the disease and those who could pass down the disease to their offspring.

The hope is that the incidence rate after the first year will decrease because those who are more likely to transmit the disease are being treated. These decisions will be reevaluated after the first year to decide which additional 5,000 people will receive the drugs next year. While ethical decisions such as how to allocate life-saving medications are difficult to make, the alternative is worse. To make everything “fair”, no one would receive treatment, and I think most can agree that some people is better than no people in terms of receiving medication.


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