PLoS Medicine | www.plosmedicine.org0410
March 2006 | Volume 3 | Issue 3 | e160
Rational Choices for Allocating
Antiretrovirals in Africa: Treatment
Equity, Epidemiological Effi ciency,
David P. Wilson, Sally M. Blower
We agree with the thesis of Rosen et al.  that, despite
initiatives such as the World Health Organization’s “3 by
5” program, rationing of HIV/AIDS antiretroviral therapy
(ART) will be necessary in the majority of African countries.
Diffi cult choices will need to be made, and choices will be
constrained due to the limited health infrastructure and lack
of qualifi ed health personnel in many African countries.
Rosen et al. outlined a number of useful rationing systems
and selection criteria .
However, some of the strategies they suggest are
unfortunately not feasible in practice. For example, targeting
behavioral core groups (high-risk groups, e.g., female sex
workers) may well be impossible as it is not always possible
to identify behavioral core groups. Furthermore, once the
prevalence of HIV becomes extremely high in the general
population (as it already is in many African countries),
the concept of a behavioral core group will be relatively
Previously, it has been shown, by using mathematical
modeling, that targeting a virologic core group for treatment
could be a very effective public health strategy for controlling
herpes epidemics . Only relatively few of the individuals
infected with herpes simplex virus type 2 (HSV-2) are high viral
shedders, and these individuals constitute the virologic core
group. These individuals disproportionately contribute to the
HSV-2 incidence rate. Thus, treating only the relatively few
individuals who constitute the virologic core group has been
shown to have a substantial effect on reducing the incidence
of herpes . Such a public health strategy for controlling
herpes epidemics would be feasible, as it would be possible to
identify the high viral shedders (i.e., the virologic core group)
. Such a strategy would also ensure that relatively few drugs
would be needed to achieve epidemic control.
We suggest that when considering how to ration
antiretrovirals among individuals with HIV in Africa, instead
of targeting behavioral core groups, HIV virologic core groups
should be targeted. Individuals with HIV who constitute
the HIV virologic core group would be easy to identify
simply by measuring viral load. The virologic core group
will be composed of individuals with a high viral load. These
individuals would not only be people in the late stage of
disease, but would also include recently infected individuals,
who have a high viral set point. Targeting the HIV virological
core group would have several advantages: it would increase
treatment equity (as these individuals have the greatest need
for treatment), it would be epidemiologically effi cient, and it
would also be feasible. Whereas targeting the HIV behavioral
core group would decrease treatment equity, it may or may not
be epidemiologically effi cient and would not be feasible.
Treatment equity and epidemiological effi ciency are
likely to have very different weights in each African society.
Previously, we have shown, by using operational research
methodology, that it is possible to use mathematics to decide
how to achieve treatment equity . Thus, it is possible to
devise a mathematically ethical solution to decide how to
allocate a scarce supply of antiretrovirals if the objective is to
achieve treatment equity . We have shown that treatment
equity is only possible in some areas of South Africa if each of
the available health-care facilities treat individuals with HIV in
a large catchment area (radius of approximately 40–60 km2)
. Hence, in some African countries, it may be impossible
to achieve treatment equity even if it is possible to achieve a
rationing strategy that would ensure the maximum reduction
of the epidemic. Therefore, government offi cials and health
policy experts in each African country will have to decide
the relative weight that they wish to place on treatment
equity versus epidemiological effi ciency when they decide
how to ration their scarce supply of antiretrovirals. We also
stress that when using mathematical models to evaluate any
rationing strategy, single scenarios should not be used to
make complex decisions. There is a large degree of variability
in the parameters that defi ne each strategy and a great deal
of heterogeneity in how a given strategy will be implemented.
Accordingly, we recommend that time-dependent uncertainty
boundaries should always be presented in any analysis when
modeling is being used for health policy decision making .
In addition, detailed time-sensitivity analyses should also be
presented so that it is possible to evaluate the robustness of
the results .
Finally, we would like to stress the tremendous value in
preferentially making ART available to mothers with HIV
(especially women who are pregnant or breast-feeding), both
to prevent vertical transmission and to act as a therapeutic
intervention for the mother. Not only would this rationing
strategy reduce the burden of orphan support, but the
treatment regimen is relatively cheap and is extremely
effective in reducing transmission to infants and increasing
the life expectancy of the mother. Therefore, we strongly
recommend that no pregnant woman with HIV be overlooked
in the rationing of ART. ?
David P. Wilson (firstname.lastname@example.org)
University of New South Wales
Sydney, New South Wales, Australia
Sally M. Blower (email@example.com)
University of California Los Angeles
Los Angeles, California, United States of America
1. Rosen S, Sanne I, Collier A, Simon JL (2005) Rationing antiretroviral
therapy for HIV/AIDS in Africa: Choices and consequences. PLoS Med 2:
e303. DOI: 10.1371/journal.pmed.0020303
2. Blower S, Wald A, Gershengorn H, Wang F, Corey L (2004) Targeting
virological core groups: A new paradigm for controlling herpes simplex
virus type 2 epidemics. J Infect Dis 190: 1610–1617.
3. Wilson DP, Blower SM (2005) Designing equitable antiretroviral allocation
strategies in resource-constrained countries. PLoS Med 2: e50. DOI:
4. Blower S, Bodine E, Kahn J, McFarland W (2005) The antiretroviral
rollout and drug-resistant HIV in Africa: Insights from empirical data and
theoretical models. AIDS 19: 1–14.
Citation: Wilson DP, Blower SM (2006) Rational choices for allocating antiretrovirals
in Africa: Treatment equity, epidemiological effi ciency, and feasibility. PLoS Med
Copyright: © 2006 Wilson and Blower. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
PLoS Medicine | www.plosmedicine.org 0415
and source are credited.
Competing Interests: The authors have declared that no competing interests exist.
Prioritizing Investment in Medical
The dire need to reform medical education in South Asia
has been well emphasized in the PLoS Medicine Editorial
. It is encouraging to note that efforts are under way to
devise strategies to bring about this reformation. However,
for such reforms to be effective, it is crucial that the opinions
of medical students and young doctors are also taken
into account. Students’ roles should be enhanced from
those of mere consumers of medical education to those of
contributors . They are important stakeholders, and their
active participation in policymaking will facilitate the creation
of more robust solutions.
The need for drastic improvement in health research
in South Asia is well established. The need for research in
medical education is perhaps even greater. Unfortunately,
indigenous data pertaining to medical education in this
region are limited. Only a small number of studies have
attempted to explore the concerns of students and doctors
in matters pertaining to, for example, medical decision
making and health research [3,4]. The establishment of
a research culture is fraught with diffi culties but is not
impossible . It is my opinion that, to bring about reform,
both a “bottom-up” and a “top-down” approach are needed.
The former needs ample student exposure to research
during medical school. The latter is essentially linked to
the availability of funds. No amount of community-oriented
training, for example, will compensate for the defi ciency
of properly qualifi ed health professionals in rural areas. It
is only when there is suffi cient fi nancial and professional
security that the greater purpose of educational reform
will stand fulfi lled. It is hard to envisage how this can be
achieved when the bulk of budgetary spending pertains to
debt-servicing and defense expenditure.
Alongside medical education, parallel investment should
be sought in health education, not only because our
physicians are not cognizant of current treatment practices
, but also because our patients have a poor knowledge of
common diseases that affl ict them . The interaction of
better-informed patients and properly qualifi ed doctors may
signifi cantly improve community health. For impoverished
nations, the importance of preventive medicine is manifold as
it offers the most economical way of combating disease. There
is some evidence to suggest that our medical students are not
“prevention” oriented, and, thus, more emphasis must be
placed on preventive medicine .
It is also hoped that such investment will lead to nationally
oriented research activities and not to a mere replication of
Western studies. The study evaluating the signifi cant protective
effects of hand washing in children from common childhood
diseases is one such example . Another example is a
study evaluating the effects of garlic on dyslipidemia .
Further studies of this kind may prove helpful in combating
the cardiovascular disease epidemic in Pakistan. Garlic is
potentially a much cheaper alternative to statins, the latter
being unaffordable for most segments of Pakistani society.
Similarly, medical education institutions such as Aga Khan
University in Pakistan, which is a private-sector entity, have
started problem-based, community-oriented teaching in
medical schools. The outcome of these curricular changes
remains to be seen. Indeed, there is hope for South Asia, but
for such hope to materialize, we need selfl ess individuals,
strong institutions, and perhaps above all a more just and
realistic distribution of the national fi nancial resources. ?
Lahore Cantt, Lahore, Pakistan
1. PLoS Medicine Editors (2005) Improving health by investing in medical
education. PLoS Med 2: e424. DOI: 10.1371/journal.pmed.0020424
2. Awasthi S, Beardmore J, Clark J, Hadridge P, Madani H, et al. (2005) Five
futures for academic medicine. PLoS Med 2: e207. DOI: 10.1371/journal.
3. Jafarey AM, Farooqui A (2005) Informed consent in the Pakistani milieu:
The physician’s perspective. J Med Ethics 31: 93–96.
4. Aslam F, Qayyum MA, Mahmud H, Qasim R, Haque IU (2004) Attitudes
and practices of postgraduate medical trainees to wards research; a snapshot
from Faisalabad. J Pak Med Assoc 54: 534–536.
5. Aslam F, Shakir M, Qayyum MA (2005) Why medical students are crucial
to the future of health research in South Asia. PLoS Med 2: e322. DOI:
6. Jafar TH, Jessani S, Jafary FH, Ishaq M, Orkazai R, et al. (2005) General
practitioners’ approach to hypertension in urban Pakistan. Disturbing
trends in practice. Circulation 111: 1278–1283.
7. Jafary FH, Aslam F, Mahmud H, Waheed A, Shakir M, et al. (2005)
Cardiovascular health knowledge and behavior in patient attendants at four
tertiary care hospitals in Pakistan—A cause for concern. BMC Public Health
8. Aslam F, Mahmud H, Waheed A (2004) Cardiovascular health—Behaviour
of medical students in Karachi. J Pak Med Assoc 54: 492–495.
9. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, et al. (2005)
Effect of handwashing on child health: A randomized controlled trial.
Lancet 366: 225–233.
10. Ashraf R, Aamir K, Shaikh AR, Ahmed T (2005) Effect of garlic on
dyslipidemia in patients with type 2 diabetes mellitus. J Ayub Med Coll
Abbottabad 17: 60–64.
Citation: Aslam F (2006) Prioritizing investment in medical education. PLoS Med
Copyright: © 2006 Fawad Aslam. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author
and source are credited.
Competing Interests: The author has declared that no competing interests exist.
March 2006 | Volume 3 | Issue 3 | e166 | e159