DECISION MAKER PRIORITIES FOR PROVIDING ANTIRETROVIRAL THERAPY IN HIV-INFECTED SOUTH AFRICAN ADULTS: A QUALITATIVE ASSESSMENT

Purpose: In resource-limited settings, successful HIV treatment scale-up efforts have been tempered by reports of increased funding shortfalls. We aimed to determine the priorities, including ethical considerations, of decision makers for HIV antiretroviral programs.

Method: We conducted qualitative interviews with decision makers, defined broadly as stakeholders or policymakers involved in South Africa’s HIV treatment scale-up efforts. We used a purposive sampling strategy to identify 12 respondents. Respondents engaged in one-on-one, semi-structured, 1-hour interviews that were digitally recorded and transcribed. We developed an Interview Guide, with pre-test interviews conducted to ensure general concepts were included. The Guide contained open-ended questions regarding key priorities and contextual factors for HIV antiretroviral program decision making; follow-up probes were used to clarify ethical considerations. We evaluated textual data from the interviews iteratively to identify themes regarding program priorities and ethical considerations. Saturation, indicating sample size sufficiency, was achieved since information gained from final interviews reiterated information gained in previous ones.

Result: Among the 12 respondents, 10 (83%) lived and worked in South Africa; all self-identified as decision makers working in the health sector. Respondents came from Western Cape, Gauteng, and KwaZulu-Natal provinces and worked primarily in urban settings. Respondents supported prioritizing individual patients based on treatment adherence, pregnancy status to prevent maternal-to-child HIV transmission and/or orphans, and severity of illness. However, priorities based on severity of illness varied, with first-come/first-serve, prioritization of the most severely ill, and prioritization of the least severely ill discussed. Respondents opposed prioritizing based on patient socioeconomic or -demographic characteristics. Other priorities included the number receiving treatment; how treated patients are distributed in the population (e.g, urban/rural); and treatment policy (e.g., number of antiretroviral regimens). Considerations motivating respondent priorities included (1) humanitarian concerns at the individual and/or societal levels; (2) personal responsibility for individual patients; and/or (3) clinical outcomes (e.g., patient-level morbidity and mortality, saving the most lives) and/or social outcomes (e.g., restoring patients as functional family members).

Conclusion: Decision makers have a wide range of priorities for antiretroviral provision in South Africa, and the motivations underlying these priorities suggest at times conflicting ethical considerations for providing HIV treatment when resources are limited. Understanding both will help in developing a framework to quantify decision maker preferences for attributes of alternative HIV treatment programs in resource-limited settings.