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National HIV treatment guidelines in Tanzania and Ethiopia: are they legitimate rationing tools?
  1. K A Johansson1,2,
  2. D Jerene2,3,
  3. O F Norheim1,2
  1. 1
    Division of Medical Ethics, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
  2. 2
    Centre for International Health, University of Bergen, Bergen, Norway
  3. 3
    Arba Minch Hospital, Arba Minch, Ethiopia
  1. Kjell Arne Johansson, Division of Medical Ethics, Department of Public Health and Primary Health Care, Centre for International Health, University of Bergen, PB 7804, 5020 Bergen, Norway; Kjell.Johansson{at}


Objective: To provide an ethical analysis of whether the Ethiopian and Tanzanian national HIV/AIDS treatment guidelines can be considered legitimate and fair rationing tools.

Method: Qualitative study and ethical analysis involving guideline documents and interviews with nine key members involved in the development of the guidelines. The analysis followed an editing organising style. The theoretical framework was a guideline-specific framework based on theories of just resource allocation in healthcare and conditions that ensure fair processes in guideline development. According to this framework, legitimate rationing requires reasons for patient selection to be explicit, public and relevant, and decisions must be open to question and revision.

Results: The only explicit rationing criteria that both guidelines recommended were clinical antiretroviral treatment indications. Explicit non-clinical rationing criteria were expressed in a separate Ethiopian implementation guideline. Neither of the guideline development processes fully satisfies minimal requirements of procedural fairness. There is a lack of transparency. The reasons for decisions are rarely given and are not publicly available. This reduces the opportunity for public questioning, debate and revisions. The guidelines were based on expert opinion and consensus. Recommendations from the WHO were copied without much discussion, disagreement or adjustment.

Conclusions: The two national HIV treatment guidelines discussed are de facto mechanisms for rationing but were developed using methods that do not fully satisfy the requirements of fair processes.

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  • Funding: Johansson and Jerene received funding from the University of Bergen, Norway, and Norheim from a Young Investigator Award, Norwegian Research Council, Norway. The funding sources had no influence on the study design.

  • Competing interests: None.

  • Ethics approval: This study involved interviews with guideline developers and official guideline documents and did not involve patients or sensitive information about patients and therefore did not require ethics approval. Oral informed consent was collected and the interviewees were informed about the purpose of the study. Confidentiality and anonymity were assured in analysis and reporting of statements.

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