In a super specialty government medical centre, antiretroviral treatment (ART) is provided to People Living with HIV and AIDS (PLHAs). Each month, on an average, 100 PLHAs come to the centre for ART. A clinician heads this ART centre in a medical college.

The rule of thumb is that all PLHAs who are willing to receive ART undergo certain blood tests. On the basis of the test results, the clinician identifies PLHAs who are “fit” for the course of drugs. The clinician offers ART to such cases on a “first-come first-priority” basis. For various reasons, a significant proportion of PLHAs default in adhering to the therapy. Therefore, counselling is provided at the medical centre to each case selected for ART.

One PLHA, Mr K, started ART on June 2003 at this clinic. After six months of his ART course, he had to visit his home in Bihar for four months. He requested the clinic to provide him with enough drugs for this duration. The clinic refused, saying that it was against government policy. As a result, while he was away, his ART could not be continued. He returned after four months to the clinic to restart his treatment.

Due to the significant gap in treatment, the clinic requested him to undergo tests for resistance. He was initially very reluctant, but after repeated requests and consultations with the clinicians, he took the tests. The tests fortunately showed that he had not developed resistance. His ART drug was restarted.

However, soon after the treatment was resumed, he was summoned back to his home in Bihar to attend to his wife’s illness. The treatment again had to be discontinued. This time, he was away for five months. On his return, when he reported to the clinic, he again went through the tests for resistance. This time, he had developed resistance to the first-line ART he was receiving.

When he was informed about second-line ART, he made a claim for it from the clinic. He was told that according to government policy, all government clinics provide only first-line ART, and if he wanted second-line ART he would have to buy it from the market. He was not financially capable of buying medicines from the market for the long-term treatment he needed.

K believes that he has a right to receive second-line drugs from the government. He also believes that he developed resistance because of the government’s faulty policy of not providing him with drugs to take with him when he visited his hometown. He has decided to go to the courts to force the government to respect his right to get full treatment and to change the government policy of not giving medicines when someone is travelling. He is also planning to approach the Human Rights Commission to get redress for the violation of his human rights.

Questions:

1. What are the ethical implications of the rationing of ART that is practised in such cases?

2. Was it ethically correct of the doctor and counsellor to decide not to offer ART to K, a migrant worker who had to go home for a few months every year, far away from the clinic?

3. When K informed the clinic that he was going away for a few months, what should the doctors and counsellors have done?

4. Is K justified in making claims about human rights and criticising government policy?