Identification of beneficiaries of free anti-retroviral drugs in Malawi: a community consensus process.

Malawi is a southeastern Africa country that has been heavily affected by the AIDS pandemic. It is estimated that about 170,000 people were in need of highly active antiretroviral therapy (HAART) for the treatment of AIDS in 2006. At the end of 2006, at least 55,000 people in Malawi were on HAART treatment, mostly through the free public sector program. At the time the program was being initiated, an ethical question needed to be answered in respect to who would be targeted for free treatment in an environment where medications, human and other resources were not enough to cater for all who were clinically eligible to be on treatment. In this paper we report on a qualitative study that was carried out to obtain public perceptions and input as to which criteria ought to have been applied to identify persons or groups of persons to be targeted in the free HAART program. In general, there was no agreement as to who should be prioritised for HAART, whether treatment should be free to user or whether cost-sharing should be introduced. While it may have been relatively straightforward in obtaining consensus and agreement among medical practitioners on the clinical criteria for HART in Malawi, deciding on the social criteria was complex. The decision to start the nationwide HAART program was started with the understanding that virtually every social group could be justified as worth of free HAART.