When Global ART Budgets Cannot Cover All Patients, Who Should Be Eligible?

BACKGROUND: Widely expected cuts to budgets for global HIV/AIDS response force hard prioritization choices.
SETTING: We examine policies for antiretroviral therapy (ART) eligibility through the lens of the most relevant ethical approaches.
METHODS: We compare earlier ART eligibility to later ART eligibility in terms of saving the most lives, life-years, and quality-adjusted life-years, special consideration for the sickest, special consideration for those who stand to benefit the most, special consideration for recipients' own health needs, and special consideration to avoid denying ART permanently.
RESULTS: We argue that, in most low- and middle-income countries with generalized HIV/AIDS epidemic, ethically, ART for sicker patients should come before ART eligibility for healthier ones immediately on diagnosis (namely, before "universal test and treat"). In particular, reserving all ART for sicker patients would usually save more life-years, prioritize the sickest, and display other properties that some central ethical approaches find important, and that concern none-so ethically, it is "cross-theoretically dominant," as we put it.
CONCLUSIONS: In most circumstances of depressed financing in low- and middle-income countries with generalized HIV/AIDS epidemic, reserving all ART for sicker patients is more ethical than the current international standard.