Yeatman Sara, Trinitapoli Jenny
Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA.
Department of Sociology, University of Chicago, Chicago, IL, USA.
J Int AIDS Soc. 2017 Mar 8;20(1):21467. doi: 10.7448/IAS.20.1.21467.
Policies for rationing antiretroviral therapy (ART) have been subject to on-going ethical debates. Introduced in Malawi in 2011, Option B+ prioritized HIV-positive pregnant women for lifelong ART regardless of the underlying state of their immune system, shifting the logic of allocation away from medical eligibility. Despite the rapid expansion of this policy, we know little about how it has been understood and interpreted by the people it affects.
We assessed awareness and perceived fairness of the prioritization system for ART among a population-based sample of young women (n = 1440) and their partners (n = 574) in southern Malawi. We use a card-sort technique to elicit understandings of who gets ART under Option B+ and who should be prioritized, and we compare perceptions to actual ART policy using sequence analysis and optimal matching. We then use ordered logistic regression to identify the factors associated with policy awareness.
In 2015, only 30.7% of women and 21.1% of male partners understood how ART was being distributed. There was widespread confusion around whether otherwise healthy HIV-positive pregnant women could access ART under Option B + . Nonetheless, more young adults thought that the fairest policy should prioritize such women than believed the actual policy did. Women who were older, more educated or had recently engaged with the health system through antenatal care or ART had more accurate understandings of Option B + . Among men, policy awareness was lower, and was patterned only by education.
Although most respondents were unaware that Option B+ afforded ART access to healthy-pregnant women, Malawians support the prioritization of pregnant women. Countries adopting Option B+ or other new ART policies such as universal test-and-treat should communicate the policies and their rationales to the public - such transparency would be more consistent with a fair and ethical process and could additionally serve to clarify confusion and enhance retention..
抗逆转录病毒疗法（ART）的配给政策一直是持续不断的伦理辩论主题。2011年在马拉维推出的“选项B+”政策，将HIV阳性孕妇列为终身接受抗逆转录病毒治疗的优先对象，无论其免疫系统的潜在状态如何，这一分配逻辑从医疗资格转向了其他方面。尽管该政策迅速推广，但我们对其受影响人群如何理解和解释这一政策却知之甚少。
我们在马拉维南部以人群为基础的年轻女性样本（n = 1440）及其伴侣（n = 574）中，评估了抗逆转录病毒治疗优先排序系统的知晓度和感知公平性。我们使用卡片分类技术来引出对“选项B+”下谁能获得抗逆转录病毒治疗以及谁应被优先考虑的理解，并使用序列分析和最优匹配将这些认知与实际的抗逆转录病毒治疗政策进行比较。然后，我们使用有序逻辑回归来确定与政策知晓度相关的因素。
2015年，只有30.7%的女性和21.1%的男性伴侣了解抗逆转录病毒治疗的分配方式。对于在“选项B+”下原本健康的HIV阳性孕妇是否能够获得抗逆转录病毒治疗，存在广泛的困惑。尽管如此，更多的年轻人认为最公平的政策应该优先考虑这类女性，而不是相信实际政策所做的那样。年龄较大、受教育程度较高或最近通过产前护理或抗逆转录病毒治疗与卫生系统有过接触的女性，对“选项B+”有更准确的理解。在男性中，政策知晓度较低，且仅受教育程度影响。
尽管大多数受访者不知道“选项B+”使健康孕妇能够获得抗逆转录病毒治疗，但马拉维人支持将孕妇列为优先对象。采用“选项B+”或其他新的抗逆转录病毒治疗政策（如普遍检测与治疗）的国家，应向公众传达这些政策及其基本原理——这种透明度将更符合公平和道德的程序，还可以消除困惑并提高留存率。
