Swaziland, HIV and Option B+: What Can We Afford?

MSPH-14-0008.0 This case study examines the challenges and tradeoffs for a small sub-Saharan African country with limited resources as it tries to combat one of the highest rates of HIV-AIDS infection in the world. Swaziland in 1999 declared HIV-AIDS a national disaster. However, under the direction of Dr. Velphi Okello as national antiretroviral therapy (ART) coordinator at the Ministry of Health, the country gradually began to take charge of its own treatment and prevention programs. Okello learned to leverage both internal and international resources to maintain supplies of the essential but expensive ART drugs needed to treat and prevent the further spread of HIV.

Preventing mother-to-child transmissions (MTCT) had long been a priority of public health officials. Swaziland worked with global partners, including ICAP of Columbia University, to promote treatment of pregnant women infected with HIV. The country largely managed to adhere to international standards set by the World Health Organization (WHO). But in 2012, WHO guidelines called for a new regimen, Option B+, which while beneficial would impose even greater burdens on an already-stretched national budget. Okello and a multi-stakeholder Technical Working Group faced a tough call.

Use this case to promote student discussion of the challenges to a small, poor country of tackling an enormous public health crisis. That meant funding both treatment and prevention measures, accepting international aid while maintaining control of the process, and adapting international guidelines and best practices to the political, financial and cultural realities on the ground. Also ask students to discuss the ethics of prioritizing treatment for pregnant and breast-feeding women over men or never-pregnant women.

Use this case in a course/class on public health policy, HIV-AIDS, Africa, multinational aid, medical ethics or evidence-based medicine.


This case was written by Eric Smalley for the Case Consortium @ Columbia and the Mailman School of Public Health. Additional funding was provided by the Open Society Foundations. (0914)

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