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Conducting intervention studies in Africa, where medicines supply for chronic conditions is inequitable and patchy, raises major ethical issues.
Here we discuss what should the ethical approach be for a research programme in terms of provision of a steady and sustainable supply of medicines for patients with diabetes and hypertension.
The incidence of diabetes and hypertension has risen sharply in sub-Saharan Africa alongside a continuing high burden of HIV infection.1 In many settings, the prevalence figures among adults are 4%–5% for diabetes, above 25% for hypertension and 5%–20% for HIV infection.2–4 All these conditions require lifelong treatment, and they have increased substantially the demand for chronic care services in Africa, where health systems have, until recently, focused on tackling acute infectious diseases.5
There is considerable inequity in service provision for chronic diseases. HIV services, including antiretroviral therapy, are available widely for free and are organised typically in stand-alone clinics. Over 65% of people estimated to be living with HIV infection are in regular care.6 In contrast, this figure is only about 5%–20% for people living with diabetes or hypertension.3 7 A major challenge is that medicines for diabetes and hypertension are generally not provided free of charge and have to be purchased by patients. Even in those countries that do provide free medicines for hypertension and diabetes, shortages are common and patients then have to purchase the medicines from private suppliers.
Our research collaboration is evaluating a biomedical diabetes preventive intervention in people living with HIV infection in a placebo-controlled randomised trial and, separately, evaluating integrated healthcare provision compared with standard care for people living with HIV, diabetes or hypertension in a cluster-randomised controlled trial.8 There are no data on the effectiveness of these approaches from Africa. Therefore, these trials have clinical and health …
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