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HIV/AIDS and admission to intensive care units: a comparison of India, Brazil and South Africa.

People living with HIV/AIDS (PLWHA) often become ill due to opportunistic infections such as Pneumocystis jeroveci pneumonia, necessitating hospitalisation and admission to intensive care units (ICUs). Resources allocated to specialised care in developing countries seldom match their demand, resulting in decisions having to be made about who benefits from treatment and who does not. [1] In resource-constrained countries, these value-laden decisions by critical care specialists are often made in the absence of explicit policies and guidelines, and are based on individual knowledge and experience, which may be subject to bias. In South Africa the general criteria for ICU admission in the public sector include whether the patient is 'too well or too ill', and whether there is a realistic prospect of 'reversibility of organ dysfunction'. This policy is equally applicable to PLWHA who require ICU admission.

We reviewed published information on legislation and practices related to ICU admission in India, Brazil and South Africa, to assess access to critical care services in the context of HIV status.

According to the 2012 UNAIDS Global Aids Report, the BRICS countries--Brazil, Russia, India, China and South Africa --increased domestic public spending on HIV by more than 120% between 2006 and 2011. These countries currently fund, on average, more than 75% of their domestic AIDS responses and have dealt with the HIV pandemic with varying levels of success. [2] The three countries reviewed face similar problems regarding resource constraints and the numbers of available ICU beds (Table 1). India is notable in that ICU care in the country is very limited, inaccessible and unaffordable to many citizens. [3]

The Constitutional right to intensive care for PLWHA

The Constitutions of Brazil, India and South Africa enshrine a patient's right to healthcare and their right not to be refused access to emergency treatment. Legal precedents to this effect exist in India and South Africa, where this Constitutional right has withstood legal review (Table 2). These case precedents apply equally to PLWHA and access to intensive care.

Professional ethical guidelines for ICU admission

The medical associations of India, Brazil and South Africa subscribe to the international guidelines of the World Medical Association's Declaration of Geneva, which provide a framework for the appropriate conduct of the medical profession globally. [4] Each country has a professional association that guides and regulates ethical conduct, particularly with regard to PLWHA. These guidelines protect PLWHA against stigmatisation and discrimination by health professionals, particularly with regard to access to healthcare, treatment and support programmes. Similarly, the Siracusa Principles'51 spell out five criteria concerning human rights and restrictions to public health based on resource limitations. The burden of proof still falls on those who want to restrict rights, and concrete scientific and public health evidence is needed, specifically with response to Siracusa Principle 5 which states that 'the restriction of the right of access to public health cannot be unreasonable or discriminatory in its application'. [5]

Lessons to be learnt from Brazil and India

The regulatory and ethical frameworks of Brazil and India provide a useful indication of the varied challenges faced by developing nations regarding PLWHA and their access to ICU care. An important contributor to the success of Brazil's response to the HIV/AIDS epidemic is its National Health Insurance Scheme, which has strengthened its public health system, including ICU bed availability. In Brazil, health services are provided by private-public partnerships, funded by the government and freely accessible to the patient, and extending to specialist and ICU care. [6] It is therefore evident that an HIV-infected patient in Brazil who requires admission to ICU would have easy access to such level of care. The Brazilian Society of Intensive Care [7] speaks of issues of informed consent, the need for comprehensive medical records, humanising the ICUs by improving communication with patients and their families, and establishing ICU admission and discharge criteria in keeping with the 'existing laws and institutional rules'. As such, failure to comply with the provisions under the resolution will be subject to 'civil liability, and administrative and criminal sanctions'.

There is no comprehensive legislation in India addressing HIV/ AIDS and criteria for ICU admission. The number of ICU beds available is disproportionately low, in the private and public hospitals, and there is also considerable variation in the allocation and distribution of critical care services across the country, given that 70% of the country is rural. [3,8]

Notwithstanding explicit ICU admission policy at a macro level in South Africa, widespread anecdotal evidence seems to suggest that HIV status may be commonly used as an ICU exclusion criterion. This practice results in arbitrary decision-making and has no prognostic evidentiary basis, rendering such decision-making irrational. Furthermore, it is contrary to SA's legal and human rights policy frameworks.

Given the current state of affairs, policy-makers and clinicians in SA and further afield should devise explicit policy frameworks to govern ICU admissions in the context of HIV status.

Author contributions. KN conducted the study, interpreted the data and drafted the manuscript. JAS critically revised the manuscript for intellectual content. UGL conceptualised, designed and supervised the study, analysed and interpreted the data, and critically revised the manuscript for intellectual content. All authors read and approved the manuscript prior to publication.


[1.] Caldeira VM, Silva Junior JM, Oliveira AM, et al. Criteria for patient admission to an intensive care unit and related mortality rates. Rev Assoc Med Bras 2010;56(5):528-534.

[2.] UNAIDS. World AIDS Day Report 2012. contentassets/documents/epidemiology/2012/gr2012/JC2434_WorldAIDSday_ results_en.pdf (accessed 17 January 2012).

[3.] Yeolekar ME, Mehta S. ICU care in India-status and challenges. J Assoc Physicians India 2008;56:221-222.

[4.] World Medical Association. WMA Medical Ethics Manual, 2005. http://www.wma. net/en/30publications/30ethicsmanual/ (accessed 12 September 2010).

[5.] Gruskin S, Loff B. Do human rights have a role in public health work. Lancet 2002;360(9348):1880. []

[6.] Brazilian Department of STD, AIDS and Viral Hepatitis. Datasus; Sistema de Monitoramento de Indicadores do Programa Nacional de DST/Aids - MONITORAIDS (accessed 25 March 2012).

[7.] Brazilian Society of Critical Care. Resolution No. RDC-7 of 24 February 2010. http:// (accessed 22 March 2012).

[8.] Jayaram R, Ramakrishnan N. Cost of intensive care in India. Indian J Crit Care Med 2008;12(2):55-61. []

K Naidoo, J A Singh, U G Lalloo

Department of Family Medicine, School of Nursing and Public Health, Nelson R Mandela College of Medicine, University of KwaZulu-Natal, Durban

K Naidoo, MB ChB, MMed (Fam Med), LLM (Medical Law)

Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela College of Medicine, University of KwaZulu-Natal, Durban

J A Singh, LLM, PhD

Department of Pulmonology and Critical Care, School of Clinical Medicine, Nelson R Mandela College of Medicine, University of KwaZulu-Natal, Durban

U G Lalloo, MB ChB, MD

Corresponding author: U G Lalloo (
Table 1. Population to ICU bed ratio according to country

                  Brazil        India         USA           South

2012 population   199 million   1.2 billion   313 million   49 million
Number of         25 367        70 000        94 000        5 500
  ICU beds, N
Population :      ~ 1:8 000     ~ 1:14 000    ~ 1:4 000     ~ 1:10 000
  ICU bed ratio

Table 2. The right to healthcare and access to
emergency care: Case precedents

Country         Case

India           P Rathnam v. Union of India 1994 (3);
                  Supreme Court cases 394-430
                Gian Kaur v. State of Punjab 1996
                  Supreme Court; 83: 12578-12564
                Paschim Baga Khet Mansoor Samiti v. State
                  of West Bengal; AIR 1996 SC 2426
South Africa    Government of the Republic of South Africa
                  (RSA) and others v. Grootboom and
                  others (judgment: 4 October 2000)
                Minister of Health and others v. Treatment
                  Action Campaign (TAC) and others
                  (judgment: 5 July 2002)
                Soobramoney v. Minister of Health
                  (KwaZulu-Natal) 116 Case CCT 32/97
                  (judgement: 27 November 1997)
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Article Details
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Title Annotation:FORUM
Author:Naidoo, K.; Singh, J.A.; Lalloo, U.G.
Publication:Southern African Journal of HIV Medicine
Article Type:Report
Geographic Code:3BRAZ
Date:Mar 1, 2013
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