In Practice

Comorbidity in context: Part 2. Ethicolegal considerations around HIV and tuberculosis during the COVID-19 pandemic in South Africa

T M Rossouw, A G Nienaber, M T Boswell, K Moodley


The COVID-19 pandemic has brought discussions around the appropriate and fair rationing of scare resources to the forefront. This is of special importance in a country such as South Africa (SA), where scarce resources interface with high levels of need. A large proportion of the SA population has risk factors associated with worse COVID-19 outcomes. Many people are also potentially medically and socially vulnerable secondary to the high levels of infection with HIV and tuberculosis (TB) in the country. This is the second of two articles. The first examined the clinical evidence regarding the inclusion of HIV and TB as comorbidities relevant to intensive care unit (ICU) admission triage criteria. Given the fact that patients with HIV or TB may potentially be excluded from admission to an ICU on the basis of an assumption of lack of clinical suitability for critical care, in this article we explore the ethicolegal implications of limiting ICU access of persons living with HIV or TB. We argue that all allocation and rationing decisions must be in terms of SA law, which prohibits unfair discrimination. In addition, ethical decision-making demands accurate and evidence-based strategies for the fair distribution of limited resources. Rationing decisions and processes should be fair and based on visible and consistent criteria that can be subjected to objective scrutiny, with the ultimate aim of ensuring accountability, equity and fairness.

Authors' affiliations

T M Rossouw, 1 Department of Immunology, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa; University of Pretoria/South African Medical Research Council Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies

A G Nienaber, Department of Public Law, Faculty of Law, University of Pretoria, South Africa

M T Boswell, Division of Infectious Diseases, Department of Internal Medicine, Steve Biko Academic Hospital, Johannesburg, South Africa

K Moodley, Centre for Medical Ethics and Law, Department of Medicine, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa


HIV; Tuberculosis; TB; Intensive care access; Medical ethics; Law

Cite this article

South African Medical Journal 2020;110(7):625-628. DOI:10.7196/SAMJ.2020.v110i7.14857

Article History

Date submitted: 2020-06-17
Date published: 2020-06-17

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