Comorbidity in context: Part 1. Medical considerations around HIV and tuberculosis during the COVID-19 pandemic in South Africa

Infectious diseases pandemics have devastating health, social and economic consequences, especially in developing countries such as South Africa. Scarce medical resources must often be rationed effectively to contain the disease outbreak. In the case of COVID-19, even the best-resourced countries will have inadequate intensive care facilities for the large number of patients needing admission and ventilation. The scarcity of medical resources creates the need for national governments to establish admission criteria that are evidence-based and fair. Questions have been raised whether infection with HIV or tuberculosis (TB) may amplify the risk of adverse COVID-19 outcomes and therefore whether these conditions should be factored in when deciding on the rationing of intensive care facilities. In light of these questions, clinical evidence regarding inclusion of these infections as comorbidities relevant to intensive care unit admission triage criteria is investigated in the first of a two-part series of articles. There is currently no evidence to indicate that HIV or TB infection on their own predispose to an increased risk of infection with SARS-CoV-2 or worse outcomes for COVID-19. It is recommended that, as for other medical conditions, validated scoring systems for poor prognostic factors should be applied. A subsequent article examines the ethicolegal implications of limiting intensive care access of persons living with HIV or TB

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

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

Consent to research by mentally ill children and adolescents: The implications of Chapter 9 of the National Health Act

Chapter 9 of the National Health Act came into effect in March 2012. In this article examines, the Act's statutory requirements relating to the informed consent to participation in clinical research by mentally ill children and adolescents in South Africa. The necessity of doing clinical research in mentally ill children and adolescents is canvassed briefly and the requirements that chapter 9 sets out for lawful child and adolescent consent to research participation are presented. The article deliberates upon the limitations of the newly enacted legislation and proposes selective improvements. Because of the likely erosion of the minor's privacy, the article finds that the requirement that a parent or legal guardian must consent to children's and adolescents' participation in research has the potential to obstruct much-needed mental health research. This requirement is likely to be found unconstitutional. In certain circumstances, ethics committees tasked with the review of research should be allowed to dispense with parental consent; and adolescents recognised as having the necessary capacity to consent independently to research participation. Furthermore, the Act's classification of research into therapeutic and non-therapeutic categories is considered problematic. The article recommends that research permissible in minors be stated in terms of well-defined risk standards. Finally, the article finds the requirement set in subsection 71(3) for ministerial consent in the case of non-therapeutic research in children and adolescents to be overly protectionist, as it precludes the capacity of ethics committees to judge the ethics of the proposed research

The regulation of informed consent to participation in clinical research by mentally ill persons in South Africa: an overview

The article examines the legal requirements relating to the informed consent of mentally ill persons to participation in clinical research in South Africa. First; the juridical basis of informed consent in South African law is outlined; and second; the requirements for lawful consent developed in South African common law and case law are presented. Finally; the article deliberates upon the requirements for the participation of mentally ill persons in research as laid down by the Mental Health Care Act and its regulations; the National Health Act and its (draft) regulations; and the South African Constitution