Leveraging HIV care systems to improve cardiovascular disease prevention in the Kingdom of eSwatini

ABSTRACT/SUMMARY The aim of the parent R01, “Leveraging HIV care systems to improve cardiovascular disease prevention in the Kingdom of eSwatini,” is to identify the set of health services that would provide the most health to the population of Eswatini, taking into account budget constraints, healthcare workforce constraints, and pre-

existing infrastructure (e.g., HIV clinics). The research informs Eswatini’s planned implementation of universal health coverage, which will offer residents a health benefits package (HBP) of services that can be delivered within resource constraints. This Supplement proposes to strengthen Eswatini’s HBP design by incorporating

the bioethics concepts of justice (the fairness of distribution according to what is deserved) and the related concept of equity (the absence of disparities according to levels of underlying social advantage/disadvantage). Specifically, we will extend the parent award’s approach of determining which HBP would provide the most

health to the population by also taking into account how equally or unequally health benefits are allocated according to contextually relevant determinants of heath. We will (Aim 1) systematically elicit strengths of inequity aversion along key dimensions (e.g., gender, socioeconomic status, level of education, HIV status,

and other factors nominated by stakeholders) using the Delphi-based systematic group decision-making techniques used in the parent award, and (Aim 2) augment the HBP optimization process by incorporating inequity aversion using Atkinson’s method, which adjusts health outcomes according to how equitably or

inequitably they are distributed. We will then calculate the threshold level of inequity aversion needed to “flip” the status of a health service between inclusion and non-inclusion in the HBP. To contextualize the results, we will benchmark levels of inequity aversion in Aim 2 base on the information gained in Aim 1, but to ensure Aim

independence, we will also use benchmarks informed by literature, including two studies in Eastern Africa. This research will pioneer estimation of inequity aversion in a new region and with unprecedented nuance in contextualizing health determinants and their intersections. It will also will pioneer the calculation of threshold

inequity aversion levels that would be needed to change inference for policy decision-making, making the results applicable as further research on inequity aversion accrues. Insights from this project can help shape future bioethics research priorities and approaches to policy decision-making.