With the coronavirus pandemic threatening to overwhelm medical care resources in some areas of the country, many states are facing a choice they never thought they would need to make: Who gets a ventilator?

It’s a nearly immediate matter of life or death. A person with COVID-19 who needs a ventilator can die quickly without one, and removing a ventilator from someone already on one often means they’ll die within minutes, according to a March 23 article in The New England Journal of Medicine (NEJM) titled “The Toughest Triage—Allocating Ventilators in a Pandemic.”

If and when ventilator shortages emerge in the next few weeks—a likely scenario according to several governors­—doctors will need criteria to decide who gets one and who doesn’t. Statewide criteria in New York, the current epicenter of COVID-19 in the United States, target “saving the most lives, as defined by the patient’s short-term likelihood of surviving the acute medical episode,” according to the NEJM article.

Alabama’s pandemic guidelines recommend winnowing out people with certain medical conditions from even being considered for a ventilator, no matter their current medical emergency.

The state’s existing 10-year-old recommendations would explicitly deny access to lifesaving ventilators for people with certain conditions in the event of a pandemic, according to AL.com, a website that represents several Alabama newsletters.

According to the state’s “Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency,” these conditions include metastasized cancer, AIDS, end-stage liver disease (with a MELD score of over 20), “severe mental retardation,” advanced dementia and severe burns. AL.com suggests that these conditions “could disqualify patients from being put on potentially lifesaving ventilators if a pandemic grows dire enough. And some people already on ventilators could be removed from them to make space for people impacted by the pandemic, according to the guidance.”

Although AIDS is listed as one of the conditions that could result in the denial of a ventilator, the document quoted by AI.com clarifies that the “presence of [an HIV-positive] status without AIDS is not an automatic exclusion.” We all know that HIV can lead to life-threatening AIDS when untreated. But as the HIV community is well aware, the distinction between HIV and AIDS remains controversial and confusing. As federal resource HIV.gov explains the difference, people with HIV are considered to have progressed to AIDS when either their CD4 count drops below 200 or they develop one or more opportunistic infections regardless of CD4 count (in a healthy immune system, CD4 counts range from 500 to 1,600). But people with an AIDS diagnosis are not doomed to death. With treatment, many see their CD4 counts bounce back as they recover to enjoy healthy long lives. What’s more, an AIDS diagnosis is permanent, meaning that people with AIDS who see a return to health and robust CD4 numbers are still considered to have AIDS. (To learn more about this debated topic, read “Is It Time for the End of ‘AIDS’?”)

Because there is no shortage of ventilators at this time, the Alabama document is for guidance only.

In every state that faces a critical shortage of lifesaving equipment for COVID-19, wrenching decisions will need to be made. Reports from Italy describe physicians “weeping in the hospital hallways because of the choices they were going to have to make,” according to the NEJM. “In the weeks ahead, physicians in the United States may be asked to make decisions that they have never before had to face and for which many of them will not be prepared.”

To read the NEJM article, click here.

To read the AL.com article, click here.

To get the latest updates on the new coronavirus and HIV, click here.