When Choosing Antiretroviral Therapy Meets Immigration Policy: An Ethical Analysis.

Migration policies increasingly shape the conditions of care for migrants living with HIV. In France, access to residence permits on medical grounds intersects with clinical practice, raising important ethical challenges. We describe a 29-year-old woman from Guinea living in France with HIV and severe obesity, with an irregular migration status. Although virologically stable on oral antiretroviral therapy, she requests a switch to a long-acting injectable regimen, motivated by both anticipated administrative implications and the desire for greater discretion. Through this case, we examine how therapeutic reasoning in HIV care may be shaped by legal and social determinants. Using the principlism framework of Beauchamp and Childress, complemented by Tronto's ethics of care, we highlight tensions related to justice, beneficence, non-maleficence, and autonomy. Uncertainty surrounding administrative decision-making may lead patients and clinicians to perceive treatment choices as influencing legal outcomes. Differences between oral and injectable regimens raise issues of equity, feasibility, and social impact. Risks related to treatment interruption, particularly in contexts of legal instability, further complicate clinical reasoning. This case underscores the need to integrate legal and social determinants into therapeutic reasoning and supports the development of guidance from professional societies to assist clinicians facing these complex decisions.