Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Efficiency, Equity, and Reality

Background: Rationing of access to antiretroviral therapy already exists in sub-Saharan Africa and will intensify as national treatment programs develop. The number of people who are medically eligible for therapy will far exceed the human, infrastructural, and financial resources available, making rationing of public treatment services inevitable. Methods: We identified 15 criteria by which antiretroviral therapy could be rationed in African countries and analyzed the resulting rationing systems across 5 domains: clinical effectiveness, implementation feasibility, cost, economic efficiency, and social equity. Findings: Rationing can be explicit or implicit. Access to treatment can be explicitly targeted to priority subpopulations such as mothers of newborns, skilled workers, students, or poor people. Explicit conditions can also be set that cause differential access, such as residence in a designated geographic area, co-payment, access to testing, or a demonstrated commitment to adhere to therapy. Implicit rationing on the basis of first-come, first-served or queuing will arise when no explicit system is enforced; implicit systems almost always allow a high degree of queue-jumping by the elite. There is a direct tradeoff between economic efficiency and social equity. Interpretation: Rationing is inevitable in most countries for some period of time. Without deliberate social policy decisions, implicit rationing systems that are neither efficient nor equitable will prevail. Governments that make deliberate choices, and then explain and defend those choices to their constituencies, are more likely to achieve a socially desirable outcome from the large investments now being made than are those that allow queuing and queue-jumping to dominate.

Principles of Safe Policy Routing Dynamics

We introduce the Dynamic Policy Routing (DPR) model that captures the propagation of route updates under arbitrary changes in topology or path preferences. DPR introduces the notion of causation chains where the route flap at one node causes a flap at the next node along the chain. Using DPR, we model the Gao-Rexford (economic) guidelines that guarantee the safety (i.e., convergence) of policy routing. We establish three principles of safe policy routing dynamics. The non-interference principle provides insight into which ASes can directly induce route changes in one another. The single cycle principle and the multi-tiered cycle principle provide insight into how cycles of routing updates can manifest in any network. We develop INTERFERENCEBEAT, a distributed algorithm that propagates a small token along causation chains to check adherence to these principles. To enhance the diagnosis power of INTERFERENCEBEAT, we model four violations of the Gao-Rexford guidelines (e.g., transiting between peers) and characterize the resulting dynamics.