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.

On the Efficiency and Fairness of Transmission Control Loops: A Case for Exogenous Losses

We postulate that exogenous losses-which are typically regarded as introducing undesirable "noise" that needs to be filtered out or hidden from end points-can be surprisingly beneficial. In this paper we evaluate the effects of exogenous losses on transmission control loops, focusing primarily on efficiency and convergence to fairness properties. By analytically capturing the effects of exogenous losses, we are able to characterize the transient behavior of TCP. Our numerical results suggest that "noise" resulting from exogenous losses should not be filtered out blindly, and that a careful examination of the parameter space leads to better strategies regarding the treatment of exogenous losses inside the network. Specifically, we show that while low levels of exogenous losses do help connections converge to their fair share, higher levels of losses lead to inefficient network utilization. We draw the line between these two cases by determining whether or not it is advantageous to hide, or more interestingly introduce, exogenous losses. Our proposed approach is based on classifying the effects of exogenous losses into long-term and short-term effects. Such classification informs the extent to which we control exogenous losses, so as to operate in an efficient and fair region. We validate our results through simulations.