Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review

Paper published in PLoS Medicine in 2007.

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.

How Much Does It Cost to Provide Antiretroviral Therapy for HIV/AIDS in Africa?

Background: Many African countries are rapidly expanding HIV/AIDS treatment programs. Empirical information on the cost of delivering antiretroviral therapy (ART) for HIV/AIDS is needed for program planning and budgeting. Methods: We searched published and gray sources for estimates of the cost of providing ART in service delivery (non-research) settings in sub-Saharan Africa. Estimates were included if they were based on primary local data for input prices. Results: 17 eligible cost estimates were found. Of these, 10 were from South Africa. The cost per patient per year ranged from $396 to $2,761. It averaged approximately $850/patient/year in countries outside South Africa and $1,700/patient/year in South Africa. The most recent estimates for South Africa averaged $1,200/patient/year. Specific cost items included in the average cost per patient per year varied, making comparison across studies problematic. All estimates included the cost of antiretroviral drugs and laboratory tests, but many excluded the cost of inpatient care, treatment of opportunistic infections, and/or clinic infrastructure. Antiretroviral drugs comprised an average of one third of the cost of treatment in South Africa and one half to three quarters of the cost in other countries. Conclusions: There is very little empirical information available about the cost of providing antiretroviral therapy in non-research settings in Africa. Methods for estimating costs are inconsistent, and many estimates combine data drawn from disparate sources. Cost analysis should become a routine part of operational research on the treatment rollout in Africa.

Non-clinical outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review

The impacts of antiretroviral therapy on quality of life, mental health, labor productivity, and economic wellbeing for people living with HIV/AIDS in developing countries are only beginning to be measured. We conducted a systematic literature review to analyze the effect of antiretroviral therapy (ART) on these non-clinical indicators in developing countries and assess the state of research on these topics. Both qualitative and quantitative studies were included, as were peer-reviewed articles, gray literature, and conference abstracts and presentations. Findings are reported from 12 full-length articles, 7 abstracts, and 1 presentation (representing 16 studies). Compared to HIV-positive patients not yet on treatment, patients on ART reported significant improvements in physical, emotional and mental health and daily function. Work performance improved and absenteeism decreased, with the most dramatic changes occurring in the first three months of treatment and then leveling off. Little research has been done on the impact of ART on household wellbeing, with modest changes in child and family wellbeing within households where adults are receiving ART reported so far. Studies from developing countries have not yet assessed non-clinical outcomes of therapy beyond the first year; therefore, longitudinal outcomes are still unknown. As ART roll out extends throughout high HIV prevalence, low-resource countries and is sustained over years and decades, both positive and adverse non-clinical outcomes need to be empirically measured and qualitatively explored in order to support patient adherence and maximize treatment benefits.

Overlay Network Creation and Maintenance with Selfish Users

Overlay networks have been used for adding and enhancing functionality to the end-users without requiring modifications in the Internet core mechanisms. Overlay networks have been used for a variety of popular applications including routing, file sharing, content distribution, and server deployment. Previous work has focused on devising practical neighbor selection heuristics under the assumption that users conform to a specific wiring protocol. This is not a valid assumption in highly decentralized systems like overlay networks. Overlay users may act selfishly and deviate from the default wiring protocols by utilizing knowledge they have about the network when selecting neighbors to improve the performance they receive from the overlay. This thesis goes against the conventional thinking that overlay users conform to a specific protocol. The contributions of this thesis are threefold. It provides a systematic evaluation of the design space of selfish neighbor selection strategies in real overlays, evaluates the performance of overlay networks that consist of users that select their neighbors selfishly, and examines the implications of selfish neighbor and server selection to overlay protocol design and service provisioning respectively. This thesis develops a game-theoretic framework that provides a unified approach to modeling Selfish Neighbor Selection (SNS) wiring procedures on behalf of selfish users. The model is general, and takes into consideration costs reflecting network latency and user preference profiles, the inherent directionality in overlay maintenance protocols, and connectivity constraints imposed on the system designer. Within this framework the notion of user’s "best response" wiring strategy is formalized as a k-median problem on asymmetric distance and is used to obtain overlay structures in which no node can re-wire to improve the performance it receives from the overlay. Evaluation results presented in this thesis indicate that selfish users can reap substantial performance benefits when connecting to overlay networks composed of non-selfish users. In addition, in overlays that are dominated by selfish users, the resulting stable wirings are optimized to such great extent that even non-selfish newcomers can extract near-optimal performance through naïve wiring strategies. To capitalize on the performance advantages of optimal neighbor selection strategies and the emergent global wirings that result, this thesis presents EGOIST: an SNS-inspired overlay network creation and maintenance routing system. Through an extensive measurement study on the deployed prototype, results presented in this thesis show that EGOIST’s neighbor selection primitives outperform existing heuristics on a variety of performance metrics, including delay, available bandwidth, and node utilization. Moreover, these results demonstrate that EGOIST is competitive with an optimal but unscalable full-mesh approach, remains highly effective under significant churn, is robust to cheating, and incurs minimal overheads. This thesis also studies selfish neighbor selection strategies for swarming applications. The main focus is on n-way broadcast applications where each of n overlay user wants to push its own distinct file to all other destinations as well as download their respective data files. Results presented in this thesis demonstrate that the performance of our swarming protocol for n-way broadcast on top of overlays of selfish users is far superior than the performance on top of existing overlays. In the context of service provisioning, this thesis examines the use of distributed approaches that enable a provider to determine the number and location of servers for optimal delivery of content or services to its selfish end-users. To leverage recent advances in virtualization technologies, this thesis develops and evaluates a distributed protocol to migrate servers based on end-users demand and only on local topological knowledge. Results under a range of network topologies and workloads suggest that the performance of the distributed deployment is comparable to that of the optimal but unscalable centralized deployment.