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.

Dynamic Window-Constrained Scheduling for Real-Time Media Streaming

This paper describes an algorithm for scheduling packets in real-time multimedia data streams. Common to these classes of data streams are service constraints in terms of bandwidth and delay. However, it is typical for real-time multimedia streams to tolerate bounded delay variations and, in some cases, finite losses of packets. We have therefore developed a scheduling algorithm that assumes streams have window-constraints on groups of consecutive packet deadlines. A window-constraint defines the number of packet deadlines that can be missed in a window of deadlines for consecutive packets in a stream. Our algorithm, called Dynamic Window-Constrained Scheduling (DWCS), attempts to guarantee no more than x out of a window of y deadlines are missed for consecutive packets in real-time and multimedia streams. Using DWCS, the delay of service to real-time streams is bounded even when the scheduler is overloaded. Moreover, DWCS is capable of ensuring independent delay bounds on streams, while at the same time guaranteeing minimum bandwidth utilizations over tunable and finite windows of time. We show the conditions under which the total demand for link bandwidth by a set of real-time (i.e., window-constrained) streams can exceed 100% and still ensure all window-constraints are met. In fact, we show how it is possible to guarantee worst-case per-stream bandwidth and delay constraints while utilizing all available link capacity. Finally, we show how best-effort packets can be serviced with fast response time, in the presence of window-constrained traffic.