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.

Using Markets and Spam to Combat Malware

We propose an economic mechanism to reduce the incidence of malware that delivers spam. Earlier research proposed attention markets as a solution for unwanted messages, and showed they could provide more net benefit than alternatives such as filtering and taxes. Because it uses a currency system, Attention Bonds faces a challenge. Zombies, botnets, and various forms of malware might steal valuable currency instead of stealing unused CPU cycles. We resolve this problem by taking advantage of the fact that the spam-bot problem has been reduced to financial fraud. As such, the large body of existing work in that realm can be brought to bear. By drawing an analogy between sending and spending, we show how a market mechanism can detect and prevent spam malware. We prove that by using a currency (i) each instance of spam increases the probability of detecting infections, and (ii) the value of eradicating infections can justify insuring users against fraud. This approach attacks spam at the source, a virtue missing from filters that attack spam at the destination. Additionally, the exchange of currency provides signals of interest that can improve the targeting of ads. ISPs benefit from data management services and consumers benefit from the higher average value of messages they receive. We explore these and other secondary effects of attention markets, and find them to offer, on the whole, attractive economic benefits for all – including consumers, advertisers, and the ISPs.