Blockchain Papers

Özgür Yildiz

No abstract is available for this record.

Stefan Bornholdt, Kim Sneppen

Bitcoins have emerged as a possible competitor to usual currencies, but other\ncrypto-currencies have likewise appeared as competitors to the Bitcoin\ncurrency. The expanding market of crypto-currencies now involves capital\nequivalent to $10^{10}$ US Dollars, providing academia with an unusual\nopportunity to study the emergence of value. Here we show that the Bitcoin\ncurrency in itself is not special, but may rather be understood as the\ncontemporary dominating crypto-currency that may well be replaced by other\ncurrencies. We suggest that perception of value in a social system is generated\nby a voter-like dynamics, where fashions form and disperse even in the case\nwhere information is only exchanged on a pairwise basis between agents.\n

Matthew Kien-Meng Ly

I. INTRODUCTION A. What Are Currencies? B. Virtual Currencies II. BITCOIN A. What Is Bitcoin? 1. Introduction 2. The Ecosystem a. Mining b. Exchanges c. Merchants d. Innovative Ventures B. Why Are People Using Bitcoin? C. What Is Problem? 1. Criminal Activity 2. Tax Evasion 3. Investment Scams III. HOW CAN THE LEGAL SYSTEM HANDLE VIRTUAL CURRENCIES SUCH AS BITCOIN? A. Bank Secrecy Act B. Securities Regulations C. Stamp Payments Act of 1862 D. Electronic Fund Transfer Act of 1978 E. Uniform Commercial Code IV. GOVERNMENT ACTIONS RELATED TO BITCOIN A. FinCEN's Guidance on Virtual Currencies B. California's Department of Financial Institutions' Cease-and-Desist Letter to Foundation C. Asset Seizures and Arrests 1. Crackdown on Silk Road 2. Mt. Gox Assets Frozen D. Regulatory Developments as of April 2, 2014 1. New York State Department of Financial Services Inquiry into Virtual Currencies 2. Foundation Meeting with Federal Regulators 3. Senate Committee Looks into Virtual Currencies 4. Internal Revenue Service Virtual Currency Notice: Virtual Currency Is Property for U.S. Federal Tax Purposes V. WHAT DO THE RECENT GOVERNMENT ACTIONS MEAN FOR BITCOIN'S FUTURE? A. Businesses Exchanging, Buying, and Selling Bitcoins B. Merchants Accepting as an Alternative Payment Currency C. Non-Miner Users D. Miners VI. FINAL THOUGHTS I. INTRODUCTION The and Bitcoin phenomena have recently garnered a great deal of media and regulatory attention. (1) However, many people do not understand what virtual currency, let alone Bitcoin, is and how it works. Fewer still know how to interpret reports of government crackdowns on businesses. This paper explains what is, why people use it, and why government should care. In addition, this paper contemplates whether any existing legal frameworks may be used to regulate Bitcoin: Which laws can be leveraged? How can they be leveraged? What has government done to regulate thus far? The laws affecting have changed dramatically since 2013 when regulators began to recognize as a Businesses engaging in transactions now may be required to meet strict reporting and record-keeping standards. In addition, they may be required to implement anti-money laundering programs. Individual users and businesses alike will need to comply with applicable tax regimes as well. Because regulatory framework of is a new development, future of applicable laws remains uncertain. A. What Are Currencies? Currency is broadly defined as [t]okens used as money in a country. (2) The Financial Crimes Enforcement Network (FinCEN), an Agency of United States government, defines currency as the coin and paper money of United States or of any other country that [i] is designated as legal tender and that [ii] circulates and [iii] is customarily used and accepted as a of exchange in country of issuance. (3) FinCEN terms these currencies (4) Although currencies like United States Dollar (USD) used to be backed by commodities such as gold, (5) today, most real currencies are fiat currencies, which are merely backed by their respective governments. (6) By controlling money supply, governments are able to influence value of their currencies. (7) Relatively stable currency values are achieved by public trust in continued rational government manipulation of money supply. (8) B. Virtual Currencies In contrast to a real currency, a virtual currency is a medium of exchange that operates like a currency in some environments, but does not have all attributes of real currency. (9) The key difference between virtual currency and real currency is that virtual currency does not have legal tender status in any jurisdiction. …

Anastasia Sianturi

Abstract : Supporting Local Revenue in Fiscal Decentralization and Regional Development . In the framework of the implementation of regional autonomy in accordance with UU No.32 Tahun 2004 on local government . Local governments are required to be able to organize and manage his own household Sweeping based regulations and develop and increase revenue . This study aims to determine , describe and analyze the role of local revenues to support fiscal decentralization and regional development . By using this type of qualitative research method with a descriptive approach . The analytical method used is through an interactive method of Miles and Huberman . It can be concluded that the local revenue Batu City still has a low degree of fiscal decentralization , the high degree of dependence on the central government means that there is a low contribution to the financing of development in the Batu City , especially in the construction of road infrastructure , irrigation and network. Keywords: Revenue, Fiscal Decentralization, The degree of fiscal Abstrak: Pendapatan Asli Daerah dalam Menunjang Desentralisasi Fiskal dan Pembangunan Daerah. Dalam rangka penyelenggaraan otonomi daerah sesuai dengan Undang-undang No.32 Tahun 2004 tentang pemerintah daerah. Pemerintah daerah dituntut agar mampu mengatur dan mengurus rumah tangganya sendiri secara luas dan menyeluruh berdasarkan peraturan yang berlaku dan mengembangkan dan meningkatkan pendapatan asli daerah. Penelitian ini bertujuan untuk mengetahui, mendeskripsikan dan menganalisi peran pendapatan asli daerah dalam menunjang desentralisasi fiskal dan pembangunan daerah. Dengan menggunakan jenis metode penelitian kualitatif dengan pendekatan deskriptif. Metode analisis yang digunakan adalah melalui metode interaktif Miles dan Huberman. Dapat disimpulkan bahwa pendapatan asli daerah Kota Batu masih memiliki derajat desentralisasi fiskal yang rendah, tingkat ketergantungan yang tinggi terhadap pemerintah pusat berarti menunjukan adanya konstribusi yang rendah terhadap pembiayaan pembangunan pada pemerintah Kota Batu, khususnya dalam pembangunan infrastuktur jalan, irigasi dan jaringan. Kata kunci: pendapatan asli daerah, desentralisasi fiskal, derajat desentralisasi fiskal

Satoshi Nakamoto, Wei Dai

No abstract is available for this record.

Farmer, Harry Paul

Follow this and additional works at: http://digitalcommons.law.umaryland.edu/jbtl Part of the Administrative Law Commons, Antitrust and Trade Regulation Commons, Banking and Finance Commons, Business Law, Public Responsibility, and Ethics Commons, Commercial Law Commons, Comparative and Foreign Law Commons, Computer Law Commons, E-Commerce Commons, Economic Theory Commons, Internet Law Commons, Law and Economics Commons, Law and Society Commons, Legislation Commons, Public Affairs, Public Policy and Public Administration Commons, Science and Technology Commons, Science and Technology Studies Commons, Securities Law Commons, and the Technology and Innovation Commons

Artus Krohn-Grimberghe, Christoph Sorge

No abstract is available for this record.

Anna Laura Palazzo

No abstract is available for this record.

Mike Bruce, David Drozek, JungHun Choi

Looping of the colonoscope shaft is the most common problem associated with a colonoscopy procedure. One study has shown that looping occurred in 91 out of 100 cases [1]. Looping can have a variety of effects ranging from extended procedure times, incomplete examinations, or even perforation of the colon wall [2]. Another study shows that 37 perforations occurred in 116,000 patients [3]. Looping increases discomfort for the patient, requiring larger amounts of anesthesia, and increasing operation time. Looping forces the doctor to reposition the colonoscope by twisting and retracting the shaft with varying degrees of success. This additional maneuvering of the colonoscope shaft during the procedure places extra stress on the inner lining of the colon wall.The problem of looping can be lessened with the help of manipulation by the doctor. By applying pressure to the abdomen and rotating the patient on his/her left or right side, looping can be reduced [4]. Some examples of existing equipment that is currently used to help combat this problem include: a double balloon sheath around the distal tip, a shape locking overtube guide, a general overtube, or a variable stiffness colonoscope. These are devices that passively prevent looping from forming. A better way to try and solve this problem is to constantly monitor the shape of the colonoscope shaft to determine if and when a loop will form and prevent it from happening. Some of the devices that employ a similar method to this include: the computer assisted NeoGuide system, fluoroscopy, and magnetic endoscopic imaging. The first of these devices uses a computer controlled, articulated colonoscope such that each segment follows the exact same path as the segment preceding it. The latter two give the doctor a 3D image of the shaft. If these devices were less expensive, then they might be more widely used, but as it is they are very expensive.With this in mind, a proof of concept method for detecting the shape of the colonoscope shaft during the procedure is introduced. If the shape of the colonoscope shaft is known then looping can be detected and avoided more easily. It would be more beneficial to avoid a loop all together than to backtrack once it is already formed.A model was developed that consists of multiple sets of connected links to be placed along the middle of the colonoscope shaft. These links are free to rotate in two different directions to show the motion of the shaft in full. Each rotation joint is equipped with a 6 mm rotational potentiometer, an angular displacement sensor. The potentiometer is a variable resistor that increases its resistance linearly from zero to a peak value over a range of 240 deg. Every rotation joint has a potentiometer attached to it through a modified pin. Figure 1 shows a single link with potentiometer attached.This only shows a single link but the entire model has 20 links connected together to give an image of a much larger stretch of the colonoscope. The link system is designed to conform to the inside of the colonoscope shaft only increasing the stiffness marginally. The system setup is shown in Fig. 2.Figure 2 above shows the complete system diagram with all components and order of attachment. Once the model was finished it each sensor was wired together in series on the power and ground pins with a power supply. The sensor output pins were wired separately and returned to the end of the system to a data acquisition device to process the signals. The signals acquired are voltage readings from each potentiometer. Signal express was used to acquire the signal and save it as a file. The file was then inserted into a computer program in matlab, which graphed an image of the model.The linkage was formed into a straight line to show the baseline reading for the system. The second configuration was a small alpha loop with 3 cm radius. This was formed because the alpha loop is one of the most common types of loops found in the colonoscopy procedure. Both configurations are shown in Fig. 3.Once this was done, the voltage readings from the sensors were recorded into a file. This file was then inserted into a program that manipulates these values into corresponding angles based upon calibration charts. From the corresponding angles a graphical image was produced that closely resembles the original model. The matlab graphs are set to the same scale as the original model. The graphical images can be seen in Fig. 4. The straight line and alpha loop configuration both very accurately resemble the physical model with little error (Figs. 4(a) and 4(b)). This shows that the model can accurately predict complex shapes and configurations, with little error, that are commonly found inside the colon during a procedure.From the results presented above, it can be seen that the linkage model method with attached potentiometers can easily manage loops commonly found in the everyday procedure. This ability combined with the graphical imaging software can help a doctor to potentially see a loop as it is about to be formed. As has been previously said, the key to stopping loop formation is the prediction of loops before they form. With this model and software, loops can be accurately predicted and viewed during a procedure. With little to no training at all a doctor can look at the computer screen and be able to tell if the shaft of the colonoscope is approaching the tipping point between loop formation and following the colon wall around a curve such as in the sigmoid colon. This would be greatly helpful with decreasing the numbers of incomplete colonoscopies due to loop formation. Along with this, knowing the curvature of the shaft of the colonoscope and the basic knowledge of the shape of the colon, the doctor can give a more accurate description of locations of polyps discovered in the colon.Overall, this method of loop detection that has been discussed could serve as an additional tool to helping a doctor complete a colonoscopy procedure. This method could reduce procedure time due to loop formation as well as decrease pain to the patient. The doctor could also decrease the number of incomplete colonoscopies that result from looping of the colonoscope shaft.

María Cubel

The IEB research program in Fiscal Federalism aims at promoting research in the public finance issues that arise in decentralized countries.

Weberbank Daniel Schär

Vertrauen, Akzeptanz, Sicherheit und Stabilitat? Die Erfolgsattribute einer Wahrung erfullen Bitcoins nicht. Im Gesprach mit Alexander Gorlach hinterfragt Daniel Schar die Modeerscheinung.

Tetsuya Saito

This paper considers whether the stability of Bitcoin in the market as a method of payment using a dual currency money-search model. In the model, there is traditional money and Bitcoin. The two currencies are classified by the storage cost and the probability that sellers accept particular money for payments. Agents are randomly matched for transactions. To consider substitution effect between monies, we allow new entries every period. In the beginning of each period, new entrants come into the matching process with a unit of money of their choice. A certain number of sellers also come into the same process to maintain the population share of sellers at a constant level. With appropriately chosen parameters, the author finds that there can be stable and unstable equilibria of the share of bitcoiners. In this case, a stable equilibrium is a success (bitcoiners take a large share) while the other (unstable) is a failure (bitcoiners take a marginal share or vanish). However, if the inflation rate of traditional money decreases, the successful equilibrium disappears to start approaching the failure even if Bitcoin is currently widely accepted. Furthermore, welfare comparisons suggest that an increase in the share of bitcoiners has a negative effect; hence, the benefit from reductions in the transaction costs must compensate for the welfare erosion if Bitcoin is accepted as a new kind of payment system. If the author is to succeed, the Bitcoin community or the public authorities need to be prepared for protecting the system from several illicit activities.

Frank Moosig, Julia U. Holle

New British Society for Rheumatology guideline for the treatment of ANCA vasculitis This article refers to BSR and BHPR guideline for the management of adults with ANCA associated vasculitis, by E. Ntatsaki et al., doi:10.1093/rheumatology/ket445, on pages 2306–09. In this issue of the journal an expert panel from the British Society for Rheumatology (BSR) presents an update of the 2007 BSR guideline for the treatment of ANCA-associated vasculitides (AAVs) [1]. It is remarkable that in recent years enough new evidence has accumulated to call for a revision of these recommendations, in particular because it is still challenging to conduct well-designed trials in these rare conditions. Many of the authors of the guideline have contributed significantly to the field. The British vasculitis scene belongs to the most active and productive groups worldwide and is a key part of the European Vasculitis Society (EUVAS). The guideline reflects the rapidly increasing evidence from controlled trials available in the past years and now includes biologicals [namely rituximab (RTX)] as a mainstay of treatment. The Rituximab versus Cyclophosphamide in ANCA-associated Vasculitis (RITUXVAS) EUVAS trial initiated by British vasculitis experts was one of the landmark studies in this context [2]. A milestone in 2013 was the approval of RTX for the treatment of AAV. This represents the first formal drug approval for AAV by the European Medicines Agency (EMA) in more than 40 years. Accordingly, questions concerning the appropriate use of RTX are among the most prominently discussed issues in this well-structured and straightforward guideline. Despite of the significant accrual of knowledge in recent years, the guideline also reflects that we still have to face a lot of uncertainty in the treatment of AAV patients. The guideline [1] refers to patients with disease consistent with the 2012 Chapel Hill Consensus Conference definitions [3] and thereby formally excludes a significant proportion of AAV patients. This underlines the urgent need for real diagnostic, not just classification, criteria. The ongoing EUVAS/ACR study for the development of diagnostic and classification criteria for primary vasculitis will probably establish such standards. Other definitions need international harmonization in order to increase the comparability of reported data. The present guideline defines remission as BVAS ≤1 and a daily prednisolone dose of ≤10 mg for at least 6 months. The 2007 European League Against Rheumatism (EULAR) recommendations on clinical trials in AAV suggest a BVAS of zero and a prednisolone dose of ≤7.5 mg/day [4]. Several other definitions have been used in different trials and observational studies. Furthermore, the 6 month criterion for remission in the new BSR guideline [1] is problematic. The guideline recommends switching to maintenance therapy after successful induction of remission, after treatment with CYC for example. Strict compliance with the above-mentioned definition could lead to a therapeutic gap of several months or prolonged use of CYC, which clearly is not the intention of the authors. This illustrates the difficulty in defining clinically and scientifically meaningful endpoints. Other uncertainties pertain to drug treatment regimens per se. Although it is generally accepted that high-dose glucocorticoids are the mainstay of treatment, there is still a notable lack of proven information on dosing, tapering or duration of therapy. The availability of RTX for induction of remission in AAV represents a major progression. Drug approval in this case was granted on the basis of randomized controlled trials—the RAVE trial [5] and the RITUXVAS trial [2]. These studies helped to establish an alternative treatment to CYC, yet a lot of important questions remain unanswered, such as who is the ideal patient for treatment with RTX and who should still be treated with CYC? There is a consensus that when considering first-line treatment, RTX may be the better choice for younger patients in order to preserve fertility, an advantage of RTX. While this is mechanistically logical, it still lacks formal proof. The guideline also states that RTX may be preferred in patients at high risk of infections [1]. When looking at the data from RAVE [5, 6] and RITUXVAS [2], no clear superior treatment for patients at high risk of infection could be determined during the relatively short observational periods. Considering the treatment of CYC-refractory patients, the overwhelming consensus among experts that RTX should be the drug of first choice is contrasted by a prominent lack of sufficient data. Another ongoing controversy outlined in the guideline [1] is the use of RTX for maintenance of remission. According to some uncontrolled retrospective data (e.g. [7]) and the as yet unpublished results from the French MAINRITSAN trial, addressing repetitive RTX administration for maintenance, moderate repeated doses of RTX (0.5–1 g) given at relatively long intervals (4–6 months) seem to be a promising future option. Apart from proving that RTX represents an option for maintenance there is hope that it may even be superior to conventional standard maintenance treatment such as AZA. Finding the optimal dose in order to maintain maximum remission rates and to reduce potential side effects is another major issue for future research. The ongoing RITAZAREM study assessing RTX administered as a 1 g dose every 4 months vs standard AZA will help to answer these questions. When looking at distinct clinical situations in AAV, in many cases the evidence level is still that of case series. This is especially true for the rarest of the rare AVV entities, e.g. eosinophilic granulomatosis with polyangiitis (EGPA). The guideline, capturing the available data, mainly refers to GPA and microscopic polyangiitis, but not EGPA. When considering the sparse data on many of the relevant topics, this guideline [1] will be a most valuable aid for clinical decisions in daily work. The generation of further evidence from clinical trials will hopefully lead to an update of the EUVAS/EULAR 2009 [8] recommendations, making standardization of the diagnostic and classification standards a worthwhile future task of the EULAR/EUVAS. Disclosure statement: The authors have declared no conflicts of interest.

Philippa Easterbrook, Cadi J. Irvine, Marco Vitória, Nathan Shaffer · 9 authors

Introduction The 2013 ‘Consolidated guidelines on the use of antiretroviral (ARV) drugs for treating and preventing HIV infection’ [1], released in July 2013, are the latest and most comprehensive of a series of important guidelines on antiretroviral therapy (ART) over the last decade from the World Health Organization (WHO). They were developed in response to important advances in the science and practice of HIV care since publication of the 2010 WHO guidance for adults and adolescents [2], pregnant women [3] and children [4]. This includes evolving evidence on the preventive and individual clinical benefits of earlier ART, innovations in service delivery such as the progressive decentralization of HIV testing and care, and the more widespread availability and affordability of once-daily fixed-dose combinations (FDCs) ART regimens [5]. In this special supplement of AIDS, we present a series of thirteen articles and five commentaries covering key aspects of the consolidated guidelines: the process, evidence base, recommendations and guidelines implementation. In this first article, we describe the WHO process and methodology of developing these guidelines. This is followed by seven selected systematic reviews [6–12] that provided the evidence base for specific recommendations. They are presented under the section heading of the relevant guidelines population or topic: Adults and adolescents (when to start ART) [6]; Pregnant women (safety of efavirenz in pregnant and breastfeeding women) [7]; Children (what ART regimen to use in children under 3 years) [8]; ART monitoring (how to monitor treatment response in adults and children) [9,10]; Service delivery (evaluation of effectiveness of service delivery innovations of decentralization and integration) [11]; and different strategies to improve treatment adherence [12]. The systematic reviews in each section are prefaced by commentaries written by the co-chairs and/or members of the Guideline Development Groups (GDGs) that highlight key recommendations and their rationale, and provide additional context for guidance [13–17]. The International HIV/AIDS Alliance and the Global Network of People Living with HIV (GNP+) report on the findings (and lessons learnt) from their consultation on community values and preferences that also informed many of the recommendations [18]. The three concluding articles all address different aspects of the critical phase of country-level adaptation and implementation of the guidelines. This includes what is known about the current status of national adoption of the recommendations in WHO ARV guidelines [19], projections of the global impact and cost of implementation of new recommendations [20] and country-level implications of implementing these guidelines for policy makers, such as diversification of service delivery models, generation and use of data, healthcare financing, human resource capacity and supply chains for drugs and diagnostics [21]. This supplement is not intended to be an exhaustive collation of all the evidence that informed the consolidated guidelines. Several of the commissioned systematic reviews as well as modelling studies have already been published in the peer reviewed literature or are in development [22–28], and a companion AIDS supplement published in January 2014 has already collated other modelling work that contributed to the guidelines process [29]. A comprehensive summary of all supporting evidence is provided as Web Annexes in the guidelines website (http://www.who.int/hiv/pub/guidelines/arv2013/annexes/en/index.html). Distinctive features of the 2013 WHO consolidated guidelines The 2013 consolidated guidelines were distinctive from previous WHO ART guidelines, or other international ART guidelines in several ways. Providing guidance across the entire continuum of HIV care More than fifty new recommendations are provided across the cascade of HIV care, from HIV testing and diagnosis, linkage to care, using ART for prevention, ART initiation, monitoring for treatment failure and ART toxicity, and retention in care. This comprehensive approach responds to the needs of programme managers who are responsible for delivery of care across all of these steps. Expanding guidance: clinical, operational and programmatic In addition to the usual clinical recommendations, there is operational guidance on how to improve delivery of HIV care (with recommendations on task shifting, decentralization, integration and adherence and improving retention in care). The guidelines also provide a framework and tools for programme managers to consider in prioritizing implementation of recommendations according to their national context, including HIV epidemiology, levels of ART uptake, health workforce capacity and available financial resources. This integrated approach better reflects the complex interplay between clinical recommendations and implementation at facility and programme level. Addressing all ages and populations Instead of separate ART guidelines for adults, pregnant women, adolescents and children, as in previous years, guidance is provided across all age groups and populations of adults, pregnant and breastfeeding women, adolescents, and children, as well as those coinfected with tuberculosis (TB), hepatitis B and/or hepatitis C. This enables a more harmonized approach to ART regimen choice, simplifying both the role of healthcare providers, and procurement and supply chain management. Target audience: programme managers in low-income and middle-income countries As for other WHO guidelines, the primary target users are country policy makers and programme managers responsible for national and regional policy and planning decisions on ART scale-up, and in settings with limited resources. Incorporating the key guiding principles of the public health approach and health equity in ART scale-up The 2013 guidelines, as with previous WHO ART guidance, are based on a public health approach to ART scale-up that promotes simplified and standardized approaches to treatment and monitoring that facilitates the widest possible access to high-quality care at the population level [30]. This in turn requires innovations in service delivery to maximize the efficiency of HIV programmes such as through integration of HIV care with other services (e.g. maternal and child health, TB and drug dependence), improved treatment adherence and retention in care, harmonized ART regimens and more affordable diagnostics. Another key guiding principle underpinning implementation of the guidelines is promotion of human rights and health equity in national HIV policies and programmes, so that expanded access is fair and equitable; priority for ART initiation is given to those most in need; and care is provided in a supportive and responsive environment, free of stigma and discrimination. Linking new recommendations with existing guidance New recommendations on the use of ART for treatment and prevention have been harmonized with relevant selected recommendations from existing WHO guidance on HIV testing, prevention and management of coinfections. WHO guidelines development process and the GRADE approach The revision process for the 2013 guidelines was initiated in early 2012, and conducted in accordance with procedures established by the WHO Guidelines Review Committee, to ensure that WHO guidelines are developed using a transparent, evidence-based, decision-making process [31]. Since 2008, WHO has used the internationally agreed standard of the GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) to assess the quality of a body of evidence, formulate recommendations and rate their strength [32–38] (GRADE working group: http://www.gradeworkingroup.org). Quality of evidence and strength of recommendation GRADE classifies the quality of evidence into one of four levels: high, moderate, low and very low. The rating of quality of evidence from randomized controlled trials starts as high, but may be decreased because of risk of bias, inconsistency in results across studies, indirectness of evidence, imprecision and publication bias [34–36]. The rating of evidence based on observational studies starts as low, but may be increased if the magnitude of the treatment effect is very large, there is evidence of a dose–response relationship, or if residual biases would underestimate the effect size [37]. In addition to the quality of the evidence, other considerations in formulating recommendations and rating their strength include the overall balance of benefits and harms to the individual and at a population level, community values and preferences, resource use, cost-effectiveness, feasibility and constraints to implementation in multiple settings, equity and human rights implications [38] (Table 1).Table 1: Key domains considered in formulating recommendations and determining their strength (strong or conditional).GRADE also classifies strength of recommendations as either ‘strong’ or ‘conditional’ [38]. A strong recommendation is one for which the GDG was confident that the desirable effects of the recommendation outweigh the undesirable effects, while a conditional recommendation is used when it is concluded that the desirable effects probably outweigh the undesirable effects, but there is uncertainty about these trade-offs. The higher the quality of evidence, the more likely a strong recommendation can be made. A conditional recommendation is more likely when high-quality evidence is absent, the estimates of effect are imprecise, there is uncertainty or variability in how individuals value the outcomes, or the benefits are either small or not considered worth the costs. The implications of a conditional recommendation are that, although most people or settings would adopt the recommendation, some would do so only under certain conditions. The following sources of evidence and supporting material were used to inform the development of the new recommendations. Systematic reviews Systematic reviews were commissioned on forty-six topics across the continuum of HIV care, including nine on when to start ART; eleven on what ART to start; four on monitoring the response to ART; six on monitoring toxicity; and eleven on operational aspects of service delivery. The questions were framed using the Population, Intervention, Comparison and Outcome (PICO) format [33], and outsourced to seven different research teams and organizations through a process of competitive tendering. These groups then developed search protocols and conducted reviews of the available scientific evidence. A standardized GRADE evidence table was used to present quantitative summaries of the evidence and assessment of its quality for each PICO question by outcome [32]. The full list of review questions, search protocols, GRADE tables and evidence summaries for each topic are available at http://www.who.int/hiv/pub/guidelines/arv2013/annexes/en/index.html. Seven systematic reviews are included in this supplement [6–12], and others have been published elsewhere [22–28], or are in development. Consultations on community values and preferences An assessment of community values and preferences on key ARV guideline topics was coordinated by the International HIV/AIDS Alliance and the Global Network of People Living with HIV (GNP+) through both an online e-survey (n = 1088), and moderated e-forum discussions with civil society networks (n = 955) [18,39] in six languages (Arabic, Chinese, English, French, Russian and Spanish). Key topics included community preferences regarding possible recommendations (e.g. which ART regimens to use and when to initiate ART for adults, adolescents, pregnant and breastfeeding women, and children), as well as ART service delivery considerations. Four focus group discussions were also held in Uganda and Malawi on the experiences of pregnant women with lifelong ART (option B+). Finally, two e-surveys of health workers caring for HIV-infected adults (n = 98) and children (n = 342) were undertaken on similar topics covered in the community consultation through clinical networks of eight global implementing partner organizations. In addition to the report in this supplement [18], a full consultation document is available [39]. Mathematical modelling of impact and cost effectiveness We commissioned two key modelling projects on health impact (measured using disability-adjusted-life-years (DALYs)) and cost-effectiveness from the HIV Modelling Consortium (http://www.hivmodelling.org) to support the 2013 guidelines. The first examined various HIV testing strategies and criteria for ART initiation in different populations (adults, pregnant women and HIV serodiscordant couples) on the basis of data from countries representative of different HIV epidemic types (generalized, concentrated and mixed) and level of ART coverage [26]. A second project examined different strategies for monitoring treatment response (clinical, CD4+ T-cell count and viral load) and switching to second-line ART [27]. A key strength of these analyses was their use of multiple independently developed models to compare different scenarios, for which there were limited data in the literature. Additional modelling work commissioned included a causal modelling analysis of the impact of starting ART at different ages in children, based on data from the IeDEA South African collaboration [28]. A recent article has highlighted some of the challenges in using modelling data in guidelines development, including the lack of standardized criteria for rating the quality of modelling, and clarity on the positioning of modelling within the GRADE framework for decision-making [40]. It concludes with some key considerations to guide the future use of modelling in guidelines development. Feasibility surveys Reports were commissioned on country implementation experiences, including adoption of lifelong ART in pregnant and breastfeeding women (option B+) in Malawi; introducing tenofovir (TDF) in first-line ART regimens in Zambia; phasing out stavudine (d4T) in Zimbabwe; and scaling up viral load monitoring in Médecins Sans Frontières programmes in southern Africa. These are summarized in the consolidated guidelines web annexes (http://www.who.int/hiv/pub/guidelines/arv2013/annexes/en/index.html). Impact assessment of implementation of recommendations An impact assessment was undertaken using the AIDS Impact Model (AIM) and Goals model within the Spectrum modelling system [41] to estimate the number of adults and children newly eligible for ART, based on the new treatment recommendations [20]. It also examined the cost and impact that would result if ART coverage expanded to 80% of those eligible for ART. End-user survey to inform guidelines presentation and dissemination strategies An additional preparatory activity was the conduct of an internet-based survey of country-level end-users of recent WHO HIV-related guidelines. This was undertaken to understand better how WHO ART guidelines are used, and identify areas for improvement in format, presentation and dissemination of the new guidelines. The survey targeted WHO National Program Officers and Ministry of Health HIV focal persons, and was administered in English, French, Russian and Spanish between June and September 2012. Overall, there were 78 respondents from 44 countries across all regions (28% South East Asia and Western Pacific, 26% from Central and Eastern Europe, 10% Latin America and Caribbean, 28% Sub-Saharan Africa, 8% Middle East). All respondents had used at least one of twelve WHO HIV guidelines, and the majority (75%) had used them primarily in the development of national guidelines. Although the response rate was limited, and not fully representative of all end-users, there was a good geographic spread of respondents, and several consistent observations emerged. There was a broad agreement that the most critical guideline components were clearly stated recommendations with brief evidence summaries and a clear rationale supporting the recommendation (with inclusion of GRADE tables only as part of web annexes). The value of best practice examples from a wide range of different settings to support implementation was also highlighted. Specific suggestions to enhance readability included reduced length, larger font size, and greater use of colour, summary tables and algorithms. Accessibility and user engagement in dissemination of new WHO HIV guidelines were highlighted as critical factors influencing effective country-level adaptation and implementation. Specific activities to facilitate regional and country-level dissemination of the guidelines activities were in-country workshops and webinars; the availability of guidelines in all UN languages, particularly Arabic, Chinese and Russian; the continued need for printed in addition to electronic versions of the guidelines; and an improved notification system for new guidelines using e-mail together with conference and website announcements. Guideline development groups (GDGs) and process of formulating recommendations The development of recommendations was undertaken by four separate, external technical and and Service and but as a process to ensure an integrated guidelines document for adults, pregnant and breastfeeding women and There were more than GDG members across the four HIV country HIV programme guideline from or other development and of civil society and/or networks of people with HIV on the basis of four technical and regional previous with guidelines We a balance of by and All external members of the and external peer review group WHO of that included in and research support and financial There was also a at the GDG of by members within or clinical trials on either the of ART, or of specific ART Overall, the WHO and of each GDG were that there had been a of and that from the Four GDG were held in between and January The decision-making process and of recommendations first a critical review of the evidence based on systematic reviews of randomized clinical trials observational It also considered of the overall balance of benefits and harms to the individual and at a population level, community values and health preferences, resource use, cost-effectiveness, feasibility and constraints to implementation in multiple settings, and of equity and human The both the of the recommendations and the rating of its strength (strong or All decisions were by and on the recommendations, including their strength if the to be to the recommendations. were through e-mail and recommendations and of of the guidelines were to GDG and a full of the guidelines was to GDG members and peer for A group including of the four was held in 2013 to ensure and of recommendations across the guidelines. Key strength of recommendations and quality of evidence In July 2013, the guidelines were at the International AIDS conference held in and as a printed and electronic including a policy brief in seven languages (Arabic, Chinese, English, French, with an additional web that includes and all supporting and evidence as There were a of new recommendations in the 2013 WHO ‘Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection’ were recommendations on adults pregnant and on were on service delivery and four on HIV The most important new clinical recommendations were earlier ART initiation, starting ART in all adults with a CD4+ T-cell count of or prioritizing those with clinical or a CD4+ count than ART initiation of CD4+ count in pregnant and breastfeeding women, children under of HIV-infected in serodiscordant and those coinfected with or hepatitis B a first-line ART regimen of or efavirenz as a once-daily fixed-dose for adults, pregnant women and children 3 and and the use of viral load testing as the approach to monitoring ART response and treatment There were four recommendations on of testing, and also recommendations on improving the efficiency of HIV through ART delivery to primary healthcare and community ART services within child health and other to address in health and strategies to improve retention in care, and adherence to ART. the strength of recommendation and quality of evidence for all recommendations, and then according to population and of the recommendations were as and based on low or very low quality of evidence. The recommendations were of which were based on low and on very low quality evidence. were according to population and All of the service delivery and HIV testing recommendations were as with of the and of the recommendations. all strong service recommendations were based on low or very low quality evidence, this was for the twelve strong recommendations, and only of the strong recommendations in The evidence base in HIV care and for service delivery is well and these were as priority areas for operational and implementation research the guidelines More there are key challenges in consistent adherence to the GRADE guidance on rating of recommendations as strong than There is also a need to address a and some guideline group members that a conditional recommendation may not be and by strong recommendations are based on low quality evidence, it is critical that a clear rationale is A recent of recommendations from different WHO guidelines that had used the GRADE approach also that strong recommendations based on low or very low quality evidence were of strong so this is not specific to HIV care of strength of recommendations and rating of quality of evidence of recommendations in 2013 consolidated dissemination and the of the guidelines, WHO and regional have with national of health and in-country to support national and adaptation through a series of regional dissemination workshops South and held between July and The consolidated guidelines be reviewed and two as new evidence and practice in the use of ART. In there be through technical and programmatic guidance, with one in early 2014 on early diagnosis, scale-up of viral load monitoring and drug and in July 2014 on management of important including HIV-related and hepatitis use of linkage and retention in care, and community ART An science was held with key in and of key research in the 2013 consolidated guidelines and the research to inform development of future WHO also consolidated guidelines in 2014 in two other Key and which provide a of quality for HIV prevention and treatment The the of all members of the Guidelines Development and in the of the four and and for AIDS and of and Network for the of Children by AIDS, and Service for and and of South of and of Health and The WHO of the and and and We also and for with the conduct of the WHO guidelines of There are of

Charles B. Holmes, Yogan Pillay, Albert Mwango, Jos Perriëns · 9 authors

Introduction To successfully implement the 2013 WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection at country level, the implications for national and regional health systems need to be considered and addressed. The guidelines target the entire continuum of care for the HIV-infected individual, and in some cases, their partners, and those with unknown status. The guidelines include not only a more inclusive treatment initiation threshold of CD4+ T-cell count of 500 cells/μl or less for adults and adolescents, treatment for life for pregnant and breastfeeding women (or treatment for the duration of pregnancy and breastfeeding regardless of CD4+ T-cell count), treatment regardless of CD4+ T-cell count for children under 5 years of age, discordant couples, those co-infected with either tuberculosis (TB) or severe hepatitis B virus (HBV), and diversification of effective strategies to reach those with unknown status through couples testing and community-based testing. These changes, if fully enacted, will lead to an increase in treatment eligibility of over 60%, from 17.6 million globally, to 28.6 million globally, with variation in that increase by epidemic type and other epidemiologic factors [1]. However, within these increases in volume, health systems will be serving a healthier mix of patients starting antiretroviral therapy (ART), and greater proportions of pregnant women and children, and sexual partners seeking care together. The increased patient volumes and changes in the composition of those seeking care will require rapid attention to existing care delivery strategies in order to ensure that newly diagnosed individuals are served with the maximum efficiency and effectiveness, and others entering or already within the system under existing guidelines are not harmed. Additionally, to be successful over the long term, health systems and HIV programs will need strengthened adherence-support strategies. Systems of care that may already be stressed need to be further augmented through innovations, and in many cases provided with additional resources in order to become more efficient, resilient, robust and effective. The ‘Operations’ and ‘Service delivery’ sections (Chapter 9) of the guidelines address these challenges through recommendations for innovations in the models of service delivery, laboratory diagnostics and treatment delivery in the form of fixed-dose combinations (FDCs) to improve the efficiency, reach and quality of the prevention, care and treatment cascade. There are also potential gains from implementing the guidelines that could accrue to and strengthen health systems and communities, such as a healthier and more productive workforce and fewer new HIV infections, especially in newborns, and HIV-related hospitalizations, and these benefits must also be factored into HIV program and country-level decision-making surrounding adoption and adaptation of the new guidelines [2]. Our objective was to examine the implications of the new guidelines across the continuum of care for each of the elements of national health systems, starting with governance and the role of strategic planning and policy, and including diversification of service delivery models, generation and use of data, healthcare financing, human resource capacity, and supply chains for therapeutic and diagnostic commodities. Governance, strategic planning and policy The progress of discovery and change in the HIV epidemic have demanded a high degree of engagement with evolving evidence, as reflected in part by the 10 guidance documents on antiretroviral drug use issued by WHO since 2000. To date, national governments, with the support of civil society and cooperative partners, have employed a variety of approaches to new guideline adoption. Whereas earlier approaches often focused largely on clinical issues, there is now a need for much broader adoption processes to consider the complex interplay between clinical objectives, operational feasibility, issues related to equity, affordability and health systems capacity. In order to consider, adopt and implement new national guidelines with a broad coalition of support, Ministries of Health must take a strong leadership and governance role. When performed well, the key elements of the process at national level include the following: An inclusive and transparent consultative process that draws upon the best available resources, including program experts and managers, healthcare providers, civil society including people living with HIV, community and faith-based groups, key populations, technical specialists, other relevant government Ministries (e.g. Finance), budget experts and economists, researchers, academics, and health-related professional associations. Assembly, analysis and presentation of relevant clinical, programmatic and financial information. Consideration of guidelines changes in light of broader strategic policy frameworks cross-cutting a broader array of health, human rights and development issues. Clear decision-making mechanisms that allow consideration of competing demands. Clear articulation of roles and responsibility of various partners, in order to ensure accountability and oversight of the processes of change. Ensuring that the case for health in national development, including the potential benefits and risks of potential guidelines changes, is clearly communicated early and often to political leadership and external development partners. The recent process of developing and adopting new guidelines for antiretroviral drug use in pregnant and breastfeeding women in Zambia provides an instructive example of the range of activities needed to ensure that guidelines changes are made with broad stakeholder and health systems support (Fig. 1) [3,4]. National governments and civil society are encouraged to learn lessons from peers, and to participate in WHO's regional guidelines dissemination workshops that are designed to support strong national processes of guidelines change.Fig. 1: The process of changing prevention of mother-to-child transmission (PMTCT) guidelines in Zambia.Diversification and integration of service delivery models to manage patient volumes and improve retention and quality The expansion of HIV testing, care and eligibility for ART will require national governments and partners to consider how best to augment or modify their current health systems to accommodate increased volumes and new categories of patients, and to ensure retention across the care and treatment cascade. There is currently an over-reliance on a limited number service delivery models in many countries. Maximum expansion capacity and quality can be achieved by ensuring that a carefully selected variety of models are put in place and adapted strategically to take account of geography, epidemiology and local needs. Thus, it is an opportune time for governments and funders to focus on previously piloted models that are appropriate for scale-up, and to ensure that the most effective models are scaled up systematically in order to provide substantial complementary capacity to absorb new patients and provide ongoing care. Within the new guidelines, there is an increased emphasis on the importance of expanded national HIV testing and counseling strategies in order to identify ‘as many people living with HIV as early as possible after acquiring HIV infection, and link them appropriately and in a timely manner to prevention, care and treatment services’. The reality of most HIV-testing programs in most generalized epidemics is that they have been largely dominated by provider-initiated testing (most typically healthcare provider-initiated), which has been favored because of the ease of linkage to services and for its high yield and cost-effectiveness. However, it often identifies people living with HIV late in the course of HIV disease, in particular, men and adolescents, as well as key populations, who have low utilization of healthcare services. With the guidelines’ strong recommendation for community-based HIV testing and counseling with linkage to prevention, care and treatment services, governments should consider systematically expanding a number of approaches tailored for their settings, including mobile, door-to-door, index, campaign, workplace and school-based HIV testing and counseling approaches, and other strategies that ensure the inclusion of underserved groups such as children, adolescents and men. It is also important to recognize that the yield of nonclinic-based testing can be lower and more expensive from a human resource perspective, requiring a careful balance to be struck. For concentrated and low-level epidemics, governments are urged to consider guidelines that reflect WHO's strong recommendation to increase the number and diversity of the facilities in which provider-initiated testing and counseling are available, including sexually transmitted infection clinics, hepatitis and TB sites, antenatal care settings and services for key populations, notably MSM, transgender people, sex workers and people who inject drugs (Fig. 2) [5].Fig. 2: Innovative service delivery models to increase diagnosis and early antiretroviral therapy (ART) initiation among key populations in Indonesia.The capacity of national health systems to absorb the greater numbers of healthier, pregnant and individuals accompanied by partners eligible for treatment will be directly related to the extent to which ART sites are diversified, decentralized (and in some cases integrated into primary care services) and generally expanded. Extending care through different models will also relieve traditional ART sites and higher-level facilities and allow a greater focus on the sickest patients, especially in high-burden generalized epidemics. Models for consideration and rapid scale-up include ART initiation and maintenance for mothers and children in high HIV-prevalence settings integrated into antenatal care, and maternal and child health clinics, and for HIV/TB co-infected individuals into TB clinics, and other approaches that reduce the need of patients to come to clinics through community-based treatment clubs with rotating antiretroviral drug pick-up and home delivery, especially in remote rural areas. A systematic review on the impact of decentralization of ART delivery identified evidence from both randomized controlled trials and observational studies, and found that patients initiated at a hospital and maintained at a health center were more likely to be retained [6]. No difference in attrition was observed between those initiated and maintained on ART at a hospital compared to at a health center. Comparable attrition was observed after 12 months in the two trials in which ART maintenance was in the community [6]. Regions with measurable injection drug use may also consider the new strong recommendation for ART initiation integrated into clinics and sites in which opioid substitution therapy (OST) is provided. In areas with strong general outpatient services, integration of HIV services may yield greater equity with other health services, and may more directly enable HIV's chronic care models to benefit care and management responses to other chronic diseases such as diabetes and hypertension. These integrated sites must also be capacitated with on-site laboratories and referrals with a rapid turnaround for results reporting, especially for viral load, CD4+ T-cell count testing, TB testing and safety laboratories. Tiered laboratory systems must work closely with program leadership to ensure strategic investments in the best technologies for sites providing ART. Intentional analyses should be conducted to balance the convenience of point-of-care (e.g. CD4+ T-cell testing) technologies with the use of centralized high-throughput instruments. With anticipated rapid expansion of demand for viral load testing, it is essential to use internationally acceptable methods to locally validate the use of dry blood spots, as a means of viral load testing, which will allow expansion of this capacity without phlebotomy and cold chain capacity – the imminent availability of point-of-care viral load testing will also strengthen the health system's ability to provide good quality care. It is also critical to close the loop with results reporting via short message service or other secure electronic communication. Existing and new models also need to be chosen in order to intentionally retain patients in care and treatment, and ensure adherence to ART. Structural interventions such as increasing access points and decentralization through community-based models can address some of the most commonly cited reasons for disengagement with care (e.g. transport expenses, overcrowding of vertical sites). At an individual level, substantial evidence has demonstrated the benefits of two-way mobile phone text message systems, and WHO has made a strong recommendation for consideration of this approach [7]. As with numerous other proven methodologies, very few countries have systematically evaluated the needs of various vulnerable groups such as pregnant women, adolescents, key populations and healthy individuals starting ART and systematically taken appropriate packages of cost-effective adherence and retention interventions from the pilot phase, to scale. Generation and use of data for monitoring, evaluation, efficiency and quality improvement National and regional health systems of program monitoring and evaluation are fundamental to public health approaches to HIV prevention, care and treatment, and other chronic illnesses. When they work well, systems of measurement serve to provide actionable data for decision-making, starting with the clinician and service delivery sites, to regional and national program managers, related sectors (e.g. Ministries of Finance), and development partners [8]. Although the HIV response has focused substantial investments on monitoring and evaluation, the nature of the emergency response combined with weak health systems and the sheer volume of chronically ill patients have resulted in greater than expected challenges for many national systems. These challenges have been highlighted in recent studies demonstrating serious gaps in the ability of these systems to report on indicators that meaningfully measure program quality, and a lack of consistent data use at the site and regional levels to improve program quality [9]. With the influx of individuals seeking testing and care, and through sites and models not traditionally reporting on ART use (e.g. community-based antiretroviral drug pick-up and antenatal care sites), there are actions that must be taken coincident with guidelines adoption to ensure effective monitoring and evaluation of program quality. National governments and supportive cooperative partners must redouble efforts to harmonize and strengthen platforms for the use of data at levels of the health system to ensure that guidelines changes are as expected and that quality of care and patient are not models include or by the of health and development partners their implementing to review care and treatment at the and local These processes should be to and quality improvement processes that ensure clinical sites review their on critical elements of the care and treatment and have to to to quality and access to technical as on data use also to attention on the volume and of indicators and the systems that data A of potential indicators over the years has in some cases attention from those indicators considered at regional and national and countries are encouraged to their most critical indicators with the and ensure in the WHO's early indicators for HIV drug system of key indicators designed to quality improvement of ART services at level, with for and of the results for program management National governments and development partners also need to ensure systems are to allow reporting and use of the There are numerous and systems in few are fully integrated across the of care and treatment and at a national WHO is with numerous countries to improve integration of systems the Systems for HIV a of and guidelines to countries and implement a system that patient and and the impact in an integrated across maternal and child health of mother-to-child transmission and In WHO will consolidated strategic guidance that will a of indicators across the continuum of prevention, treatment and these will the key of quality HIV With this HIV program will have access to the critical indicators within with other When data are not to and important areas of the other methods may be including use of to more on critical issues that can with program quality, and traditional indicators and studies to the of critical program changes (e.g. studies of pregnant women starting ART CD4+ T-cell count of models and efficiency The HIV response ongoing and attention to to ensure the availability of for effective and with the Although the new guidelines will have much greater impact on health and of new and have the potential to reduce the of their are [1]. Ministries of Health and have critical challenges with new guideline to the and financial of potential guidelines changes in order to with local planning and to secure to support ongoing and changes to and to ensure the use of available of the of potential guidelines changes can be a variety of models, and some countries have been these of for As in of the guidelines, the of models is of the most commonly and its and resource needs models can be to the impact of guidelines changes on number of number of infections, and the of changing guidelines or approaches in a variety of epidemic models include the Health and models by the Health and for each with various and potential are encouraged to consider that is only as good as its ease of level of support, and attention must be in to ensuring the of local programmatic and Although has the of for the HIV response over the 10 years of the response in many low and some national governments have to increase their The ability of the in low and countries to further support the HIV and broader health response will be especially if traditional to These new guidelines a case for changing the course of the HIV and further resource may be by the of (e.g. more in antiretroviral drugs in the may reduce HIV that are less at for These may also be in the of such as the for Health and as for development of national that have the potential to provide a more for the HIV response and general health The has a to with to increase for methods for the efficiency by which the healthcare system resources to key and will also to and further resource For to the range of to provide ART to an individual, or provide an HIV testing and counseling by or of and for activities partners have made investments in developing these methods over recent and national governments are encouraged to to and resource use as the new guidelines are Ensuring human resource capacity to support evolving service delivery models of to the range of services to quality healthcare are a chronic in many countries. in many low and with of patients, are in some cases by only clinical and to long and for patients and a lack of attention to quality the new guidelines have many of the HIV interventions (e.g. a available in for HIV-infected and a focus on ensuring patients ART they HIV-related illnesses. These will further allow national programs to care delivery to who require less and to service delivery models and community delivery of The new guidelines also include recommendations for ART initiation to and for and community health workers to ART between has been a in the evidence for these recommendations and has successfully as a means of increasing the number of sites and to serve HIV-infected individuals (Fig. The effective use of in as a means of and expanding access to HIV care and as countries and scale-up new models of delivery, the guidelines changes provide a good to the current of various levels of and to use rapid evaluation to For the has that allow national governments to the need for additional healthcare workers on various guidelines These can also countries to approaches to and healthcare including laboratory These can form the for with professional of laboratory and and programs for other including community health workers and In order to the potential of the health including substantial numbers of new of health governments must to monitoring of program and ongoing support for the development of healthcare It is also important to frameworks to enable support and for new of health workers that have proven essential to the HIV including and community health These with the to have often been considered now are upon for delivery of services and must or and for Ensuring national supply chains are for the increase in volumes and changes in the mix of of the critical interventions in the new guidelines are on a consistent supply of essential commodities. Although national supply chains have in the 10 years of the HIV especially for antiretroviral drug there serious challenges in ensuring that clinics have For of rapid at the site level the efficiency and of and testing and prevention programs With more and expanded testing capacity for individuals their CD4+ T-cell count 500 cells/μl the case of and rapid expansion of viral load capacity, countries will to ensure that and related are with the of as antiretroviral activities for the of new guidelines include of the capacity of the and human resource capacity for transport and data management of the national supply for and need to include on antiretroviral drug that the use of fixed-dose in order to ensure adherence and supply the potential for viral load testing to up demand for and for additional HIV rapid (and other of care diagnostic such as point-of-care CD4+ T-cell and TB testing and and antiretroviral drug of of the of supply and of available technical and national of of with accountability at the levels of government and will likely have the with ensuring of key such as HIV rapid antiretroviral drugs and critical laboratory if their demand are communicated to their or supply and into The is important because the them and the to TB and work with to the demand for various of which the to the demand for their In the this and financial to of by of health services as well as civil society should be encouraged by national governments to ensure that are as early as possible that may be In the new WHO consolidated guidelines reflect not only evolving clinical also in the and of service delivery and program The most effective processes of guidelines change are by and reflect consultative processes in which and can be by partners with a in the It is expected that most countries will that there is a need to investments in the diversification of service delivery models, use and of data, development of human resources, and supply chains in order to accommodate increased patient volumes and to quality across the care and treatment cascade. and with careful for the essential elements of national health systems, the new guidelines could yield substantial for individuals living with HIV and public of There are of

Bernhard Rengs, Manuel Scholz-Wäckerle

We present a highly stylized agent-based computational model (ABM) of an artificial economic and monetary union. Contrary to other current macroeconomic ABMs, it focuses on the relations/consequences of credit-financed, high-leveraged economies, conspicuous consumption within and across borders and a monetary and economic union of individual countries. The model includes a number of boundedly rational agents of the following types: a central bank, states & governments, banks, firms and households. In summary, it enables simulations of interacting political economies within a monetary union, entailing complex interactions and interdependencies between centralized governments/central banks and decentralized markets for goods (regular and status), labor, loans as well as bonds from the bottom up. Through its modular structure, we are able to apply dynamic comparative institutional analysis by investigating medium and long-run economic effects.

Bo Li, Lin Chen, Heng Fan

No abstract is available for this record.

Caroline Gray

Abstract This article examines the relationship between the form of fiscal decentralization in Spain and the rise in tensions between the Spanish and Catalan governments during the financial crisis, in particular from mid-2010 to mid-2013. As a profound budgetary crisis unfolded at regional government level in Spain, long-standing disputes over the regional financing system and its methods of redistribution among the seventeen autonomous communities escalated. Most notably, Catalonia, one of the most indebted regions, attributed its financial woes in part to over-redistribution. This is not a straightforward connection, but the lack of clarity regarding both the workings of the regional financing system and the causes of the regions’ varying levels of fiscal (in)compliance reduced accountability and fuelled disputes among central and regional governments, giving both sides scope to offer different interpretations. The smoke and mirrors regarding regional finances combined with the nature of intergovernmental dynamics in Spain contribute to explaining the persistent inability to resolve regional fiscal problems and agree a long-lasting reform of the regional financing system.

Hyung-Kyu Yang

Abstract Mix network plays a key role in electronic voting to preserve anonymity and lots of mixnet schemes have been proposed so far. However, they requires complex and costly zero-knowledge proofs to provide their correct mixing operations. In 2010, Sebe et al. proposed an efficient and lightweight mixnet scheme based on a cryptographic secure hash function instead of zero-knowledge proofs. In this paper, we present a more efficient and faster mixnet scheme than Sebe et al.'s scheme under the same assumption. Also, our scheme is secure. Key Words : Zero-knowledge proof, e-Voting, Anonimity, Mixnet, hash function Ⅰ. Introduction Mixes are a means of untraceable communication based on a public key cryptosystem, as published by D.Chaum in 1981 [1] . A mix-network or mixnet accepts as input a collection of ciphertexts, and outputs associated plaintexts(or ciphertexts) in a randomly permuted order. A well constructed mixnet makes it infeasible for an adversary to determine which plaintext output corresponds to which ciphertext input more efficiently than by guessing at random. Proposed by D.Chaum in 1981 as a technique for anonymous e-mail and e-voting, mixnet can be categorized into decryption mix-nets and re-encryption mix-nets

Michael Backes, Cătălin Hriţcu, Matteo Maffei

We present a new type system for verifying the security of reference implementations of cryptographic protocols written in a core functional programming language. The type system combines prior work on refinement types, with union, intersection, and polymorphic types, and with the novel ability to reason statically about the disjointness of types. The increased expressivity enables the analysis of important protocol classes that were previously out of scope for the type-based analyses of reference protocol implementations. In particular, our types can statically characterize: (i) more usages of asymmetric cryptography, such as signatures of private data and encryptions of authenticated data; (ii) authenticity and integrity properties achieved by showing knowledge of secret data; (iii) applications based on zero-knowledge proofs. The type system comes with a mechanized proof of correctness and an efficient type-checker.

J.A. Bergstra, Peter Weijland

The question "what is Bitcoin" allows for many answers depending on the objectives aimed at when providing such answers. The question addressed in this paper is to determine a top-level classification, or type, for Bitcoin. We will classify Bitcoin as a system of type money-like informational commodity (MLIC).

Karabi Bezboruah

The Indian federalist system is a unique variant of federalism. Introduced by the British in 1935 and fueled by the popularity of federalism in the twentieth century as practical for a heterogeneous society, the Indian constitution framers decided on a distribution of powers between the center and the states. The uniqueness was that the constitution recognized a strong central government that directed the economy and could exercise certain legislative and executive powers over the states in times of need. Although designed as a federal system, the Indian constitution refers to it as the Union government, and is considered a centralized federation (Singh and Verney 2003). In Federalizing India in the Age of Globalization, the authors M. P. Singh and R. Saxena adopt an analytical approach to explain the development and expand understanding of federalism in India. The authors argue that this book is “the first comprehensive and systematic study of the processes of greater federalization of the Indian political system since the early 1990s” (p. ix). Chapter 1 begins with a discussion of the devolutionary decentralization in precolonial India followed by a review of the political system in British India. Chapter 2 is a comparative examination of the concept of federalism in the United States, Canada, and other countries in an attempt to draw on some commonalities and explain why a federal system of government works better for India. The authors allude to the conditions of federalism as propounded by other political scientists and expand these in the Indian context in Chapter 3. Here nationalism, multiculturalism, and federalism are explained taking into account cultural, religious, linguistic, and ethnic diversities. Noteworthy in this chapter is the discussion of the shifting territories and boundaries of the states against this diversity resulting in a push for more federal democracy through a separation of powers, and the rise of a capitalist society due to global influences. In Chapter 4, the authors discuss six indicators of increased federalization in India by underlining the decline in the central dominance over state administrative and legislative matters, the increased involvement and interest of state governments in treaties with other nations and private organizations, and increased push for functional autonomy by state governments. The authors argue that factors such as increase in the number of political parties and transformation of multiparty configuration with federal coalitions have brought about these changes. They also argue that liberalization of economic policies that led to privatization of most industries resulting in globalization and influx of global companies is another reason for the increased federalization. In the same vein, changes in judicial review and behavior pertaining to important constitutional items also are a factor in the increased federalization in India. Chapter 5 is a very interesting discussion of the formation of states in the pre-British period, during the British period, and reorganization of states post independence in 1947, with the most recent one in 2000 and another brewing in the form of Telangana in south India. Cultural and religious heterogeneity and economic disparities characterize each state, and a major reason for reorganization of states. Furthermore, this chapter briefly touches on models of state making (pp. 72–73) along linguistic lines that could be applicable in the Indian context. The authors, however, caution this trend by stating that the difference in representation between north and south India, creation of new states as a political strategy to satisfy certain groups, special status enjoyed by certain states that previously witnessed violent insurgencies, and the multitude of religion, castes, and ethnicities within each state cannot possibly be addressed through fragmentation and reorganization. Chapter 6 discusses in detail the asymmetries with respect to the constitutional provisions accorded to the states of Jammu and Kashmir and Nagaland, political asymmetries in terms of state representation in the national parliament, and fiscal asymmetries in the distribution of funds among states. Chapter 7 discusses the role of the federal second chamber, the Rajya Sabha, in the Indian Parliament in effectively representing each state’s plurality. This chamber has very little power and therefore, the authors question if its representational imbalance could be reduced through reconstitution, which then could lead to effective representations of the diversity within each state. In Chapter 8, the authors discuss the transformation of the judiciary from restraint to activism by citing federal–state and interstate disputes. The authors discuss intergovernmental relations (IGR) in Chapter 9 in the context of the executive relationships in policy making and implementation in the central and state levels. It can be understood from the discussion that besides competition by the economically developed states to attract more investors post 1991 economic reforms, not much have changed in the arena of IGR. Then in Chapter 10, the authors talk about the active participation by some state governments in the forging of international treaties by the central government, even resorting to judicial intervention in opposition to certain international agreements that were against their political ideology. In the absence of an institutionalized consultation or collaboration process between the center and the states, tensions in the center–state relationships often occur. Chapter 11 discusses the role of the centralized election commission, an autonomous body that is external to the government, and responsible for holding elections in a uniform manner, which is nondiscriminatory in nature, and allows for partnerships with local administration. The authors highlight the activism displayed by this commission as necessary in a fragmented society and for the success of electoral democracy. In Chapter 12, the authors explain the transformation in the party systems from single-party dominance to the rise of multiparty system with increased instances of minority government or coalition government, all of which contributed to increased federalization through power sharing and integration. However, the authors also recognize the multitude of pressures on the executive, and suggest electoral and party reforms akin to Canada, and active interventions by the intergovernmental bodies in generating federal consensus. In the last chapter, the authors describe briefly the development of local governments and their relationship with the center and go on to highlight the increase in democratic decentralization with increased self-governance and inclusivity to gender and castes. In sum, throughout this book, the authors advance explanatory factors for the increased federalization trends in India. In doing so, they bring to our attention several important issues, such as multiparty coalitions, competitive federalism, fiscal federalism, regionalization, judicial activism, and so forth, which are transforming the Indian political and administrative processes. The authors took pain in researching the historic basis that makes the changes more striking albeit somewhat distracting or informative based on one’s perspective. Yet, blending India’s rich history with the modern challenges of operating a country marked by plurality in every sphere is what makes this book so interesting and distinguishes it from other books on federalism. Features that are significant but not captured in this book well enough are the roles of the media and the civil society. While civil society is mentioned in the passing in the conclusion section, it could have been discussed in detail as a distinct chapter considering the important activist role that this sector has played in the Indian context. Nevertheless, this book is a comprehensive discussion of the changes in India’s political systems resulting in an evolving federalism. The judicious blend of rigidity and flexibility in operations offered by the constitution without any changes to its basic structure has equipped the Indian federal system with the strength to withstand any challenges of time.

Assaf Shomer

We calculate the probability of success of block-hiding mining strategies in Bitcoin-like networks. These strategies involve building a secret branch of the block-tree and publishing it opportunistically, aiming to replace the top of the main branch and rip the reward associated with the secretly mined blocks. We identify two types of block-hiding strategies and chart the parameter space where those are more beneficial than the standard mining strategy described in Nakamoto's paper. Our analysis suggests a generalization of the notion of the relative hashing power as a measure for a miner's influence on the network. Block-hiding strategies are beneficial only when this measure of influence exceeds a certain threshold.

Andrew Blackman

No abstract is available for this record.