Case 15-2011: A 19-year-old South African woman with headache, fatigue, and vaginal discharge.

No abstract available.This case was presented at the Fourth Annual Workshop on Advanced Clinical Care - AIDS in Durban, South Africa, September 30–October 1, 2010. The workshop was sponsored by the Harvard University Center for AIDS Research, McCord Hospital (Durban), the University of KwaZulu-Natal, the South African HIV Clinicians Society, and the Department of Health of KwaZulu-Natal

Using quality improvement to accelerate highly active antiretroviral treatment coverage in South Africa

IntroductionThe authors report on a health systems strengthening intervention using quality improvement (QI) methods at the subdistrict level to accelerate highly active antiretroviral treatment (HAART) initiation in South Africa.MethodsUsing a phased scale-up design between August 2006 and November 2009, 14 primary healthcare clinics, one community health centre, one district hospital and one tertiary hospital in a subdistrict were recruited into a ‘learning network’ using QI methods to facilitate cross-facility learning/mentorship/support. Clinic teams consisting of nurses, counsellors, clerks and/or doctors set collective and individual performance targets, analysed their care systems using ‘real-time’ data feedback, and designed/implemented a set of simple changes to improve HIV testing and HAART initiation rates across the region.Data analysisPrimary clinic data were used to measure HAART initiation rates (primary outcome) and HIV testing (secondary outcome). We analysed data variation/trends using an interrupted time series design. Logistic regression analysis was applied to examine trends in HAART initiation during the intervention phases.ResultsClinics in the learning network increased HIV testing by 301.8% from 891/month (SD=94.2) to 3580/month (SD=327.7) (p<0.0001). Monthly HAART initiations increased by 185.5% from 179/month (SD=17.22) to 511/month (SD=44.93) (p<0.0001). During the pilot (phase I), the monthly rate of HAART initiations increased by 3.6 patients. In the prototype collaborative (phase II), there was no acceleration in the rate of increase (3.3/month, p=0.92). Significant acceleration was observed in the rate of increase during the QI scale up (phase III) (10.1/month, p<0.001). The proportion of estimated need for HAART met in the region increased from 35.8% to 72.4% at a time of rapid population growth.ConclusionA QI approach, using learning networks to teach simple data-driven methods for addressing system failures, with increased training and resource inputs, can assist districts to quickly reach universal coverage targets

HIV-positive kidney transplants for HIV-positive individuals: Attitudes and concerns of South African patients and health care workers

In South Africa, an estimated 30% of the cadaveric donor pool is HIV-infected; in consequence, these organs are discarded. An undersupply of donor organs combined with limited resources, tends to exclude HIV-positive patients from renal replacement programmes. We evaluated the acceptance of using HIV-positive donor kidneys for transplantation into HIV-infected recipients, and found that the vast majority (90% of health care workers and 80% of patients, N=20 and 80, respectively) found this approach acceptable for expanding the organ donor pool, which indicates broad patient and health care worker support for using HIV-infected donor kidneys.Participants: 80 patients were recruited from four different groups: those with HIV on stable antiretroviral (ARV) therapy but with no kidney disease; stable antiretroviral therapy, with kidney disease, including on dialysis; and HIV-uninfected patients, both on dialysis and those with functional kidney transplants. Discussions with 20 health care workers were also conducted. Results: The vast majority (90% of health care workers and 80% of patients, n=20 and 80 respectively) found transplant of HIV-infected organs to HIV-positive recipients an acceptable method for expanding the organ donor pool. This study found no significant difference between the groups of patients regarding whether they approved of using HIV-positive donors; HIV positive patients were willing to accept kidneys from HIV-infected family members, while HIV-negative patients were very unlikely to accept HIV-infected organs. Health care workers expressed concern about initiatives to expand the donor pool and educate patients concerning transplant eligibility. Conclusion: These findings indicate broad patient and health care worker support for the use of HIV-infected donor kidneys for some types of renal patients

Setting ART initiation targets in response to changing guidelines: The importance of addressing both steady-state and backlog

Background. Target setting is useful in planning, assessing and improving antiretroviral treatment (ART) programmes. In the past 4 years, the ART initiation environment has been transformed due to the change in eligibility criteria (starting ART at a CD4+ count &lt;350 cells/μl v. &lt;200 cells/μl) and the roll-out of nurse-initiated management of ART.Objective. To describe and illustrate the use of a target-setting model for estimating district-based targets in the era of an expanding ART programme and changing CD4+ count thresholds for ART initiation. Method. Using previously described models and data for annual new HIV infections, we estimated both steady-state need for ART initiation and backlog in a North West Province district, accounting for the shift in eligibility. Comparison of actual v. targeted ART initiations was undertaken. The change in CD4+ count threshold adds a once-off group of newly eligible patients to the pool requiring ART – the backlog. The steady-state remains unchanged as it is determined by the annual rate of new HIV infections in previous years.Results. The steady-state need for the district was 639 initiations/month, and the backlog was ~15 388 patients. After the shift in eligibility in September 2011, the steady-state target was exceeded over several months with some backlog addressed. Of the total backlog for this district, 72% remains to be cleared.Conclusion. South Africa has two pools of patients who need ART: the steady-state of HIV-infected patients entering the programme each year, determined by historical infection rates; and the backlog created by the shift in eligibility. The healthcare system needs to build long- term capacity to meet the steady-state need for ART and additional capacity to address the backlog.

The prevalence of smoking and the knowledge of smoking hazards and smoking cessation strategies among HIV- positive patients in Johannesburg, South Africa

Background. While the detrimental effects of smoking among HIV-positive patients have been well documented, there is a paucity of data regarding cigarette smoking prevalence among these patients in South Africa (SA).Objectives. To establish the frequency, demographics, knowledge of harmful effects, and knowledge of smoking cessation strategies among HIV-positive patients in Johannesburg, SA.Methods. We conducted a prospective cross-sectional survey using a structured questionnaire to interview HIV-positive patients attending the HIV Clinic at the Charlotte Maxeke Johannesburg Academic Hospital between 1 July and 31 October 2011.Results. Of 207 HIV-positive patients attending an antiretroviral therapy (ART) roll-out clinic, 31 (15%) were current smokers (23.2% of males and 7.4% of females) and a further 45 (21.7%) were ex-smokers. Most of the current smokers (30/31 patients) indicated their wish to quit smoking, and among the group as a whole, most patients were aware of the general (82.1%) and HIV-related (77.8%) risks of smoking and of methods for quitting smoking. Despite this, however, most (62.3%) were not aware of who they could approach for assistance and advice.Conclusions. Given the relatively high prevalence of current and ex-smokers among HIV-positive patients, there is a need for the introduction of smoking-cessation strategies and assistance at ART roll-out clinics in SA.