Trends in the distribution of South African health care expenditure

The lack of critical distinction between the public and the private health sectors and what they represent has allowed the claim to be made that South African health care expenditure levels compare favourably with international standards. This paper considers the distribution of health expenditure between the public and the private sectors in South Africa, within these sectors and also on the basis of population group.The extent of maldistribution of health care resources among the people of South Africa is highlighted. The data analysed in this paper indicate that an increasing proportion of public sector expenditure has been spent on curative services, that the gap in real per capita expenditure between the 'homelands' and other public sector departments has been widening, and that per capita expenditure has been increasing more rapidly in the private sector than in the public sector, particularly in the 1980s

Assessment of epidemic projections using recent HIV survey data in South Africa: A validation analysis of ten mathematical models of HIV epidemiology in the antiretroviral therapy era

Background: Mathematical models are widely used to simulate the effects of interventions to control HIV and to project future epidemiological trends and resource needs. We aimed to validate past model projections against data from a large household survey done in South Africa in 2012. Methods: We compared ten model projections of HIV prevalence, HIV incidence, and antiretroviral therapy (ART) coverage for South Africa with estimates from national household survey data from 2012. Model projections for 2012 were made before the publication of the 2012 household survey. We compared adult (age 15-49 years) HIV prevalence in 2012, the change in prevalence between 2008 and 2012, and prevalence, incidence, and ART coverage by sex and by age groups between model projections and the 2012 household survey. Findings: All models projected lower prevalence estimates for 2012 than the survey estimate (18·8%), with eight models' central projections being below the survey 95% CI (17·5-20·3). Eight models projected that HIV prevalence would remain unchanged (n=5) or decline (n=3) between 2008 and 2012, whereas prevalence estimates from the household surveys increased from 16·9% in 2008 to 18·8% in 2012 (difference 1·9, 95% CI -0·1 to 3·9). Model projections accurately predicted the 1·6 percentage point prevalence decline (95% CI -0·3 to 3·5) in young adults aged 15-24 years, and the 2·2 percentage point (0·5 to 3·9) increase in those aged 50 years and older. Models accurately represented the number of adults on ART in 2012; six of ten models were within the survey 95% CI of 1·54-2·12 million. However, the differential ART coverage between women and men was not fully captured; all model projections of the sex ratio of women to men on ART were lower than the survey estimate of 2·22 (95% CI 1·73-2·71). Interpretation: Projections for overall declines in HIV epidemics during the ART era might have been optimistic. Future treatment and HIV prevention needs might be greater than previously forecasted. Additional data about service provision for HIV care could help inform more accurate projections. Funding: Bill & Melinda Gates Foundation

A Bayesian approach to uncertainty analysis of sexually transmitted infection models

10.1136/sti.2009.037341Sexually Transmitted Infections863169-174STIN

Guest Editorial: Rapidly changing mortality profiles in South Africa in its nine provinces

No Abstrac

The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: a model-based analysis

This study aims to assess trends in human immunodeficiency virus (HIV) incidence in South Africa, and to assess the extent to which prevention and treatment programmes have reduced HIV incidence. Two models of the South African HIV epidemic, the STI (sexually transmitted infection) HIV Interaction model and the ASSA2003 AIDS and Demographic model, were adapted. Both models were fitted to age-specific HIV prevalence data from antenatal clinic surveys and household surveys, using a Bayesian approach. Both models suggest that HIV incidence in 15-49 year olds declined significantly between the start of 2000 and the start of 2008: by 27 per cent (95% CI: 21-32%) in the STI/HIV model and by 31 per cent (95% CI: 23-39%) in the ASSA2003 model, when expressed as a percentage of incidence rates in 2000. By 2008, the percentage reduction in incidence owing to increased condom use was 37 per cent (95% CI: 34-41%) in the STI-HIV model and 23 per cent (95% CI: 14-34%) in the ASSA2003 model. Both models also estimated a small reduction in incidence owing to antiretroviral treatment by 2008. Increased condom use therefore appears to be the most significant factor explaining the recent South African HIV incidence decline.

Sexual behaviour patterns in South Africa and their association with the spread of HIV: insights from a mathematical model

This paper aims to quantify the effects of different types of sexual risk behaviour on the spread of HIV in South Africa. A mathematical model is developed to simulate changes in numbers of sexual partners, changes in marital status, changes in commercial sex activity, and changes in the frequency of unprotected sex over the life course. This is extended to allow for the transmission of HIV, and the model is fitted to South African HIV prevalence data and sexual behaviour data. Results suggest that concurrent partnerships and other non-spousal partnerships are major drivers of the HIV/AIDS epidemic in South Africa.

The effect of early initiation of antiretroviral treatment in infants receiving pediatric auto immune deficiency syndrome mortality in South Africa

<p><b>BACKGROUND:</b> Guidelines for treatment of pediatric HIV have recently changed to recommend that all infants who are identified as HIV-infected should start antiretroviral treatment (ART) immediately, regardless of their immunologic or clinical status. This study aims to assess the likely impact of this change in guideline in South Africa.</p> <p><b>METHODS:</b> A mathematic model was developed to simulate mother-to-child transmission of HIV, disease progression and death of HIV-infected children <15 years of age. The model is calibrated to South African data sources, including prevention of mother-to-child transmission program coverage data, pre-ART survival data, ART program statistics and pediatric HIV prevalence studies.</p> <p><b>RESULTS:</b> Relative to what would be expected in the absence of early ART initiation, the number of infant AIDS deaths over the 2010-2025 period is expected to drop by 23.6% (95% CI: 22.5-24.5%) at current levels of polymerase chain reaction (PCR) diagnosis, and by 34.2% (95% CI: 32.7-35.6%) if PCR diagnosis increases to 80% of perinatally infected infants at 2 months. However, the pediatric HIV disease burden has shifted towards older children in recent years. The effect of early ART on total pediatric AIDS mortality during the 2010-2025 period is therefore modest: a 9.8% reduction (95% CI: 7.9-12.6%) at current levels of PCR diagnosis, and a 14.2% reduction (95% CI: 11.4-18.2%) if PCR coverage increases to 80% of perinatally infected infants.</p> <p><b>CONCLUSION:</b> The changes in ART guidelines for infants will have a significant impact on pediatric AIDS mortality at young ages, but further efforts are required to reduce the substantial growing AIDS mortality in older children.</p&gt

The effect of early initiation of antiretroviral treatment in infants on pediatric AIDS mortality in South Africa: a model-based analysis

The changes in ART guidelines for infants will have a significant impact on pediatric AIDS mortality at young ages, but further efforts are required to reduce the substantial growing AIDS mortality in older children.