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 <350 cells/µlv. <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

Prevalence, risk factors and risk perception of tuberculosis infection among medical students and healthcare workers in Johannesburg, South Africa

BACKGROUND: Tuberculin skin test (TST) and interferon gamma release assays (IGRAs) are both recommended for routine screening of healthcare workers (HCWs) in low tuberculosis (TB)-burden countries. More recently, based on scarce data, the World Health Organization strongly recommended that IGRA should not be used for occupational screening in high-burden settings. OBJECTIVE: To assess the prevalence of latent tuberculosis infection (LTBI) determined among highly exposed HCWs and low-exposed medical students in Johannesburg, South Africa. Methods. We performed a cross-sectional study using both TSTs and IGRAs to determine the prevalence rate of LTBI in 79 medical students and 120 HCWs providing HIV and/or TB care. RESULTS: The prevalence of LTBI among HCWs was 2- to 4-fold higher than that among medical students (56.7% v. 26.6% TST-positive; 69.2% v.15.2% IGRA-positive, respectively), with 3-fold higher odds for TST positivity and 12-fold higher odds for IGRA positivity among HCWs compared with students. Despite the perception of being at high risk, few HCWs protected themselves against LTBI. The majority of HCWs reported that they would participate in annual TST or IGRA screening. CONCLUSION: Infection control strategies and occupational screening programmes for professional and lay HCWs, as well as medical students, should be implemented in all high-burden settings. Further research is needed to determine whether IGRA or TST is the optimal assay for periodical screening of HCWs in high-burden settings

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 <350 cells/µlv. <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

New horizons in the treatment of HIV infection

No abstract available

The pathology of familial breast cancer: histological features of cancers in families not attributable to mutations in BRCA1 or BRCA2

Breast cancers arising in carriers of mutations in the breast cancer susceptibility genes, BRCA1 and BRCA2, differ histologically from each other and from breast cancers unselected for a family history. However, a substantial proportion of families with multiple cases of breast cancer is not attributable to these two genes (non-BRCA1/2 families). We have now characterized the pathology of 82 breast cancers from non-BRCA1/2 families. Breast cancers in non-BRCA1/2 families were of lower grade (P = 0.0018), showed fewer mitoses (P < 0.0001), less nuclear pleomorphism (P = 0.0014), less lymphocytic infiltrate (P < 0.0001), a lesser extent of the tumor with a continuous pushing margin (P = 0.004), a lesser extent of the tumor composed of solid sheets of cells (P = 0.0047), less necrosis (P = 0.002), and were more likely to be of invasive lobular type (P = 0.0003) than breast cancers arising in BRCA1 mutation carriers. In comparison with BRCA2 tumors, non- BRCA1/2 tumors were lower grade (P = 0.017) and exhibited less pleomorphism (P = 0.01) and more tubule formation (P = 0.05). In comparison with control breast cancers unselected for a family history of the disease, non-BRCA1/2 tumors were of significantly lower grade (P = 0.001), showed less pleomorphism (P = 0.0002), and had a lower mitotic count (P = 0.003). The results indicate that non-BRCA1/2 breast cancers differ histologically from both BRCA1 and BRCA2 breast cancers and are overall of lower grade. They also suggest that non-BRCA1/2 breast cancers differ from nonfamilial breast cancers, but these differences may be attributable to various types of bias