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Background Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. Methods and findings We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression ( Conclusions In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. Clinical Trial registration NCT02536768., Author(s): Matthew P. Fox 1,2,3,*, Sophie Pascoe 3, Amy N. Huber 3, Joshua Murphy 3, Mokgadi Phokojoe 4, Marelize Gorgens 5, Sydney Rosen 1,3, David Wilson 5, Yogan Pillay 4, [...]

Problem The World Health Organization has produced clear guidelines for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). However, ensuring that all PMTCT programme components are implemented to a high quality in all facilities presents challenges. Approach Although South Africa initiated its PMTCT programme in 2002, later than most other countries, political support has increased since 2008. Operational research has received more attention and objective data have been used more effectively. Local setting In 2010, around 30% of all pregnant women in South Africa were HIV-positive and half of all deaths in children younger than 5 years were associated with the virus. Relevant changes Between 2008 and 2011, the estimated proportion of HIV-exposed infants younger than 2 months who underwent routine polymerase chain reaction (PCR) tests to detect early HIV transmission increased from 36.6% to 70.4%. The estimated HIV transmission rate decreased from 9.6% to 2.8%. Population-based surveys in 2010 and 2011 reported transmission rates of 3.5% and 2.7%, respectively. Lessons learnt Critical actions for improving programme outcomes included: ensuring rapid implementation of changes in PMTCT policy at the field level through training and guideline dissemination; ensuring good coordination with technical partners, such as international health agencies and international and local nongovernmental organizations; and making use of data and indicators on all aspects of the PMTCT programme. Enabling health-care staff at primary care facilities to initiate antiretroviral therapy and expanding laboratory services for measuring CD4+ T-cell counts and for PCR testing were also helpful. Probleme LOrganisation mondiale de la Sante a elabore des lignes directrices claires pour la prevention de la transmission mere-enfant (PTME) du virus de l'immunodeficience humaine (VIH). S'assurer que tous les elements du programme de PTME soient mis en ceuvre de maniere qualitative dans tous les etablissements presente cependant des defis. Approche Bien que l'Afrique du Sud ait lance son programme de PTME en 2002, plus tard que la plupart des autres pays, le soutien politique a augmente depuis 2008. La recherche operationnelle a recu davantage d'attention, et les donnees objectives ont ete utilisees plus efficacement. Environnement local En 2010, environ 30% de toutes les femmes enceintes en Afrique du Sud etaient seropositives, et la moitie de tous les deces d'enfants de moins de 5 ans etaient associee au virus. Changements significatifs Entre 2008 et 2011, la proportion estimee de nourrissons de moins de 2 mois exposes au VIH, ayant subi une reaction en chaine par polymerase (PCR) de routine visant a detecter la transmission precoce du VIH, est passee de 36,6% a 70,4%. Le taux estime de transmission du VIH a diminue, passant de 9,6% a 2,8%. Les enquetes basees sur la population en 2010 et 2011 ont signale des taux de transmission de 3,5% et 2,7%, respectivement. Lecons tirees Voici certaines actions essentielles pour ameliorer les resultats du programme: assurer la mise en ceuvre rapide des changements de politique de PTME sur le terrain, grace a la formation et a la diffusion des lignes directrices; assurer une bonne coordination avec les partenaires techniques, comme les agences de sante internationales et locales et les organisations non gouvernementales; et utiliser les donnees et les indicateurs relatifs a tous les aspects du programme de PTME. Il est aussi utile de permettre au personnel soignant des etablissements de soins de sante primaires d'initier un traitement antiretroviral et de developper les services de laboratoire pour les decomptes de cellules CD4+ T et les tests PCR. Situacion La Organizacion Mundial de la Salud ha presentado unas directrices claras para la prevencion de la transmision del virus de la inmunodeficiencia humana (VIH) de la madre al nino. No obstante, habra que superar algunos desafios para asegurar la puesta en marcha de todos los elementos del programa de prevencion a in de alcanzar un nivel de calidad elevado en todas las instalaciones. Enfoque Aunque Sudafrica inicio su programa de prevencion en el ano 2002, mas tarde que la mayoria de los paises, el apoyo politico ha aumentado desde 2008. Se ha prestado mas atencion a las investigaciones operativas y los datos objetivos se han utilizado con mayor eicacia. Marco regional En 2010, alrededor del 30% de las mujeres embarazadas en Sudafrica eran seropositivas, y la mitad de todas las muertes en ninos menores de cinco anos estuvieron asociadas al virus. Cambios importantes Entre los anos 2008 y 2011, la proporcion estimada de ninos menores de dos meses expuestos al VIH que se sometio a las pruebas rutinarias de reaccion en cadena de la polimerasa aumento del 36,6% al 70,4%, y la tasa estimada de transmision del VIH se redujo del 9,6% al 2,8%. Las encuestas de poblacion de los anos 2010 y 2011 reflejaron unas tasas de transmision del 3,5% y el 2,7%, respectivamente Lecciones aprendidas Las actividades fundamentales para mejorar los resultados del programa incluyeron: garantizar la implementacion rapida de los cambios en la politica de prevencion de la transmision a nivel de campo mediante cursos formativos y la difusion de las directrices; garantizar una coordinacion adecuada entre los socios tecnicos, tales como las agencias sanitarias internacionales y las ONG locales e internacionales; y utilizar los datos e indicadores acerca de todos los aspectos del programa de prevencion de la transmision del VIH de la madre al nino. Tambien resulto muy util permitir al personal sanitario de los centros de atencion primaria iniciar terapias antirretrovirales y ampliar los servicios de laboratorio para realizar los recuentos de linfocitos T CD4+ y las pruebas de reaccion en cadena de la polimerasa., Introduction The magnitude of the problem of human immunodeficiency virus (HIV) infection in South Africa is illustrated in Fig. 1, which shows the rise of the HIV pandemic since 1990 [...]

In Africa, resistance to anti-tuberculosis (TB) drugs has been assumed to be low (1). In 2002, the national drug resistance survey showed rates of multidrug-resistant (MDR) TB in South Africa [...]

: Introduction: In 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The City of Johannesburg – one of South Africa's metropolitan municipalities and also a health district – has over 600,000 people living with HIV (PLHIV), more than any other city worldwide. We estimate what it would take in terms of programmatic targets and costs for the City of Johannesburg to meet the Fast‐Track targets, and demonstrate the impact that this would have. Methods: We applied the Optima HIV epidemic and resource allocation model to demographic, epidemiological and behavioural data on 26 sub‐populations in Johannesburg. We used data on programme costs and coverage to produce baseline projections. We calculated how many people must be diagnosed, put onto treatment and maintained with viral suppression to achieve the 2020 and 2030 targets. We also estimated how treatment needs – and therefore fiscal commitments – could be reduced if the treatment targets are combined with primary HIV prevention interventions (voluntary medical male circumcision (VMMC), an expanded condom programme, and comprehensive packages for female sex workers (FSW) and young females). Results: If current programmatic coverage were maintained, Johannesburg could expect 303,000 new infections and 96,000 AIDS‐related deaths between 2017 and 2030 and 769,000 PLHIV by 2030. Achieving the Fast‐Track targets would require an additional 135,000 diagnoses and 232,000 people on treatment by 2020 (an increase in around 80% over 2016 treatment numbers), but would avert 176,000 infections and 56,500 deaths by 2030. Assuming stable ART unit costs, this would require ZAR 29 billion (USD 2.15 billion) in cumulative treatment investments over the 14 years to 2030. Plausible scale‐ups of other proven interventions (VMMC, condom distribution and FSW strategies) could yield additional reductions in new infections (between 4 and 15%), and in overall treatment investment needs. Scaling up VMMC in line with national targets is found to be cost‐effective in the medium term. Conclusions: The scale‐up in testing and treatment programmes over this decade has been rapid, but these efforts must be doubled to reach 2020 targets. Strategic investments in proven interventions will help Johannesburg achieve the treatment targets and be on track to end AIDS by 2030., Introduction In 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The Fast‐Track [...]

South Africa has the highest burden of HIV-associated tuberculosis. Yogan Pillay tells Fiona Fleck how the health Ministry has brought the two programmes and services together. Q: How did you [...]