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Abstract Background In low-resource settings, patients’ use of multiple healthcare sources may complicate chronic care and clinical outcomes as antiretroviral therapy (ART) continues to expand. However, little is known regarding patterns, drivers and consequences of using multiple healthcare sources. We therefore investigated factors associated with patterns of plural healthcare usage among patients taking ART in diverse South African settings. Methods A cross-sectional study of patients taking ART was conducted in two rural and two urban sub-districts, involving 13 accredited facilities and 1266 participants selected through systematic random sampling. Structured questionnaires were used in interviews, and participant’s clinic records were reviewed. Data collected included household assets, healthcare access dimensions (availability, affordability and acceptability), healthcare utilization and pluralism, and laboratory-based outcomes. Multiple logistic regression models were fitted to identify predictors of healthcare pluralism and associations with treatment outcomes. Prior ethical approval and informed consent were obtained. Results Nineteen percent of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. A further 15% of respondents reported additional expenditure on self-care (e.g. special foods). Access to health insurance (Adjusted odds ratio [aOR] 6.15) and disability grants (aOR 1.35) increased plural healthcare use. However, plural healthcare users were more likely to borrow money to finance healthcare (aOR 2.68), and incur catastrophic levels of healthcare expenditure (27%) than non-plural users (7%). Quality of care factors, such as perceived disrespect by staff (aOR 2.07) and lack of privacy (aOR 1.50) increased plural healthcare utilization. Plural healthcare utilization was associated with rural residence (aOR 1.97). Healthcare pluralism was not associated with missed visits or biological outcomes. Conclusion Increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Plural healthcare utilization may be an indication of patients’ dissatisfaction with perceived quality of ART care provided. Healthcare expenditure of a catastrophic nature remained a persistent complication. Plural healthcare utilization did not appear to influence clinical outcomes. However, there were potential negative impacts on the livelihoods of patients and their households.

Abstract Background South Africa’s maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country’s Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, “patient-oriented” barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Methods A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. Results Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. Conclusions To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these “patient-oriented” barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.

The Immunization and Vaccines-related Implementation Research Advisory Committee (IVIR-AC) is the primary advisory body of the World Health Organization conducting independent reviews of immunization-related implementation research, with a primary focus on transmission and economic modeling analyses that estimate the value and impact of vaccines. From 10 to 13th September 2024, IVIR-AC convened virtually for its second of two semi-annual meetings to provide feedback and recommendations across six sessions including: pneumococcal vaccination strategies that rely on indirect protection; vaccine impact modeling for chikungunya; The Lancet Commission on strengthening the use of epidemiological modeling of emerging and pandemic infectious diseases; methods for immunization coverage estimation; setting immunization research priorities in the South-East Asian Region; and modeling evidence related to typhoid conjugate vaccine schedules. This report summarizes the sessions, proceedings, and recommendations from that meeting., Competing Interests: Declaration of competing interest P. L. is supported financially by the Bill & Melinda Gates Foundation. S. S. was supported by the World Health Organization for this work. A. N. S. was financially supported by the World Health Organization for this work, and is additionally supported by the Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, and the National Institutes of Health. M. K. is supported by the Bill & Melinda Gates Foundation. A. B. H. was supported by the Australian National Health and Medical Research Council for this work, is additionally supported by PATH, the World Health Organization, and Gavi, the Vaccine Alliance, and has received consulting fees from the Australian NSW Ministry of Health, WHO Europe and Asian Development Bank. A. P. is supported by Gavi, the Vaccine Alliance, Imperial College London, the Bill & Melinda Gates Foundation, and the World Health Organization. A. N. S. and A. B. H. report travel related support from the World Health Organization to attend previous IVIR-AC meetings. All other authors have no declarations., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The World Health Organization's Immunization and Vaccines-related Implementation Research Advisory Committee (IVIR-AC) serves to independently review and evaluate vaccine-related research to maximize the potential impact of vaccination programs. From 28 June - 1 July 2024, IVIR-AC was convened for an ad hoc meeting to discuss new evidence on criteria for rubella vaccine introduction and the risk of congenital rubella syndrome. This report summarizes background information on rubella virus transmission and the burden of congenital rubella syndrome, meeting structure and presentations, proceedings, and recommendations., Competing Interests: Declaration of competing interest P. L. was supported by the Bill & Melinda Gates Foundation for this work. S. S. was supported by the World Health Organization for this work. A. N. S. was financially supported by the World Health Organization for this work, and is additionally supported by the Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, and the National Institutes of Health. K. F. is employed by the Bill & Melinda Gates Foundation. M. F. is supported by the National Science Foundation, the Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, Centers for Disease Control and Prevention, and Imperial College London. E. V. was supported for this work by Gavi, the Vaccine Alliance via the Vaccine Impact Modeling Consortium (VIMC), which is jointly funded by Gavi, the Vaccine Alliance and the Bill & Melinda Gates Foundation. C. J. E. M. has previously received travel funds to visit the Max Plank Institute of Evolutionary Anthropology. A. K. W. was supported for this work by Gavi, the Vaccine Alliance, is additionally supported by the Bill & Melinda Gates Foundation, and has previously received travel funds from Gavi, the Vaccine Alliance. M. K. was supported for this work by the Bill & Melinda Gates Foundation. A. P. is supported by Gavi, the Vaccine Alliance, Imperial College London, the Bill & Melinda Gates Foundation, and the World Health Organization. A. B. H. was supported by the Australian National Health and Medical Research Council for this work, is additionally supported by the Australian NSW Ministry of Health, PATH, the World Health Organization, and Gavi, the Vaccine Alliance, and has received consulting fees from the Australian NSW Ministry of Health, WHO Europe and Asian Development Bank. A. N. S. and M. F. report travel related support from the World Health Organization to attend previous IVIR-AC meetings. All other authors have no declarations., (Copyright © 2024. Published by Elsevier Ltd.)

Background: COVID-19 vaccines were rolled out in South Africa beginning in February 2021. In this study we retrospectively assessed the cost-effectiveness of the vaccination programme in its first two years of implementation., Method: We modelled the costs, expressed in 2021 US$, and health outcomes of the COVID-19 vaccination programme compared to a no vaccination programme scenario. The study was conducted from a public payer's perspective over two time-horizons - nine months (February to November 2021) and twenty-four months (February 2021 to January 2023). Health outcomes were estimated from a disease transmission model parameterised with data on COVID-19-related hospitalisations and deaths and were converted to disability adjusted life years (DALYs). Deterministic and probabilistic sensitivity analyses (DSA and PSA) were conducted to assess parameter uncertainty., Results: Incremental cost-effectiveness ratio (ICER) was estimated at US$1600 per DALY averted during the first study time horizon. The corresponding ICER for the second study period was estimated at US$1300 per DALY averted. When 85% of all excess deaths during these periods were included in the analysis, ICERs in the first and second study periods were estimated at US$1070 and US$660 per DALY averted, respectively. In the PSA, almost 100% of simulations fell below the estimated opportunity cost-based cost-effectiveness threshold for South Africa (US$2300 DALYs averted). COVID-19 vaccination programme cost per dose had the greatest impact on the ICERs., Conclusion: Our findings suggest that South Africa's COVID-19 vaccination programme represented good value for money in the first two years of rollout., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The Immunization and Vaccine-related Implementation Research Advisory Committee (IVIR-AC) is the World Health Organization's key standing advisory body to conduct an independent review of research, particularly of transmission and economic modeling analyses that estimate the impact and value of vaccines. From 26th February-1st March 2024, at its first of two semi-annual meetings, IVIR-AC provided feedback and recommendations across four sessions; this report summarizes the proceedings and recommendations from that meeting. Session topics included modeling of the impact and cost-effectiveness of the R21/Matrix-M malaria vaccine, meta-analysis of economic evaluations of vaccines, a global analysis estimating the impact of vaccination over the last 50 years, and modeling the impact of different RTS,S malaria vaccine dose schedules in seasonal settings., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: S. S. was supported by the World Health Organization for this work. A. N. S. was financially supported by the World Health Organization for this work, and is additionally supported by the Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, and the National Institutes of Health. A. B. H. was supported by the Australian National Health and Medical Research Council for this work, is additionally supported by PATH, the World Health Organization, and Gavi, the Vaccine Alliance, and has received consulting fees from the Australian NSW Ministry of Health, WHO Europe and Asian Development Bank. W. J. M. is supported by the National institutes of Health. A. P. is supported by Imperial College London, the Bill & Melinda Gates Foundation, the World Health Organization, and the University of Oslo. X. W. has served as a Data Safety Monitoring Board member for several China-made COVID-19 vaccines. S. S., A. N. S., and A. B. H. report travel related support from the World Health Organization to attend previous IVIR-AC meetings. All other authors have no declarations., (Copyright © 2024. Published by Elsevier Ltd.)

Evaluating vaccine-related research is critical to maximize the potential of vaccination programmes. The WHO Immunization and Vaccine-related Implementation Research Advisory Committee (IVIR-AC) provides an independent review of research that estimates the performance, impact and value of vaccines, with a particular focus on transmission and economic modelling. On 11-13 September 2023, IVIR-AC was convened for a bi-annual meeting where the committee reviewed research and presentations across eight different sessions. This report summarizes the background information, proceedings and recommendations from that meeting. Sessions ranged in topic from timing of measles supplementary immunization activities, analyses of conditions necessary to meet measles elimination in the South-East Asia region, translating modelled evidence into policy, a risk-benefit analysis of dengue vaccine, COVID-19 scenario modelling in the African region, therapeutic vaccination against human papilloma virus, the Vaccine Impact Modelling Consortium, and the Immunization Agenda 2030 vaccine impact estimates., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

There are limited published data within sub-Saharan Africa describing hospital pathways of COVID-19 patients hospitalized. These data are crucial for the parameterisation of epidemiological and cost models, and for planning purposes for the region. We evaluated COVID-19 hospital admissions from the South African national hospital surveillance system (DATCOV) during the first three COVID-19 waves between May 2020 and August 2021. We describe probabilities and admission into intensive care units (ICU), mechanical ventilation, death, and lengths of stay (LOS) in non-ICU and ICU care in public and private sectors. A log-binomial model was used to quantify mortality risk, ICU treatment and mechanical ventilation between time periods, adjusting for age, sex, comorbidity, health sector and province. There were 342,700 COVID-19-related hospital admissions during the study period. Risk of ICU admission was 16% lower during wave periods (adjusted risk ratio (aRR) 0.84 [0.82-0.86]) compared to between-wave periods. Mechanical ventilation was more likely during a wave overall (aRR 1.18 [1.13-1.23]), but patterns between waves were inconsistent, while mortality risk in non-ICU and ICU were 39% (aRR 1.39 [1.35-1.43]) and 31% (aRR 1.31 [1.27-1.36]) higher during a wave, compared to between-wave periods, respectively. If patients had had the same probability of death during waves vs between-wave periods, we estimated approximately 24% [19%-30%] of deaths (19,600 [15,200-24,000]) would not have occurred over the study period. LOS differed by age (older patients stayed longer), ward type (ICU stays were longer than non-ICU) and death/recovery outcome (time to death was shorter in non-ICU); however, LOS remained similar between time periods. Healthcare capacity constraints as inferred by wave period have a large impact on in-hospital mortality. It is crucial for modelling health systems strain and budgets to consider how input parameters related to hospitalisation change during and between waves, especially in settings with severely constrained resources., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Jamieson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

By May 2021, South Africa (SA) had experienced two 'waves' of COVID-19 infections, with an initial peak of infections reached in July 2020, followed by a larger peak of infections in January 2021. Public health decisions rely on accurate and timely disease surveillance and epidemiological analyses, and accessibility of data at all levels of government is critical to inform stakeholders to respond effectively. In this paper, we describe the adaptation, development and operation of epidemiological surveillance and modelling systems in SA in response to the COVID-19 epidemic, including data systems for monitoring laboratory-confirmed COVID-19 cases, hospitalisations, mortality and recoveries at a national and provincial level, and how these systems were used to inform modelling projections and public health decisions. Detailed descriptions on the characteristics and completeness of individual datasets are not provided in this paper. Rapid development of robust data systems was necessary to support the response to the SA COVID-19 epidemic. These systems produced data streams that were used in decision-making at all levels of government. While much progress was made in producing epidemiological data, challenges remain to be overcome to address gaps to better prepare for future waves of COVID-19 and other health emergencies., Competing Interests: Conflicts of interest. None.

In South Africa (SA), the first case of COVID-19 was reported on 5 March 2020 from a traveller who had returned from Italy. Increases in COVID-19 cases and deaths necessitated the design and implementation of community screening, testing, and tracing as a control strategy. The SA government's plans to implement community-based screening, testing, contact tracing and movement modelling during the early phases of the COVID-19 pandemic presented both opportunities and challenges. In this article, we present our experiences, opportunities and lessons for community-based COVID-19 response, anchoring these efforts in the primary healthcare system., Competing Interests: Conflicts of interest. None.

Countries such as South Africa have limited intensive care unit (ICU) capacity to handle the expected number of patients with COVID-19 requiring ICU care. Remdesivir can prevent deaths in countries such as South Africa by decreasing the number of days people spend in ICU, therefore freeing up ICU bed capacity., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Dexamethasone and remdesivir have the potential to reduce coronavirus disease 2019 (COVID)-related mortality or recovery time, but their cost-effectiveness in countries with limited intensive care resources is unknown., Methods: We projected intensive care unit (ICU) needs and capacity from August 2020 to January 2021 using the South African National COVID-19 Epi Model. We assessed the cost-effectiveness of (1) administration of dexamethasone to ventilated patients and remdesivir to nonventilated patients, (2) dexamethasone alone to both nonventilated and ventilated patients, (3) remdesivir to nonventilated patients only, and (4) dexamethasone to ventilated patients only, all relative to a scenario of standard care. We estimated costs from the health care system perspective in 2020 US dollars, deaths averted, and the incremental cost-effectiveness ratios of each scenario., Results: Remdesivir for nonventilated patients and dexamethasone for ventilated patients was estimated to result in 408 (uncertainty range, 229-1891) deaths averted (assuming no efficacy [uncertainty range, 0%-70%] of remdesivir) compared with standard care and to save $15 million. This result was driven by the efficacy of dexamethasone and the reduction of ICU-time required for patients treated with remdesivir. The scenario of dexamethasone alone for nonventilated and ventilated patients requires an additional $159 000 and averts 689 [uncertainty range, 330-1118] deaths, resulting in $231 per death averted, relative to standard care., Conclusions: The use of remdesivir for nonventilated patients and dexamethasone for ventilated patients is likely to be cost-saving compared with standard care by reducing ICU days. Further efforts to improve recovery time with remdesivir and dexamethasone in ICUs could save lives and costs in South Africa., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objective: To characterise the environmental presence of hepatitis A virus (HAV) in low- and middle-income countries (LMICs)., Design: Systematic review and meta-analysis., Data Sources: EBSCOhost, PubMed, Scopus, ScienceDirect, Clinical Key and Web of Science were searched. Grey literature was sourced by searching the following electronic databases: Open Grey, National Health Research Database and Mednar., Eligibility Criteria for Including Studies: Cross-sectional and ecological studies reporting HAV environmental presence and conducted in LMICs between January 2005 and May 2019, irrespective of language of publication., Data Extraction and Data Synthesis: Relevant data were extracted from articles meeting the inclusion criteria, and two reviewers independently assessed the studies for risk of bias. High heterogeneity of the extracted data led to the results being reported narratively., Results: A total of 2092 records were retrieved, of which 33 met the inclusion criteria. 21 studies were conducted in Tunisia, India and South Africa, and the rest were from Philippines, Pakistan, Morocco, Chad, Mozambique, Kenya and Uganda. In Tunisian raw sewage samples, the prevalence of HAV ranged from 12% to 68%, with an estimated average detection rate of 50% (95% CI 25 to 75), whereas HAV detection in treated sewage in Tunisia ranged from 23% to 65%, with an estimated average detection rate of 38% (95% CI 20 to 57). The prevalence of HAV detection in South African treated sewage and surface water samples ranged from 4% to 37% and from 16% to 76%, with an estimated average detection rates of 15% (95% CI 1 to 29) and 51% (95% CI 21 to 80), respectively. Over the review period, the estimated average detection rate of environmental HAV presence appeared to have declined by 10%., Conclusion: The quality of included studies was fair, but sampling issues and paucity of data limited the strength of the review findings., Prospero Registration Number: CRD42019119592., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The aetiology and burden of viral-induced acute liver failure remains unclear globally. It is important to understand the epidemiology of viral-induced ALF to plan for clinical case management and case prevention., Participants: This systematic review was conducted to synthesize data on the relative contribution of different viruses to the aetiology of viral-induced acute liver failure in an attempt to compile evidence that is currently missing in the field. EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science were searched for relevant literature published from 2009 to 2019. The initial search was run on 9 April 2019 and updated via PubMed on 30 September 2019 with no new eligible studies to include. Twenty-five eligible studies were included in the results of this review., Results: This systematic review estimated the burden of acute liver failure after infection with hepatitis B virus, hepatitis A virus, hepatitis C virus, hepatitis E virus, herpes simplex virus/human herpesvirus, cytomegalovirus, Epstein-Barr virus and parvovirus B19. Data were largely missing for acute liver failure after infection with varicella-zostervirus, human parainfluenza viruses, yellow fever virus, coxsackievirus and/or adenovirus. The prevalence of hepatitis A-induced acute liver failur was markedly lower in countries with routine hepatitis A immunisation versus no routine hepatitis A immunisation. Hepatitis E virus was the most common aetiological cause of viral-induced acute liver failure reported in this review. In addition, viral-induced acute liver failure had poor outcomes as indicated by high fatality rates, which appear to increase with poor economic status of the studied countries., Conclusions: Immunisation against hepatitis A and hepatitis B should be prioritised in low-income and middle-income countries to prevent high viral-induced acute liver failure mortality rates, especially in settings where resources for managing acute liver failure are lacking. The expanded use of hepatitis E immunisation should be explored as hepatitis E virus was the most common cause of acute liver failure., Registration: PROSPERO registration number: CRD42017079730., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The burden of viral-induced acute liver failure (ALF) around the world still remains unclear, with little to no data collected regarding the disease incidence in general and synthesised data on the relative contribution of different viruses to the aetiology of ALF is missing in the field. The aim of this review is to estimate the burden (prevalence, incidence, mortality, hospitalisation) of ALF following infection HAV, HBV, HCV, HDV, HEV, EBV), HSV1, HSV2, VZV, parvo-virus B19, HPIVs, YFV, HVV-6, CMV, CA16 and/or HAdVs . Establishing the common aetiologies of viral-induced ALF, which vary geographically, is important so that: (1) treatment can be initiated quickly, (2) contraindications to liver transplant can be identified, (3) prognoses can be deterined more accurately, and most importantly, (4) vaccination against viral ALF aetiologies can be prioritised especially in under-resourced regions with public health risks associated with the relevant attributable diseases., Methods and Analysis: EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science databases will be searched for relevant literature published and grey literature from 2009 up to 2019. Published cross-sectional and cohort studies will be eligible for inclusion in this review. Qualifying studies will be formally assessed for quality and risk of bias using a standardised scoring tool. Following standardised data extraction, meta-analyses will be carried out using STATA. Depending on characteristics of included studies, subgroup analyses and meta-regression analyses will be performed. This review will be reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines., Ethics and Dissemination: No ethics approval is required as the systematic review will use only published data already in the public domain. Findings will be disseminated through publication in a peer-reviewed journal., Prospero Registration Number: CRD42018110309., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This paper considers the affordability of using public sector health services for three tracer conditions (obstetric care, tuberculosis treatment and antiretroviral treatment for HIV-positive people), based on research undertaken in two urban and two rural sites in South Africa. We understand affordability as the 'degree of fit' between the costs of seeking health care and a household's ability-to-pay. Exit interviews were conducted with over 300 patients for each of the three tracer conditions in each of the four sites (i.e. a total sample of over 3600). Total direct costs for the service used at the time of the interview, as well as other health related costs incurred during the preceding month either for self-care or the use of plural providers were assessed, as were a range of indicators of ability-to-pay. The percentage of households incurring direct costs exceeding 10% of household consumption expenditure and those borrowing money or selling assets as a mechanism for coping with the burden of direct costs were calculated. Logistic regressions were also conducted to identify factors that were significantly associated with these indicators of affordability. There were significant differences in affordability between rural and urban sites; costs were higher, ability-to-pay was lower and there was a greater proportion of households selling assets or borrowing money in rural areas. There were also significant differences across tracers, with a higher percentage of households receiving tuberculosis and antiretroviral treatment borrowing money or selling assets than those using obstetric services. As these conditions require expenses to be incurred on an ongoing basis, the sustainability of such coping strategies is questionable. Policy makers need to explore how to reduce direct costs for users of these key health services in the context of the particular characteristics of different treatment types. Affordability needs to be considered in relation to the dynamic aspects of the costs of treating different conditions and the timing of treatment in relation to diagnosis. The frequently high transport costs associated with treatments involving multiple consultations can be addressed by initiatives that provide close-to-client services and subsidised patient transport for referrals., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objectives: The scaling up of antiretroviral treatment (ART) for HIV-infected adults requires a sizeable investment of resources in the South African public health care system. It is important that these resources are used productively and in ways that reach those in need, irrespective of social status or personal characteristics. In this study we evaluate whether the distribution of ART services in the public system reflects the distribution of need among adults in the urban population., Methods: Data from a 2008 national survey were used to estimate the distribution of socioeconomic status (SES) and sex in HIV-positive adults in urban areas. These findings were compared to SES and sex distributions in 635 ART users within 6 urban public ART facilities., Results: Close to 40% of those with HIV are in the lowest SES quintile, while 67% are women. The distributions in users of ART are similar to these distributions in HIV-positive people., Conclusions: Patterns of ART use in study settings correspond to patterns of HIV in the urban population at the national level. This suggests that the South African ART programme is on track to ensure equitable delivery of treatment services in urban settings., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Purpose: In South Africa (SA), anecdotal evidence for the incidence of shoulder, back and neck pain in school children is alarming but no scientific studies have confirmed this impression. The purpose of the present study was to determine the relationship between pain and school bag carriage in scholars in Durban, SA., Method: A study was carried out at four different schools in the Verulam and Chatsworth Regions in Kwa-Zulu Natal, SA. Schools were selected by convenience. One hundred and seventy six scholars between the ages of 11 and 14 years correctly filled out a questionnaire with open-ended and closed-ended questions. Each child also had his/her body and bag weight measured., Results: In this study, most of the scholars experienced shoulder and a combination of shoulder and other bodily pain. The majority of the children carried backpacks over two shoulders. The type of bag carried was significantly related to pain experienced (0.00). A significantly larger number of female scholars experienced pain., Conclusion: The shoulder and other bodily pain experienced by the sample of scholars are strongly related to the type of bag and the gender of the children. More in-depth studies into identifying risk factors for bodily pains in school children are indicated.