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INTRODUCTION: WHO recommends antiretroviral treatment (ART) for all HIV-positive individuals. This study evaluated the association between baseline CD4 count and attrition in a cohort of HIV positive adults initiating ART at three department of health (DOH) clinics routinely providing ART at baseline CD4 counts >500cells/μL for the HPTN 071 (PopART) trial. METHODS: All clients attending the DOH clinics were managed according to standard care guidelines with the exception that those starting ART outside of pertinent local guidelines signed research informed consent. DOH data on all HIV-positive adult clients recorded as having initiated ART between January 2014 and November 2015 at the three study clinics was analysed. Attrition, included clients lost to follow up or died, and was defined as 'being three or more months late for an antiretroviral pharmacy pick-up appointment'. All clients were followed until attrition, transfer out or end May 2016. RESULTS: A total of 2423 clients with a median baseline CD4 count of 328 cells/μL (IQR 195-468) were included of whom 631 (26.0%) experienced attrition and 140 (5.8%) were TFO. Attrition was highest during the first six months of ART (IR 38.3/100 PY; 95% CI 34.8-42.1). Higher attrition was found amongst those with baseline CD4 counts > 500 cells/μL compared to those with baseline CD4 counts of 0-500 cells/μL (aHR 1.26, 95%CI 1.05 to 1.52) This finding was confirmed on subset analyses when restricted to individuals non-pregnant at baseline and when restricted to individuals with follow up of > 12months. CONCLUSIONS: Attrition in this study was high, particularly during the first six months of treatment. Attrition was highest amongst clients starting ART at baseline CD4 counts > 500 cells/μL. Strategies to improve retention amongst ART clients, particularly those starting ART at baseline CD4 counts >500cells/μL, need strengthening. Improved monitoring of clients moving in and out of ART care and between clinics will assist in better understanding attrition and ART coverage in high burden countries.

INTRODUCTION: Antiretroviral treatment (ART) guidelines recommend life-long ART for all HIV-positive individuals. This study evaluated tuberculosis (TB) incidence on ART in a cohort of HIV-positive individuals starting ART regardless of CD4 count in a programmatic setting at 3 clinics included in the HPTN 071 (PopART) trial in South Africa. METHODS: A retrospective cohort analysis of HIV-positive individuals aged ≥18 years starting ART, between January 2014 and November 2015, was conducted. Follow-up was continued until 30 May 2016 or censored on the date of (1) incident TB, (2) loss to follow-up from HIV care or death, or (3) elective transfer out; whichever occurred first. RESULTS: The study included 2423 individuals. Median baseline CD4 count was 328 cells/μL (interquartile range 195-468); TB incidence rate was 4.41/100 person-years (95% confidence interval [CI]: 3.62 to 5.39). The adjusted hazard ratio of incident TB was 0.27 (95% CI: 0.12 to 0.62) when comparing individuals with baseline CD4 >500 and ≤500 cells/μL. Among individuals with baseline CD4 count >500 cells/μL, there were no incident TB cases in the first 3 months of follow-up. Adjusted hazard of incident TB was also higher among men (adjusted hazard ratio 2.16; 95% CI: 1.41 to 3.30). CONCLUSIONS: TB incidence after ART initiation was significantly lower among individuals starting ART at CD4 counts above 500 cells/μL. Scale-up of ART, regardless of CD4 count, has the potential to significantly reduce TB incidence among HIV-positive individuals. However, this needs to be combined with strengthening of other TB prevention strategies that target both HIV-positive and HIV-negative individuals.

BACKGROUND: The theme of the 2014 Southern African Rural Health Conference was 'Building resilience in facing rural realities'. Retaining health professionals in South Africa is critical for sustainable health services. Only 12% of doctors and 19% of nurses have been retained in the rural areas. The aim of the workshop was to understand from health practitioners why they continued working in their rural settings. CONFERENCE WORKSHOP: The workshop consisted of 29 doctors, managers, academic family physicians, nurses and clinical associates from Southern Africa, with work experience from three weeks to 13 years, often in deep rural districts. Using the nominal group technique, the following question was explored, 'What is it that keeps you going to work every day?' Participants reflected on their work situation and listed and rated the important reasons for continuing to work. RESULTS: Five main themes emerged. A shared purpose, emanating from a deep sense of meaning, was the strongest reason for staying and working in a rural setting. Working in a team was second most important, with teamwork being related to attitudes and relationships, support from visiting specialists and opportunities to implement individual clinical skills. A culture of support was third, followed by opportunities for growth and continuing professional development, including teaching by outreaching specialists. The fifth theme was a healthy work-life balance. CONCLUSION: Health practitioners continue to work in rural settings for often deeper reasons relating to a sense of meaning, being part of a team that closely relate to each other and feeling supported. CONTEXTE: Le thème de la Conférence sur la Santé rurale en Afrique australe en 2014 était "Développer la Resilience pour faire face aux réalités rurales'. Il est crucial de retenir les professionnels de la santé en Afrique du Sud pour avoir des services de santé durables. Seuls 12% des médecins et 19% des infirmiers ont été retenus dans les zones rurales. Le but des ateliers était de demander aux professionnels de santé pourquoi ils continuaient à travailler dans les zones rurales. ATELIER-CONFÉRENCE: L'atelier comprenait 29 médecins, gestionnaires, médecins de famille académiques, infirmières et collaborateurs cliniques d'Afrique du Sud, avec une expérience de travail de trois semaines à 13 ans, souvent dans des zones rurales reculées. Au moyen de la technique du groupe nominal, la question suivante a été examinée, 'Qu'est-ce qui vous fait aller au travail chaque jour? Les participants ont réfléchi sur leur situation de travail et ont fait une liste et évalué les raisons importantes pour continuer de travailler. RÉSULTATS: Cinq thèmes principaux sont apparus. La raison la plus forte pour rester travailler à la campagne était un objectif commun, provenant d'un sens profond. La seconde était de travailler en équipe, où le travail d'équipe était lié aux attitudes et relations, au soutien des spécialistes itinérants et à la possibilité de mettre en œuvre les compétences cliniques individuelles. La troisième était une culture de soutien, suivie par des opportunités de croissance et de développement professionnel continu, telles que la formation par des spécialistes de sensibilisation. Le troisième thème était un bon équilibre entre la vie familiale et professionnelle. CONCLUSION: Les professionnels de santé continuent à travailler dans les zones rurales pour des raisons souvent plus profondes liées à leur raison d'être, leur appartenance à une équipe dont les membres sont étroitement liés et au sentiment d'être soutenus.

BACKGROUND: An integrated audit tool was developed for five chronic diseases, namely diabetes, hypertension, asthma, chronic obstructive pulmonary disease and epilepsy. Annual audits have been done in the Western Cape Metro district since 2009. The year 2012 was the first year that all six districts in South Africa's Western Cape Province participated in the audit process. AIM: To determine whether clinical audits improve chronic disease care in health districts over time. SETTING: Western Cape Province, South Africa. METHODS: Internal audits were conducted of primary healthcare facility processes and equipment availability as well as a folder review of 10 folders per chronic condition per facility. Random systematic sampling was used to select the 10 folders for the folder review. Combined data for all facilities gave a provincial overview and allowed for comparison between districts. Analysis was done comparing districts that have been participating in the audit process from 2009 to 2010 ('2012 old') to districts that started auditing recently ('2012 new'). RESULTS: The number of facilities audited has steadily increased from 29 in 2009 to 129 in 2012. Improvements between different years have been modest, and the overall provincial average seemed worse in 2012 compared to 2011. However, there was an improvement in the '2012 old' districts compared to the '2012 new' districts for both the facility audit and the folder review, including for eight clinical indicators, with '2012 new' districts being less likely to record clinical processes (OR 0.25, 95% CI 0.21-0.31. CONCLUSION: These findings are an indication of the value of audits to improve care processes over the long term. It is hoped that this improvement will lead to improved patient outcomes. CONTEXTE: Un instrument de vérification intégré a été conçu pour cinq maladies chroniques, telles que le diabète, l'hypertension, l'asthme, les maladies pulmonaires obstructives chroniques et l'épilepsie. Des vérifications annuelles ont été effectuées depuis 2009 dans la région métropolitaine du Western Cape. C'est en 2012 que pour la première fois les six districts de la Province du Western Cape en Afrique du Sud ont pris part au processus de vérification. OBJECTIF: Déterminer si les vérifications cliniques améliorent les soins pour maladies chroniques dans les districts sanitaires avec le temps LIEU: Province du Western Cape, Afrique du Sud. MÉTHODES: On a fait des vérifications internes des processus et de la disponibilité des équipements dans les établissements de soins primaires, ainsi qu'une vérification de 10 dossiers par condition chronique par établissement. On a utilisé un programme d'échantillonnage aléatoire systématique pour sélectionner les 10 dossiers à vérifier. Les données combinées de tous les établissements ont fourni un aperçu provincial et permis de comparer les districts. On a fait une analyse pour comparer les districts qui ont pris part au processus de vérification de 2009 à 2010 ('2012 anciens') aux districts qui ont commencé la vérification récemment ('2012 nouveaux'). RÉSULTATS: Le nombre d'établissements vérifiés a augmenté progressivement de 29 en 2009 à 129 en 2012. Les améliorations entre les différentes années sont modestes et la moyenne générale provinciale semble pire en 2012 qu'en 2011. Cependant, on remarque une amélioration dans les districts "2012 anciens" par rapport aux districts '2012 nouveaux' pour la vérification des établissements et la vérification des dossiers, y compris huit indicateurs cliniques, avec les districts '2012 nouveaux' qui sont moins susceptibles d'enregistrer les processus cliniques (OR 0.25, 95% CI 0.21-0.31). CONCLUSION: Ces résultats sont une indication de la valeur des vérifications pour améliorer les processus à long terme. Nous espérons que cette amélioration se traduira par de meilleurs résultats chez les patients.