n South African Medical Journal - Setting ART initiation targets in response to changing guidelines : the importance of addressing both steady-state and backlog : research

Volume 104, Issue 6
  • ISSN : 0256-9574
  • E-ISSN: 2078-5135



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/µl v. < 200 cells/µl) and the roll-out of nurse-initiated management of ART.

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.
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.
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.
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.

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