SIGNIFICANCE: Although the global response to COVID-19 has demonstrated that some progress has been made in ensuring timely access to new medical interventions in Africa, much more needs to be done to strengthen the global systems that enable equitable access to health technologies during public health emergencies

BACKGROUND: People living with HIV (PLHIV) who have low CD4 counts require advanced clinical care (ACC) to minimise morbidity and mortality risk. These patients include immunological non-responders (INRs) with low CD4 counts despite a suppressed viral loadOBJECTIVES: To determine the proportion of patients with low CD4 counts after antiretroviral therapy (ART) initiation and to describe INRs within that groupMETHODS: Routine Three Interlinked Electronic Registers.Net (TIER.Net) data from four South African districts were analysed for adult PLHIV on ART > 12 months. Immunological non-responders were defined as patients on ART > 4 years who were virally suppressed (viral load < 1000 copies/mL) with a CD4 count ≤ 350 cell/mm³RESULTS: Baseline CD4 was recorded for 80.9% of the 869 571 patients newly initiating ART, with 37.2% of those starting ART since 2017 having baseline counts ≤ 200 cells/mm³. Amongst all 1 178 190 patients on ART, only 46.5% had a CD4 test after ART initiation and of these, 14.3% had CD4 ≤ 200 cells/mm³. This proportion was highest amongst patients on ART ≤ 2 years (19.7%) (p < 0.001). Amongst virally suppressed patients, 20.0% were INRs. Immunological non-response was significantly more likely amongst patients on second-line ART (adjusted odds ratio [aOR] 1.79), those aged 35-45 and ≥ 45 years (aOR 1.15 and 1.50, respectively), males (aOR 2.28) and patients with confirmed TB (aOR 2.49), and was significantly less likely in cases with higher baseline CD4 count (aOR 0.35CONCLUSION: CD4 testing subsequent to ART initiation is poorly implemented and there is a notable proportion of patients with low CD4 counts. Guidelines regarding CD4 testing and ACC need to be more widely implemented to identify patients with low CD4 counts and improve their outcomes

BACKGROUND: Despite widespread availability of antiretroviral therapy (ART) in South Africa, there remains a considerable burden of human immunodeficiency virus (HIV)-related morbidity and mortalityOBJECTIVES: To describe ART initiation and outcome trends over time, with a focus on clients presenting with advanced HIV-infection, so as to identify interventions to reduce morbidity and mortalityMETHODS: Routine TIER.Net data from HIV-infected adults who had a documented baseline CD4 count and were newly initiating ART in Johannesburg or Mopani districts from 2004 to 2017 were analysed. Trends in baseline CD4 count and 5-year mortality were investigated and the population initiating ART with CD4 < 200 cells/mm³ was describedRESULTS: The Johannesburg and Mopani data sets comprised 203 131 and 101 814 records, respectively. Although median CD4 count increased over time, the proportion of initiations at CD4 < 200 cells/mm³ in 2017 remained high (Johannesburg 39%, Mopani 35%). Mortality was significantly increased among clients with CD4 < 200 compared to those with higher baseline counts (p < 0.001). Even though mortality among clients with low CD4 declined over time, likely because of improved drug regimens, in 2016-2017 mortality was still significantly increased among these clients (p < 0.001). Delivery of cotrimoxazole prophylaxis to clients with low CD4 declined over time to < 30% in 2017 and was associated with clinical stage. Presentation with CD4 < 200 cells/mm³ was associated with older age, male gender and hospitalisationCONCLUSION: A concerningly large proportion of South Africans still initiate ART at low CD4 counts. This is associated with increased mortality and requires targeted interventions to improve delivery of prophylactic regimens and early engagement in care

INTRODUCTION: South Africa is moving towards achieving elimination of mother-to-child transmission (eMTCT) but gaps remain in eMTCT programmes. Documenting successful outcomes of health systems interventions to address these gaps could encourage similar initiatives in the future. METHODS: We describe the effectiveness of a Quality Improvement Project (QIP) to improve HIV retesting rates during pregnancy among women who had previously tested negative by redesigning the clinic process. Eight poorly-performing clinics were selected and compared with eight better-performing control clinics in a subdistrict in North West Province. Over nine months, root cause analysis and testing of change ideas using Plan-Do-Study-Act cycles were used to identify and refine interventions. Analysis of patient flow showed that women were referred for retesting following their nurse-driven antenatal visits, and many left without retesting as this would have further prolonged their visit. Processes were redesigned and standardised, where a counsellor was charged with retesting patients before antenatal consults. Staff were mentored on data collection and interpretation process. Quality improvement nurse advisors monitored indicators bi-weekly and adjusted interventions accordingly. RESULTS: Retesting in intervention clinics rose from 36% in the three months pre-intervention to full coverage at month nine. At the end of the study, retesting in intervention clinics was 20% higher than in controls. Retesting also increased in the subdistrict overall. CONCLUSION: Service coverage and overall impact of HIV programmes can be raised through care-process analysis that optimises patient flow, supported by targeted QI interventions. These QI methodologies may be effective elsewhere for identifying new HIV infections in pregnant/breastfeeding women, and possibly in other services.

O presente artigo visa analisar as concepções dos integrantes do corpo docente e administrativo de uma escola pública do município de Goiânia a respeito de educação integral e tempo integral. Trata-se de um estudo qualitativo de cunho etnográfico no qual foram utilizados os seguintes instrumentos de geração de dados: observação-participante, entrevistas, anotações de campo e leitura dos documentos oficiais que legislam sobre a educação integral e tempo integral no Brasil e no município de Goiânia. A análise dos domínios culturais, sugerida por Spradley (1980), revelou que o tempo integral não tem chegado às nossas escolas públicas de maneira planejada, prejudicando, assim, a efetivação da educação integral nessas instituições de ensino.

This article aims at identifying the school staff's conceptions about integral education and fulltime schooling from a public school in Goiânia. It is a qualitative study based on ethnography in which the following instruments of generating data were used: participant observation, field notes, interviews, and the official documents that discuss integral education and fulltime schooling in Brazil and in Goiânia. The cultural domains analysis, suggested by Spradley (1980), revealed that the fulltime schooling model has not been well planned and established in our public schools, undermining the integral education effectiveness in these educational institutions.

Humanitarian emergencies result in a breakdown of critical health-care services and often make vulnerable communities dependent on external agencies for care. In resource-constrained settings, this may occur against a backdrop of extreme poverty, malnutrition, insecurity, low literacy and poor infrastructure. Under these circumstances, providing food, water and shelter and limiting communicable disease outbreaks become primary concerns. Where effective and safe vaccines are available to mitigate the risk of disease outbreaks, their potential deployment is a key consideration in meeting emergency health needs. Ethical considerations are crucial when deciding on vaccine deployment. Allocation of vaccines in short supply, target groups, delivery strategies, surveillance and research during acute humanitarian emergencies all involve ethical considerations that often arise from the tension between individual and common good. The authors lay out the ethical issues that policy-makers need to bear in mind when considering the deployment of mass vaccination during humanitarian emergencies, including beneficence (duty of care and the rule of rescue), non-maleficence, autonomy and consent, and distributive and procedural justice.

Las emergencias humanitarias causan el desplome de los servicios de atención de salud esenciales y, a menudo, provocan que la atención sanitaria de las comunidades vulnerables pase a depender de organismos externos. En entornos con recursos limitados esto puede darse en un contexto de pobreza extrema, desnutrición, inseguridad, bajos niveles de alfabetización e infraestructuras deficientes. Bajo estas circunstancias, suministrar alimentos, agua y refugio, así como limitar la aparición de brotes de enfermedades transmisibles representan las principales preocupaciones. Cuando se dispone de vacunas eficaces y seguras para reducir el riesgo de aparición de brotes de enfermedades, la distribución potencial de las mismas constituye un factor clave en las situaciones de emergencia sanitaria. Las consideraciones éticas son fundamentales a la hora de decidir sobre la distribución de las vacunas. La asignación de vacunas con suministro limitado, los grupos destinatarios de las mismas, las estrategias de entrega, así como la monitorización y los estudios durante las emergencias humanitarias graves implican consideraciones éticas que, a menudo, derivan de un enfrentamiento entre el beneficio individual y el bien común. Los autores exponen los problemas éticos que los responsables políticos deben tener en cuenta a la hora de considerar cómo distribuir la vacunación masiva durante las emergencias humanitarias, lo cual incluye principios como la beneficencia (el deber de atención y la regla del rescate), la no maleficencia, la autonomía y el consentimiento, así como la justicia distributiva y procesal.

Les urgences humanitaires entraînent une rupture des services de soins de santé essentiels et elles rendent souvent les communautés vulnérables dépendantes des organismes externes pour leurs soins. Dans les milieux où les ressources sont comptées, cela peut se produire sur fond d'extrême pauvreté, de malnutrition, d'insécurité, de faible niveau d'alphabétisation et d'infrastructures insuffisantes. Dans ces circonstances, fournir nourriture, eau et abri, tout en limitant les épidémies de maladies transmissibles, devient une préoccupation centrale. Lorsqu'il existe des vaccins sûrs et efficaces pour limiter les risques d'épidémies, leur éventuel déploiement est un facteur clé pour satisfaire les besoins sanitaires d'urgence. Les considérations éthiques sont essentielles pour se prononcer sur le déploiement de la vaccination. La distribution de vaccins en quantités limitées, les groupes cibles, les stratégies de vaccination, la surveillance et la recherche lors de situations d'urgence humanitaire graves impliquent tous des considérations éthiques souvent nées de la tension entre le bien individuel et le bien commun. Les auteurs exposent les questions éthiques que les décideurs doivent garder à l'esprit lorsqu'ils envisagent le déploiement d'une vaccination de masse pendant les urgences humanitaires, notamment la bénéficience (devoir de diligence et devoir d'assistance), la non-maléficience, l'autonomie et le consentement, ainsi que la justice de répartition et l'équité procédurale.