title: Setting ART initiation targets in response to changing guidelines: The importance of addressing both steady-state and backlog.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Wits Reproductive Health and HIV Institute, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa. cmartin@wrhi.ac.za.
authors.forename: Catherine
authors.initials: C
authors.lastname: Martin
authors.forename: Nicolette P
authors.initials: NP
authors.lastname: Naidoo
authors.forename: W D Francois
authors.initials: WD
authors.lastname: Venter
authors.forename: Ambereen
authors.initials: A
authors.lastname: Jaffer
authors.forename: Pierre M
authors.initials: PM
authors.lastname: Barker
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000706:statistics & numerical data; D018791:CD4 Lymphocyte Count; D019983:Guideline Adherence; D006678:HIV; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006285:Health Planning; D006801:Humans; D015994:Incidence; D015995:Prevalence; D012189:Retrospective Studies; D013019:South Africa / Q000453:epidemiology
chemical_list: D044966:Anti-Retroviral Agents