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ART coverage among HIV‐positive population varies, depending on the countries, between 10% (e.g. Indonesia) and 65% (Botswana). Death rates and new HIV infections have been linked to ART coverage. Therefore, streamlining tasks and roles to expand treatment and care and to provide quality and equitable health is an ongoing concern globally. One concept that has been applied to improve the delivery of HIV services is that of task shifting. Defined as the systematic delegation of tasks from doctors to cadre with less training such as nurses or lay workers, task shifting has been used as an effective strategy to address the current healthcare worker shortage in many African countries. A body of literature supports the use of task shifting as a successful approach in delivering healthcare services including HIV testing, counselling and ART treatment. In addition, in a time of economic burden and scare resources, task shifting may also help to relieve the situation. This concern is highlighted in recommendation of WHO to strengthen and expand human capacity among healthcare workers. The major issues that are raised are: How can task shifting be implemented in a way that is sustainable? How can clinical care services be organized to maximize the potential of the task‐shifting approach while ensuring safety, efficiency and effectiveness? What preconditions must be met, what are the country‐specific factors that will guide decision‐making in the implementation of task shifting? In addition, task shifting should be implemented alongside other efforts to increase the numbers of skilled health workers. Quality assurances mechanisms should provide the necessary checks balances to protect both service users and health workers.

BackgroundNon‐AIDS‐defining malignancies (NADM) are becoming a major cause of mortality in the era of highly active antiretroviral therapy. We wished to investigate the incidence, risks factors and outcome of NADM in an urban cohort.MethodsWe carried out an observational cohort of HIV patients with 12,746 patient‐years of follow up between January 2002 and March 2009. Socio‐demographics and clinical characteristics of patients diagnosed with NADM were retrospectively compared with the rest of the cohort. Causes of death and risk factors associated with NADM were assessed using logistic regression. Survival analyses were performed with Kaplan‐Meier estimates. Cancer incidences were compared with those of the general population of the Brussels‐Capital Region using the standardized incidence ratio (SIR).ResultsForty‐five NADM were diagnosed. At inclusion in the study, patients with NADM were older than patients without NADM (47 years vs. 38 years, p < 0.001), had a longer history of HIV infection (59 months vs. 39 months, p = 0.0174), a lower nadir CD4 count (110 cells/mm3 vs. 224 cells/mm3, p < 0.0001) and a higher rate of previous AIDS events (33% vs. 20%, p = 0.0455) and of hepatitis C virus co‐infection (22.2% vs. 10%, p = 0.0149). In multivariate analysis, age over 45 at baseline (OR 3.25; 95% CI 1.70‐6.22) and a nadir CD4 count of less than 200 cells/mm3 (OR 3.10; 95% CI 1.40‐6.87) were associated with NADM. NADM were independently associated with higher mortality in the cohort (OR 14.79; 95% CI 6.95‐31.49). Women with cancer, the majority of whom were of sub‐Saharan African origin, had poorer survival compared with men. The SIR for both sexes were higher than expected for Hodgkin's lymphoma (17.78; 95% CI 6.49‐38.71), liver cancers (8.73; 95% CI 2.35‐22.34), anal cancers (22.67; 95% CI 8.28‐49.34) and bladder cancers (3.79; 95% CI 1.02‐9.70). The SIR for breast cancer was lower in women (SIR 0.29; 95% CI 0.06‐0.85).ConclusionsAge over 45 and a nadir CD4 count of less than 200 cells/mm3 were predictive of NADM in our cohort. Mortality was high, especially in sub‐Saharan African women. Cancers with increased incidences were Hodgkin's lymphoma and anal, bladder and liver cancers in both sexes; women had a lower incidence of breast cancer.

Donación de AGERS ; Ponencia presentada en el Risk Management Forum , Monte Carlo, celebrado en Monte Carlo, 15 al 18 de octubre de 1989 ; Sumario: Le Sida nous réapprend aussi, ce que l'on savait déjà mais que l'on occultait, que la santé ne peut être dissociée du contexte social culturel, économique et politique

IntroductionCervical infection with high‐risk human papillomavirus (HRHPV) induces cervical cancer and is present in 14% of women in Europe. We assessed the prevalence and incidence of cervical HRHPV in a cohort of HIV‐positive women living in Belgium.MethodsProspective observational program of screening and follow up of HRHPV cervical infection performed by Hybrid Capture in 825 HIV‐positive women between 2002 and 2011. Women without normal cervix at baseline were excluded.ResultsThe final analysis included 652 women: median age 38 years, African origin (81%), median HIV follow‐up (66 months), median CD4 count (426 cells/μL) and 79% on antiretroviral therapy (cART). At baseline, HRHPV prevalence was 43% and decreased significantly as both age and CD4 cell count increased: highest prevalence (100%) in women <30 years and <200 CD4/μL and lowest (19%) in women >40 years and >500 CD4/μL (p<0.0001, multivariate analysis). The relative risk (RR) to carry HRHPV at baseline decreases proportionally by 11% for each 5 years‐age increase and by 11% for each 100 CD4 cells/μL rise (RR=0.89, 95% CI: 0.85‐0.93; p<0.0001, Poisson regression for both). During follow‐up, incidence rate of HRHPV was 13.4 per 100 women‐years.ConclusionsWe found a high HRHPV prevalence of 43% and an incidence rate of 13 per 100 women‐years in this cohort of HIV‐positive women living in Europe and on cART. Women under 40 years‐age had the highest prevalence even with CD4 count >350 cells/μL. The magnitude of HRHPV epidemiology should prompt to evaluate the clinical efficacy of vaccines against HPV in HIV‐infected women.