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Border Violence Prompts Railroad to Seek Waiver
The Federal Railroad Administration is seeking public comment on a request by Union Pacific to transfer some train safety inspections away from a rail yard in El Paso due to border violence.
One of the country's largest freight railroad operators is requesting permission from the federal government to adjust its operations in Texas because of violence on the Mexican side of the border, including the fatal shooting in May of a train yard worker in Ciudad Juárez.
Union Pacific filed a request with the Federal Railroad Administration in May to transfer federally required train brake tests away from its international rail yard to two of the company's other rail yards in El Paso. Both rail yards are within 10 miles of the international yard, but they are not as close to the border as the international yard, UP spokesman Jeff DeGraff said.
"We're looking to move these inspection points a little further out to give us some distance there so that we can limit our exposure," DeGraff said.
The federal government published UP's waiver request in the federal register on Saturday to allow for public comment.
Each day, six trains run through UP's international yard in El Paso — three traveling north from Mexico and three traveling south into Mexico — according to the company's waiver request. On the other side of the border, the trains pass through the FXE Interchange Yard run by Ferrocarriles Nacionales de México (FXE).
In the waiver request, UP cites "several reports of gunfire heard across the border" and a May 6 incident in which an "FXE yard foreman" was fatally shot. UP filed its waiver request a week after the foreman's death.
"That was not a UP employee, but it happened very close to our yard, which is one of our main concerns," DeGraff said.
There have been 270 murders in 2014 so far in Ciudad Juárez, just across the Rio Grande from El Paso. That's slightly fewer than than the 276 murders over the same period in 2013 but significantly higher than the city saw a decade earlier, according to a recent El Diario report. El Paso, despite its neighbor's troubles, is regularly cited as one of the safest cities in the country for its size.
In 2010, UP made a similar request to waive brake inspections at the El Paso International Yard. That request did not mention border violence, though. It cited an interest in moving freight traffic through El Paso more efficiently. The FRA denied the request, and said it was not "in the public interest and consistent with railroad safety at this time."
The Federal Railroad Administration did not immediately respond to a request for comment Monday.
Joseph Faust, a spokesman for Burlington Northern Santa Fe railways, a Fort Worth-based freight railroad firm that also operates a rail yard in El Paso, said the company has not filed a waiver request related to border violence. He declined to say whether the company plans to in the future.
Earlier this year, César Duarte, the governor of the Mexican state of Chihuahua, proposed building a bypass around Ciudad Juárez to move the rail line out of the heart of that city, citing concerns including pedestrian fatalities.
Julián Aguilar contributed to this report.
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Facebook today denied that it may have accidentally exposed personal user data to advertisers and other third parties for several years, as claimed this week by two security researchers at Symantec Corp.
The researchers in a blog post Tuesday noted that a Facebook programming error -- since fixed -- could have allowed advertisers to access member profiles, photographs and chat messages and to post messages and mine personal data from them.
According to Symantec, the leaks stemmed from a faulty API used by developers of Facebook applications. It caused "hundreds of thousands" of Facebook applications to accidentally expose the so-called access tokens that are granted by users to Facebook applications. "Each token or 'spare key' is associated with a select set of permissions, like reading your wall, accessing your friend's profile, posting to your wall, etc.," the researchers said.
Any third party or advertiser associated with an application developer that had used the faulty API would have had access to the tokens, allowing them to perform whatever actions the tokens allowed. While it's unclear how many advertisers even knew what was going on, the potential repercussions of the data leaks are "far and wide," Symantec claimed.
But Facebook downplayed the issue and argued that Symantec's report has a "few inaccuracies."
"We appreciate Symantec raising this issue and we worked with them to address it immediately," Facebook spokeswoman Malorie Lucich said in an emailed comment. But, "specifically, no private information could have been passed to third parties, and the vast majority of tokens expire within two hours," she said.
"The report also ignores the contractual obligations of advertisers and developers, which prohibit them from obtaining or sharing user information in a way that violates our policies," Lucich said.
She added that Facebook has no evidence of information being used in a way that violates company policies. "We take any potential issue seriously and quickly took steps to prevent this from happening again."
A Symantec spokesman this afternoon said the company still believes its original report is accurate, but did not comment further.
Kevin Haley, director at Symantec security response said that while it's likely that third-parties had not noticed the leak, it would be hard to say for sure whether someone noticed it and took advantage of it.
The issue is unlikely to improve Facebook's already battered reputation on the privacy front. The company has been at the center of numerous privacy related issues over the past couple of years.
Last October, for instance, the company found itself in the middle of a major firestorm after the Wall Street Journal reported that several popular Facebook applications such as FarmVille, Texas HoldEm Poker and FrontierVille had been secretly sending user information to advertisers.
Last year, the company was also hit with a lawsuit after some members claimed that changes the company made to its privacy settings made it even harder for users to control access to their personal data.
"This breach does not surprise me, because I've seen its like before in Facebook and in other Web sites [and] platforms," said Chris Palmer, technology director at the Electronic Frontier Foundation. "Although this bug might quite likely be an accident, it is not the first of its kind in Facebook."
Providing advertisers with detailed profiles of Facebook users has been part of Facebook's business model, he said. "Therefore we can expect for this kind of security failure to arise again," he said. "The business model requires Facebook to walk a fine line between keeping advertisers happy and not angering too many users."
Jeffrey Chester, executive director of the Center for Digital Democracy (CDD), said Facebook is working with a growing list of third parties who are in the business of collecting Facebook user information. "The company has the data collection for ad targeting spigot turned on -- so it's not a surprise that user information is leaking out to the others," Chester said.
"Facebook needs more than a digital plumbing job -- it needs to put a privacy policy in place that allows its members to actually control their information," Chester said.
Jaikumar Vijayan covers data security and privacy issues, financial services security and e-voting for Computerworld. Follow Jaikumar on Twitter at @jaivijayan or subscribe to Jaikumar's RSS feed . His e-mail address is email@example.com .
Read more about privacy in Computerworld's Privacy Topic Center.

subset: commoncrawl


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21st Century Community Learning Centers Program-Cohort 10 Year 1/5
Division: Student and Field Services
Office: Student Support Services
View Published NGO Document (Microsoft Word)
Purpose: The 21st Century Community Learning Centers Program Continuation Grant: Cohort 10 is intended to supplement the education of students in grades 4-12, who attend schools eligible for Title I schoolwide programs or schools where a minimum of 30 percent of students are from low-income families. The program aims to assist students in attaining the skills necessary to meet New Jersey's Core Curriculum Content Standards. Therefore, all 21st CCLC programs must provide participating students with academic enrichment opportunities that complement the regular school day. The vision for New Jersey's 21st CCLC Program is to develop high quality out-of-school time programs through community learning centers that provide services not just to the child but to the entire family unit. Currently, New Jersey's 21st CCLC Program is comprised of 48 grantees throughout the state. Grantees include local education agencies (LEAs), non-profit, for-profit, community-based, and faith-based organizations, operating solely or in partnership with other agencies. Eligibility to apply for this 21st CCLC continuation grant is open to all NJ public or private agencies, LEAs, nonprofit organizations, city or county government agencies, faith based organizations, institutions of higher education (IHEs) and for-profit agencies that are not currently receiving 21st CCLC funding. The first year of this five year program is September 1, 2014 - August 31, 2015.
Eligible Agencies: NJ public or private agencies, local education agencies, non-profit organizations, city or county government agencies, faith-based organizations, institutions of higher education and for-profit agencies
|Approximate Number of Awards: 10-12
|Grant Program Type: Competitive
|Total Amt. Available: $8,800,000
|Application Due Date: 4/3/2014


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Hallo, users of the Fishing Area Promotional Tool.
Starting next week, we are no longer going to allow fishing areas that start with a number. This has been abused far too much to ensure that areas hop to the top of the list even if the name itself is completely inaccurate. So, a filter will be put in place server-side which automatically drops any entry which does this, and all FAPTs from this point out will have that filter coded into place to prevent it from happening to start with.
Please note that this is a community resource, not a game to see who can sneak under the rules the closest. If you falsify your entry in a way that cheapens the value of the Area List, you will be sent an IM requesting you change your entry or face delisting, regardless of whether or not it passed a filter. The filter is just the first arbiter; we are always the final subjective judge as to the appropriateness of FAPT entries.
Since you can always promote your fishing area by other venues such as our forums or Social Chat or any number of community sites and groups, participation in the FAPT is a privilege, not a right.
EDIT: Note that when we say you'll be delisted if you don't comply with the spirit of the area list, we mean from the area list. Not "banned from ever fishing again" or anything extreme like that. As noted, the FAPT is optional; you can always promote your area list through other venues, and this has nothing to do with your ability to fish in general or anything else.


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Details of post offices in india with pincode 560098. There are total of 1 post offices in Bangalore, Karnataka, India with same pincode. Places are and Rajarajeshwarinagar
Are you looking for a pin code? then start searching pin code. India post is one of the biggest postal service in world with more than 150000 pin codes.


text:
Wesley Clark on Civil Rights
NATO General; Democratic Candidate for President
I saw prejudice at an early age, and came to dislike it in all its forms. Maybe I was acutely sensitive to it since I'd come to Little Rock from Chicago. Over the years I've seen prejudice against blacks by whites, prejudice by Northerners against Southerners, and by Southerners against Yankees.
I believe no one should be denied a crack at a team, a neighborhood, a school or a job because of race, ethnic group, gender, religion, or any other unfair discriminator. Because of this, I am a strong believer in Affirmative Action.
A: I support measures to protect the American flag. The flag is deeply personal to me. I have led men into battle and combat under that flag. I believe that a very narrow protection for the flag will not undermine anyone's ability to express the full range of their views about America.
CLARK: I'm very concerned about the Patriot Act. It was passed in haste. It's very long. What we would do is suspend all the portions of the Patriot Act that have to do with search and seizure: sneak-and-peek searches; library records; and so on. If they want a wiretap, they can do it the old-fashioned way, go to a judge with probable cause.
And then, bring the whole act back into the Congress. Lay it out. Ask former Attorney General John Ashcroft to come and testify on his use and abuse of the Patriot Act. What provisions were used, for what, for what good? Why couldn't it have been done another way? And then we're going to put together the right kind of authorities for law enforcement to keep us safe. We cannot win the war on terror by giving up the very freedoms we're fighting to protect.
Opponents say such an amendment violates free speech rights. General Clark repeated those concerns, even as he expressed support for the amendment. "The respect that the flag is due is not because of a constitutional amendment," he said. "It's really because of what we believe in our hearts and the way we act as Americans." He added, "No administration should ever say that if you disagree with it that you're not being patriotic."
The flag amendment bill in 2000 fell four votes short of the necessary 2/3 required for a constitutional amendment to be sent to the voters.
A: There are gays who serve in the US armed forces, and they do a very good job. But when they acknowledge who they are and their sexual preference, they leave. So I've got a very good comfort level with it. I think everybody deserves the right to serve. And when I'm president, I'm going to make sure that we treat every man, woman and child in America with dignity and respect. And that includes the opportunities to serve in the US armed forces
A: I've seen it work in some units, but I get a lot of reports where it doesn't work. And I think it depends on the service and the unit. It depends, to some extent, on the commander. The policy needs to be reviewed because there are so many indications that it's not working. You start a review with the presumption that it isn't. Let the armed forces leadership go back through it and give us a better policy so that every American who desires to serve can.
A: One of my Army friends came to me. He said, "Sir, I've got a little bit of trouble with your position on gays in the military." I said, "Well, let me explain it to you this way. If you had a son or daughter who was gay, would you love them? And he said, "Well, yes." I said, "And wouldn't you want them to have the same rights and the same opportunities in life as everybody else?"
A: I don't believe sexual orientation is a matter for the military to worry about, so long as behavior is appropriate. I will challenge the military to review the existing policy, and if it doesn't work, which all evidence suggests is the case, will ask the military to come up with something more fair and better for the people concerned and the country. In my view, every person who is qualified should be given the opportunity to serve, and each person should be treated with dignity and respect. There are other models, like don't ask/don't misbehave which some armies have adopted, and they should be looked at.
The British have a system called, 'Don't ask, don't misbehave.' I think the leaders in the armed forces will look at that some day. I think we need to charge the men and women responsible for the armed forces to come forward with that answer. I think that has to come from them based on what we need for the armed forces, as well as, you know, their concerns about society as a whole.
|Other candidates on Civil Rights:
|Wesley Clark on other issues:
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Ababrelton Surname Ancestry Results
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aaronson aarsen aarstad aart aarvold aas aasanemeset aaserud aasgaard aashton aass aassmore aasulsch aauxe aavant aavon aavora aayton ab ab adam aba abach aback abadam abadee abadham abadi abadie abadien abadir abadjian abadjoglous abadoo abady abaich abaitna abaitua abajingin abakanowicz abale
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Muleshoe Marine Bales would have been proud
The capture of Saddam Hussein won't bring back Kem Bales' energetic country boy known for his confidence and charm. And it doesn't make the pain of losing a son to the war in Iraq any easier.
But it does bring to fruition everything U.S. Marine Chad Eric Bales fought for and believed in, Kem said, and for that the Muleshoe resident was elated when he heard of Hussein's capture early Sunday morning.
"I think it's a great day, I really do," Kem said on Sunday afternoon. "I know Chad would have been so proud ..."
Chad, a U.S. Marine who spent many summers in Muleshoe with his father, died in a non-combat accident in Iraq on April 3 when his convoy wrecked into another during a sandstorm. Kem said the convoy in front of his son's slid off course and hit a sand dune, resulting in a wreck that killed Chad instantly.
Kem, sporting a United States Marine Corp. hat on Sunday, said Hussein is directly responsible for the death of his son, and he is hoping the capture eases tensions between U.S. military forces and the residents of Iraq.
"I still miss Chad a lot," Kem said. "He always had a happy, easy-go-lucky attitude."
Chad's grandmother Gail Wilcox, also of Muleshoe, experienced mixed emotions when asked about Hussein's capture Sunday evening.
"Do you want to make me cry?" the 66-year-old Wilcox said. "It wasn't worth losing my grandson for. This war has touched me in a way that I will never look at the world like I used to."
Wilcox noted her grandson's dedication to the war efforts, his belief that what he was fighting for was right and American.
Wilcox recalled the angriest she'd ever seen Chad. It was Sept. 11, 2001, when terrorists flew two airplanes into the World Trade Center in New York City, killing almost 3,000 Americans.
"Chad told me on that day: 'I didn't know them by name and I didn't know them by sight, but they were my family,'" Wilcox said.
Chad had many friends in Muleshoe, where he attended Muleshoe High School his junior year (1999-2000) and lived nearly every summer since his second birthday, his father said. On April 13 more than 1,000 Muleshoe residents memorialized Chad at the Muleshoe high's football stadium.
More than eight months after his death, one of Chad's goals as a Marine — the capture of Hussein — came true.
"If Chad were there he would have been dancing in the streets," Wilcox said.


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There's a certain phrase I've come to really dislike.
All my life, I've heard this phrase whenever I go through a rough patch. *And by rough patch, I mean a prickly, gnarly patch that leaves me bleeding to near death*. You're probably familiar with those kinds of "patches".
"God will never give you more than you can handle" is the phrase I'm referring to.
And it's a sweet sentiment, really. The people who say it are speaking from caring and concerned hearts.
BUT–it isn't true.
I know that sounds harsh, but I promise I haven't suddenly lost my mind or have become an angry-with-God bitter woman who hates the world. Actually, when I realized the simple fact that God can–and will–give us more than we can possibly bear, it got easier.
And it all started to make more sense.
I've often trudged through trials that overwhelm me. Ever since my childhood there have been trials that have made me "grow up" pretty fast. But granted, I know for a fact you've had your own fair share too, because that's the reality of life. But this last trial is the one that shook me to my core and had me searching like a mad woman for answers as to why it was happening–and how I could possibly even survive it.
I lost my Dad to cancer last month–if you're a follower of mine, this is old news. But–it was absolutely horrific.
Every day leading up to his death was like walking through every level of hell–slowly– for lack of a better term. There's no other way to describe it. The images…the sounds…the sleepless nights…the cries for God while we look on, helpless…the torment of rubbing morphine in his cheeks, praying it'll absorb–but to no avail. The horrible, wrenching pain that came with lifting him up, laying him back down, lifting him up, laying him back down…because he became so restless and cried out for "home" every few minutes. And all along, in the back of my mind, I reminded myself that millions of people go through this, and have already gone through this, very thing. And it is simply unbearable. If you disagree–it's because you haven't been there.
This trial was so consuming that I hate to even put it in the past tense–sometimes it still consumes me. Yesterday, at my Dad's memorial service, it consumed me all over again.
I've suffered from nightmares where I relived the memory over and over mercilessly–I sometimes see his face on strangers that pass and worry that I'm going crazy. I cry over sad songs in the car and torture myself with stacks of pictures and yellowed photo albums. It's beyond just missing him. And even with a firm testimony of the gospel and with peace that he is exactly where the Lord prepared him for, it is still too much for me to handle at times. It steals my breath–and it can steal my joy.
So, the other day, I turned to the scriptures. I needed help.
I wanted to know where that phrase was that people kept repeating to me in church and at work and over the phone. Why did the Lord "trust me so much"?! Why did He think I could handle these kinds of trials?
And then I realized: I couldn't find that quote because it isn't there.
It never mentions anywhere in the scriptures that the Lord won't give you more than you can handle. Yes, in 1 Corinthians 10:13 it speaks of Him giving us an escape from temptations so that it's not too much to bear. But when it comes to pain, trials, heartache, and burdens– not once does it say it won't be more than we can bear. Instead, it beautifully says this instead:
"Come unto me, all ye that labour and are heavy laden, and I will give you rest. Take my yoke upon you and learn of me…for my yoke is easy, and my burden is light." (Matt. 11: 28-30)
The words struck my heart, as you can imagine. Christ is speaking to those of us who are carrying burdens much too heavy for our own shoulders. And in that one verse he simply states the reason why we are given more than we can handle: It's so we can come to him. It's so we can trust him enough to hand over our heavy, crippling burdens and let him carry the load.
You might be heavy laden right now like I was before reading and re-reading and re-reading once again this scripture that has never stuck out to me as much as it has lately.
You might be shrunken with sadness or drowning in debt. You might be overwhelmingly angry at someone at church or aching under the pressures of raising children or maybe the inability to have them. You might be dealing with a terminal disease and you still have young children. And chances are–you might need your Redeemer to find you on the path and take up that heavy cross you're dragging. Besides, even he tells us that he's more equipped to carry it, so why not hand it over?
I've come to learn–slowly but surely–why I need Him.
I suppose it's because of pride that I always thought I could just do things on my own. I'm strong, I'd say. I'm a tough cookie. I can help others through their tribulations while carrying mine all by myself. Well…wasn't I wrong.
I didn't really know what needing him meant until I had no other choice. I didn't know what it meant until I wrapped my arms around my middle so I wouldn't fall apart–or the time I choked on tears and yelled toward Heaven. Or the times when I was utterly alone, and the silence was too much to bear. Those are the times that taught me he's not just a want or a convenient symbol of love or a reason to do good deeds.
No, he's the very air we breathe.
And he's the only one who can make it bearable when life is simply anything but.
By: Kayla Lemmon
The 10th Ward Mission wants to give a special thanks to Kayla Lemmon for permission to post this blog she wrote. Our ward mission leader thought it was a perfect post for our ward blog. Thank you Kayla for a wonderful post!


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text:
Overwhelmed Mom Syndrome — It's a Real Thing
Running a household is grueling enough without ADHD. Here are 8 life-saving tips for parents with executive function deficits, lagging patience, and hardly enough time to read this.
Managing the home is one of the most unfriendly lines of work that anyone with attention deficit disorder (ADHD or ADD) could undertake.
But the multiple-task coordination required to keep a household functioning smoothly bumps directly against the executive-function difficulties inherent in ADHD. Adding to that is the pervasive gendered division of housework, where women are still the ones expected to manage a household. This makes for a crisis of overwhelmed mothers with ADHD.
It is key to recognize the challenges on the domestic front, be realistic and forgiving of yourself, and put organization systems in place that will help you work around the difficulties.
Tough Work, Indeed
Consider the job description of homemaker and child-care giver: "You're required to provide all the organization and structure for three or more people. Tasks are poorly defined, filled with distractions, and require constant multitasking. Because much of the work — including cooking, cleaning, and laundry — is boring, you must be able to function without needing a high level of interest or stimulation.
"Appearance is important as well: You must create an attractive household, attending to the details of décor and the children's clothing. It is also important to maintain a calm demeanor while caring for children, who, by definition, have problems with attention and behavior.
You'll need to carefully structure their lives in order to give them the calm, supportive, organized home environment they need to succeed at school and with friends. Excellent calendar and scheduling skills are critical. You are required to prioritize without guidance, and work without incentives, such as raises, bonuses, promotions, or even the support and company of co-workers."
[Free Download: The Parenting Guide for Moms with ADHD]
Would anyone with ADHD (or, without, for that matter) apply for an impossible job like this?
Of course not.
Yet many women with ADHD remain determined to achieve these ideals, even though, as Lynn Weiss, Ph.D., notes in her book Attention Deficit Disorder in Adults (Taylor Trade) (#CommissionsEarned), "an ordinary day for a woman is a nightmare for a woman with ADHD."
Kathleen Nadeau, Ph.D., co-author of ADD-Friendly Ways to Organize Your Life (Routledge) (#CommissionsEarned), points out that mothers with ADHD "may be struggling valiantly with demands which are often difficult, if not impossible, to meet." Women with ADHD, no matter how successful in other areas of life, struggle on the household front. They may ponder on the "how to be a good mom" question, and experience stress and a feeling of failure to measure up.
Take Control — Now
What to do? First, stop beating yourself up about ADHD patterns. Instead, create a household that can accommodate them. An ADHD-friendly house is one that is easy to clean and easy to keep in order — one that works for you and everyone else in the household. That means finding creative solutions to the daily challenges you face. Nadeau points out eight common problem areas below, and offers innovative approaches for each. Good luck!
[Self-Test: Could You Have an Executive Function Deficit?]
1. Need housework help? Do whatever it takes to hire a cleaning person. Don't immediately assume that you can't afford such a service. If necessary, take on part-time employment just to pay for a cleaning person. Look at it this way: Housecleaning is a part-time job for which you are poorly suited. Why not take on a job at which you can excel?
2. Hate laundry? Most individuals with ADHD do. Instead of letting laundry pile up, do one load every morning. Better yet, train the children to do their own. Can't remember to sort, fold, and return clean laundry to the appropriate spots? Put out two baskets: one for clean clothes, the other for dirty clothes. Let household members find the clothes they need and deposit soiled ones in the designated basket.
3. Need a quick de-clutter? Use the old garbage-bag trick. Get a big bag and drop unneeded items from every room into it.
4. Mail building up? Most ADHD households struggle with the daily influx of mail (mostly junk, interspersed with the occasional, carefully hidden important item). Stick to this simple mail-handling routine: Open the mail while standing next to the kitchen trashcan. Throw away junk mail immediately — or, better yet, drop it into a handy recycling basket. Then, place any bills (unopened) in one pile, important correspondence (that which requires a response) in a second. Immediately take both piles to the desk where they "live" — the bills to the "bill-to-be paid" slot; the correspondence to the pile for "action" items.
5. Need a home for newspapers and magazines? Place a pretty recycling basket in the room where they are typically read. Toss in reading matter when you've finished with it. Another family member can easily find the magazine or newspaper he or she's looking for on the top of the pile.
6. Hunting for important items every morning? Create a "ready-set-go" site in your home — this can be a small bookshelf, with hooks on the wall next to it. Place all items needed the next day — books, papers, clothes to take to the cleaners — on the shelves or hooks. Mount a bulletin board above the bookshelf, so you can tack up reminder slips: "Robby, dentist, 4:30 Tuesday."
7. Redecorating or remodeling? Take ADHD into account as you make decisions. A dark rug in front of the sink catches drips, and a hardwood floor hides crumbs and spots that would be glaringly evident on linoleum. Sponge-painted walls make a great fingerprint-hider and are attractive to boot.
8. Need peace and quiet? Most ADHD households are lively, cluttered places. Not a problem, except for the fact that women with ADHD sometimes need to downshift for a few moments in a quiet space. Turn one room into a calm, visually appealing space where you can go to gather yourself. Make it a house rule that this room is for solitude or quiet conversation only — not a place to bicker, tease the dog, or argue with your mom.


text:
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SAMJ: South African Medical Journal
On-line version ISSN 2078-5135
Print version ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.99 n.9 Pretoria Sep. 2009
Estimation of adult antiretroviral treatment coverage in South Africa
Muhammad Aarif AdamI; Leigh F JohnsonII,*
IBBusSc, S Afr Med J 2009; 99: 661-667.Sanlam Life Insurance Limited, Bellville, W Cape
IIPhD, AIA, Centre for Actuarial Research, University of Cape Town
OBJETIVES: To estimate the annual numbers of individuals receiving antiretroviral treatment in South Africa up to mid-2008, and the coverage of antiretroviral treatment in adults according to various definitions of need.
METHODS: Antiretroviral coverage is defined as the number of patients receiving antiretroviral treatment at a point in time, divided by the number needing treatment. Numbers of patients receiving antiretroviral treatment are estimated from public sector data, and data provided by disease management programmes and NGO programmes. The unmet need for treatment in adults is estimated using a Markov model of HIV progression in adults, combined with estimates of annual new HIV infections from a national AIDS and demographic model.
RESULTS: By the middle of 2008, 568 000 adults and children were receiving antiretroviral treatment in South Africa, with the public health sector accounting for 79% of this total. Using the current Department of Health criteria for defining antiretroviral eligibility (CD4+ count <200/µl or World Health Organization (WHO) stage 4), antiretroviral coverage in adults was 40.2% in 2008 up from 4.9% in 2004. Coverage increases to 54.2% if eligibility is based on WHO stage 4 only, but falls to 22.2% if the Southern African HIV Clinicians Society guidelines are used to define eligibility. Coverage in 2008 varied between provinces, from 25.8% in the Free State to 71.7%
CONCLUSIONS: Significant progress has been made in expanding access to antiretroviral treatment in South Africa since 2004, but a substantial unmet need for treatment in adults remains.
Death notification statistics confirm that AIDS is dramatically affecting mortality in South Africa.1 Demographic and epidemiological models suggest that antiretroviral treatment is the only intervention that can achieve a substantial reduction in AIDS mortality in South Africa in the short term.2,3 South Africa therefore urgently needs to expand and strengthen services providing antiretroviral treatment. Before 2004, access to antiretroviral drugs was limited mainly to medical scheme beneficiaries. However, following the announcement of a comprehensive care, management and treatment programme by the Department of Health (DoH) in late 2003,4 antiretroviral treatment has become increasingly accessible, and significant progress has been made in enrolling patients onto the public antiretroviral treatment programme.
Despite this progress, there remains a significant unmet need for antiretroviral treatment in South Africa; monitoring of antiretroviral coverage is therefore important to identify where the shortfall is greatest and to quantify coverage according to different definitions of 'need'. However, monitoring of antiretroviral coverage in South Africa is challenging for several reasons. Although the DoH regularly co-ordinates data collection for the public health sector, there is no centrally co-ordinated data collection system for the private sector and non-governmental organisations (NGOs). In addition, the numbers routinely reported by the DoH are the numbers of patients cumulatively enrolled on antiretroviral treatment, and there are no estimates of public-sector patients currently receiving antiretroviral treatment, except in the Western Cape. Coverage is also difficult to estimate because demographic projection models usually estimate only the numbers of individuals in different WHO clinical stages,2,5 whereas definitions of eligibility are usually based on a combination of clinical and CD4+ criteria.4,6,7 This makes it difficult to estimate the denominator in the antiretroviral coverage calculation.
Much is unknown regarding antiretroviral coverage in South Africa. The aim of this paper is to quantify the coverage in South Africa up to the middle of 2008, according to various definitions of antiretroviral treatment eligibility, and to quantify the relative levels of coverage in the nine provinces and the changing contribution of different providers to the antiretroviral rollout in South Africa.
Following the convention of UNAIDS and the World Health Organization (WHO), antiretroviral coverage is calculated as the number of individuals receiving antiretroviral treatment, divided by the sum of the number of untreated individuals needing treatment and the number of treated individuals.8,9 Estimates of the numbers receiving treatment are obtained from public sector programme reports and data collected from the private sector, while estimates of the unmet need for treatment are derived from a model of HIV progression in HIV-infected individuals. Although numbers receiving treatment are calculated for both adults and children, antiretroviral coverage is calculated for adults only, since definitions of antiretroviral eligibility and rates of HIV progression differ between children and adults.
Estimation of numbers receiving antiretroviral treatment
Estimates of the numbers of patients starting antiretroviral treatment each year in public health facilities are obtained from unpublished reports of the cumulative numbers of patients who have started antiretroviral treatment at different times (Department of Health internal report dated 7 May 2009: National Strategic Plan for HIV and AIDS/CCMT monthly statistics, March 2009).10 To allow for mortality and loss to follow-up after starting treatment, rates of retention are applied to these annual numbers of individuals starting therapy. Based on estimates of retention in the Western Cape,11 it is assumed that the probability of remaining on treatment for the first 6 months after starting therapy is 0.895, and the annual probability of remaining on treatment thereafter is 0.935. The number of individuals receiving treatment at time t (in years) is thus calculated as:
where S(t1) is the number of individuals starting treatment between time t 1 and time t. It is assumed that individuals starting treatment between time t 1 and time t do so, on average, at time t ½.
Estimates of the numbers of patients receiving antiretroviral treatment through disease management programmes (DMPs), workplace treatment programmes (WPTPs) and NGO programmes operating outside of public health facilities are based on three data sources:
1. early published data from Aid for AIDS,12 which was treating approximately 80% of all antiretroviral patients in 2002 13
2. early data on NGO programmes operating before 2004 14
3. more recent data collected from individual programmes from 2005 to 2008. 15
Since programmes do not provide estimates at regular intervals, and since information is missing for some programmes during certain periods, estimates of numbers of patients receiving treatment at the middle of each year are obtained by using linear interpolation and extrapolation of estimates at other time points. The number of individuals starting treatment between time t 1 and time t, S(t1), is estimated by entering the private sector estimates of N(t1) and N(t) into equation (1) and assuming that the rates of retention in the private sector16,17 are the same as those in the Western Cape.
For some years, data on the provincial distribution of treatment numbers are not available. In these years, we assumed that the proportion of individuals treated in a particular province, and for a given sector (private/public/NGO), was the same as that estimated in the most recent year. For the public and NGO sectors, the most recent provincial distributions are for 2008. For the private sector, a provincial distribution could be obtained only for 2003, based on a weighting of the 2003 population5 by the proportion of the population with medical cover18 and the proportion of medically insured individuals on antiretroviral treatment. 12
Estimation of unmet need for treatment
The unmet need for treatment was estimated by using a Markov model of HIV progression that divides HIV-infected adults into compartments based on their current CD4+ count, clinical status and current receipt of antiretroviral treatment (Fig. 1). The initial CD4 distribution of HIV-infected adults, at the time they acquire HIV, as well as the probabilities of transition between the HIV stages in Fig. 1, are set at the rates estimated by Hendriks et al.19 from men in Amsterdam from 1990 to 1996. These rates were selected from several other possible sources,19-22 because they produced an estimated median HIV survival time consistent with medians estimated for South Africa in other studies23,24 and because they produced a distribution of CD4+ counts in HIV-infected adults roughly consistent with the distributions observed in South African surveys. 25-27
Assumptions about the annual number of new adult HIV infections were obtained from the ASSA2003 AIDS and Demographic model.5 The model projects the change in the number of infected individuals in the different CD4 stages at monthly intervals, adding new infections and removing individuals who die or start antiretroviral treatment. Non-HIV mortality is set at a rate of 0.005 per annum, equal to the average non-HIV mortality rate in HIV-positive South African adults estimated by the ASSA2003 model. The numbers of adults starting antiretroviral treatment in each period are set at 90% of the S(t) estimates obtained previously, since approximately 10% of those receiving antiretroviral treatment are children. Based on data from South African treatment programmes,17,28,29 we assumed that 35% of adults starting treatment had already progressed to AIDS and the balance started therapy when their CD4+ count was <200/µl, prior to the development of clinical AIDS.
Estimates of unmet need are calculated according to three definitions:
1. conservative criteria that include only adults with untreated AIDS
2. current criteria used by the DOH,4 which include all adults with untreated AIDS or a CD4+ count <200/µl
3. criteria recommended by the Southern African HIV Clinicians Society,7 which include all adults with untreated AIDS or a CD4+ count <350/µl.
Sensitivity analysis
To assess the sensitivity of the unmet need estimates to key variables, the following plausible ranges of parameter values are considered. The proportion of adults starting treatment who have already progressed to AIDS is varied between 20% and 50%,17,28,29 and the rate at which individuals discontinue treatment owing to death or loss to follow-up is varied between 0.7 times and twice the rates estimated from the Western Cape data, based on variability in rates of retention observed within South Africa.28,30,31 The annual numbers of new HIV infections in adults are varied between the upper and lower limits of the 95% prediction intervals calculated in a previous uncertainty analysis.24 In addition, alternative estimates of rates of transition between CD4 stages are considered. 19-22
By the middle of 2008, an estimated 568 000 adults and children were receiving antiretroviral treatment in South Africa, which is more than twice the number 2 years previously, and more than 10 times the number at the middle of 2004 (Table I). Although 72% of patients in 2004 were receiving treatment through DMPs or WPTPs, this proportion declined to 15% by mid-2008, following the rapid scaling up of antiretroviral access in the public health sector (Fig. 2a). The proportion receiving treatment through NGO programmes has remained stable at around 6%, though this figure varies substantially between the provinces (Fig. 2b).
Over the years 2000 - 2008, the estimated CD4 distribution of the HIV-infected adult population changed substantially (Fig. 3a). The proportion of infected adults who have a CD4+ count >350/µl and are not on treatment has decreased from 70% in 2000 to 54% in 2008, and the proportion of infected adults in need of treatment, by current DoH eligibility criteria, has increased from 13% to 25% over this period. However, the proportion of infected adults who have CD4+ counts >350/µl and are not on treatment was relatively uniform across the provinces in 2008, at between 53% and 57% (Fig. 3b).
Antiretroviral coverage in adults has improved substantially, rising from 4.9% in 2004 to 40.2% in 2008, according to DoH eligibility criteria (Table II). Estimates of coverage change substantially when different definitions of treatment eligibility are used; when 'unmet need' is defined only as untreated AIDS, antiretroviral coverage in 2008 is estimated at 54.2%, but when 'unmet need' is defined according to the Southern African HIV Clinicians Society guidelines, coverage is estimated at only 22.2% (Fig. 3c). Adult antiretroviral coverage also varies greatly between provinces, ranging from 25.8% in the Free State to 71.7% in the Western Cape in 2008. Similar variability is observed when using the HIV Clinicians Society guidelines to define unmet need (Fig. 3d).
The total number of untreated adults needing antiretroviral treatment, at the middle of 2008, is estimated to be around 760 000 using the DoH eligibility criteria, 430 000 using the AIDS sick criterion, and 1.79 million using the HIV Clinicians Society criteria (Table III). These estimates of unmet need are relatively insensitive to changes in the assumed rates of retention on antiretroviral treatment and the assumed proportion of those starting treatment who have already progressed to AIDS. However, the estimates are very sensitive to the uncertainty regarding the annual numbers of new HIV infections in South Africa; the estimated total number of untreated adults who are sick with AIDS or have a CD4+ count <200/µl changes to 480 000 and 1.01 million when the lower and upper estimates of the annual new adult HIV infections are substituted into the model. The estimates of unmet need are also quite sensitive to the choice of HIV progression parameters. Using the progression parameters estimated by Hendriks et al.19 for men in Amsterdam over the 1985 - 1990 period, the unmet need reduces to 600 000, but using the progression parameters estimated by Longini et al.21 for USA military personnel, the unmet need increases to 990 000.
This study demonstrates significant progress in the provision of antiretroviral treatment in South Africa, particularly after the phasing in of antiretroviral treatment in the public health sector after 2003. However, a large unmet need for antiretroviral treatment remains and, by the middle of 2008, only 40.2% of adults needing antiretroviral treatment were receiving it. A significant barrier to the expansion of the antiretroviral treatment programme is the limited number of public health facilities providing treatment and their shortage of health workers. An urgent need therefore exists for greater decentralisation of antiretroviral treatment services32 and greater recruitment and retention of health workers in the public health sector.33-36 A further barrier to improving antiretroviral coverage is the high proportion of eligible individuals who are unaware of their HIV status; in the 2005 HSRC household survey, for example, only 36% of HIV-infected adults had ever been tested for HIV.37 Stigma and confusion regarding the efficacy of antiretroviral treatment relative to traditional medicines are also significant factors inhibiting access to antiretroviral treatment;32 leaders at all levels must present clear and consistent messages to overcome these barriers.
Our analysis also demonstrates significant inequality in access to antiretroviral treatment in South Africa, with coverage in mid-2008 ranging from 25.8% in the Free State to 71.7% in the Western Cape. This appears to be mostly owing to variability in the performance of the public health sector, since the provinces with the highest coverage (Western Cape and Northern Cape) have the highest proportions of patients managed in the public sector, and the provinces with low coverage (Free State, Eastern Cape, Mpumalanga and Limpopo) have low proportions of patients managed in the public sector. The high coverage in the Western Cape and Northern Cape could also reflect their relatively low HIV prevalence.
We present a novel approach to estimating the unmet need for antiretroviral treatment. Although it is possible to conduct surveys to measure the unmet need for treatment at a given time,25, 38 this analysis shows that the CD4 distribution in the HIV-infected population can be expected to change substantially over time. Since it is costly to conduct surveys, mathematical models provide a simple alternative method for estimating the change in the unmet need for treatment as the epidemic progresses. The Spectrum model employed by UNAIDS, for example, estimates unmet need in adults by assuming that the CD4+ count in infected adults falls below the 350 and 200 thresholds at specified rates, based on CD4 data from Africa.39 The ASSA2003 model, which is commonly used in setting antiretroviral treatment targets in South Africa, quantifies unmet need in terms of WHO clinical staging,2 although this is a poor indication of unmet need according to combined CD4 and clinical criteria.38, 40-42 A mathematical model proposed by Williams et al.43 estimates unmet need based on local CD4 data, but does not incorporate clinical criteria. It would therefore appear that few mathematical models exist for estimating unmet need according to the combined clinical and CD4 criteria that are commonly used in defining antiretroviral eligibility. 4,6,7
Although our model has the advantage of quantifying unmet need in terms of various combinations of clinical and CD4 criteria, it is, like other models,3,44 parameterised using data that are not local to the setting in which the model is applied. Since distributions of CD4+ counts in HIV-negative adults and rates of CD4 decline in HIV-infected adults differ substantially between populations,43, 45 the HIV progression parameters that have been calculated from men in Amsterdam could be inappropriate for South Africa. We chose the progression parameters estimated from men in Amsterdam because they yielded the model results most consistent with South African data. For example, the model estimates of the proportion of untreated adults with CD4+ counts <200 (19%), 200 - 349 (20%), and 350 - 499 (25%) in 2004, are roughly consistent with the ranges measured in South African surveys between 2002 and 2005 (10 - 22%, 19 - 28% and 18 - 26% respectively).25-27 In addition, the median survival time estimated using the Amsterdam cohort data (10.8 years in the absence of highly active antiretroviral treatment) is roughly consistent with the median of 10.5 years estimated for South African gold miners aged 25 - 34 at the time of HIV acquisition23 and the median of 10.8 years estimated for adults aged 29 at the time of HIV acquisition, based on South African mortality data and HIV prevalence data.24 This suggests that the HIV progression parameters estimated from the Amsterdam cohort serve as a reasonable approximation to those in South Africa.
A potential concern is that data on the numbers starting treatment in the public sector could be subject to significant double-counting,8 and the rates of antiretroviral retention estimated from the Western Cape public health sector11 might not be applicable to other provinces. However, the estimates of numbers currently receiving antiretroviral treatment in the public health sector (Table I) are consistent with unpublished public sector drug distribution estimates produced by Aspen Pharmacare, which suggests that bias owing to double-counting and inter-provincial differences in antiretroviral retention is not substantial. Another limitation is the absence of data from some of the smaller DMPs and from individuals paying for their own treatment outside of DMPs,15 which may result in some under-estimation of antiretroviral coverage. Further work is needed to explore definitions of antiretroviral coverage other than the standard UNAIDS/UNGASS indicator, e.g. the proportion of newly eligible individuals in a given year who start treatment. Such measures may provide a more accurate indicator of recent programme performance, as they are not affected by the numbers of patients enrolled in the past. Further work is also required to produce separate estimates of antiretroviral coverage in men and women and to develop a separate model for estimating antiretroviral coverage in children.
We thank the many DMPs and NGOs that provided data from their programmes, and Andrew Boulle for providing helpful comments on an earlier version of this paper .
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Accepted 11 May 2009.
* Corresponding author: L Johnson (firstname.lastname@example.com)