published_or_final_version / Nursing Studies / Master / Master of Nursing

Faculty of Health Science School of Public Health 0310820y gapawi@yahoo.com / Introduction: A study of adherence was conducted at the HIV Clinic of Helen Joseph Hospital, Johannesburg between June and September 2004. First it measured the level of adherence of patients (referred to as participants in this report) to antiretroviral medications. The relationship between adherence results and the viral load of the participants was explored. Factors such as treatment regimens, patient-provider relationship, patients’ knowledge of HIV treatment, disclosure of HIV status and support for HIV positive individuals were also studied with regard to adherence to antiretroviral therapy. Methods: Out of a total eligible pool of 198 patients, 184 patients were included in the study, representing 92.9% response rate. Participants were interviewed using a questionnaire and their HIV RNA concentrations (viral loads) ascertained. Adherence was defined as >= 95% (higher adherence) if a participant missed 0-2 medication doses and < 95% (lower adherence) if >2 doses were missed over a 23-day recall period. Results: Reported missed medication doses = 0 for 82.6% (152/184), 1 for 9.6% (14/184), 2 for 2.2% (4/184), 3 for 3.8% (7/184), 4 for 2.2% (4/184), 5 for 1.1% (2/184) and 11 for 0.5% (1/184) of the sample. The adherence level of 92.4% (170/184) of the sample was >= 95% and that of 7.6% (14/184) was < 95% of expected doses. A total of 116 participants had undetectable HIV RNA concentrations (i.e. viral load <50 copies/ml) and 64 had detectable viral load. Among the higher adherence category of participants 67.7% (113/167) had undetectable viral load compared with 23.1% (3/13) of the lower adherence category (χ2 = 10.46; p = 0.002). Participants who reported lower adherence had a mean log10 viral load of 2.90 compared to the higher adherence category with a mean log10 viral load of 0.81 (p<0.001). The mean duration of treatment for lower adherence category of participants was v 7.2 months compared with 13.3 months for the higher adherent participants (p = 0.025). Overall, participants with higher adherence were over six times more likely than those with lower adherence of achieving undetectable plasma HIV RNA (OR = 6.98; p = 0.004). Inadequate knowledge about HIV treatment where participants never heard of treatment adherence (p = 0.001), viral load (p = 0.001), or Cd4 cell count (p < 0.001); where participants believed that drugs cure HIV (p = 0.026), that one can stop treatment if one feels better (p < 0.001); and participants not knowing that HIV treatment is for life (p < 0.001) were associated with lower adherence. Other factors which predicted lower adherence were dietary restrictions (p = 0.007), drug side effects (p < 0.001), forgetting medication doses (p = 0.001) and missing clinic appointments (p = 0.001). Higher adherence was more likely to be reported where provider could speak patients’ preferred language (p = 0.035), assist patients with treatment difficulties (p = 0.002) and where provider was seen to be not too busy to listen to patients (p = 0.044). The method by which patients received information about HIV and its treatment did not affect reported adherence levels (p = 0.805). Disclosure of HIV status to both partner and family member (p < 0.001), and receiving social support from family members (p = 0.007) were found to be associated with reported higher adherence. Socio-demographic characteristics such as age (p = 0.174), gender (p = 0.159), level of formal education (0.107) as well as economic characteristics such as earning money (p = 0.104) and having a telephone (p = 0.124) were not associated with adherence to antiretroviral medications. Conclusion: This study suggests that the HIV-positive patients in the HIV clinic of Helen Joseph Hospital can maintain a high level of adherence to regimen of antiretroviral treatment. However, there is a need to develop strategies to enhance educational vi programmes and strengthen knowledge of HIV treatment among lower adherence category of patients, and to improve patients’ self-management and care for mediation pills. Further research is recommended to assess broader psychosocial factors predicting adherence in this population, and to ascertain what really happens to ARV pills dispensed to patients.

Thesis (M.A.(Community-Based Counselling Psychology))--University of the Witwatersrand, Faculty of Humanities, 2013. / The amount of research that examines adherence to antiretroviral treatment is now immeasurable. However, research on understanding the subjective experiences of men who have sex with men (MSM) and living with HIV while taking antiretroviral therapy remains limited. This research uses a qualitative methodology, using semi-structured interviews, carried out on nine participants who frequently use a Johannesburg support group aimed at MSM living with HIV. The time period of these men living with HIV and taking antiretroviral therapy varied from a number of months to many years. The interviews were audio-recorded and transcribed. In terms of analysis, thematic content analysis was used identified the enablers and barriers to treatment adherence. These were broken into biopsychosocial factors with the main outcomes of this research suggesting that adherence is complex and influences are far beyond just biological. The majority of the elements raised by the participants indicate the significance of psychological and social factors. This makes the development of adherence interventions aimed at MSMs more detailed than simply following medical provider directions. There appeared to be consensus that although some participants of this research would prefer to not take antiretroviral therapy because of the side-effects, the alternative for them was something that they wanted to consider, such as illness and death. The belief that the medication is keeping them healthy, improving quality of life and allowing them to focus on day-to-day living seemed to dominate over the psychological effects of the condition or the medication in terms of adherence. Because of the way that HIV is perceived within society, the threat of discrimination is real and for many of the participants shape the way they see themselves, the world and this in turn guides their thinking when it comes to issues, especially with disclosure. Above all, this research explores the antiretroviral adherence factors specifically associated to MSM.

Thesis (MPH)-- University of Limpopo, 2011 / Background The increased access to HAART and increased survival of perinatally HIV-infected children have given rise to challenges that parents and caregivers face of disclosure of HIV serostatus to their infected children. Given the increased number of children on ART in the country health care providers and caregivers are now faced with the challenge of a population of children who have not been disclosed. The issue of disclosure should be viewed as a great public health concern. Aim and objectives The aim of the study was to determine the socio-demographics of caregivers and children and determine caregivers’ reasons for disclosure and non-disclosure of HIV diagnosis to children on antiretroviral therapy. Methodology: A quantitative descriptive study using researcher administered questionnaires was conducted with a sample of 149 disclosed and non-disclosed caregivers of children aged 4-17 enrolled in an antiretroviral treatment programme of a district hospital. Data were cleaned, coded and captured on Microsoft Excel and analysed in STATA version 10. Results Of 149 caregivers, 97.99% were females, and 2.01% were males, age ranged from 19-81 years with a mean age of 42 years, 25% attained primary education, 51% the grade not completed, 21% completed grade 12, and 3% had a tertiary education, 55.7% were unemployed, 27.3% fully employed, 14% were pensioners, 3% were schooling. Of the 149 children, 58% were girls, 42% boys, aged range of 4-17 years, mean age of 8.3 years, mean diagnosis age was 6 years, mean time on ARVs was 3.1years, and mean disclose age was 9.3 years. Majority (52.3%) children were cared for by mothers, (28.2%) by grandparents, and of the rest (17.4%) by other relatives, only 2% by their fathers. About 38% single orphans having lost their biological mothers, 35% were double orphans. About 39.6% of children were disclosed to and 60.4% not disclosed to. For those children to whom disclosure had been made 52.5% were disclosed to between ages 6-10, 35.6% between ages 11-15, 10.2% between ages 1-5. Reasons for disclosure were varied, and most cited were adhere to medication (36.5%), consistent questioning about disease and medications (36.5%), fear of accidental disclosure (9.5%), prompted by health professionals (7.9%), and child reaching puberty (3.2%). Reasons for non disclosure were also varied, most cited were child was too young to understand the disease, child will tell others, fear of stigma and discrimination, and did not have the skills to disclose Conclusions Prevalence of disclosure was much higher (39.5%) than other findings and there was greater involvement of health care providers in disclosing HIV to children. The study found a low disclosure rate among biological mothers who were in majority in the sample. Adherence to medication and persistent questioning about the disease and medication were the most cited reasons for disclosing HIV to children. Majority of caregivers delayed disclosure fearing that children will tell others because they are still too young to understand the implications of the diagnosis. Fear of stigma and discrimination also influenced disclosure. Caregivers delayed disclosure because they did not have the skills to disclose and explain HIV to children. Recommendations We recommend that disclosure guidelines be developed and healthcare providers trained in disclosure counselling to better advice caregivers on how to disclose to, thus making HIV disclosure to children an integral part of the comprehensive care of children on ART. Strengthening of life skills education programs at school to take into account the situation of children living with HIV Key words: Disclosure, non-disclosure, caregiver, children, ART, South Africa

Thesis(MSc(Med)(Pharmacy))--University of Limpopo, 2012. / CHAPTER 1 INTRODUCTION 1.1 INTRODUCTION This chapter presents the background and rationale for the study followed by the problem statement. The aim and objectives of the study as well as the significance of the study will also be explained. 1.2 BACKGROUND AND RATIONALE FOR THE STUDY In the past decade, patient satisfaction has become an important performance and outcome measure of health care (Moret, Nguyen, Pillet, Faissard, Lombrail & Gasquet, 2007). Although high levels of patient satisfaction are important for a successful strategy against Human Immuno-deficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), research into patient satisfaction with health care services in general, and with antiretroviral treatment (ART) services in particular, has been limited in South Africa (Myburgh, Solanki, Smith & Lalloo, 2005). In a weakened healthcare system, it is even more crucial to ensure a high quality of care and patient satisfaction to maximise the benefits of scarce resources. In addition, patient views on the quality of public sector antiretroviral (ARV) care are relatively unexplored (Igumbor, 2003; Myburgh et aI., 2005). The assessment of satisfaction among hospitalised patients is increasingly recognised as a major component of quality management in patient care. Continuous quality improvement, comparison of hospital performances and demands for accountability are some of the reasons that lead hospitals to measure patient satisfaction (Ross, Steward & Sinacore, 1995). As has been observed in many industrialised countries, the provision of ART via public health systems, can transform AIDS from a fast, insidious killer into a more manageable, though still incurable, chronic illness (Abdool Karim, 2005). However, in resource-limited settings, there are many challenges in successfully scaling-up ART and reorienting service delivery towards chronic disease care. Shortages in human resources for healthcare are often cited as the most important obstacle to a specific for all ART sites in the province should be developed and monitored. A long term strategy to address the critical shortage of healthcare professionals should be developed by provincial policy makers which will in the long run reduce long waiting times experienced by our clients.

<p>Namibia is severely affected by the HIV/AIDS epidemic, with an estimated HIV prevalence of 17.8%. A comprehensive, public HIV/AIDS treatment and care programme was established in 2003 by the government of Namibia in association with its development partners. The introduction of antiretroviral therapy [ART] has dramatically decreased HIVrelated mortality and morbidity, improved quality of life, revitalized communities and transformed perceptions of HIV/AIDS from a plaque and death sentence to a manageable chronic condition. Intermediate Hospital Oshakati (IHO) in the Oshana region, is one of the six pilot hospitals where highly antiretroviral therapy (HAART) was initiated. Adherence to antiretroviral therapy (ART) is a key factor in ensuring optimal clinical outcomes and is associated with improved survival among HIV and AIDS patients. Sustained high levels of adherence (taking 95% or more of medication as prescribed) are essential for treatment success. Suboptimal adherence to treatment has been associated with virologic, immunologic and clinical failure, and may increase the risk of resistance to first-line ART drugs. Studies conducted in various parts of the country including the Oshakati district, report small proportions of patients defaulting on ART. Defaulting from treatment raises questions about adherence to ART as it can be assumed that poor adherence would precede defaulting from treatment. This study explored factors that influence poor adherence to ART among patients at Intermediate Hospital Oshakati.</p>

<p>The highly active antiretroviral therapy (HAART) drug agent, indinavir, and the endocrine disruptor compound, 2,4-dichlorophenol (2,4-DCP), are directly related to two of South Africa&rsquo / s, and in fact, two of the globe&rsquo / s most fundamentally important and comprehensively researched subjects areas, which includes, HIV/AIDS and water pollution. In fact&nbsp / these two compounds share multiple significant commonality factors. Firstly, they have a profound effect on the health aspects of humans, albeit from opposite sides of the&nbsp / &lsquo / equation&rsquo / . Secondly, in the context of metabolism, they both share the same rout of biotransformation, and as such, both have a profound effect on the main first pass&nbsp / metabolising hepatic enzyme, CYP450 3A4, as well as xenobiotics sharing the same metabolic athway. Thirdly and perhaps more importantly, in direct relation to the human mortality, their levels preferentially require constant or regular monitoring, a process, at this stage, is still only officially possible with complex specialized analytically-based techniques. Moreover, these techniques are only based on centralized detection and quantification, which essentially means expensive procedures, and long waiting periods for results. This thesis firstly reports on the development and characterization of reagent-less and cobalt(III) sepulchrate [Co(Sep)3+] mediated biosensor platforms (biosensor platform 1 and biosensor platform 2), with human recombinant heme thiolate, cytochrome P450 3A4 isoenzyme (CYP3A4), as biorecognition component. Secondly, each biosensor platform was evaluated by using an entirely different category of compound as model substrate, with the overall objective being the development of alternative analytical method for the detection and quantification of each of these substrates, by amperometric transduction method. In this regard biosensor platform 1 was evaluated for the detection of 2,4-dichlorophenol, whereas biosensor platform 2 was evaluated for the detection of protease inhibitor (PI) HAART drug, indinavir. Fourthly, this dissertation also reports on the use of genetic engineering as complimentary method during biosensor investigations, as source for continuous supply of catalytically active biological recognition component. With respect to the preparation of the biosensors in particular, biosensor platform 1 was constructed by entrapping the commercially sourced full-length, wild type CYP3A4 on a pre-formed electroactive carrier matrix, consisting of Co(Sep)3+&ndash / modified nafion membrane on a glassy carbon electrode. In this regard, the nafion-Co(Sep)3+ composite was prepared by integrating the Co(Sep)3+ species into a pre-formed nafion film through manual drop-coating and mixing methods.&nbsp / In addition to this, the so-formed biosensor was re-inforced by a thin nafion layer as outer-film. The complete biosensor may be denoted as GCE||naf|CMECo( Sep)3+|flCYP3A4|naf. Biosensor platform 2 on the&nbsp / other hand, was constructed by entrapment of the N-terminally modified human recombinant CYP3A4 (consisting only of the heme domain and the surrounding apoprotein), prepared locally through genetic engineering, as a histidine-tagged, catalytically active soluble construct, denoted nCYP3A4, in a biocompatible ionically crosslinked hydrogel-composite membrane. Enzyme immbilization in this case was also realized on a pre-formed nafion-Co(Sep)3+ carrier matrix film, however, in this case the electroactive carrier&nbsp / matrix was prepared by integrating the electroactive Co(Sep)3+ species deep within the nafion microstructure through potentiostatic electrodeposition method at a costant&nbsp / potential of +450 mV for 1200 sec. The so prepared biosensor, is denoted GCE||naf|El- Co(Sep)3+|nCYP3A4|Agrs-PEI-PVA. In this regard, biosensor for platform 2, different variables affecting the performance and stability of the biosensor were evaluated. Selected ex-situ characaterization methods, including scanning electrochemical microscopy (SEM), Fourier Transform Infrared (FTIR) and UVVis spectroscopy was used as complimentary characterization methods , morphological and structural charaterization, revealed&nbsp / the formation of a highly stable electroactive composite film for the carrier matrix in biosensor platform 2 , exhibiting a compact nature and a smooth consistancy in which the&nbsp / electroactive Co(Sep)3+ mediating species was embedded deep within the microstructure of the pre-formed nafion film. Moreover, the method of preparation was highly reproducible, while voltammetric studies also corroborated the stability of the carrier matrix film. Overall, the design path used for this method was shown to be an improvement&nbsp / as compared to the design path used for biosensor platform 1, particularly with regard to the carrier matrix. Nevertheless, the proposed substrates were successfully detected&nbsp / and quantified by the individual biosensor plaforms. In this regard, the dynamic linear range of the GCE||naf|CMECo( Sep)3+|flCYP3A4|naf biosensor, for 2,4-DCP exhibited an&nbsp / upper limit of 45&nbsp / A, with the sensitivity determined as 0.038 A M-1. In addition to this, the LOD was calculated as 0.043 g L-1, which was lesser than the USA Environmental Protection Agency&rsquo / s (EPA) drinking water equivalent level (DWEL) for 2.4-DCP. In the case of the GCE||naf|El-Co(Sep)3+|nCYP3A4|Agrs-PEI-PVA biosensor, the linear&nbsp / concentration range for indinavir was shown to be between 2.183 M 3.552 M, while the sensitivity was determined as 0.035 A M-1. Morover, the LOD value, determined as 59.72 mg L-1 was suggested to be of signifiance with regard to the maximum plasma concentration, CMax, with respect to the ritonavir-boosted regimen, which is the proposed method of administering indinavir. This can also be of value for HIV/AIDS patients who are poor metabolizers, as they will have significantly elevated concentration of the drug,&nbsp / when administered with ritonavir as booster. Above and beoynd these results, the overpotential for the reduction of dioxygen, which is a crucial step in the catalytic cycle of the&nbsp / CYP3A4 enzyme, was significantly reduced by the GCE||naf|El-Co(Sep)3+|nCYP3A4|Agrs-PEI-PVA biosesnor, as compared to the other biosensor.</p>

<p>The highly active antiretroviral therapy (HAART) drug agent, indinavir, and the endocrine disruptor compound, 2,4-dichlorophenol (2,4-DCP), are directly related to two of South Africa&rsquo / s, and in fact, two of the globe&rsquo / s most fundamentally important and comprehensively researched subjects areas, which includes, HIV/AIDS and water pollution. In fact&nbsp / these two compounds share multiple significant commonality factors. Firstly, they have a profound effect on the health aspects of humans, albeit from opposite sides of the&nbsp / &lsquo / equation&rsquo / . Secondly, in the context of metabolism, they both share the same rout of biotransformation, and as such, both have a profound effect on the main first pass&nbsp / metabolising hepatic enzyme, CYP450 3A4, as well as xenobiotics sharing the same metabolic athway. Thirdly and perhaps more importantly, in direct relation to the human mortality, their levels preferentially require constant or regular monitoring, a process, at this stage, is still only officially possible with complex specialized analytically-based techniques. Moreover, these techniques are only based on centralized detection and quantification, which essentially means expensive procedures, and long waiting periods for results. This thesis firstly reports on the development and characterization of reagent-less and cobalt(III) sepulchrate [Co(Sep)3+] mediated biosensor platforms (biosensor platform 1 and biosensor platform 2), with human recombinant heme thiolate, cytochrome P450 3A4 isoenzyme (CYP3A4), as biorecognition component. Secondly, each biosensor platform was evaluated by using an entirely different category of compound as model substrate, with the overall objective being the development of alternative analytical method for the detection and quantification of each of these substrates, by amperometric transduction method. In this regard biosensor platform 1 was evaluated for the detection of 2,4-dichlorophenol, whereas biosensor platform 2 was evaluated for the detection of protease inhibitor (PI) HAART drug, indinavir. Fourthly, this dissertation also reports on the use of genetic engineering as complimentary method during biosensor investigations, as source for continuous supply of catalytically active biological recognition component. With respect to the preparation of the biosensors in particular, biosensor platform 1 was constructed by entrapping the commercially sourced full-length, wild type CYP3A4 on a pre-formed electroactive carrier matrix, consisting of Co(Sep)3+&ndash / modified nafion membrane on a glassy carbon electrode. In this regard, the nafion-Co(Sep)3+ composite was prepared by integrating the Co(Sep)3+ species into a pre-formed nafion film through manual drop-coating and mixing methods.&nbsp / In addition to this, the so-formed biosensor was re-inforced by a thin nafion layer as outer-film. The complete biosensor may be denoted as GCE||naf|CMECo( Sep)3+|flCYP3A4|naf. Biosensor platform 2 on the&nbsp / other hand, was constructed by entrapment of the N-terminally modified human recombinant CYP3A4 (consisting only of the heme domain and the surrounding apoprotein), prepared locally through genetic engineering, as a histidine-tagged, catalytically active soluble construct, denoted nCYP3A4, in a biocompatible ionically crosslinked hydrogel-composite membrane. Enzyme immbilization in this case was also realized on a pre-formed nafion-Co(Sep)3+ carrier matrix film, however, in this case the electroactive carrier&nbsp / matrix was prepared by integrating the electroactive Co(Sep)3+ species deep within the nafion microstructure through potentiostatic electrodeposition method at a costant&nbsp / potential of +450 mV for 1200 sec. The so prepared biosensor, is denoted GCE||naf|El- Co(Sep)3+|nCYP3A4|Agrs-PEI-PVA. In this regard, biosensor for platform 2, different variables affecting the performance and stability of the biosensor were evaluated. Selected ex-situ characaterization methods, including scanning electrochemical microscopy (SEM), Fourier Transform Infrared (FTIR) and UVVis spectroscopy was used as complimentary characterization methods , morphological and structural charaterization, revealed&nbsp / the formation of a highly stable electroactive composite film for the carrier matrix in biosensor platform 2 , exhibiting a compact nature and a smooth consistancy in which the&nbsp / electroactive Co(Sep)3+ mediating species was embedded deep within the microstructure of the pre-formed nafion film. Moreover, the method of preparation was highly reproducible, while voltammetric studies also corroborated the stability of the carrier matrix film. Overall, the design path used for this method was shown to be an improvement&nbsp / as compared to the design path used for biosensor platform 1, particularly with regard to the carrier matrix. Nevertheless, the proposed substrates were successfully detected&nbsp / and quantified by the individual biosensor plaforms. In this regard, the dynamic linear range of the GCE||naf|CMECo( Sep)3+|flCYP3A4|naf biosensor, for 2,4-DCP exhibited an&nbsp / upper limit of 45&nbsp / A, with the sensitivity determined as 0.038 A M-1. In addition to this, the LOD was calculated as 0.043 g L-1, which was lesser than the USA Environmental Protection Agency&rsquo / s (EPA) drinking water equivalent level (DWEL) for 2.4-DCP. In the case of the GCE||naf|El-Co(Sep)3+|nCYP3A4|Agrs-PEI-PVA biosensor, the linear&nbsp / concentration range for indinavir was shown to be between 2.183 M 3.552 M, while the sensitivity was determined as 0.035 A M-1. Morover, the LOD value, determined as 59.72 mg L-1 was suggested to be of signifiance with regard to the maximum plasma concentration, CMax, with respect to the ritonavir-boosted regimen, which is the proposed method of administering indinavir. This can also be of value for HIV/AIDS patients who are poor metabolizers, as they will have significantly elevated concentration of the drug,&nbsp / when administered with ritonavir as booster. Above and beoynd these results, the overpotential for the reduction of dioxygen, which is a crucial step in the catalytic cycle of the&nbsp / CYP3A4 enzyme, was significantly reduced by the GCE||naf|El-Co(Sep)3+|nCYP3A4|Agrs-PEI-PVA biosesnor, as compared to the other biosensor.</p>

<p>Namibia is severely affected by the HIV/AIDS epidemic, with an estimated HIV prevalence of 17.8%. A comprehensive, public HIV/AIDS treatment and care programme was established in 2003 by the government of Namibia in association with its development partners. The introduction of antiretroviral therapy [ART] has dramatically decreased HIVrelated mortality and morbidity, improved quality of life, revitalized communities and transformed perceptions of HIV/AIDS from a plaque and death sentence to a manageable chronic condition. Intermediate Hospital Oshakati (IHO) in the Oshana region, is one of the six pilot hospitals where highly antiretroviral therapy (HAART) was initiated. Adherence to antiretroviral therapy (ART) is a key factor in ensuring optimal clinical outcomes and is associated with improved survival among HIV and AIDS patients. Sustained high levels of adherence (taking 95% or more of medication as prescribed) are essential for treatment success. Suboptimal adherence to treatment has been associated with virologic, immunologic and clinical failure, and may increase the risk of resistance to first-line ART drugs. Studies conducted in various parts of the country including the Oshakati district, report small proportions of patients defaulting on ART. Defaulting from treatment raises questions about adherence to ART as it can be assumed that poor adherence would precede defaulting from treatment. This study explored factors that influence poor adherence to ART among patients at Intermediate Hospital Oshakati.</p>

Thesis (M.Nurs.)--University of Hong Kong, 2008. / Includes bibliographical references (p. 49-57)