There has been growing research on the impact of HIV on family planning and fertility behaviours with studies showing conflicting results. However, these relationships have been understudied in sub-Saharan Africa, especially during the postpartum period. Based on the differences reported in different studies as well as the lack of studies performed in South Africa during the postpartum period, further research is required to investigate differences in fertility desire and use and need for family planning among and between HIV-infected and HIV-uninfected women. The aim of this study was to compare family planning use, fertility desires and unmet family planning need at 12 months postpartum in a population of HIV-infected and HIV-uninfected women from Gugulethu, Cape Town. The thesis components include a study protocol, a literature review investigating previous work on family planning uptake, fertility desire and unmet family planning need in sub-Saharan Africa, and an analysis of secondary data from three contributing studies performed in Gugulethu, Cape Town of HIV-infected and HIV-uninfected women who participated at 12 months postpartum. Logistic regression was used to model associations between HIV status and family planning use, fertility desires and unmet family planning need. Of the 854 women included in this analysis, 497 (58.0%) were HIV-infected and 357 (42.0%) were HIV-uninfected. Family planning prevalence was 62.3%, injectable contraceptives were the most common FP methods used among participants (>90.0%) and 37.2% of participants had an unmet family planning need. Only 8 participants (0.9%) had an immediate fertility desire (wanted to have a child within the next 12 months) and 20.9% wanted to have a child sometime in the future. Family planning use and unmet family planning need did not differ by HIV status however, fertility desires significantly differed by HIV status. In multivariable analysis, HIV status was not associated with family planning use or unmet family planning need. HIV status was significantly associated with future fertility desire. HIV-infected women were significantly less likely to have a future fertility desire than HIV-uninfected women (OR=0.3, 95% CI=0.2 to 0.4, p<0.001). Age, parity, intended pregnancy and discussed family planning/ pregnancy with partner were also significantly associated with future fertility desire. HIV status appears to be associated with fertility desires in this population. No significant association was found between family planning use and unmet family planning need in this population by HIV status. Family planning services need to be strengthened for all women in this population and access to a larger variety of family planning methods is needed.

Includes bibliographical references. / The aim of this study was to investigate the quality of service delivery for HIV-infected women at antenatal clinics in the Western Cape and Free State provinces, South Africa and to highlight areas for improvement. It was part of a larger one to determine the effectiveness of PMTCT programmes in 4 countries. These two provinces were selected because the researchers had access to facilities there. The population included all clinics with antenatal services in these provinces. Pregnant women attending the clinics were selected to assess care at these services. The sampling frame for the facility survey consisted of the antenatal clinics that referred patients to the delivery sites where the first component of the PEARL study, a cord blood surveillance exercise had taken place.

Includes bibliographical references. / [ Background ] PMTCT has become freely available in many African countries however the impact of these interventions at the population level has not been widely estimated. [ Aim ] The aim of this study was to estimate the proportion of HIV infected/exposed mother and infant pairs who received the appropriate prophylaxis. [ Methods ] Cord blood specimens were collected anonymously from women delivering in 10 facilities in the Free State from November 2007 to April 2008. Collected specimens were tested for antibodies to HIV. Specimens found to be seropositive were tested for the presence of nevirapine using chromatography. All PMTCT sites used single dose nevirapine as the minimum prophylaxis, a few used dual therapy including zidovudine and nevirapine and some included nevirapine-based HAART for eligible women. Information was also collected from the clinical records. Maternal PMTCT coverage was determined through cord blood chromatography and infant coverage was determined from documentation of receipt on the clinical records. [ Results ] 1619 specimens were collected from women who gave birth to live infants were collected and tested (3.6% collection rate). 472 specimens tested positive for HIV antibodies on cord blood testing giving an HIV prevalence of 29.2% (95% CI 26.9-31.4%). Only 45.8% (95% CI 41.2-50.4%) of the 472 live infants born to HIV-infected mothers received both the maternal and infant doses of ARV prophylaxis. Reasons for failed dosing included, pre-test counseling not offered, refused testing, positive test resultnot received, prophylaxis was not dispensed, mother did not adhere and infant did not receive the prophylaxis dose. [ Conclusion ] This study showed that coverage in the Free State Province is poor despite the national expansion of PMTCT services to all antenatal sites. Failures occurred at each step of the PMTCT cascade and resulted in low coverage. Interventions should be introduced at each step of the PMTCT cascade to increase coverage.

Includes bibliographical references. / Health outcomes generally improve with increasing socio-economic status [SES]. This is referred to as the socioeconomic gradient in health. With regard to HIV, this gradient has been observed to conform to this general pattern and is consistent in developed countries but not in sub-Saharan African [SSA] countries. In SSA, observed patterns include; direct, inverse, lack of association and, dynamic association where the relationship changes over time. In general, literature shows that the relationship between SES as measured by education or asset quintiles and HIV changed from a direct association in early phases of the HIV epidemic to an inverse association in mature epidemics in majority of countries in SSA. In this study, we used a combination of measures of SES including education, assets, employment status and type of occupation to investigate the association between SES and HIV prevalence using data from a study that evaluated effectiveness of prevention of mother to child transmission of HIV program in Western Cape and Free State Provinces of South Africa.

Rodent infestations are a common problem in low socio-economic areas surrounding Cape Town. The presence of rodents can lead to the contamination of food, damage of infrastructure and the spread of rodent-borne diseases. To control rodent infestations, people in these areas resort to the use of illegal street pesticides which can also compromise their health.

Introduction. In South Africa, HIV-positive women receiving antiretroviral therapy (ART) often are lost to care postpartum and strategies to support long-term engagement in care are needed. Mobile health (mHealth) interventions are emerging as potential strategies for supporting long-term engagement in the prevention of mother-to-child transmission (PMTCT) of HIV care continuum. Smartphone technology and mobile data are getting cheaper and more accessible, however little research has been done to explore the potential for smartphone-based interventions in the PMTCT cascade in low-resource settings. This study explored smartphone use and the acceptability and feasibility of mHealth interventions among postpartum women who were attending the Gugulethu Community Health Centre in Cape Town, South Africa. Methods. This mini-dissertation is composed of three parts. Part A, the protocol, outlines the study methodology and the ethical considerations of the proposed study. Part B, the structured literature review, synthesises available data on uses of mobile phone-based applications to support the PMTCT continuum as well as end-user perceptions and preference for mHealth interventions for PMTCT. The review considered published quantitative and qualitative studies that were conducted in sub-Saharan Africa, the most comparable settings to the study population. Part C, the journal ready manuscript, presents the results of six focus group discussions (FGDs) conducted with 27 HIV-positive, postpartum women who were using a smartphone. Questions assessed the respondent’s general smartphone use, as well as their exposure to and perceptions of mHealth interventions. Results. The review shows that, despite a range of evidence on short message service (SMS) and/or voice call interventions, smartphone-based interventions have not been a focus of prior research to support the PMTCT continuum of care or maternal lifelong ART. Results are promising for SMS and/or voice call to enhance maternal retention, infant HIV testing and infant ART initiation. The review found evidence of acceptability and feasibility of mHealth interventions offered directly to women, or also including their partners and health workers as support systems to address PMTCT challenges. The primary research found little turnover in phones and phone numbers, and about half the women shared their devices with family and friends. Respondents reported high familiarity with smartphone applications such as WhatsApp and Facebook, with WhatsApp cited as the preferred method of smartphone communication. Women had access to reliable data sources such as data bundles, airtime and Wi-Fi, with data bundles perceived as the most cost-effective method to access the internet. Nearly all women were familiar with MomConnect, a national mHealth text support service in South Africa, and most described it positively. Women expressed interest in future HIV mHealth applications including complementary health information on physical activity, nutrition, mental health and basic social services. Conclusions. In the context of rapidly increasing access to smartphones, even in low-resource settings, these findings suggest that future smartphone mHealth interventions may be appropriate to support the PMTCT continuum of care in low-income settings of South Africa. These results call for further studies to evaluate the feasibility and effectiveness of smartphone interventions in similar settings.

Introduction: Routine viral load (VL) monitoring is important for assessing the effectiveness of ART in South Africa. There is little information however, on how the longitudinal VL patterns change for subgroups of persons living with HIV (PLHIV) who have experienced at least one elevated VL. We investigated the possible longitudinal VL patterns that may exist among this unique population. Methods: This mini-dissertation offers three components; a research protocol (Section A), a literature review (Section B) and a journal ready manuscript (Section C). We examined HIV VL data for the Western Cape from 2008 to 2018, taken from the National Health Laboratory Services (NHLS). Using< 1000 copies/mL as a threshold for viral suppression, we identified 109092 individuals who had at least one instance of an elevated VL. A nonparametric (KML-Shape) and a model-based (LCMM) clustering technique were used to identify latent subgroups of longitudinal VL trajectories among these individuals. Results: Both the KML-Shape and LCMM clustering techniques identified five latent viral load trajectory subgroups. KML-Shape found majority of individuals' trajectories belonged to clusters that had a decreasing longitudinal VL trend (76.6% of individuals), while LCMM found a smaller proportion of individuals' trajectories belonged to clusters that had a decreasing longitudinal trend (52.5% of individuals). Most of the trajectory subgroups identified had long periods of low-level viremia. Conclusion: Although majority of individuals belonged to clusters that had downward trends, further research is needed to better understand factors contributing to membership of clusters that did not have a downward longitudinal trend. Understanding these factors may help in the development of targeted HIV prevention programs for these individuals.

The use of in vitro fertilization (IVF) has increased over the last several decades in the United States. The influence of IVF on pregnancy complications is not well understood and current methods for quantifying overall success of IVF procedures may be flawed. The aims of this dissertation were to evaluate the extent to which various aspects of IVF treatment are associated with the risk of ischemic placental disease (IPD, defined as preeclampsia, placental abruption, or small for gestational age infant) and to apply novel methods for measuring live birth after IVF success. We used data from a large tertiary care center and an affiliated infertility treatment center. In Study 1, we found an increased risk of IPD in pregnancies conceived by donor and autologous IVF compared with non-IVF pregnancies (risk ratio (RR): 2.5, 95% confidence interval (CI): 2.1-3.1 and RR 1.8, 95% CI: 1.7-2.0, respectively), and the risks were consistently higher for donor IVF pregnancies than autologous IVF pregnancies. In Study 2, we found an increased risk of IPD in pregnancies in the highest and middle tertiles of serum progesterone levels among autologous IVF cycles compared with the lowest tertile (RR 2.0, 95% CI 1.3-3.3 and RR 1.6, 95% CI 0.6-2.6, respectively), although the results were not imprecise. In study 3, we used inverse probability-of-censoring weighting (IPCW) to address a potential violation of the uninformative censoring assumption of the Kaplan-Meier (KM) survival analysis to calculate the cumulative incidence of live birth after multiple cycles of IVF. The two approaches were similar (cumulative incidence of live birth 69.1% using IPCW and 73.9% using KM). However, additional information is needed to calculate better IPCW weights, which may be more important when investigating exposure/outcome relationships. Our results suggest that women undergoing IVF, particularly donor IVF, might benefit from counseling about the increased risk of IPD. Our results also suggest that IPCW methods offer an improvement over other methods for validly estimating cumulative incidence of live birth across multiple IVF cycles. The routine application of IPCW methods to estimating incidence of live birth in epidemiologic studies will allow patients to make better-informed decisions about whether to pursue treatment.

Certain pitfalls associated with propensity score matching have come to light, recently. The extent to which these pitfalls might threaten validity and precision in pharmacoepidemiologic research, for which propensity score matching often is used, is uncertain. We evaluated the “propensity score matching paradox” – the tendency for covariate imbalance to increase in a propensity score-matched dataset upon continuous pruning of matched sets – as well as the utility of coarsened exact matching, a technique that has been posed as a preferable alternative to propensity score matching, especially in light of the “propensity score matching paradox”. We show that the “propensity score matching paradox” may not threaten causal inference that is based on propensity score matching in typical pharmacoepidemiologic settings to the extent predicted by previous research. Moreover, even though coarsened exact matching substantially improves covariate balance, it may not be optimal in typical pharmacoepidemiologic settings due to the extreme loss of study size (and resulting increase in bias and variance) that may be required to build the matched dataset. Finally, we explain variability in 1:1 propensity score matching without replacement as well as methods that were developed to account for this variability, with application of these methods to an example claims-based study. / 2021-06-03T00:00:00Z

The focus of this study was on potential social determinants of health factors that influence the prevalence of type 2 diabetes in the general population of Canada, with emphasis on the disproportion in rates of the disease between Aboriginal and non-Aboriginal populations of Canada. This study also examined the risk factors that are peculiar to the general, Aboriginal, and non-Aboriginal population of Canada. A total number of 101,080 individuals who were 18 years and above provided data for this study. The data and information obtained from these participants were used to answer the major research questions regarding if there was any association between the social determinants of health and the prevalence of type 2 diabetes in the Aboriginal and non-Aboriginal populations of Canada. Multiple logistic regression technique was the main statistical method adopted for this study. Results showed that smoking was peculiar to the prevalence of the disease in the Aboriginal population. It was also revealed that, while the same risk factors could be responsible for both Aboriginals and non-Aboriginals, the odds of having this disease was higher among Aboriginals in Canada. The results also indicated that risk factors such as sleep apnea, scoliosis, migraine, asthma, and osteoporosis to be significantly associated with the prevalence of type 2 diabetes in Canada. While scoliosis reduces the odds of type 2 diabetes in the non-Aboriginal population, it increased the odds in the Aboriginal population. The adverse and disproportionate impact of these risks factors on Aboriginals in Canada means governments at all levels in Canada and other stakeholders need to pay attention to the problem of smoking, sedentary and unhealthy lifestyle, lack of quality education, and income opportunities.