Introduction. Previous studies have established that infants born to mothers with advanced HIV disease and co-infections are smaller, premature and have rapidly progressive HIV disease and an early death. King Edward VIIIth Hospital, in Durban, admits many sick mothers and manages a large proportion of low birth weight and ill newborns. On discharge and follow-up, the mortality and morbidity of these infants are known to be high and are related to the prematurity. How much is related to being HIV exposed is still uncertain. Aim. To determine the perinatal transmission rate of HIV-1 and mortality at 12 months in HIV exposed infants that were admitted to and discharged from the Neonatal Unit, in Durban, South Africa. Methods. In this observational study, data from the outpatient charts of HIV exposed infants that required specialised neonatal care and subsequent follow up, between the period November 2007 and December 2009, were collected. Perinatal transmission rates and mortality of these infants were compared with maternal and infant risk factors. Results. Data on 463 HIV exposed, predominantly low birth weight infants are presented. The median maternal CD4 count was 309cells/mm3 with 16.8% of mothers commenced on HAART. Maternal co-infection with TB was found in 19.2% of the cohort. Early HIV transmission occurred in 11.5% of infants and was influenced by the type of ARV exposure (None, 20%; single dose NVP, 14.3%; dual therapy, 10.6%; maternal HAART, 8.5%). The dual therapy regimen for 7 days was more protective than that for 28 days (p=0.045). HIV infection was associated with higher risk of neonatal sepsis (RR 1.6; 95% CI, 1.1-2.3; p=0.015). The mortality for the cohort at 12 months was 10%. Maternal HAART was associated with a lower mortality: 2.95% vs.10.2% (RR 3.0; 95% CI, 0.4-20.5). There was a higher mortality rate in those that were low birth weight (RR 4.2; 95% CI, 1.02-18.8; p=0.037); those that were HIV infected (RR 4.8; 95% CI, 1.9-11.6; p=0.002) and those that were breastfeeding compared to formula feeding (RR 2.7; 95% CI, 1.1-6.8; p=0.038). Discussion. Rates of HIV transmission within the PMTCT programme were similar to that reported by the Department of Health. Early maternal ARVs for PMTCT prophylaxis, prevents HIV transmission. The coverage of maternal HAART was sub-optimal. Breastfeeding was associated with a higher HIV transmission rate and was most likely associated with non-exclusive breastfeeding during neonatal admission. Recommendations. Maternal HAART or ARV prophylaxis should be commenced early in the pregnancy for the best benefits. Meticulous attention should be paid to the feeding practices of high risk HIV exposed infants admitted for specialised neonatal care. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2012.

HIV-1 specific CD4+ T cell activity in clade C infected subjects has not been studied. CD4+ T cells play a vital role in controlling infectious diseases and there is a need to augment our knowledge of HIV immunology to aid vaccine design. We therefore embarked on a study to characterize HIV-1 specific CD4+ T cell activity in both adults and infants; assess the relationship between CD4+ and CD8+ immune responses; and the relationship between CD4+ T cell activity and markers of disease progression (viral loads and CD4 counts). Our study revealed that the magnitude of CD8+ T cell responses correlated significantly with CD4+ T cell responses, but that the percentage of CD8+ T cells directed against HIV-1 was always greater than that of CD4+ T cells. Gag was the frequently targeted HIV-1 protein by CD4+ T cells and had the highest density of epitopes targeted by CD4+ T cells. Patients with either a dominant CD4 or CD8 T cell response against Gag had significantly lower viral loads than patients in whom non-Gag proteins were the main target (p< 0.0001 for CD4 activity and p= 0.007 for CD8 responses). Single IFN- producing CD4+ T cells were present in significantly higher numbers than cells producing both IFN- and IL-2 simultaneously (p=0.009). Gag also dominated the CD4+ T cell response in acutely infected infants with IFN- production detected more frequently than IL-2 or TNF- . Longitudinal analysis of infants receiving early ARV treatment and then ceasing after 12 months revealed that early treatment conferred no protection against increasing viremia and disease progression. CD4+ T cell responses were detected sporadically in untreated infants indicating a dysfunctional immune response in the face of constant exposure to high levels of viremia. Taken together, the data reveal that a vaccine inducing Gag specific CD4+ T cell responses has the potential to confer some degree of protection, but other immunological parameters need to be investigated especially in infants. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2011.

Background: Despite years of implementation, the program for PMTCT is not reaching the HIV positive pregnant women. Poor documentation as well as poor monitoring and evaluation for the program has contributed to the poor performance. This has led to South Africa being one of the 12 countries in the world with an increasing child mortality rate which is related to HIV/AIDS. Multi-steps and the complexity of the program and poor documentation have resulted in gaps in the provision of care. Objective: The aim of the study was to assess the documentation of the core activities of Prevention of Mother-to-Child Transmission of HIV program provided to pregnant women from antenatal, maternity and post-natal care at a selected Regional hospital in Ethekwini District. Methods: A non-experimental retrospective descriptive exploratory design informs the study. Provides a description of whether the activities of PMTCT are perfomed through the use of documented activities on patient’s charts. A data extraction tool was used to extract information, with the demographic information as well as the key activities of PMTCT. One hundred and thirty charts of women who had delivered in the hospital of study were sampled. Results: The study revealed gaps in the documentation of some activities, with dual therapy initiated at antenatal clinic documented to be n=98(75%), whilst NVP to the baby was 105/130 (80%). The results are in contrast with Horwood’s (2010) study which reported 91% receiving the Nevirapine prophylaxis. Although there are children missed by the program, it is interesting to note that more babies are receiving prophylaxis compared to women receiving NVP. The cd4 count, n=78(60%) uptake, seems not to be doing well, with only n=45(35%) , which is supported by Horwood’s (2010) study that showed much improvement in the cd4 uptake (70%) compared to the study results of 60%, but less cd4 results documented were reported by Horwood (2010), showing 33% respectively. Conclusion: The National strategic Plan’s (SADOH, 2007- 2011/2013) for South Africa, as well as the global Millennium Development Goals can only be achieved if all the activities for the PMTCT are improved. Documentation of activities remains the key to improved care. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2011.