MPH / Department of Public Health

Department of Advanced Nursing Science / MCur

Background: Non-disclosure of HIV positive status to a partner threatens to reverse gains made in prevention of mother-to-child transmission (PMTCT) in resource limited settings. Determining the association between non-disclosure and infant HIV acquisition is important to justify focussing on disclosure as a strategy in PMTCT programmes. Objective: To determine the association between non-disclosure of HIV positive status to a partner and mother-to-child transmission (MTCT). Methods: Using a matched case-control design, we compared 34 HIV positive infants to 146 HIV negative infants and evaluated whether the mothers had disclosed their HIV status to their partner. Results: Non-disclosure was more frequent among cases (overall, 16.7%; cases, 52.8%; controls 7.6%), p<0.001 and significantly associated with MTCT (aOR 8.9 (3.0-26.3); p<0.0001), with male partner involvement partially mediating the effect of non-disclosure on MTCT. Conclusions: There is a need for PMTCT programs to focus on strategies to improve male partner involvement and partner disclosure without compromising the woman’s safety. / Health Studies / M. (Public Health)

Thesis (MMed (Medical Microbiology))--University of Stellenbosch, 2006. / One of the major routes of transmission of human immunodeficiency virus (HIV) in the developing world is vertical transmission from mother to infant – pre-, intra-, or post-partum. In the Western Cape, HIV-1 subtype C is the predominant subtype in the heterosexual population, and this trend was expected to be seen amongst cases of mother-to-child transmission of HIV. The aim of this study was to perform genetic characterisation and phylogenetic analysis of the HIV-1 genome in positive serum/plasma samples obtained from children (age 0 to 18 months) from 2000-2002, and temporally related specimens from their mothers. We obtained 27 suitable pairs of samples taken within 6 months of delivery. From this pool, we obtained 21 infant DNA sequences and 17 maternal sequences, resulting in 16 mother-infant pairs. All patient sequences were identified as HIV-1 subtype C, and, as expected, mother and infant viral sequences clustered together. In some cases where a mother was suspected to have two dominant quasispecies based on the electropherogram, only one sequence was detectable in the infant. Single or multiple amino acid deletions were consistent between mothers and infants, and some pairs showed the same amino acid deletions seen in other pairs.

Thesis (MBA)--Stellenbosch University, 2003. / Some digitised pages may appear illegible due to the condition of the original hard copy / ENGLISH ABSTRACT: After sexual transmission of HIV, mother-to-child (MTCT) transmission is the most common cause of HIV infection in South Africa. The Western Cape government, through the Premier, has committed itself to providing access for all HIV positive women in the province attending antenatal clinics to MTCT prevention programmes by the end of 2003. The MTCT prevention programme is aimed at intervening transmission during pregnancy, during the birth of the baby and post delivery during breast-feeding of the newborn baby. The HIV virus attacks and destroys the cells of the immune system by being incorporated into the reproductive cycle of the cell. Antiretroviral drugs in the fight against HIV target two aspects of this replication cycle of the virus and as such do not halt the infection but slow it down by preventing the replication of the virus. MTCT internationally has been reduced dramatically by the use of antiretroviral drugs (AZT) antenatally, during birth and post-natally for mother and baby. However this regimen was found to be not suitable for resource-poor countries due to the complexity in administration, compliance and costs. Poor countries have developed alternative MTCT prevention programmes based on shorter course regimens and on alternative antiretroviral drugs. MTCT prevention In South Africa initially did not have the support of the national government. However, the -Western Cape Administration had developed a regional programme phasing in MTCT prevention at all state clinics within the province. The cost drivers associated with the MTCT prevention programme include costs associated with the HIV tests, costs for pre- and post-test counselling, costs for the antiretroviral drugs and costs for substitute feeding to replace breast-feeding to prevent viral transmission during breast-feeding. Depending on the option exercised, costs can be calculated per HIV positive baby averted. As regards substitute feeding, which is a substantial cost driver and a major disadvantage to the newborn baby as regards protection from common childhood diseases such as diarrhea, research from Tanzania showed that ARV therapy during childbirth could suppress HIV transmission through breast-feeding during the first few weeks after childbirth, thus enabling an optimal combination of breast-feeding in the first few crucial weeks of the newborn's life for the protective benefits of breast-milk and formula feeding thereafter to ensure protection for the infant from HIV transmission through breastfeeding. The data were subjected to a sensitivity or a "what-if' analysis usmg an Excel spreadsheet. Costs per HIV averted were calculated for each assumed parameter in the model that was developed. As regards prevalence, the MTCT prevention programme is most cost effective at the lower levels of the seroprevalence of HIV in the population served. If the seroprevalence is above the "cross-over" or "optimal" point for the regimen an alternative regimen should be assessed. As regards levels of identification and number accepting intervention the principle of an economy of scale applies and therefore, a level of 100 percent in both cases should be targeted. This will be dependent on wide scale advertisements and support for the programme with active efforts to destigmatise the infection. Innovative programmes such as the mothers-to-mothers-to-be (M2M2B) programme must be encouraged. / AFRIKAANSE OPSOMMING: Na seksuele oordraging van HIV is moeder tot kind (MTK) oordraging die algemeenste rede van HIV infeksie in Suid Afrika. Die Wes-Kaapse regering, deur die Premier, het hulself verbind om toegang vir alle HIV positiewe vroue in die provinsie, wat voorgeboorte klinieke bywoon, tot MTK voorkomingsprogramme voor die einde van 2003 moontlik te maak. Die MTK voorkomingsprogram is gerig op die tussenkoms van transmissie gedurende swangerskap, gedurende die geboorte en die nasorg tydens die borsvoeding periode van die pasgebore baba. Die HIV virus val die selle van die immuun sisteem aan en' vernietig dit. Die virus word geïnkorporeer tot die reproduksie siklus van die sel. Antiretrovirale wat teen die virus gerig is, is gerig teen twee aspekte van die replikasie siklus van die virus en sodoende sal die medikasie die infeksie nie staak nie, maar eerder vertraag as gevolg van die voorkoming van die replikasie. Moeder-tot-kind infeksie is internasionaal drasties verminder deur die gebruik van antiretrovirale (AZT) gedurende die tydperk voor geboorte, gedurende die geboorte en gedurende nasorg van die moeder en baba. Hierdie regimen is egter nie altyd moontlik in arm lande nie vanweë die kompleksiteit van die administratiewe toepassing en kostes. Arm lande het alternatiewe MTK voorkomingsprogramme ontwikkel, gebaseer op korter kursusse en alternatiewe antiretrovirale. Die voorkoming van MTK infeksie in Suid-Afrika het eers nie die ondersteuning van die nasionale regering geniet nie. Die Wes-Kaapse Adminstrasie het onafhanklik van die nasionale regering, streeksprogramme ontwikkel vir die infasering van MTK voorkoming in alle klinieke in die Provinsie. Die kostedrywers wat met MTK voorkomingsprogramme geassosieer word, sluit in die koste van HIV toetse, koste van voor-en-na toets berading, koste van die antiretrovirale en alternatiewe voeding om virale transmissie te voorkom gedurende die tydperk van borsvoeding. Afhangende van die opsies wat gebruik is, kan die koste van elke baba wat nie HIV opdoen nie, bereken word. Sover dit alternatiewe voeding aangaan, wat 'n belangrike kostedrywer is en 'n nadeel vir elke baba is sover dit teen beskerming van algemene kindersiekte soos diarrhea gaan het navorsing in Tanzanië bewys dat ARV terapie gedurende geboorte ook HIV transmissie deur borsvoeding gedurende die eerste paar weke na geboorte onderdruk wat 'n optimale kombinasie van borsvoeding in die eerste paar kritiese weke van die nuutgebore baba se lewe vir die beskermende voordele van moedersmelk en formulêre voeding daarna te versterk met beskerming van die baba teen HIV transmissie deur borsvoeding. Deur die gebruik van 'n Excel werkblad en 'n "wat as" metode van analiese koste van HIV opdoen in bereken word vir elke aanvaarding. Sover dit voorkoms betref is die MTK voorkomingsprogramme die mees effektief hoe laer die "seroprevalence" van HIV in die populasie gedien word. As die "seroprevalence" hoër as die optimale punt is, moet 'n ander metode bereken word. Sover dit die mate van identifisering en hoeveelheid die tussenkoms aanvaar in 'n mate van 100 persent moet in beide gevalle die mikpunt wees. Dit sal afhang van grootskaalse advertensies en ondersteuning van die programme met bedrywige pogings om die' infeksie te destigmatiseer. Nuwe programme soos die moeder tot nuwe moeder (M2M2B) program moet aangemoedig word.

The purpose of this Qualitative study was to explore HIV related stigma experienced by women enrolled in the Prevention of Mother to Child (PMTCT) prgramme in the EThekwini District, Kwazulu Natal. Descriptriptive phenomenology informed the study design, data collection and analysis. Despite increasing access to Prevention of Mother to Child Transmission initiatives, including anti-retroviral drugs, the Stigma of being HIV positive, particularly for women, largely outweigh the potential gains from available treatments. HIV/AIDS related stigma drives the epidemic underground and is one of the main reasons that people do not wish to know their HIV status Purposeful sampling was used to select seven women attending PMTCT programme in the EThekwini District. These women were selected in four clinics in the District. Data was collected through in-depth interviews lasting about 45 minutes to an hour. These interviews were tape recorded and later transcribed to aid analysis. The Colaizzi method of data analysis was utilized. Four themes emerge from the data, each with three to eight subthemes confirming the experiences and presence of stigma during programme participation. All participants reported incidence of being stigmatized, particularly in the Health care setting. They took great strides to keep their HIV status confidential to a point of going against programme directives to ensure secrecy of their status thus avoid HIV related stigma. Number of recommendations were made in relation to the PMTCT programme and if accepted will assist in mitigating stigma in HIV related stigma in the PMTCT progarmme and thus reduce vertical transmission. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2011.

In July 2011, The Malawi government started implementing an innovative PMTCT policy known as Option B+ strategy that provides universal lifelong ART for all HIV-infected pregnant and breastfeeding women regardless of clinical or immunological stage. Even though Option B+ strategy is a good choice for Malawi, there is fear that the programme may be affected by poor access, utilisation, adherence and retention. Aim: The aim of this study was to explore the lived experiences of HIV-positive women on Option B+ strategy in a selected district hospital in Malawi. Methodology: A Hermeneutics phenomenological approach was used in this study to explore the lived experiences of HIV-positive women on Option B+ strategy through in-depth interviews of five purposely sampled information rich sources. Interviews were audio-taped and transcribed, then manual data analysis using Giorgi’s approach was employed to identify meaningful segments and develop categories, themes and sub-themes. Results: The lifelong commitment was described as the most challenging aspect of Option B+ strategy. Participants demonstrated lack of knowledge and understanding of Option B+ strategy and its implications which rendered them poorly prepared and unready for the task. The un optional Opt-out HIV testing resulted in participants feeling left out in their own care, as health professionals dominated the care from HIV testing throughout the process. The importance of male involvement in PMTCT was revealed in promoting partner HIV testing, disclosure, support, and prevention of further HIV spread. Barriers to participation were described in terms of attitudes of health care workers, stigma and discrimination. Despite the overemphasised need for women to be supported on Option B+ strategy participants were not willing to seek available sources of formal support. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2013.

Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--Stellenbosch University, 2008. / Objective: Primary: To investigate the effect of pasteurisation on the composition of expressed breast milk from HIV positive mothers and its adequacy in relation to the growth of their VLBW premature infants. Methods: A descriptive, prospective case-controlled pilot study was performed in 3 regional state hospitals in the Western Cape, South Africa. The control and study groups consisted of 12 HIV negative and 11 HIV positive mothers, with their VLBW premature infants, respectively. All mothers (19 - 35 years old) belonged to the Xhosa ethnic group. All infants were born <34 weeks gestation and birth weight <1500g. Eight breast milk samples were collected on days 6, 7, 13, 14, 20, 21, 27 and 28 from all mothers during the first 28 days after birth. Breast milk was expressed by hand or pump from either the right or left breast. Half of each breast milk sample was kept raw. The remaining sample was Pretoria pasteurised, after which both samples were subdivided into 3 or 4 aliquots to determine energy, protein, carbohydrate, fat, folate, calcium, phosphorus, magnesium, sodium, otassium, iron, copper, zinc content and HI viral load (study group only). The mothers’ dietary intake during pregnancy and lactation was obtained by means of a quantitative food frequency questionnaire and repeated 24-hour recall respectively. The infants’ dietary intake was recorded daily. Mothers’ anthropometric measurements taken at study entry and exit were weight, height and mid-upper arm circumference. All infants’ daily weight, as well as length and head circumference at birth and on day 28 postpartum was obtained. Biochemical analysis was performed on the blood samples obtained at study entry and exit from all mothers and infants. For statistical analysis, Statistica® (release no 7, 2006) was used for repeated measures analysis of variance (ANOVA) to determine the effect of HIV, pasteurisation, milk expression and time on the composition of the breast milk. Results: There was no significant difference in the studied macro- and micronutrient composition between raw or pasteurised expressed breast milk from HIV positive and HIV negative mothers with premature infants. A significant decline in breast milk protein (p<0.01), magnesium (p=0.045), potassium (p=0.002), zinc (p<0.01) and copper (p=0.03) content was observed for the whole study population over time, while folic acid content increased significantly (p=0.012) over time. The sodium/potassium ratio of both groups remained strongly indicative of the presence of sub-clinical mastitis. A significant (p=0.03) greater mean volume of milk was obtained with pump [42.5 Standard Deviation (SD) 18.1 ml], compared to hand expression [36.7 (16.7) ml]. Method of expression did not result in a significant difference in breast milk composition for any of the nutrients studied. Eight (35%) infants were born SGA while 21 (91%) infants were SGA on day 28. The infants gained a mean of 16.37 (4.5) g/kg/day (i.e. 91% of the recommended growth rate of >18g/kg/day) from the day on which birth weight was regained. The control and study group infants respectively consumed a mean of 3.27 (1.36) and 3.21 (1.36) g protein/kg/day and 138.1 (33.8) and 142.3 (33.8) kcal total energy/kg/day. This corresponds to a PER of 2.6 (control group) and 2.5 (study group) respectively, which cannot provide for the increased growth needs of the SGA infant in need of catch-up growth. Six infants experienced an incident of Grade 1 NEC which resolved and all completed the study. Two (18%) HIV-exposed infants were found to be HIV positive at 28 days post delivery. Four participating infants died. No adverse event or mortality was related to the study protocol as no intervention was undertaken. Conclusion: HIV positive Xhosa mothers provide as nutritious breast milk to their VLBW premature infants as HIV negative Xhosa mothers. Maternal nutrient intake during pregnancy and lactation did not have a significant effect on the nutritional composition of breast milk, except for folate content.

Background: Non-disclosure of HIV positive status to a partner threatens to reverse gains made in prevention of mother-to-child transmission (PMTCT) in resource limited settings. Determining the association between non-disclosure and infant HIV acquisition is important to justify focussing on disclosure as a strategy in PMTCT programmes. Objective: To determine the association between non-disclosure of HIV positive status to a partner and mother-to-child transmission (MTCT). Methods: Using a matched case-control design, we compared 34 HIV positive infants to 146 HIV negative infants and evaluated whether the mothers had disclosed their HIV status to their partner. Results: Non-disclosure was more frequent among cases (overall, 16.7%; cases, 52.8%; controls 7.6%), p<0.001 and significantly associated with MTCT (aOR 8.9 (3.0-26.3); p<0.0001), with male partner involvement partially mediating the effect of non-disclosure on MTCT. Conclusions: There is a need for PMTCT programs to focus on strategies to improve male partner involvement and partner disclosure without compromising the woman’s safety. / Health Studies / M. (Public Health)

Depuis la description des premiers cas de SIDA pédiatriques en 1983, d’importants progrès ont été réalisés dans la compréhension des mécanismes de transmission, puis dans la prévention de celle-ci, et dans la connaissance de l’histoire naturelle de l’infection par le VIH chez l’enfant. Depuis 1996 les multithérapies ARV ont permis une diminution considérable de la transmission verticale et de la morbidité et mortalité des enfants infectés par le VIH.<p>Les buts de ce travail ont été :<p>• d’évaluer, dans le contexte de l’offre de soin mise en place dans un centre de référence,<p>l’impact de l’administration prophylactique des traitements ARV pendant la grossesse sur la transmission verticale du virus.<p>• de déterminer si l’instauration précoce d’un traitement ARV chez les enfants infectés à la naissance et encore asymptomatiques améliorait le devenir de l’enfant.<p>• de contribuer à l’évaluation de l’impact de l’exposition à la maladie maternelle et aux traitements ARV sur le devenir des enfants non infectés nés de mères infectées par le VIH.<p><p>Une étude rétrospective portant sur les enfants nés de mères infectées par le VIH et suivis à l’hôpital St-Pierre entre 1986 et 2002, nous a permis de comparer 3 cohortes de naissance correspondant à différents types de prise en charge. Nous avons pu montrer que le taux de transmission a diminué globalement de 10% durant la période précédant l’administration de prophylaxie ARV à 5% durant la troisième période où les multithérapies étaient recommandées en prophylaxie durant la grossesse. Nous avons montré<p>que chez les mères qui ne bénéficiaient pas de prophylaxie ARV le taux de transmission avait augmenté significativement entre 1986 et 2002; le plus souvent suite à une prise en charge trop tardive de la grossesse, à un dépistage tardif de la séropositivité maternelle, ou à une mauvaise compliance au traitement.<p>Chez le nouveau-né infecté par le VIH, la multiplication virale est beaucoup plus importante<p>et prolongée que lors de la primo-infection chez l’adulte. Parallèlement, l’évolution clinique de l’infection peut être rapide dans un quart des cas, et aboutir au SIDA ou au décès avant l’âge de 1 an, sans qu’il existe de bons facteurs prédictifs de cette évolution défavorable en début de vie. Jusqu’en 2007, les différentes recommandations internationales indiquaient de débuter un traitement chez les nourrissons infectés lors d’apparition de symptômes cliniques ou d’immunodépression. Cependant dès 1996, certains centres dans des pays industrialisés, dont l’équipe de pédiatrie du CHU St Pierre, ont décidé d’initier un traitement ARV chez tous les nourrissons infectés dès confirmation du diagnostic. En 2006, nous avons initié une étude rétrospective multicentrique incluant 13 cohortes européennes visant à étudier l’impact du traitement précoce sur l’évolution clinique et biologique de l’enfant. Les données de 210 enfants,nés entre 1996 et 2004 et infectés à la naissance ont été analysées, et ont permis de dé4<p>montrer que les enfants traités avant l’âge de 3 mois avaient un risque de développer un sida ou de décéder 5 fois inférieur aux enfants traités après cet âge. Des résultats similaires ont été observés dans une étude randomisée réalisée en Afrique du Sud et publiée simultanément. Depuis, les recommandations internationales ont été revues<p>et préconisent la mise sous traitement de tous les nourrissons infectés. L’analyse des données biologiques a permis de montrer que la réponse virologique immédiate était plus rapide avec un pic de charge virale moins élevé et que la chute des lymphocytes CD4 était moins prononcée lorsque le traitement était débuté précocement.<p>Avec la généralisation de la prophylaxie ARV pendant la grossesse, le nombre d’enfants exposés in utero au VIH mais indemnes de l’infection a considérablement augmenté.<p>Des études, menées principalement dans des pays en développement, ont révélé un risque accru de morbidité et de mortalité infectieuse ainsi que la survenue d’infections sévères inhabituelles chez ces enfants. Nous avons été frappés durant le suivi de ces enfants par la survenue d’un nombre élevé d’infections néonatales causées par le streptocoque du groupe B (GBS). La comparaison avec le taux d’infection observé dans une population contrôle (estimé sur base des naissances survenues pendant la même période dans le même hôpital) nous a permis de décrire une incidence 19 fois supérieure d’infection à GBS chez les enfants exposés au VIH et non infectés que chez les enfants contrôles. Il s’agit du premier travail publié évoquant une susceptibilité accrue aux infections des enfants exposés non infectés dans un pays industrialisé.<p>En conclusion, la prophylaxie ARV pendant la grossesse et en début de vie a permis de diminuer considérablement la transmission verticale de l’infection à VIH. Un dépistage manqué, une prise en charge tardive de la grossesse, ou la mauvaise adhérence au traitement sont encore responsables d’infection du nouveau-né. Lors de confirmation<p>d’infection du nourrisson par le VIH, il est très important de débuter un traitement le plus rapidement possible afin de contrôler rapidement la multiplication virale, de maintenir une bonne immunité et de prévenir le développement de la maladie. Enfin, en l’absence d’infection du nourrisson par le VIH, il est important de poursuivre le suivi pendant les premières années de vie puisqu’il semble que les enfants exposés au<p>VIH et non infectés soient plus susceptible aux infections sévères. Ceci a été démontré en ce qui concerne les infections néonatales à GBS. / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished