In the context of HIV high infection rate in South Africa, an assumption can be made that there is a high prevalence of HIV-associated neurocognitive disorders or cognitive linguistic deficits. The aim of this study was to determine assess whether highly active antiretroviral therapy (HAART) affected the cognitive – linguistic abilities of individuals living with HIV and AIDS before and after HAART use; and to determine whether their functional performance in terms of engaging in activities of daily living was affected by HAART use. Adults living with HIV and AIDs were recruited through purposive convenience sampling to participate in the study. They were divided into three groups. The experimental and cross sectional group included participants who were HIV infected and initiated HAART. The comparison group included participants who elected not to start HAART. Participants in all three group were assessed using the Cognitive – Linguistic Quick Test and were also required to fill out a structured interview scale at baseline, four and eight months. For the experimental group 55 participants were tested at baseline, 55 at four months and 52 at eight months after HAART initiation. The comparison group included 21 participants who tested at baseline, ten at four months and nine at eight months. The cross sectional group included different participants who recruited at baseline (55) before HAART initiation, then again at four (44) and eight months (42) after HAART initiation. Descriptive analysis revealed that the mean scores for both the Cognitive – Linguistic Quick Test (CLQT) and the structured interview schedule (IS) in all the cognitive domains increased for all three groups from four and eight months after testing. However the severity ratings provided by the CLQT indicated that neurocognitive deficits were still prevalent among the participants after HAART intiation. The most impaired cogntive – linguistic ability was executive functions and the least impaired was language. One way ANOVA analysis on the CLQT and IS revealed that was a signiifcant difference in performance between the three groups at baseline, four and eight months. Repeated measures analysis revealed significant differences or improvements within participants across the three time periods. The greatest improvement was observed from baseline to eight months especially on the CLQT. ANCOVA analysis on the Cognitive- Linguistic Quick Test indicated that education had a major impact on cognitive – linguistic abilities followed by age and CD4 count. However, ANCOVA analysis on the structured interview scale revealed that the effect of time, participant group and to a lesser extent age influenced the participants cognitive – linguistic abilities when it came to perfroming activities of daily living. Quantitave inquiry using content analysis showed that participants in all three groups cited attention, followed by visual and language problems as hindering their abilities to perform activities of daily living. The implications from this study revealed that even though HAART improves cognitive –linguistic abilities, neurocognitive deficits were still prevalent. Therefore findings suggest that health professionals need to monitor the neurocognitive impairments of their patients so as determine levels of functional performance.

Besides constituting major obstacle to effectively addressing HIV/AIDS, Stigma has remained among the least understood experiences of PLWHA. Limited knowledge and understanding of HIV/AIDS related S&D has very much contributed to poor implementation and in most cases failure of HIV intervention programmes at national, regional and international levels. Sociological analysis of Stigma in PLWHA lends verifiable insight into the nature, extent and comprehensiveness of HIV/AIDS related Stigma. With 129 participants from Gauteng regions of Ekurhuleni, Sedibeng and West Rand, the study confirms that Stigma and Discrimination (S&D) still thrives, quantifying its magnitude, implications and impacts in the lives of the HIV infected. Inter alia, the findings showcase the complex matrix analysis of emotion and behaviour associated with HIV/AIDS related S&D. Finally, the study offered a comprehensive recommendation on how to address HIV/AIDS related S&D at individual/family, institutional/community and government levels. / Sociology / M.A. (Social Behaviour Studies in HIV/AIDS)

The humanised Aids patient increasingly finds itself a part of mainstream popular rhetoric. There was a time however, when the Aids patient was no more than a disease ravaged corpse without rights. Conventional histories and analyses tend to gloss over this fact, or argue that the new, authentic patient is a triumph of wisdom over brute ignorance, fear and superstition. Such accounts overlook their own role and the part played by the bio-medical sciences in constructing the Aids patient. This thesis, in contradistinction, traces the Aids patient's portrayal in South African bio-medical discourses, applying to it the work of Michel Foucault. In doing so the dynamic interactions of power and knowledge are brought under the spotlight. / Psychology / M.A. (Psychology)

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: HIV infection, substance abuse, and psychiatric disorders are major public health issues in South Africa. Psychiatric disorders and substance-use disorders together have a negative impact on the health outcomes of people living with HIV and AIDS (PLWHA), such as poor adherence to anti-retrovirals (ARVs), HIV disease progression, lower CD4 counts, vulnerability to opportunistic infections, high viral loads, possible drug resistance, and an earlier onset of death. The overall aim of this study was to investigate the relationship between substance abuse practices and the health status and health behaviour of patients attending HIV clinics in the Cape Metropole. The study used a cross-sectional study design for collecting data on hazardous or harmful use of alcohol and problematic drug use, demographic information and health status among patients attending eight HIV clinics in the Cape Metropole. A sub-sample of patients were assessed on the following domains: depression, psychological distress, psychopathology, post-traumatic stress disorder (PTSD), risky sexual behaviour, adherence to ARVs, levels of resilience, levels of social support and patient’s work, family and social functioning. Of the 608, 10% of consecutively selected patients completed an additional psychiatric diagnostic interview (Mini International Neuropsychiatric Interview). The main findings to emerge from this study are: 1. Patients reporting hazardous or harmful use of alcohol and/or drug use are significantly more likely to be non-adherent to ARVs and have lower CD4 counts than their non-substance abusing counterparts 2. Hazardous or harmful use of alcohol has a direct influence on CD4 count resulting in lower CD4 counts and participants being less likely to be on ARVs. 3. Hazardous or harmful use of alcohol has a direct relationship in predicting tuberculosis (TB). 4. Hazardous or harmful users of alcohol and/or problematic drug users are more likely to report psychological distress (anxiety and depression), depression and low levels of family support than their non-using counterparts. 5. Participants who met the criteria for major depression are significantly more likely to be non-adherent to ARVs. 6. Gender, depression, psychological distress, and PTSD were found to be significant determinants of hazardous or harmful use of alcohol. 7. Psychological distress (anxiety and depression) is significant in directly predicting ARV non-adherence. 8. Male participants and those who stopped taking their ARVs were more likely to have lower CD4 counts than female participants and those who did not stop. 9. PTSD was found to predict psychological distress indicating that participants who experienced trauma were more likely to suffer from psychological distress (anxiety and depression) compared to those who did not experience any PTSD. Participants with lower levels of family support were more likely to suffer from psychological distress than those with high levels of family support. / AFRIKAANSE OPSOMMING: MIV infeksie, dwelmmisbruik en geestesversteurings is groot gesondheidskwessies in Suid-Afrika. Geestesversteurings en dwelmmisbruik het gesamentlik 'n negatiewe uitwerking op die gesondheid van mense wat met MIV en VIGS saamleef (PLWHA), soos byvoorbeeld nie-nakoming in die gebruik van antiretrovirale (ARV’s), MIVsiekteverloop, laer CD4-tellings, vatbaarheid vir opportunistiese infeksies, hoë virale ladings, moontlike weerstand teen medikasie en 'n verkorte leeftyd. Die oorkoepelende doel van hierdie studie was om die verhouding tussen dwelmmisbruik en die gesondheidstatus en -gedrag van pasiënte wat MIV klinieke in die Kaapse Metropool besoek, te bestudeer. Die studie het 'n deursnee-ontwerp gebruik om data in te samel oor die nadelige en gevaarlike gebruik van alkohol en problematiese dwelmgebruik, demografiese inligting, en die gesondheidstatus onder pasiënte wat agt MIV klinieke in die Kaapse Metropool besoek het. 'n Subgroep pasiënte geassesseer op die volgende gebiede: depressie, psigologiese angsversteuring, psigopatologie, posttraumatiese stresversteuring (PTSV), riskante seksuele gedrag, nakoming in die gebruik van ARV’s, weerstandigheidsvlakke , vlakke van sosiale ondersteuning, asook pasiënte se werk, familie en sosiale funksionering. Van die 608 deelnemers is 10% van die pasiënte opeenvolgend geselekteer om 'n addisionele diagnostiese psigiatriese onderhoud te ondergaan (Mini International Neuropsychiatric Interview). Die vernaamste bevindinge wat uit die studie gekom het, is: 1. Pasiënte wat nadelige en gevaarlike gebruik van alkohol en/of dwelms rapporteer is beduidend meer geneig om nie die gebruik van ARV’s na te kom nie, en het laer CD4-tellings as hulle eweknieë wat nie dwelms misbruik nie. 2. Die nadelige en gevaarlike gebruik van alkohol het 'n direkte invloed op CD4- tellings wat lei tot laer CD4-tellings en dat pasiënte minder geneig is om op ARV’s te wees. 3. Die nadelige en gevaarlike gebruik van alkohol hou direk verband met die voorspelbaarheid van tuberkulose (TB). 4. Nadelige en gevaarlike gebruikers van alkohol en/of problematiese dwelmgebruikers, is meer geneig om psigologiese angsversteurings (angs en depressie), depressie, en laer vlakke van familieondersteuning te rapporteer as hul niegebruiker-eweknieë. 5. Deelnemers wat aan die kriteria vir ernstige depressie voldoen, is aansienlik meer geneig tot nie-nakoming in die gebruik van ARV’s. 6. Daar is gevind dat geslag, depressie, psigologiese angs en PTSV beduidende bydraende faktore is tot die nadelige en gevaarlike gebruik van alkohol. 7. Psigologiese angsversteurings (angs en depressie) is beduidend om direk die nie-nakoming van ARV’s te voorspel. 8. Manlike deelnemers en diegene wat hul ARV’s gestaak het, was meer geneig om laer CD4-tellings te hê as vroulike deelnemers en diegene wat nie die gebruik van medikasie gestaak het nie. 9. Daar is gevind dat PTSV psigologiese angs voorspel het wat aandui dat deelnemers wat trauma ondervind het, meer geneig was om aan psigologiese angsversteurings (angs en depressie) te ly in vergelyking met diegene wat geen PTSV ervaar het nie. Deelnemers met laer vlakke van familieondersteuning was meer geneig om aan psigologiese angsversteurings te ly as diegene met hoë vlakke van familiebystand.

Text in English / The aim of the study was to explore the experiences of adult offenders living with HIV (OLWHIV) not qualifying for antiretroviral therapy (ART). Such offenders are put on the pre-antiretroviral therapy (pre-ART) program after HIV diagnosis. Follow up of OLWHIV is done every six months to ensure prompt treatment. Research objectives include exploration of experiences of OLWHIV on the pre-ART program, the accessibility of the program and the challenges thereof. An exploratory, qualitative study with face-to-face interviews was conducted. Purposive sampling of the eight participants was done to conduct the study. Seven out of eight participants accessed the pre-ART program well but had little knowledge of the pre-ART program. Furthermore, participants experienced little support from partners and health care workers. The study showed institutional constraints such as poor diet, shortage of staff and humiliation from Correctional officers. Participants portrayed commitment in the support group irrespective of the challenges experienced. The study further showed that the self-care theory could enhance the pre-ART program but that institutional constraints deterred the progress. Participants made recommendations such as strengthening of partnerships for support groups, good diet, and an increase of staff capacity. Overall study recommendations include implementation of universal test and treat and mixed methods for future studies. / Sociology / M.A. (Social Behaviour Studies in HIV/AIDS)

Besides constituting major obstacle to effectively addressing HIV/AIDS, Stigma has remained among the least understood experiences of PLWHA. Limited knowledge and understanding of HIV/AIDS related S&D has very much contributed to poor implementation and in most cases failure of HIV intervention programmes at national, regional and international levels. Sociological analysis of Stigma in PLWHA lends verifiable insight into the nature, extent and comprehensiveness of HIV/AIDS related Stigma. With 129 participants from Gauteng regions of Ekurhuleni, Sedibeng and West Rand, the study confirms that Stigma and Discrimination (S&D) still thrives, quantifying its magnitude, implications and impacts in the lives of the HIV infected. Inter alia, the findings showcase the complex matrix analysis of emotion and behaviour associated with HIV/AIDS related S&D. Finally, the study offered a comprehensive recommendation on how to address HIV/AIDS related S&D at individual/family, institutional/community and government levels. / Sociology / M.A. (Social Behaviour Studies in HIV/AIDS)

The humanised Aids patient increasingly finds itself a part of mainstream popular rhetoric. There was a time however, when the Aids patient was no more than a disease ravaged corpse without rights. Conventional histories and analyses tend to gloss over this fact, or argue that the new, authentic patient is a triumph of wisdom over brute ignorance, fear and superstition. Such accounts overlook their own role and the part played by the bio-medical sciences in constructing the Aids patient. This thesis, in contradistinction, traces the Aids patient's portrayal in South African bio-medical discourses, applying to it the work of Michel Foucault. In doing so the dynamic interactions of power and knowledge are brought under the spotlight. / Psychology / M.A. (Psychology)

South Africa has an estimated 920 000 patients on antiretrovirals (ARVs), the largest number of patients in any country. ARV therapy demands adherence levels in excess of 95% to avoid development of drug resistance, but adherence to ARV therapy is estimated to be only between 50% and 70%. Poor medication adherence is acknowledged as a major public health problem, reducing the effectiveness of therapy and promoting resistance to ARVs. More than two thirds of the South African population have marginal reading skills and this significantly influences a patient’s ability to read and understand health-related information. Patient education materials tailored for the South African population could be a useful aid in facilitating communication with patients and perhaps impact positively on their medicine-taking behaviour. This behaviour is influenced by patient knowledge, beliefs, attitudes and expectations and includes self-management, self-efficacy and adherence. Self-efficacy, which refers to patient confidence in the ability to self-manage medicine taking, is a key factor influencing adherence. This study aimed to develop illustrated patient information leaflets (PILs) and medicine labels for all first-line ARV regimens used in the public health sector in South Africa and, using a randomised control study design, to investigate the impact of these illustrated information materials on knowledge, medication-taking behaviours and health outcomes in HIV/AIDS patients taking ARVs. To achieve this aim, the objectives were to assess HIV/AIDS and ARV-related knowledge, as well as self-efficacy and adherence to ARV therapy; to assess the influence of demographic variables on knowledge, adherence and self-efficacy; to assess the influence of the information materials on knowledge, self-efficacy and adherence and to assess the association of knowledge with health outcomes. Medicine labels and PILs, both English and isiXhosa, were developed for ARV regimens 1a, 1b, 1c and 1d. The 8-item Morisky Medication Adherence Scale (MMAS-8) and HIV Treatment Adherence Self Efficacy Scale (HIV-ASES) instruments for measuring respectively adherence and self-efficacy, were modified to optimize clarity, simplicity and cultural acceptability and were translated into isiXhosa using a multi-stage translation-back translation. The questions and the rating scales, for both the MMAS and HIV-ASES, underwent preliminary qualitative evaluation in focus group discussions. Patients were recruited from local Grahamstown clinics. A pilot study to evaluate applicability of the instruments was conducted in 16 isiXhosa AIDS patients on ARVs and the results from this study informed further modifications to the instruments. One hundred and seventeen patients were recruited for the randomised control trial and were randomly allocated to either control group (who received standard care) or experimental group (who received standard care as well as pictogram medicine labels and the illustrated PIL). Interviews were conducted at baseline and at one, three and six months. Data were analysed statistically using the t-test, chi-squared test and ANOVA (Analysis of Variance) at a 5% level of significance. Correlations were determined using Pearson and Spearman rho correlations. Approval was obtained from Rhodes University Ethical Standards Committee, Settlers Hospital Ethics Committee and the Eastern Cape Department of Health. The results of this research showed that illustrated PILs and medicine labels enhanced understanding of HIV/AIDS and ARV information, resulting in a mean overall knowledge score in the experimental group of 96%, which was significantly higher than the 75% measured in the control group. Variable knowledge scores were measured in three areas: baseline knowledge of general HIV/AIDS-related information was good at 87%, whereas knowledge scores relating to ARV-related information (60%) and side-effects (52%) were lower. These scores improved significantly in the experimental group over the 4 interviews during the 6 month trial duration, whereas in the control group, they fluctuated only slightly around the original baseline score. There was no significant influence of gender on knowledge score, whereas health literacy, education level and age tested (at one and three months) had a significant influence on knowledge. Self-efficacy and adherence results were high, indicating that the patients have confidence in their ability to adhere to the ARV therapy and to practice optimal self-care. Age, gender and education, in most cases, significantly influenced self-efficacy, but were found to have no effect on adherence. The CD4 count improved over the trial duration which may have been influenced by a number of factors, including better knowledge of ARVs and improved adherence. No significant parametric correlation was found between knowledge score and change in CD4 count, however, Spearman's rho showed significance (rs=0.498; p=0.022). Both patients and healthcare providers were highly enthusiastic about the illustrated labels and PILs, and indicated their desire for such materials to be routinely available to public sector HIV/AIDS patients. The isiXhosa version of the PIL was preferred by all the patients. These simple, easy-to-read leaflets and illustrated medication labels were shown to increase understanding and knowledge of ARVs and HIV/AIDS in low-literate patients, and their availability in the first-language of the patients was central to making them a highly useful information source.

Department of Public Health / MPH

Department of Advanced Nursing Science / MCur