PhDH / Department of Public Health / Background: Since the introduction of three-tiered systems appointments, there are a large number of missed appointments among Human immunodeficiency virus-positive clients on Antiretroviral. However, no one knows why these clients missed their scheduled times. Missing of appointments predicts poor adherence and is associated with poor clinical outcomes. Objectives: The proposed study aimed at developing a strategy for reducing the missing of appointments among adults on Antiretroviral Therapy in the Limpopo Province, South Africa. The objectives of the study are to determine patients’ behaviour, the socio-environmental and economic factors that contribute to the missing of appointments and develop strategies to enhance compliance with appointments by Human immunodeficiency virus-positive clients on Antiretroviral therapy in the Limpopo Province. Method: A qualitative research design was used to address the study objectives. Non-probability purposive sampling was used to sample health care centres in Limpopo Province, patients, Professional Nurses and Community Health Workers. Individual interview and focus group discussions strengthened the triangulation of data obtained from the participants. Creswell’s model provided details for data analysis and interpretation. Trustworthiness and Ethics: Measures to ensure data quality, such as credibility, dependability, conformability and transferability, were observed. The researcher ensured compliance with ethical standards to protect the rights of the participants. Approval for this study was obtained from the University of Venda Research Ethics Committee and the Limpopo Department of Health Research Ethics. Results: The study revealed various factors that contribute to the missing of appointments by Human immunodeficiency virus positive-clients on Antiretroviral Therapy. Specific socioeconomic, behavioural, environmental and health service-related factors appear to prevent adherence to appointments. These factors include a lack of family support and client engagement, the absence of financial means, and cultural and religious beliefs. Lack of client involvement in planning their care and poor referral of clients to community health workers were ranked high as being the most contributing factors to clients missing their appointments. Strategy development: Phase 2 of this study dealt with the development of the strategy aimed at reducing the missing of appointment by adults on Antiretroviral Therapy based on the findings of the study. The strengths, weaknesses, opportunities and threats matrix was triangulated in Political, Environmental, Social, Technological and Legal analysis to develop this approach to reduce the missing of appointments among adults on Antiretroviral therapy. A transtheoretical framework illustrated how to implement the strategy. Validation of the developed strategy ensured that the system is free of errors and checked the applicability of the strategies utilising a quantitative design. A simple random sampling approach was used to select the population to participate in this study using the questionnaire developed by the researcher. Almost all respondents agreed that the strategy would facilitate reduced missing appointments by adults on Antiretroviral therapy. Recommendations: Clients involvement and engagement throughout the process of a treatment plan is essential to identify some of the barriers that might contribute to poor adherence to appointment by clients on Antiretroviral therapy. Community health workers and nurses should be capacitated with knowledge and skills to identify the clients at risk of defaulting treatment and appointments and provide counselling that will facilitate behaviour modifications. / HWSETA

MSc (Microbiology) / Department of Microbiology / Background: Patients on antiretroviral (ART) are expected to be at least 95% adherent to their treatment, as this will increase their chances of achieving treatment success (maximum and durable suppression of HIV-1 viral load); non-adherence may lead to the development of HIV drug resistance, which may lead to virologic failure and treatment failure. Therapeutic drug monitoring (TDM) has been reported to be the most efficient method to assess treatment adherence in HIV individuals, since it quantifies the concentration of ARTs in biological matrices. This is very effective when using a robust technique such as liquid chromatography tandem mass spectrometry (LCMS/MS), which has played a significant role in the evaluation and interpretation of bioavailability, bioequivalence and pharmacokinetic data. Even with patient adherence, various intra-individual factors have an influence on the expression and function of the genes responsible for the transport (MDR1) and metabolism (CYP2B6) of Efavirenz (EFV). This may lead to single nucleotide polymorphisms (SNPs) in these genes, and this may affect the way antiretrovirals (ARVs) are metabolized. The aim of this study was to evaluate the EFV concentration in plasma to assess patient adherence to treatment and correlate this with genomic occurrences in human and viral genes. Hypothesis: The concentration of ARVs in patient plasma can be used to estimate adherence to treatment; while ARVs’ transport and metabolism can affect bioavailability in a patient’s system. Research Question: Can EFV concentration in plasma be used to estimate patient adherence to treatment? Can transport and metabolism of EFV affect their bioavailability in the patient’s system? Objectives: To determine EFV concentration in plasma to assess patient adherence to treatment and correlate this with genomic occurrences in human genes and viral genes. Methodology: Twenty blood samples were collected from HIV positive individuals before treatment initiation (baseline) and between six to twelve months following treatment initiation (follow-up). The concentration of EFV in patient plasma was measured by LC-MS/MS technique. To infer other factors influencing patient pharmacokinetics output, drug resistance and human genetic characteristics were analyzed. A 1.65kb fragment of the HIV-1 Pol gene was amplified and sequenced to determine drug resistant mutations; while 363bp and 289bp of the MDR-1 and CYP2B6 human genes respectively, were also amplified and sequenced to determine polymorphisms in the transport and metabolism genes. Obtained sequences were manually edited and analyzed using Geneious Version 11.1.5 software. The Stanford HIV Drug Resistance database was used for drug resistant mutation (DRMs) analysis and MDR1 and CYP2B6 test sequences were compared with variant reference sequences to detect the presence of any SNPs. Results: The plasma EFV concentration at baseline and follow-up range was as follows: 0 – 1183ng/ml and below limits of quantification (BLQ) to 15,670ng/ml, respectively. At baseline, 0ng/ml is the expected plasma EFV concentration for patients about to commence treatment; however, two out of twenty patients had 769.9 and 1,183ng/ml drug levels in their system. Post treatment, plasma EFV levels in patients are expected to range from 1,000 – 4,000ng/ml, however, of the twenty patients, two had <1,000ng/ml, and three patients had >4,000ng/ml in their plasma. For Pol amplification, 35% (7/20) were positively amplified at baseline and 25% (5/20) were positively amplified from the follow-ups; 100% (20/20) samples were amplified for both CYP2B6 and MDR1 genes. Detection of drug resistance in the baseline Pol sequences revealed the absence of major mutations in both NRTI and NNRTI drug classes. The G516T polymorphism was present in 15% of the study participants while the homozygous GG and heterozygous GT genotype was present in 25% and 40% of the study participants, respectively. Allele determination was impossible in 20% of the samples, due to the poor nature of the sequence. The homozygous TT variant polymorphism at position 3435 was absent in the entire population, however, the CC and CT genotype was present in 15% and 85% of the study participants respectively. Analysis of EFV concentration in close proximity with the human genetic characteristics reveals that the presence of a Single Nucleotide Polymorphism affects the pharmacokinetic output observed. Discussion and Conclusion: Post treatment, 90% of the study participants indicate adherence to treatment, with only 10% of them having lower than expected EFV concentrations, implying they were non-adherent to their treatment. However, because plasma drug concentrations only reflect a patient’s adherence pattern for a few hours to at most two days, the adherence patterns of these individuals cannot be concluded with certainty. Using plasma EFV as a biomarker to evaluate adherence to treatment in HIV seropositive individuals is a feasible technique, however, its application in non-research settings is still a drawback due to the cost of the method. Characterizing patient inter-individual differences should be taken into consideration, especially since any polymorphism in their transporter and metabolizing genes may influence their overall treatment success. / NRF

Dissertation submitted in fulfillment of the requirements for the Degree of Magister Technologiae: Consumer Science Food and Nutrition, Durban University of Technology, 2011. / Nutrition plays a fundamental role in the care and support of people living with the Human Immunodeficiency Virus (HIV) and children in particular are affected by HIV and the Acquired Immunodeficiency Syndrome (AIDS) epidemic in Africa in various ways. The epidemic puts children at risk physically, psychologically and economically. Children are indirectly affected by HIV and AIDS when the epidemic has a negative impact on their communities and the services these communities provide. Undernutrition is a major problem in HIV-positive children in South Africa with severe malnutrition as a common finding in HIV-positive children. HIV contributes to an increased incidence and severity of undernutrition and micronutrient deficiency. Low serum levels of vitamins A, E, B6, B12 and C, betacarotene, selenium, zinc, copper and iron deficiencies are frequently documented during all stages of HIV-infection. Malnutrition in turn further weakens the immune system which increases the susceptibility to infections and the duration and the severity of infections. Thus, the immune response is less effective and less vigorous when an individual is undernourished. Although guidelines exist for the treatment and management of HIV-infected children, it is clear from the literature that exceptional measures are needed to ensure the health and well-being of the children are met. Furthermore, residential care should not only be considered as a last resort for children’s care, but also as an intervention that requires more than merely addressing children’s basic physical needs. Nutrition education has been utilised globally and in South Africa to address nutrition related problems. The main purpose of nutrition education is to provide individuals with adequate and accurate information, skills and motivation to buy, produce and consume the correct foods to stay healthy and lead an active life. Aim The purpose of this study was to develop reliable and valid nutrition education material for the child care workers (CCWs) of Immune Compromised children vi resident in Children’s Homes in the Durban area in order to maintain the child’s immune system and to optimise their quality of life. Methodology The FAO framework used for planning, implementing and evaluating a nutrition education programme was followed to develop the nutrition education material in this study. Phase I included a situational analysis of the children homes involved. The residential care settings that participated in this study included three Children’s Homes in Durban. The total purposive sample included: boys (5–19 years) n = 112, girls (5–19 years) n = 38 and CCWs n = 40. The sample of HIV-positive children included boys (5–19 years) n = 3 and girls (5– 19 years) n = 6. The physical measurements obtained for this study to determine nutritional status were weight and height. The anthropometric measurements were captured and analysed by the researcher using the World Health Organisation’s AnthroPlus version 1.0.2. Statistical software. The following indices were included: height-for-age (stunting), weight-for-age (underweight) and BMI-for-age (overweight and wasting). The WHO growth standards for school-aged children and adolescents were used to compare the anthropometric indicators. Dietary intake measurements were done by analysing the cycle menus by means of the Food Finder® Version 3 computer software program and comparing the results with the Dietary Reference Intakes (DRIs), specifically the EAR and AI where the EAR were not available. The data were analysed to determine the adequacy of energy and nutrient intake. Average portion sizes were established by the plate waste studies method as well as observation of practices, interviews with the central buyer and focus group discussions with the CCWs. Nutrition knowledge of the CCWs was determined by a self-administered questionnaire developed and tested for reliability and validity. The problems identified in Phase I through the implementation of the questionnaires and other methods directed the design of messages in Phase II. Once suitable media was selected, nutrition education material was developed based on existing guidelines pertaining to HIV and AIDS. The material developed was then tested for reliability and validity before it was produced. vii Results The anthropometric measurements indicated that the majority of the HIV-negative boys and girls were of normal height-for-age and weight-for-age. The results also showed that possible risk of overweight and overweight were more prevalent in girls whereas underweight was more prevalent in boys. Furthermore, the results indicated that a third (33.0%) of the HIV-positive children were stunted and 16.7% was severely stunted. Findings of the menu analysis indicated that both girls and boys consumed three times more carbohydrates than the recommended intake. The DRIs for girls and boys were met for energy and protein in all the age groups except boys aged 14-18 years did not meet the DRI for energy. However, the comparison of the actual intake of the macro nutrients with the WHO guidelines indicated that the protein (10.78%) and carbohydrate (58.07%) is within the recommendations of 10- 15% and 55–75% respectively. This comparison also showed that the total fat intake of 31.15% was above the recommended intake of 15-30%. None of the age groups met the DRIs for fibre. The comparison of the intake with the WHO guidelines also indicated that the total dietary fibre intake was only 19.67g/day and not 27–40g/day. The actual fruit and vegetable intake was a mere 68.64g/day instead of 400g/day as recommended. None of the groups met the DRIs for calcium and iodine. The results clearly showed that micro nutrient inadequacies were more prevalent in the dietary intake of age groups 9-13 and 14-18 years in both girls and boys. Inadequate intake of magnesium, vitamin A, vitamin C, riboflavin, niacin, vitamin B6, pantothenate, biotin, vitamin E and vitamin K were evident in the age group 14-18 year. Overall, it is evident from the results on nutrition knowledge that although the respondents’ knowledge was fair on general nutrition guidelines, the results of the nutrition knowledge questionnaire indicated that knowledge on the importance of a variety in the diet is lacking. The CCWs displayed a very poor knowledge of the recommended number of fruit and vegetable portions per day as well as correct serving sizes of vegetable portions. A very poor knowledge also existed regarding the role of healthy eating in maintaining and supporting the immune system and a limited knowledge on correct hygiene practices was noted. The fridge magnets developed included five messages relating to nutrition and four messages relating to food safety and hygiene. viii Conclusion This study established that malnutrition is apparent in the children’s homes and that there were many gaps in the nutrition knowledge of the CCWs. These gaps included the role of good nutrition in the support and maintenance of the immune system and the importance of adequate intake of fruit and vegetables daily. The NEM developed in this study will address these gaps.

Thesis (MEdPsych))--University of Stellenbosch, 2010. / Bibliography / ENGLISH ABSTRACT: Teachers have been strategically positioned to mediate information that might lead to increased HIV and AIDS knowledge and preventative measures among school-based youth. This study attempted to understand such teachers' knowledge and attitudes within a particular social context using the Bio-ecological systems model of Bronfenbrenner. The systems model provided the framework for understanding teachers' knowledge and attitudes of HIV and AIDS given their choices in terms of background, knowledge, attitude, and their links with multiple systems. The study was conducted within the qualitative paradigm. Semi-structured interviews were conducted with thirteen intermediate phase primary school teachers from seven primary schools in Phillipi, Cape Town. This study showed that teachers were aware of being part of complex systems. They expressed their difficulties with teaching HIV and AIDS education in the classroom, particularly conditioned by cultural taboos. This study further showed that teachers. interactions, particularly with people living with HIV and AIDS, changed their knowledge of, and attitudes towards, HIV and AIDS and the teaching thereof. It also pointed to the dissonance between teachers' beliefs and behaviours in serving people living with HIV and AIDS. For some teachers, religious beliefs provided the means with which to deal with the HIV and AIDS pandemic. For others, particularly some female teachers, unequal gendered roles and expectations with regard to sex and sexuality in their communities had a direct impact on the spread of HIV and AIDS and safe-sex practices (knowledge) in their communities. Finally, teachers were actively and critically engaged with systems that impact upon them; particularly, the Macrosystem of the Education Department (in this case, the Western Cape), and the Microsystems of the societies and communities within which their schools were located. In summary, the study showed that a contextual, system-related approach to teachers in the classroom highlighted how they related to HIV and AIDS. Such complex, and inter-connected relations cannot be ignored by teachers, educators, policy-makers, material developers and trainers. More studies will give us a better model of the challenges and opportunities facing those who are helping stem the tide of the pandemic. / AFRIKAANSE OPSOMMING: Onderwysers is in 'n strategiese posisie om inligting oor te dra aan jong leerders wat sal lei tot meer kennis van MIV en ook sal voorkom dat dit versprei. In hierdie studie is onderneem om onderwysers se kennis en denkwyse in 'n besondere sosiale verband te verstaan, deur gebruik te maak van die Bio-ekologiese stelsels-model van Bronfenbrenner. Die stelsels-model voorsien die raamwerk om onderwysers se kennis en houdings van MIV/VIGS te verstaan, aangesien hulle keuses maak in terme van hulle agtergrond, kennis, denkwyse en hulle kontak met meervoudige stelsels. Hierdie studie is uitgevoer in die kwalitatiewe paradigma. Halfgestruktureerde onderhoude is uitgevoer met dertien intermediêre fase primêre-skool onderwysers by sewe primêre skole in Philippi, Kaapstad. Hierdie studie het bewys dat onderwysers bewus is daarvan dat hulle deel vorm van ingewikkelde stelsels. Hulle het te kenne gegee dat hulle dit moeilik vind om MIV/VIGS opvoeding te gee in die klaskamer, veral as gevolg van kulturele taboes. Hierdie studie het ook bewys dat onderwysers se interaksie, veral met mense wat met MIV/VIGS saamleef, hulle kennis van en houding teenoor MIV/VIGS, en die onderrig daarvan, verander het. Dit het ook die verskil tussen onderwysers se godsdienstige oortuigings en houdings uitgewys wanneer hulle in kontak kom met mense wat met MIV/VIGS saamleef. Sommige onderwysers het hulle godsdienstige oortuigings gebruik wanneer hulle met die MIV/VIGS pandemie gewerk het. Sommige onderwyseresse veral, het gevind dat ongelyke geslagsrolle en verwagtinge ten opsigte van seks en seksualiteit in hulle gemeenskappe 'n direkte invloed gehad het op die verspreiding van MIV/VIGS en veilige sekspraktyke in hulle gemeenskappe. Onderwysers was aktief betrokke by stelsels wat 'n invloed op hulle gehad het, veral die Makrostelsel van die Onderwysdepartement (in hierdie geval die Wes-Kaap), en die Mikrostelsels van die samelewings en gemeenskappe waar die skole hulself bevind. In opsomming, het hierdie studie bewys hoedat 'n kontekstuele, stelsel- verwante benadering tot onderwysers in die klaskamer in verhouding staan met kennis en houdings teenoor MIV/VIGS. Sulke komplekse en onderlinge verhoudings kan nie deur onderwysers, beleidmakers, materiële ontwikkelaars en afrigters geïgnoreer word nie. Verdere navorsing en studies sal vir ons 'n meer effektiewe model bied van die uitdagings en geleenthede wat onderwysers in die gesig staar en wat sal help om die pandemie hok te slaan.

The aim of the study was to explore the accessibility of antiretroviral treatment amongst people living with HIV and AIDS at Public Health Care Facilities in Gert-Sibande Region in Mpumalanga. The study was conducted at a selected Public Health Care facility in Gert Sibande Region at Msukaligwa Municipality in Mpumalanga. The study focused primarily on people attending wellness programmes that are living with HIV and AIDS, receiving antiretroviral treatment in Public Health Care facilities. Research design of the study was exploratory which fundamentally used to explore a new topic or to learn more about issues where little is known. The research approach was purely qualitative methodology which allowed the researcher to explore deeply the perceptions of people living with HIV and AIDS and the capabilities in the provision of antiretroviral treatment at public health care facilities in Msukaligwa municipality of Gert-Sibande Region in Mpumalanga. Qualitative interview is the method that has been used to gather data from 23 participants who took part in the study. Questions of the interview were semi-structured in-depth one-on-one interviews and were used to explore understanding in relation to the accessibility of antiretroviral treatment amongst people living with HIV and AIDS at Public Health Care Facilities in Gert- Sibande Region in Mpumalanga. The findings of the study revealed that, there is good accessibility of antiretroviral treatment at public health care facilities in Msukaligwa Municipality of Gert-Sibande Region in Mpumalanga. There is also an existence of negative staff attitude towards patients and a probable poor service delivery at the referral local clinics. It can be concluded that there is a need to re-look into the current Hospital’s reception filing system and the turnaround time at certain areas of the Hospital and the capacitation of staff at the wellness centre. There is also a need to intensify the established programmes and the encouragement of people on treatment to take their antiretroviral treatment consistently. / Health Studies / M.A. (Social behaviour Studies in HIV & AIDS)

There are many inequities that exist in health-care that stem from culture related communication misunderstandings. In most cases where doctors and patients from different cultural and linguistic background interact, doctors use medical language which is different from everyday language used by patients. Patients enter this communication context with anxiety because they depend on the physicians to give them accurate information concerning their health, but they do not always understand all the terms used by physicians to inform them about their conditions. In some cases interpreters are used but their expertise is often inadequate and the interpreting of the patient’s statements to the health staff is also prone to distortion by interpreter / doctor because of the lack of proper understanding of the messages / languages. This may result in a deterioration of the patient’s health condition and unavoidable complications.

Introduction: Adherence to Highly Active Antiretroviral Therapy (HAART) is critical for optimal therapeutic outcomes. A possible factor in adherence is the impact of HAART on sexual functioning. Methods: A mixed methods approach was used. A cohort of 14 people living with HIV/AIDS (PLWHA) in Grahamstown was identified. Two semi-structured interviews and two structured questionnaires were administered. In-depth interviews were conducted with two HIV counsellors in so as to obtain a different perspective on the topics. The theoretical framework used three health behaviour models: the Health Belief Model, Leventhal‘s Common-Sense Model of self regulation and the Transtheoretical model. Results: The participants were between 27 and 49 years old and had been on HAART for between 9 months and 10 years. Six participants were support staff members from Rhodes University and eight from the Raphael Centre – a local NGO which assists PLWHA.In most of the participants HAART was associated with increased libido and improved sexual functioning (sexual activity and sexual enjoyment). The use of alcohol increased risky sexual behaviour. Issues of adherence were seemingly not directly affected by the effects of HAART on sexuality. PLWHA, especially women, face challenges related to their sexuality, some of which are not directly related to their illness and treatment. The fear of transmitting drug resistant HIV or getting re-infected, stigma, disclosure issues,difficulties negotiating for safe sex among women, HAART-related lipodystrophic changes that affect one‘s sense of self and unmet reproductive needs are some of the problems that were reported. The men‘s dislike for condoms was overt and blatant. Discussion: Being diagnosed with HIV and reaching a point where treatment is requiredare life-changing events. Making decisions about one‘s life (including adherence to HAART, alcohol use and knowingly partaking in risky sexual encounters) become all the more significant in the context of AIDS. Intentional non-adherence is informed by the individual‘s assessment of the costs and benefits of taking treatment. Cultural influences,gendered power relations and misconceptions strongly influence sexual behaviours. Conclusion: The general lack of attention among health care providers concerning issues related to PLWHA‘s sexuality and reproductive issues needs to be addressed. Insights fromthe theoretical models should be integrated with empirical findings in designing adherence interventions.

MPM / Oliver Tambo Institute of Governance and Policy Studies

MPM / Oliver Tambo Institute of Governance and Policy Studies

MSc (Microbiology) / Department of Microbiology