Assignment (MPhil)--University of Stellenbosch, 2006. / ENGLISH ABSTRACT: The aim of this study was to investigate practical methods of monitoring AIDS related wasting and lipodystrophy in a resource-poor clinical setting with HIV infected women as the population group of interest. Measurement of body composition changes using anthropometry is both cost- and time-efficient. Various different skinfolds were taken and two different equations (the equations of Pollock et al. (1975) and Durnin and Womersley (1974) for calculating body fat were used to determine the most promising method or methods of monitoring body composition changes in a clinical setting. Detailed anthropometric measurements were performed, as well as selected measurements for haematological parameters and quality of life (QoL) for a group of 8 participants on antiretroviral medication (ART group) and 6 participants who were not on treatment (TN group). New variables namely, intra-abdominal indicator (IAI) and a percent of ideal body mass to percent of ideal arm circumference ratio (%IBW:%IAC) were investigated as possible indicators of lipodystrophy. Although measurements were taken at various timepoints, three specific time-points were chosen for data-analysis for the ART group and two time points for the TN group. These three time-points were, baseline (on the day of recruitment for TN participants and within one month before the initiation of treatment for ART participants), short-term (2 to 12 weeks after treatment initiation or the baseline measurement or for the ART and the TN participants) and long-term (within one and a half year of treatment initiation for the ART group). ART and TN participants did not differ for many variables at baseline. The major differences between ART and TN were in measured and derived variables of the arm, especially percent of ideal arm circumference (%IAC) and upper arm fat area (UAFA), which were significantly lower in the ART group. CD4+ and QoL improved significantly for the ART participants from baseline to long-term. This was not associated with changes in muscle mass, but rather some fat mass variables. Participants on antiretroviral medication exhibited changes relating to abdominal obesity. It was concluded that antiretroviral therapy contributed greatly to the QoL of the participants and it probably aided in the recovery from wasting for at least one participant in this study. Measures of the arm can be used in a rural clinical setting to effectively monitor patients with regard to AIDS related wasting. The new variables IAI and %IBW:%IAC could be helpful in the monitoring of lipodystrophy and should be investigated in future research. / AFRIKAANSE OPSOMMING: Die doelwit van hierdie studie is om praktiese metodes te ondersoek om VIGS-verwante uittering en lipodistrofie te meet in ‘n plattelandse kliniese omgewing (waar hulpbronne dikwels beperk is) met MIV ge-infekteerde vroue as populasiegroep. Die gebruik van antropometrie om veranderinge in liggaamssamestelling te meet is beide koste- en tydeffektief. Verskeie velvoumetings is geneem en twee verskillende vergelykings (die vergelykings van Pollock et al. (1975) en Durnin en Womersley (1974)) is gebruik om liggaamsvetinhoud te bereken, met die doel om ‘n belowende metode te vind om veranderinge in liggaamssamestelling te meet in ‘n kliniese omgewing. Verskeie antropometriese metings is geneem, sowel as uitgesoekte hematologiese en lewenskwaliteitmetings (QoL) vir ‘n groep van agt deelnemers wat antiretrovirale medikasie ontvang het (ART groep) en ses deelnemers wat nie hierdie behandeling ontvang het nie (TN groep). Nuwe veranderlikes (binnebuikindikator (IAI) en die verhouding van persentasie van ideale liggaamsmassa tot persentasie van ideale armomtrek (%IBW:%IAC)) is ondersoek as moontlike aanwysers van lipodistrofie. Drie spesifieke tydpunte vir die ART groep en twee tydpunte vir die TN groep is gekies uit die verskeie tydpunte waarby metings geneem is, nl. basislyn (gedefinieer as die dag wat TN deelnemers in die studie opgeneem is en 0 tot 4 weke voor die begin van behandeling vir die ART deelnemers), korttermyn (2 tot 12 weke nadat behandeling begin is of na die basislyn meting) en lang-termyn (binne een en ‘n half jaar nadat behandeling begin is vir die ART groep). By die basislyn tydpunt het min van die ART en TN deelnemers se gemete veranderlikes verskil. Die ART en TN groepe het hoofsaaklik verskil ten opsigte van veranderlikes wat betrekking het op die arm, veral persentasie van ideale armomtrek (%IAC) en bo-arm vetarea (UAFA). Hierdie twee veranderlikes was beduidend laer in die ART groep as in die TN groep. CD4+ seltelling en lewenskwaliteit tellings het beduidend verbeter vir die ART deelnemers van die basislyn tot die lang-termyn tydpunt. Hierdie veranderinge is nie samehangend met veranderinge in spiermassa nie, maar eerder met sommige vetmassa veranderlikes. Deelnemers wat antiretrovirale medikasie ontvang het, het veranderinge getoon wat gedui het op ‘n verhoogde neerlegging van vet in die buikarea. Ten slotte is bevind dat antiretrovirale medikasie bygedra het tot die verbeterde lewenskwaliteit van die deelnemers en dat dit waarskynlik ook die omkeer van uittering van ten minste een deelnemer aangehelp het. Daar is ook bevind dat armverwante metinge gebruik kan word in die plattelandse kliniese omgewing om pasiënte suksesvol te monitor ten opsigte van VIGSverwante uittering. Die nuwe veranderlikes, IAI en %IBW:%IAC kan moontlik gebruik word om lipodistrofie-verwante veranderings te meet en die gebruik van hierdie veranderlikes behoort ondersoek te word in verdere navorsing.

This thesis argues that corporations qua corporations are moral agents sui generis and hence capable of being held morally responsible. I argue that corporations qua corporations are responsible for the actual and foreseen consequences of their actions. I analyse normative theories and the different proscriptive responsibilities they place on moral agents and hence corporations. I examine Kantianism, utilitarianism and virtue ethics. I argue for a unique normative ethical theory that incorporates reasoning from all three of the normative theories. I argue for a broad range of reasons to factor into deciding whether an act is ethical or not. One of the claims of this thesis is that ethical theories must incorporate an agent’s motivation, intention and character traits as relevant to deciding on whether an action is ethical or not. My thesis argues for an indispensable role for the virtues while at the same time incorporating impartial beneficence and universal rationality from utilitarianism and Kantianism. This position I, following the literature, refer to as moderate virtue theory. Having established corporate qua corporate responsibility I question the pharmaceutical corporation’s practice of patenting life saving medication during a state of pandemic in poor countries. The moderate virtue theory position prioritises contexts and the actual human condition and criticises normative theories that attempt to give universal, abstracted answers to ethical problems. It is for this reason and the current (2003) HIV/AIDS pandemic that I focus on a particular context. I examine the practice of patenting life saving medication within South Africa and argue, applying moderate virtue theory, that this act cannot be justified. I argue that a pharmaceutical corporation that patents life saving medication in South Africa cannot justify that action and thus is morally responsible for that action. I also argue that corporations patenting HIV/AIDS medication in South Africa have unethical motivations and intentions.

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

This study was influenced by two sociological theories namely: Durkheim’s Structural Functionalism and Relativism. In terms of Durkheim’s Structural Functionalism, I claim that the aspects of social structures, cultural norms and values, which are among its main components, are also among the main components of Indigenous Knowledge Systems (IKS). In line with Relativism, this study argues against Durkheim’s claim that social structures, and cultural norms and values determine human choices and behaviour. It is claimed that in line with my understanding of IKS in this study social structures, cultural norms and values are relative aspects, because they change and differ from context to context even if their carriers are the same, and human choice in different times and places play a vital role in determining decisions. These theories have been applied practically by examining the relationship between Indigenous Knowledge Systems (IKS) and good governance. The study asserts that IKS has the potential to improve the efficiency and effectiveness of policies at the local municipality level. Thus, the study has sought to understand the extent to which IKS is incorporated in the policy development and implementation at the local municipality level. This investigation has been undertaken in the thematic context of HIV/AIDS. I investigated the extent to which IKS is incorporated into policy development and implementation related to HIV/AIDS at the local municipality level. The study has argued that the extent to which IKS is appropriated into policy development and implementation relies on the power dynamics between the provincial and national spheres of government on the one hand, and the local municipality leaders and officials on the other. The study has found that local municipality leaders and officials have a strong affinity to the IKS due to their proximity to the local citizens. But, political leaders at the national and provincial spheres of the South African government exert influence on the local municipality leaders and officials to exercise their power with limited response to the IKS needs of the local communities. / Sociology / D. Phil. (Sociology)

This study takes the concept of ubuntu, which means humanness and applies it to healthcare issues in general, and women's health, in particular. Ubuntu is based on the reality of interdependence and relatedness. It is a philosophy or way of life that finds its roots and meaning in humanity. The values espoused in ubuntu emphasize caring, sharing, reciprocity, co-operation, compassion and empathy in recognition that for human beings to develop, flourish and reach their full potential, they need to conduct their relationships in a manner that promotes the well-being of others. The values championed in ubuntu are what inform and shape African cultural, social, political and ethical thought and action. / Thesis (Ph.D.)-University of KwaZulu-Natal, Pietermaritzburg, 2007.

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)

Background: South Africa has a generalised HIV epidemic which is managed through free Antiretroviral Therapy (ART). Adherence to ART has emerged as a crucial issue in HIV/AIDS therapeutics. Purpose: The aim of the study was to explore determining factors for poor and excellent adherence to ART for HIV positive patients residing in Barberton, a mining town in Mpumalanga Province. Methodology: A generic qualitative research design was undertaken. Data was collected through in-depth qualitative interviews from a purposive sample of 13 ART patients. Qualitative interpretive analysis was employed. Findings: The study found that excellent adherence to ART is significantly associated with the availability, effectiveness and comprehensiveness of HIV services, psychological support and medical advances. Side effects of ART, opportunistic infections and alcohol and drug use hinder adherence. However, longer duration on ART enhanced self-efficacy and facilitated adherence. Successful ART is dependent on taking ARVs as prescribed and executing necessary lifestyle changes. / Health Studies / M.P.H.

South Africa's HIV prevalence rate is estimated to be 5.7 million and at the end of2007 a total of 45845 HIV/AIDS adult patients were taking antiretroviral therapy (ART). The global incidence of HIV/AIDS has been slowly decreasing over the years but is still widespread. This disease is still more prevalent in sub-Saharan Africa than in other parts of the world, with more than 60% people living with HIV/AIDS. Highly active antiretroviral therapy (HAART), the treatment of choice, slows the progression of the human immunovirus but demands a high adherence rate in excess of 95%. Patients who are poorly informed about antiretrovirals (ARVs) and misunderstand medicine-taking instructions or experience unexpected side effects may interrupt therapy, predisposing them to the development of resistance. Such patients need information but, given the poor literacy skills prevalent in South Africa, written information is often not fully comprehended and is often written at too high a reading level. The objectives of this research project were to design, modify and evaluate HIV / AIDS patient education materials for low-literate isiXhosa speaking adults residing in Grahamstown and to examine their impact on the understanding of various aspects of the disease and its treatment. Pictograms illustrating common side effects of ARVs (e.g. stavudine, efavirenz, lamivudine), as well as various sources 'for purchasing nonprescription medicines, storage and medicine-taking instructions were designed and evaluated both qualitatively, using group discussions, and quantitatively through individual interviews where interpretation of the pictograms was assessed. These pictograms were incorporated in a patient information leaflet (PIL) which had been specifically designed for people with limited reading skills and was a simple document containing the minimum of essential text. A previously developed PIL was modified in collaboration with the target population and two versions were produced, one incorporating pictograms illustrating side effects, the other with none. Pictograms were used in both to illustrate other medicine-taking instructions. The PILs were tested objectively to assess the readability, format, content, and general design. They were translated into isiXhosa prior to being qualitatively and quantitatively evaluated in a low-literate isiXhosa speaking population. Understanding of the PILs was assessed by asking a series of questions about the PIL content. Participant opinion of the readability and appearance of the PIL was recorded. The relationship between PIL understanding and selected demographic variables was investigated. Findings from this study illustrated that well designed pictograms assist in the location of information in written leaflets and they may enhance understanding of the information. It was further demonstrated that education influences total understanding of PIL content thus emphasizing the need for tailor-written information in accordance with the education level of the target population. A desire to receive PILs incorporating pictograms was expressed by the majority of participants. Collaboration with the intended target population is essential to design culturally acceptable, easily interpreted pictograms and to produce user-friendly, easy-to-read, comprehensible patient education materials. The rigorous, iterative design, modification and testing process described in this study is one that should be adopted in producing all health-related education materials.

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.