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Thesis (MSc)--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: The primary aim of the study was to determine the applicability of the theory of planned behaviour (TPB) in predicting adherence to ART among South African patients attending public health clinics. The second aim was to determine the relationship between self-reported adherence and viral load. The results from the hierarchical multiple regression analyses revealed that the linear combination of the variables of the TPB significantly explained 12% of the variance in intentions to adhere to ART. Perceived behavioural control was the only variable that significantly predicted intentions to adhere to ART. The inclusion of perceived stigma was not a useful addition to the model. The results also reflect the relationship between intentions to adhere to treatment and self-reported adherence, which was not significant. The TPB was unable to significantly account for variance in self-reported treatment adherence. When perceived stigma was added to the TPB, the model was still unable to significantly explain variance in self-reported adherence. Nonetheless, attitudes towards treatment were the only variable that significantly accounted for variance in self-reported treatment. It was concluded that interventions aimed at improving adherence among South African patients attending public health clinics, should aim to encourage positive attitudes towards treatment, should aim to increase perceived subjective norms, should increase the patients’ perceptibility that they are able to be adherent and should aim to decrease perceived stigma. Improving adherence to ART can result in increasing the quality of life of patients living with HIV/AIDS. / AFRIKAANSE OPSOMMING: Die primêre doel van die studie was om vas te stel of die teorie van beplande gedrag (TPB soos voorgestel in die studie) antiretrovirale terapie (ART) nakoming onder Suid-Afrikaanse pasiёnte by publieke gesondheidsklinieke kan voorspel. Die sekondêre doel was om die verhouding tussen self-gerapporteerde volgehoue behandeling en virale lading te bereken. Die uitslae van die hiёrargiese veelvuldige regressie analise het getoon dat die linêere kombinasie van die veranderlikes van TPB 12% van die verandering in ART voornemens akkuraat kon voorspel. Waargenome gedragsbeheer was die enigste veranderlike wat ART voornemens akkuraat kon verklaar het. Die insluiting van waargenome stigma was nie beduidend ten opsigte van die model nie. Geen beduidende verband tussen voorneme om met behandeling vol te hou en self-gerapporteerde volgehoue-behandelingsgedrag word uitgebeeld. Waargenome gedragsbeheer kon wel ‘n bydrae lewer om verandering in die voorneme om met behandeling vol te hou verklaar. Die TPB kon egter nie ‘n verduideliking bied vir die verandering in self-gerapporteerde volgehouebehandelingsgedrag nie. Toe waargenome stigma by die TPB gevoeg is, was die model steeds nie daartoe instaat om die verandering in self-gerapporteerde volgehouebehandelingsgedrag te verklaar nie. Nietemin, houdings teenoor behandeling was die enigste veranderlike wat verandering in self-gerapporteerde gedrag verklaar. Daar is tot die gevolgtrekking gekom dat intervensies gerig op die verbetering van volhoubare gedrag onder Suid-Afrikaanse pasiёnte wat openbare gesondheidsklinieke bywoon,positiewe houding teenoor behandeling moet aanmoedig, subjektiewe norme verhoog, die pasiёnte se persepsie dat hulle instaat is om volhoubare gedrag kan toon moet verhoog en ook waargenome stigma moet verminder. Beter ART nakoming kan lei tot ‘n toename in die MIV/VIGS pasiёnt se kwaliteit van lewe.

Magister Public Health - MPH / Background: Human Immune Deficiency Virus (HIV) is a public health challenge worldwide. Antiretroviral therapies (ART) are medications that treat HIV virus infection by suppressing the virus and stopping progression of HIV disease, and that improve quality of life. People initiated on ART need to adhere to their treatment for the rest of their lives. In 2016, there were 7,1 million people (age 15-49) in South Africa living with HIV, representing 19 % of the global HIV burden, with 56% of the adults on ART. Life expectancy of South Africans for both males and females improved between 2009 and 2011 because of ART treatment. People lost to follow up while on ART compromise their own health and the long term positive benefits of the ART regimen, and hence there is a growing emphasis to improve the retention of people who are already on treatment. Aim: This study was conducted examining HIV positive South African Clothing and Textile Workers Union (SACTWU) members who are currently on ART treatment and had previously been lost to follow up (LTFU) from ART care. The study aimed to explore factors associated with LTFU of clients on ART treatment and care among the South African Clothing and Textile Union members living with HIV and attending the SACTWU Worker Health Program Clinic.

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Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--Stellenbosch University, 2008. / Background and objectives: An understanding of the effect of HAART on different aspects of health, including nutritional status, of HIV-infected individuals in South Africa is needed to ensure that appropriate population-specific guidelines and policies can be developed. This study aimed to investigate the impact of HAART on nutritional status, focusing on changes in anthropometric measures, and to explore the relationship between these measures and immunological and virological response to HAART. Methods: A prospective study of 30 adult females was carried out at a clinic in Cato Manor, KwaZulu-Natal. Anthropometric measurements, including weight, mid-upper arm circumference (MUAC), waist circumference, hip circumference, body mass index (BMI) and waist-to-hip ratio (WHR), were performed at baseline and 12 and 24 weeks after commencing HAART. Laboratory values, including CD4 lymphocyte count, viral load, albumin and haemoglobin as well as bioelectrical impedance analysis data, including lean body mass (LBM), fat mass (FM) and body fat percentage (BF%), were collected at baseline and after 24 weeks on HAART. Results: Overall, there was a statistically significant increase in all anthropometric measures, except WHR and LBM. The mean weight change was 3.4±5.8kg (p=0.006). Fifty percent of the subjects had a BMI above normal at baseline and mean BMI increased from 25.6±5.7kg/m2 to 27.3±5.6kg/m2 (p=0.007). Seventy percent of subjects gained weight, 18.5% had a stable weight and 11.1% lost weight. The weight gain in most subjects was attributable to a gain in FM while in subjects who lost weight, the loss consisted mainly of LBM. Some patients with stable body weight experienced changes in the relative proportions of fat and lean mass. Six patients showed evidence of disproportionate gains and losses in body circumference measurements which may be indicative of fat redistribution. Subjects with lower CD4 lymphocyte counts experienced greater increases in weight, BMI, FM and BF%. The strongest correlation was observed with FM (rs=-0.53; p=0.00). Greater increases in weight, BMI, MUAC, waist circumference, hip circumference, FM and BF% were seen in those with lower baseline haemoglobin. Baseline viral load and albumin did not correlate significantly with changes in any anthropometric variables. Change in CD4 count was only significantly associated with baseline MUAC (rs=0.40; p=0.04). Change in viral load was significantly correlated with baseline weight, LBM, FM, BF% and MUAC with the strongest correlation being with weight (rs=0.44; p=0.01). No significant association was found between anthropometric changes and changes in CD4 count and viral load between baseline and the 24-week visit. Conclusion: Overall, subjects experienced a significant increase in most anthropometric measures. There appears to be a relationship between some anthropometric and laboratory measures but this needs clarification. The findings of this study demonstrate the value of including circumference measurements and body composition techniques as part of nutritional status assessment and demonstrate the need for studies to determine the prevalence and significance of overweight and obesity in the HIV-infected population. Research is needed to determine the best methods of bringing about the most favourable anthropometric changes to enhance the health of patients on HAART.

Master of Public Health - MPH / Background: HIV has reached epidemic proportions globally with Sub-Saharan Africa carrying the greatest burden (71%). It is estimated that there are 37 million people world-wide infected with HIV, and an estimated 6.8 million live in South Africa. Globally there were 2.1 million adolescents living with HIV in 2014. Improved access to Antiretrotiviral Therapy (ART) has led to a steep decline in HIV incidence and HIV-related mortality. Yet despite these successes in terms of HIV treatment outcomes, HIV-related mortality amongst adolescents has increased. Adolescents are defined by the WHO as individuals between 10 and 19 years old. WHO states that adolescents have poorer access to ART, are at a higher risk of disengaging from care and have special needs to keep them motivated to remain in care. The uptake of adolescents into the South African ART programme is low and those that are enrolled into the programme have poorer adherence than their adult counterparts. Aim: The aim of the study was to explore the factors that influence adherence to ART amongst adolescents in a primary health care clinic in a low socio-economic, urban setting in Cape Town. Methodology: An exploratory qualitative design was employed where data was collected through two key informant interviews with staff from an urban primary health care clinic. Four focus group discussions and eight individual in-depth interviews were held with adolescents and young people who accessed ART at this health facility. Audio data was digitally recorded and transcribed verbatim. Data was analyzed using content analysis. Results: The study identified school commitments, strained teacher-pupil relationships, negative household dynamics and ill-treatment by non-biological caregivers as major reported barriers to adherence. In addition, poor service delivery, missing and misplaced files and long waiting times came under major criticism. Fear of intended or unintended disclosure of HIV status, perceived stigma and discrimination, treatment fatigue and having unstructured lives, profoundly influenced ART adherence. Finally, having a strong support system, disclosing to a trustworthy person and having goals and ambitions served as motivators to remain adherent to ART. Conclusions: This study highlighted the complexity of ART adherence amongst this age group due to school factors, social factors, health services factors, therapy related factors and patient factors. Interventions to improve adherence should aim to address treatment fatigue, disclosure, household dynamics, service delivery factors, as well as the impact of school commitments and symptoms of depression on ART adherence amongst adolescents.

>Magister Scientiae - MSc / Adverse effects are a significant factor that determine how long patients will tolerate a given antiretroviral drug regimen. They also influence treatment options, and play an important role in the much needed adherence to treatment by patients on Highly Active Antiretroviral Therapy (HAART). This study is aimed at understanding adverse effects experienced by patients on the first line antiretroviral therapy at Keetmanshoop Hospital in Namibia. Methods : A retrospective quantitative method was used to review records of patients on first line antiretroviral treatment who started treatment between November 1st 2007 and December 1st, 2008 and followed up until they reached 36 – 48 months on treatment. Records of 94 patients were found eligible to be included in the study. Data was analysed using Stata 12 data analysis software. Results : The most reported adverse effect was musculoskeletal disorders (25%) whereas headache (16%) was the least reported. Low haemoglobin (78%) was the most common recorded hematologic adverse effect whereas low red cell distribution width and low mean platelet volume were the least recorded adverse effects (0%). A Male patient was more likely to experience a low haemoglobin levels compared to a female patient (adjusted OR: 3.29, 95% CI: 1.3 – 8.3). A male patient was found to be 64% times less likely to experience a higher mean cell haemoglobin compared to a female patient (adjusted OR. 0.31, 95% CI: 0.11 – 0.87). A patient on nevirapine was more likely to experience an elevated creatinine level compared to a patient on efavirenz (adjusted OR; 36.0, 95%CI: 2.02 – 62.5). At baseline, a patient who had prior exposure to ART had an 81 times (adjusted OR: 81.4, 95%CI: 5.3 – 119, p-value=0.00) increased odds of experiencing a high mean cell volume (MCV) compared to a patient with no ART exposure. A patient with a higher CD4 count was also less likely to experience a low hemoglobin compared to a patient with low CD4 count (adjusted OR; 0.31, 95% CI: 0.12 – 0.77). The author recommends further studies with higher sample size to confirm whether higher creatinine levels are more prevalent in patients on nevirapine compared to patients on efavirenz; this will have clinical implications especially in patients with impaired renal system. Antiretroviral treatment increases chances of developing macrocytosis anaemia; clinical implication of this condition may need to be investigated.

Magister Public Health - MPH / Background: The hallmark of HIV infection is immunosuppression which predisposes to unusual infections and malignancies generally known as opportunistic diseases (ODs). Globally, ODs are the major cause of morbidity and mortality in people living with HIV (PLHIV). Since the advent of Highly Active Antiretroviral Therapy (HAART), a significant decline in AIDS progression and ODs has been observed globally. However, most of the evidence suggesting sustained decline in AIDS progression and ODs has come from high-income settings with relatively less burden of ODs in the pre-HAART era. The findings of studies in high-income settings may not be generalizable to resource-limited settings. Lack of information regarding the burden of ODs in HAART-experienced populations in Nigeria and the risk factors for their occurrence has made it difficult to fully assess the sustained efficacy of HAART in the country. The aim of this study was to investigate the prevalence of and risk factors for HIV-related opportunistic diseases amongst HAART patients at the Federal Medical Centre (FMC) in Owerri, Nigeria. Study design and setting: A quantitative, cross-sectional descriptive and analytical study was conducted with 354 adult HIV-infected patients 15 years and above, who were on HAART for a minimum of 12 weeks at the HIV clinic of the FMC, Owerri, South-east Nigeria. Patients currently manifesting an OD whose onset ante-dated the commencement of HAART were excluded. The participants were recruited by simple random sampling. Data collection: Using a structured questionnaire, data was collected by clinicians through interviews, physical and laboratory examinations for patients that provided informed consent and met the study criteria. The questionnaire captured patient’s socio-demographic information and other relevant clinical/laboratory data. Data Analysis: The data was analysed using Epi info version 3.5.1 and Open Epi Version 2.2.1. Descriptive statistics for HIV-related ODs were carried out using percentages and frequencies tables for categorical variables and means (SD) or medians (IQR) for numerical variables. In univariate analysis, the Chi-square test was used to determine significance of association between OD and socio-demographic and clinical variables while the Student "t"-test was used to compare group means. Logistic regression model (multivariate analysis) was used to determine the independent risk factors for the occurrence of ODs using parameters that had a p-value of <0.25 on univariate analysis. All reported p-values <0.05 were considered statistically significant. Results: The mean age of the participants was 41.1 ± 10.0 years; and females were in the majority (65.8%). Over 40% of them were rural dwellers, 50.4% belonged to the lower socioeconomic class, and 55% had a monthly household income less than 20,000 Naira. Fifty percent (50%) of them had advanced immunosuppression at first presentation. The median duration of HAART (3 years) paralleled the median duration of HIV diagnosis (3.4 years) and HAART adherence rate was 78%. The overall prevalence of ODs was found to be 22.4%. Among the 76 patients diagnosed with ODs, the leading conditions were candidiasis (38.2%), TB (34.2%), dermatitis (25%), chronic diarrhoea (6.6%) and sepsis (6.6%). The independent risk factors for the occurrence of ODs were household income less than 20,000 Naira (Adjusted odds ratio [AOR] = 2.4, 95% CI 1.1-5.1), HIV duration of less than 3 years (AOR= 2.1, 95% CI 1.1- 4.2), advanced WHO clinical stage at baseline (AOR= 8.1, 95% CI 4.0-16.4), baseline haemoglobin less than 10 g/dl (AOR= 2.9, 95% CI 1.3-56.1), current CD4 cell count less than 200 cells/μl (AOR= 3.0, 95% CI 1.14-6.2), and HAART non-adherence (AOR= 5.4, 95% CI 2.6-11.2). Past history of TB was found to be a strong predictor of TB (AOR= 5.3, 95% CI 1.4-20.2). Conclusions: Opportunistic diseases are common in patients receiving HAART in Nigeria and candidiasis and TB remain the leading conditions. Late presentation and HAART non-adherence are among the strongest risk factors for ODs in patients receiving HAART. Others include duration of HIV diagnosis less than 3 years, presence of anaemia at the time of first presentation and having a low CD4 cell count while on HAART. Beyond these clinical risk factors, poverty increases the risk of developing an OD during HAART and may emerge a strong determinant of HIV-related ODs in developing countries. Recommendations: A high index of suspicion for ODs remains necessary in HAART patients. Health education on HIV screening and early presentation should be intensified. PLHIV who are anaemic before commencement of HAART, those with low CD4 cell count despite HAART use, and low-income earners should become target groups for a more aggressive evaluation for ODs. Prophylaxis for TB and fungal infections in the absence of active disease should be widely implemented in developing countries. HAART adherence should be intensified.

Master of Public Health - MPH / Poor adherence to antiretroviral therapy (ART) among paediatric and adolescent patients remains a big concern to health workers at Onandjokwe CDC clinic in Oshikoto Region of Namibia. Despite successes in the scale up of ART in Oshikoto Region the clinic experienced high prevalence of poor adherence to ART among adolescent patients. Out of 631 adolescents alive and on ART in this clinic, 154 (24%) had records of poor drug adherence between Jan 2015 and August 2015; which compared poorly to only 4 % of 7289 adults currently on ART who have records of poor adherence during the same period. The aim of the current study was to explore barriers to adherence to antiretroviral therapy among these adolescents. Among the study population of 631 adolescents on ART in Onandjokwe, a sample population of 154 had records of poor adherence (scored below 85%) to ART between June 2015 and August of the same year were considered for the study but among them 16 adolescents were recruited as the study sample. Additionally, 5 caregivers of adolescents on ART, 6 Healthcare Providers were selected as key informants. A voice recorder and field notes were being used during data collection. Two 2 sessions of Focus Group Discussions (FGD) were held with adolescents while 2 FGD sessions held with 5 caregivers and 6 healthcare providers to elicit expert opinions. Lastly, 5 In-depth interviews were conducted with individual adolescents who missed ART medicine follow up for 1 month or more between January and August of 2015. Data Analysis was performed using hand manipulation by grouping responses into main study objectives/themes. Data cleaning, translation of voice transcription from Oshiwambo to English language and incorporating of non-verbal expressions was also done. The results indicate that factors contributing to poor ART adherence among adolescents are patient and family related, socio-economic, and related to substance abuse, stigma and discrimination, health care and health systems, as well as the environment and weather.

The introduction of highly active antiretroviral therapy (HAART) has resulted in a significant decrease in the mortality and morbidity associated with the acquired immunodeficiency syndrome (AIDS). Several problems are associated with HAART and include high costs of treatments, poor availability of drugs in low-income countries, poor compliance, severe adverse effects and drug resistance. Therefore, the focus of current research is the development of new antiretroviral drugs, improved treatment strategies and the discovery of new drugs derived from plants. Green tea (GT) and its active constituent epigallocatechin gallate (EGCg) have been found to be protective against cancer, cardiovascular and neurodegenerative diseases and were found also to have antimicrobial, antimalarial and more importantly antiviral activity. EGCg, in vitro has been shown to inhibit the human immunodeficiency virus (HIV) viral enzymes reverse transcriptase and protease, destroy viral particles and interfere with the attachment of gp120 to cellular receptor CD4. The aims of this study were firstly to investigate the in vitro antiretroviral activity of GT and EGCg on the LP-BM5 defective murine leukemia virus (MuLV) that induces a disease in C57BL/6 mice similar to AIDS in humans and secondly to investigate the effects of GT and EGCg on the in vitro cytotoxicity and antiretroviral activity of current antiretroviral drugs zidovudine (AZT), indinavir (IDV), hydroxyurea (HU) and chloroquine (CQ). To achieve the above aims an in vitro model that represents cell-to-cell spreading of the LP-BM5 MuLV was developed. Firstly the presence of the LP-BM5-defective virus in the BM5 cell line was confirmed using transmission electron microscopy (TEM) to identify viral particles, PCR and RT-PCR were used to determine the presence of viral DNA and RNA respectively and viral infectivity was confirmed in C57BL/10 mice. The cytotoxicity of each drug and combination was evaluated with the MTT assay in the SC-1 cell line, the predominant cell type in the in vitro cell culture model. GT was the least cytotoxic, followed by AZT, IDV, EGCg, HU and CQ. Co-cultures (BM5:SC-1, 1:10000) that represented cell-to-cell transmission of the virus were established. Real time PCR for proviral DNA revealed that IDV, AZT and HU completely suppressed, CQ dose dependently reduced while GT and EGCg had no effect on viral transmission. Findings using AZT and IDV thus validated the use of this in vitro co-culture model for first line screening of new drugs and plant extracts. The effect of GT or EGCg in combination with AZT, IDV, HU or CQ was also evaluated as GT or EGCg could enhance the antiretroviral effects or decrease cellular toxicity of these drugs. For GT with AZT a mix of synergism and antagonism on cell toxicity was observed with little to no effect on the antiretroviral activity of AZT. Antagonism on cell toxicity was observed for GT with IDV, with no effect on the antiretroviral activity of IDV. In contrast EGCg significantly reduced the antiretroviral activity of IDV. A strong antagonistic effect was observed for GT with HU, with GT reducing the antiretroviral effect of HU. For combinations of AZT with EGCg and HU with EGCg a similar effect was observed as for AZT and HU respectively combined with GT. Synergism in cytotoxicity was observed between GT and CQ associated with a significant decrease in viral loads while EGCg combined with CQ had an opposite effect at higher concentrations. In conclusion, the in vitro co-culture model of BM5 and SC-1 cells was successfully used to evaluate combinations of GT and EGCg with AZT, IDV, HU and CQ. Interesting and often contradicting effects were observed, such as seen for IDV in combination with GT and EGCg as well as CQ in combination with GT and EGCg. These effects may be of clinical relevance and further investigation is warranted. / Dissertation (MSc)--University of Pretoria, 2009. / Anatomy / unrestricted