Objective: To investigate hearing loss among perinatally HIV-infected (PHIV+) adolescents on antiretroviral therapy (ART), and HIV-non-infected (HIV-) adolescents in Cape Town, South Africa. Methods: A cross-sectional analysis was carried out to describe the prevalence, nature and predictors (demographic, past medical history, clinical findings) of hearing loss in adolescents between 9 and 14 years of age. Screening pure-tone air-conduction (AC) thresholds above 30 decibels (dB) were considered to be indicative of debilitating hearing loss. Statistical analysis included univariate analysis and multivariate logistic regression. Results: The cross-sectional analysis included data from 540 participants; consisting 273 males (51%), 267 females, 432 PHIV+ and 108 HIV-, with a median age of 12 years. Hearing impairment was observed in 19% of all the adolescents in the study. Multivariate analysis showed the following predictors for any hearing loss: an unmarried primary caregiver (odds ratio (OR) 0.59; 95% confidence interval (CI), 0.39;0.91, p = 0.015), being female (OR 1.67; 95% CI, 1.12;2.51; p = 0.013) and reports of being troubled by ear pain or discharge in the last month (OR 2.54; 95% CI, 1.55;4.17; p = <0.001) after adjustment. Univariate analysis showed an association between hearing loss and a longer duration on ART among PHIV+ adolescents (OR 1.80, 95%CI 1.17;2.75, p = 0.007). Conclusion: The prevalence of hearing loss appears to be comparable between PHIV+ and HIVadolescents in Cape Town. In low resource settings, a history of ear pain or discharge within the last month may be used as a screening tool for a hearing assessment, and guide referral for formal hearing tests.

The cornerstone in the fight against HIV/AIDS is prevention followed by the access to and use of highly active antiretroviral treatment (HAART). Adherence is the greatest patient- enabled predictor of treatment outcome for the patients on HAART, as good adherence leads to a decrease in disease progression and death. There is no ‘gold standard’ in the measurement of adherence. Also, factors that influence adherence and hence the prevalence of adherence differ across different settings making it necessary to determine local adherence prevalence as well as factors that might impact on it. This was a cross sectional study which assessed the prevalence of one- week adherence to antiretroviral therapy at St Rita’s hospital through an abridged version of the questionnaire developed by the Adult Aids Clinical Trials Group in the United States. Results from the questionnaires were compared to the results from a decrease in plasma viral load to undetectable limits within six months. The study found out that the prevalence of one- week adherence by self-report was 96.8% (95% CI: 93.2 – 98.9%). Using a decrease in viral load to undetectable limits within six months of initiating treatment as a tool to assess adherence, the prevalence in this study was 96%. A combined prevalence of 94% was found for this study. These results were identical to a few results locally but it was much higher than most local studies. The explanation for this apparent higher adherence rate might be that the study site has not reached its maximum capacity for the delivery of service as it is still operating at just below the staff/patient ratio recommended by the Department of health. The study also found out that being a member of an AIDS support group was a facilitator to adherence while lack of adherence counselling and monitoring is a barrier. Based on these findings it is therefore recommended that measures should be put in place to ensure improving existing adherence counselling and monitoring, encouraging patients to belong to at least one AIDS support group, more decentralization of antiretroviral therapy roll out to the districts that are yet to roll out and providing financial assistance through improved access to disability grants for those who qualify and income generating activities for the unemployed that do not qualify for disability grant.

Research report submitted in fulfilment of the degree of Master of Public Health (MPH) at the University of Witwatersrand July 2015 / Introduction: Swaziland is facing a very high HIV prevalence and critical human resources for health (HRH) crisis. The Nurse Initiated and Managed Anti-Retroviral Treatment (NIMART), a task shifting program to capacitate nurses to offer ART services, was introduced in 2009 by the government of Swaziland to address the human resources for health (HRH) challenges in the country. Although the country has attained 80% coverage in ART provision amongst adults, the ART coverage in children below 15 years of age is 9% which falls way below the WHO stipulated proportion of 15% in that age group. In addition, ever since the NIMART was introduced there have been limited studies done in Swaziland to explore the perceptions of health workers with regards to its implementation. This study explored providers’ perceptions on the facilitators and barriers to the NIMART implementation in Manzini Region. Materials and Methods: An exploratory qualitative study was used to explore providers’ perceptions of the facilitators and barriers to the implementation of NIMART services in Manzini Region, Swaziland. A semi-structured interview guide was used to interviews with nurses, clinic managers and medical doctors who were purposively selected from five urban and three rural clinics offering NIMART services in Manzini Region, Swaziland. Thematic content analysis was used to analyse data guided by the Donabedian conceptual framework. Results: The findings showed that two weeks training was offered to the professional nurses before they were certified as NIMART nurses. The first week of training was mainly theory classes while the second week was on-site practical training. The NIMART program was perceived as vital by the providers interviewed as it improved access to ART, reduced patient waiting times, empowered nurses and was a cost effective program to address the shortages of doctors in the country. Structural factors like availability of health facilities, professional nurses, antiretroviral drugs and antiretroviral treatment guidelines at the facilities visited were reported by most respondents as facilitators of the implementation of the program. Process factors like the training of NIMART nurses in some facilities, the partnership between the Ministry of Health and various nongovernmental organisations, the health workers commitment and team work greatly facilitated NIMART implementation. Structural barriers like limited paediatric antiretroviral regimen choices and limitations in paediatric ART policy and legislation were mentioned to negatively affect ART uptake in children. Other barriers like children’s dependency on adult caregivers for their health issues and poor socioeconomic circumstances in communities were mentioned to be hampering ART uptake in children. Process factors like inadequate training of the NIMART nurses in some clinics, parents’ and caregivers’ myths and misconceptions around HIV, AIDS and ART, high HIV and AIDS stigma and poor access to health services were also raised. Conclusion and Recommendations: Even though there were facilitating factors of the NIMART program like availability of ART drugs and ART treatment guidelines which have been seen to have played a major role in ART uptake in adults, there are still many barriers to the implementation of NIMART as evidenced by the poor ART uptake in children. The inadequate training of NIMART nurses on paediatric ART, children’s total dependency on adults for their health needs and parents’ and caregivers’ misconceptions around HIV and AIDS negatively impacted the paediatric ART program. Other barriers included poor socioeconomic status and paediatric ART policy and legislation limitations. As a result, the recommendations are that the NIMART training program for nurses be improved with particular emphasis on paediatric ART. There is need to incorporate NIMART training into the nursing curriculum to ensure that more nurses are trained in ART provision. Community awareness needs be raised to address the issues around stigma, myths and misconceptions of HIV and AIDS through educational programs. There is also a need to increase the recruitment of nurses and improve motivation of nurses through provision of incentives.

Master of Public Health - MPH / It is well documented that mortality rates have decreased and the survival of HIV and AIDS patients has been prolonged since the introduction of highly active antiretroviral therapy (HAART) in 1996. Although HAART has dramatically improved the prognosis of HIV disease, some HIV patients on HAART still die of HIV related illnesses. It is important to understand what these factors are in order to mitigate the impact on these factors on patient survival and achieve better outcome for these patients. The aim of this study was to determine risk factors for long term survival of patients on HAART in Uganda. Data for 2,244 out of 30,000 clients receiving care and treatment at TASO Entebbe was retrospectively analyzed. TASO Entebbe is a non-governmental HIV clinic that provides care and treatment to HIV positive clients. Long term survival in this case was defined as survival for more than 5 years after initiation on HAART. Logistic regression and survival analysis were conducted. Female clients had a 12% lower risk of death compared to the male clients (AHR=0.88 [CI: 0.443- 0.936]). Clients that had pulmonary TB had 1.3 times higher risk of death compared to clients that did not have pulmonary TB (AHR=1.33 [CI: 1.162-2.733]). Clients initiated at CD4 cell counts less than 250 cells/μl had almost 7 times higher adjusted odds of death compared to those initiated at CD4 cell counts greater than 500 cells/μl (AOR= 6.95 [CI: 2.882-16.744]) and clients initiated at CD4 cell counts between 250 cells/μl and 500 cells/μl almost 3 times higher adjusted odds of death compared to clients initiated at CD4 cell counts greater than 500 cells/μl (AOR 2.56 [CI: 1.004-6.520]). It is recommended that an aggressive HIV testing strategy be put in place to facilitate early identification of HIV positive patients. Early identification would enable early initiation into HAART well before the CD4 cell counts fall below 500 cells/μl. The observed higher risk of mortality amongst men suggests interventions to promote early HIV testing and treatment initiation amongst men. The observed high risk of mortality for patients with pulmonary TB, calls for aggressive TB case finding and treatment of positive in order to reduce the HIV/TB related mortality.

Thesis (MPH.) -- University of Limpopo, 2019 / Virological failure occurs when the viral load fails to supress to undetectable limit and immunological failure is when the immune system fails to improve with the CD4 count remaining low on clients on antiretroviral drugs. These being markers of poor adherence to antiretroviral drugs or treatment failure. Upon routine blood-monitoring of students on antiretroviral drugs, the researcher noticed that some students’ viralload levels were not suppressing and their immune system was not improving. The purpose of the study was to identify the experiences of those students whose viral load is not suppressing and their immune system not improving. The objective was to identify and describe the experiences of students with immunological and virological failure on antiretroviral drugs at the University of Limpopo. A qualitative, explorative and descriptive study design was used. Convenience purposive sampling method was adopted. Using a semi-structured interview guide, face-toface interviews were conducted on 10 students on antiretroviral drugs at the Student Health and Wellness Centre, University of Limpopo. Techs’ method was used to analyse data. Guba’s model for establishing trustworthiness was used. The study yielded the following themes: Disclosure, stigma, antiretroviral drugs packaging, side effects of antiretroviral drugs and service delivery. The study concluded that students are afraid to take their treatment for fear of stigmatisation and disclosure is still a problem. Students tend to forfeit taking drugs when studying for examinations due to side effects of the drugs. It is recommended that service delivery and antiretroviral drugs packaging be user friendly. Key words: Disclosure, stigma, side effects, antiretroviral drugs packaging and antiretroviral drugs.

Thesis (PhD)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Introduction: Since the South African public sector antiretroviral roll-out programme started in 2004, the success of antiretroviral combination therapy (cART) has been experienced in terms of survival, prevention of mother-to-child transmission (PMTCT) and quality of life. However, as the programme matures, viral resistance to the constituent drugs will increase. Monitoring antiretroviral drug resistance (ARVDR) should therefore be a priority in the public health approach to HIV treatment. Methods: A cross-sectional investigation of genotypic antiretroviral drug resistance in: a) HIV-infected mothers who were exposed to a PMTCT regimen of short course azidothymidine (AZT) with single dose nevirapine (NVP) during labour. b) HIV-infected adults and children who were cART-naïve (transmitted or initial resistance). c) HIV-infected adults and children who were failing cART (drug-induced or acquired resistance). In case of adults, this includes patients on a first-line, non-nucleoside reverse transcriptase (NNRTI)-based regimen, or on a second-line, protease inhibitor (PI)-based regimen, and in case of children, this includes patients on a first-line PI-based regimen. Results: In mothers who received a PMTCT-regimen that combined AZT and NVP the prevalence of NNRTI resistance mutations was 17.1% (95% CI: 8.7-25.6%). The prevalence of transmitted ARVDR in adults was low, as was initial ARVDR in young children (mostly PMTCT-exposed), except for NNRTI resistance in children who had received NVP as part of PMTCT. Drug-induced resistance was found in adults failing first-line NNRTI-based cART, with 83% having resistance to ≥1 drug. In contrast, adult patients failing second-line PI-based cART had a low prevalence of PI resistance; the predominant reason for failure was poor drug exposure, as detected by measuring lopinavir concentrations in blood plasma and hair samples. In contrast, PI resistance in children was not rare, largely due to historic exposure to un-boosted PIs. This resulted in extensive resistance to PIs and reverse transcriptase inhibitors (RTI) in some children. Conclusions: A combined regimen of short course AZT with intrapartum NVP for PMTCT may, in addition to reducing the risk of neonatal infection, also reduce the risk of NVP resistance in the mothers compared to a regimen of NVP only. In South Africa, the prevalence of transmitted ARVDR remains low relative to industrialised countries, probably as comparatively little time has elapsed since the scale-up of cART. Adults failing first-line cART are likely to respond to second-line cART, without failure due to resistance. However some children with PI and RTI resistance cannot be adequately treated with drugs currently available through the roll-out programme. This emphasizes the urgent need for a rational and science-based approach to managing cART-experienced children, including access to additional drugs to form a third-line paediatric cART regimen. / AFRIKAANSE OPSOMMING: Inleiding: Sedert die begin van die Suid Afrikaanse publieke sektor antiretrovirale uitrol program in 2004 is die sukses van antiretrovirale kombinasie-behandeling (k-ARB) ervaar in terme van oorlewing, voorkoming van moeder na kind oordrag (VMKO) en lewenskwaliteit. Nietemin, sal weerstandigheid teen die middels wat in die antiretrovirale program gebruik word toeneem soos wat die program gevestig raak. Die monitoring van antiretrovirale middel-weerstandigheid is derhalwe ‘n prioriteit in gemeenskap-gesondheid benadering tot MIV behandeling. Metodes: ‘n Deursnit ondersoek van genotipiese antiretrovirale middel-weerstandigheid in: a) MIV-geïnfekteerde moeders wat blootgestel is aan VMKO regimen bestaande uit ‘n kort kursus AZT met ‘n enkeldosis nevirapien (NVP) tydens kraam. b) MIV-geïnfekteerde volwassenes en kinders wat komibinasieterapie-naïef (oorgedraagde of inisiële weerstandigheid) is. c) MIV-geïnfekteerde volwassenes en kinders wat k-ARB faal (middel-geïnduseerde weerstandigheid). In geval van volwassenes, sluit dit pasiënte op ‘n eerste-linie, non-nucleosied tru-transkriptase inhibitor (NNRTI)-regimen, en tweede-linie protease inhibitor (PI)-gebaseerde regimen, en in geval van kinders, sluit dit pasiënte in op ‘n eerste-linie PI-gebaseerde regimen. Resultate: In moeders wat ‘n gekombineerde AZT en NVP VMKO-regimen ontvang het, was die voorkoms van NNRTI weerstandigheid 17.1% (95%-vertrouensinterval: 8.7-25.6%). Die voorkoms van oorgedraagde ARVMW in MIV-geïnfekteerde volwassenes en kinders wat kombinasieterapie-naïef is, was laag, so ook ARVMW in jong kinders (meestal VMKO-blootgestel), behalwe vir non-nukleosied tru-transkriptase inhibitor (NNRT) weerstandigheid in kinders wat NVP ontvang het deur VMKO. Middel-geïnduseerde weerstandigheid was gevind in volwassenes wat die eerste-linie NNRTI-gebaseerde k-ARB gefaal het, met 83% wat weerstandigheid teen ≥1 middel het. Volwassenes wat ‘n tweede-linie protease inhibitor (PI) –gebaseerde k-ARB gefaal het , het ‘n lae voorkoms van PI weerstandigheid, met die oorwegenede oorsaak, swak middel-bloostelling, soos bepaal deur van lopinavir-konsentrasies in bloed plasma en hare. In teenstelling hiermee was PI weerstandigheid nie skaars in kinders nie, hoofsaaklik weens historiese blootstelling an ongeskraagde PI-behandeling. Dit het tot uitgebreide weerstandigheid tot PIs en tru-transkritptase inhibitors (RTI) in sommige kinders gelei. Gevolgtrekkings: ‘n Gekombineerde regimen van ‘n kort kursus AZT met NVP tydens kraam vir VKMO, mag bykomend tot die vermindering die risiko van pasgebore infeksie, ook die kans vir weerstandigheid teen NVP in die moeders verlaag in vergelyking met ‘n regimen van NVP-alleen. Die voorkoms van oorgedraagde ARVMW is tans laag in vergelyking met geïndustrialiseerde lande, waarskynlik aangesien daar nog betreklik min tyd verloop het sedert k-ART wyd beskikbaar gemaak is. Volwassenes wat eerstelyn kombinasie terapie faal sal waarskynlik goed reageer op tweede-linie terapie, sonder terapie faling weens middelweerstandigheid. Daarenteen kan sommige kinders met protease inhibitor en tru-transkriptase weerstandigheid nie voldoende behandel word met die huidig-beskikbare middels in die uitrol program nie. Dit beklemtoon die dringende noodsaaklikheid van ‘n rasionele en wetenskaplike benadering tot k-ART in kinders, met ‘n lang terapie geskiedenis, wat toegang tot bykomende medikasie behels om `n derde-linie regimen saam te stel.

Thesis (MPH.) --University of Limpopo, 2018 / Background: The prevalence of HIV in South Africa has increased largely due to the combined effect of new infections, and a successfully expanded antiretroviral treatment programme, which has increased survival among people living with HIV. As the up-scaling of patients on ART has been increased, the aim of the current study was to investigate the variations of the clinical outcomes between patients initiated with CD4 < 350 and of those above 350 after the implementation of the new eligibility criteria for ARV therapy. Methods The current study used quantitative approach to retrospectively review a total of 488 records of adult patient who were registered in health facilities which were purposefully sampled from Sekhukhune District of Limpopo Province. SPSS version 23.0 was used to analyse data. Results Approximately 60% of the patients initiated on ART were having CD4 count <350 and male patients were more at 74% as compared to females at 54.7%. Patients who started ART with a baseline CD4 >350 had a high rate of lost to follow up within 3 months after start of ART at 15% than those with a baseline CD4 <350 at 10.2. More patients were lost to follow-up shortly after starting treatment at 3 months at an average of 13.8% in both CD4 counts. Majority of patients retained in care were those who started ART treatment with a baseline CD4<350 at 87.4%. Viral load completion rate at 12 months was higher than that of 6 months, at 86.8 and 80.5 respectively. Patients with a baseline CD4 >350 suppressed more than those who started ART with a baseline CD4 <350 at both 6 and 12 months at >90% suppression rate. Lastly, most of the patients died within 3 months of ART treatment and had a baseline CD4 < 350 than at 2.4% those with a baseline CD4 >350 at 0.6%. Conclusions The implementation of the new eligibility criteria of ART initiation improves the clinical outcome of patients on ART. There are still patients that are missed to be monitored viral load bloods which play a key role in determining the clinical outcomes of patients. Clinicians and nurses should adhere to the recommended time frames for monitoring of ART patients to improve clinical outcomes. Keywords: HIV/AIDS, antiretroviral therapy, clinical outcome, ART initiation; Eligibility Criteria;

No description available.

Background: Whether the non-inferior efficacy and safety results of switching virologically suppressed HIV-1-infected patients from nevirapine immediate-release (NVP-IR) to NVP extended-release (NVP-XR) demonstrated in the TRANxITION study conducted in Europe and North America are also applicable to virologically suppressed HIV-infected Taiwanese patients remains unknown. We evaluated the comparative safety and efficacy of continuing NVP-IR versus switching to NVP-XR in virologically suppressed HIV-infected Taiwanese adults receiving combined antiretroviral therapy (cART) regimens. Methods: We conducted a retrospective cohort study at Kaohsiung Veterans General Hospital from April 1, 2013, to March 31, 2015. Eighty-four virologically suppressed HIV-infected adults receiving NVP-IRcART were split into two groups: those continuing with NVP-IR (n = 49) and those being switched to NVP-XR (n = 35). Demographic characteristics, clinical variables, and laboratory findings were compared. Therapeutic drug monitoring of steady-state plasma NVP concentrations and genotype analysis of CYP2B6 516 were also performed in 22 participants. The primary endpoint was continued virological suppression at the end of the study. Secondary endpoints were time to loss of virological response and adverse events. Results: During a mean follow-up of 18.4 months, the NVP-XR group demonstrated similar success at maintaining virological response compared with the NVP-IR group (82.9% vs. 85.7%; P = 0.72). Cox regression analysis indicated that there were no significant differences between NVP regimens for time to loss of virological response (hazard ratio: 0.940; P = 0.754). Furthermore, there were no significant differences in adverse events between these two groups. In the 22 participants, there was a non-significantly lower level of steady-state plasma NVP concentrations in the NVP-XR group than in NVP-IR recipients (5145.0 ng/mL vs. 6775.0 ng/mL; P = 0.267). The prevalence of CYP2B6 516 GT was 86.6%, and there was no significant difference in the distribution of CYP2B6 516 between these two groups. Conclusions: We found that switching from NVP-IR to NVP-XR appeared to have similar safety and efficacy compared with continuing NVP-IR among virologically suppressed, HIV-infected Taiwanese patients. Our finding of higher C-trough levels in both groups compared with other studies conducted in Caucasian populations and the high prevalence of CYP2B6 516 GT requires further investigation in a larger Taiwanese cohort.

MSc (Med), Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand / Background. South Africa is currently experiencing one of the most severe AIDS epidemics in the world. The major challenge lies in prompt identification and early initiation of treatment in those eligible for HAART. Clinical staging has previously been recommended for use in settings where CD4 + count testing is not available. We conducted secondary data analysis to determine whether clinical symptoms and signs are useful in predicting the need for HAART initiation (CD4 + count < 200 cells/μL) in South Africa. Methods. Screening data from a randomized controlled trial in women who were HIV positive were analysed. All participants were interviewed using a structured questionnaire to elicit symptom history and then physical examination was done. Participants were staged using WHO criteria. Blood was drawn for CD4 + testing. The association between signs and symptoms and a CD4 + < 200 cells/μL was assessed using logistic regression. Results. Among 589 HIV infected women aged between 18 and 58 years, 90% were assessed as WHO clinical stages I/II. The median CD4 + count was 403 cells/μL (IQR: 273-586). Among women who were WHO stage I/II, 13% had CD4 + count < 200 cells/μL and required HAART. The WHO clinical staging had a low sensitivity (4%) but high specificity for detecting those that require treatment. Conclusion: In a setting where asymptomatic patients are diagnosed with HIV, clinical assessment can not replace CD4 + count testing as a method of identifying those that need treatment.