Magister Public Health - MPH / In recognition of high dual burden of tuberculosis (TB) and Human Immunodeficiency virus(HIV) in Sub-Saharan Africa, the World Health Organization (WHO, 2004) provided guidance for implementing integrated HIV/TB services. This strategy has been implemented using different models ranging from partial to fully integrating, and evaluations of these models have been conducted to determine their effectiveness. The aim of this study was to describe and contrast the effectiveness of different models of implementation of HIV and TB integration at primary care level within the Tuberculosis (TB) programme in Livingstone District, Zambia The specific objectives of the study included; 1. To describe the models of integrated HIV and TB services that are currently implemented at four health facilities within the TB programme in Livingstone District at primary health care level. 2. To describe and contrast the coverage and quality of HIV diagnosis in the Tuberculosis(TB) programme achieved in the different facilities representing fully and partially integrated models of service delivery. 3. To describe and contrast the coverage and quality of HIV prevention activities in the Tuberculosis (TB) programme achieved in the different health facilities representing fully and partially integrated models of service delivery. 4. To describe and contrast the coverage and quality of HIV care activities received by coinfected clients in the Tuberculosis (TB) programme in the different facilities representing fully and partially integrated models of service delivery. 5. To describe the quality and outcomes of TB diagnosis and treatment in the different facilities representing fully and partially integrated models of service delivery. A research design using quantitative methodologies: a cross sectional survey and structured observations or review of patient records (quantitative) were used. The records of 814 TB clients notified in 2010 served as the study population while the sample of 464 (232 from partially and 232 from fully integrated) were randomly selected. Two data collection tools namely: patient record and HIV/TB register review; facility staff interviews (key informant interviews) were used and the results were analyzed using Epi info statistical package. In the study, all respondents gave informed consent and no personal information was collected from the retrospective record review. The HIV prevention interventions in this study were rated below 30% except for of HIV education (97%). Statistically significant differences (p-value<0.001) existed for condom provision at facility level. Poor performance reported for STI screening (below 2%) and PMTCT information (below 15%). The HIV testing rate was 94% among TB clients which was higher than the counseling coverage of 88%. Statistically significant differences (p value <0.001) at facility level existed for clients who received HIV test results. Sixty three percent (63%) of TB clients were also co- infected with HIV. ART assessment for TB clients was below 40% and statistically significant differences (p value=<0.001) between facilities were identified for this indicator. ART assessment of TB clients at the same facility they tested for HIV was above 50% for all facilities. The continuation of cotrimoxazole was poor at 38% and statistically significant differences (p value=<0.001) were identified for this indicator between facilities. Sputum testing was 85% while the cure rate was poor at 28% average for all facilities. Statistically significant differences (p-<0.001) were noticed at model level for clients cured. Although HIV prevention and care services were introduced in the TB program in Livingstone,they were not comprehensive enough to respond to the high HIV and TB co-infectivity. For HIV prevention, other than HCT and HIV education, the rest of the critical interventions such as condom provision, STI screening and treatment, and PMTCT intervention were neglected. The HIV care services such as ART assessment and CPT implementation were also poor. There is need to put in place systems to improve these services in the district to improve treatment outcomes. The differences that were noted in performance for the majority of the indicators were mainly at facility level as being a fully integrated facility did not guarantee effective integration or better performance.

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 / Background: The repercussions of being HIV positive coupled by the complications of antiretroviral therapy are likely to cause distress, emotional and psychological problems particularly among children infected by the virus. The limited support services for children experiencing distress intensify the urgency to address this challenge. Despite the availability of social workers and nurses' interventions currently in place, the number of children in need of psychological care continues to increase. This is particularly true at Deborah Retief Memorial (DRM) hospital, one of the main antiretroviral therapy facilities in Kgatleng district, Botswana. Method: The purpose of this study was to explore and describe the perceptions of social workers, nurses and caregivers on key factors contributing to psychological distress of HIV positive children. A descriptive, exploratory qualitative study design that employed the use of in-depth interviews was used to conduct this study. Participants included four caregivers of HIV positive children who seek antiretroviral therapy at DRM hospital Infectious Diseases Control Clinic, together with five nurses and two social workers who worked in the same clinic. Conventional content analysis was used to analyse the in-depth interview transcripts. Results: Perceived psychological stressors for HIV positive children included disclosure of HIV status, orphanhood, social problems, lifelong treatment, stigma, poor caregiver-child relationship and lack of caregiver‟s love, care and support. However the caregivers did not fully understand the psychological distress the HIV positive children were experiencing, hence were unable to recognize it in these children. The study highlighted that major challenges faced by the health-workers included lack of qualified personnel, lack of adequate knowledge and skills, and a non-conducive working environment required to effectively assist children with psychological distress. The findings also indicated the need for education and support of caregivers and HIV positive children by the educators, family and health-worker systems. Conclusion: The profile of key stressors of psychological distress, the challenges and support needs suggested by the participants in this study can provide a framework for improving the existing services for HIV positive children with psychosocial problems. This information is important for use in training nurses and social workers involved with children with psychological behaviours.

Magister Legum - LLM

The purpose of this study was to evaluate the impact of a HIV/AIDS module, taught for approximately 24 hours over eight weeks in six schools, on the knowledge, behaviour and attitudes of grade 11 biology learners, and to identify problems their teachers had in teaching the module. The module contains detailed scientific content on HIV/AIDS and outcomes-based assessment activities. The answers written by each learner in a pre-, post- and retention test and questionnaire that included both open and closed questions on general and functional knowledge, attitudes and skills were analysed for significant changes. A narrative written by each learner was analysed to determine how the module had dealt with issues that affected his I her life. A structured interview was conducted with each teacher to identify difficulties he I she experienced in implementing the module. Classroom observations were used to monitor the implementation of the intervention in order to provide information to verify the findings of the tests, questionnaires, narratives and interviews. Analysis of the tests and questionnaires showed a significant improvement in the means scored in the pre, post- and retention tests. An ANOVA showed that the difference was unlikely to be attributable to chance. Narrative analysis resulted in a number of common themes being identified. The learners were profoundly glad to have been taught this information and many of them provided evidence of how the module impacted on their lives and sexual behaviour. Their knowledge has empowered and motivated them to control their own lives. The teacher interviews established some of the common difficulties that the teachers experienced in teaching the module. These were verified by the classroom observations. The main problems were the lack of facilities and limited time to teach about HIV/AIDS. / Dissertation (MEd (Curriculum and Instructional Design and Development))--University of Pretoria, 2006. / Curriculum Studies / unrestricted

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

Introduction: Clostridium difficile infection (CDI) is a common hospital-acquired infection and a financial burden on the healthcare system. There is a need to reduce its impact on patients and the entire health system. More accurate estimates of the financial impact of CDI will assist hospitals in creating better CDI reduction strategies with limited resources. Previous research has not sufficiently accounted for the skewed nature of hospital cost data, baseline patient mortality risk, and the time-varying nature of CDI. Objective: We conducted a retrospective cohort study to estimate the cost impact of hospital-acquired CDI from the hospital perspective, using a number of analytical approaches. Method: We used clinical and administrative data for inpatients treated at The Ottawa Hospital to construct an analytical data set. Our primary outcome was direct costs and our primary exposure was hospital-acquired CDI. We performed the following analyses: Ordinary least square regression and generalized linear regression as time-fixed methods, and Kaplan-Meier survival curve and Cox regression models as time-varying methods. Results: A total of 49,888 admissions were included in this study (mean (SD) age of 64.6 ± 17.8 years, median (IQR) baseline mortality risk of 0.04 (0.01-0.14)). 360 (0.73%) patients developed CDI. Estimates of incremental cost due to CDI were substantially higher when using time-fixed methods than time-varying methods. Using methods that appropriately account for the time-varying nature of the exposure, the estimated incremental cost due to CDI was $8,997 per patient. In contrast, estimates from time-fixed methods ranged from $49,150 to $55,962: about a six fold difference. Conclusion: Estimates of hospital costs are strongly influenced by the time-varying nature of CDI as well as baseline mortality risk. If studies do not account for these factors, it is likely that the impact of hospital-acquired CDI will be overestimated.

This study describes hospital nurses' experiences caring for patients with AIDS. A modified version of Speigelberg's phenomenological approach was used which explored the nurses' experiences from their perspective. A total of eight nurses who had cared for patients with AIDS were interviewed. The findings indicated that caring for these patients is stressful. The researcher identified sources of stress as both internal and external. Internal stressors included: (1) fear of contracting AIDS; (2) homophobia; and (3) caring for dying AIDS patients. The two external stressors were patient variables and societal views. Lack of perceived emotional support from nursing administration further increased the stress. These nurses believed this form of support was essential. In order to cope with these experiences, the nurses utilized their usual coping strategies. Common ones were being physically active, relaxing, and talking with others. Different coping strategies were used to deal with the specific stressors. These were identified by the researcher as: (1) rationalization; (2) knowledge-seeking; (3) withdrawal; and (4) involvement. This study's findings emphasize the need for support for all nurses caring for patients with AIDS. Implications for nursing education, practice, and research were identified. / Applied Science, Faculty of / Nursing, School of / Graduate

AIDS is a leading high-risk disease with multiple-faceted impact worldwide. It is impacting on a number of sectors. This subject was chosen because of personal interest, and also because of lack of research on the subject in the South African Post Office (SAPO). The researcher’s work in Durban, at the SAPO as an Employee Assistance Professional for two years, has exposed her to an increasing number of employees infected and affected by HIV/AIDS. As an Employee Assistance Professional the researcher is expected to support these employees. Through working with employees who are infected and affected by HIV/AIDS the researcher felt interested in the subject, especially in investigating how HIV/AIDS is affecting SAPO. The researcher also wanted to contribute to increasing the knowledge base, and to contribute to the development of the organization. This study will assist management to gain insight into the impact of HIV/AIDS on the workplace, and then to be able to plan for the future. This study was focused on the impact of HIV/AIDS in the SAPO in Durban. It was designed to understand the psychosocial impact of HIV/AIDS on both the infected and the affected employees. The aim of the study was to explore the impact at in individual level and at the organization as a whole. A particular area of interest was on the impact caused by HIV/AIDS on their benefits and the execution of work of the employees. Data was gathered by a questionnaire through a sample of 33 supervisors and 10 managers from the Post Offices around Durban who were selected using systematic random sampling. Efforts were made to ensure that cultural diversity in the Post Office is represented in the sample. A literature review was conducted on the subject of HIV/AIDS and its impact in the workplace. Key concepts of the study were the following; Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), and impact. The study found that both the infected and affected employees were affected physically and psychologically by HIV/AIDS in different ways. It was indicated that the impact was also experienced in different ways. The impact depended on the type of a job of an infected employee. Employees were found to be at various stages and relapsing to and from backward stages, most of the time. As a final product of the applied research used for this study, some guidelines to make a difference to the impact are proposed. Proposals constitute future broad guidelines with regard to HIV/AIDS services to be provided by the Employee Assistance Professional and management, and the support to be provided to both the HIV infected and affected employees. / Dissertation (MSD (EAP))--University of Pretoria, 2005. / Social Work and Criminology / unrestricted

Human immunodeficiency virus (HIV) is currently the most significant infectious pathogen and the causative agent of acquired immune deficiency syndrome (AIDS). Unfortunately, due to lack of resources, delivery of antiretroviral therapy (ART) to countries where they are most needed, such as South Africa, Botswana, Lesotho, Malawi and Swaziland, is limited and inefficient. Moreover, the short supply and high cost of antiretroviral drugs have caused researchers to turn to plants as prospective therapies in the search for alternative anti-HIV or immunomodulatory compounds. In an African context, traditional medicines are of great importance, not so much as an alternative to treatment, but in many cases as the only source of treatment. There are various South African plants used medicinally which possess phytochemical constituents that target certain mediators of inflammation and the immune system. In African regions where patients do not have access or financial capability to obtain conventional antiretroviral treatment, traditional herbal medicines are used as primary treatment of HIV/AIDS, regardless of the fact that the safety, toxicity and efficacy of these products are not yet fully understood and that a risk for adverse effects exists. Hypoxis hemerocallidea Fisch&C. A. Mey. (Hypoxidaceae) as well as Sutherlandia frutescens L. R. Br. (Leguminosae) have various effects on the immune system and due to claims about their immune boosting properties, they are two of the most common African herbal compounds being used for HIV management in South Africa. In this study, the immune modulating properties of H. hemerocallidea and S. frutescens were investigated in order to determine whether anectodal claims made about these plants could be supported. Differentiated THP-1 and U937 macrophages were treated with aqueous extracts of H. hemerocallidea and S. frutescens as well as with solutions of compound standards reputedly isolated from these plants such as beta-sitosterol, found in H. hemerocallidea, canavanine, pinitol and gammaaminobutyric acid (GABA) which are present in S. frutescens Cytotoxicity of the test compounds was determined using the 3-(4,5-dimethylthiazol- 2-yl)-2,5-dephenyl tetrazolium bromide (MTT) assay. Antioxidant capacity was assessed using the Trolox equivalence antioxidant capacity (TEAC) and Oxygen radical antioxidant capacity (ORAC) assays. Determination of prostaglandin E2 (PGE2) concentration in treated THP-1 and U937 cell culture supernatants was performed by ELISA. Concentrations of cytokines (IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, TNF-á and IFN-ϒ) in treated THP-1 and U937 cell culture supernatants were determined by flow cytometry. Curcumin, a well-known immunomodulatory compound, was used as a positive control. Results of cytotoxicity assessments showed that H. hemerocallidea (0.1 – 1.9 mg/ml), S. frutescens (0.1 – 1.6 mg/ml), beta-sitosterol (0.2 – 25 ìM), canavanine, pinitol and GABA (1.5 – 200 ìM) were not cytotoxic to THP-1 and U937 macrophages and had cytotoxicity profiles comparable to that of the positive control, curcumin (0.8 - 25 ìM). The TEAC and ORAC assays showed different results in the antioxidant capacities of the test compounds. The purported antioxidant activity of H. hemerocallidea was confirmed by the TEAC assay with antioxidant effects equivalent to 0.2 mg/ml Trolox. Canavanine showed antioxidant activity equivalent to approximately 0.17 mg/ml Trolox and comparable to that of curcumin in the ORAC assay, suggesting its involvement in the inhibition of peroxyl radical-induced oxidation. Flow cytometry results showed that curcumin (20 ìg/ml and 10 ìg/ml) and beta-sitosterol (25 ìg/ml and 12.5 ìg/ml) reduced IL-1â and IL-8 production and significantly (p<0.05) decreased the production of TNF-á. This suggests that betasitosterol could indeed possess anti-inflammatory properties, with effects comparable to the known anti-inflammatory effect of curcumin in terms of cytokine profiles. Beta-sitosterol (25 ìg/ml) and pinitol (50 ìg/ml) significantly (p<0.001) decreased extracellular PGE2 levels in U937 macrophages by 233.4 pg/ml and 281.7 pg/ml, respectively and were the only two compounds showing greater reductions in PGE2 than curcumin. In conclusion, results of this study do not provide enough evidence to support all anecdotal claims about the ‘immune boosting’ properties of S. frutescens and H. hemerocallidea, but the compounds canavanine, beta-sitosterol and pinitol were found to have modulatory effects on certain aspects of the immune system. / Dissertation (MSc)--University of Pretoria, 2011. / Pharmacology / unrestricted