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ABSTRACT The formulation and approval of the Operational Plan for Comprehensive Care, Management and Treatment for HIV/AIDS in 2003 was a major victory for the roll-out of anti-retroviral therapy (ART) in the public sector in South Africa. Since its initiation in 2004, the ART Programme has expanded rapidly and realised considerable gains in prolonging life. However, it has also faced major constraints and implementation has been uneven across provinces. This study investigates the impact of organisational capacity upon levels of adherence to ART in two public sector sites in Gauteng. The study uses the Chronic Care Model (CCM) proposed by Edward Wagner (2004). The CCM identifies four major components as crucial to effective clinical outcomes for the management of chronic care. These factors are (1) prepared proactive practice teams; (2) delivery systems design; (3) decision support; and (4) clinical information systems. Both sites demonstrated different strengths and constraints. Strengths included the presence of motivated champions leading the ART service, positive patient-provider relationships, shifting of tasks to lower level health workers to deal with the shortage of skilled staff, good relationships with non-governmental organisations and the innovation to deal with challenges in a way that does not compromise the quality of care provided to patients using the CCMT service. Overall constraints that were identified in the two facilities include the shortage of skilled staff, burn-out among staff, a shortage of space, inconsistent data collection and interpretation, as well as poor integration and collaboration between local and provincial government in relation to the shared responsibility for the provision of Tuberculosis (TB) treatment and other related CCMT services. Despite these barriers, levels of adherence exceeded 85% in both sites.

Magister Public Health - MPH / HRQOL of HAART recipients at the Kagera region hospital was generally lower than that of the general population. However, their general health perceptions and mental health status were comparable to those of the general population, suggesting effectiveness of HAART in improving some subjective experiences of HIV morbidity. Chronic diseases were the main factor negatively affecting HRQOL of recipients.

MPH, Maternal and Child Health, Faculty of Health Sciences, University of the Witwatersrand / Due to the high prevalence of HIV in South Africa, all pregnant women are offered an HIV test as part of the package of services offered during ante natal care (ANC). All women who present to an ANC clinic for the first time for that given pregnancy are given group talks about HIV and the availability of services to protect their children from HIV through Prevention of Mother to Child Transmission (PMTCT) services. Following these group discussions, all the women are then counselled on a one on one basis and are offered an HIV test. Women who decide not to take the test can opt out of testing at this stage, those who do go ahead and test are also offered post test counselling after which their test result is given to them. All HIV tests are conducted using rapid HIV test kits which make results known within 15 minutes, the results are given to the women on the same day of testing. Women whose CD4 count is below the antiretroviral treatment(ART) initiation threshold† are fast tracked onto ART , those whose CD4 is above the threshold should then be referred to other services which can help them maintain their health.1 These services are part of the Comprehensive Care, Management and Treatment (CCMT) approach. They include: CD4 count monitoring; treatment for opportunist infections; social workers, and support groups for psychosocial support.2 For purposes of this study, these services are collectively referred to as Wellness services. Thus PMTCT should serve as a gateway to either ART or Wellness services. This study therefore sought to describe the linkages between PMTCT, ART and Wellness by reviewing service utilisation levels and referral systems at sampled health facilities in Soweto. Data for this study were collected via a cross sectional record review of PMTCT registers and an ART initiation register at sampled health facilities. PMTCT registers were reviewed for the period January to March 2008 to determine what service had been given to pregnant women who accessed PMTCT services for the first time during that period † In his speech on World AIDS Day (December 1st 2009) President Jacob Zuma announced that CD4 count threshold for treatment initiation will be raised from 200 to 350 as of April 2010. 0707048E 2 and which follow on services they had been referred to. ART registers were reviewed for the period January to August 2008 to determine which of the pregnant women who had been referred to ART from the PMTCT service points at the sampled clinics accessed the service. Key informant interviews were also conducted with staff at PMTCT, ANC, ART and voluntary counselling and testing (VCT) service points at the sampled facilities. Descriptive statistics were run using SPSS version 17.0, comparisons were done using OpenEpi and key informant interview data were thematically analysed using Atlas TI version 5.2.0. Records at the PMTCT clinics showed that of the 1350 women who attended ANC clinics at the sampled facilities between January and March 2008, all but one agreed to test for HIV. Twenty-nice percent (388) tested positive for HIV. Of these 388 HIV positive women, 20% (77 women) had CD4 counts below 200 and were therefore eligible for initiation of ART. Review of records at the ART clinic showed that only 23% (n = 18, N = 77) of all ART eligible women had accessed the service. Review of the PMTCT register also showed that a significant proportion, 37% (n = 144, N =388), of women who tested HIV positive did not return to the clinics for their CD4 count results. These women therefore missed opportunities to access other follow on services to which they could have been referred and possibly ART as 31% (24 women) of these women were also eligible for ART. Review of records at Wellness services was not possible as no indications were made in the PMTCT registers of follow on services other than ART to which HIV positive women were referred. Thus the greater majority of women who were eligible for ART (77% of the 77 eligible women) did not access ART which they required to help them maintain their physical wellbeing. These women missed the opportunity to access holistic health care services, it is not known if they accessed ART services at other health facilities. Without the required antiretroviral therapy, it is highly likely that their women’s health status deteriorated such that they faced higher chances of morbidity and ultimately mortality. 0707048E 3 The review of records at both PMTCT and ART service points showed poor data management systems as referrals from PMTCT to ART were not always documented against client names in the PMTCT registers. Communication systems between the service points were also found to be poorly structured as there were no systematic feedback mechanisms on clients referred and seen. Linkages to Wellness services were even more poorly structured as no referrals to services which fall under Wellness were documented in the PMTCT registers. Key informants interviewed suggested several possible reasons why PMTCT and ART services were not being fully utilised as was evidenced by the of 37% of women who were not retained in care as they did not return for CD4 results and the low ART utilisation rate of 23%. Possible reasons suggestions were: ignorance of the need to access ANC services, preference for traditional medicine, fear of stigmatisation within their communities and poor staff attitudes towards patients. The key informants also suggested measures they thought could improve utilisation, these include hire of more staff, improved staff wages, improved interdepartmental communication and a bottom up approach to service improvement. A suggestion was also made to include PMTCT messaging in general HIV/AIDS information education communication material so as to raise awareness of the availability of PMTCT interventions. Although there were linkages between PMTCT, ART and Wellness services, these linkages were poorly developed and drop out from services was high. Efforts to follow up on patients or to retain them in care were not well developed as the data management systems employed by the service points were not consistently used nor did they facilitate patient monitoring and follow-up. Furthermore, the structural and managerial separation of the ART service point from PMTCT as well as the lack of standard protocols for referral to Wellness introduced barriers to service utilisation for women who required these services.

Master of Public Health - MPH / BACKGROUND: The Zambian anti-retroviral therapy (ART) program has successfully enrolled over 770, 000 people living with HIV (PLWH), out of a population of 1.2 million PLWH. This tremendous success has overburdened the clinic system resulting in many challenges for both patients and healthcare staff. To promote ART initiation, adherence, and retention and at the same time relieve pressure on the health system, a home-based ART delivery model (HBM) was piloted in two urban communities of Lusaka. This study explored levels of acceptability of the model and factors influencing this among PLWH living in the two communities. Acceptability was defined as degree of fit between the patient’s expectations and circumstances and the home-based delivery model of ART, taking into consideration all the contextual elements surrounding the patient. METHODOLOGY: A qualitative study of HBM acceptability was nested within a clusterrandomized trial comparing outcomes in patients receiving HBM intervention compared to the standard of care in two communities in Lusaka, Zambia. Using an exploratory qualitative study design and a purposive sampling technique, qualitative data were collected using observations of HBM delivery (n=12), in-depth interviews with PLWH (n=15) and Focus Group Discussions with a cadre of community health workers called community HIV care providers (CHiPs) administering the HBM (n=2). Data were managed and coded using Atlas.ti 7 and analysed thematically. RESULTS: Overall, the HBM was found to be a good fit with the lives and expectations of PLWH and therefore highly acceptable to them. This acceptability was influenced by a combination of cross cutting clinic based, program design and socio-economic factors that have been categorized into push and pull factors. Push factors were those related to the challenges that PLWH faced when accessing ART from the clinic and included congestion, long waiting times, confidentiality breaches and stigma arising from attending a dedicated clinic. These factors resulted in considerable direct and indirect livelihood opportunity costs. The HBM as an alternative had a number of ‘pull factors’. PLHW described services offered through the model as convenient, confidential, trusted, personalized, less stigmatizing, comprehensive, client centred, responsive, and respectful. Disclosure of client’s HIV status to people they lived with was found to be critical for the acceptability of the model. CONCLUSIONS AND RECOMMENDATIONS: The HBM is highly acceptable and this acceptability is influenced by a combination of crosscutting push and pull factors. Key to the HBM’s acceptability was its delivery design that was responsive to individual patient needs and the steps CHiPs took to minimize the ever-present threat of disclosure and stigma. Future adoption and scaling up of HBM should recognize the importance of these design features.

FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / A SÃndrome de ImunodeficiÃncia Adquirida (AIDS) infantil foi reportada pela primeira vez ao Centro de Controle de DoenÃas (CDC â Atlanta) em 1982. A Aids tem sido alvo de muitos estudos cientÃficos em todo o mundo. Em decorrÃncia disto, tÃm sido desenvolvidos medicamentos que possibilitaram a melhoria da qualidade de vida dos portadores do HIV e/ou doentes de Aids e, a cada ano, sÃo disponibilizados novos medicamentos. A introduÃÃo da HAART (Highly Active Antiretroviral Therapy) modificou o prognÃstico de crianÃas infectadas pelo HIV, com drÃstica reduÃÃo da mortalidade. Acompanhar a terapia antirretroviral (ARV) e os parÃmetros laboratoriais de CD4 e carga viral de crianÃas infectadas com o vÃrus HIV-1 atendidas no Hospital SÃo Josà de DoenÃas Infecciosas (HSJ) e que deram entrada no LaboratÃrio Central de SaÃde PÃblica do Estado do CearÃ, LACEN-Ce. No perÃodo de 01 de junho a 31 de dezembro de 2006, 88 crianÃas provenientes do HSJ deram entrada no LACEN-Ce. Durante os anos de 2007 e 2008, as crianÃas foram acompanhadas quanto Ãs caracterÃsticas demogrÃficas, imunolÃgicas, virolÃgicas e farmacoterapÃuticas atravÃs dos prontuÃrios mÃdicos. As crianÃas incluÃdas deveriam ter pelo menos um exame de CD4/ano e um exame de carga viral/ano. Os dados foram analisados segundo o teste de Fisher, teste G (Willams), qui-quadrado de partiÃÃo e teste ANOVA com pÃs-teste de tendÃncia. O teste de correlaÃÃo tambÃm foi utilizado para as variÃveis: idade, valores de CD4 e carga viral. Foram investigadas 45 crianÃas portadoras do vÃrus HIV-1. Em relaÃÃo ao sexo, 25 (55,6%) crianÃas eram do sexo feminino e 20 (44,4%) eram do sexo masculino. As crianÃas que possuÃam atà 2 anos de idade no momento do diagnÃstico confirmatÃrio para HIV foram as mais prevalentes com 44,4%. Em relaÃÃo à etnia, 77,8 % (n=35) eram pardos. Dos municÃpios do CearÃ, a capital do estado, Fortaleza, à a localidade com maior nÃmero de pacientes, 20 (45,5%). As cidades do interior do estado totalizam 24 (54,5%) pacientes. A contagem absoluta de cÃlulas CD4 variou de 117 a 2.402 cÃlulas/mm3. A carga viral de HIV variou de indetectÃvel (< 50 cÃpias RNA-HIV/mL) a 1.300.000 cÃpias RNA-HIV/mL. Em relaÃÃo ao uso de terapia ARV, 93,3% (42) usavam medicamentos, enquanto que 6,7% (3) nÃo usavam. O esquema triplo era usado por 75,5% pacientes, a terapia dupla por 11,1 e 6,7 % usavam 4 medicamentos. A manutenÃÃo da terapia ARV ocorreu em 24 (57,1%) pacientes, enquanto que em 18 (42,9%) houve a troca dos medicamentos. Os pacientes tratados com terapia tripla apresentaram melhor resposta imunolÃgica e virolÃgica do que os outros tratamentos ARVs (duplo, quÃdruplo e sem tratamento), justificando sua escolha como regime preferencial de tratamento, mostrando que a terapia seguida pela maioria dos pacientes esta em conformidade com a preconizada pelo Guia de Tratamento ClÃnico da infecÃÃo por HIV em pediatria.

Magister Public Health - MPH / South Africa has the largest burden of HIV in the world with 7.9 million people living with HIV and 4.4 million registered on antiretroviral therapy (ART) in 2017. KwaZulu-Natal is hardest hit by the HIV epidemic with a prevalence of 27% among adults aged 15 to 49 years old. With the widespread ART uptake, the spectrum of HIV related admissions in hospitals has changed over the last decade. Hypertension, diabetes, cardiovascular disease, and renal failure have become significant reasons for inpatient care. Increased life expectancy, rising non-communicable diseases (NCDs) and easier access to ART have played a significant change in the landscape of inpatients as compared to the pre-ART era. To provide integrated healthcare to the patient, it is necessary to understand the prevalence and patterns of HIV comorbidities for efficient and effective service delivery to HIV patients at facility-level.

<p>Background and Objectives: There are some methodological and clinical challenges in conducting HIV related research. A subset of such challenges include: non-availability of a universally accepted method to quantify subclinical atherosclerosis in HIV patients; ultrasound imaging techniques aimed at quantifying atheroma burden and endothelial dysfunction have been proposed, however there is no universally accepted ultrasound protocol; conflicting inferences on the nature ofthe relationship between anti-retroviral therapy (ART) and cardiovascular disease (CVD) due to small sample sizes; and missing data from longitudinal studies and ultrasound data. The objective of this thesis is to investigate selected aspects of the afore-mentioned issues, and to provide recommendations for future research.</p> <p>Methods:</p> <p>Project 1: We compared the construct validity of carotid artery intima media thickness (IMT) and brachial artery flow mediated vasodilation (FMD); two non-invasive ultrasound techniques used in measuring the extent of sub-clinical atherosclerosis. Baseline and one-year follow-up data were obtained for a sample of 257 subjects aged 35 years or older, recruited into an ongoing study of cardiovascular risk in HIV. An ultrasound technique having statistically significantly strong association with known CVD risk factors was adjudged to have good construct validity. The relationship between baseline IMT or FMD and known CVD risk factors was studied using multiple regression analysis. We modelled the relationship between progression of IMT or FMD and risk factors using fixed-effects models.</p> <p>Project 2: To more precisely investigate the relationship between ARTs and IMT (as a surrogate for CVD), we pooled cross-sectional baseline, record-level data for 1,032 patients recruited across three cohort studies in Canada, France and USA in a metaanalysis. We investigated the association between exposure to ARTs and CVD using hierarchical linear models.</p> <p>Project 3: On missing data, we studied the impact ofan inclusive strategy for conducting multiple imputation (MI) on the efficiency ofregression parameter estimates using Monte-Carlo simulation. In an inclusive strategy, all final analysis variables are included in a multivariate normal model to impute plausible values for missing data. This issue is not well studied for longitudinal HIV data.</p> <p>Results and Conclusions:</p> <p>Project 1: Baseline IMT was significantly associated with age (p < 0.001), male gender (p = 0.034), current smoking status (p < 0.001), systolic blood pressure (p < 0.001) and total:HDL cholesterol ratio (p = 0.004). IMT progression was significantly associated with age (p < 0.001), male gender (p = 0.0051) and current smoking status (p = 0.011). Neither extent nor progression ofFMD was significantly associated with any of the examined vascular risk factors. IMT was adjudged to have better construct validity than FMD.</p> <p>Project 2: Similar to some (but not all) previous studies, AR Ts do not appear to lead to CVD independent of traditional risk factors. However, exploratory analysis of two-way interactions suggests statistically significant moderating effects between ARTs and traditional risk factors. These results warrant further investigation into potential moderating effects between ARTs and known CVD risk factors.</p> <p>Project 3: In conducting MI, simulation results show that a strategy that includes all final analysis model variables in the imputation model provides the least combined variability and bias for final regression estimates. This is important to note because final regression estimates are used in making clinically relevant inferences in practice.</p> / Thesis / Doctor of Philosophy (PhD)

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style="font-size: 10pt / font-family: &quot / Times New Roman&quot / ,&quot / serif&quot / ">Background: The care and treatment for people with HIV/AIDS (PLWHA) at the Kagera regional hospital began in February 2005. It is important to evaluate quality of life (QOL) of highly active anti-retroviral therapy (HAART) recipients periodical to assess HAART&rsquo / s effectiveness. This study aimed to assess the health-related QOL (HRQOL) of HAART recipients and determine factors associated with it, two years after the programme had started at the kagera regional hospital in Tanzania. Results: The HRQOL of HAART recipients was generally lower than that of the general population. However, the general health perceptions (p=0.191) and mental health (p=0.161) means score of HAART recipients were not different from those of the Tanzanian general population. About 89% of the HAART recipients reported better health than in the previous years. Chronic diseases were associated with lower HRQOL of HAART recipients independently of other factors. HAART recipients with chronic diseases co-morbidity were more likely to score below the general population&rsquo / s mean score for mental health (p=0.007). While the effect of chronic diseases on HRQOL among those who recorded CD4+ cell increase was negative (OR=13.6,95%CI=3.7 / 49.9), there was no effect on those who did not have such an increase. Adherence to ARVs and CD4+ cell count were not associated with HRQOL. &nbsp / &nbsp / &nbsp / &nbsp / &nbsp / &nbsp / <span style=""> <o:p></o:p></span></span></p> <p style="margin-bottom: 0.0001pt / line-height: normal / " class="MsoNormal"><span style="font-size: 12pt / font-family: &quot / Times New Roman&quot / ,&quot / serif&quot / "><o:p>&nbsp / </o:p></span></p> <span style="font-size: 12pt / font-family: &quot / Times New Roman&quot / ,&quot / serif&quot / "><span style="">&nbsp / </span><span style="">&nbsp / </span><span style="">&nbsp / </span><span style="">&nbsp / </span><span style=""> </span><o:p></o:p></span></p> <p>&nbsp / </p>

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style="font-size: 10pt / font-family: &quot / Times New Roman&quot / ,&quot / serif&quot / ">Background: The care and treatment for people with HIV/AIDS (PLWHA) at the Kagera regional hospital began in February 2005. It is important to evaluate quality of life (QOL) of highly active anti-retroviral therapy (HAART) recipients periodical to assess HAART&rsquo / s effectiveness. This study aimed to assess the health-related QOL (HRQOL) of HAART recipients and determine factors associated with it, two years after the programme had started at the kagera regional hospital in Tanzania. Results: The HRQOL of HAART recipients was generally lower than that of the general population. However, the general health perceptions (p=0.191) and mental health (p=0.161) means score of HAART recipients were not different from those of the Tanzanian general population. About 89% of the HAART recipients reported better health than in the previous years. Chronic diseases were associated with lower HRQOL of HAART recipients independently of other factors. HAART recipients with chronic diseases co-morbidity were more likely to score below the general population&rsquo / s mean score for mental health (p=0.007). While the effect of chronic diseases on HRQOL among those who recorded CD4+ cell increase was negative (OR=13.6,95%CI=3.7 / 49.9), there was no effect on those who did not have such an increase. Adherence to ARVs and CD4+ cell count were not associated with HRQOL. &nbsp / &nbsp / &nbsp / &nbsp / &nbsp / &nbsp / <span style=""> <o:p></o:p></span></span></p> <p style="margin-bottom: 0.0001pt / line-height: normal / " class="MsoNormal"><span style="font-size: 12pt / font-family: &quot / Times New Roman&quot / ,&quot / serif&quot / "><o:p>&nbsp / </o:p></span></p> <span style="font-size: 12pt / font-family: &quot / Times New Roman&quot / ,&quot / serif&quot / "><span style="">&nbsp / </span><span style="">&nbsp / </span><span style="">&nbsp / </span><span style="">&nbsp / </span><span style=""> </span><o:p></o:p></span></p> <p>&nbsp / </p>