Thesis presented in partial fulfilment for the degree of Master of Management (in the field of Public Sector Monitoring and Evaluation) to the Faculty of Commerce, Law, and Management, University of the Witwatersrand 2016 / The purpose of this research was to assess outcomes of the antiretroviral treatment intervention in Mankweng. The antiretroviral treatment intervention was conceived with the aim to reduce HIV transmission through viral load suppression. Literature has shown that viral load is used as a tool to measure the performance of the intervention and studies on viral load outcomes in rural settings of Limpopo are limited. For this reason, the research was focused on viral load suppression with the aim of (1) determining the proportion of adults with viral load suppression among people taking antiretroviral treatment for 12 months, and (2) identifying factors associated with failure to achieve viral load suppression among people on antiretroviral treatment for 12 months. Binomial logistic regression model was used to identify factors associated with failure to suppress viral load. This study used the theory of change to interpret its findings as well as theories of behavioural planning and self-regulation models to understand the logic that underpins the theory of change. The findings revealed that the majority (78%) of adults achieved viral load suppression, and a quarter of the individuals failed to suppress the viral load. There was no significant difference in baseline characteristics between people who achieved viral load suppression and those who did not. In addition, males, with a low CD4 and opportunistic illnesses when in the primary disease stages were more likely to fail to suppress the viral load. Moreover, people who were initiated on a 3-pill containing treatment and do not have social support were also likely to fail to achieve viral load suppression. Although the study showed a trend of likelihood towards failure to achieve viral load suppression, the estimates were not statistically significant. Theoretical arguments from this study suggest that failure to achieve viral load was attributed to poor adherence to treatment. This is supported by the logic that underpins the theory of change, in which the assumption of adherence was possibly violated. However, the results chain framework highlighted that the implementation of the intervention was effective as it led to good outcomes and an effective intervention. Drawing all this together, the study highlights the need for intensified adherence counseling during treatment in order to improve the performance of the intervention. Author: Ramatsobane Johanna Ledwaba, Thesis Title: Outcomes of the antiretroviral treatment intervention in Mankweng, Johannesburg, March 2016 / GR2018

The HIV/AIDS pandemic has implications at every level of social functioning. It affects individuals, families, communities and organisations. The burden of caring for those exposed, affected and infected is vast, but one of the most significant developments which have the potential to reduce disease burden is antiretroviral therapy. Antiretroviral therapy (ART) is complex and difficult to administer, and requires a learning process which is mediated through a number of means. Vygotskian theory was utilised to better understand the process of adherence through mediated learning, and as a framework for explaining compliance. In this study, mediated learning occurs both in the context of the clinic staff and the clinic attendees, and the caregivers and the child. Therefore Vygotsky‟s theory offers useful insight into this process. This qualitative study aimed to research the factors which contribute to ART adherence in a small sample of HIV positive children who are attending a local clinic. Eight child-caregiver dyads were interviewed, and drawings utilised to better understand child and caregiver factors which contribute to compliance. There were a number of psychosocial factors identified which contribute to compliance, or lack thereof, including social support, stigma, medication fatigue, disclosure, access difficulties, psychoeducation, and motivation. A number of qualitative differences were also identified between children who knew their HIV status and those who did not. These differences emerged primarily through the analysis of the child participants‟ drawings and there appeared to be a number of inter- and intrapersonal benefits to disclosure. The factors identified in this study, if better understood, can inform interventions to improve compliance on ART. / Thesis (M.Soc.Sci.)-University of KwaZulu-Natal, Pietermaritzburg, 2010.

The introduction of antiretroviral drugs (ARVs) in 1996 transformed the treatment of HIV and AIDS, improving the quality and greatly prolonging the lives of many infected people. HIV (Human Immunodeficiency Virus) is the virus that is believed to cause AIDS. AIDS (Acquired Immune Deficiency Syndrome) is the collection of illnesses or symptoms that ultimately results in death. Antiretroviral (ARVs) drugs or Highly Active Antiretroviral Therapy (HAART) is the treatment that has been applied to combat the HI virus in a bid to slow down the progression of AIDS and ultimately prolong the life of the infected individual. The study aimed to explore and describe the factors contributing to adherence and non-adherence to ARVs in individuals on treatment. A sample of 81 individuals who have been on ARV and HAART treatment for six months or more was used. The methodology used was exploratory-descriptive and the data obtained was quantitative in nature. A biographical questionnaire and questionnaire with questions aimed at ascertaining the possible factors that contribute to individuals either adhering to or defaulting on their treatment, such as side effects and cost of treatment, was administered. The data obtained was analysed by means of descriptive statistics and frequency counts. The results of the study showed that the sample had a fairly high level of adherence. The factors that could undermine adherence were identified as lack of support, as familial and health provider support acts as a motivator to adhere; substance abuse as it can lead to forgetting to take treatment; unemployment and poverty, as these can lead to an inability to return for follow up clinic visits or failure to have food to take with the pills; and the type of treatment regimen whereby the more complex the treatment is the more likely it is that adherence will be difficult to maintain. Suggestions were made as to future research involving antiretroviral therapy (ART). Finally the limitations as well as the value of the research were outlined.

A research report submitted to the Faculty of Humanities University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Arts (Migration and Displacement Studies), March 2017 / Background: Policy responses to communicable diseases and other noncommunicable ones in South (ern) Africa have not adequately engaged with mobility. While Southern African Development Community member states have all adopted clear policies and programmes to deal with communicable diseases for their population in South Africa and elsewhere, deliberately, these do not extend to non nationals. In South Africa, there is a perception that many health care workers are not aware of national health policies and legislation that affect their practice, which leads to poor outcomes. But, in reality, a number of polices and guidelines are incomplete or inapplicable to non nationals, making frontline discretion unavoidable. Objectives: This study mainly sought to understand the practices that frontline health care workers adopt to navigate a space of blurred policy and the “grey areas inbetween” (McConnel, 2010), in relation to migration and antiretroviral treatment, using bottom-up policy analysis, namely “street-level bureaucracy” (Lipsky, 2010) as an analytical tool. Methods: Qualitative methods were used including policy review, literature review, in-depth interviews with frontline health care workers and participant observation. Findings: Empirical research in Vhembe district and Johannesburg found that in spite of several institutional challenges, health care workers were providing health care services and antiretroviral treatment to various categories of non-nationals reliant on public health care, albeit sometimes with some difficulties. But, the difficulties they faced in providing antiretroviral treatment were policy and systems related, in that, those that had a hard time accessing treatment did so because they were not in possession of identity documents, required referral letters or spoke non-native languages in the absence of translation services. This thesis illustrates the various innovations frontline health care workers employed to address these challenges. It demonstrates that health care workers discretion plays a crucial role in health care delivery, and there is need to recognise the importance of informal elements such as human relationships, communication networks, leadership and motivation towards the policy function of the country’s health system. It concludes that the informal practices of frontline health care workers ought not only to be recognised but also strengthened where possible. / XL2018

The introduction of Antiretroviral (ARV) treatment has allowed for many children living with human immunodeficiency virus (HIV) to survive to adolescence. However for this to be a reality adherence to treatment is important. Many studies suggest that during adolescence adherence can be very challenging. However not much research has been done within the South African context to understand what HIV positive adolescents are experiencing, particularly in relation to ARV adherence. The aim of this research study was to explore the experiences of adolescents on antiretroviral therapy (ART) in order to understand what helps them to adhere to their medication and the challenges that they may have with adherence. This was achieved by carrying out 5 semi-structured in-depth interviews with HIV positive adolescents on ARVS at a shelter for HIV positive women and children in Johannesburg. A thematic content analysis was used to analyse the transcribed interviews. The results indicated several factors that both assist with adherence and those that challenge adherence. The participants reflected on the importance of full disclosure which increases their understanding of the importance of adherence, having people they trust whom they can confide in and who also support them to take and adhere to the ARVs, and having a positive experience at the hospital when they go for their regular checkups. Certain defence mechanisms adopted by the adolescents to help them cope with living with HIV and having to take medication every single day of their lives were also identified. The fact that acceptance is a process was also suggested by the research findings. The challenges the adolescents face were those of stigma and a fear of being rejected, bad experiences associated with taking medication, such as the negative side effects and the disruption of their leisure time, and negative experiences from going to the hospital. This study yielded some rich information that may aid in understanding what adolescents are experiencing and facing which may inform future research studies on this topic and policies which may assist with an increase in adherence.

Thesis (MSc (Genetics))--University of Stellenbosch, 2007. / The results of pharmacotherapy can vary both within and between different populations and ethnic groups. Although numerous factors are believed responsible for observed discrepancies in drug response, genetic differences, most often in the form of single nucleotide polymorphisms (SNPs), between individuals and ethnic groups are an important and at times predominant factor. The response to antiretroviral (ARV) drugs for the treatment of human immunodeficiency virus (HIV)-infection is not dissimilar. Marked variations in both ARV efficacy and occurrence of adverse drug reactions (ADRs) have been observed on both an individual and ethnic group level, which are largely attributed to polymorphisms within genes involved in the metabolism and transport of these compounds – such genes include the CYP2B6 and CYP3A4 genes, both members of the cytochrome P450 (CYP) gene superfamily, and the multidrug-resistance 1 (MDR1) gene encoding an efflux transporter protein, phosphoglycoprotein (PGP). An improved understanding of the genetic influences on ARV drug response could lead to improved therapies with fewer side-effects and minimised drug resistance. The main aim of this study was thus to investigate the genetic basis of observed differences in ARV therapy (ART) response in South African ethnic groups. Deoxyribonucleic acid (DNA) samples were collected from 206 HIV-positive individuals of Mixed-Ancestry and Xhosa ethnicity that were currently or prospectively receiving ART. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis was employed to screen the A-392G SNP in CYP3A4, the G516T and A785G SNPs in CYP2B6, and the T-129C, C1236T, G2677T/A and C3435T SNPs in MDR1. Hardy-Weinberg equilibrium (HWE) and haplotype analyses were subsequently performed on the resultant SNP genotype and ...

HIV-positive adolescents are an increasingly numerous and challenging population in the South African HIV/AIDS epidemic. Their access to, and retention in, ART care has become a pressing public health concern. Comprised of four journal articles, this thesis explores the practice of antiretroviral treatment (ART) among a cohort of HIV-positive adolescents (age 10-19) in South Africa's Eastern Cape. By 'practice', I mean the volatile, situated and relational 'work' that goes into young people's everyday achievement of ART - into consuming daily medication, regularly attending health appointments, and participating in HIV programmes. Through an exploration of the ways in which some HIV-positive adolescents use, appropriate, or reject ART care; this thesis contributes to a much-needed evidence-base on the needs and survival strategies of adolescent ART users. Data for this study was gathered through eight months of multi-method ethnographic fieldwork with 23 HIV-positive youth, their families, and local health workers. The findings elucidate adolescent ART as a complex (and often volatile) form of social incorporation, through which young people negotiate survival, care and moral connection in contemporary South Africa. Enrolling in ART meant being encompassed into a (often hierarchical) set of social relationships, through which adolescents sought belonging, recognition and protection, amid profound insecurity. Through ART and its associated programmes, adolescents and their families attempted to strengthen familial ties, appeal to powerful patrons, petition for care, and access basic resources. Yet these pursuits were often deeply ambivalent, as discipline, blame, and resentment often came encased in the terms of care. At the crux of each article is an attempt to understand how adolescents, often alongside their families, negotiated both the social stakes and possibilities of ART. Through these discussions, we might better be able to grasp the fragility and complexity of young people's retention in ART.

Submitted in fulfilment of the requirements for the Degree of Doctor in Public Management, Durban Universit of Technology, 2017. / HIV-AIDS has infected more than 37 million individuals globally and has resulted in approximately 35 million HIV-AIDS related deaths globally since its discovery 35 years ago. HIV-AIDS remains a global and local health crisis as, despite innovative and accessible HIV-AIDS prevention efforts, the disease continues to spread. UNAIDS estimated over 2 milliion new HIV-AIDS infections with 700 000 of these infections occurring in young African women in 2015, revealing that the burden of HIV-AIDS is far from over (UNAIDS, 2016). As more individuals become infected with HIV-AIDS, more infected individuals are living longer, productive lives due to the international rollout and scale-up of life-saving antiretroviral (ARV) therapy aimed at halting disease progression. In 16 years, the world has initiated over 16 million HIV-infected individuals onto ARV programmes across the world aimed at preserving first line drug effectiveness of treatment, less resistance and lower mortality and morbidity rates( UNAIDS, 2016). This number is set to double as countries across the globe take bold steps to provide ARV treatment for all, based on latest WHO guideline changes. The initiative of ARV roll out for all HIV-positive individuals globally, brings with it the challenges and complexities of infrastructure support, resource allocation, uninterrupted drug supply, global access and clinical training requirements for HIV-AIDS programmes across the globe. Quality management systems with monitoring and evaluation frameworks in particular play a pivotal role in planning, allocating and utilising resources for optimal health benefits.This research study reviews available data on the prevalence of quality management systems in HIV-AIDS healthcare and identifies gaps and smart practises towards recommendations for comprehensive global HIV-AIDS standards development. This research study aims to propose a conceptual monitoring and evaluation framework derived from quality management systems for management of HIV-AIDS private sector programmes that can be used in both public and private healthcare sectors through analysis of current conceptual frameworks in the HIV-AIDS healthcare and the HIV-AIDS programmes within the South African context of HIV-AIDS healthcare provision. / D

It is estimated that 6742 South African women are diagnosed with cervical cancer and 3681 women die from the disease every year. In 1993, The Centers for Disease Control declared cervical cancer an Acquired Immunodeficiency Syndrome defining illness. Apart from persistent human papillomavirus infection, HIV infection is the most common co-factor contributing to cervical cancer in South Africa. Studies have noted that in HIV positive women, there has been an occurrence of faster progression to more advanced stages of cervical cancer with high cases of treatment failure and recurrence. There is limited literature available regarding the prognosis of HIV positive women who suffer from cervical cancer. Women who are HIV positive and have cervical cancer have not been evaluated in detail regarding their response and adherence to cervical cancer treatment. Standard treatment protocols for this set of patients have not been defined. The aim of this study was to assess how HIV positive women who have been diagnosed with cervical cancer responded and adhered to cervical cancer therapy which includes: curative radiotherapy; curative chemotherapy; concurrent chemoradiation or palliative radiotherapy. The study also evaluated the effects of the concurrent use of antiretrovirals and cervical cancer treatment. This was done to determine whether invasive cervical cancer in women who were HIV positive could be managed using the same treatment protocols as patients who were HIV negative. A historical cohort design was employed for the study. The study was conducted at the Oncology Department of a tertiary level hospital located in the Eastern Cape Province, South Africa. The total sample consisted of 196 medical records of women diagnosed with cervical cancer between 2005 and 2008. One hundred women were HIV negative, 83 were HIV positive and the HIV status of 13 women could not be determined. The records were audited over a period of two years from the date of diagnosis. The term „complete response‟ referred to patients who had no recurrence of cervical cancer and no evidence of metastases after undergoing treatment. At one month following treatment there was a significant difference in the incidence of complete response between the HIV positive patients and the HIV negative patients (Chi2 = 16.4, d.f. = 1, p = 0.00005, Cramer‟s V = 0.31). The significant difference in response to treatment between the HIV positive patients and the HIV negative patients was maintained at six months after treatment (Chi2 = 15, d.f. = 1, p = 0.00011, Cramer‟s V = 0.34), 12 months after treatment (Chi2 = 20.5, d.f. = 1, p = 0.00001, Cramer‟s V = 0.37), 18 months after treatment (Chi2 = 9.8, d.f. = 1, p = 0.00173, Cramer‟s V = 0.28) and 24 months after treatment (Chi2 = 5.0, d.f. = 1, p = 0.02571, Cramer‟s V = 0.26). At each of these intervals, cases of treatment failure and metastases were significantly higher in the HIV positive women than in the HIV negative women. Although there was no significant difference in the incidence of adherence between the HIV negative women, the HIV positive women who were on HAART and the HIV positive women who were not on HAART, there was a significant difference in the incidence of the various reasons for non adherence between the various groups. These reasons included: missed scheduled appointments (Chi2 = 2.9, d.f. = 2, p = 0.02385, Cramer‟s V = 0.31); low blood count (Chi2 = 4.0, d.f. = 2, p = 0.01327, Cramer‟s V = 0.15); radiotherapy induced skin breakdown (Chi2 = 0.6, d.f. = 2, p = 0.04581, Cramer‟s V = 0.16) and radiotherapy induced diarrhoea (Chi2 = 6.9, d.f. = 2, p = 0.03118, Cramer‟s V = 0.19). According to the 2004 National Antiretroviral Treatment Guidelines, cervical cancer patients would fall into the WHO stage IV category of HIV disease thus all patients with confirmed diagnosis of invasive cervical cancer should be commenced on antiretrovirals as soon as the cancer diagnosis is made regardless of their CD4 count. However, in the current study, 13 percent (n= 83) of the HIV positive women were not on antiretrovirals. The study concluded that HIV positive women had a higher incidence of both treatment failure and metastases to cervical cancer treatment. Standard radiotherapy and concurrent chemoradiation cervical cancer treatment protocols should be still be used in both HIV negative patients and HIV positive patients so as not to compromise tumour control. Furthermore, in accordance with the antiretroviral treatment guidelines, all HIV positive patients with cervical cancer should receive antiretrovirals irrespective of their CD4 count.

The supply of Antiretrovirals (ARVs) to HIV/AIDS patients in most of the provinces in South Africa is hindered by various factors such as ineffective and inefficient drug procurement, and drug distribution systems. In the QwaQwa district in the Free State Province, a major barrier to the consistent supply of Highly Active Antiretroviral Treatment was identified to be the lack of an effective and efficient ARV drug distribution system. This resulted in major drug supply shortages in the QwaQwa district. A continuous, uninterrupted supply of ARVs to HIV/AIDS patients is critical to avoid drug resistance and therapy failure. Failure of a patient to respond to treatment results in a deterioration of a patient's health, and ultimately leads to death. The purpose of the study was to determine whether the ARV drug distribution practices at the Manapo Hospital in the QwaQwa district were effective and efficient in the management of ARVs. The distribution practices reviewed were the ordering, transportation, the management of inventory and warehousing, and the distribution of treatment to HIV/AIDS patients. Quantitative exploratory, descriptive and contextual methods were used to determine the relationship between the ARV drug distribution practices and the effective management of the ARVs. The study comprised of a sample size of twenty-one participants. The sample size entailed the Manapo Hospital pharmacists and pharmacist assistants who have been or are currently involved in the distribution of ARVs in the QwaQwa district since the initiation of the ARV rollout programme in 2004. The study revealed that the practices performed in the management of ARVs in the QwaQwa district were neither effective nor efficient in the distribution of ARVs. The recommendations of the study were identified to further ensure the effective and efficient management of the ARV drug distribution system, which will ensure a consistent supply of treatment to HIV/AIDS patients. Guidelines were developed for better circulation, thus meeting the objectives of the research.