Thesis (MPH)University of Limpopo (Medunsa Campus), 2011. / INTRODUCTION: Antiretroviral therapy (ART) has been proven to significantly improve the quality and quantity of lives of patients infected with HIV. However, several barriers exist that prevent children from being initiated on treatment on time. Studies in adults have shown that the timing of treatment influence outcomes of ART; but little is known about this in children. Hence, the need for this study. The purpose of this study was to characterize the outcomes of late initiation of ART in HIV- positive children seen at the Mildmay Jajja Home center. METHODOLOGY: The study was a cross-sectional survey involving all children who were initiated at the Mildmay Jajja Home in 2005 and had had been on ART for at least 18 months. Two sets of data were collected, for the children on ART: their age and sex were recorded. In addition, based on the Ugandan clinical guidelines for ART, children were grouped into two groups; those 6 six years and below; and those above 6 years. Clinical variables recorded were baseline and repeated measurements of bodyweights, and CD4 counts; weight and CD4 counts at the time of initiation of ART, at 12 months and at 18 months. For the care providers: their age, gender, education level, relationship to the child was recorded. Three outcomes of treatment were assessed, adherence level by the 12th month on treatment; hospitalisation by the 12th month (during the first 12 months of treatment); and survival or death at by the 12th and 18th month on treatment. RESULTS: In total, 114 children were included in the sample. Among them, 54.4% of children were initiated late. Based on age, children 6 years old and younger were more likely and significantly initiated late as compared to those over 6 years old as about 70% of them were actually initiated late. Based on sex, female children older than 6 years were significantly initiated late as compared to boys. The characteristics of care providers that were associated with children being initiated late were being male, less than 40 years old, with a primary school level of education, and not knowing their own HIV status. With regard to outcomes of the treatment, adherence, hospitalisation, and survival were assessed. Overall, 59.4% of children achieved an adherence level of 90% or more; 17.3% of children had been hospitalised at least once; and the mortality was 17.5% during the 2 year period covered by the study. Adherence was influenced slightly by the timing of the start of the treatment since less than half (46.34%) of those initiated late achieved an adherence level of 90% or more as compared to over 53% among those initiated timely. Though there was not statistically significant difference, adherence was slightly better in children whose care providers were biological parents, whose HIV status was known as positive, and female. With regard to hospitalisation, children less than 6 years were significantly more hospitalised than the older ones; their care providers were relatives, not educated, and of unknown HIV status. Those initiated late were significantly more hospitalised than those initiated timely (63.15% versus 36.84%, p=0.03). With regard to survival, the majority of children who died were over 6 years old, and female. The majority of their care providers were female, under 40 years old, and known HIV-positive. In children initiated late, the mortality was 50% (n=14) and 83.3% (n=6) respectively by the 12th and 18th month of treatment as compared to those initiated timely. In conclusion, 54.4% of children were initiated late. Late initiation was associated with negative outcomes such as low adherence to treatment as less than half of them achieved a adherence level of 90% or more; hospitalisation as those initiated late were significantly more hospitalised than those initiated timely; and high mortality since among those who died, 50% and 83.3% of deaths occurred respectively by the 12th and 18th month of treatment among those initiated late. In order to minimize the probability that the majority of children are initiated late, a general awareness campaign should be directed at the general public so that they can be sensitized to the need to bring children to medical attention as soon as possible

BACKGROUND: Highly active antiretroviral therapy(HAART) is used in pregnancy to suppress viral load(pVL) before delivery, reducing risk of vertical HIV-transmission. Nelfinavir(NFV) containing HAART has been highly used in pregnancy, but dosages may be inadequate due to the physiologic changes that occur. Given concerns regarding optimal viral suppression in pregnancy, drug toxicity and resistance development, NFV levels need to be evaluated in this population to guide dosing recommendations. METHODS: As part of a prospective cohort study maternal blood was collected at 18-28wks, 32-37wks and at delivery. Times of last medication dose and blood sampling were recorded and drug levels were measured using HPLC MS-MS. NFV concentration-ratios(NFV-CRs) were calculated by dividing individual levels by a time-adjusted population value. Plasma NFV concentrations and NFV-CRs were compared across gestational age and correlated to variables of interest. Rate and maintenance of viral suppression were analyzed in relation to NFV concentrations and CRs. Statistical tests included ANOVA, χ2, linear regression, and Kaplan Meier estimates. RESULTS: 113 samples were collected from 32 subjects. Samples were eliminated if not in steady state (n=20); 93 samples from 32 subjects were analyzed. Mean NFV-CR at 18-28wks (1.1±0.73) and 32-37wks (0.86±0.73) were not significantly different but were both significantly higher by ANOVA (p=0.049) than the mean NFV-CR at delivery (0.44±0.50). CRs were highly variable. Of 49 antepartum samples, 49%(24) had a CR<0.90 (clinically relevant threshold). Four women reached a pVL <50 copies/mL by 34wks but had a detectable pVL at delivery. One woman never reached an undetectable pVL in pregnancy. Minimum and mean NFV-CRs in these 5 women were not significantly different than those who achieved and maintained virologic suppression. Vertical HIV transmission rate was 0%. CONCLUSIONS: There were no HIV transmissions but 16% (5/32) of women were inadequately suppressed at delivery, which is of concern. Factors associated with inadequate suppression and NFV-CRs need to be explored in conjunction with patient/physician reported adherence and viral resistance profiles. Extreme variability in CRs may limit the potential usefulness of random timed drug levels in all pregnant women.

BACKGROUND: Highly active antiretroviral therapy(HAART) is used in pregnancy to suppress viral load(pVL) before delivery, reducing risk of vertical HIV-transmission. Nelfinavir(NFV) containing HAART has been highly used in pregnancy, but dosages may be inadequate due to the physiologic changes that occur. Given concerns regarding optimal viral suppression in pregnancy, drug toxicity and resistance development, NFV levels need to be evaluated in this population to guide dosing recommendations. METHODS: As part of a prospective cohort study maternal blood was collected at 18-28wks, 32-37wks and at delivery. Times of last medication dose and blood sampling were recorded and drug levels were measured using HPLC MS-MS. NFV concentration-ratios(NFV-CRs) were calculated by dividing individual levels by a time-adjusted population value. Plasma NFV concentrations and NFV-CRs were compared across gestational age and correlated to variables of interest. Rate and maintenance of viral suppression were analyzed in relation to NFV concentrations and CRs. Statistical tests included ANOVA, χ2, linear regression, and Kaplan Meier estimates. RESULTS: 113 samples were collected from 32 subjects. Samples were eliminated if not in steady state (n=20); 93 samples from 32 subjects were analyzed. Mean NFV-CR at 18-28wks (1.1±0.73) and 32-37wks (0.86±0.73) were not significantly different but were both significantly higher by ANOVA (p=0.049) than the mean NFV-CR at delivery (0.44±0.50). CRs were highly variable. Of 49 antepartum samples, 49%(24) had a CR<0.90 (clinically relevant threshold). Four women reached a pVL <50 copies/mL by 34wks but had a detectable pVL at delivery. One woman never reached an undetectable pVL in pregnancy. Minimum and mean NFV-CRs in these 5 women were not significantly different than those who achieved and maintained virologic suppression. Vertical HIV transmission rate was 0%. CONCLUSIONS: There were no HIV transmissions but 16% (5/32) of women were inadequately suppressed at delivery, which is of concern. Factors associated with inadequate suppression and NFV-CRs need to be explored in conjunction with patient/physician reported adherence and viral resistance profiles. Extreme variability in CRs may limit the potential usefulness of random timed drug levels in all pregnant women.

Background Adherence to HAART is key to any successful HAART programme. In Madzikane KaZulu Memorial Hospital ARV Clinic, there is an increasing number of patients on HAART and an increasing number of patients still awaiting HAART initiation. With the paucity of healthcare personnel in this rural district hospital, suboptimal patient’s preparation for HAART often occurs, and the HAART defaulter rate is on the increase. This is may be attributed to an interplay of factors affecting HAART adherence. Aim and Objectives The aim of this research was to determine the prevalence of established factors associated with adherence to Highly Active Antiretroviral Therapy (HAART) in non-adhering patients at the Madzikane KaZulu Memorial Hospital (MKMH) ARV clinic. The objectives were: • To conduct an audit on all case files of patients on HAART over the study period. • To explore the behavioural aspects of poor HAART adherence in a focused group discussion. • To describe the factors associated with good HAART adherence Methods Study design: A cross-sectional descriptive study which focused on determining the prevalence of established factors( patient-related, therapy-related and facility-related factors) affecting HAART adherence at the ARV clinic was carried out among identified HAART non-adhering patients. Patients that were not adhering with HAART between the period of January 2009 and December 2010 were selected for the study. These patients were 19 years or more and had been on HAART for at least two months. The study was carried out between November and December 2010. The result of the focused group discussion was utilized to refine the development of the questionnaire. Setting: The study was conducted at the Madzikane KaZulu Memorial Hospital ARV clinic. This is a modern 269 bed district hospital in the Mount Frere, Alfred Nzo district, Eastern Cape Province of South Africa. This is a predominantly rural region. Results: Data for analysis was provided by 215 patients that fulfilled the inclusion criteria. The prevalence rate of the factors affecting HAART adherence at the hospitals ARV clinic was 24%. A total of 60% of the patients were females. Majority of the patients (86.1%) had treatment supporters, and more than half of the patients (57.2%) were unemployed and not on disability grant. A total of 62.8% of the patients prefer to take their ARV at a clinic near them, and the majority of these patients (96.3%) want to start taking their ARV in a nearby clinic within 6months. The female gender, unemployment not on disability grant, longer period on HAART, Regimen 1A ARV( stavudine or tenofovir plus lamivudine and efavirenz according to the National ART guideline 2004 and its modified version of April 2010) single marital status and probably poorly selected unprepared treatment supporters, are associated with poor HAART adherence at this ARV clinic. Conclusion The study revealed that the prevalence rate of the factors affecting HAART adherence at the Madzikane KaZulu Hospital ARV clinic was 24% amongst HAART non-adhering patients. These patients had the prevalence rate of patient-related factors (12.4%) more than double of the prevalence rates of therapy related factors (5.8%), and facility related factors (5.7%). Topmost amongst the associated factors for not adhering to HAART were: not belonging to a support group, the pills making the patient feel unwell, and the ARV clinic being too far from where the patients live. Efforts should be targeted at enrolling the patients in support groups, encouraging the use of HAART regimens that have good tolerability profiles, and establishing the down referral.

In South Africa, the highest HIV prevalence is amongst young people, who may have the greatest potential to contribute to the country’s economy. South Africa has one of the world’s largest antiretroviral (ARV) rollout programs. Like all medications, ARVs need to be taken as prescribed to be safe and effective. Excellent adherence is necessary to ensure that drug resistance does not develop. HIV cannot be cured, and at present ARVs must be taken for the rest of the patient’s life. In the ARV clinic in Knysna, an unanticipated category of patients has been identified: those who “bounce” in and out of long term therapy. Not only do these patients put their own health at risk, but the development and transmission of drug resistant HIV threatens the potential treatment options of the whole community. One of the problems identified in recurrently defaulting patients, is the difficulty in maintaining long term adherence to an ARV treatment program, while in full time employment. This is because as time goes on, patients need to balance the need for ARV care, which has rigorous clinic attendance parameters, with work attendance. Many employees have only twelve days of paid sick leave per annum, and patients require an average of eleven clinic visits in the first six months of treatment. This qualitative study gauges whether the services provided to HIV positive people living in Knysna meets the needs of their employers. The study interviewed both employees and employers to gauge the effects of HIV on local businesses, and explored the knowledge and attitudes of employers towards services provided by the Knysna ARV program. Employers were asked to suggest ways in which the services could be improved to better meet their needs, and ultimately, the needs of their employees.

Orientador: Paulo Câmara Marques Pereira / Banca: Domingues Alves Meira / Banca: Sueli Aparecida Calvi / Banca: Alcyone Artioli Machado / Banca: Jacqueline Pontes Monteiro / Resumo: O advento da utilização da terapia antiretroviral de alta atividade (HAART), a partir de 1996, representou um profundo impacto na história natural da infecção pelo HIV, promovendo uma importante e sustentada supressão na replicação viral, elevando a sobrevida e a qualidade de vida dos pacientes soropositivos. No entanto, gradualmente, foi se observando que a terapia antiretroviral é acompanhada de alterações metabólicas, como dislipidemia, principalmente hipertrigliceridemia, resistência insulínica, hiperglicemia e lipodistrofia, isto é, redistribuição da gordura corporal. Ensaios epidemiológicos demonstram correlação entre os níveis elevados de triglicerídeos (TG) e maior incidência de doença arterial coronariana (DAC). Autores sugerem a intervenção dietética como parte do tratamento da hiperlipidemia, incluindo aumento da ingestão de fibra solúvel (10g-25g/dia). Há estudos demonstrando que tanto o colesterol quanto os triglicerídeos séricos diminuem com a utilização de fibra alimentar. Alguns observaram redução apenas nos níveis séricos de triglicerídeos, enquanto que outros não verificaram alteração no metabolismo lipídico. O objetivo do presente estudo foi avaliar o efeito da fibra solúvel (goma guar parcialmente hidrolisada) suplementar sobre a hipertrigliceridemia e o perfil imunológico de indivíduos HIV positivo em tratamento com HAART. Foram estudados 19 pacientes HIV positivo com hipertrigliceridemia (níveis séricos ³ 150 a < 500mg/dL), sendo 63,16% do sexo masculino e 36,84% feminino, com média de idade de 43,52 ± 9,22 anos. Esses indivíduos utilizavam o mesmo esquema HAART há pelo menos seis meses, sem mudança da terapia durante o estudo e receberam 20g de fibra solúvel por dia, durante quatro meses... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The advent of highly active antiretroviral therapy (HAART), since 1996, represented a profound impact on the natural history of HIV-infection by promoting important and sustainable viral replication suppression and increasing survival and quality of life among seropositive patients. Nonetheless, antiretroviral therapy has been observed to be accompanied by metabolic alterations such as dyslipidemia, especially hypertriglyceridemia, insulin resistance, hyperglycemia and lipodystrophy (body fat redistribution). Epidemiological studies have demonstrated a correlation between high triglyceride (TG) levels and higher incidence of coronary artery disease (CAD). Some investigators suggest dietary intervention as part of hyperlipidemia treatment, including an increase in soluble fiber intake (10-25g/day). Whereas some studies have demonstrated that both cholesterol and serum triglyceride levels decrease with the use of food fiber, others have shown just a serum triglyceride decrease, and others failed to observe any alteration in lipid metabolism. The purpose of this study was to assess the effect of soluble fiber® (partially hydrolyzed guar gum) supplementation on hypertriglyceridemia and immune profile in HIV-positive individuals on HAART. Nineteen HIV-positive individuals with hypertriglyceridemia (serum levels 150 to < 500 mg/dL) were studied. Of these individuals, 63,16% were males and 36,84% females, with mean age of 43,52 ± 9,22 years. These individuals had been on the same HAART regimen for at least 6 months, had no change in therapy during the study and received 20g/day of soluble fiber for four months at pre-established times. Clinical-nutritional, biochemical (total proteins, albumin, globulin, total cholesterol, LDL-c, HDL-c, TG, TG/HDL-c and LDL-c/HDL-c)... (Complete abstract click electronic access below) / Doutor

Made available in DSpace on 2014-06-11T19:22:49Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-12-20Bitstream added on 2014-06-13T19:28:12Z : No. of bitstreams: 1 segatto_afm_me_prud.pdf: 307549 bytes, checksum: b37359a27c088a907d37cb6899f6d330 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Após a introdução da terapia anti-retroviral altamente ativa (TARV), houve significativo aumento da sobrevida e melhora da qualidade de vida de indivíduos portadores de HIV, porém, esses tratamentos têm efeitos colaterais que podem causar transtornos para seus usuários, dentre os quais, a lipodistrofia. Além de causar um novo estigma estético para os portadores do vírus a síndrome pode elevar o risco de doenças cardiovasculares e diabetes. Nesse contexto, torna-se importante dar atenção a estratégias de prevenção e tratamento da síndrome. A atividade física pode ser uma alternativa válida para este fim, no entanto existem poucos estudos que tratam dessa temática. Desse modo, o objetivo do presente estudo foi verificar a possível associação entre o nível de atividade física e a ocorrência de lipodistrofia relacionada ao uso de terapia anti-retroviral em indivíduos portadores de HIV. A casuística foi formada por 42 indivíduos portadores de HIV em uso de TARV, todos pacientes do Centro de Testagem e Aconselhamento da cidade de Presidente Prudente. O nível de atividade física foi obtido pela aplicação do questionário internacional de atividade física (IPAQ), enquanto a lipodistrofia foi diagnosticada pela técnica de auto-relato do paciente... / After the introduction of the Highly Active Antiretroviral Therapy (HAART), there was significant increase in survival and improved quality of life among HIV-infected individuals, however, these treatments have side effects that may cause inconvenience to its users, among which lipodystrophy is. Besides causing a new aesthetic stigma for those with the virus, the syndrome may increase the risk of cardiovascular disease and diabetes. In this context, it becomes important to pay attention to strategies for prevention and treatment of the syndrome. Physical activity may be a valid alternative for this purpose, however there are few studies that address this issue. Thus, the purpose of this study was to investigate the possible association between level of physical activity and lipodystrophy occurence related to the use of antiretroviral therapy in HIV-infected individuals. The sample consisted of 42 HIV patients under antiretroviral therapy, all patients of the Center for Counseling and Testing in the city of Presidente Prudente. The level of physical activity was achieved by using the international physical activity questionnaire (IPAQ), whereas lipodystrophy was diagnosed by the technique of self-report of the patient... (Complete abstract click electronic access below)

Made available in DSpace on 2014-06-11T19:24:16Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-07-28Bitstream added on 2014-06-13T20:31:21Z : No. of bitstreams: 1 oliveira_oca_me_botfm.pdf: 592027 bytes, checksum: 64bb656e1e07bb63f132e5aca2ffecd3 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Universidade Estadual Paulista (UNESP) / A aids é uma doença causada pelo HIV, que compromete o sistema imune do organismo. O advento da terapia antirretroviral (TARV) altamente eficaz promoveu melhora substancial do prognóstico dessa doença e da qualidade de vida dos pacientes com HIV/AIDS. Durante seu tratamento prolongado notam-se algumas alterações hematológicas, como anemia e macrocitose, bem como carências de micronutrientes como a vitamina B12 e ácido fólico. O objetivo do presente trabalho é determinar a relação entre macrocitose e anemia e o uso de ARV ou a deficiência de vitamina B12 ou de ácido fólico. Foram avaliados 110 pacientes HIV-positivos, comparando-se aqueles em uso de TARV com AZT (G1), em TARV sem AZT (G2) e sem o uso de TARV (G3). Os pacientes dos três grupos não apresentaram variações significativas quanto aos níveis de hemoglobina (p=0,584). Os pacientes do G1 apresentaram VCM aumentado quando comparados aos do G3 (p<0,05), bem como os do G2 em relação aos do G3 (p<0,001). As dosagens de vitamina B12 do G1 e G3 foram menores do que as encontradas pelo G2 (p=0,008). As dosagens do ácido fólico não apresentaram diferença estatística entre os grupos (p=0,956). Conclui-se que os indivíduos em uso de TARV apresentaram macrocitose, embora esta não pudesse ser relacionada ao tipo de TARV ou à deficiência de vitamina B12, como também a deficiência de ácido fólico não esteve relacionada ao uso de TARV nem à macrocitose / AIDS is a chronic disease characterized by HIV infection and results in immunodeficiency. HAART is an effective approach to this disease, substantially improving quality of life and prognostic factors. It has become frequent the occurrence of hematologic disorders such anemia and macrocytosis, as well as micronutrients deficiency with the outcome of the treatment. The objective of this study is to correlate macrocytosis, anemia and HAART collateral effects with B12 vitamin and folic acid deficiencies. 110 HIV positive patients were included and divided in 3 groups: HAART with AZT (Group 1), HAART without AZT (Group 2) and without any antiretroviral treatment (Group 3). All groups did not have difference related to hemoglobin level (p=0,584). G1 had higher VCM levels than G3 (p<0,05), as well as G2 than G3 (p<0,001). G1 and G3 Vitamin B12 levels were smaller than those from G2 (p=0,008). Folic acid measurements did not differ among groups (p=0,956). We conclude that patients in HAART treatment had macrocytosis, even though this could not be related to an specific drug among HAART treatment or vitamin B12 deficiency. However, folic acid deficiency was not related neither to HAART nor macrocytosis

Magister Public Health - MPH / Namibia is one of the countries in the world most affected by HIV/AIDS with the national prevalence of 18.8% in 2010. In 2010, it was reported that an estimated 180,000 Namibians were living with HIV/AIDS; of which 95,000 adult women, 69,000 adult men and 16,000 children. An estimated 6,700 deaths was recorded in 2009 with an estimated number of 70,000 orphans due to the disease. The introduction of anti-retroviral therapy (ART) in public health facilities in Namibia in 2003 has improved the quality of lives of patients with advanced HIV disease, prolonged their lives and enabled them to be economically productive. By 2010 about 90,000 patients were enrolled on ART program in all 34 district hospitals and 3 intermediate referrer hospitals. Adherence to antiretroviral therapy is a key attribute of clinical HIV care and the overall determining factor in gauging the effectiveness of treatment. Good adherence to ART is vital to sustain low viral loads and prevent the development of drug resistant HIV strains. Although the patient retention rate on ART at the Katima Mulilo Hospital was 98.3%, with increased patient uptake to the program in future, there is a need to be aware of factors that influence adherence to ART as such findings could inform the expanded ART program in Caprivi region. An explorative, qualitative study was conducted where in-depth interviews were conducted with 24 ART patients and key informants interviews with 2 health workers. Data were audiotape recorded and transcribed verbatim. Thematic and content analysis of transcribed data was performed.

Masters of Public Health - see Magister Public Health / Introduction: HIV and AIDS continues to be a major public health challenge for Zambia, which has the highest HIV prevalence rate of 13.1% in sub-Saharan Africa. Although individuals living with HIV/AIDS in Zambia have increased access to antiretroviral treatment (ART), not all patients who are initiated on antiretroviral treatment remain in care; with some patients being lost at different points in the continuum of care. The current study aimed to explore the factors affecting retention in care among patients receiving antiretroviral treatment at three primary health facilities in the Kabwe district in Zambia. Methodology: An exploratory qualitative study design was used to explore the patient, health systems and socio-economic factors that underlie retention on ART in three purposefully selected primary health care facilities in Kabwe district. Data was collected through in-depth interviews with 45 ART patients and three focus group discussions with 20 health care providers. The content of the transcribed interviews was analyzed thematically. Findings: The overall retention rate of the ART sites was found to be 65%. The main patient factors that influenced retention in care were side effects of antiretroviral drugs and weight increase as a sign of good health. The social related factors that influenced patient retention in care were stigma and non-disclosure of HIV status, faith healing, use of herbal remedies and alcohol use. The health system factors that contributed to poor retention of patients in care were long waiting times due to staff shortage, high patient load, travel distance to ART centers and transportation cost. Other health system factors reported by participants included shortage of third line ARV drugs and inadequate space in ART clinic. Finally, food shortage and mobility of patients due to employment were some of the identified economic factors that influenced patient retention in care. Conclusions: A large proportion of adult patients initiating ART in Zambia are poorly retained in care because of patient, health system, social and economic factors. In order to improve retention, more nurses and clinical officers should be trained in ART management to improve skills and address staff shortages. It would also be useful for Zambia to introduce community drug distribution points for delivering ARV refills to reduce the workload on the existing ART sites and reduce on the distances that patients have to travel to ART centers. Additionally, efforts should also be made to improve ART care by extending ART clinic days to include all the days of the week except Sundays.