Master of Public Health - MPH / Poor adherence to antiretroviral therapy (ART) among paediatric and adolescent patients remains a big concern to health workers at Onandjokwe CDC clinic in Oshikoto Region of Namibia. Despite successes in the scale up of ART in Oshikoto Region the clinic experienced high prevalence of poor adherence to ART among adolescent patients. Out of 631 adolescents alive and on ART in this clinic, 154 (24%) had records of poor drug adherence between Jan 2015 and August 2015; which compared poorly to only 4 % of 7289 adults currently on ART who have records of poor adherence during the same period. The aim of the current study was to explore barriers to adherence to antiretroviral therapy among these adolescents. Among the study population of 631 adolescents on ART in Onandjokwe, a sample population of 154 had records of poor adherence (scored below 85%) to ART between June 2015 and August of the same year were considered for the study but among them 16 adolescents were recruited as the study sample. Additionally, 5 caregivers of adolescents on ART, 6 Healthcare Providers were selected as key informants. A voice recorder and field notes were being used during data collection. Two 2 sessions of Focus Group Discussions (FGD) were held with adolescents while 2 FGD sessions held with 5 caregivers and 6 healthcare providers to elicit expert opinions. Lastly, 5 In-depth interviews were conducted with individual adolescents who missed ART medicine follow up for 1 month or more between January and August of 2015. Data Analysis was performed using hand manipulation by grouping responses into main study objectives/themes. Data cleaning, translation of voice transcription from Oshiwambo to English language and incorporating of non-verbal expressions was also done. The results indicate that factors contributing to poor ART adherence among adolescents are patient and family related, socio-economic, and related to substance abuse, stigma and discrimination, health care and health systems, as well as the environment and weather.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Science in Physiotherapy. Johannesburg, 2015 / The Human Immunodeficiency Virus (HIV) has been found to cause muscle weakness, wasting and peripheral neuropathies. The specific relationship between lower limb muscle strength and lower limb function in HIV positive patients on Highly Active Antiretroviral Therapy (HAART) has not been examined. The aims of the current study were to establish lower limb muscle strength in HIV positive patients on HAART, establish lower limb muscle strength in HIV negative people, compare lower limb muscle strength between patients who are HIV positive on HAART and HIV negative people, establish lower limb function in patients who are HIV positive on HAART and to establish the relationship between lower limb muscle strength and lower limb function in patients who are HIV positive on HAART. A cross-sectional, descriptive study design was used. Dynamometry was used to measure lower limb muscle strength. The lower Extremity Functional Scale (LEFS) was used to determine lower limb function. A pilot study was done to establish the feasibility and proficiency required to perform hand held dynamometry. Intra and inter-rater reliability were also determined during the pilot phase. Intra and inter-rater reliability were high for the raters' measurement of lower limb muscle strength using a dynamometer with 'r' values of 0.97. For HIV positive patients on HAART, 19% (n=22) were in the age band 45-49years, whereas 33% (n=10) of HIV negative subjects were in age interval 25-29 years. Those over 45 years who were HIV positive on HAART constituted 57% (n=64) of the sample. The mean muscle strength obtained ranged from 9.30kg/m2 in ankle dorsiflexors to 15.80kg/m2 in hip extensors in HIV positive people on HAART for an average of 4 years while knee flexors generated 11.81 kg/m2 and knee extensors generated 15.36kg/m2 in this cohort.Jn the HIV negative matched group, the mean muscle strength ranged from 11.20 kg/m2 in ankle dorsiflexors to 17.70 kg/m2 in hip extensors while knee flexors generated 12.65kg/m2 and knee extensors generated 17.07kg/m2. The majority 78% (n=88) of HIV positive patients on HAART had no difficulty with lower limb function while 22% (n=17) had difficulty. Only 2% (n=2) of HIV positive patients on HAART had quite a bit of difficulty with lower limb functional activities after measurements using the Lower Extremity Functional scale (LEFS). A multiple linear regression showed that there was a positive correlation coefficient of r=0.71 (p-value= 0.00) between lower limb muscle strength and lower limb function. The coefficient of determination 0.50 means that 50% of the changes in lower limb function are attributable to lower limb muscle strength. Gender, employment status and mode of transport also positively affected lower limb function. A detailed regression model showed that lower limb ankle plantar flexors contributed the most to lower limb function in this cohort. This is contrary to International literature which states that hip and trunk muscles are the most active in HIV negative people during lower limb functional activities. That plantar flexors contribute the most in lower limb functional activities instead of hip and trunk muscles confirms the existence of proximal weakness in this cohort which was established by other researchers. This study highlighted that 50% of lower limb function is a result of lower limb muscle strength in HIV positive people on HAART attending an outpatient clinic in Mutare, Zimbabwe. Ankle plantar flexors instead of hip flexors were the most active muscle group in lower limb functional activities in this cohort. It therefore means exercise prescription to activate/strengthen hip flexors and other proximal muscles will improve this population's lower limb functional activities since progressive resisted aerobic exercises have been proved to strengthen muscles. / AC2016

Sub-Saharan Africa is the region in the world most severely affected by HIV, and Tanzania is among the most severely affected countries in the region. The introduction of antiretroviral treatment has offered hope to people living with HIV/AIDS, improving their quality of life significantly. Still, there are individuals living with HIV who either lack access to ART, or choose not to make use of the available treatments. The purpose of this thesis is to identify underlying factors perceived as barriers for HIV- positive individuals to initiate and maintain Antiretroviral treatment in Babati District, Tanzania. Twenty semi-structured interviews were carried out between the 15th of February and 6th of March 2016. The interviews were conducted with ART-patients, health workers and members of the community. An analysis was made within a theoretical framework based upon Goffman's notion of stigma and the Initial Behavioral Model by Andersen. The following obstacles to access to ART were indicated by the findings: HIV/AIDS related stigma issues, discrimination, economic barriers, ignorance due to lack of education, counseling on HIV treatment, and beliefs that HIV can be cured by traditional healers.

Magister Public Health - MPH / Adolescents living with HIV (ALHIV) are notably underserved by national HIV programmes globally due to their unique needs. Of particular concern is limited access to and availability of adolescent-friendly ART services, which contributes to poor ART adherence and retention in care in many sub-Saharan African countries. Poor adherence in adolescents has been associated with medicine side effects, pill fatigue, non-disclosure of status to the child, inadequate information on HIV, caregiver-child communication, caregiver’s health beliefs and stigma, and lack of knowledge on the rationale of taking medicines. Several interventions have been developed to improve ART adherence and retention in care amongst ALHIV through peer groups and psychosocial support. The Teen Club intervention was introduced in 2010 at Intermediate Hospital Katutura Paediatric ART clinic in Windhoek to improve ART adherence and retention in care amongst ALHIV by providing psychosocial support in a group environment. However, to date no formal evaluation of the effectiveness of the Teen Club intervention in Namibia has been conducted. The aim of the study was to compare the effects of the Teen Club intervention against standard care on treatment outcomes for ART (i.e. adherence, retention in care and viral suppression) in adolescents at Intermediate Hospital Katutura Paediatric ART clinic in Namibia. Methods: A retrospective cohort analysis of HIV positive adolescents aged 10-19 years, who were accessing ART between 1 July 2015 and 30 June 2017 was conducted. Patient data was extracted from the electronic Patient Monitoring System (ePMS), individual Patient Care Booklets and the teen club attendance register. Adherence to ART was measured through pill counts; and retention by kept clinic visits. Viral load results were assessed to measure levels of viral suppression. Adolescents with viral loads ≥ 1000 copies/ml were classified as not virally suppressed whilst those with viral loads <1000 are virally suppressed (with those <40 fully suppressed). Results: The total sample was 385 participants; with 78 of them in the Teen Club (exposed) and 307 adolescents in standard care (unexposed).

Master of Public Health - MPH / Background: Globally, it is estimated that about 1.8 million adolescents (aged 10–19 years) were living with HIV in 2015. In Kenya an estimated 133,455 adolescents were living with HIV in 2015, of which 75% (105,679) were in need of antiretroviral therapy (ART). Among adolescents on ART in 2016, 63% reported viral suppression; which is far below the UNAIDS targets of 90%. Viral suppression (having less than 1000 copies of viral RNA/ml of blood) is a key indicator of HIV treatment success, and is associated with better quality of life and reductions in HIV incidence at a population level. Homabay County recorded the highest HIV prevalence (26%) and the highest number of adolescents living with HIV in Kenya (15,323) in 2015. By the end of June 2017 5,709 adolescents were initiated on ART in Homabay County. Despite the successes in initiating HIV positive adolescents on ART, little is known about the factors that are associated with viral suppression. The current study investigated the factors associated with viral suppression among adolescents initiated on ART before November 30, 2017 in Homabay County, Kenya. Methods: A descriptive cross-sectional study was conducted among 925 adolescents registered on ART for at least 6 months and with at least one documented viral load in the last 12 months, in six health facilities in Homabay County. Data was extracted from the electronic medical records and exported into an excel spreadsheet. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated to viral suppression using Stata 12.0.

Magister Public Health - MPH / Background: TB is one of the most common opportunistic infections in the HIV infected population. In 2014, of the 9.6 million people estimated to have TB globally, 1.2 million were also infected with HIV. In the same year WHO reported 400 000 TB deaths in HIV infected people worldwide. TB Prevention strategies include ensuring HIV infected people take ART, TB infection control, treatment of TB cases and pharmacological prevention of primary TB infection or progression of latent TB into active TB. Isoniazid preventive therapy for a minimum of six months has been recommended to reduce the risk of TB in people living with HIV. Aim: The study’s aim was to determine the programmatic outcomes of isoniazid preventive therapy (IPT) and factors associated with treatment completion among people living with HIV aged 15 years and above at the AIDS Healthcare Foundation LaMvelase clinic in Manzini Swaziland, who were enrolled for IPT during the period March to December 2014. Methodology: This was a quantitative retrospective analytical cohort study that reviewed 3642 patient care records. IBM SPSS 20 was used for descriptive and statistical analysis of the data. Descriptive statistics were calculated and reported as frequencies and percentages. Bivariate statistics were carried out to test independent associations between socio-demographic and clinical characteristics, and IPT completion. Further multiple logistic regression analysis was done to determine the nature of association between the dependent and independent variables which had p < 0.1.

Magister Public Health - MPH / Background: The goal of ART therapy is sustained viral load suppression with good immunological and clinical response. This optimal response to therapy results in the prevention of emergent ART drug-resistant mutations, decrease morbidity, and AIDS-related mortality and sustained retention on ART. Kenya, like most countries in Sub-Saharan Africa, has scaled-up the use of ART and is currently implementing a “Test and Treat” strategy in which any client identified and confirmed with an HIV diagnosis is initiated ART. Few studies have been carried out to ascertain the response of HIV patients initiating treatment in resource-limited settings. Moreover, it has been demonstrated that a certain proportion of patients fail to adequately respond to therapy and therefore require therapy modification. Aim: To assess treatment outcomes and calculate retention of HIV infected adult patients’ (15 years and above) initiating ART at Kakamega County General Hospital. The primary study outcome was the treatment outcome of patients-initiated ART two to three years prior to the study; while, the role of WHO criteria for screening treatment failure was assessed as a secondary outcome. Methods: This was a retrospective cohort study in which patients initiating ART between June 2014 and March 2015 were followed up until they were censored or study closed in August 2017. 284 patients were enrolled in the study after accurately matching information in their clinic files and the electronic medical record. Data were collected from patient records using a chart abstraction tool and transferred to an Access database from where the cleaning and validation of entries were done. Data from Access was transferred to STATA 15.1 for analysis. Descriptive statistics and inferential statistics were then performed to answer the research questions.

MSc, Paediatrics and Child Health, Faculty of Health Sciences,University of the Witwatersrand / Background To investigate whether in-utero exposure to highly active antiretroviral treatment (HAART) is associated with low birth weight and/or preterm birth in a population of South African women with advanced HIV infection. Methods A retrospective observational study was performed on women with CD4 cell counts ≤250 cells/mm3 attending antenatal antiretroviral clinics at two clinics in Johannesburg between October 2004 and March 2007. Low birth weight (<2.5kg) and preterm birth rates (<37 weeks) were compared in those exposed versus unexposed to HAART during pregnancy. Effects of different HAART regimen and duration (<28 weeks or ≥ 28 weeks) were assessed. Results Among HAART-unexposed infants 27% (60/224) were low birth weight (LBW) compared to 23% (90/388) of early HAART-exposed and 19% (76/407) of late HAART-exposed infants (P=0.05). In the early HAART group, older maternal age was associated with LBW and higher CD4 cell count protective against LBW (AOR 1.06, 95% CI 1.00- 1.12 and AOR 0.58, 95% CI 0.46-0.73, P<0.001, respectively). HAART-exposed infants had an increased risk of preterm birth vii (<37 weeks) (15% [138/946] versus 5% [7/147], p=0.001), with early (<28 weeks) nevirapine and efavirenz having the strongest associations with preterm birth (AOR 5.4, 95%CI 2.1-13.7, P<0.001 and AOR 5.6, 95%CI 2.1-15.2, P=0.001, respectively). Conclusion Among infants born to women with CD4 cell counts <250 cells/mm3, HAART exposure was associated with preterm birth, but not with low birth weight. More advanced immunosuppression was a significant risk factor for both LBW and preterm birth, highlighting the importance of earlier HAART initiation in pregnant women, both to optimize maternal health and to improve infant outcomes

The national programme of expanded access to antiretroviral therapy in the South African public health sector has resulted in hundreds of thousands of South Africans being subjected to prolonged therapy with the risk of adverse drug effects. Among the most common adverse effects are metabolic disorders one of which is mitochondrial toxicity. Mitochondrial toxicity may manifest as hyperlactatemia. The study was designed to determine the frequency with which hyperlactatemia occurs in HIV – infected adults on long-term antiretroviral therapy (ART). The objective was to determine the proportion of patients with blood lactate levels that exceed a predetermined cut-off level and to attempt to relate hyperlactatemia to a set of factors namely, gender, age, obesity, symptoms, type of ART regime and duration of ART use. The study was conducted at an ART clinic in the provincial state hospital of Bongani in the town of Welkom in Free State. The target population was male and female adult patients (18 years and above) on ART for a duration of 1 year or longer. Participants were selected by a random sampling of hospital case file numbers using random table numbers. The patients answered a set of 7 questions on symptoms, underwent weight and height measurements before having blood drawn for lactate assays Blood specimens for lactate assays were processed at the local National Health laboratory.

Introduction: South Africa has embarked on a massive roll out of ARVs to more than 1.4 million people living with HIV/AIDS. Provision of ARVs to people living with HIV/AIDS encounters many challenges associated with adherence. Properly taken ARVs have been shown to reduce viral loads to undetectable levels and increase the CD4 count. This in turn leads to a drop in opportunistic infections and better health outcomes but the requirements for adherence are high. Several patient-related factors have been reported to affect adherence rates. Nonadherence on the other hand has been reported to lead to the development of drug resistant strains of HIV. It recognised that the resistance to ARVs can quickly lead to build up of highly resistant strains in the blood due to one week of missed medication. Aims and objectives: This study set out to identify factors which affect adherence to HAART among adults on HAART in two health facilities in Gauteng province in 2006.The main objectives were to assess the patient adherence using viral load response and self-report data. Secondly, the study was to determine factors that facilitate adherence and finally barriers to adherence at the two sites. Materials and methods: A cross sectional study was done at the two ARV facilities in Gauteng from July to November 2006. Two physiological methods -CD4 counts and plasma viral load, and one subjective-3 day recall self- report methods were used to asses adherence. Exit interviews and record reviews were done to collect data. Virologic outcome was the preferred surrogate marker for adherence. Univariate and bivariate analyses were done to determine measures of association. Measures of association (Chi square) at a 95% significance level for factors affecting adherence were then determined and results obtained. Results: The mean age was 36.9 years (range 18-70 years) and 73.5% were women. Self-report data (n=343) indicated 98.4% in the higher adherence category (taken 100% of their doses). Viral load data (n=343) showed that 88.8% were in the adherence lower category (<400 RNA copies). Viral load outcome (“adherence”) was significantly associated with the length on treatment (p<0.05) and patients who had been on treatment for 12-24 months had lower viral load than those who had been treatment for a shorter time (<12 months) or longer (>24months). However, gender (p=1.000), age (p=0.223), level of education (p=0.697) and access to social grants (p=0.057) were not associated with “adherence”. Socio-economic status was significantly associated with viral load outcome (p<0.01) as well as cost (n=185; p<0.05). Individuals who incurred the highest costs (>R25) were the least likely to adhere followed by those facing average costs (R15-25) compared to the reference group (< R15). Conclusion: Adherence rates of 88.8% suggest that respondents from both facilities can optimally adhere to their medication when they have been on ARVs for longer than a year. These are minimum adherence rates. There were factors that still hinder adherence at both the individual patient level. There is still a need for more targeted interventions especially towards men who were noted to have a relatively low uptake of HAART within the two sites.