Thesis (MSC)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: South Africa is shouldering the highest burden of HIV-infection. Inter-individual differences in response to antiretroviral treatment (ART) and the limited availability of second and third-line ART regimens call for optimising first-line ART in South African populations. Measuring antiretroviral drug levels in patients may be of clinical value as an intermediate indicator of treatment response and may moreover serve to assess the genetic variation underlying differential drug exposure. This study aimed to determine the effect of SNPs in the CYP2B6 gene and efavirenz (EFV) levels measured in hair on ART outcomes in females of two South African populations. Female Xhosa (XH) (n = 81) and Mixed Ancestry (MA) (n = 53) patients receiving the first-line regimen component EFV for at least three months donated saliva for genomic DNA extraction and 20 strands of hair for determination of EFV concentrations by high performance liquid chromatography. Regulatory and exonic regions in the CYP2B6 gene, which codes for the major metabolising enzyme of EFV, were subjected to bi-directional sequence analysis in 15 XH and 15 MA individuals to assess common genetic variation in these populations. Out of 45 single nucleotide polymorphisms (SNPs) identified, 17 SNPs of known or predicted functional importance in EFV metabolism, including four novel SNPs, were genotyped in the entire patient cohort by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) analysis. All SNPs were tested for Hardy-Weinberg equilibrium (HWE) and maximum likelihood haplotypes and assessed for an association with EFV levels measured in hair, likelihood of developing adverse drug reactions (ADRs) and virological response to EFV-based treatment. After correcting for age and ethnicity, homozygous carriers of c.516G>T (CYP2B6*6) had significantly increased EFV levels (p = 0.0021; mean: 12.0 ng/mg; IQR: 3.95 – 6.99 ng/mg; n = 12), as did heterozygotes of c.983T>C (CYP2B6*18) (p = 0.0005; mean: 7.315 ng/mg; IQR: 6.59 – 15.10 ng/mg; n = 10). No CYP2B6*18 homozygotes were detected. No association between EFV levels and virological response was evident (p = 0.8467), but CYP2B6*6 predicted increased odds of virological failure (VL > 80 copies/ml) after correcting for adherence, race, age, weight, time on treatment, baseline CD4, smoking, alcohol and WHO disease stage (p = 0.0328). Carriers of the CYP2B6*1 allele had increased odds (OR = 5) of favourable treatment outcome (VL < 80 copies/ml). In accordance with other studies, this study provides evidence that genetically predisposed poor metabolisers of EFV may be at increased risk of virological failure, possibly following non-adherence. Concurrently, these patients may be more vulnerable to adverse drug reactions and are more frequent in the XH (13%) than MA (4%). These results should be verified in larger patient cohorts, but contribute to a better understanding of the effect of genetic factors on EFV exposure and ART outcome in two South African populations. The outcomes of this study may thus provide recommendations for prospective studies and impact future clinical decisions. / AFRIKAANSE OPSOMMING: Suid-Afrika dra die grootste las van MIV-infeksies. Inter-individuele verskille in reaksie op anti-retrovirale terapie (ART) en die beperkte beskikbaarheid van tweede- en derde-linie ART-reekse regverdig die optimisering van eerste-linie ART in Suid-Afrikaanse bevolkings. Meting van antiretrovirale middel-vlakke in pasiënte, as ‘n intermediêre aanduiding van reaksie op behandeling, kan van kliniese belang wees en kan ook die waarde van die bepaling van genetiese variasie, onderliggend aan differensiële blootstelling aan middels, bepaal. Die doel van hierdie studie is om die effek van enkel-nukleotied polimorfismes (SNPs) in die CYP2B6-geen en efavirenz (EFV)-vlakke in hare op ART-uitkoms te bepaal in vroue van twee Suid-Afrikaanse bevolkingsgroepe. Vroulike Xhosa (XH) (n = 81) en Gemengde Herkoms (GH) (n = 53) pasiënte wat EFV as deel van eerste-linie ART vir ten minste drie maande ontvang het, het speekselmonsters vir genomiese DNA-ekstraksie en 20 hare vir die bepaling van EFV-konsentrasies deur hoë werkverrigting vloeistofchromatografie (“HPLC”) geskenk. Regulatoriese en eksoniese areas in die CYP2B6-geen, wat vir die vernaamste metaboliserende ensiem van EFV kodeer, is deur middel van tweerigting-volgordebepalings-analise in 15 XH en 15 GH individue ondersoek om gemeenskaplike genetiese variasie in hierdie bevolkings te bepaal. Uit ‘n totaal van 45 SNPs wat geïdentifiseer is, is 17 SNPs wat bekende of voorspelde belangrike rolle in EFV-metabolisme speel, insluitend vier nuwe SNPs, ondersoek. Hierdie SNPs is in die volledige pasiënt-kohort gegenotipeer deur polimerase-ketting reaksie gebaseerde restriksie fragment lengte-polimorfisme (PKR-RFLP) analise. Alle SNPs is getoets vir Hardy-Weinberg-ewewig (HWE) en maksimum waarskynlikheidshaplotipes en is geassesseer vir assosiasie met EFV-vlakke gemeet in hare, die waarskynlikheid om ongunstige reaksies tot die middel te ontwikkel en virologiese reaksie op EFV-gebaseerde behandeling. Nadat vir ouderdom en herkoms gekorrigeer is, het homosigotiese draers van c.516G>T (CYP2B6*6) beduidend verhoogde EFV-vlakke (p = 0.0021; gemiddeld: 12.0 ng/mg; IQR: 3.95 – 6.99; n=12) getoon, so ook heterosigote vir c.983T>C (CYP2B6*18) (p = 0.0005; gemiddeld: 7.315 ng/mg; IQR: 6.59 – 15.10 ng/mg; n = 10). Geen CYP2B6*18 homosigote is gevind nie. Daarbenewens is geen duidelike assosiasie tussen EFV-vlakke en virologiese reaksie gevind nie (p = 0.8467), maar CYP2B6*6 het verhoogde waarskynlikheid op virologiese mislukking (VL > 80 kopieë/ml) getoon nadat daar vir mddel-getrouheid, ras, ouderdom, gewig, tydsduur van behandeling, basis-CD4, rook, alkohol en Wêreld Gesondheids Organisasie siekte-fase gekorrigeer is (p = 0.0328). Draers van die CYP2B6*1-alleel het verhoogde waarskynlikheid (OR = 5) op gunstige behandelingsuitkomste getoon (VL < 80 kopieë/ml). In ooreenstemming met ander studies verskaf hierdie studie bewyse dat pasiënte wat geneties geneig is tot stadige metabolisme van EFV ‘n hoër risiko kan hê vir virologiese mislukking, wat moontlik ‘n gevolg is van middel-ontrouheid. Hierdie pasiënte kan ook meer geneig wees tot vatbaarheid vir ongunstige middel-reaksie en kom meer voor in die XH (13%) as in die MA (4%). Hierdie resultate moet in groter pasiënt-kohorte gestaaf word, maar dra by tot ‘n beter begrip van die effek van genetiese faktore op blootstelling aan EFV en ART-uitkoms in twee Suid-Afrikaanse bevolkings. Die uitkomste van hierdie studie kan dus as aanbevelings gebruik word vir voornemende studies en ook toekomstige kliniese besluite beïnvloed. / The Medical Research Fund (MRC) for funding this project. The University Centre for Studies in Namibia (TUCSIN) and Deutscher Akademischer Austausch-Dienst (DAAD) for financial support

PhD (Molecular Medicine and Haematology), Faculty of Health Sciences, University of the Witwatersrand / Background: The availability of highly active antiretroviral (ARV) treatment in the South African government sector has reduced the morbidity and mortality associated with HIV-1 infection. However, ARV drug resistance and toxicity are major obstacles to achieving and maintaining virus suppression, but there is no provision for ARV drug resistance testing in the public sector. To date, most studies of ARV drug resistance in HIV-1 reverse transcriptase (RT) and protease (PR), are based on sequence data from HIV-1 subtype B, whereas subtype C is the predominant circulating subtype in South Africa. Moreover, host genetic polymorphisms associated with ARV drug toxicity have not been investigated in South African populations. This study evaluated viral and host genetic factors associated with ARV treatment outcome in 812 ARV drug-naive South African AIDS participants enrolled on the CIPRA-SA study from Johannesburg and Cape Town. Methodology: An affordable in-house genotyping protocol (subtype C specific) was established and validated to monitor the emergence of ARV drug resistance. This assay was used to genotype all CIPRA-SA participants failing the first- and second-line ARV drug regimens. Allellic discrimination assays to identify the G1344A, A6986G, G516T and C3435T SNPs in CYP3A4, 3A5, 2B6 and MDR-1, respectively, associated with ARV metabolism and absorption were performed. Results: The in-house ARV drug resistance assay successfully genotyped 95% of patient samples, including non-C subtypes from 8 African sites. Treatment failure was experienced in 371 participants, mainly due to toxicity (n=134) or virological failure (n=83). Overall, CIPRA-SA participants with a lower CD4+ T-cell count at study onset were more likely to experience viral failure. Genotyping using the in-house assay revealed that 6 participants had ARV drug resistance mutations at study entry. Treatment failure of 58 participants was a result of ARV drug resistance mutations, whereas 19 had no known ARV drug resistance mutations. The most frequent mutations were M184V (67%) and K103N (50%). K65R was present (3%) and one participant harboured TAMs. Longitudinal genotypic analysis showed that NNRTI mutations accumulated at a rate of one per three months left on failing therapy. No PR mutations were detected amongst participants experiencing second-line failure. The four SNPs analysed occured in similar frequencies between a background and the CIPRA-SA cohort. Furthermore, no statistically significant association could be found between these four SNPs and viral failure and/or toxicity. Conclusion: Overall, HIV-1 subtype C-infected individuals receiving ARV therapy develop many of the known subtype B drug resistance mutations. However, the ARV drug resistance patterns in the closely monitored CIPRA-SA cohort were less complex compared to published data from the region, confirming that more frequent viral load monitoring, genotyping, and a virological failure cut-off value of 1000 RNA copies/ml ensure a better prognosis, and preserve future ARV treatment options.

A l’ère de l’objectif cible « 90-90-90 » de l’ONUSIDA de réduction de la pandémie liée à HIV, il est important d’évaluer régulièrement la cascade de prise en charge des personnes vivant avec le virus HIV afin d’en vérifier l’avancement et d’identifier d’éventuels obstacles à sa réalisation. Pour cela nous avons étudié tout d’abord efficacité du traitement antirétroviral (TAR) dans le sang de personnes nouvellement dépistées séropositives à Bamako (Mali). Dans un deuxième travail nous avons évalué la faisabilité des tests de charge virale et de résistance génotypique aux antirétroviraux à partir de sang total séché sur un support de type buvard (DBS). La troisième partie de nos travaux était consacrée à des aspects plus physiopathologiques avec l’évaluation du traitement sur les réservoirs salivaires et génitaux (patients de Bamako) et sur le microbiote vaginal, ainsi que l’étude du profil de résistance des souches archivées dans l’ADN cellulaire de biopsies rectales. Nous avons tout d’abord observé un taux important de perdus de vue à un an dans la cohorte de Bamako (environ 45%). Nous avons également constaté un taux élevé de résistance primaire aux ARV à Bamako et au Tchad (>15%). De manière rassurante, le succès virologique au bout de 1 an chez les personnes traitées était d’environ 90% ce qui correspond à l’objectif de l’ONUSIDA (3ème 90) et un faible niveau de mutations acquises a été observé chez ces personnes adhérentes au traitement. Nous avons démontré l’efficacité du TAR sur le compartiment salivaire et constaté une compartimentation du virus au niveau cervico-vaginal chez certaines femmes traitées (27%) présentant une excrétion virale au niveau vaginal avec une charge virale plasmatique indétectable et/ou des séquences génétiques différentes sur le gène pol entre le virus isolé dans la muqueuse et celui provenant du sang. De plus, une dysbiose était observée avant la mise sous traitement, avec normalisation de la flore sous TAR efficace. En ce qui concerne le travail sur les biopsies rectales, des profils similaires ont été observés entre la souche plasmatique majoritaire au moment de la mise sous TAR et celle archivée dans le rectum 1 à 5 ans après traitement. En conclusion, nos travaux apportent des informations nouvelles sur le déroulement des différentes étapes de la prise en charge de l’infection par HIV dans les pays en développement : tout d’abord une faible adhésion au traitement ce qui peut constituer un obstacle majeur à la réalisation du plan 90/90/90 ; une forte prévalence de la résistance primaire qui plaident en faveur de l’accessibilité aux différentes classes d’antirétroviraux et de leur utilisation rationnelle, de l’utilisation généralisée en routine des tests de charge virale et du développement d’un réseau de surveillance de la résistance aux ARV dans les pays à ressources limitées ; des données d’efficacité de traitement sur les réservoirs muqueux mettant en évidence l’existence d’une dysbiose et d’une compartimentation du virus au niveau génital ce qui pose le problème du risque résiduel de transmission chez certaines personnes, même sous ARV. / Regularly assess to UNAIDS cascade 90-90-90 is important to check the progress and identify any obstacles to its implementation. For this we first studied efficacy of antiretroviral treatment (ART) in the blood of newly diagnosed HIV-positive in Bamako (Mali).In a second work we evaluated the feasibility of viral load and genotypic resistance tests from dried blood spot (DBS). The third part of our work is dedicated to pathophysiological aspects with evaluation of treatment on salivary and genital reservoirs (Bamako patients) and on the vaginal microbiota, as well as the study of the resistance profile of the strains archived in cellular DNA of rectal biopsies. We observed a high rate of lost to follow-up at one year in the Bamako cohort (45%). We also found a high rate of ART primary resistance in Bamako and Chad (> 15%). Reassuringly, the virological success after 1 year of treated follow was about 90% in these adherents. We also demonstrated the efficacy of ART in the salivary compartment and found a compartmentalization of the virus at the cervico-vaginal level in some women under ART. In addition, a dysbiosis was observed before ART, and a normal flora under effective ART. Similar profiles were observed on the main strain isolated in blood at the time of diagnosis and on the archived strain in the rectum after 1 to 5 years of ART.In conclusion, our work provides new information on the progress of the treatment stages of HIV infection in developing countries: low adherence to treatment which can constitute a major obstacle to achieve the plan 90/90/90; a high prevalence of primary resistance advocating accessibility and rational use of different classes of antiretrovirals drugs, widespread routine use of viral load tests and the development of ARVs resistance surveillance network in resource-limited countries; treatment efficacy data on mucosal reservoirs revealing the existence of genital dysbiosis and viral compartmentalization, which raises the problem of the residual risk of transmission in some people, even under ARVs.

No description available.

Thesis (MSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Efavirenz is an antiretroviral drug used in the treatment of HIV-positive patients as part of first line triple-highly active antiretroviral therapy. Treatment response varies among individuals and adverse drug reactions tend to occur, as a result of the variation in the rate of efavirenz metabolism among individuals. This is partly caused by genetic variation; therefore the study of genes involved in the metabolism of efavirenz, such as CYP2B6, could potentially enhance treatment success. The effect of CYP2B6 SNP 516G>T (part of the CYP2B6*6 allele) is particularly important, as individuals homozygous for the minor allele of this SNP have significantly increased efavirenz levels. Furthermore, nuclear receptors, specifically constitutive androstane receptor, encoded by NR1I3, and pregnane X receptor, encoded by NR1I2, are involved in the regulation of the genes responsible for efavirenz metabolism and could therefore indirectly influence the pharmacokinetics of efavirenz. The current study identified variants in the NR1I3 and NR1I2 genes through in silico analysis, bi-directional sequencing and literature searches. A total of nine NR1I3 and ten NR1I2 target variants were subsequently genotyped in 132 HIV-positive female patients from the Xhosa and Cape Mixed Ancestry populations. The resulting genotype and allele frequencies were statistically analysed to search for correlations between genetic variations and available efavirenz levels in hair samples, treatment outcome as measured by viral load, and the occurrence of adverse drug reactions. The minor allele of a NR1I2 5’-upstream SNP, rs1523128 (6334A>G), was significantly associated with decreased efavirenz levels. From analysis of the effect of composite SNPs, NR1I3 5’-upstream SNP rs55802895 (258G>A) in conjunction with CYP2B6*6, was significantly associated with efavirenz-levels. It was found that the minor allele of rs55802895 inhibited the effect of CYP2B6*6, resulting in normal efavirenz levels for individuals homozygous for the minor allele of both SNPs. Additionally, when the target NR1I3 and NR1I2 variants were analysed in conjunction with six SNPs from CYP1A2, CYP2A6, CYP3A4 and CYP3A5, 11 compound genotypes were shown to be statistically associated with mean EFV plasma levels. The study emphasises the complexity of efavirenz metabolism, and the importance of transcriptional regulation in xenobiotic metabolism. / AFRIKAANSE OPSOMMING: Efavirenz is ‘n antiretrovirale middel wat gebruik word in die behandeling van HIV-positiewe pasiënte as deel van drievoudige hoogs-aktiewe antiretrovirale terapie. Reaksie op behandeling verskil tussen individue en nadelige newe-effekte, wat veroorsaak word deur die verskil in tempo waarteen efavirenz gemetaboliseer word, neig om voor te kom. Hierdie verskille word gedeeltelik veroorsaak deur genetiese variasie; dus kan die studie van gene betrokke by die metabolisme van efavirenz, soos CYP2B6, moontlik die sukses van behandeling verhoog. Die effek van CYP2B6 SNP 516G>T (deel van die CYP2B6*6-alleel) is veral belangrik, want individue wat homosigoties is vir die minderheids-alleel het betekenisvol hoë efavirenz-vlakke. Nukleêre reseptore, spesifiek konstitutiewe androstane reseptor, deur NR1I3 gekodeer, en pregnane X reseptor, deur NR1I2 gekodeer, is betrokke by die regulering van die gene verantwoordelik vir efavirenz-metabolisme en kan dus die farmakokinetika van efavirenz beïnvloed. Die huidige studie het variante in NR1I3 en NR1I2 identifiseer deur in silico-analise, bi-direksionele volgordebepaling en ’n literatuurstudie. Nege NR1I3 en tien NR1I2-variante in totaal is vervolglik gegenotipeer in 132 HIV-positiewe vroulike pasiënte van Xhosa en Kaapse Gemengde Afkoms populasies. Die gevolglike genotipe- en alleelfrekwensies is statisties geanaliseer om vir korrelasies tussen genetiese variasies en beskikbare efavirenz-vlakke in haarmonsters, uitkoms van behandeling gemeet in virale lading en die voorkoms van nadelige newe-effekte te soek. Daar is gevind dat die minderheids-alleel van ’n NR1I2 5’-stroomop SNP, rs1523128 (6334A>G), betekenisvol geassosieer is met ’n daling in efavirenz-vlakke. Vanuit die saamgestelde SNPs, is die NR1I3 5’-stroomop SNP rs55802895 (258G>A), tesame met CYP2B6*6, betekenisvol geassosieer met efavirenz-vlakke. Daar is gevind dat die minderheids-alleel van rs55802895 die effek van CYP2B6*6 demp, en gevolglik normale efavirenz-vlakke in individue homosigoties vir die minderheids-allele van albei SNPs veroorsaak. Addisioneel is die teiken NR1I3 en NR1I2 variante gemeenskaplik met ses SNPs van CYP1A2, CYP2A6, CYP3A4 en CYP3A5 geanaliseer en 11 gekombineerde genotipes is statisties geassosieer met gemiddelde EFV plasma vlakke. Hierdie studie beklemtoon die kompleksiteit van efavirenz-metabolisme en die belangrikheid van transkripsionele regulering in xenobiotiese metabolisme. / National Research Foundation (NRF)

Made available in DSpace on 2014-06-11T19:29:34Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-08-18Bitstream added on 2014-06-13T20:59:47Z : No. of bitstreams: 1 machado_da_me_botfm.pdf: 1394729 bytes, checksum: cf122227c1c036a13854129f11cd25e1 (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / O presente estudo teve por objetivo descrever características sóciodemográficas, psicossociais, clínicas, índices de qualidade de vida, ocorrência de transtorno mental comum, de sintomas depressivos de pacientes portadores de Hepatite C crônica, em tratamento no Ambulatório de Hepatites Virais da Disciplina de Gastroenterologia Clínica do HC da FMB-UNESP, em três momentos de seu tratamento com Interferon Peguilado e Ribavirina: antes do início, nas 12ª e 24ª semanas de tratamento. Foram também estudadas as associações das variáveis sócio-demográficas e clínicas, de transtorno mental comum (TMC), sintomas depressivos, da forma de tratamento com índices de qualidade de vida (QV) nos três momentos estudados e com os resultados de exames indicativos da resposta virológica ao tratamento (detecção do RNA do vírus da Hepatite C pelo método de PCR). Método: Realizou-se estudo transversal e de seguimento. Uma amostra de conveniência foi estabelecida, tendo-se estudado 82 pacientes no estudo transversal e feito o seguimento de 46 no terceiro e sexto mês após o início do tratamento. Utilizou-se formulário estruturado para investigar aspectos sócio-demográficos e clínicos. Sintomas depressivos foram avaliados pelo Beck Depression Inventory (BDI). Utilizou-se o Self Reporting Questionnaire (SRQ) para avaliar Transtorno Mental Comum e o uso nocivo de álcool foi avaliado por meio do Alcohol Use Disorders Identification Test (AUDIT). A qualidade de vida foi estudada por meio do The Medical Outcomes Study 36 item Short-Form Health Survey (SF-36). O estudo das associações entre variáveis categoriais foi feito pelo teste do Qui–quadrado (ou Fisher, se adequado). Os Testes de Mann–Whitney e de Kruskal Wallis foram utilizados para comparar as distribuições dos vários domínios do SF-36. Para comparação entre os dados nos momentos subseqüentes foram... / This study aimed at describing socio-demographic, psychosocial and clinical characteristics as well as quality of life indexes, occurrence of common mental disorder and depressive symptoms of patients with chronic hepatitis C undergoing treatment at the Viral Hepatitis Outpatient Unit of the Botucatu Medical School – UNESP, at three different moments of their treatment with Peguilated Interferon and Ribavirin: immediately before treatment, 12 and 24 weeks after its introduction. The association of socio-demographic and clinical variables as well as those for common mental disorder (CMD), depression symptoms and form of treatment with quality-of-life (QL) indexes was evaluated at the three studied moments. The association of such variables with test results indicating virological response to treatment (detection of the hepatitis C virus RNA by the PCR method) was also investigated. Method: A convenience sample was established, and 82 patients were studied in a cross-sectional and follow-up investigation. Forty-six patients were followed 3 and 6 months after the beginning of treatment. A structured questionnaire was used to investigate socio-demographic and clinical aspects. Depression symptoms were evaluated by the Beck Depression Inventory (BDI). The Self Reporting Questionnaire (SRQ) was utilized to evaluate common mental disorder, and harmful use of alcohol was evaluated by the Alcohol Use Disorders Identification Test (AUDIT). Quality of life was assessed by the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The study of the associations between categorial variables was performed by the chi-square test (or Fisher, if adequate). The Mann-Whitney and Kruskal Wallis tests were used to compare the distribution of various domains of SF-36. McNemar’s Exact Test was used for category variables to compare the data at the subsequent moments, and Friedman’s Test was... (Complete abstract click electronic access below)

Master of Public Health - MPH / Background: HIV has reached epidemic proportions globally with Sub-Saharan Africa carrying the greatest burden (71%). It is estimated that there are 37 million people world-wide infected with HIV, and an estimated 6.8 million live in South Africa. Globally there were 2.1 million adolescents living with HIV in 2014. Improved access to Antiretrotiviral Therapy (ART) has led to a steep decline in HIV incidence and HIV-related mortality. Yet despite these successes in terms of HIV treatment outcomes, HIV-related mortality amongst adolescents has increased. Adolescents are defined by the WHO as individuals between 10 and 19 years old. WHO states that adolescents have poorer access to ART, are at a higher risk of disengaging from care and have special needs to keep them motivated to remain in care. The uptake of adolescents into the South African ART programme is low and those that are enrolled into the programme have poorer adherence than their adult counterparts. Aim: The aim of the study was to explore the factors that influence adherence to ART amongst adolescents in a primary health care clinic in a low socio-economic, urban setting in Cape Town. Methodology: An exploratory qualitative design was employed where data was collected through two key informant interviews with staff from an urban primary health care clinic. Four focus group discussions and eight individual in-depth interviews were held with adolescents and young people who accessed ART at this health facility. Audio data was digitally recorded and transcribed verbatim. Data was analyzed using content analysis. Results: The study identified school commitments, strained teacher-pupil relationships, negative household dynamics and ill-treatment by non-biological caregivers as major reported barriers to adherence. In addition, poor service delivery, missing and misplaced files and long waiting times came under major criticism. Fear of intended or unintended disclosure of HIV status, perceived stigma and discrimination, treatment fatigue and having unstructured lives, profoundly influenced ART adherence. Finally, having a strong support system, disclosing to a trustworthy person and having goals and ambitions served as motivators to remain adherent to ART. Conclusions: This study highlighted the complexity of ART adherence amongst this age group due to school factors, social factors, health services factors, therapy related factors and patient factors. Interventions to improve adherence should aim to address treatment fatigue, disclosure, household dynamics, service delivery factors, as well as the impact of school commitments and symptoms of depression on ART adherence amongst adolescents.

Magister Public Health - MPH / In the context of human resource crisis in African countries, the World Health Organization has proposed task-shifting as an approach to meet the ever-increasing need for HIV/AIDS care and treatment services. Rwanda started the process of task shifting towards nurse-based care in ART services in June 2010. After one year of implementation, a need to determine whether task shifting program has been implemented as intended and if it achieved its primary goal of increasing accessibility of people living with HIV to ARV therapy and improving nurse capacity in HIV patient care was imperative.A multi-method program evaluation study design, combining cross sectional, retrospective review and retrospective cohort sub-studies were used to evaluate the implementation,maintenance processes and outcomes of task shifting in 13 Health Centres (HCs) located in the catchment area of Kibagabaga District Hospital, in Rwanda. The study population consisted of HCs providing task shifted care (n=13), nurses working in the ART services of the 13 HCs(n=36), and more than 9,000 patients enrolled in ART care in the 13 HCs since 2006. All 13 HCs and 36 nurses were included in the evaluation. Routine data on patients enrolled in the pre-task shifting period (n=6 876) were compared with the post task shifting period (n=2 159), with a specific focus on data in the 20-months periods prior to and after task shifting. A cohort of patients 15 years and older, initiated onto ART specifically by nurses from June to December 2010 was sampled (n=170) and data extracted from patients medical files.Data collection was guided by a set of selected indicators. Three different data collection tools were used to extract data related to planning, overall programmatic data and individual data from respectively, the program action plans/reports, HIV central databases and patients medical files. Descriptive analysis was performed using frequencies, means and standard deviations (SD). The paired and un-paired t-tests were used to compare means, and chi-square test was used to compare categorical variables. To compare and to test statistical difference between two repeated measurements on a single sample but with non-normally distributed data, Wilcoxon signed rank test was used. To judge if current task shifted care is better, similar or worse than non-task shifted care, comparisons were made of program outputs and outcomes from the central database prior to and after the period of task shifting, and also with the cohort of nurse initiated patients.Results showed that 61% of nurses working in the ART program were fully trained and certificated to provide ART. Seven out of 13 HCs met the target of a minimum of 2 nurses trained in ART service delivery. Supervision and mentorship systems for the 13 HCs were well organized on paper, although no evidence documenting visits by mentors from the local district hospital to clinics was found. In term of accessibility, the mean number of patients newly initiated on ART per month in the HCs increased significantly, from 77.8/month (SD=22.7) to 93.9/month (SD=20.9) (t test (df=38), p=0.025). A small minority of patients was enrolled in late stages of HIV, with only 15% of the patient cohort having CD4 counts of less than 100 cell /μL at initiation on ART. The baseline median CD4 cell count was 267.5 cells /μL in the cohort as a whole. With respect to quality of care, only 8.8% of patients in the cohort had respected all appointments over a mean follow up period of 17.2 months; and although follow up CD4 counts had been performed on the majority of patients (80%), it was done after a mean of 8.5 months(SD=2.7) on ART, and only a quarter (24.7%) had been tested by 6 months (as stipulated by guidelines). From central ART program data, a small but significant increase of patients on 2nd line drugs was observed after implementation of task shifting (from 1.98% to 3.00%, 2=13.26,p<0.001), although the meaning of this shift is not entirely clear.The median weight gain was 1 kg and median CD4 increase was 89.5 cells /μL in the cohort after 6 months of receiving task shifted care and treatment. These increases were statistically significant for both male and female patients (Wilcoxon signed rank test, p<0.001). With regard to loss to follow up, only three of the 170 patients in the cohort followed up by nurses had been lost to follow-up after a mean of 17.2 months on treatment. The routine data showed a decrease of patients lost to follow up, from 7.0% in the pre-task shifting period to 2.5% in the post-task shifting period. In general, the mortality rate was slightly lower in the post-task shifting period than in the pre-task shifting (5.5% vs 6.9% respectively), although this was not statistically significant (2=2.4, df=1, p=0.1209).This study indicates that, after over one year of implementation of task shifting, task shifting enabled the transfer of required capacity to a relatively high number of nurses. In an already well established programme, task shifting achieved moderate improvements in uptake (access) to ART, significant reductions in loss to follow up, and good clinical outcomes. However,evaluation of process quality highlighted some concerns with respect to adherence to testing guidelines on the part of providers and follow up visits on the part of patients. Improvements in processes of monitoring and follow up are imperative for optimal mid-term and long-term task shifting in the ART program.

Les enfants infectés par le VIH en Afrique subsaharienne sont exposés à un risque de malnutrition élevé au cours de leur vie. Or, les données sur la nutrition chez ces enfants sont encore limitées en Afrique de l’Ouest. L’objectif global de cette thèse est d’étudier la relation entre nutrition et infection par le VIH, chez les enfants infectés vivant en Afrique de l’Ouest. Plus spécifiquement, il s’agit d’estimer la prévalence de la malnutrition, de décrire l’évolution de la croissance après l’initiation du traitement antirétroviral, et d’évaluer des interventions nutritionnelles à intégrer au sein de la prise en charge pédiatrique du VIH. Les principaux résultats montrent une prévalence élevée de la malnutrition chez ces enfants, proche de 50 % avant la mise sous traitement antirétroviral. L’initiation du traitement a des effets positifs sur la croissance, d’autant plus important que l’initiation se fait de façon précoce. Un déficit pondéral est plus facilement corrigeable qu’un déficit statural, mais une part non négligeable d’enfants continue d’être malnutrie même après deux ans de traitement. En complément du traitement antirétroviral, des interventions de soutien nutritionnel sont donc nécessaires pour lutter contre la malnutrition chez ces enfants. Celles évaluées sont efficaces pour ceux malnutris aigues, mais pas pour ceux avec une malnutrition chronique. De plus, la croissance peut être un marqueur utile de la progression du VIH pédiatrique.L’intégration de la prise en charge nutritionnelle au sein de la prise en charge globale du VIH pédiatrique est possible en Afrique de l’Ouest, mais d’autres études et des actions de plaidoyer sont à développer pour l’adapter au mieux. / HIV-infected children in sub-Saharan Africa are exposed to high risk of malnutrition duringtheir life. However, data on the nutrition of HIV-infected children are still limited in West Africa.Thus, the main objective of this thesis is to better investigate the link between nutrition and HIVinfection among HIV-infected children in West Africa. More specifically, it is aimed to estimate theprevalence of malnutrition, to describe growth evolution after antiretroviral treatment initiation, andto assess proposed nutritional interventions to integrate to pediatric HIV care. The main results showa high prevalence of malnutrition among these children, around 50% before antiretroviral treatmentinitiation. This initiation had positive effects on growth evolution; all the more important whenantiretroviral treatment is early initiated. Weight deficiency is easier to recover than heightdeficiency, but a substantial part of children stay malnourished even after two years of treatment. Inaddition to antiretroviral treatment, nutritional support interventions are needed to fight againstmalnutrition among these children. Those assessed were efficient for acute malnourished children,but not for those with chronic malnutrition. Furthermore, growth could be a useful marker of HIVprogression. Integration of nutritional care into global pediatric HIV care is possible in West Africa,but further studies and advocacy work have to be developed to better adapt it.

L’objectif de cette thèse était d’étudier les associations potentielles entre les traitements antirétroviraux reçus par les femmes enceintes infectées par le VIH et les complications pouvant survenir au cours de la grossesse ou être diagnostiquées dans la période néonatale. Ce travail est issu en majeure partie des données de l’Enquête Périnatale Française (ANRS-EPF), cohorte nationale multicentrique ayant inclus plus de 20 000 couples mères-enfants depuis 1986. Actuellement, presque toutes les femmes sont traitées par combinaisons antirétrovirales puissantes (cART ; 98% en 2013) et le taux de transmission est inférieur à 1% : 0.6% (IC95% : 0.4%-0.8% pour la période 2005-2013). La première partie portait sur le risque d’accouchement prématuré dont le taux a augmenté significativement entre la période 1990-1993 et 2005-2009, passant de 9.2% à 14.3%. Le risque d’accouchement prématuré était significativement associé au traitement par cART, par rapport aux monothérapies et bithérapies d’INTI, et au traitement débuté avant la conception par rapport aux traitements débutés en cours de grossesse. La survenue d’une cytolyse hépatique était fréquente (17%), et était liée à la fois à la prématurité, et au type de traitement, plus fréquentes avec les IP qu’avec les inhibiteurs non nucléosidiques de la transcriptase inverse. La perturbation du bilan hépatique pourrait être un facteur intermédiaire dans la relation entre traitements et accouchement prématuré. La seconde partie portait sur les malformations congénitales. D’une part, elle a permis de mettre en évidence une association entre exposition à l’efavirenz au premier trimestre de grossesse et les malformations neurologiques, bien que concernant peu de cas (n=4) et n’atteignant la significativité que dans une analyse de sensibilité. Cette association incite à maintenir une vigilance chez les enfants exposés in utero à cette molécule classée tératogène par la FDA mais prescrite de plus en plus largement. D’autre part, l’exposition au premier trimestre à la zidovudine était associée à la survenue de malformations cardiaques. La troisième partie a complété cette étude par une analyse de la fonction cardiaque, des modifications infracliniques de la contractilité et de l’épaisseur des parois du ventricule gauche ont été mises en évidence chez les enfants exposés in utero à une combinaison de traitement contenant la zidovudine et la lamivudine. Ces résultats ne remettent pas en question l’efficacité majeure des traitements antirétroviraux pour la prévention de la transmission de la mère à l’enfant du VIH, mais incitent à la poursuite d’une surveillance épidémiologique des effets indésirables potentiels, de manière à optimiser les prescriptions pour un meilleur rapport bénéfice/risque. / Our objective was to study potential associations between antiretroviral treatment and obstetrical or neonatal complications in a population of HIV-positive pregnant women. Most of the analyses were conducted with data from the French Perinatal Cohort (ANRS-EPF), an ongoing multicenter national cohort with more than 20 000 mother-infant pairs included since 1986. In the recent years, most women receive combination antiretroviral therapies (cART ; 98% en 2013) and the trasnsmission rate is consistently under 1% : 0.6% (IC95% : 0.4%-0.8% for 2005-2013). Risk of preterm birth was significantly associated with cART, when compared to NRTI monotherapy or dual therapy, and with timing of treatment, higher for women treated at conception than for those initiating treatment during pregnancy. The occurrence of liver enzyme elevation was frequent (17%), and was associated both with preterm birth and with PI-based treatment, when compared to NNRTIs. LEE could be an intermediate factor between cART and preterm birth. The second part of this work was a study of congenital birth defect in the cohort, and showed an association between first trimester-exposure to efavirenz and neurological defects, but this concerned small numbers (n=4), and reached significance only in a sensitivity analysis. This association encourages us to maintain awareness concerning this molecule, considered teratogenic by the FDA but more and more largely prescribed. We also reported an association between first-trimester exposure to zidovudine and congenital heart defects. In a third part, we studied heart function, differences in contractility and septum thickness of the left ventricle was found, among girls exposed to a combination containing zidovudine and lamivudineThese results do not question the great progress of antiretroviral treatment in the prevention of mother-to-child transmission, but they encourage us to continue epidemiologic surveillance of potential side effects, in order to optimize prescriptions for an improved benefit/risk ratio.