Magister Public Health - MPH / The aim of the study is to explore the barriers associated with low VCT uptake by the TB patients attending primary health care clinics within the Buffalo City municipality. The study population was drawn from TB patients attending the primary health care facilities in Buffalo city municipality in the Eastern Cape Province. Eight participants were purposively selected to include those who had accepted VCT as well as those who did not.

Purpose: The purpose of this study is to assess risk factors associated with TB co-infection in HIV/AIDS patients taking antiretroviral therapy (ART). Methodology: An observational, analytic, case-control and quantitative study was conducted on a randomly selected 367 HIV and AIDS patients of whom 92 of them were TB co-infected. Data collection was done by using self-structured questionnaire. Result: In this study, educational status, waste disposal system, monthly income, contact history with a patient of active tuberculosis or presence of a family member with active tuberculosis, drug adherence, knowledge on tuberculosis prevention and history of exposure to substance were factors independently associated with the occurrence of active tuberculosis among HIV and Aids patients taking ART. Conclusion: The findings highlight the need for on-going educational, informational and other interventions to address the risk factors of tuberculosis in HIV and Aids patients in order to decrease the rate of TB co-infection / Health Studies / M.A. Public Health

PhD (Microbiology) / Department of Microbiology / Diarrhoea is still a major problem worldwide. Enteric pathogens such as Enteroaggregative E. coli (EAEC), Enteropathogenic E. coli (EPEC) and Enterotoxigenic E. coli (ETEC) have been reported to cause diarrhoea in children under the age of 5 years. The incidences of these pathogens are due to factors such as poor water quality, sanitation and hygiene practices. Infections with these pathogens result in diarrhoea and have been reported to result in severe disease outcomes more especially in children under 2 years of age. EPEC infections have been well studied using in vitro analyses, with studies highlighting the adherence traits, proteins and virulence genes involved in pathogenesis and inflammatory responses. EPEC is characterized by localized adherence with microcolony formation at the site of infection. In vivo studies have reported on human EPEC infection. However, the current animal models have not been able to replicate clinical outcomes (such as diarrhoea and weigh loss) of EPEC infection similar to humans. Therefore, there is still a need for a suitable small animal model that mimic clinical outcomes of human EPEC infections in vivo. Children living in poor environmental conditions are more susceptible to diarrhoeal pathogens. Furthermore, the incidences of children being exposed to co-infections (more than one pathogen at the same time) is relatively high. The EAEC/EPEC (A/P) and EPEC/ETEC (P/T) co-infections have been increasingly detected in children with and without diarrhoea. It has been suggested that patients infected with these co-infections might result in severe disease outcome than those infected with single pathogens. Pathogens are constantly evolving and the microbe-microbe interaction in the host can result in these pathogens competing for the same niche and thus result in increased virulence. Interaction of co-infections can lead to increased inflammatory responses thus affecting the infected host. The first objective of this study was to develop an EPEC murine model using weaned C57BL/6 mice that have been pretreated with antibiotic cocktail. Mice were orally infected with wild-type (WT) typical EPEC, bfp- and escN mutant strains. The WT had transient weight loss and wet stools with mucous; and the bfp- infected mice also had transient weight loss and bloody stool appearance. Increase in inflammatory biomarkers MPO, LCN-2, CRP, IL-6 and SAA were observed in the WT and bfp- infected mice. The mice infected with escN mutant did not exhibit any weight changes and the stools were similar to the uninfected mice. Furthermore, no inflammatory biomarkers were observed in mice infected with the escN mutant. Metabolic perturbations were observed in WT EPEC infected mice at day 3 post infection with the TCA cycle metabolites (reduced succinate, citrate, fumarate, cis-aconitate) being excreted at lower quantities indicating that the energy production in the infected mice was greatly affected. The second objective of this study was to determine the interaction between the P/T coinfections using in vitro and in vivo analyses. In vitro, human colorectal tumour 8 (HCT-8) cells were infected with single strains of ETEC, EPEC and both the pathogens and incubated for 3 hours. After infection the cells were analysed for bacterial adherence using real-time PCR. The single strains adhered at the same rate similar to the P/T coinfected cells. IL-8, as a marker of inflammatory response, was measured using ELISA. The results indicated that the P/T co-infected cells had a significant increase in IL-8 response higher than the single infections. The P/T co-infections were further analysed in vivo using the EPEC murine model developed in this study. Interestingly, mice infected with P/T co-infections developed severe diarrhoea accompanied with significant increased weight loss and some mice died during the 3-day infection period. The inflammatory responses MPO, LCN-2 and SAA were higher in the co-infected mice indicating a synergistic effect. The bfp and eltA virulence genes were significantly increased in the P/T co-infections. The third objective of this study was to determine the interaction between A/P coinfections using in vitro and in vivo analyses. HeLa cells and HCT-8 cells were infected with EAEC, EPEC and both the pathogens at the same time in order to determine adherence and inflammatory responses. EAEC adherence was higher than EPEC and A/P co-infections adherence. A/P co-infections did not have increased IL-8 response in HCT-8 cells when compared to EAEC alone. The virulence genes involved in EPEC adherence and Type 3 Secretion System (bfp, eae, tir, ler, per, espB and espA) were significantly reduced in A/P co-infected cells. An interesting adherence trait was observed between the A/P co-infections in HeLA cells, EAEC was found to adhere around EPEC altering the localized adherence pattern. The A/P co-infections were further analysed using the EPEC murine model developed in this study. The A/P infected mice had diminished weight changes and EAEC shedding was enhanced when EPEC was present. Faecal inflammatory biomarkers MPO and LCN-2 in A/P infected mice did not have any additive effect. The findings of this study contributed significantly to the knowledge of human EPEC infection in weaned C57BL/6 mice, highlighting clinical outcomes, inflammatory responses and metabolic perturbations. Furthermore, this study also highlighted the interaction of P/T and A/P co-infections using in vitro and in vivo analyses in order to determine the disease severity and outcomes. It was observed in this study that coinfections can result in either synergistic or antagonistic effects. Further studies are therefore, required in order to understand the underlying mechanisms that are involved during co-infections and this can further assist in the development of therapeutic interventions. / NRF

Einleitung: Eimeria (E.) spp. und Toxoplasma (T.) gondii sind intrazelluläre Protozoen aus dem Phylum Apicomplexa und stellen bedeutende Pathogene dar. Infektionen mit Eimeria spp. sind Auslöser der Kokzidiose, welche eine der ökonomisch bedeutsamsten Erkrankungen in der Geflügelproduktion darstellt. Die Toxoplasmose des Huhnes hingegen verläuft in der Regel subklinisch. Da beide Parasiten, Eimeria spp. und Toxoplasma gondii, weltweit verbreitet sind, können natürliche Koinfektionen auftreten. Prävalenzstudien mit Hilfe molekularer und serologischer Untersuchungsmethoden sind geeignet, um die Vorkommen, Verbreitung, und Speziesidentität von einzelnen Apicomplexa zu untersuchen, was zu besserer Diagnose, Kontrolle, und Bestandsüberwachung beiträgt. Trotz vorliegender Hinweise, dass bei Koinfektionen zu einer Interaktion zwischen Eimeria und Toxoplasma kommt, existieren Erkenntnislücken hinsichtlich der Häufigkeit und der Bedeutung von natürlichen Koinfektionen des Huhnes unter Feldbedingungen, insbesondere mit Augenmerk auf verschiedene Nutzungstypen, Produktions- und Haltungsbedingungen. Ziele der Untersuchungen: Die Ziele der Untersuchungen waren die Erhebung der Prävalenzen von verschiedenen Eimeria spp. und von T. gondii bei Hühnern, sowie die Häufigkeit ihres Auftretens als Einzel- und Koinfektionen unter Feldbedingungen unter Berücksichtigung verschiedener Nutzungstypen und Haltungsbedingungen in Griechenland. Tiere, Material und Methoden: Die Auswahl der für diese Feldstudie untersuchten Hühnerbestände erfolgte auf Basis der Anzahl von kommerziellen Hühnerhaltungen in drei Hauptregionen Griechenlands. Nach offiziellen Angaben des griechischen Ministeriums für Ländliche Entwickung und Lebensmittel konzentriert sich die griechische Geflügelindustrie hauptsächlich auf Epirus (im Nordwesten), Zentralmazedonien, und Zentralgriechenland. Die Probenentnahme erfolgte in kommerziellen und Hinterhofhaltungen, wobei die Probenanzahl proportional zur Anzahl entsprechender Haltungsformen in der jeweiligen Region gewählt wurde (n = 50). Es wurden Legehennen (n = 21), langsam wachsende Broiler (n = 15) und Hinterhofhühner beprobt (n = 14), welche verschiedenen Produktions- und Haltungsbedingungen zugeordnet waren (Haltung in ausgestalteten Käfigen, Bodenhaltung mit Einstreu und Biohaltung). Konventionelle intensive Broileraufzuchten wurden nicht berücksichtigt. Für die Erhebung der Häufigkeiten von Eimeria spp.-Infektionen wurden aus allen ausgewählten Beständen Einstreuproben gesammelt (n = 756). Die Broilerherden wurden zu einem Zeitpunkt bei der Schlachtung erneut beprobt, indem die Därme der Einzeltiere gesammelt wurden (n = 162). Die Einstreu-/Darminhaltsproben wurden quantitativ mittels McMaster-Verfahrens auf den Eimeria spp.-Oozystengehalt (als Oozysten pro Gramm Kot, OPG) untersucht. Die Eimeria-Oozysten aus positiven Proben wurden für weitere molekulare Analysen aufgereinigt und aufbewahrt. Die Eimeria-Speziesbestimmung erfolgte durch spezies-spezifische DNA-Nachweise, und die Quantifizierung der einzelnen Arten erfolgte semiquantitativ. Um die Häufigkeit von T. gondii-Infektionen zu bestimmen, wurden Blutproben (n = 1,021) von Einzeltieren zur serologischen Untersuchung mittels TgSAG1 ELISA entnommen, zeitgleich zur o. g. Beprobung der Bestände für die Einstreuproben. Für Hinterhofhaltungen mit Tieren variablen Alters wurden ältere Tiere bevorzugt beprobt, und in kommerziellen Legehennenhaltungen wurden die Tiere im Alter von ca. 10 Monaten beprobt. In beiden Fällen wurden von T. gondii-seropositiven Tieren bei der Schlachtung die Herzen gewonnen (n = 322). In Broilerhaltungen wurden ebenfalls Blutproben und das Herz während des Schlachtungsprozesses zum T. gondii-Nachweis entnommen. Das Herzgewebe wurde in einer magnetic capture Polymerasekettenreaktion (mc-PCR) sowie einem Mausbioassay auf Präsenz und Genotyp einzelner Isolate untersucht. Parallel zu den Laboruntersuchungen wurden Daten zu Haltungsbedingungen, Biosicherheitsmaβnahmen, Lage, Bestandsgröβe, Krankheitsgeschichte etc. mittels standardisierter Fragebögen erfasst, um potenzielle Risikofaktoren für Eimerien- und/oder T. gondii-Infektionen zu bestimmen. Die Datenanalyse erfolgte durch Multilevel-Modelling (generalized linear mixed modelling fit by maximum likelihood (Laplace approximation)) mittels dem R-Programm (https://www.r-project.org, Version 4.0.2, Paket lme4), dem Kruskal-Wallis-Test und bivariaten Spearman-Korrelationen im PSPP-Prgramm (GNU PSPP 1.3.0). Ergebnisse: Insgesamt lag die Nachweisrate für Eimeria spp.-Infektionen bei 85,7 %. Alle sieben Hühnereimerienspezies wurden identifiziert, wobei E. acervulina (79,3 %) und E. tenella (65,5 %) die höchste Prävalenz aufwiesen. Infektionen mit mehreren Eimeria-Arten (79,3 %) waren deutlich häufiger anzutreffen als Einzelinfektionen (20,7 %). Als Risikofaktoren wurden Herdengröβe, Art des Auslaufs und Produktionssystem identifiziert. Zwischen respiratorischen Erkrankungen und mittlerer OPG wurde in Broilerhaltungen eine sehr starke Korrelation beobachtet (P < 0.001). Biohaltungen zeigten eine höhere Prävalenz von E. tenella (P = 0,023). Nutzung einer bewachsenen Auslauffläche war stark mit der Präsenz von E. brunetti korreliert (P < 0,001). Die T. gondii-Seroprävalenz über alle untersuchten Tiere betrug 9,5 %. Dabei testeten 41,2 % aller Hinterhofhühner seropositive. In 70 % der Bio- und Freilaufhaltungen wurde mindestens ein Tier seropositiv getestet. Es wurden keine T. gondii-seropositiven Broiler gefunden, obwohl mit Hilfe der mc-PCR positive DNA-Nachweise erfolgten. Dies belegt die hohe Sensitivität der mc-PCR und ihre potenzielle Eignung für die Detektion früher Infektionen bei Hühnern. Die T. gondii-Isolate, welche im Mausbioassay gewonnen wurden, wurden als Typ II (ToxoDB#3) genotypisiert, was durch Mikrosatellitenanalyse bestätigt wurde. Für T. gondii-Infektionen wurden Produktionssystem und Futterautomatisierung als Risikofaktoren identifiziert, wobei Auslaufbeweidung die Wahrscheinlichkeit für T. gondii-Infektionen erhöht. Die Gegenwart von Katzen stellte hingegen keinen nachweisbaren Risikofaktor für T. gondii-Seropositivität auf Bestands- oder Einzeltierniveau dar. Koinfektionen mit beiden Protozoen wurden in 87% aller untersuchten Hühnerbestände nachgewiesen, wobei Hinterhof-, Bio-, und Freilandhaltungen am häufigsten betroffen waren. In den moisten Fällen von Koinfektionen wurde E. acervulina nachgewiesen. Schlussfolgerungen: Die Prävalenz sowohl von Eimeria spp. als auch von T. gondii war generell hoch und auf einem vergleichbaren Niveau mit den Ergebnissen früherer Studien in anderen Ländern. Faktoren wie Produktionssystem, Haltungs- und Managementbedingungen sind mit dem Risiko von Mono- oder Koinfektionen verbunden. Die gewonnenen Erkenntisse erlauben die gezielte Planung zukünftiger Studien hinsichtlich sich ändernder Haltungsbedingungen, z. B. dem Trend zur verstärkten Bio- und tierfreundlichen Hühnerhaltung uns dem Einsatz langsam wachsender Rassen. Es besteht auch in Griechenland ein Bedarf an nachhaltiger Kontrolle von Kokzidieninfektionen, einschlieβlich der Minimierung zoonotischer Erreger wie T. gondii in Nutztierbeständen. Die verwendeten serologischen und molekularen Methoden können nach den Studienerkenntnisse ausserdem zur frühzeitigen Überwachung von T. gondii–Infektionen in Hühnerbeständen beitragen.:Chapter 1 - Introduction Chapter 2 - Literature Review 2.1 Eimeria spp. 2.1.1 Life cycle 2.1.2 Diagnosis and control of Coccidiosis in chickens 2.1.3 Economic Impact of Coccidiosis 2.1.4 Prevalence of Eimeria spp. in chicken farms 2.1.5 Data of chicken coccidiosis from Greece 2.2 Toxoplasma gondii 2.2.1 Life cycle 2.2.2 Toxoplasmosis and Zoonotic Importance 2.2.3 Prevalence in poultry and risk factors 2.2.4 T. gondii data from Greece 2.3 Co-existence of Eimeria spp. and Toxoplasma gondii in chickens Chapter 3 - Overview of own scientific work 3.1 Aims 3.2 Presentation of own scientific work: Publications 3.2.1 Publication 1: Prevalence and molecular detection of Eimeria species in different types of poultry in Greece and associated risk factors. 3.2.2 Publication 2: Prevalence and molecular characterization of Toxoplasma gondii in different types of poultry in Greece, associated risk factors and co-existence with Eimeria spp. Chapter 4 - Overreaching Discussion Chapter 5 - Conclusions Chapter 6 - Summary Chapter 7 - Zusammenfassung Chapter 8 - References Acknowledgements / Introduction: Eimeria spp. and Toxoplasma gondii are intracellular Apicomplexan protozoa and represent important pathogens for chickens. Coccidiosis, caused by Eimeria spp. is one of the most notable diseases in chickens having a high economic impact on the poultry industry worldwide, while toxoplasmosis is usually subclinical in these hosts. As both Eimeria spp and Toxoplasma gondii have a broad worldwide distribution, natural co-infections in chickens can occur. Prevalence studies using molecular and serological techniques have proven a very useful approach to study the diversity and distribution of these parasites’ mono-infections, further contributing to more efficient diagnosis, control and monitoring. Despite existing indications that these two parasites interact when the host is infected simultaneously, there are still knowledge gaps regarding the frequency and impact of naturally occurring co-infections under field conditions, particularly in different types of poultry, production and housing systems. Objective: Determination of the level of occurrence of Eimeria spp. and Toxoplasma gondii mono- and co-infections under field conditions, in different types of chickens and farm profiles in Greece. Animals, materials and methods: Selection of poultry operations was based on the number of commercial farms in three major Greek regions, as poultry farms in Greece are highly concentrated in Epirus (in North-Western Greece), Central Macedonia, and Central Greece, based on the data from the Hellenic Ministry of Rural Development and Food. Sampling from both commercial operations and backyard farms was conducted proportionately to their frequency (n=50) and type of flocks included in the study were layers (n=21), slow-growing broilers (n=15) and backyard chickens (n=14), under different production and housing systems (enriched cages, floor-housed in litter, free-range and organic systems). Conventional intensively reared broilers were not included in the study. To record Eimeria spp. occurrence, faecal samples were collected from the litter of the chicken housing (n=756). Broiler flocks were followed up to the slaughterhouse for a second sampling where the whole gut was collected (n=162). Samples were quantitatively examined by a modified McMaster technique to calculate oocysts per gram (OPG) of faeces, followed by collection and purification of the oocysts for further molecular analysis. Species identification was performed by multiple PCR assays using species-specific primers and PCR bands were categorized by intensity semiquantitavely. To record Toxoplasma gondii infections, simultaneously to faecal sampling, blood samples (n=1,021) were also collected from individual animals for serological T. gondii detection via TgSAG1 ELISA. In our sampled broiler flocks, animals were sampled at slaughter, where blood samples and the heart were collected for T. gondii detection. In backyard flocks, blood samples were taken from the older animals and in layers from individual animals (at the age of approximately 10 months). Toxoplasma positive animals were followed up to slaughter to collect heart tissue (n=322), further processed for bioassay in KO mice and mc-PCR in order to characterize Toxoplasma gondii isolates. In parallel, potential risk factors and impact regarding mono- and co-infection of both parasites were investigated through an obtained questionnaire containing additional information about farm management, biosecurity status, location, production rate and diseases history. For the data analysis a multilevel-modelling (generalized linear mixed modelling fit by maximum likelihood (Laplace approximation)) was performed using R (https://www.r-project.org) version 4.0.2, by applying the package lme4, as well as Kruskal-Wallis tests and bivariate correlations in PSPP statistical program (GNU PSPP 1.3.0). Results: Overall Eimeria spp. positivity level was 85.7%. All seven Eimeria species were identified with E. acervulina (79.3%) and E. tenella (65.5%) being the most prevalent ones. Mixed infections (79.3%) were more common than single-species (20.7%) Significant identified risk factors were flock size, type of outdoor area, and production system. A very strong correlation (p < 0.001) was found between the presence of respiratory disease and the average OPG level in broiler farms. Organic flocks showed higher prevalence of E. tenella (p = 0.023), while presence of vegetation at the outdoor area correlated strongly with E. brunetti (p < 0.001). Toxoplasma gondii seroprevalence was 9.5%. 41.2% of the backyard chickens sampled were seropositive and 70% of the organic and free-range layer farms had at least one Toxoplasma gondii seropositive hen. No serologically positive broilers were found, however mc-PCR revealed positive samples, stressing out the high sensitivity and potential contribution of this method in early detection of the parasite. Toxoplasma gondii isolates obtained by mouse bioassay were genotyped and found to belong to type II (ToxoDB#3) as confirmed also by microsatellite typing. The most significant risk factors were production system and feeding system automation, with free-grazing practices increasing the likelihood for Toxoplasma infections. Presence of cats showed no association with Toxoplasma gondii seropositivity on a farm and individual animal level. The two protozoan parasites were found to co-exist in 87% of the studied poultry operations, with backyard, organic and free-range farms showing the highest occurrence. E. acervulina was the species identified in most of the co-existence cases. Conclusions: Prevalence of both Eimeria spp. and Toxoplasma gondii is overall high and comparable with findings from similar studies in other countries. Production system, husbandry and management conditions relate to increased risk of both mono- and co-infections, giving useful insights and indications for future studies, particularly in the light of increasing application of slow-growing, organic and “higher welfare” poultry farming practices. It could be shown that also in Greece there is a need for sustainable coccidiosis control, both in terms of Eimeria spp. infection control and of a minimization of T. gondii introduction to operations. A combination of the serological and molecular methods used in this study can contribute to earlier and more accurate diagnosis of Toxoplasma gondii infections in chickens, which is a crucial and sensitive subject for safeguarding transmission to humans.:Chapter 1 - Introduction Chapter 2 - Literature Review 2.1 Eimeria spp. 2.1.1 Life cycle 2.1.2 Diagnosis and control of Coccidiosis in chickens 2.1.3 Economic Impact of Coccidiosis 2.1.4 Prevalence of Eimeria spp. in chicken farms 2.1.5 Data of chicken coccidiosis from Greece 2.2 Toxoplasma gondii 2.2.1 Life cycle 2.2.2 Toxoplasmosis and Zoonotic Importance 2.2.3 Prevalence in poultry and risk factors 2.2.4 T. gondii data from Greece 2.3 Co-existence of Eimeria spp. and Toxoplasma gondii in chickens Chapter 3 - Overview of own scientific work 3.1 Aims 3.2 Presentation of own scientific work: Publications 3.2.1 Publication 1: Prevalence and molecular detection of Eimeria species in different types of poultry in Greece and associated risk factors. 3.2.2 Publication 2: Prevalence and molecular characterization of Toxoplasma gondii in different types of poultry in Greece, associated risk factors and co-existence with Eimeria spp. Chapter 4 - Overreaching Discussion Chapter 5 - Conclusions Chapter 6 - Summary Chapter 7 - Zusammenfassung Chapter 8 - References Acknowledgements

Thesis (Ph.D. (Nursing Science)) -- University of Limpopo, 2017 / The aim of this study was to develop a model to ensure the integration of Tuberculosis (TB) and Human Immune Deficiency Virus (HIV) services in the Primary Health Care (PHC) facilities of Limpopo Province. An explanatory sequential mixed method was used in this study to develop a model for ensuring the integration of TB and HIV services in the PHC facilities of the Limpopo Province. The researcher collected quantitative data followed by qualitative data. Quantitative data was collected through administration of questionnaires to 450 PHC nurses in the five districts of Limpopo Province. The qualitative data was collected by conducting focus group discussions to five groups of Community Home Based Carers (CHBCs) and five groups of TB/HIV co-infected patients in the five districts of Limpopo Province. Audiotape and field notes were used to capture verbal and non-verbal cues. The Statistical Package for Social Sciences (SPSS) computer programme version 22.0 was used for capturing and analysis of the quantitative data. Content analysis was used to analyse the qualitative data from the CHBCs and the TB and HIV co-infected patients’ focus group discussions. The study revealed lack of knowledge and skills on TB and HIV management due to insufficient training of PHC nurses about TB and HIV management. Staff shortage of PHC nurses in the facilities was also indicated by PHC nurses. Furthermore, TB and HIV coinfected patients are faced with challenges in the PHC facilities and in the community. Challenges that are faced by CHBCs and the TB and HIV co-infected patients include negative attitudes of some clinic staff members towards them. The patients’ families also have some negative attitudes towards the CHBCs as they leave the patients to them without assisting them in the caring duties. The community members also has negative attitudes as they do not accept the CHBCs in their homes to support the patients. Based on the results, a model was developed to ensure the integration of TB and HIV services. The model was validated by PHC nurses and the experts in research and model development. The validation results showed that the model was clear and simple to be used in the PHC facilities for integration of TB and HIV services. The study recommends that the model should be used by PHC facilities for integration of TB and HIV services. The PHC nurses should attend TB and HIV capacity-building courses.

Liver disease is now a leading cause of non-AIDS related morbidity and mortality in people living with HIV (PLWH). The present study investigated the interplay between adverse lifestyle factors that are prevalent in PLWH, biological mediators of liver pathogenesis, and a non-invasive measure of liver fibrosis (FIB-4 index) in HIV mono- and HIV/HCV co-infected individuals. The results of this investigation in the Miami Adult Studies of HIV (MASH) cohort show that the odds of liver fibrosis progression significantly increased over two years for HIV mono-infected participants who drank alcohol hazardously (OR 3.038, P=0.048), and had BMI ≥ 28kg/m2 (OR 2.934, P=0.027). Cocaine use reduced the odds of advancing one stage of liver fibrosis (OR 0.228, P=0.038), but an interaction between high BMI and cocaine use slightly raised the odds by 4.8% of liver fibrosis progression (P=0.072). HIV/HCV co-infected participants showed interactions between cocaine use and high BMI with increased FIB-4 stage (OR 4.985, P= 0.034), however no lifestyle factors could independently predict FIB-4 stage in this group. Biological mediators previously associated with liver pathogenesis were associated with higher FIB-4 index over 2 years in a subset of (n=65) HIV mono-infected participants. Plasma measures of oxidative stress (% oxidized glutathione: OR 4.342, P= 0.046), hepatocyte-specific apoptosis (Cytokeratin-18 (CK-18): OR 1.008, P=0.021), and microbial endotoxin (lipopolysaccharide (LPS): OR 1.098, P= 0.097) were associated with having higher odds of progressing at least one stage of FIB-4 over 2 years. The same biological mediators were also associated with liver fibrosis within HIV infected people who also had a harmful lifestyle characteristic. FIB-4 index was significantly associated with % oxidized glutathione in obese subjects (β=0.563, P=0.018), TGF-β1 in cocaine users (β=0.858, P=0.027), and CK-18 in HIV infected individuals without any adverse lifestyle factors (β=0.435, P=0.015). Taken together, the findings of these studies describe interrelationships between HIV disease status, lifestyle, and biological mediators of liver fibrosis. The results show interactions between lifestyle conditions and the mediators of liver fibrosis may account for higher rates of liver disease in HIV infection. Research is warranted to develop personalized therapeutics for PLWH to curb the burden of liver disease.