Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2008. / Women globally, and especially in sub Saharan Africa, are disproportionately affected by HIV and AIDS. Factors driving the HIV and AIDS pandemics include the oppression of women and gender inequality. Despite an intensified focus on women and girls in an attempt to reduce vulnerability to HIV little real progress has been made. This is in part because the sophisticated analysis of risk, vulnerability and our understanding of the pandemics is not match by equally sophisticated responses to prevention, care, treatment and support. Power over / male domination, evident at every level of society, fuels the pandemics, and makes women vulnerable. Using feminist understandings of power and domination this thesis explores the notion of subverting power. Through a series of case studies the notion of negative and positive power is explored; positive power includes power with, power to and power within. Examples of women’s resistance individually and collectively using the different types of power are highlighted. The thesis demonstrates that that women are not powerless and can and do affect change in their lives in all sites of struggle, that is can increase bodily autonomy, improve intimate relationships and challenge inequality in the households and community. Based on the learnings from the case study a theoretical model that addressed power as problem and solution in the context of HIV and AIDS is presented.

The need for a family therapeutic counselling programme in the management of HIV/AIDS was established by the researcher in 2001 (den Hollander 2001). The focus of this study was to develop the training programme model in family therapeutic counselling for church leaders and lay counsellors. This was accomplished using a variety of samples and research instruments, by firstly exploring the issues and problems facing people and families living with HIV/AIDS and then how best churches could respond as faith-based community organizations. At a theoretical level, this study sought to compare the paradigms of contextual and narrative family therapy with the theory and practice of social work and practical narrative theology, in order to integrate these paradigms into an incorporated response to the HIV/AIDS pandemic. The main research methodology was the Intervention Research Model as adapted from De Vos (2001). This model consists of six phases, consisting of problem analysis and project planning, information gathering and synthesis, design, early development and pilot testing, evaluation and advanced development, and dissemination of the training model. During the analysis phase an extensive literature research, as well as several field studies, both quantitative and qualitative were conducted. During the development phase, three pilot studies were designed and performed, in attempt to accommodate the context specific problems of different families and communities. The results of these two phases indicated a need for pastoral training in family therapeutic counselling, specifically in the areas of mental health, trauma and bereavement and child participation. Importantly, the need to intervene meaningfully to alleviate structural problems such as poverty and food insecurity were clearly indicated, with the study recommendation being for active networking across all stakeholders so that therapeutic counselling may work in tandem with these community based efforts. Recommendations in respect of offering such training are to provide a comprehensive structure of training, supervision and counselling practice. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2009.

Estimation of current levels of human immunodeficiency virus (HIV) incidence is essential for monitoring the impact of an epidemic, determining public health priorities, assessing the impact of interventions and for planning purposes. However, there is often insufficient data on incidence as compared to prevalence. A direct approach is to estimate incidence from longitudinal cohort studies. Although this approach can provide direct and unbiased measure of incidence for settings where the study is conducted, it is often too expensive and time consuming. An alternative approach is to estimate incidence from cross sectional survey using biomarkers that distinguish between recent and non-recent/longstanding infections. The original biomarker based approach proposes the detection of HIV-1 p24 antigen in the pre-seroconversion period to identify persons with acute infection for estimating HIV incidence. However, this approach requires large sample sizes in order to obtain reliable estimates of HIV incidence because the duration of antigenemia before antibody detection is short, about 22.5 days. Subsequently, another method that involves dual antibody testing system was developed. In stage one, a sensitive test is used to diagnose HIV infection and a less sensitive test such is used in the second stage to distinguish between long standing infections and recent infections among those who tested positive for HIV in stage one. The question is: how do we combine this data with other relevant information, such as the period an individual takes from being undetectable by a less sensitive test to being detectable, to estimate incidence? The main objective of this thesis is therefore to develop likelihood based method that can be used to estimate HIV incidence when data is derived from cross sectional surveys and the disease classification is achieved by combining two biomarker or assay tests. The thesis builds on the dual antibody testing approach and extends the statistical framework that uses the multinomial distribution to derive the maximum likelihood estimators of HIV incidence for different settings. In order to improve incidence estimation, we develop a model for estimating HIV incidence that incorporate information on the previous or past prevalence and derive maximum likelihood estimators of incidence assuming incidence density is constant over a specified period. Later, we extend the method to settings where a proportion of subjects remain non-reactive to a less sensitive test long after seroconversion. Diagnostic tests used to determine recent infections are prone to errors. To address this problem, we considered a method that simultaneously makes adjustment for sensitivity and specificity. In addition, we also showed that sensitivity is similar to the proportion of subjects who eventually transit the “recent infection” state. We also relax the assumption of constant incidence density by proposing linear incidence density to accommodate settings where incidence might be declining or increasing. We extend the standard adjusted model for estimating incidence to settings where some subjects who tested positive for HIV antibodies were not tested by a less sensitive test resulting in missing outcome data. Models for the risk factors (covariates) of HIV incidence are considered in the last but one chapter. We used data from Botswana AIDS Impact (BAIS) III of 2008 to illustrate the proposed methods. The general conclusion and recommendations for future work are provided in the final chapter. / Theses (Ph.D.)-University of KwaZulu-Natal, Pietermaritzburg, 2013.

Background: Breastfeeding is known to have benefits both for maternal and child health. Some questions around the benefits and risks of breastfeeding in the presence of HIV infection still remain unclear. Aims: To study the effects of infant feeding mode by HIV-positive mothers, on maternal and child health. In addition, to assess the effect of nutritional supplementation to HIV-positive lactating mothers on nutritional and health status of mothers and their infants and on the quality of breastmilk. Methods: The study had 2 components; a prospective study to examine the impact of infant feeding mode on nutritional and health indices in mothers and their infants and within it a nested randomized controlled clinical trial to study the impact of a daily 50 g soya/peanut based supplement during breastfeeding on the above parameters. The measurements included anthropometry; body composition indicators (using both deuterium dilution and BIA); haematology and biochemical markers; as well as incidence rates of opportunistic infections and clinical disease progression. Breastmilk was analysed for both macro and micronutrients. Cervical screening was offered to all the women. Results: AFASS criteria were fulfilled by 38.7% of the formula feeding mothers. No significant differences between the formula feeding and breastfeeding groups in terms of haematological, immunological and body composition changes were seen. Breastfeeding mothers had significantly lower events with high depression scores (p=0.043). Longer duration of breastfeeding was observed to be significantly associated with a mean increase in CD4 count (74 cells/μL) and better health outcomes. The supplement made no significant impact on any maternal or child outcomes except for a limited effect on mothers with low BMI, where it was significantly associated with preventing loss of lean body mass (p=0.026). Breastfeeding infants had a significantly lower risk of diarrhoea and hospitalisation at 3 months (p=0.006 and 0.014 respectively). Both breastfeeding and longer duration of breastfeeding was significantly associated with better development scores and growth parameters. Supplementation made no impact on breastmilk composition. Of the 86 mothers who agreed for cervical screening, 27.6% had human papilloma virus infection. Conclusions: Breastfeeding is not harmful to the mother despite the presence of HIV infection. On the contrary we observed both breastfeeding and longer breastfeeding duration to be associated with better maternal and child outcomes. Mothers are still choosing formula feeding inappropriately presumably because of the availability of free formula and/or sub-optimal counseling. The new (2010) local PMTCT guidelines based on WHO recommendations should reverse this. Food insecurity was prevalent amongst 32% of our study population, highlighting the need to include sustainable and empowering solutions to encounter this problem. Less sustainable solutions such as nutritional supplementation should be targeted to the malnourished and in emergency situations. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2012.

Highly active antiretroviral therapy (HAART) is currently the only treatment that effectively reduces the morbidity and mortality of individuals infected with Human Immunodeficiency Virus-1 (HIV-1). Standard HAART regimens typically comprise 2 nucleoside reverse transcriptase inhibitors and either one non-nucleoside reverse transcriptase inhibitor or a protease inhibitor. These drugs bind to and inhibit the HIV-1 Reverse Transcriptase and Protease enzymes respectively, thereby suppressing viral replication. The nucleoside reverse transcriptase inhibitors promote mitochondrial (mt) dysfunction by strongly inhibiting mt polymerase gamma (Pol-y) and subsequently, mtDNA replication. In contrast, the non-nucleoside reverse transcriptase inhibitors, efavirenz (EFV) and nevirapine (NVP) do not inhibit Pol-y although EFV has been shown to induce mt depolarisation ( mlow) in vitro at supra-therapeutic concentrations. However, the capacity of non-nucleoside reverse transcriptase inhibitor drugs to induce mt toxicity in vivo previously remained undetermined. The objective of this study was to determine the influence of EFV and NVP on peripheral lymphocyte mt transmembrane potential (Avj/m) and apoptosis in HIV-1-infected patients treated with these non-nucleoside reverse transcriptase inhibitors. Thirty-two HIV-1-infected patients on HAART between 4 and 24 months (12 on EFV, 20 on NVP) and 16 HAART-naive HIV-1-infected patients were enrolled into this study. All participants were black South African patients. Spontaneous peripheral lymphocyte apoptosis and mlow were measured ex vivo by flow cytometry for all patients. CD4 T-helper apoptosis for the EFV and NVP cohorts was 19.38% ± 2.62% and 23.35% ± 1.51% (mean ± SEM), respectively, whereas total lymphocyte mlow was 27.25% ± 5.05% and 17.04% ± 2.98%, respectively. Both parameters for each cohort were significantly lower (P < 0.05) than that of the HAART-naive patients. The NVP cohort exhibited both a significant time dependent increase in peripheral lymphocyte ö¿mlow (P = 0.038) and correlation between Thelper apoptosis and low (P = 0.0005). These trends were not observed in the EFV cohort. This study provides evidence that both EFV and NVP induce peripheral lymphocyte ö¿ m low in HIV-1-infected patients on non-nucleoside reverse transcriptase inhibitor-based HAART, which in the case of NVP is sufficient to induce the apoptosis cascade. / Thesis (M.Med.Sci.)--University of KwaZulu-Natal, 2008.

Background and Objectives The improved uptake of antenatal Opt-out testing has been documented internationally. In South Africa little is known about the efficiency and die acceptability of Opt-out testing. This study compared VCT with Opt-out testing by measuring the efficiency (defined as uptake of testing, number of women identified as HIV positive and consultation duration of the testing approach) and the acceptability to patients and staff. Methodology We conducted a prospective, quasi-experimental equivalent time-samples clinical trial in which we enrolled a consecutive sample of women who presented at die McCord Hospital antenatal clinic from June to August 2006. The study consisted of 2 phases. During the 6 week intervention period women were offered HIV testing with the Opt-out mediod. During die 6 week control period women were offered midwife-provided VCT. Efficiency was measured in each phase, with 150 participants in the VCT arm and 150 in die Opt-out arm. Participants also completed a survey questionnaire. In depth interviews were conducted with 9 purposefully selected participants from each arm. Two focus group discussions were held with staff. The staff focus group findings were followed-up and validated by conducting in-depdi interviews with die staff members who participated in die focus groups 18 mondis later. Results The uptake of HIV testing during the VCT period was 134/150(89.3%) compared to 147/150(98.0%) in die Opt-out period (p<0.001). The percentage of women identified as being HIV positive during the VCT period was 7.33% (11/150) vs. 12.6% (19/150) during the Opt-out period (p=0.133). Time was saved as a decrease in the duration of midwife consultations from 34 min (VCT) to 26 min (Opt-out) was found with p<0.001. Qualitative analysis revealed Opt-out testing to be an acceptable way of testing. Patients found Opt-out emotionally less distressing than VCT (p<0.05). Staff reported that Opt-out decreased the burden on human resources (only one person needed to facilitate the group and shorter consultations) while it identified more women infected with HIV. Conclusion Opt-out testing is significantly more efficient and acceptable than VCT. Opt-out testing should include a group pre-test information session, adequate and ongoing post-test counselling, to be effective and acceptable. / Thesis (M. Med.)-University of KwaZulu-Natal, Durban, 2008.

This dissertation, employing an array of theoretical approaches under the rubric of Systems Thinking, explores the reality and experiences of family members that mainly provide care at home for their loved ones who live with or are directly affected by HIV & AIDS. Employing a multidisciplinary approach, the dissertation demonstrates how Systems Thinking, feminist and indigenous knowledge principles can be employed for a better understanding of the contemporary construction of family and experiences of caregivers in an HIV & AIDS context. The discussion of the dissertation is based on data analysed following in-depth interviews with fifteen caregivers of the Bhambayi community. The findings of the study reflect a significant change in the definition and practice of parenting. It was found that HIV & AIDS forces a re-definition of the concept and practice of parenting beyond the traditional boundaries of age, sex and gender. Aligned with this main finding was that parenting practices and coping strategies are largely influenced by a strong commitment to the well-being of the children as well as societal constructs. The thesis of this dissertation is that the HIV & AIDS context and associated gender and cultural stereotypes are principally responsible for a significant shift in the understanding of the concept and practice of parenting within an African context. The study thus submits that a Systems Thinking approach ought to be used by interventionists to better understand and thus contribute towards improving the lives of families or communities in similar circumstance as that of the Bhambayi families. / Thesis (M.Com.)-University of KwaZulu-Natal, Westville, 2009.

HIV is major public problem in the world and in Sub-Saharan Region in particular. The literature has shown that mental disorders and particularly depression are common among people living with HIV/AIDS, but that little is known about the prevalence of depression and factors associated with it, among people living with HIV/AIDS in Rwanda. A descriptive, cross-sectional study was done to assess the prevalence of depression, the clinical profile and the factors associated with depression among people living with HIV and attending a primary health care centre in Kigali-Rwanda. This study was informed by the stress and vulnerability framework. A questionnaire was used to collect socio-demographic and HIV related medical information, while depression was assessed using the Beck Depression Inventory Scale, with a cut off of less than 10 for no depression and above 10 scoring positive for depression. Respondents were randomly selected from the patient appointment list for patients who were scheduled during the period of data collection and according to the sample selection criteria. The sample consisted of 96 people living with HIV. Permission to conduct the study was requested and obtained from the University of Kwazulu-Natal Ethics Committee, from the CNLS Research and Ethics Committee in Rwanda and from the management of the health care centre to consult patients' files. Data was analyzed using the Statistical Package for the Social Sciences (SPSS for window, 15). Descriptive data was analyzed by means of frequencies, mean and standard deviation. Cross tabulation using Pearson' chi-square test was performed to test the association between sociodemographic factors and HIV related medical information and depression for categorical variables, while t-test for independent simple test was performed for continuous variable. Multi logistic regression analysis was performed to test further association between the above mentioned factors with depression, while controlling for confounders. The results were presented by means of tables, histograms and graphs. The findings of the study revealed that depression is very high among HIV-infected patients attending a primary health care centre in Kigali, with a prevalence of 41.7%. The most frequent depressive symptoms presented were pessimism, fatigability, sad mood; lack of satisfaction, somatic preoccupation, loss of libido, crying spells, work inhibition, irritability, social v withdrawal and loss of appetite. The majority of respondents scored mild to moderate depression, whereas few had moderate to severe depression and only very few scored severe depression. Having considered all other socio-demographic and HIV related medical factors that were studied, being a female, having presented many HIV-related symptoms in the month prior to data collection, and having less than 250 CD4 counts were statistically associated with depression. On the other hand, having high social and family support was a protector factor to depression. Although the results of this study are not generalizable to the Rwandan population living with HIV, they underscore the importance of integrating mental health in HIV/AIDS services for the care of those who present mental problems related to HIV such as depression. / Thesis (MN)-University of KwaZulu-Natal, Durban, 2010.

This study focuses on women with both pre-eclampsia and Human Immunodeficiency Virus (HIV). Pre-eclampsia is a pregnancy-specific syndrome that occurs after 20 weeks gestation. Thrombocytopenia is the most common haematological abnormality in pre-eclampsia. Further, studies suggest that the immunological mechanism plays some role in the aetiology of pre-eclampsia. The immunological hallmark of HIV infection is a progressive decline in the number of CD4 T lymphocytes and significant haematological abnormalities are also common in HIV-infected individuals i.e. anaemia, thrombocytopenia and leukopenia. The study population comprised of two groups i.e., pre-eclamptic HIV-positive African women and preeclamptic HIV-negative African women as the control group. Samples were analysed for haematological parameters (full blood count) and immunological markers (flow cytometry). There was no statistical significance in the following parameters: RBC, Hb, haematocrit, MCV, MCH, MCHC, platelets, MPV, WBC, lymphocytes, neutrophils, eosinophils, monocytes, basophils and CD8. There was a statistical difference in the CD3 and CD4 counts between both the groups. However, the CD3 and CD4 counts were within the normal range in the HIV-negative pre-eclamptic group and even though CD3 decreased, it was still within the normal range in the HIV-positive pre-eclamptic group, with CD4 decreasing below the normal range in the HIV-positive pre-eclamptic group. This suggests that immune mechanisms involving CD estimations do not play a role in pre-eclampsia since the decrease in the counts can be solely attributed to HIV infection. Results obtained in this study do not show any severe haematological or immunological abnormalities when women have both pre-eclampsia and HIV infection. / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, 2007.

Background: The HIV epidemic has greatly affected sub-Saharan Africa, with the highest prevalence in the world found in Swaziland. One in three pregnant women in Swaziland has HIV. One of the PMTCT strategies is primary prevention of HIV among women who are uninfected. Understanding the reasons why pregnant women continue to seroconvert is the key in meeting this strategy. Purpose: The purpose of this study is to determine the factors associated with seroconversion among pregnant women utilizing Raleigh Fitkin Memorial Hospital in 2012. Objectives: The objectives of this study are to: determine the proportion of HIV non-infected pregnant women who are retested for HIV during pregnancy; determine the gestational age at which pregnant women are retested for HIV; establish the proportion of women who were initially HIV non-infected and seroconverted during pregnancy; and establish the factors associated with seroconversion during pregnancy. Methods: An observational cross-sectional study design with both descriptive and analytic components was carried out at Raleigh Fitkin Memorial Hospital. Systematic sampling was used for the recruitment of 381 pregnant women who were initially HIV non-infected. An interviewer-administered questionnaire and chart review were used to collect demographic and clinical data. The data was analyzed using descriptive and analytic statistics. Results: The results of the study show that demographic factors such as age and educational level are associated with HIV seroconversion during pregnancy. The findings also highlight how partner factors play a role in HIV seroconversion. The results indicate that sexual behaviours 333of the pregnant women contribute greatly to HIV seroconversion. Conclusion: Pregnant women continue to engage in risky sexual behaviours during pregnancy and there is need to strengthen counseling on preventive measures throughout the antenatal care period. There is also need for programs to explore possibility of providing antiretroviral drugs for pre-exposure prophylaxis to all HIV negative women during pregnancy. / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, Durban, 2013.