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A research report submitted to the Faculty of Health sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Science in Medicine in Epidemiology and Biostatistics 30th May 2012 / Introduction The burden of HIV/AIDS is higher in the sub-Saharan region and multiple sexual partnerships are among the sexual behaviors that put people at risk of HIV transmission. The main aim of this study was to determine the prevalence and associated demographic, socio-economic and behavioral factors of multiple sexual partnerships among men in Zimbabwe. Materials and Methods This was an analytical cross-sectional study that used data from the Zimbabwe Demographic Health Survey 2005-06. Negative binomial regressions were fitted to identify factors associated with multiple sexual partnerships among men in Zimbabwe. Results The prevalence of multiple sexual partnerships was 13.5 %, 12.9%, and 11.2% among the formerly, never and currently married men respectively. Among the formerly married men, the risk factors significantly associated with multiple sexual partnerships included access to newspapers (RR= 1.28; 95% CI:1.02 , 1.60). Formerly married men aged 35-44 years had lower risk of engaging in multiple sex partnerships (RR = 0.59, 95%CI: 0.42, 0.83) than the other age groups. Relative to formerly married men in Manicaland, formerly married men in Mashonaland East region had lower risks of having more sexual partners. Age at first intercourse and sexual attitude were also significantly associated with multiple sexual partnerships among the formerly married men iv Among the never married men, the risk factors associated with multiple sexual partnerships included employment status (RR = 1.33%; 95%CI: 1.17, 1.52), Watching TV (RR = 1.33%; 95%CI: 1.05, 1.69) and sexual attitude (RR = 1.37%; 95% CI: 1.05, 1.79). Relative to never married men in Manicaland, the never married men in Mashonaland East and Mashonaland West had lower risks of having multiple sexual partners. Among the married men, the risk factors associated with multiple sexual partnerships included first intercourse at the age of 19 years or below (RR = 1.07%; 95% CI: 1.04, 1.11) and sexual attitude (RR = 1.16%; 95% CI: 1.09, 1.23). Protective factors included higher level of education (RR = 0.87%; 95% CI: 0.77, 0.98), being 35-44 (RR = 0.94%; 95% CI: 0.89, 0.99) or 45-54 years old (RR = 0.93%; 95% CI: 0.88, 0.99) and being from Mashonaland East (RR= 0.89%; 95%CI: 0.85, 0.93) region. Discussion and Conclusions The results show that after adjusting for potential confounders in the multivariate negative binomial regression analysis; age, geographical region, education, working status, frequency of reading newspapers/magazines/TV, age at first intercourse and sexual attitude remained significantly associated with MSP. However, the extent to which each of these factors was associated with multiple sex partnership varied among marital status groups, therefore HIV/AIDS intervention programs should be designed accordingly.

Thesis (MSc (Clinical Psychology)) -- University of Limpopo, 2012. / The aim of the study is to investigate the HIV and Aids knowledge, attitudes, behaviour and beliefs of University of Limpopo undergraduate students (Medunsa Campus) registered for modules in psychology. South African tertiary institutions have a high rate of HIV infection. Empirical evidence indicates that generally male students have multiple partners during their years at university. Various studies reveal that the use of condoms is relatively low amongst students. This investigation utilized a quasi-experimental survey design as it was deemed an appropriate method with which to answer the research question. The questions used in the survey were underpinned by the Health Belief Model (HBM) and the Protection Motivation Theory (PMT). Several open-ended questions were added to lend a qualitative aspect to the study. Proportionate stratified sampling was used. Using this method a sample of students was randomly allocated in each educational level (first year, second year and third year) according to the true proportional number of students in each level. Quantitative data was analyses using descriptive statistics and an independent t-test to look for differences between the means of the male and female groups. Results underpinned other research in this arena For instance, the majority of participants indicated that they know that using a male condom or female condom can prevent the spread of Aids. This suggests that this percentage would take the positive health related action of using a condom. However, fifty one respondents (35.66%) indicated that they were very likely to believe that they would feel uncomfortable buying condoms and forty five respondents (31%) were likely to believe that they would feel uncomfortable buying condoms. This indicates that knowledge is not a good predictor of a positive health related action. Quantitative and qualitative results suggest that stigmatizations and racism exist in the samples attitudes towards aspect of HIV and Aids. The only significant result between the means of the two groups suggests that males are more likely to indulge in high risk sexual behaviours than females.

Thesis (MPH) -- University of Limpopo, 2012. / Background: The HIV pandemic continues to be a major public health problem in Sub-Saharan Africa where 22.5 million people were infected with HIV in 2009 and South Africa remains one amongst the countries with the highest HIV epidemic. The number of HIV-positive and AIDS patients is increasing annually and there are no specialised oral health institutions that provide oral health care to HIV/AIDS patients. HIV and AIDS continues to have profound impact on all health training and education (Medical, Dentistry, Nursing etc.) and clinical care, hence it is crucial for all the health care students to be educated about HIV/AIDS disease. Dental student’s knowledge about HIV/AIDS, attitudes towards HIV-positive patients and infection control practices are of importance as they are the future oral health care providers. The Purpose: The purpose of the study was to determine the knowledge, attitudes and practices of third, fourth and fifth year dental students on HIV-positive and AIDS patients at the Medunsa Oral Health Centre (MOHC). Materials and Methods: This was a cross-sectional study conducted among 139 dental students at MOHC using a self administered questionaire with 30 closedended questions. T-test, one-way Anova (analysis of variance), multiple regressions and Pearson’s correlation were applied by Stata IC/10 to assess, determine and describe the knowledge, attitude and infection control practices of third, fourth and fifth year dental students, respectively and also find an association between demographic variables, knowledge, attitudes and practices. Results: The response rate was 86% (120/139), 33 of third year, 47 of fourth year and 40 of fifth year dental students. Gender was statistically significant towards knowledge and females were more knowledgeable about HIV/AIDS as compared to males (p=0.058). However, almost (98.3%) all dental students were not sure “HIV increases other infections, including oral infections as well”. More than half (53.1%) of third year dental students were not sure “persistent generalised lymphadenopathy vi is associated with stage 2 of HIV infection”. In this study, ethnic groups and level of study (BDS4 & BDS5) were found to be significant predictors of attitude regarding HIV-positive patients (p=0.001) (p=0.055) (p=0.001). Practice was found to be a significant predictor of knowledge regarding HIV/AIDS (p=0.046). Pearson’s correlation coefficient showed students with positive attitude scores had significantly excellent practice regarding HIV/AIDS (r=0.2912) (p=0.001). Good knowledge translates into excellent infection control practices, whilst positive attitude towards HIV/AIDS patients yield excellent infection control practices. Conclusion: The dental students at MOHC relatively have a good understanding of HIV/AIDS (particularly the mode of transmission) but to lesser extent, disease progress and oral manifestation. The lack of knowledge on HIV/AIDS and inconsistency regarding certain infection control procedures may be a reflection of insufficient HIV/AIDS teaching and clinical supervision of students in the wards. There is a need to improve the current dental curriculum by including HIV/AIDS module and incorporate a clinical component of dental screening at the ARV clinics.

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Monitoring the epidemic of Human Immunodeficiency Virus (HIV) infection plays a vital role in tracking the leading edge of HIV transmission and designing intervention programs both at individual and population level. At individual level, it is imperative to identify newly infected individuals to reduce onwards transmission. At population level, knowledge on the HIV incidence is essential to monitor the spread of the epidemic and plan/evaluate HIV prevention programs. This dissertation will examine the way in which biomarker data can be used to monitor the HIV epidemic. There are two primary aims of this thesis: a) to investigate the use of biomarkers in quantifying the recency of HIV infection at individual level and b) to estimate quantities such as mean window period and testing rate that are the building blocks for estimating HIV incidence at population level. We apply and further develop existing statistical methods to answer the research questions of interest. At individual level, we investigate the use of one or more biomarkers to quantify the recency of HIV infection. We propose a novel approach to make probabilistic statements on the recency of HIV infection by combining the knowledge on the growth of such biomarkers with observations from a newly diagnosed individual. Univariate and bivariate non-linear mixed-effects models are implemented in a fully Bayesian framework. A simulation study is conducted to investigate the biomarkers’ features that affect the accuracy of the estimation of recency. The research findings suggest that rapidly evolving biomarkers of antibody response, such as LAg Avidity, provide reliable estimates of the probability of recency. The proposed methods are applied to a panel of individuals for whom information on various biomarkers is given along with an estimated date of detectable infection. At population level, we focus on estimating two fundamental ingredients, the mean window period and the HIV testing rate, required for estimating HIV incidence using biomarker data. We compare commonly used statistical methods and explore the use of multi-state models in estimating the mean window period of the fourth generation Architect Avidity. We further investigate the factors that are associated with the probability of having an HIV test and the HIV testing rate using surveillance data. Logistic and count regression models using the Generalized Estimating Equations (GEE) approach are employed to make inference at population level about the probability of testing and HIV testing rate respectively.

The objectives of the study are to explore the effectiveness of the ABC HIV prevention strategy in South Africa with the purpose of establishing problem areas of the ABC HIV prevention strategy in South Africa. A systematic review design was followed. Electronic databases; Google scholar, Medline and PubMed were searched using broad combination of keywords to obtain all relevant articles. Studies written in English, published between 2000 and 2010, were selected if they met the inclusion criteria. In order to be included the study had to discuss the ABC HIV prevention strategy with the focus on effectiveness of the strategy. The Critical appraisal instrument for qualitative research studies (CASP, 2006) and Quality Assessment Tool for Quantitative studies (Effective Public Health Practice Project, 2005) were used to critically appraise the 9 studies that met the inclusion criteria. Thematic analysis was used for the analysis process. The findings regarding each objective were combined in a summary of findings. The findings revealed that the South African population engages in sexual activities at an early age. Males and females have concurrent sexual partnerships, which mean they are not faithful to their primary sexual partners and lastly, women are unable to use or negotiate condom use. Identified problem areas of the ABC HIV prevention strategy in South Africa were that the age gap between sexual partners is a problem as women cannot negotiate condom use with their seniors. The notion of love and romance that influences the use of condoms, has a negative impact whereby condom use is unacceptable in a long term relationship, irrespective of the level of faithfulness. Low socio-economic status of women that makes women to be dependent on men and also prone to engage in transactional sex. Lastly, local norms about sexuality that men subscribe to, to prove masculinity. / Thesis (M.Cur) North-West University, Mafikeng Campus, 2011

MSc (Med) Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Focus in public health research is shifting to the role of socio-economic factors in the promotion of health. Hence, an understanding of the roles socio-economic factors plays in improving health and health-seeking behaviour is important for public health policy. This study examined the relationship between socio-economic factors and HIV infection in rural Limpopo Province South Africa, an area characterized by poverty differentials and migration. Various possible social and economic risk factors (such as nationality, education status, marital status, employment status, migration status and socio-economic status) for HIV infection are analysed and discussed. This is secondary data analysis was carried out during the period June 2001 to March 2005 among 2345 14-35 year old residents in eight (8) villages in rural Limpopo. Married participants (OR 0.53 [95%CI 0.28 – 1.00]), those from poor (OR 0.49 [95%CI 0.28-0.85]) and less poor households (0.38 [95%CI 0.21-0.70]) are less likely to contract HIV infection. Noteworthy from these analyses also is the increased risk for HIV infection seen among female participants, those not currently schooling (OR 1.9 [95%CI 1.2 – 3.3]) and non-South African citizens (OR 5.18 [95%CI 1.04-25.8]). Conclusion: Women, out-of school youths and non South African citizens are shown to be high-risk population groups for HIV infection. HIV prevention programs that target identified vulnerable population groups and increased social support for the family may contribute to mitigating the spread of HIV in rural South Africa.

Capítulo I: Para evaluar el efecto sinérgico de IL-12/IL-18 y M-CSF/GM-CSF en la diferenciación de los monocitos y su impacto en el estallido respiratorio y el metabolismo del colesterol de los monocitos derivados en macrófagos, los monocitos fueron diferenciados durante 7 días en presencia de la combinación de la granulocyte-macrophage colony-stimulating factor (GM-CSF) y macrophage colonystimulating factor (M-CSF) o la interleucina 12 (IL-12) e IL-18 para producir respectivamente la M / GM-Ф y IL12/IL18- Ф. Como control, los monocitos fueron diferenciados sólo con M-CSF, GM-CSF, IL-12 e IL-18 para producir respectivamente la M-Ф, GM-Ф, IL12-Ф y IL18-Ф. El análisis de muestras de cuatro donantes de monocitos demostró una diferencia en el metabolismo del colesterol y el estallido respiratorio de las subpoblaciones de macrófagos. Los M/GM-Ф y IL12/IL18-Ф estimulados producieron alto nivel de H2O2 y mieloperoxidasa, y generaron gran cantidad de HOCl en respuesta al PMA. Por el contrario, mostraron bajos niveles de enzima antioxidante catalasa. Además intensificaron la oxidación de LDL y acumularon de forma espontánea gran cantidad de colesterol cuando incubado con la lipoproteína de baja densidad nativa. Los resultados sugieren que las vías M-CSF/GM-CSF o IL12/IL18 podría ser algunas señales sinérgica crítica experimentado por los monocitos / macrófagos durante su diferenciación in-vivo, en el que su potencial aterogénico o su capacidad de oxidar el LDL aumenta. Capítulo II: Estudios recientes muestran que el rebote de la carga del VIH-1 después de largos períodos de interrupciones del tratamiento (IT), resulta en un estallido de biomarcadores de la enfermedad arterial coronaria (CAD). Hemos investigado si las interrupciones cortas inducen un estallido de estos biomarcadores, si los niveles de estos biomarcadores vuelven a la basal durante la reintroducción del tratamiento y si los estallidos eran relacionados con el número de interrupciones. Los biomarcadores de CAD CRP, CXCL8, dímero-D, MMP-9 y los lípidos plasmáticos fueron medidos a partir de muestras de plasma almacenadas de 21 sujetos con infección crónica por el VIH-1 sometidos en un estudio de evaluación de seis ciclos de "2 semanas de interrupción" / "4 semanas reintroducción" de la terapia antirretrovirales. Los sujetos fueron agrupados en aquellos con un rebote de la carga viral después de interrumpir el tratamiento y los que no sufrieron del rebote. Los niveles de CRP, MMP-9, CXCL8, dímero-D y los triglicéridos aumentaron significativamente después de cada IT en los pacientes con el rebote de la carga viral. Los cambios de incremento medio en los sujetos sin rebote de la carga viral eran muy bajos en comparación con la basal y sin interés clínico como los valores se mantuvieron entre los rangos plasmáticos normales. Ningún efecto tiempo se observó durante la IT a la excepción de la CRP. Todos los biomarcadores volvieron a los niveles basales después de cada reinicio del tratamiento. Los resultados sugieren que las IT antirretroviral de tan sólo dos semanas son asociadas con un estallido de relevancia clínica de los biomarcadores de CAD aguda, que indica la importancia de la adherencia al tratamiento. / We organized the thesis into two chapters: Chapter I: To evaluate the synergic effect of IL-12/IL-18 and M-CSF/GM-CSF on monocytes differentiation and their impact on the respiratory burst and cholesterol metabolism of monocytes-derived macrophages, monocytes were differentiated for 7 days in the presence of both granulocyte-macrophage colonystimulating factor (GM-CSF) and macrophage colony-stimulating factor (M-CSF) or Interleukin-12 (IL- 12) and IL-18 to produce respectively M/GM-Ф and IL12/IL18-Ф. As control, monocytes were differentiated only with M-CSF, GM-CSF, IL-12 and IL-18 to produce respectively M-Ф, GM-Ф, IL12- Ф and IL18-Ф. Samples analyses of four monocytes donors demonstrated a differential in the cholesterol metabolism and respiratory burst of macrophage subpopulations. Stimulated M/GM-Ф and IL12/IL18-Ф produce high level of H2O2 and myeloperoxidase; and generate significant amount of HOCl in response to PMA. In contrast, they show low levels of anti-oxidant enzyme catalase. Moreover they intensify LDL oxidation and spontaneously accumulate significant amount of cholesterol when incubated with unmodified low-density lipoprotein. The results suggest that M-CSF/GM-CSF or IL12/IL18 pathways might be some critical synergic signals experienced by monocytes/macrophages during their differentiation in-vivo; in which their atherogenic potential or their capacity to oxidize LDL increase. Chapter II: Recent studies show that HIV-1 load rebound after long periods of treatment interruptions (TI), results in a burst of coronary artery disease (CAD) biomarkers. We investigate whether short interruptions induce a burst of these biomarkers, whether their levels return to the baseline during treatment resumption and if the burst were related to the number of interruptions. CAD biomarkers CRP, CXCL8, D-dimer, MMP-9 and plasma lipids were measured from stored plasma samples of 21 chronically HIV-1 infected subjects enrolled in a study evaluating six cycles of “2 weeks off” / “4 weeks on” antiretroviral therapy. Subjects were clustered into those with a viral load rebound after stopping treatment and those without. The levels of CRP, MMP-9, CXCL8, D-dimer and triglycerides rose significantly after each TI in subjects with viral load rebound. Changes of means increment in subjects without viral load rebound were too low relative to the baseline and without clinical interest as values stayed between the normal plasma ranges. No times effect was observed during TI except for CRP. All biomarkers return to baseline levels after each treatment resumption. The results suggest that antiretroviral TI as short as two weeks are associated with a clinically relevant burst of acute CAD biomarkers, that indicating the importance of adhering to treatment.

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