Includes bibliographical references / BACKGROUND: A viral load monitoring algorithm in the 2013 Western Cape Department of Health PMTCT guidelines include VL measurement in women who are antiretroviral (ART)-experienced at presentation for antenatal care, the timing of subsequent VL measurements and criteria for regimen change. The study evaluates the implementation of the algorithm in women who are virologically nonsuppressed and determines the outcomes of virological resuppression and infant PCR status. METHODS: This retrospective cohort study focused on all ART-experienced women who presented for antenatal care at one of two primary level Maternity Obstetric Units (MOUs) in Khayelitsha, Cape Town between July 2013 and June 2014. The study used routine data from facility registers, clinical records and electronic monitoring systems at the MOU, and referral ART sites and hospitals. Data collected included age, ART clinic, start date and regimen, and maternal VL and infant PCR results. RESULTS: Forty percent of the 1412 HIV-positive pregnant women, were ART-experienced, of whom 14.1 % were VNS. Predictors of being VNS included a duration on ART of more than 4 years (p= 0.04), attending an ART clinic other than that in the facility (p= 0.02), being on a second-line ART regimen (p=0.07) and being younger than 25 years (p= 0.05). The algorithm was correctly followed in up to 87.5% of women identified as VNS. The rate of virological resuppression by three months postpartum was 70.0% to 82.3%. Excluding three neonates who died, all of the 82.2% of infants tested were PCR negative. CONCLUSIONS: Nearly 15% of ART-experienced women were virologically nonsuppressed on presentation for antenatal care. Levels of adherence to the guideline, and virological resuppression rates of up to 82.3% are encouraging. The implementation of the VLM algorithm could be improved by the integration of obstetric and ART care, the adoption of a single electronic monitoring system and the use of standardised integrated clinical stationery.

Includes bibliographical references / Integration is an important emerging health systems issue, which has relevance to different health programmes. Improving prevention of mother-to-child transmission of HIV (PMTCT) programs in South Africa would reduce preventable maternal and infant morbidity and mortality, assist with achieving Millennium Development Goals 4 and 5, and help in the response to the WHO call for the elimination of MTCT, the new international PMTCT goal. Integrating PMTCT care into routine maternal and child health programmes has been recommended as a way to optimize PMTCT care. The Part B literature review in this dissertation examines the reasons why PMTCT programmes need to engage with integration as an issue, challenges to implementing integrated programmes, followed by a discussion of the benefits and lessons to consider in planning integrated PMTCT programmes. Theoretical concepts and frameworks such as Atun's framework, complexity, Theory of Change and innovation in health systems are discussed, as they have key relevance to the research findings. Lessons about implementing health system changes can be learned from programmes which have done so successfully. Using Case Study methodology, the process of developing the fully integrated longitudinal clinic at McCord Hospital is described in Part C, and reflections on the experience of providing integrated care are captured through qualitative interviews with the staff. Recommendations regarding innovation and change within complex systems are made, emphasizing the need to understand contexts which are receptive to change and the importance of leadership in managing change.

Background: Intimate Partner Violence (IPV) is recognized globally as a major public health concern linked to numerous adverse physical, mental, sexual and reproductive health outcomes. IPV is associated with both pregnancy and HIV-infection independently, but there are few data on IPV in populations of HIV-infected pregnant women. We examined the prevalence and predicators of IPV among pregnant women initiating lifelong antiretroviral therapy (ART) in a large primary care clinic in Cape Town, South Africa. Methods: Consecutive pregnant women seeking antenatal care in Gugulethu, Cape Town were recruited into the MCH-ART study examining service models for postpartum ART care. IPV, depression, alcohol and drug use, and emotional distress were assessed using the 13-item WHO Violence Against Women questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), alcohol and drug use disorders identification test (AUDIT/DUDIT) and the Kessler-10 (K-10) scale, respectively. Questionnaires were administered privately by trained interviewers. Women identified with specific IPV or mental health concerns were referred to appropriate services. Logistic regression was used to examine factors independently associated with experiences of IPV after adjusting for age and socioeconomic status. Results: From April 2013-May 2014, 623 women were enrolled (median age, 28 years):97% reported being in a relationship, 38% were married and/or cohabiting and 70% reported not having discussed or agreed on pregnancy intentions prior to conception . Overall, 21%(n=132) reported experiencing ≥ 1 act of IPV in the past 12 months, including emotional violence(15%), physical violence(15%) and sexual violence(2%). Of those reporting any IPV, 48% reported experiencing multiple types. Emotional and physical violence were most prevalent among women 18-24 years old, while sexual violence was most commonly reported among women 25-29 years old. Women who reported not discussing or disagreeing on pregnancy intentions with their partners prior to conception were significantly more likely to experience violence(p=0.030), and women who experienced IPV reported higher levels of substance abuse, depression and emotional distress(p<0.001 for all associations). Discussion: These data demonstrate high levels of IPV in this population. While the potential impact of HIV-infection, pregnancy and pregnancy intention on the risk of IPV and related factors require further research, IPV-related screening and support services should be considered as part of the package of care for ART in pregnancy.

Includes bibliographical references / Proper implementation of and adherence to antiretroviral therapy (ART) is significantly associated with better health and longer life in HIV-positive individuals. Consistent, adequate adherence has been shown to lead to a suppressed viral load. A low viral load delays the virus's progression and leads to better health outcomes for the individual. Adequate adherence is especially important among HIV-positive pregnant women. How well a woman adheres to her ART can not only improve her health during pregnancy but can protect the infant from HIV by preventing in utero transmission of the virus. Continuing ART protects against transmission via breastmilk later in the infant's life. While the benefits of good adherence are undeniable, the definition of adequate adherence varies widely in the literature. Taking 80 to 100% of pills as prescribed is commonly used as the threshold for adequate adherence levels. Various methods exist for measuring ART adherence, and while some are more reliable than others, there is no gold standard. This ambiguity in ART research extends to pregnant women, with even less known about HIV infected women established already on ART who then become pregnant. Changes in treatment protocols in the Western Cape and improvement of ART delivery throughout South Africa have resulted in this group of long-term users growing in size. Without more research into the barriers of ART adherence in these women, efforts to scale up treatment programs and to end mother to child transmission of HIV will ultimately fail. This dissertation is an exploration of these ideas. It begins to fill the gap in current knowledge related to ART compliance in pregnant women, and gives new insights into how specific barriers to adherence can adversely affect this specific group of established ART users.

Carcinoma of the cervix is frequently diagnosed in the department of Radiation Oncology in Charlotte Maxeke Johannesburg Academic Hospital(CMJAH). It is therefore is a condition of priority and there is scarce literature in the management of HIV positive patients. OBJECTIVES: The primary objective of the research is to determine the overall survival of 2yrs and more, as well as to determine acute and late toxicity for patients completing prescribed radiation treatment. The secondary objective was to determine the impact of highly active antiretroviral therapy on survival and toxicity. The study is limited to HIV positive women presenting with cervical cancer. DESIGN & METHOD: The study is a retrospective study of patients treated at Charlotte Maxeke Johannesburg Academic Hospital between 2008-2009. Inclusion criteria: Females between the ages of 18 and 70, Stages IB2 – Stage IIIB carcinoma of the cervix who have completed planned radiation therapy with or without chemotherapy. The sample size was 151 patients. RESULTS: The mean age was 42.7yrs. The median CD4 count was 309 and 26.2% had CD4 counts below 200.The majority of patients had either Stage IIB (55.0%) or IIIB (31.8%). The total dose to Point A was a median dose of 74Gy. The majority of patients had either Grade II (38.4%) or III (31.1%) toxicity. Significant association between these adverse events and HAART status was rated as p=0.0008. The most common late complication was cystitis (15.9%). Overall survival at 2 years was 100% for Stage I, 92.8% for Stage II and 96% for Stage III. CONCLUSION: The median age was lower than in the HIV negative patients. The acute complications for those not on HAART, were higher in comparison to patients on HAART. The overall survival at 2 yrs. was above 90% for all stages in this study / GR2018

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No description available.

Organisms of the <i>Mycobacterium avium</i> complex cause disseminated infections in 25 to 50 % of patients with AIDS. To assess the likelihood of exposure to M avium, we attempted to recover M. avium complex from environmental samples in geographical areas (Boston, Massachusetts; Hanover, New Hampshire; Helsinki, Finland; Nairobi, Kenya; and Kinsasha, Zaire) located near <i>M. avium</i> infected AIDS patients. Although <i>M. avium</i> was recovered from environmental samples at all sites, it was found more frequently in water supply systems in the United States and Finland (8/25, 32 %) compared to water supply samples from Africa (0/14, 0%). To determine if <i>M. avium</i> isolates recovered from the same geographical area as AIDS patients shared phenotypic and genetic characteristics with clinical AIDS <i>M. avium</i> isolates (recovered by collaborating laboratories), the ability to grow at 43°C, cadmium-and streptomycin-resistance, and the presence of plasmids were used as epidemiological markers. We found that environmental isolates in this study shared similar characteristics with the clinical AIDS <i>M. avium</i> isolates. Compared to developed countries, the prevalence of <i>M. avium</i> infections among AIDS patients in developing countries (i.e., Africa) is very low. To determine if <i>M. avium</i> was absent in the African environment, we attempted to recover the organisms from water and soil in Kampala, Uganda. <i>M. avium</i> was recovered from 43 % of environmental samples, and these isolates shared similar phenotypic and genetic characteristics with <i>M. avium</i> isolates from the United States. Cigararette smoking was identified as a possible risk factor for HIV infected individuals. M avium isolates were recovered from several brands of cigarettes, suggesting that cigarettes are a possible source of infection. / Master of Science

Latino men who have sex with men (MSM) in the United States experience a disproportionate and growing HIV burden. In spite of germinal studies and recent advances reported in the scientific literature, there is a noteworthy gap in our understanding of the factors that influence HIV transmission and acquisition among Latino MSM. The goal of this dissertation is to explore how cultural, spatial, and syndemic contexts influence two HIV-related risk behaviors among Latino MSM: serodiscordant condomless anal intercourse (SDCAI) and number of male causal partners. Specifically, I aimed to assess the how acculturation, neighborhood characteristics, and co-occurring epidemics may each contribute to HIV-related risk among Latino MSM. For this project, I utilized data from the NYCM2M study (R01 HD059729; PI: B. Koblin), a cross-sectional study of the relations among neighborhood environmental characteristics, sexual risk behaviors, anxiety and depression, and alcohol and substance use among urban MSM. First, I examined the association between indices of acculturation and the two HIV-related risk behavior outcomes, in addition to assessing if acculturation moderates the influence of sexual minority stressors and peer condom use norms on those same outcomes. The results indicated that relationships between the two sexual minority stressors and SDCAI were strongest among two groups: English-speaking and foreign-born Latino MSM, groups considered to be high and low, respectively, on acculturation. Second, I examined the ethnicity- and gay-related neighborhood correlates of the HIV-related risk behavior outcomes. The results showed that living in areas with a higher proportion of men reporting experiences of ethnicity-based discrimination and higher levels of gay community connectedness were both associated with an increased likelihood of engaging with 5 or more casual sexual partners, while living in an area with a higher foreign-born population was associated with a lower likelihood of the same. Third, I examined both established and population-relevant syndemic conditions to assess the association between syndemic burden and the HIV-related risk behavior outcomes among Latino MSM, and assessed if outness moderated these potential relationships. The results indicated a significant, positive association between the number of syndemic conditions and SDCAI, but, upon testing for moderation, this relationship only existed among men with high levels of outness about their sexual orientation. The results also showed that having any syndemic conditions, regardless of the number, was associated with having more casual sexual partners. Overall, this dissertation highlights the importance of studying HIV-related risk behaviors through multiple contextual lenses among Latino MSM. Specifically, the results suggest a strong need to attend to how cultural factors, spatial environments, and syndemic factors may shape HIV burden among Latino MSM. Taken together, these studies provide evidence for the development of multi-level, multicomponent HIV-reducing interventions that specifically target the differing needs among subgroups of Latino MSM, rather than treating them as a single, monolithic group for study and intervention.

For the first twenty-five years of Ghana’s national response to HIV/AIDS, the government, like most nations in Africa, did not include gay and bisexual—locally known as sasoi—and other men who have sex with men (MSM) as a high-risk group for HIV in its policies. In 2011, Ghana finally addressed this policy blind spot by acknowledging sasoi and other MSM as a key population at-risk for HIV and in need of policy and programmatic interventions—a shift that is occurring in many parts of Africa. Using Ghana as a case study of this policy shift on the continent, my dissertation examined: why sasoi and other MSM were not initially acknowledged in Ghana’s national AIDS policies; why and how the government decided to include MSM as a key population in its national AIDS policies and programs; what cultural, social, and political factors have affected the development, implementation, and reception of these policies and programs; how sasoi and other MSM perceive and experience these policy and programmatic efforts; and how sasoi and other MSM experience life in a country that criminalizes and stigmatizes same-sex sexual activities. Using ethnographic methods, I conducted a 12-month qualitative study in Ghana. I conducted: interviews with 43 state and non-state policymakers and stakeholders, HIV frontline workers, and sasoi and other MSM; focus group interviews with 18 peer educators; participant observations of policy and HIV prevention work, and meetings and other events related to the research scope; and archival research of media coverage of homosexuality. My findings indicate that Ghana’s MSM policy blind spot was due to: 1) the criminalization and stigmatization of same-sex sexualities in the country, 2) a construction of the Ghanaian epidemic as driven by migrant female sex workers, and 3) international AIDS researchers’ categorization of HIV in Africa as heterosexual, which informed donor policies and stipulations. However, in 2011, the government shifted to include MSM as a KP at risk for HIV in light of mounting epidemiological data on MSM HIV prevalence and risk, NGO advocacy efforts, and international donor policy changes that now recognize MSM as a KP in Africa. I conceptualize this change as a paradigm shift in Ghana’s national AIDS policies from a general population paradigm to a key populations paradigm that includes MSM as biomedical citizens at higher risk for HIV. The country’s progress in addressing HIV among sasoi and other MSM using evidence-based policies has earned it status as a model country in Africa in MSM HIV efforts. Stakeholders, however, face significant challenges rooted in the country’s sociocultural context, namely institutionalized homophobia and heterosexism, a dated and underfunded healthcare system, and inadequate HIV funding. Implementation of MSM HIV policies has come into conflict with the country’s legal and sociocultural realities in Ghana, where male same-sex sexual activities are criminalized and socially stigmatized. Moreover, stakeholders are strategically discreet in how they implement MSM HIV policies and programs and are hesitant to publicly push any advocacy efforts that might come across as supporting or promoting homosexuality, in fear of social and political retribution. Despite this strategy, I argue that MSM HIV efforts have attracted public attention and criticism and have constituted, in part, the politicization of homosexuality in Ghana, reshaping public representations and perceptions of homosexuality and presenting challenges to the ongoing efforts to address HIV among MSM. Stakeholders must evaluate these unintended consequences alongside the intended policy objectives and outcomes to strengthen efforts to reduce the burden of HIV among sasoi and other MSM in Ghana.