Thesis (MCurr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Taking into consideration the long duration of standard treatment for Mycobacterium tuberculosis (TB), the high prevalence of HIV co-infection and the growing prevalence of drug-resistant TB, there is an urgent need for improved treatment approaches for TB and HIV. However, there is inadequate information regarding the burden being placed on the Department of Health (DOH) systems by the current treatment of patients established on Antiretroviral Therapy (ART) who are newly diagnosed with TB, and by their clinical management. The aim of the study was to determine what proportion of patients established on ART were newly diagnosed with TB, and what their clinical and treatment outcomes were in different public sector settings in the eThekwini Region, KwaZulu-Natal (KZN). Approval for the study was obtained from the Human Research Committee of Stellenbosch University and from the Biomedical Research Committee, KZN. The study used a retrospective, quantitative, cohort technique at both TB and ART clinics at three sites in the eThekwini region, KZN. These sites were DOH clinics and were selected as they all had a TB clinic and a DOH-registered ART clinic. The study focused on a period of one year prior to a patient established on ART developed TB. The study population comprised all TB patients who attended the selected DOH clinics. A data collection tool was developed and pilot-tested. A small sample of patient files (n=15, representing 2% of the study population) was randomly selected; five from each site. The files and data were excluded from the main study. A total of 1824 files (579 from the TB clinics and 1245 from the ART clinics) were reviewed. The data were captured into an electronic database (EpiData Version 3.3) and analyzed using STATA (Version 11.0) with the assistance of a statistician. The findings show that of the study sample from the TB clinics (N=579), 78% (454/579) were newly diagnosed with TB. Of the new TB cases, 90% (409/454) had pulmonary TB and 71% (413/579) were HIV-positive. Nearly 50% (68/137) of the patients had commenced ART prior to TB diagnosis and treatment, and 14% (19/137) had commenced ART after TB. Of those who commenced ART prior to TB diagnosis and treatment, 29% (20/68) had commenced ART more than three months prior to acquiring TB. The findings from the ART clinics show that of the files (N=1245) reviewed, 40% (501/1245) had TB, and of these 8% (42/501) developed TB after three months or more of ART. Missing data in the patient medical files was a major challenge. The lack of recorded data about ART in the TB clinics and about TB in the ART clinics suggests suboptimal clinical management and poor integration of HIV and TB services. It was therefore not possible to derive a combined HIV-TB outcome measure. Recommendations to promote and implement the integration of TB and HIV services included policy changes and implementation, management and practice suggestions, education and training to integrate TB/HIV services and increase research to identify gaps in clinical management and to improve integration of services. / AFRIKAANSE OPSOMMING: Met inagneming van die lang duur van die standaard behandeling vir Mycobacterium tuberkulose (TB), hoë voorkoms van MIV-infeksie en die groeiende voorkoms van dwelmweerstandige TB, is daar ’n dringende behoefte aan verbeterde behandelingbenaderings vir TB en MIV. Daar is egter ’n gebrek aan inligting oor die las geplaas op die Departement van Gesondheid (DvG) se stelsels deur die huidige behandeling van pasiënte op antiretrovirale terapie (ART) wat gediagnoseer is met TB en deur hul kliniese bestuur. Die doel van die studie was om vas te stel watter persentasie van pasiënte wat op ART gevestig is, wel met TB gediagnoseer is, en wat hul kliniese en behandeling-uitkomste was in verskillende openbare-sektorinstellings in die eThekwini-streek, KwaZulu-Natal (KZN). Goedkeuring vir die studie is verkry van die Menslike Navorsingskomitee van die Universiteit van Stellenbosch en van die Biomediese Navorsingskomitee, KZN. Die studie het gebruik gemaak van ’n retrospektiewe, kwantitatiewe ‘cohort’-tegniek by beide TB en ARB-klinieke op drie plekke in die eThekwini-streek, KZN. Hierdie terreine was DvG-klinieke en is gekies omdat hulle almal oor ’n TB-kliniek en 'n DvGgeregistreerde ART-kliniek beskik. Die studie het gefokus op ’n tydperk van een jaar voor ’n pasiënt wat op ART is, TB ontwikkel het. Die studiepopulasie bestaan uit alle TBpasiënte wat die geselekteerde DvG-klinieke bygewoon het. ’n Data-insamelinginstrument is ontwikkel en getoets. ’n Klein voorbeeld van die pasiëntlêers (n = 15, 2% van die studie bevolking verteenwoordig) is ewekansig gekies: vyf uit elke plek, en die data is vervat in ’n elektroniese databasis (EpiData Version 3,3). ’n Totaal van 1824 lêers (579 in die TB-klinieke en 1245 lêers in die ART-klinieke) is ondersoek. Die data is ontleed deur gebruik te maak van Stata (weergawe 11,0) met die hulp van ’n statistikus. Die bevindinge toon dat van die studiemonster in die TB-klinieke (N = 579), 78% (454/579) met TB gediagnoseer is. Van die nuwe TB-gevalle, het 90% (409/454) pulmonêre TB gehad en was 71% (413/579) MIV-positief. Byna 50% (68/137) van die pasiënte het ART begin vóór hulle TB-diagnose en -behandeling, en 14% (19/137) ART ná TB. Van dié wat ART voor TB-diagnose en -behandeling begin het, het 29% (20/68) meer as drie maande voor die opdoen van TB met ART begin. Die bevindinge van die ART-klinieke toon dat van die lêers (N = 1245) wat bestudeer is, 40% (501/1245) TB het, en hiervan het 8% (42/501) TB na drie of meer maande van ART ontwikkel. Ontbrekende data in die pasiënt se mediese lêers was ’n groot uitdaging. Die gebrek aan aangetekende data oor ART in die TB-klinieke en oor TB in die ART-klinieke dui op suboptimale kliniese bestuur en swak integrasie van MIV- en TB-dienste. Dit was dus nie moontlik om ’n gesamentlike MIV-TB uitkomsmaatreël af te lei nie. Aanbevelings om die integrasie van TB- en MIV-dienste te bevorder en te implementer, het beleidveranderinge en -implementering ingesluit, asook bestuur- en praktykvoorstelle, onderwys en opleiding om TB-/MIV-dienste by DvG-vlak te integreer en meer navorsing om gapings in die kliniese bestuur te identifiseer en die integrasie van dienste te verbeter.

Thesis (MScMedSc)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Background: HIV-positive patients have a significantly weakened immune system which makes them highly susceptible for opportunistic infections, requiring additional treatment. Cryptococcal meningitis and oropharyngeal candidiasis are treated with oral fluconazole. A great potential for drug-drug interactions (DDIs) between fluconazole and antiretrovirals (ARVs), efavirenz, nevirapine, and lopinavir/ritonavir, exists due to interference in common metabolic pathways. The outcome may result in the development of adverse drug reactions or drug resistance and treatment failure. Aim: The primary aim of this thesis was to evaluate the effect of fluconazole on the pharmacokinetics of efavirenz, nevirapine and lopinavir/ritonavir in HIV-infected patients diagnosed with cryptococcal meningitis or oropharyngeal candidiasis. Methods: A prospective study was conducted in 80 HIV-positive, treatment experienced adults (≥18 years old) treated in three different outpatient clinics in the Western Cape region. Patients were subdivided according to ARV regimen and the use of fluconazole. A sparse sampling design was used and corresponding ARV serum concentrations were determined by established HPLC and GC methods. Fluconazole serum concentrations were determined by a newly developed HPLC method. Patient characteristics, concomitant medications, clinical test data and ARV serum concentrations were included in a NONMEM generated, onecompartment, open pharmacometric model with first order elimination to detect any drugdrug interactions between fluconazole and the studied ARVs. The secondary outcome was to establish which patient characteristics influence ARV pharmacokinetics. Results: From 80 outpatients, a total of 276 ARV serum samples (137 efavirenz, 67 nevirapine and 72 lopinavir) were collected for pharmacokinetic evaluation. Efavirenz clearance was correlated with race and concomitant use of rifampicin. No significant covariates were established in the nevirapine model. In the lopinavir model, concomitant use of clotrimazole and the antituberculosis combination isoniazid, pyrazinamide and rifampicin were identified as significant covariates. Discussion: No significant effects of fluconazole on the pharmacokinetics of any of the studied ARVs were observed. Varying efavirenz plasma concentrations in different ethnic populations may be due to differences in gene expression particularly CYP2B6. Coloured patients had significantly lower efavirenz serum concentrations (56.8% decrease in clearance), which has not been previously described in the South African context. Although gender was not a significant covariate in the nevirapine model, female patients tended to have higher nevirapine serum concentrations. TB treatment in all patients receiving lopinavir consisted of a combination of isoniazid, pyrazinamide and rifampicin, each with different effects on CYP isoenzymes. The exact contributing factor of each drug in the ultimate decrease in lopinavir clearance (46.4%) can therefore not be established. Conclusions: Given the limitations of the sample size in the present study, no statistical significant effect of fluconazole on the pharmacokinetics of the investigated ARVs could be demonstrated. A retrospective analysis of the data showed various co-factors that influence the pharmacokinetics of the investigated ARVs. This data needs to be confirmed in a prospective study as the identified covariates are appropriate in the management of HIVinfected patients in the South African context. / AFRIKAANSE OPSOMMING: Agtergrond: HIV-positief pasiënte het ‘n aansienlike verswakte immuunstelsel, wat hul hoogs vatbaar tot opportunistiese infeksies maak, en dus, addisionele behandeling benodig. Cryptococcal meningitis en orofaringeale kandidiase word met orale flukonasool behandel. As gevolg van middeling in algemene metaboliese paaie is daar ‘n groot moontlikheid van middel-middel interaksies tussen flukonasool en die antiretrovirale (ARV) middels, efavirenz, nevirapine, en lopinavir/ritonavir. Die uitkomste hiervan mag tot die ontwikkeling van nadelige middel-middel interaksies of middelweerstandigheid en mislukte behandeling lei. Doel: Die primêre doel van hierdie tesis was om die effek van flukonasool op die farmakokinetika van efavirenz, nevirapine en lopinavir/ritonavir in HIV geïnfekteerde pasiënte met gediagnoseerde cryptococcal meningitis en orofaringeale kandidiase te evalueer. Metodes: Die studie was met 80 HIV-positief, behandeling-ervare volwassenes (≥18 jaar) onderneem. Voorafgenoemde was in drie verskillende buitepasiëntklinieke in die Wes-Kaap behandel. Pasiënte was volgens ARV regimen en die gebruik van flukonasool, of dan nie, verder verdeel. ‘n Beperkte steekproef ontwerp was gebruik, en ooreenstemmende ARV serum konsentrasies is deurgevestigde HPLC en GC metodes vasgestel. Flukonasool serum konsentrasies was deur ‘n nuutontwikkelde HPLC metode vasgestel. Pasiëntkenmerke, gepaardgaande medikasie, kliniesetoets data en ARV serum konsentrasies was by ‘n NONMEM genereerde, een-kompartement, oop farmakometriese model met eerste orde eliminasie ingesluit om enige middel interaksies tussen flukonasool en die bestudeerde ARVs op te tel. Die sekondêre uitkomste was om vas te stel watter pasiënt kenmerke ARV farmakokinetika beïnvloed. Resultate:Uit 80 buitepasïente was ‘n totaal van 276 ARV serum monsters (137 efavirenz, 67 nevirapine en 72 lopinavir) vir farmakokinetiese evaluasie gekollekteer. Efavirenz opruiming was met ras gekorreleer asook gepaardgaande gebruik van rifampisien. Geen betekenisvolle ko-variante was in die nevirapine model vasgestel nie. In die lopinavir model het die gepaardgaande gebruik van clotrimazole en die anti-tuberkulose kombinasie isoniazied, pyrazinamied en rifampisien, lopinavir opruiming verminder. Bespreking: In hierdie studie is geen betekenisvolle effekte van flukanosool op die farmakokinetika van enige van die bestudeerde ARVs waargeneem nie. Afwisselende efavirenz plasma konsentrasies in verskillende etniese populasies mag aan verskille in geenuitdrukking, veral CYP2B6, toegeskryf word. Kleurling pasïente het betekenisvolle verlaagde efavirenz serum konsentrasies getoon (56.8% verlaging in opruiming). Hierdie bevinding is nog nooit voorheen in die Suid-Afrikaanse konteks beskryf nie. Alhoewel geslag nie ‘n beduidende ko-variant in die nevirapine model was nie, het vroulike pasïente geneig om hoer nevirapine serum konsentrasies te hê. TB behandeling, in alle pasïente wat lopinavir ontvang het, het uit die volgende kombinasie bestaan: isoniazied, pyrazinamied en rifampisien, elk met hul eie effekte op CYP isoensieme. Die presiese bydra van elke middel in die uiteindelike verlaging (46.4%) in lopinavir opruiming kan dus nie vasgestel word nie. Gevolgtrekking: Gegewe die beperkings van die steekproef in die huidige studie, kon geen statistiese beduidende effek van flukonazool op die farmakokinetika van die betrokke ARVs gedemonstreer word nie. ‘n Retrospektiewe analise van die data het gewys dat verskeidene ko-faktore die farmakokinetika van die betrokke ARVs beïnvloed. Hierdie data moet in ‘n prospektiewe studie bevestig word omdat die geidentifiseerde covariates die bestuur van MIV-positiewe pasiente in die Suid-Afrikaanse konteks te verbeter.

Thesis (MSc)--Stellenbosch University, 2012. / Background: While Selection of reverse transcriptase (RT) mutation has been reported frequently, protease (PR) mutations on antiretroviral therapy (ART) including boosted Protease inhibitor (PI) have not been reported as much in Zambia. Affordable in-house genotyping assays can been used to expand the number of patients receiving drug resistance geno-typing, which can aid in determining prevalence of RT/PI emerging mutations. Methods: A previously published drug resistance genotyping assay was modified and used to genotype RT and PR genes. 19 patients virologically failing first-line regimen and 24 failing second-line regimen were studied to determine resistance patterns. Virological failure was defined as failing to maintain <1000 copies/mL during ART. Only major and minor RT and PR mutations (IAS-USA 2010) were considered for analysis. The in-house assay was validated by comparing sequence data of 7 previously ViroSeq tested samples and 5 randomly selected samples to determine reproducibility. Results: The in-house assay efficiently amplified all 12 validation samples with the lowest sample scoring 99.4% sequence homology. The most common RT mutation was M184V (79% n=19) and (71% n=24) first and second-line respectively. No significant differences were reported in all the other RT mutations between first-line and secondline regimens. Drug resistant PI mutations (I54V, M46I and V82A all present 20.8%) were only found in the second-line regimen and were insignificant, p= 0.0562. Conclusion: The in-house assays can be used as alternatives for commercial kits to genotype HIV-1C in Zambia without compromising test quality. The insignificant PI drug resistant mutations which were found, despite virological failure in patients, could indicate a possibility of other mutations within the HIV-1 genome that could reduce PI susceptibility.

Thesis (MMed)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background: HIV is the defining pandemic of our era, with an estimated 5.9 million people infected in South Africa according to World Health Organization (WHO) estimates for 2011. The expression and treatment of non-AIDS defining cancers has become an important consideration in this cohort, as antiretroviral therapy (ART) has prolonged survival in a subgroup previously at risk of early mortality. Study Design: A retrospective cohort study of all women seen at the Combined Breast Cancer Clinic at Tygerberg Hospital between January 2010 and December 2011, stratified into three subgroups based on HIV status. Methods: Of the 816 patients screened, 586 met inclusion criteria; of which 31 (5.3%) patients were HIV positive, 420 (71.7%) HIV negative, and 135 (23%) had an unknown HIV status. The disease phenotype was described in each subgroup, as well as toxicities associated with standard chemotherapy regimens, with an emphasis on completion rates of systemic cytotoxic treatment. The insult of cytotoxic therapy to the CD4 count was described for this cohort. Results: Women with HIV had a statistically significant (p<0.001) younger age at presentation of breast cancer with a median age of 42 years (range 39 – 45 years) in comparison with the HIV-negative cohort with a median age of 54 years (range 53 – 55 years) . No difference was detected in disease phenotype when stage at presentation (p=0.7874), histological subtype (p=0.3375), grade of differentiation (p=0.8297), nodal involvement (p=0.0998) or hormone-receptor positivity (p=0.6285) was considered. Completion rates for systemic chemotherapy were excellent (>90%) regardless of HIV-status and no statistically significant toxicity was observed. The median CD4 count at diagnosis was 477 cells/μL (range 234 – 807 cells/μL), with a nadir value of 333 cells/μL (range 62 – 713 cells/μL), representing a decrease of 30.2% during treatment. One case of suspected treatment-related mortality was recorded. Conclusion: This retrospective study confirmed that women infected with HIV had a younger age at breast cancer diagnosis when compared to women with a negative HIV-status. No difference in disease phenotype could be demonstrated for women with HIV, denoting the coexistence of two common chronic diseases. Chemotherapy was tolerated well, but caused a median decline in CD4-count of 30% during treatment. / AFRIKAANSE OPSOMMING: Agtergrond: Infeksie met die Menslike Immuungebrek-Virus (MIV) is die pandemie van ons era, met ‘n geraamde 5.9 miljoen mense geïnfekteerd in Suid-Afrika volgens die Wêreld Gesondheids-Organisasie (WGO) in 2011. Kankers wat nie met MIV geassosieer word nie, het n belangrike oorweging in hierdie populasie-groep geword as gevolg van die gebruik van anti-retrovirale terapie wat die lewensverwagting van mense met MIV verleng. Navorsingsontwerp: ‘n Retrospektiewe kohort studie van alle vroue wat tydens die tydperk Januarie 2010 en Desember 2011 by die Gekombineerde Borskanker Kliniek te Tygerberg Hospitaal behandel was, verdeel in 3 groepe volgens hul retrovirale status. Metodes: ‘n Totaal van 819 vroue was oorweeg vir insluiting in die studie, waarvan 586 aan die insluitingskriteria voldoen het. Daar was 31 vroue met MIV (5.3%), 420 vroue het MIVnegatief getoets (71.7%), en 135 (23%) vroue waarvan die MIV-status onbekend was. Die fenotipe van borskanker was beskryf vir elke sub-groep, sowel as die toksiteite wat geassosieer word met die gebruik van standaard chemoterapie-skedules, insluitend die effek van chemoterapie op die CD4-telling. Bevindinge: Vroue met MIV het op ‘n statisties noemenswaardige (p<0.001) jonger ouderdom gepresenteer met borskanker (gemiddelde ouderdom 42 jaar, reikwydte 39 – 45 jaar) in vergelyking met vroue wat MIV-negatief was (gemiddelde ouderdom 54 jaar, reikwydte 53 – 55 jaar). Geen verskil was waargeneem in die fenotipe van borskanker in vroue met MIV vir die stadium by diagnose (p = 0.7874), histologiese tipe (p=0.3375), graad van differensiasie (p = 0.8297), nodale betrekking (p = 0.0998) of hormoon-reseptor status (p=0.6285) nie. Voltooing van sistemiese chemoterapie is bereik in meer as negentig persent van gevalle onafhanklik van MIV-status. ‘n Gemiddelde CD4-telling van 477 selle/μL (reikwydte 234 – 807 selle/ μL) met diagnose het ‘n gemiddelde afname van 30.2% tydens behandeling getoon na ‘n gemiddelde waarde van 333 selle/ μL (reikwydte 62 – 713 selle/ μL). Gevolgtrekkings: Hierdie retrospektiewe studie het bevind dat vroue met MIV op ‘n jonger ouderdom met borskanker presenteer as vroue wat MIV-negatief is. Geen noemenswaardige verskil was waargeneem in die fenotipe van borskanker in vroue met MIV nie, en dui daarop dat borskanker en MIV twee algemene, maar onafhanklike entiteite is. Chemoterapie was goed getolereer met ‘n gemiddelde afname in die CD4-telling van 30.2% tydens chemoterapie.

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Medroxyprogesterone acetate (MPA) and norethisterone (NET) and its derivatives (norethisterone enanthate (NET-EN); norethisterone acetate (NET-A)), designed to mimic the actions of the endogenous hormone progesterone (Prog), are extensively used by women as contraceptives and in hormone replacement therapy (HRT). A number of reports have indicated that these synthetic progestins affect immune function in the female genital tract thereby increasing the risk of acquiring sexual transmitted infections. Despite these findings, very little is known about their mechanism of action at the cellular level, in particular their steroid receptor-mediated effects on cytokine gene expression. In the first part of this thesis, the effect of Prog, MPA and NET-A on the expression of the endogenous pro-inflammatory cytokine gene, interleukin (IL)-12p40, and anti-inflammatory cytokine gene, IL-10, was investigated in a human ectocervical epithelial cell line, Ect1/E6E7. Quantitative realtime PCR (qPCR) showed that all three ligands significantly upregulated the tumor necrosis factor alpha (TNF )-induced IL-12p40 gene expression, while IL-10 gene expression was downregulated. Moreover, by reducing the glucocorticoid receptor (GR) levels with siRNA, these effects were shown to be mediated by the GR. A more detailed investigation into the molecular mechanism of the progestogen-induced upregulation of IL-12p40 gene expression, using chromatin immunoprecipitation (ChIP), siRNA, co-immunoprecipitation and re-ChIP analyses, showed that the progestogen-bound GR is recruited to the CCAAT enhancer binding protein (C/EBP)- regulatory element of the IL-12p40 promoter, most likely via an interaction with the transcription factor C/EBP . Similar experiments for the progestogen-induced downregulation of IL-10 gene expression showed that the progestogen-bound GR is recruited to the signal transducer and activator of transcription (STAT)-3 regulatory element of the IL-10 promoter, most likely via an interaction with the transcription factor STAT-3. The second part of this study elucidated the influence of the HIV-1 accessory viral protein R (Vpr) on progestogen-induced regulation of IL-12p40, IL-12p35 and IL-10 in the Ect1/E6E7 cell line. Results showed that in these cells, the overexpression of Vpr significantly modulated the effects of Prog, MPA and NET-A on the mRNA expression of IL- 12p40 and IL-10, while only the NET-A effect was modulated on IL-12p35. Moreover, reducing the GR protein levels by siRNA suggested that the GR is required by Vpr to mediate its effects. Taken together, these results show that Prog, MPA and NET-A promote the pro-inflammatory milieu in the ectocervical environment, and that during HIV-1 infections, this milieu is modulated. Furthermore, the results suggest that the use of MPA or NET in vivo may cause chronic inflammation of the ectocervical environment, which may have important implications for ectocervical immune function, and hence susceptibility to infections such as HIV-1. / AFRIKAANSE OPSOMMING: Medroksieprogesteroon asetaat (MPA), noretisteroon (NET) en derivate daarvan noretisteroon enantaat (NET-EN); noretisteroon asetaat (NET-A), ontwerp om die funksies van die natuurlike hormone progesteroon (Prog) na te boots, word wêreldwyd deur vroue as voorbehoedmiddels sowel as vir hormoon vervangingsterapie (HVT) gebruik. Daar is verskeie aanduidings dat hierdie sintetiese progestiene die immuunfunksie in die vroulike geslagskanaal kan beïnvloed en ook die moontlike vatbaarheid van seksueel oordraagbare infeksies kan verhoog. Ten spyte hiervan, is baie min bekend oor hulle meganisme van werking op ‘n molekulêre vlak, veral in die besonder hul effek op sitokinien geenuitdrukking. Die effek van Prog, MPA en NET-A op die geenuitdrukking van ’n endogene pro-inflammatoriese sitokinien, interleukin (IL)-12, en ’n anti-inflammatoriese sitokinien, IL-10, asook die onderliggend meganisme van werking, in ’n menslike ektoservikale sellyn, Ect1/E6E7, is in die eerste deel van hierdie studie ondersoek. Kwantitatiewe “realtime” polimerisasie ketting reaksie (PKR) het getoon dat al drie die ligande die tumor nekrosis faktor alfa (TNF- )-geïnduseerde IL-12p40 geenuitdrukking opreguleer en IL-10 geenuitdrukking onderdruk. Verder is gevind dat induksie van IL-12p40 en inhibisie van IL-10 deur Prog, MPA en NET-A deur die glukokortikoïed reseptor (GR) gedryf word, aangesien volledige opheffing van die effekte op hierdie sitokinien gene waargeneem is wanneer die GR proteïen vlakke deur middel van kort inmengende ribonukleïensuur (siRNS) verminder is. 'n Meer beskrywende ondersoek in die molekulêre meganisme is uitgevoer deur gebruik te maak van chromatien immunopresipitasie (ChIP), siRNS, mede-immunopresipitasie en her-ChIP analises. Hierdie resultate het voorgestel dat die progestogeen (Prog en die sintetiese progestiene)-gebonde GR tot die CCAAT verbeterende bindings protein (C/EBP)- regulatoriese element van die IL-12p40 promotor betrek word en dat die transkripsie faktor C/EBP benodig word om transkripsie van die IL-12p40 geen te aktiveer. Met betrekking tot IL-10, het die resultate voorgestel dat die progestogeen-gebonde GR tot die sein transduksie en aktiveerder van transkripsie (STAT)-3 regulatoriese element van die IL-10 promotor betrek word en dat die transkripsie faktor STAT-3 benodig word om transkripsie van die IL-10 geen te onderdruk. Die tweede deel van die studie het die invloed van die MIV-1 aksesorale virale proteïen R (Vpr) op sitokinien geenuitdrukking, spesifiek die progestogeen-geïnduseerde regulering van IL-12p40, IL-10 en IL-12p35, in die Ect1/E6E7 sellyn ondersoek. Resultate het getoon dat ooruitdrukking van Vpr in hierdie sellyn die effekte van Prog, MPA en NET-A op die mRNS uitdrukking van IL-12p40 en IL-10, en slegs die NET-A effek op IL-12p35, aansienlik moduleer. Vermindering van die GR proteïen vlakke deur middel van siRNS het getoon dat Vpr die GR benodig om hierdie veranderinge mee te bring. In samevatting, die resultate van hierdie proefskrif stel voor dat Prog, MPA en NET-A die pro-inflammatoriese milieu in die ektoservikale omgewing bevorder, en dat hierdie milieu gedurende MIV-1 infeksies verander. Verder, die resultate van hierdie studie impliseer dat die gebruik van MPA en NET in vivo nadelige lokale immuunonderdrukkende effekte mag hê wat kan lei tot kroniese inflammasie van die ektoservikale omgewing en ‘n moontlike verhoging in die vatbaarheid van infeksies soos MIV-1.

Thesis (PhD)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: The prevention of mother-to-child transmission (PMTCT) of HIV is a key maternal and child health intervention in the context of the HIV/AIDS pandemic in South Africa. Accordingly, the PMTCT programme has been incorporated in the District Health Management Information System (DHMIS) that collects monthly facility-based data to support the management of public health services. To date, there has not been a comprehensive evaluation of the PMTCT information system. By comparing the experiences in two health districts, using the Performance of Routine Information System Management (PRISM) framework and tools, this study seeks to evaluate the availability, quality and use of process and output indicators for monitoring PMTCT interventions. A comparative analytical and observational study was undertaken using a multi-method approach which included: a self-administered survey of health information personnel to assess confidence and competence levels for routine health information system (RHIS) tasks, an assessment of the routine PMTCT data for quality, completeness, accuracy, and data use; and a facility survey of RHIS processes and resources. In addition, in-depth interviews with 22 key informants and observations in health facilities were conducted. Data were collected from 57 health facilities in a convenience sample of two health districts, and also from 182 health information personnel in the 57 health facilities, three sub-districts, and two district offices. Descriptive statistics, χ2-test, correlation and multiple regression analyses were conducted using STATA® Version 13. A general inductive approach was also used to analyse the qualitative data, which was used for triangulation. The study revealed considerable data quality concerns for the PMTCT information with an average accuracy between the register and routine monthly report of 51% and between the routine monthly reports and DHMIS database of 84% suggesting that the primary point of departure for accurate transfer of data is during the collation process. The importance of human factors was emphasised by the observation that the average confidence level for performing RHIS-related tasks (69%) was not commensurate with the average competence levels (30%). Education was found to be associated with competence, implying that levels of education may be associated with the level at which RHIS competencies are acquired; and that three years or more of post-matriculation education is necessary. Motivation, on the other hand was not associated Stellenbosch University https://scholar.sun.ac.za iv with competence. The study observed the absence of processes such as data-quality checks and data-analysis in place in facilities. There was a general absence of a culture of information use, as a result of lack of trust in the data, and the inability of programme and facility managers to analyse, interpret and use information. We observed differences in the data accuracy by organisational authority, and multivariate analysis and qualitative information suggested that feedback may be an essential process to ensure quality. Although the PRISM framework has been developed from a multi-disciplinary evidence base, this study has been able to validate some of the internal assumptions but has also found some aspects that were not supported such as motivation and data display. Data collected from a larger number of facilities will be required to investigate this further. Institutional capacity to improve RHIS processes, ensure core competencies for RHIS-related tasks are needed, and in the longer term, measures to tackle problems associated with low pass rates in numeracy subjects among high school learners are needed. Further exploration of the possible factors that may influence data accuracy, such as supervision, training and leadership are needed as well as investigating the relationships between human and institutional agency-related aspects, in particular, how individual actions can bring about changes in institutional routines. Further study is needed to determine how decision for planning and evaluating key programmes such as PMTCT are made, and what informs such decisions if not routine data. / AFRIKAANSE OPSOMMING: In die lig van Suid Afrika se MIV/VIGS-pandemie kan ’n ingryping op gesondheidsvlak ’n belangrike rol speel om moeder-na-kind-oordrag (beter bekend as PMTCT) van MIV te voorkom. ’n Inligtingstelsel vir distriksgesondheidsbestuur – die DHMIS – was ontwerp vir die invordering van maandelikse fasiliteitsdata, wat gebruik kan word om die bestuur van openbare gesondheidsdienste en -programme te ondersteun. Die inligtingstelsel self was nog nie omvattend evalueer nie. Hierdie studie het die ervarings van twee gesondheidsdistrikte vergelyk met behulp van die PRISM- (Performance of Routine Information System) raamwerk en -instrumente. Derhalwe het hierdie studie die beskikbaarheid, gehalte en gebruik van proses- en uitsetaanwysers probeer bepaal om die PMTCT-ingrypings te monitor. ’n Vergelykende analitiese en waarnemingstudie is onderneem met behulp van ’n veelvuldige benadering. Die verskillende metodes het ’n selfopname onder gesondheidsinligtingspersoneel ingesluit om hul selfvertroue en bevoegdheid in roetinegesondheidsinligtingstelsel (RHIS)-take te evalueer. Daar was ook ’n assessering van die PMTCT-roetinedata om datagehalte, -volledigheid, -akkuraatheid en -gebruik te beoordeel.’n Fasiliteitsopname oor RHIS-prosesse en –hulpbronne was ook gedoen. Ander navorsingsmetodes het diepte-onderhoude met 22 sleutelpersone ingesluit, sowel as waarnemings in gesondheidsfasiliteite. Data is van 182 gesondheidsinligtingpersoneel van die 57 gesondheidsfasiliteite in ’n geriefsteekproef van twee gesondheidsdistrikte ingesamel. Deskriptiewe statistiek, χ2-toetsing, korrelasie en veelvoudige regressie is met behulp van STATA® weergawe 13 ontleed. ʼn Algemene induktiewe benadering is ook gevolg om die kwalitatiewe data te ontleed. Die studie toon dat menslike faktore ’n impak op datagehalte en -inligting kan hê, met ’n gemiddelde akkuraatheidsyfer van 51% van beide die register en roetine maandelikse verslae. Die akkuraatheid van die maandelikse verslae en RHIS databasis is 84%, wat aandui dat akkuraatheid slegs toegepas word indien inligting uit die staanspoor korrek aangeteken word. Die impak van menslike hulpbronafaktore was beklemtoon toe daar bevind was dat hoewel 69% van RHIS-dataverwerkers vertroue getoon het in die gebruik van RHIS-verwante take, slegs 30% wel bevoeg was om die werk te doen. Opvoeding was grootliks geassosieer met bevoegdheid, wat moontlik voorstel dat sekere vlakke van opvoeding benodig word vir spesifieke RHIS-bevoegdhede. Minsten drie jaar tersiêre opleiding word aanbebeel. Motivering was nie met Stellenbosch University https://scholar.sun.ac.za vi bevoegdheid geklassifeer nie. Die studie het bevind dat daar te min aandag aan datagehalte en –analise gegee word in fasiliteite. Oor die algemeen was daar nie ’n ordentlike kultuur van inligtinggebruik nie, a.g.v. die feit dat daar nie vertroue in die data was nie. Terselftertyd was program- en fasiliteitbestuurders nie bevoeg om inligting te analiseer en ontleed nie. Ons het verskille in die akkuraatheid van data opgetel wat deur organisasie-hoofde gedoen was. Meervoudige analise en kwalitatiewe informasie stel voor dat terugvoering ’n belangrike deel van die proses moet wees om kwaliteit te verseker. Hoewel die PRISM-raamwerk saamgestel was uit ’n multi-dissiplinêre bewyslewering, kon hierdie studie sommige van die interne voorneme valideer, maar daar was aspekte wat nie gestaaf kon word nie. Inligting van ’n groter aantal fasiliteite sal benodig word om verder hierna ondersoek in te stel. Institusionele kapasiteit word benodig om RHIS-prosesses te verbeter en basiese vaardighede vir RHIS-verwante take te verseker. Op langtermynvlak moet daar ook gekyk word na probleme wat lei tot laë slaagsyfers in syfervaardighede in hoërskoolleerders. Verdere ondersoek moet ingestel word om vas te stel watter faktore moontlik akkurate data teweeg kan bring. Dit sluit toesig, opleiding en leierskap, asook die verhoudings tussen menslike en agentskap-verwante aspekte in. Die feit dat optrede op individuele vlak veranderings in institusionele roetines kan aanbring, moet spesifiek na gekyk word. Verdere studies kan help om vas te stel hoe besluite vir beplanning en evaluaring vir hoofprogramme soos PMTCT gemaak word – asook hoe die besluite gemaak word indien hulle nie roetine voorafgaan nie.

Thesis (DMed (Medicine. Internal Medicine))-University of Stellenbosch, 2005. / Mycobacterium tuberculosis (M. tuberculosis) accounts for more adult deaths than any other infectious agents. The present study included 162 patients with tuberculous pericarditis; 50% of the tuberculous pericarditis patients studied were human immunodeficiency virus (HIV) positive, compared to only 4.2% of patients who presented with non-tuberculous pericardial effusions. A steady year-to-year rise in HIV prevalence was observed in this 6-year study. Although the prognosis of pericardial tuberculosis (TB) is excellent with appropriate medical treatment, untreated pericardial TB has a mortality of 80-85%. It is thus important to diagnose tuberculous pericarditis efficiently. Traditionally, the diagnosis of pericardial TB is established by positive mycobacterial culture and/or histological evidence of necrotising granulomatous inflammation of the pericardium. Our study confirmed the insensitivity of pericardial fluid culture and pericardial biopsy in the diagnosis of pericardial TB, and at the time of clinical decision-making, results were usually not available. To overcome these difficulties, we explored various alternative strategies and this resulted in two diagnostic tools, namely a diagnostic rule and a diagnostic algorithm or classification tree. By means of classification and regression tree analysis, we allocated a weighted diagnostic index to each of five independently predictive features (fever, night sweats, weight loss, serum globulin >40 g/L and peripheral blood leukocyte count <10x109/L). A total diagnostic index of 6 or more corresponded to 82-86% sensitivity and 76-87% specificity for a diagnosis of tuberculous pericarditis. When possible, pericardial fluid should be aspirated to determine adenosine deaminase (ADA) levels and pericardial differential leukocyte counts. Fluid should also be sent for Gram stain and culture. The proposed diagnostic classification tree utilises the independently predictive attributes of pericardial adenosine deaminase levels, pericardial fluid lymphocyte/neutrophil ratios, peripheral leukocyte counts and the HIV status. Applying this prediction model to our entire data set of 233 patients resulted in 96% sensitivity and 97% specificity for the correct diagnosis of tuberculous pericarditis. Generally, patients were critically ill at the time of enrolment; 90% of tuberculous pericarditis presented with echocardiographic features of cardiac tamponade. Echoguided percutaneous pericardiocentesis with an indwelling catheter and intermittent daily aspiration was highly effective and safe. It is likely that the combination of this drainage technique and the early initiation of anti-tuberculous chemotherapy contributed to the almost complete absence of constriction in the patients studied, and our data do not support the routine use of adjunctive corticosteroids in patients with tuberculous pericarditis. Tuberculous exudates result from a Th1 mediated immune response characterised by lymphocyte dominance, significantly elevated levels of gamma-interferon (IFN-γ) and undetectable levels of interleukin-4 (IL-4). IFN-γ levels were not influenced by HIV status in spite of the severely diminished pericardial CD4+ lymphocyte counts observed in this study. It is thus likely that in HIV positive patients IFN-γ production is partly maintained by activated CD8+ T cells, which were significantly elevated in HIV positive patients compared to HIV negative tuberculous pericarditis patients. This finding underlines the importance of IFN-γ in the human immune response against M. tuberculosis. We also demonstrated that the presence of ADA in pericardial fluids reflects the activity of the cellular immune response. Both IFN-γ and ADA can be utilised as sensitive and specific diagnostic tools for pericardial TB.

Thesis (MComm)--Stellenbosch University, 2002. / ENGLISH ABSTRACT: South Africa faces one of the world's most severe HIV/AIDS epidemics. Whereas the disease was initially only regarded as a serious health crisis, it is now clear that the epidemic will also have economic repercussions. The objective of this study is to project the extent of the macro-economic impact of HIV/AIDS in South Africa over the next 10 to 15 years. The study commences with a discussion of the key characteristics of HIV/AIDS and the current status of the epidemic in South Africa. The demographic inputs used are based on projections produced by the HIV/AIDS model of Metropolitan Life (the Doyle model). The methodology and key assumptions behind the Doyle model are described briefly, after which the demographic projections are presented and discussed. The paper contains a summary of previous approaches to modelling the economic impact of HIV/AIDS, as well as a presentation and discussion of their simulation results. In reviewing the available literature on the economic impact of HIV/AIDS, it becomes apparent that researchers have not yet reached consensus on the economic impact of HIV/AIDS in South Africa - estimates of the impact on GDP growth range anywhere between a reduction of 0.3 and 2.0 percentage points over the next 10 to 15 years. The approach that is used in modelling the economic impact of HIV/AIDS in this study comprises the following: Firstly, a no-AIDS forecast of the South African economy is generated using the annual macro-econometric forecasting model of the Bureau for Economic Research. Secondly, the channels through which the epidemic would likely impact on the economy are identified and modelled. These include slower growth in the population and the labour force; higher employee benefit contributions by employers and employees; indirect costs to the private and public sectors (e.g. lower productivity and higher recruitment and training costs); and higher health and welfare expenditure by the government, as well as an increase in tax rates. The economic effects of each impact channel are analysed independently, after which the different impact channels are combined in the model for the aggregated AIDS inclusive simulation. The results are presented in the form of comparisons between "no-AIDS" and "AIDS" projections for key economic variables for the period 2001 to 2015. The paper also contains results from a macro-economic sensitivity analysis, in which seven of the key assumptions are altered in order to test the sensitivity of the model to these changes. Simulation results indicate that the epidemic will have a negative impact on economic growth in South Africa - real GDP growth could fall from a projected average of 3.7% over the period 2002-2015 without HIV/AIDS to between 3.4% and 3.1 % per year with HIV/AIDS. In contrast, real per capita GDP growth is projected to be 0.7 to 1.0 percentage points higher compared to a no-AIDS scenario, as the adverse impact of the epidemic on the population will outweigh the negative impact on real GDP. / AFRIKAANSE OPSOMMING: Suid-Afrika staar een van die wêreld se ernstigste MIV/VIGS epidemies in die gesig. Aanvanklik is die siekte slegs as 'n erge gesondheidskrisis beskou, maar vandag is dit duidelik dat die epidemie ook ekonomiese gevolge sal hê. Die oogmerk van hierdie studie is om die omvang van die makro-ekonomiese impak van MIV/VIGS oor die volgende 10 tot 15 jaar in Suid-Afrika te beraam. Die proefskrif begin met 'n bespreking van die belangrikste eienskappe van MIV/VIGS en die huidige stand van die epidemie in Suid-Afrika. Die demografiese insette wat gebruik word, is gebaseer op projeksies van Metropolitan se MIV/VIGS model (die Doyle model). Die metodiek en die sleutel aannames van die Doyle model word kortliks bespreek, waarna die demografiese projeksies aangebied en bespreek word. Die studie bevat 'n opsomming van benaderings wat van te vore gebruik is om die ekonomiese impak van MIV/VIGS te modelleer, asook 'n voorlegging en 'n bespreking van hul resultate. 'n Oorsig van beskikbare literatuur oor die ekonomiese impak van MIV/VIGS bring aan die lig dat daar in werkilikheid nog geen konsensus oor die omvang van die impak op die Suid-Afrikaanse ekonomie bereik is nie. Beramings van die impak op BBP groei oor die volgende 10 tot 15 jaar wissel van 'n vermindering met 0.3 tot 2.0 persentasie punte. Die benadering wat in hierdie studie gevolg word om die ekonomiese impak van HIV/VIGS te modelleer behels die volgende: Eerstens word 'n vooruitskatting van die Suid- Afrikaanse ekonomie sonder MIV/VIGS gegenereer met die hulp van die makroekonometriese vooruitskattings model van die Buro vir Ekonomiese Ondersoek. Die tweede stap behels die identifisering en die modellering van die verskillende kanale waardeur die epidemie moontlik die ekonomie kan affekteer. Dit sluit onder andere die volgende in: stadiger groei in die populasie en die arbeidsmag; hoër bydraes deur werkgewers en werknemers aan werknemer-bystandfondse; indirekte onkostes vir die privaat en openbare sektore (bv. laer produktiviteit en hoër werwings- en opleidings koste); 'n toename in staatsbesteding op gesondheids en welsyns dienste; asook 'n styging in belastingkoerse. Die ekonomiese implikasies van elkeen van die kanale word individueelontleed, waarna die verskillende kanale saamgevoeg word vir die oorkoepelende simulasie. Die resultate word aangebied in die vorm van vergelykings tussen "geen-VIGS" en "VIGS" projeksies vir sleutel ekonomiese veranderlikes oor die periode 2001-2015. Die proefskrif bevat ook 'n voorlegging van die resultate van 'n makro-ekonomiese sensitiviteits ontleding, waarin sewe van die sleutel aannames verander is met die doelom die gevoeligheid van die model vir hierdie veranderinge te bepaal. Die resultate toon dat die epidemie 'n negatiewe uitwerking op ekonomiese groei in Suid-Afrika sal hê - die gemiddelde groeikoers in die reële BBP oor die periode 2001-2015 mag daal van 'n geprojekteerde 3.7% sonder MIV/VIGS tot tussen 3.4% en 3.1 % met MIV/VIGS. In teenstelling toon die resultate dat die gemiddelde groeikoers in per capita reële BBP tussen 0.7 en 1.0 persentasie punte hoër mag wees vergeleke met die "geen-VIGS" scenario. Die toename in per capita BBP groei kan toegeskryf word aan die skerp daling in die groei van die populasie as gevolg van MIV/VIGS.

published_or_final_version / abstract / Microbiology / Doctoral / Doctor of Philosophy

Section A provides a conceptual critical review of the literature pertinent to the consideration of Mothers living with HIV/AIDS (MLWHA), with a particular focus on African mothers. This review first highlights relevant contextual factors, including discussing prevalence rates and the current reconceptualisations of HIV. This is followed by theories and research relevant to MLWHA, whilst considering wider contextual, social and cultural factors. Thirdly, the theoretical links of the reviewed literature to coping models and strategies are made, and specific cultural factors considered. Finally, suggestions for future research are highlighted. Section B provides the findings of a qualitative investigation conducted to explore the experience of African women living in the UK after being diagnosed with HIV during their pregnancy. Twelve participants completed a short demographic questionnaire, and participated in a one-to-one semi-structured interview. The interview was designed to address multiple personal, interpersonal, and systemic issues related to their HIV status, and HIV in the context of motherhood. Data were analysed using interpretative phenomenological analysis (IPA). Themes which emerged included: HIV being part of one’s wider tapestry, community and systemic influences and responses to HIV, experiencing a different story of HIV, and the mother-child relationship. Strikingly, the aspect of HIV that these women reported finding most distressing was their inability to breastfeed, which seemed central to their cultural identity as mothers. While the generalisability of these findings is clearly limited, nevertheless it seems important for clinicians to (i) recognise that HIV may not always be the primary difficulty facing their clients, and may be amongst numerous other factors, (ii) consider systemic and contextual factors, including cultural influences and past trauma, (iii) focus on client resources and capacity for resilience, and (iv) support clients to access local resources, including support groups, (v) attend to issues around confidentiality, disclosure decisions and breastfeeding, and (vi) hold in mind the potentially powerful and helpful affect for these women of witnessing different narratives around HIV. The continuing need to counteract stigma and discrimination, including from health professionals and from the media, was also apparent. Section C provides a critical appraisal and reflection on the research process, including, evaluating what research skills were learned, which research skills the researcher wishes to develop in the future, what would the researcher have done differently given the chance, how will the research shape or inform the researcher’s clinical practice, and what future research related to the studied area would the researcher consider carrying out.