Introduction Human immunodeficiency virus (HIV) infection is becoming a global epidemic. In HIV-infected individuals, anorectal diseases are common and the commonest indications for surgical intervention. However, it has not been clear whether the cause and management of anorectal conditions differ in patients who are HIV negative and those who are HIV positive. Aim To compare the presentation of perianal diseases in HIV +ve and HIV –ve patients and to determine the best therapy for perianal diseases in HIV +ve patients Methods The study period was from 1999 to 2002. Patients seen at Helen Joseph Hospital during the author’s gastroenterology fellowship period and those from his private practice were recruited. Those who agreed to HIV testing and who were treated by the author were included in the study. The patients were categorized according to HIV status, CDC classification and perianal pathology. Standardized questionnaires were used for every patient. Patients were reviewed every two weeks after the procedure until fit for discharge. Results The sample comprised 241 patients: 100 HIV+ve (63 males and 37 females) and 141 HIV-ve (61 males and 80 females). The mean age of the HIV+ve patients was 34,8y (range 17-62y), and the mean age of the HIV-ve patients was 41y (range 5-82y). Follow-up was from two weeks to two years. The pathology included 62 (25 +ve, 37 -ve) haemorrhoids, 67 (27 +ve, 40 –ve) fistulas, 59 (25 +ve, 34 -ve) abscesses, 46 (11 +ve, 35 -ve) fissures, 24 (22 +ve, 2 -ve) anal ulcers, four (3 +ve, 1 -ve) anal warts, two (both +ve) pilonidal sinuses, three (all -ve) anal cancers and two (1 +ve, 1 -ve) hidradenitis suppurativa. Nine patients with haemorrhoids (4+ve, 5-ve) were treated conservatively, 11 patients with haemorrhoids (6+ve, 5-ve) had rubber band ligation and 42 patients with haemorrhoids (15+ve, 27-ve) had haemorrhoidectomy. Thirteen patients (1+ve, 12-ve; p<0.001) had complex fistulas and 8 patients (7+ve, 1-ve; p=0.006) had multiple fistulas. Ten HIV -ve patients with complex fistulas and seven patients with trans-sphincteric fistulas (3+ve, 4-ve) needed more than six weeks to heal after treatment. Thirty patients with anal fissures had sentinel piles, but there were none in the patients with anal ulcers (p<0.0001). Thirteen HIV +ve patients with anal ulcers had an abnormally weak anal tone, but only one HIV +ve patient with anal fissure had a weak anal tone (p<0.001). In the patients with anal fissure, 37 (8+ve, 29-ve) had a high anal tone, but none of the patients with anal ulcers had increased anal tone (p<0.0001). Of the 59 patients with perianal suppuration, 23 (8+ve, 15-ve) had primary fistulotomy as well as drainage of the abscess. Conclusions Multiple fistulas were more commonly seen in advanced HIV patients, whereas complex fistulas were more commonly seen in HIV negative individuals. Healing after fistula surgery is determined more by the type of fistula than the HIV status or stage. Anal fistulas associated with perianal suppuration can be treated the same way in both HIV negative and positive patients, without increased complications. Careful physical examination is essential to differentiate between anal ulcers and fissures. Both conditions are common, and have similar symptoms in HIV positive patients. They can, however, be readily and safely distinguished on clinical examination, since fissures are associated with high anal tone, and a sentinel pile, while the AIDS ulcer lacks the sentinel pile, and the pressure is low. Anal malignancies, especially squamous cell carcinoma, have been uncommon in our experience. With the addition of anti-retroviral therapy and antibiotics, haemorrhoids may be safely treated according to standard principles (rubber band ligation and haemorrhoidectomy, as appropriate). Our practice has favoured a conservative approach in patients with advanced HIV disease. However, anti-retroviral therapy and antibiotics may improve the safety and outcome after surgical procedures.

ABSTRACT This study was designed to screen antiretroviral therapy (ART)-naïve human immunodeficiency virus (HIV) infected patients for proteinuria, using urine dipsticks, at the HIV outpatient clinic at Johannesburg Hospital in an attempt to detect and treat early renal disease. In those with persistent proteinuria, a marker of kidney disease, renal biopsy was performed, ART with and without angiotensin-converting enzyme inhibitors (ACE-I) was initiated and patients were followed up for immunological and renal responses. After a minimum period of 12 months, a repeat biopsy was performed, where possible, to determine whether the histological lesions had responded to treatment. During urinary screening, proteinuria, leucocyturia and microscopic haematuria were common. Sterile leucocyturia may be associated with co-morbid sexually transmitted infection or tuberculosis. In the group that underwent renal biopsy with treatment, the renal and immunological response, before and after ART was highly statistically significant. Renal and immunological responses to ART were assessed by reduction in proteinuria with increased GFR, increased CD4 count with reduction in HIV viral load, respectively. On biopsy, HIV-associated immune complex disease was more common than HIVAN, a finding that contradicts international and some local data. Resolution of proteinuria was relatively rapid in comparison to the histological response to treatment, an effect not previously shown. This is the first study of its kind, to the author’s knowledge, that prospectively evaluates the effect of ART with/ ACE-I in ART-naïve HIV infected patients with both clinicopathological and histological criteria. It has shown unequivocally, that renal disease, particularly if detected and treated early in HIV infection, is responsive to treatment. These findings suggest screening for early detection and treatment of HIV-associated renal disease should be mandatory in HIV clinics in South Africa.

International literature, most of which originates from First-world countries where HIV predominantly affects socially marginalised minority populations, has well-described the burden of mental disorder, particularly depressive and anxiety disorders in HIV-infected individuals. The few studies conducted in developing countries show contradictory results. This study aimed to describe the occurrence of mental disorders; particularly depressive and anxiety disorders, in a population of HIV-infected individuals attending HIV-treatment sites in Gauteng and Mpumalanga in South Africa from November 2004 to November 2005. A cross-sectional descriptive-analytic study, it included a clinical diagnostic interview and a semi-structured interview to explore postulated risk and protective factors, including demographic, clinical and psychosocial variables, for depressive and anxiety disorders in HIV-infected individuals. Three hundred and two (302) individuals were interviewed at the Perinatal HIV Research Unit’s associated Wellness clinics and at the Chris Hani Baragwanath Hospital’s Nthabiseng HIV clinic. Just over thirty percent of participants had a current mental disorder and the lifetime prevalence of mental disorder was 40%. Almost 17% of participants had a current depressive disorder and almost 16% had a lifetime depressive disorder. The occurrence of major depressive disorder, current and lifetime, was 3.64% and 10.26% respectively. Sixty percent of participants with lifetime major depressive disorder had their first onset after diagnosis of HIV status. The occurrence of current and lifetime anxiety disorder was almost 4%. Substance use disorders were common, affecting 7.6% of the participants at time of interview. Lifetime prevalence of substance use disorders was 18.9%, suggesting that knowledge of HIV status or other interventions may have resulted in this significant decrease. Identified significant risk factors for depressive disorder included a history of a lifetime depressive disorder, moderate or severe psychosocial stress and feelings of isolation. Being in a support group was found to be a protective factor against depressive disorder. While the results in this study are conservative compared to those of other similar South African studies in HIV-infected individuals, there was a statistically significantly increased occurrence of depressive and anxiety disorders (combined) compared to general population prevalence studies of these disorders in South Africa. Ways of improving access to mental healthcare for HIV-infected individuals and the general population, are discussed

M.Med.(Anaesthesia), Faculty of Health Sciences, University of the Witwatersrand, 2011 / BACKGROUND Multiple studies have been conducted comparing the efficacy and duration of analgesia obtained from spinal anaesthesia containing local anaesthetics as well as opioids. The literature available has not considered the individual‟s HIV status as a variable. Postoperative analgesic duration and requirements in this group of patients may differ due to the occurrence of acute and chronic pain syndromes, pain arising from the disease itself, side effects of treatment for HIV infection, or opportunistic infections. Response to opioid analgesia may be altered due to previous opioid exposure, potential increase in nociception, drug interactions and emotional status. OBJECTIVES The primary objective of this study was to determine the time to post-operative analgesic request in HIV-positive and negative individuals having caesarean sections under spinal anaesthesia containing bupivacaine or bupivacaine and fentanyl. The secondary objectives of this study were to determine if factors such as height, ethnicity, level of education, CD4 count, and antiretroviral therapy impacted on the duration of analgesia obtained.

MSc (Med), Virology, Faculty of Health Sciences, University of the Witwatersrand / Bartonella is a genus of fastidious bacteria responsible for a wide range of both symptomatic and asymptomatic infections. Bartonellae are often considered obligate pathogens where infection is concurrent with immunological suppression of the host. The objectives of this study were: to determine the prevalence of Bartonella infections in HIV-positive patients presenting for treatment at a Gauteng HIV-clinic, to determine the extent of bartonellae affecting the healthy population, to determine the seroprevalence of Bartonella henselae and Bartonella quintana antibodies in HIV-negative antenatal patient sera taken from various maternity units in Gauteng public hospitals, and to investigate cats, dogs, and rodents in Johannesburg for carriage of bartonellae. A total of 382 HIV-positive patients attending the HIV clinic and 42 clinically healthy volunteers agreed to participate. Three-hundred and forty-two residual sera from the national antenatal survey were selected and tested for IgG and IgM antibodies against Bartonella. There were 179 dogs, 98 cats and 124 rodents enrolled in this study. The seroprevalence for Bartonella in humans was carried out using IgG and IgM commercially available kits. HIV-positive patients were found to have 32% IgG and 14% IgM seroprevalence, whereas the healthy volunteers had a lower IgG (19%) and higher IgM seroprevalence than the HIV-positive counterparts. All blood samples were cultured, but only the cat and rodent specimens yielded isolates. These were sequenced for species identification. The cat isolates were 99 and 100% similar to B. henselae URBHLIE 9 previously isolated from a patient with endocarditis, and the rat isolates were 98 – 99% similar to either RN24BJ (candidus ‘B. thailandensis’) or RN28BJ, previously isolated from rodents in China. The PCR prevalences were: 22.5% in HIV-positive patients; 9.5% in clinically healthy volunteers; 23.5% in cats; 9% in dogs; and 25% in rodents. Findings of this study have important implications for HIV-positive patients

Stellenbosch University. Faculty of Medicine and Health Sciences. Interdisciplinary Health Sciences. Family Medicine and Primary Care. / Thesis (MFamMed) -- Stellenbosch University, 2010. / Bibliography / ENGLISH ABSTRACT: Introduction: This thesis summarises the findings of a medical audit on the management of Cryptococcal Meningitis (CM). The study population of HIV positive adults (N = twenty five) were admitted during November 2009 – June 2010 to five hospitals of the Cape Winelands (East) District, Western Cape, South Africa. In the context of the HIV pandemic, CM has become the most common cause of community-acquired meningitis, and has poor outcomes if left untreated. The South African HIV Clinician Society has published treatment guidelines in 2007. These guidelines have been used by the audit team to compile a list of measurable criteria (with set targets) to evaluate the structure, process and outcome of CM management. A pilot audit (2008) at the regional hospital has demonstrated that certain target standards were not met. Aims and Objectives: The aim was to improve the quality of the clinical care of HIV-patients diagnosed with CM in the Cape Winelands (East) district. The objectives included the review of the audit criteria and target standards, demonstrating improvement in quality of CM care at the Level 1 and 2 hospitals, identifying new interventions based on the findings and providing recommendations to the health facilities. Methods In 2009, the researcher formed a new audit team, reviewed the audit criteria and held teaching interventions based on the national treatment guidelines. An intervention, based on the findings of the pilot audit, aimed at improving the clinical team’s adherence to the treatment guidelines. Results The audit identified the following areas that did not meet the target standards: the availability of Amphotericin B (Ampho B) and spinal manometers; the use of manometry in all initial lumbar punctures (LPs); completing fourteen days of the required Ampho B treatment; renal monitoring in patients on Ampho B; commencement of antiretroviral treatment (ART) by week four; and, the two-month survival figures post-diagnosis. The re-audit at the Level 2 hospital highlighted the need for improved medical record keeping to aid the audit process. Arrangement of inpatient ART counselling happened more consistently at the Level 1 hospitals. Adherence to the ART target and measures to prevent Ampho B related morbidity is comparable to that of the Level 2 hospital. The audit has also provided insight to the researcher and audit team on the practical challenges of conducting a prospective data collection technique across different care settings. Recommendations Level 1 hospitals should continue to manage CM patients. The availability of spinal manometers and closer adherence to renal monitoring require attention. Formal feedback to the audit team and clinical teams is planned. A multimodal interdisciplinary Quality Improvement approach (such as an integrated care pathway) is recommended and a future re-audit is encouraged to assess improved adherence to the CM management guidelines. The buy-in of stakeholders (management, health care workers and patients), the ongoing support of an audit team and a committed Quality Improvement environment will allow the medical audit process to become ingrained in the South African public healthcare setting. / AFRIKAANSE OPSOMMING: Inleiding Hierdie tesis bied ‘n opsomming van die sleutelbevindinge van ‘n mediese oudit van Cryptokokkale Menigitis (CM) sorg. Die studie groep van MIV-positiewe volwassenes (N = vyf-en-twintig) het binne-pasiënt behandeling ontvang gedurende November 2009 tot Junie 2010 in vyf hospitale van die Kaapse Wynland (Oos) distrik. In die konteks van die MIV pandemie het CM die mees algemene oorsaak van gemeenskapsverworwe meningitis geword, en het swak uitkomste indien onbehandeld. Die Suid-Afrikaanse HIV Clinici Vereniging het in 2007 behandelingsriglyne gepubliseer. Hierdie riglyne het die oudit span gebruik om ‘n lys van meetbare kriteria (met teiken standaarde) saam te stel om die struktuur, proses en uitkoms fasette van CM sorg te evalueer. ‘n Proef oudit (2008) by die streekshospitaal het getoon dat sekere teiken standaarde nie behaal was nie. Doelstelling Die doelstelling was om die kwaliteit van kliniese sorg van MIV-pasiënte met CM (in die Kaapse Wynland (Oos) distrik) te verbeter. Die doelstelling sluit in die hersiening van die oudit kriteria, die bevesting van verbetering in kwaliteit CM sorg by vlak 1 en 2 hospitale, identifisering van nuwe ingreep-moontlikhede gebaseer op die bevindinge en die verskaffing van toepaslike aanbevelings aan die gesondheidsorg fasiliteite. Metodes Die navorser het in 2009 ‘n nuwe oudit span gevorm, die oudit kriteria hersien en opleidingsingrepe geskoei op die nasionale riglyne gefasiliteer. Opleidingsingrepe, gebaseer op bevindinge van die proef oudit, het ten doel gehad dat die kliniese span die nasionale riglyne nakom. Resultate Die oudit het die volgende areas uitgelig waar daar nie aan die teikenstandaarde voldoen was nie: the beskikbaarheid van Amphotericin B (Ampho B) en spinale manometers; die gebruik van manometrie in alle aanvanklike lumbaal punksies (LPs); voltooi van die veertien dae Ampho B behandelingsteiken; nierfunksie monitoring van pasiënte op Ampho B; aanvang van anti-retovirale behandeling teen week vier; en, die twee maande oorlewing post-diagnose syfers. Die opvolg oudit by die vlak 2 hospitaal bevestig die belang van verbeterde kliniese notas om die oudit proses te vergemaklik. Die reël van binne-pasiënt ART berading gebeur meer bestendig in Vlak 1 hospitale. Bereiking van die ART teiken en maatreëls om Ampho B verwante morbiditeit te voorkom, is vergelykbaar met die bevindinge by die vlak 2 hospitaal. Die oudit het die navorser en die oudit span ingelig rakende die praktiese uitdagings om ‘n prospektiewe data insamelingsmetode te poog in verskillende kliniese kontekste. Aanbevelings Vlak 1 hospitale kan steeds CM pasiënte versorg. Die beskikbaarheid van spinale manometers en deeglike nierfunksie monitering sal die behaling van teiken standaarde vergemaklik. Formele terugvoer aan die oudit span en kliniese span word beoog. ‘n Multimodale interdissiplinêre Kwaliteitsverbeterings benadering (soos ‘n geïntegreerde sorgplan) word aanbeveel en ‘n toekomstige oudit word aangemoedig om verbetering in toepassing van die CM riglyne te evalueer. Dit is belangrik om die sleutelspelers (bestuur, gesondheidswerkers en pasiënte) te betrek. Verder word voortgesette ondersteuning van die oudit span en ‘n toegewyde omgewing van kwaliteitsverbetering aanbeveel. Sodoende sal die oudit proses in Suid-Afrikaanse publieke sorg geintegreer word.

MMed (Family Medicine), Faculty of Health Sciences, University of the Witwatersrand / The family care-giver has a pivotal role to play in the management of the chronically ill HIV/AIDS patient. The well being of the care giver is therefore crucial since impairment of their physical or mental health could impact negatively on the management of the HIV patients. Aim The purpose of this qualitative study was to find out the psychosocial impact of care-giving on the family care-giver of the chronically ill HIV/AIDS patient in home based care. Methodology In-depth, tape recorded, unstructured interviews were conducted on eleven care-givers recruited at an adult HIV clinic at United Bulawayo Hospitals, Bulawayo, Zimbabwe. Relevant demographic data was collected from each participant. The interviews were then transcribed before analysis of the data was done. Results The care-givers biggest challenge was meeting care costs such as food, transport and medical expenses. Certain conditions relating to the care-recipients‟ health and family issues such as abandonment of the ill patient and orphans added to the burden of care. Carers also had health and physical factors that impacted on their psychosocial well being. All these issues resulted in a spectrum of emotions such as helplessness, sadness, anxiety and anger but despite this the carers still reported on positive aspects of their care-giving role. Conclusion Care-giving impacted negatively on the care-givers‟ psychosocial well being but there were also positive aspects to the role.

MPH, Faculty of Health Sciences, University of the Witwatersrand / Background: The increase use of highly active antiretroviral therapy (HAART) among patients with HIV infection and AIDS has led to increasing reports of metabolic abnormalities such as diabetes mellitus, hypertension, dyslipidaemia and obesity. Therefore, it is important to explore the burden of these diseases among HIV infected patients. Objectives: To determine the burden of metabolic diseases (hypertension, diabetes, obesity and dyslipidaemia) in patients attending HIV clinic at the Charlotte Maxeke Johannesburg Academic Hospital (JHBH). Methodology: It was a cross-sectional study. The study population included patients attending JHBH HIV clinic and on HAART for more than one year. A sample size of 304 patients, including 237 females and 67 males partook in this study. Anthropometric measurements were taken from patients and blood samples of these patients were sent to laboratory for lipograms, HbA1c, random glucose, CD4 lymphocytes counts as well as HIV viral load testing. The data was analysed with standard statistical software Epi-info version 6.0. Both descriptive and analytical statistics was used. Results: The prevalence of metabolic syndrome according to the IDF was 20.4 %; obesity (BMI 30 kg/m2) was 16.8% and patients that were overweight (BMI > 25 kg/m2 and BMI < 29.9 kg/m2) was 28.6%; hypercholesterolemia (TC 5.0 mmol/l) = 35.5%; HDL< 1.29 mmol\L in females was 58% and HDL <1.04 mmol/l in males was 36%; elevated triglycerides 1.7 mmol/l was 30% and only 16% was classified as being hypertensive (BP 140/90 mmHg and / or on Hypertensive medication). The majority of the patients (86.2%) had a CD4 lymphocyte count 200 X 106 cells/l and 84% of patients had less than detectable limits for viral loads (VL< 40 copies / μl), which has been reported as optimum levels for metabolic diseases in HAART recipients. Conclusion: These results clearly indicate that there is a growing burden of metabolic diseases among HIV patients on HAART attending the Johannesburg hospital HIV clinic. The current study also indicates that the metabolic disturbances are more frequent in women than in men, except for hypertension.

Thesis (MPH.) --University of Limpopo, 2013 / Setting: The study was undertaken in St Rita’s Hospital, a district hospital for healthin Makhuduthamaga Municipality, Sekhukhune District, Limpopo Province. The purpose of the study was to describe client experiences of HIV-positive post-disclosure tosexual partners at St Rita’s Hospital, Limpopo Province. Research design and methodology: A qualitative, descriptive and phenomenological design was used. Purposive sampling was used to select 15 HIV-positive clients to participate in the study. Semi-structured interviews were conducted for data collection until saturation was reached. Data analysis was done using Techs open-coding method. Research findings: The study found that most of the clients were shocked and worried after testing HIV-positive. Participants whose sexual partners were aware that they were sick, indicated their wish to test and to immediately disclose their HIV-positive status. The study identified that some women found it difficult to disclose their HIV-positive status to sexual partners and continued to have unprotected sex in spite of ongoing counselling and support provided at the clinic. Some women participants who disclosed to sexual partners were accepted and some were rejected by sexual partners. Some women who disclosed their HIV-positive status to sexual partners were unable to motivate sexual partners to be counselled together and have mutual disclosure. These participants therefore continued to have unprotected sex with sexual partners and some became pregnant as sexual partners indicated that they tested HIV-negative elsewhere and were not keen to use condoms. Female participants did not indicate the use of female condoms as part of their responsibility to prevent transmission of HIV. Implications, recommendations and conclusions: The barriers which female participants face to disclose their HIV-positive status to sexual partners and not being able to insist on the use condoms may contribute to a high rate of HIV transmission and disease incidence. There should be establishment of consortiums at community level to provide quality support and follow up to vii clients who face challenges or fear to disclose their HIV-positive status to sexual partners. KEYWORDS • Clients’ experiences • Disclosure • Experiences, • Sexual partner • HIV-positive

Thèse de doctorat--Psychologie--Metz--Université Paul Verlaine, 2005. Titre de soutenance : Les déterminants psychosociaux de l'observance thérapeutique chez les personnes infectées par le VIH : représentations et valeurs. / Bibliogr. p. 231-242.