Mothers living with HIV (MLH) are the focus of this narrative study. HIV is increasingly seen as a chronic illness because of medical advances in its treatment. Much research with HIV positive mothers is situated within the dominant biomedical discourse focusing more on outcome rather than experience and, while valuable, it fails to provide insight into their subjective experiences. In Ireland, women represent a third of the newly diagnosed HIV population (O’Donnell, Moran and Igoe 2013), many of whom have children, and migrant African-origin women represent a significant percentage of these new diagnoses. However, no research has examined contemporary maternal HIV experiences within an Irish context. This is an important fact considering the changing nature of HIV and that most HIV positive women are prescribed Highly active antiretroviral treatment (HAART) during their pregnancies and so give birth to HIV negative babies. This study explores the HIV maternal experience as the psychosocial impact of being HIV positive persists even though it is increasingly seen as a chronic illness. The original contribution to knowledge of this thesis is to provide insight into the experiences of mothers living with HIV in Ireland. My study involved adopting a narrative approach to interviewing a purposive sample of eleven HIV positive mothers living in Ireland who were at different points on the motherhood trajectory, and were from both high and low HIV prevalence countries. The analysis of this study’s narratives drew on a combination of theoretical perspectives including HIV stigma frameworks (Campbell et al., 2007, Herek 2002), social capital theory (Putnam 1995), medicalisation and HIV normalisation. The interviews reveal the centrality of being a mother to the study participants and how being HIV positive affects mothering. Being an HIV positive mother means protecting children from HIV from the moment of diagnosis , during and after pregnancy; minimising the impact of HIV in everyday life; having an awareness of the persuasiveness of HIV stigma; and managing HIV disclosure. Peer support was a significant factor for these mothers and all were members of an HIV support organisation in Dublin. Linking the findings of this study to wider theoretical literature allows for a greater understanding of the lives of HIV positive mothers in the HIV normalisation era and accentuates the multidimensional impact of maternal HIV infection.

AIM: The aim of this study was to a) find out which recommendations are given by nurses regarding breastfeeding to HIV infected mothers, at Muhimbili hospital and the adherence of these, and (b) to find out the nurses’ opinions regarding the WHO recommendations and the parents’ adherence to these. The study will also look into if the nurses are aware of any changes in knowledge among the parents in an HIV context.METHOD: There were eight semi-structured interviews with open ended questions that were performed at Muhimbili Hospital. All the interviews were recorded and transcribed with content analysis.RESULT: The nurses’ recommendations are adapted to the mothers’ socio-economical situation. The benefits of replacement foods are emphasized if conditions are suitable, otherwise exclusive breast feeding is recommended. Some recommendations are difficult to follow due to poor sanitary standards, low economical standard and stigmatization. Cultural norms may affect the mothers’ choice of feeding method as it might raise suspicions in their community if they do not breastfeed. The knowledge of mother-to-child-transmission has increased but to reduce the transmission rates more knowledge is still needed and a change in attitude towards HIV infected mothers.CONCLUSION: The recommendations given by the nurses to HIV-positive mothers are not directly according to the ones by the WHO although the content is similar. The recommendations are adjusted in accordance to the Tanzanian women’s individual situation. Adherence problems to the recommendations are due to lack of economic recourses and stigmatization from the community. In order to improve the adherence of the given recommendations a reduction in stigmatization is needed, through increased knowledge and changes in attitudes.

Since the implementation of the prevention of mother–to–child transmission of HIV program in South Africa in 2001, infant deaths due to HIV and AIDS have still remained high. HIV–exposed infants need to be taken for follow–up, schedule at six weeks, for PCR HIV testing. When the infant is found to be HIV–positive, the antiretroviral treatment is commenced for life (DOH, 2010). This benefits them in that the earlier they start treatment, the higher their quality of life and their life expectancy will be. Health workers face a problem in that there are still mothers of HIV–exposed infants who do not return their babies for the 6 weeks of age follow–up schedule and their babies therefore do not benefit from the treatment and care. The study looked at the reasons for the low follow–up of babies born to HIV–positive mothers according to HIV–positive mothers and nurses and counsellors and what strategies can be used by nurses and counsellors to encourage the mothers to bring their babies for follow–up. To answer these questions, qualitative, exploratory and contextual design was used. Purposive sampling was done with participants who had knowledge about the research problem. HIV–positive mothers were individually interviewed and nurses and counsellors were interviewed in a focus group. Five individual interviews and three focus group interviews were conducted. The focus groups were interviewed twice for each question mentioned. Responses were satisfactory with the following categories emerging from the findings: fear about disclosure, denial of status, insufficient knowledge about HIV, accusations about who is the actual “giver” of HIV and incongruent health education on HIV and AIDS and the management thereof in the case of babies with HIV, with specific reference to incorrect and/or insufficient information. Recommendations are made concerning these issues, so as to effect an increase in the follow–up of babies born to HIV–positive mothers. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2012.

Since the implementation of the prevention of mother–to–child transmission of HIV program in South Africa in 2001, infant deaths due to HIV and AIDS have still remained high. HIV–exposed infants need to be taken for follow–up, schedule at six weeks, for PCR HIV testing. When the infant is found to be HIV–positive, the antiretroviral treatment is commenced for life (DOH, 2010). This benefits them in that the earlier they start treatment, the higher their quality of life and their life expectancy will be. Health workers face a problem in that there are still mothers of HIV–exposed infants who do not return their babies for the 6 weeks of age follow–up schedule and their babies therefore do not benefit from the treatment and care. The study looked at the reasons for the low follow–up of babies born to HIV–positive mothers according to HIV–positive mothers and nurses and counsellors and what strategies can be used by nurses and counsellors to encourage the mothers to bring their babies for follow–up. To answer these questions, qualitative, exploratory and contextual design was used. Purposive sampling was done with participants who had knowledge about the research problem. HIV–positive mothers were individually interviewed and nurses and counsellors were interviewed in a focus group. Five individual interviews and three focus group interviews were conducted. The focus groups were interviewed twice for each question mentioned. Responses were satisfactory with the following categories emerging from the findings: fear about disclosure, denial of status, insufficient knowledge about HIV, accusations about who is the actual “giver” of HIV and incongruent health education on HIV and AIDS and the management thereof in the case of babies with HIV, with specific reference to incorrect and/or insufficient information. Recommendations are made concerning these issues, so as to effect an increase in the follow–up of babies born to HIV–positive mothers. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2012.

Magister Curationis - MCur / Background: In the South Africa, the number of HIV- positive pregnant women is rising and has resulted in more than 70,000 babies being born with HIV infection annually since the year 2000. In response to the escalating number of HIV-positive pregnant women, the Department of Health of South Africa, decided, in 2002, to implement the Prevention of Mother to Child Transmission (PMTCT) programme at 18 pilot sites in the country. An effective PMTCT programme could reduce the incidences of maternal and child mortalities in the country. An evaluation of the effectiveness of the PMTCT programme that was done in 2010 showed that, although the programme was rendered effectively during pregnancy and labour, there were still irregularities that appeared, especially during the postnatal period. Khayelitsha was the first pilot site in South Africa to provide Antiretroviral Therapy and initiate the Nurse Initiated Management of Antiretroviral Therapy (NIMART) at primary care level in the public sector. Midwives are the health professionals who render the PMTCT services to HIV-positive mothers and their babies until six weeks post-delivery. They have managed to test almost 100% of pregnant women during the antenatal period and the HIV-positive women were started on the PMTCT programme during their first visit. Aim: The aim of this study was to explore the challenges that midwives faced in rendering care to postnatal HIV-positive mothers enrolled in the PMTCT programme at the Khayelitsha Community Health Clinic in the Western Province of South Africa. Method: An exploratory design and qualitative approach was followed. The study population consisted of midwives who were rendering PMTCT services to HIV-positive mothers and their infants during the postnatal period. Purposive sampling was conducted until data saturation was reached. Six participants were included in the sample. The participants were informed about the study by means of an Information Sheet, advised that the study was voluntary and reminded that they could withdraw from the study at any time, without prejudice. In-depth, unstructured individual interviews were conducted with each of the participants. With the permission of participants, an audio tape recorder was used during the interviews to collect data, while the researcher took field notes to supplement and verify the voice recordings, after the interviews. The seven steps of Colaizzi were used to analyse the data. Six themes and sixteen sub-themes emerged during the data analysis. Trustworthinesswas maintained by using the criteria of Guba’s model, i.e. credibility, transferability, conformability and dependability. Permission to conduct the study was obtained from the appropriate ethical committees; the Department of Health, the Khayelitsha Community Health Clinic, as well as, the Senate Research Committee of the University of the Western Cape. Participants were asked to sign Informed Consent forms before participating in the study. The ethical principles of privacy, anonymity, withdrawal, confidentiality and consent were strictly adhered to. Findings: The study found several challenges faced by midwives while implementing the PMTCT programme during the postnatal period. These challenges included: the shortage of NIMART-trained staff attending to the high number of clients per day; the lack of manpower with data base systems to trace mothers who did not come back after delivery; and mothers who did not come back for postnatal appointments because of denial, non-disclosed HIV status and socioeconomic reasons. Furthermore, the participants also reported on midwives experiencing ‘burnout’ as a result of the hectic working environment at the Khayelitsha Community Health Clinic. Recommendations: There is an urgent need for all midwives in the MOU’s to be NIMART-trained. NIMART should be standardize and be the part of the curriculum that taught in all the tertiary institutions and be updated in a yearly basis as part of the in-service training or education for all practising midwives. The South African Government should introduce home visits in the PMTCT programme. Data-bases of all MOU’s and facilities that offer PMTCT services need to be synchronized and these MOU’s and facilities should all follow the same PMTCT guidelines. Further research should be done on the same topic at other clinics and MOU’s that render the PMTCT programme in the Western Cape.

The study investigated the feasibility of the Ottawa decision support tool to assist HIV positive mothers' infant feeding choice. The aim was to explore and describe the feasibility of the Ottawa Decision Support Tool (ODST) in counselling HIV infected pregnant women on decision-making regarding the choice of safe infant feeding. The finding of this study will assist and support HIV positive mothers to be independent decision makers in choosing an infant feeding option for their babies. A descriptive qualitative research approach guided the researcher to explore and describe the feasibility of the ODST to assist HIV positive mothers' infant feeding choice. This study is based on the Ottawa decision support framework (ODSF). Three focus group that comprised midwives as participants were conducted. The first focus group was conducted in January 2013 and the two subsequent ones in August 2013. Data was analysed using a framework approach. The following themes emerged from data-analysis: • Appropriateness • Receptiveness of intervention • Effectiveness Conclusions were drawn based on the attained objectives of the study. The overall conclusion was that the ODST is feasible to assist HIV positive mothers' infant feeding choice. Limitations of the study were identified and recommendations were made for nursing practice, nursing education and further research. / MCur, North-West University, Potchefstroom Campus, 2015

The study investigated the feasibility of the Ottawa decision support tool to assist HIV positive mothers' infant feeding choice. The aim was to explore and describe the feasibility of the Ottawa Decision Support Tool (ODST) in counselling HIV infected pregnant women on decision-making regarding the choice of safe infant feeding. The finding of this study will assist and support HIV positive mothers to be independent decision makers in choosing an infant feeding option for their babies. A descriptive qualitative research approach guided the researcher to explore and describe the feasibility of the ODST to assist HIV positive mothers' infant feeding choice. This study is based on the Ottawa decision support framework (ODSF). Three focus group that comprised midwives as participants were conducted. The first focus group was conducted in January 2013 and the two subsequent ones in August 2013. Data was analysed using a framework approach. The following themes emerged from data-analysis: • Appropriateness • Receptiveness of intervention • Effectiveness Conclusions were drawn based on the attained objectives of the study. The overall conclusion was that the ODST is feasible to assist HIV positive mothers' infant feeding choice. Limitations of the study were identified and recommendations were made for nursing practice, nursing education and further research. / MCur, North-West University, Potchefstroom Campus, 2015

Mother-to-child transmission (MTCT) of HIV is the most significant source of HIV infection in young children. As the HI virus has been identified in cell-free and cell-associated compartments of breast milk, it is clear that breast milk is one of the ways in which mother-to-child transmission of HIV can take place in addition to in utero and intrapartum transmission. While breastfeeding carries the risk of HIV transmission, not breastfeeding carries significant health risks for infants and young children, such as an increased risk of diarrhoea and pneumonia, morbidity and mortality. When an HIV-positive mother decides to breastfeed her baby, pasteurisation of expressed breast milk (EBM) could be a possible infant-feeding option to limit transmission of the HI virus through breast milk, since this method has shown to effectively inactivate HIV type 1. Three methods of pasteurisation of human milk were investigated in this study: Holder pasteurisation, flash-heating and Pretoria pasteurisation. The systematic review is a helpful method to summarise the best-quality empirical evidence of the benefits and limitations of a specific method, such as heat treatment, and to provide recommendations for future research. Therefore, the aim of this study was to critically synthesise by means of a systematic review the best available existing evidence and to provide a clear overview of the effectiveness of heat treatment of EBM as an in-home procedure to inactivate the HI virus, and in so doing limit mother-to-child transmission of HIV. This study provides the clinical practitioner with accessible information on the effectiveness of heat treatment of EBM as an in-home procedure in terms of (1) safety, inactivation of the HI virus and retaining the protective and nutritional value of the EBM; (2) feasibility as an in-home procedure; and (3) acceptability by the mothers and their communities. This information could be used to improve clinical practitioners‟ knowledge and include it in their health education to contribute to the prevention of mother-to-child transmission. This study is based on the framework of the model for evidence-based clinical decisions of Haynes, Devereaux and Guyatt (2002). The search strategy was conducted in March/April 2009. The initial search resulted in 574 articles. After thorough screening of potentially relevant studies on heat treatment of EBM, the studies that met the inclusion criteria were critically appraised and scored based on their methodological qualities using standardised instruments. After 6 months, the search was updated. The search obtained 1 article. The final sample involved 12 articles. Conclusions were integrated and synthesised as a basis for developing a clear overview of the best available existing evidence. Finally, the findings of the study were synthesised and the research was evaluated, a conclusion was given, limitations were identified and recommendations were formulated for nursing practice, education and research. The bottom-line answer concluded that heat treatment of EBM should be emphasised as a safe alternative for feeding exposed infants (those of an HIV-positive mother, those of uncertain HIV status or during weaning if the mother cannot afford formula or cow‟s milk), but should be supported with appropriate information to the individual mother, her family and the community. Overall it can be concluded that existing evidence of the effectiveness (in terms of safety, feasibility and acceptability) of heat treatment of EBM, particularly Pretoria pasteurisation, used as a simple in-home procedure, is insufficient, and further research is required. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2010

Mother-to-child transmission (MTCT) of HIV is the most significant source of HIV infection in young children. As the HI virus has been identified in cell-free and cell-associated compartments of breast milk, it is clear that breast milk is one of the ways in which mother-to-child transmission of HIV can take place in addition to in utero and intrapartum transmission. While breastfeeding carries the risk of HIV transmission, not breastfeeding carries significant health risks for infants and young children, such as an increased risk of diarrhoea and pneumonia, morbidity and mortality. When an HIV-positive mother decides to breastfeed her baby, pasteurisation of expressed breast milk (EBM) could be a possible infant-feeding option to limit transmission of the HI virus through breast milk, since this method has shown to effectively inactivate HIV type 1. Three methods of pasteurisation of human milk were investigated in this study: Holder pasteurisation, flash-heating and Pretoria pasteurisation. The systematic review is a helpful method to summarise the best-quality empirical evidence of the benefits and limitations of a specific method, such as heat treatment, and to provide recommendations for future research. Therefore, the aim of this study was to critically synthesise by means of a systematic review the best available existing evidence and to provide a clear overview of the effectiveness of heat treatment of EBM as an in-home procedure to inactivate the HI virus, and in so doing limit mother-to-child transmission of HIV. This study provides the clinical practitioner with accessible information on the effectiveness of heat treatment of EBM as an in-home procedure in terms of (1) safety, inactivation of the HI virus and retaining the protective and nutritional value of the EBM; (2) feasibility as an in-home procedure; and (3) acceptability by the mothers and their communities. This information could be used to improve clinical practitioners‟ knowledge and include it in their health education to contribute to the prevention of mother-to-child transmission. This study is based on the framework of the model for evidence-based clinical decisions of Haynes, Devereaux and Guyatt (2002). The search strategy was conducted in March/April 2009. The initial search resulted in 574 articles. After thorough screening of potentially relevant studies on heat treatment of EBM, the studies that met the inclusion criteria were critically appraised and scored based on their methodological qualities using standardised instruments. After 6 months, the search was updated. The search obtained 1 article. The final sample involved 12 articles. Conclusions were integrated and synthesised as a basis for developing a clear overview of the best available existing evidence. Finally, the findings of the study were synthesised and the research was evaluated, a conclusion was given, limitations were identified and recommendations were formulated for nursing practice, education and research. The bottom-line answer concluded that heat treatment of EBM should be emphasised as a safe alternative for feeding exposed infants (those of an HIV-positive mother, those of uncertain HIV status or during weaning if the mother cannot afford formula or cow‟s milk), but should be supported with appropriate information to the individual mother, her family and the community. Overall it can be concluded that existing evidence of the effectiveness (in terms of safety, feasibility and acceptability) of heat treatment of EBM, particularly Pretoria pasteurisation, used as a simple in-home procedure, is insufficient, and further research is required. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2010

Thesis (MScMedSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Despite the decreased rate of HBV horizontal transmission in South Africa (SA) due to the HB vaccine, the risk of perinatal transmission remains of concern, especially in HIV/HBV co-infected women. Loss of HBV immune control, resulting in higher HBV replication and thus increasing the risk of transmission is described in HIV/HBV co-infected women. Chronic hepatitis is a well-recognized risk factor for hepatocellular carcinoma (HCC). The presence of specific HBV mutations has been reported in chronic and HCC patients and is used in algorithms for the prediction of HCC in CHB patients in Asia. While these mutations are extensively described in male patients, little is known regarding the antenatal and paediatric populations. This study aimed to determine the prevalence of HBV infection in HIV-exposed infants and to investigate the presence of HCC-related mutations in pregnant women and HIV-exposed children in SA. Residual samples of infants born to HIV-infected mothers were collected from the P1041 study previously conducted in SA. HBV markers (HBsAg, anti-HBs and anti-HBc) were tested on the Architect (Abbott). HBsAg positive samples were tested for HBV DNA to determine HBV viral loads. HBV strains were characterised by sequencing of the HBsAg gene and genotypes were determined by phylogenetic analysis using HepSEQ (www.hepseq.org.uk). For the HCC-related mutations investigation, samples and data were collected from three HBV-related studies: the NHLS Paediatric Study, an Antenatal Study and the current study. Pre-S, basal core promoter (BCP) and pre-core data was collected from all samples. Multiple alignments were formed and the nucleotide sequences of these extracts were translated into protein sequences. These protein sequences were compared manually to the HBV reference genes to identify HCC-related mutations. Of 850 HIV-exposed infants tested, three infants were positive for both HBsAg and HBV DNA. Two samples show evidence of past, but cleared HBV infection. Sequence analysis showed that the infants were infected with a subgenotype A1. At follow up, only one infant and mother were able to be traced and contacted. The infant was HIV-infected and had been on an ART regimen, including lamivudine for two years. HBV testing showed that the infant was HBsAg positive and had an undetectable viral load. Core sequence analysis showed clustering between mother and infant sequences. Transmission of mutant HBV previously associated with HCC prompted the question of what the prevalence of mutations in the antenatal and paediatric population is. In this investigation of HCC-related mutations study, a higher prevalence of combined pre-S, BCP and pre-core mutations was found in HIV-infected as compared to HIV-uninfected women. This study shows that vertical transmission is occurring in HIV-exposed infants in SA despite HB vaccination. Data described in this study suggests the importance of HB vaccination closer to the time of birth in SA. Moreover, data on the higher prevalence of HCC-related mutations in HIV-infected pregnant women provide a background for further longitudinal studies to confirm these findings and their implications in SA. / AFRIKAANSE OPSOMMING: As gevolg van die beskikbaarheid van die Hepatitis B virus (HBV) entstof , het horisontale transmissie van die virus drasties in Suid-Afrika (SA) verminder. Ten spyte hiervan, is daar steeds ‘n hoë risiko van perinatale transmissie van swanger vroue na hulle babas, dit word veral gesien met MIV/HBV positiewe vroue. Dit is wyd beskryf dat vroue wat mede-besmet is met MIV/HBV gewoonlik beheer verloor oor hulle immuunstelsel, wat lei tot ‘n hoër mate van HBV replikasie en dus ‘n hoër risiko van virus oordrag. Kroniese hepatitis is wel bekend as ‘n hoë risiko faktor vir HCC. Die teenwoordigheid van spesifieke HBV mutasies in kroniese en HCC pasiënte word alreeds in Asië gebruik in sekere algoritmes en formules om infeksie aan te dui en te voorspel. Hierdie mutasies is omvattend beskryf in manlike pasiënte, maar baie min is bekend in voorgeboorte en pediatriese gevalle. In hierdie studie het ons die teenwoordigheid van HCC-verwante mutasies in swanger vroue en MIV-blootgestelde kinders in Suid-Afrika ondersoek. Monsters is verkry van babas gebore van MIV-positiewe moeders van die P1041 studie wat voorheen in SA gedoen is. Die HBV merkers (HbsAg, teen-HBs en teen-HBc) was op die Architect (Abbott) getoets. HBsAg positiewe monsters was getoets vir HBV DNA om die virale lading te bepaal. Die verskeidenheid HBV stamme was gekarakteriseer deur die virus se nukleïensuur volgordes te bepaal. Die verskillende genotipes is bepaal deur filogenetiese analises te doen met behulp van die HepSEQ (www.hepseq.org.uk) program. Vir die HCC-verwante mutasie studie is monsters en data vergelyk met 3 HBV-verwante studies: die NHLS pediatriese studie, ‘n voorgeboorte studie en hierdie spesifieke studie. Voor-S, basale kern promoter en voor-kern data was van alle monsters bekom. ‘n Veelvoudige belyning was gedoen met die nukleïensuur volgordes van die verskeie DNA ekstrakte, wat daarna vertaal is in proteïen volgordes. Hierdie proteïenvolgordes translasie was by hand vergelyk met verwysings gene om die relatiewe HCC mutasies te probeer identifiseer. Van die 850 blootgestelde MIV babas wat getoets is, het 3 positief getoets vir beide HbsAg en HBV DNA. Twee monsters het bewys van verlede , maar vrygestelde HBV infeksie. Data analise bewys dat die babas met subtipe A1 besmet was. Ons kon slegs een moeder en baba paar opvolg en kontak vir verdere toetse. Die baba was MIV-positief en was op antiretrovirale behandeling , insluitend lamivudine, vir ten minste 2 jaar. HBV toetse het gewys dat die baba HbsAg positief is en ‘n onopspoorbare virale lading gehad het. Kern nukleïensuur volgorde analise het groepering getoon tussen die ma en baba se virus monsters . Die transmissie van die mutante HBV wat geassosieer is met HCC het gelei tot die vraag wat die voorkomssyfer is van hierdie spesifieke mutasies in die voorgeboorte en pediatriese populasies in SA. In hierdie studie het ons ‘n hoër gekombineerde voorkomssyfer gevind van die voor-S, basale kern promoter en voor-kern mutasies in MIV-positiewe vroue, in vergelyking met MIV-negatiewe vroue. Hierdie studie bewys dus dat vertikale transmissie van HBV in blootgestelde MIV babas steeds plaasvind, ten spyte van HBV inenting. Die data wat in hierdie studie beskryf was dui daarop dat die belangrikheid van HBV inenting nader aan die tyd van die geboorte in SA gegee moet word.As gevolg van die hoë voorkomssyfer van HCC-verwante mutasies in swanger vroue, is daar verdere longitudinale studies nodig om hierdie bevindinge en hul implikasies in SA te bevestig.