Thesis (MSc)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: As the only effective treatment for HIV/AIDS, adherence to antiretroviral therapy (ART) is critical for successful treatment outcomes. Despite its open availability since the national rollout in 2004, adherence to ART has remained sub-optimal and the number of individuals shifted to the more expensive second-line therapy on steady increase. The literature reports more commonly on individual, psychological, and behavioural barriers to treatment. However, there has been a vast interest in the structural barriers that prohibit adherence to ART. In previous research, my colleagues and I identified the following structural barriers to treatment adherence: stigma-related barriers, the disincentives associated with disability grants, poor relationships with clinic staff, lack of privacy at clinics for counselling and treatment, transport difficulties in travelling to the clinic, long patient waiting times, food insecurity, substance abuse and the absence of substance abuse programmes, and migration. The data were arrived at by means of triangulated qualitative interviews obtained from patients, patient advocates, doctors, and nurses. Together, these qualitative data formed phase 1 of this study. The next step or phase 2, in this research was to develop a valid and reliable quantitative instrument based on these qualitative data. Therefore the primary aim of the study presented in this thesis was to identify the underlying factor structure of four scales aimed at measuring adherence at two levels namely, adherence to clinic attendance, and adherence to pill-taking. After sampling a group of almost 300 persons living with HIV (PLWH) four valid and reliable scales assessing structural barriers to adherence to ART were derived at with Cronbach alpha coefficients ranging from 0.87 to 0.91. For each scale, a general or higher order factor was determined by means of hierarchical transformation suggesting that the items on each of the scales were dominated by a single underlying factor. The findings of this research suggest that it is possible to assess the structural barriers to adherence that PLWH face on a daily basis. With a proper means, such as these scales, to assess structural barriers to adherence to ART clinicians may be able to identify patients who are likely to default and provide adequate attention to the most distressing barriers. / AFRIKAANSE OPSOMMING: Antiretrovirale terapie (ART) is die enigste effektiewe behandeling teen MIV/Vigs. Behandeling met hierdie terapie kan slegs suksesvol voltooi word indien die medikasie ononderbroke en gereeld geneem word. Alhoewel medikasie vrylik beskikbaar was sedertdien die nasionale bekendstelling in 2004, het die aantal individue wat na duurder tweede lyn terapie oorgegaan het toegeneem. Die volhoubaarheid van ART was dus nie optimaal nie. Dit kan toegeskryf word aan individuele -, sielkundige - en gedragstruikelblokke tydens behandeling wat tans baie aandag geniet in die literatuur. Om by te voeg, strukturele hindernisse tot ART geniet ook tans baie aandag. Met hierdie as agtergrond, was die primêre doel van die studie om die onderliggende faktor struktuur van vier skale wat strukturele hindernisse tot ART op twee vlakke meet, naamlik getroue kliniek bywoning en neem van medikasie, te indentifiseer. Ons het met vorige navorsing die volgende strukturele hindernisse tot ART geidentifiseer: stigma-verwante hindernisse, hindernisse wat verband hou met ongeskiktheidstoelaes, swak verhoudings met kliniek personeel, die gebrek aan privaatheid by klinieke in terme van berading en behandeling, vervoerprobleme, lang wagtye vir pasiënte, voedselonsekerheid, dwelmmisbruik en die afwesigheid van middelmisbruik-programme, asook migrasie. Data aangaande bogenoemde strukturele hindernisse is ingesamel deur middel van kwalitatiewe onderhoude met pasiënte, pasiënt-advokate, dokters en verpleegsters (fase 1). Gedurende fase 2 van hierdie studie is 'n geldige en betroubare kwantitatiewe instrument op grond van hierdie kwalitatiewe data ontwikkel. 'n Steekproef van ongeveer 300 MIV-geinfekteerde individue het deelgeneem. Vier geldige en betroubare skale is ontwikkel ten opsigte van die assessering van strukturele hindernisse in terme van gereelde gebruik van antiretrivale middels, met Cronbach alpha koëffisiënte tussen 0.87 en 0.91. Vir elke skaal is 'n algemene of hoër-orde faktor bepaal deur middel van hiërargiese transformasie wat daarop dui dat die items op elk van die skale gekenmerk is deur 'n enkele onderliggende faktor. Ons bevindinge dui daarop dat dit moontlik is om die strukturele hindernisse wat MIV individue daagliks tot ART ondervind te meet. Met die gebruik van hierdie skale sal klinici dus in staat wees om pasiënte te identifiseer wat moontlik van ART sal afwyk of die terapie sal staak met die klem op mees onstellende hindernisse.

Highly active antiretroviral therapy (HAART) is currently the only treatment that effectively reduces the morbidity and mortality of individuals infected with Human Immunodeficiency Virus-1 (HIV-1). Standard HAART regimens typically comprise 2 nucleoside reverse transcriptase inhibitors and either one non-nucleoside reverse transcriptase inhibitor or a protease inhibitor. These drugs bind to and inhibit the HIV-1 Reverse Transcriptase and Protease enzymes respectively, thereby suppressing viral replication. The nucleoside reverse transcriptase inhibitors promote mitochondrial (mt) dysfunction by strongly inhibiting mt polymerase gamma (Pol-y) and subsequently, mtDNA replication. In contrast, the non-nucleoside reverse transcriptase inhibitors, efavirenz (EFV) and nevirapine (NVP) do not inhibit Pol-y although EFV has been shown to induce mt depolarisation ( mlow) in vitro at supra-therapeutic concentrations. However, the capacity of non-nucleoside reverse transcriptase inhibitor drugs to induce mt toxicity in vivo previously remained undetermined. The objective of this study was to determine the influence of EFV and NVP on peripheral lymphocyte mt transmembrane potential (Avj/m) and apoptosis in HIV-1-infected patients treated with these non-nucleoside reverse transcriptase inhibitors. Thirty-two HIV-1-infected patients on HAART between 4 and 24 months (12 on EFV, 20 on NVP) and 16 HAART-naive HIV-1-infected patients were enrolled into this study. All participants were black South African patients. Spontaneous peripheral lymphocyte apoptosis and mlow were measured ex vivo by flow cytometry for all patients. CD4 T-helper apoptosis for the EFV and NVP cohorts was 19.38% ± 2.62% and 23.35% ± 1.51% (mean ± SEM), respectively, whereas total lymphocyte mlow was 27.25% ± 5.05% and 17.04% ± 2.98%, respectively. Both parameters for each cohort were significantly lower (P < 0.05) than that of the HAART-naive patients. The NVP cohort exhibited both a significant time dependent increase in peripheral lymphocyte ö¿mlow (P = 0.038) and correlation between Thelper apoptosis and low (P = 0.0005). These trends were not observed in the EFV cohort. This study provides evidence that both EFV and NVP induce peripheral lymphocyte ö¿ m low in HIV-1-infected patients on non-nucleoside reverse transcriptase inhibitor-based HAART, which in the case of NVP is sufficient to induce the apoptosis cascade. / Thesis (M.Med.Sci.)--University of KwaZulu-Natal, 2008.

Thesis presented in partial fulfilment for the degree of Master of Management (in the field of Public Sector Monitoring and Evaluation) to the Faculty of Commerce, Law, and Management, University of the Witwatersrand 2016 / The purpose of this research was to assess outcomes of the antiretroviral treatment intervention in Mankweng. The antiretroviral treatment intervention was conceived with the aim to reduce HIV transmission through viral load suppression. Literature has shown that viral load is used as a tool to measure the performance of the intervention and studies on viral load outcomes in rural settings of Limpopo are limited. For this reason, the research was focused on viral load suppression with the aim of (1) determining the proportion of adults with viral load suppression among people taking antiretroviral treatment for 12 months, and (2) identifying factors associated with failure to achieve viral load suppression among people on antiretroviral treatment for 12 months. Binomial logistic regression model was used to identify factors associated with failure to suppress viral load. This study used the theory of change to interpret its findings as well as theories of behavioural planning and self-regulation models to understand the logic that underpins the theory of change. The findings revealed that the majority (78%) of adults achieved viral load suppression, and a quarter of the individuals failed to suppress the viral load. There was no significant difference in baseline characteristics between people who achieved viral load suppression and those who did not. In addition, males, with a low CD4 and opportunistic illnesses when in the primary disease stages were more likely to fail to suppress the viral load. Moreover, people who were initiated on a 3-pill containing treatment and do not have social support were also likely to fail to achieve viral load suppression. Although the study showed a trend of likelihood towards failure to achieve viral load suppression, the estimates were not statistically significant. Theoretical arguments from this study suggest that failure to achieve viral load was attributed to poor adherence to treatment. This is supported by the logic that underpins the theory of change, in which the assumption of adherence was possibly violated. However, the results chain framework highlighted that the implementation of the intervention was effective as it led to good outcomes and an effective intervention. Drawing all this together, the study highlights the need for intensified adherence counseling during treatment in order to improve the performance of the intervention. Author: Ramatsobane Johanna Ledwaba, Thesis Title: Outcomes of the antiretroviral treatment intervention in Mankweng, Johannesburg, March 2016 / GR2018

The background. HIV and AIDS is a huge problem in sub-Saharan Africa where an estimated 22.5 million people were living with HIV in 2007.1 South Africa has the worst epidemic in the world.1 There were about 5.5 million people living with HIV and 1000 AIDS deaths daily in South Africa by the end of 2005.17 In 2007 the number of people living with HIV in South Africa increased to 5.7 million.1 The HIV prevalence in Umkhanyakude district, KwaZulu Natal, where Hlabisa subdistrict is situated, amongst public antenatal clinic attenders was 39.8% in 2007.19 AIDS is the cause of 50.0% of deaths in the Hlabisa sub-District.15 In 2003 the South African government decided to provide antiretroviral therapy (ART) in the public health sector, giving hope to thousands of people who are in need of this intervention to improve their quality of life and reduce premature deaths.7,13 However adherence to antiretroviral drugs is essential for successful treatment. Adherence to antiretroviral therapy in South Africa as in other African countries was expected to be low31 (<95.0%), however, in a study that was done in Cape Town during 1996 – 2001, the authors concluded that adherence was high.28 The aim of that study was to identify predictors of low adherence (<95.0%) and failure of viral suppression (>400 HIV copies/mm3). Pill counts and records of treatment refills from pharmacy were used to measure adherence.28 The results revealed no significant difference in adherence between patients on protease inhibitor based regimens and/or those on nonnucleoside based regimens nor with socioeconomic status, sex and HIV stage. Independent predictors of low adherence were English language speaking, age, and three times per day dosing. The following were found to be independent predictors of failure of viral suppression: baseline viral load, <95.0% adherence, age and dual nucleoside therapy.28This study however was done in an urban area before the antiretroviral therapy (ART) roll out in South Africa when the cost of treatment limited the accessibility of ART. These patients may have been different to patients who access free treatment in public health facilities today. Other South African studies have also reported good adherence rates.39,40 In another study in Soweto, South Africa, adherence was high, 88.0% of patients achieved > 95.0% goal, 9.0% achieved 90.0-95.0% adherence and only 3.0% achieved <90.0%.39In a study done at Khayelitsha, adherence was also high, viral load level was < 400 in 88.1%, 89.2%, 84.2%, 75% and 69.7% of patients at 3, 6, 12, 18 and 24 months.40 However, Soweto and Khayelitsha are urban and different from Hlabisa, and it is difficult to generalize these results to the sub-district. This study intended to assess how adherent patients are to antiretroviral therapy in a typical rural district in order to inform policy to enhance adherence to ART. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2008.

Uganda has experienced 1.6 million deaths to HIV/AIDS related illness. Introduction of free-ART in rural hospitals that bear the burden od AIDS reduces adults morbidity and mortality. The study design was a quantitative, retrospective and descriptive design through data mining of medical records. In the six years, hospital admissions decreased by 16.7% and the median age at death increased by seven years. Hospital admissions decreased from three to seven deaths per 100 admissions per month. Male and female mortality was 1:1.6 and females in the 15-34 age group had a 37% higher likeliness of dying in hospital compared to males. Deaths from sub-countries with an ART site reduced by 4% to 8.6%. The data revealed that despite ART coverage of 60%, mortality rates showed a rising trend. Free access to ART's over three years did not make any observable changes to overall mortality. Therefore, ART access contributed to a decline in overall hospital admissions, an increase in median age at time of death and a reduction in deaths from sub-counties with an ART site. There was no reduction in overall hospital mortality rate. / M.A. (Public Health) / Health Studies

Uganda has experienced 1.6 million deaths to HIV/AIDS related illness. Introduction of free-ART in rural hospitals that bear the burden od AIDS reduces adults morbidity and mortality. The study design was a quantitative, retrospective and descriptive design through data mining of medical records. In the six years, hospital admissions decreased by 16.7% and the median age at death increased by seven years. Hospital admissions decreased from three to seven deaths per 100 admissions per month. Male and female mortality was 1:1.6 and females in the 15-34 age group had a 37% higher likeliness of dying in hospital compared to males. Deaths from sub-countries with an ART site reduced by 4% to 8.6%. The data revealed that despite ART coverage of 60%, mortality rates showed a rising trend. Free access to ART's over three years did not make any observable changes to overall mortality. Therefore, ART access contributed to a decline in overall hospital admissions, an increase in median age at time of death and a reduction in deaths from sub-counties with an ART site. There was no reduction in overall hospital mortality rate. / M.A. (Public Health) / Health Studies

The purpose of the study was to evaluate the IMB skills model for its relevance to the Ethiopian context. According to the model, adherence-related information and motivation work through adherence-related behavioural skills to affect adherence to ART. Quantitative, analytical, observational, cross-sectional, institution-based study was conducted to evaluate the model by assessing those patients who have and do not have the right information, motivation, and behavioural skills whether they have or do not have good adherence to ART. Data was collected using structured questionnaires where a total of 400 randomly selected participants provided data on adherence-related information, motivation and behavioral skills as well as adherence behavior per se. Data was analysed using the Statistical Package for Social Sciences (SPSS) version 20.0. Both descriptive and inferential statistics used in the study. Only 90.75 % of the total sample population reported ART adherence rate of more than or equal to 95% in this study. Free and restricted model tests, through bivariate and multivariate analyses, used to assess the propositions of the IMB model of ART adherence and provided support for the interrelations between the elements proposed by the model. The study has supported the applicability of the IMB model of adherence to the Ethiopian context highlighting its application in adherence-promotion intervention efforts. The findings revealed the need for on-going educational, informational and other interventions to address the knowledge, motivation and adherence behavioural skills of patients in order to improve the current levels of ART adherence behaviour. / Health Studies / D. Litt. et. Phil. (Health Studies)

The purpose of the study was to evaluate the IMB skills model for its relevance to the Ethiopian context. According to the model, adherence-related information and motivation work through adherence-related behavioural skills to affect adherence to ART. Quantitative, analytical, observational, cross-sectional, institution-based study was conducted to evaluate the model by assessing those patients who have and do not have the right information, motivation, and behavioural skills whether they have or do not have good adherence to ART. Data was collected using structured questionnaires where a total of 400 randomly selected participants provided data on adherence-related information, motivation and behavioral skills as well as adherence behavior per se. Data was analysed using the Statistical Package for Social Sciences (SPSS) version 20.0. Both descriptive and inferential statistics used in the study. Only 90.75 % of the total sample population reported ART adherence rate of more than or equal to 95% in this study. Free and restricted model tests, through bivariate and multivariate analyses, used to assess the propositions of the IMB model of ART adherence and provided support for the interrelations between the elements proposed by the model. The study has supported the applicability of the IMB model of adherence to the Ethiopian context highlighting its application in adherence-promotion intervention efforts. The findings revealed the need for on-going educational, informational and other interventions to address the knowledge, motivation and adherence behavioural skills of patients in order to improve the current levels of ART adherence behaviour. / Health Studies / D. Litt. et Phil. (Health Studies)

This quantitative study sought to identify and describe factors influencing HIV disclosure and sexual practices among 340 PLWHA on ART at Mbabane National Referral VCT/ART Centre, Swaziland. Data were collected using a structured questionnaire. A high general HIV disclosure rate (94.1%; f=320; N=340) was observed of which 57.5% (f=184; n=320) was to sexual partners. X2 procedures indicate an association with gender, residential region, religion, and period of being on ART. The majority (70.2%; f=179; n=255) of the respondents used condoms all the time to avoid infecting their sexual partners (99.2%; f=243; n=245) and to avoid contracting STIs (99.2%; f=243; n=245). X2 procedures indicate an association with gender, residential region, marital status, number of sexual partners, knowledge of the HIV status of sexual partners and period of being on ART. The single leading reason for not using the condom was sexual partners’ refusal to use condoms (85.7%; f=54; n=63). / Health Studies / M.A.(Health Studies)

This quantitative study sought to identify and describe factors influencing HIV disclosure and sexual practices among 340 PLWHA on ART at Mbabane National Referral VCT/ART Centre, Swaziland. Data were collected using a structured questionnaire. A high general HIV disclosure rate (94.1%; f=320; N=340) was observed of which 57.5% (f=184; n=320) was to sexual partners. X2 procedures indicate an association with gender, residential region, religion, and period of being on ART. The majority (70.2%; f=179; n=255) of the respondents used condoms all the time to avoid infecting their sexual partners (99.2%; f=243; n=245) and to avoid contracting STIs (99.2%; f=243; n=245). X2 procedures indicate an association with gender, residential region, marital status, number of sexual partners, knowledge of the HIV status of sexual partners and period of being on ART. The single leading reason for not using the condom was sexual partners’ refusal to use condoms (85.7%; f=54; n=63). / Health Studies / M.A.(Health Studies)