Magister Public Health - MPH / Background: Disclosure in the context of HIV is the sharing of information about one’s HIV-positive status with someone else. In the case of people living with HIV (PLHIV), many factors influence their decision to disclose. As with other illnesses there is a concern about possible discrimination or stigma. On the other hand, disclosure can lead to higher levels of support and better management of HIV infection. Types of disclosure can also vary depending on the need of the PLHIV, being partial or full, in order to gain the most benefit. Self-disclosure or mediated disclosure with the assistance of someone else is controlled by the PLHIV, whereas involuntary or forced disclosure might not be under the PLHIV's control and thus more likely to have negative consequences. No studies have been done in the rural area of Linguère, Senegal or in the rest of the country to identify the factors that influence the decisions of PLHIV around disclosure. Senegal has a concentrated HIV epidemic with national HIV prevalence stable at 0.7% in 2005 and 2010 Demographic and Health Surveys. Linguère District's HIV prevalence was at 0.8% in 2003. By knowing more about what motivates PLHIV to disclose or not disclose their status, service providers and others can better support PLHIV to practise beneficial disclosure. Aim: The aim of this study was to explore factors that influence the decision to disclose or not disclose one's HIV-positive status to regular sexual partners, friends and family in Linguère District,Senegal. Methods: A qualitative method with in-depth interviews was used to explore the factors that influenced decisions concerning disclosure. Fifteen PLHIV were identified through purposive sampling based on criteria such as marital status, gender and prior disclosure decisions. In addition, four service providers from the AIDS service organization, Projet SSP, and the district health and social workers served as key informants. The interviews were recorded, transcribed and translated from the local languages into French. Record reviews of the HIV/AIDS service organization complemented the interviews. The fieldwork was conducted in the study setting for two weeks in January 2012. The data was analysed through thematic analysis. Findings: The main themes that emerged as reasons for disclosure were maintaining psychosocial well-being, existence of trusting relationships, need for support with health care, reciprocal obligations and concern for others, whereas reasons for non-disclosure included stigma and discrimination and negative impact on family. However, the factors varied from one participant to another and could not consistently be attributed to one group or another, whether man or woman, married or divorced,etc. Influencing factors were related to gaining support for the participant or avoiding problems. Concerns about stigma were great and included reference to wanting others to have soutoura— privacy, dignity, respect. There were also factors which took into consideration the consequence for the person to whom they might disclose, such as desire to avoid upset or desire to seek testing and possible care for a spouse. Of the participants who had disclosed, there were no cases of severe negative consequences. Not one participant expressed regret for having disclosed, rather they acknowledged that there were positive benefits for themselves and sometimes also the other person to whom disclosure was made. The roles of the service providers and the support group were also influential in decision-making around disclosure, with a good number of cases of mediated disclosure. Conclusion: In line with consequence theory, PLHIV weighed up their benefits and costs when decisions around disclosure were contemplated. The benefits were that PLHIV who chose to disclose gained from increased social support and better management of their HIV infection. At the same time further transmission of infection was potentially reduced and others were oriented for testing and for access to care if needed. In general, HIV continues to be a particularly stigmatising condition and thus the majority of PLHIV in this study judged that it is not worth the risk of possible abandonment,rejection or slander to disclose their status, regardless of the fact that few have actually experienced severe negative consequences as a result of actual disclosure. Because of support provided through service providers and the support group, however, those participants who had chosen to disclose to someone outside of the support group were reaping benefits and also likely avoiding the need to turn to risky activities, such as transactional sex or formal sex work. Recommendations: Recommendations drawn from this study include the need to support programmes or initiatives which seek to reduce HIV-related stigma. There is also the need for leaders in the community to show support for PLHIV which can reduce stigma. Health care and service providers should be aware of the needs of PLHIV and the changes that may arise over time which could lead to a decision to practise beneficial disclosure. They should also learn from the experiences shared by other PLHIV which can in turn be shared. They should receive further training in order to better understand the complexity of disclosure and to assist with mediated disclosure.

Magister Public Health - MPH / Background: Even though there have been marked increases in the number of patients accessing HIV care and treatment in sub-Saharan Africa, challenges in patient retention remain. Most health systems in sub-Saharan Africa routinely report on loss to follow up of patients, but only a limited number of factors associated with loss to follow up are measured. In Kenya there is limited research on loss to follow up in HIV care and treatment programs. This study reports on rates of loss to follow up and factors associated with loss to follow up at the New NyanzaProvincial General Hospital (NNPGH) in Kisumu, Kenya. Methods: A retrospective cohort study of 4,740 adult patients that was registered for HIV and AIDS care and treatment between 2003 and 2008 was conducted. Data was analysed using SAS 9.2 and STATA 10. Cox proportional hazard ratio was calculated to describe the association between risk factors and loss to follow up. Results of the total 4740 patients, 64.6% were female, males [median age of 36 (IQR 30-44) years vs. 32 (IQR 26-39) years for females] were older than females, more males (68.3%) were married, more females (6.2%) had no education and 68% of all patients enrolled had been lost to follow up over 6 years. Risk for lost to follow up was greater amongst males (Adjusted Hazard Ratio (AHR) =1.12; 95% Confidence Interval (CI) = 1.02-1.22); younger patients(15-30 vs. >40 years: AHR=1.37, 95%CI = 1.23 – 1.53; and 31-40 vs. >40 years: AHR=1.15, 95%CI=1.03-1.28); those who were unemployed (AHR=1.14, 95%CI=1.05-1.25); and having advanced HIV disease (WHO stage 4 vs. WHO stage 1: AHR=1.53, 95%CI=1.29-1.81). Patients on ART (AHR=0.64, 95%CI=0.52-0.78) at enrollment were less likely to be lost to follow-up compared to those in HIV care. Conclusion: More attention is needed in developing retention strategies for patients with much focus on patients on care. Targeted intervention is required to improve retention amongst males, unemployed patients, patients with advanced HIV disease and younger patients. Additionally, targeted follow up in the community for patients on care is required.

Magister Public Health - MPH / Background: Adherence of patients on antiretroviral therapy to lifelong treatment is a major challenge within the public health system in Namibia. Missed appointments have been shown to contribute to poor clinical outcomes and treatment failure, which may necessitate switching to more expensive antiretroviral regimens. In resource limited settings monitoring of appointments for antiretroviral medication pick up is a documented and feasible method for assessing minimum levels of adherence to antiretroviral medication. Aim: This study was aimed at evaluating the effects of telephonic short message service reminders influence on adherence to scheduled antiretroviral medication pick up appointments. It was also aimed at evaluating how socio-demographic parameters might moderate the effectiveness of short message service reminders. Study design: A randomized double blind controlled study design was employed. Methodology: Stable patients attending the ART clinic were recruited and randomly assigned to either an intervention or control group, until the sample size of 398 was reached in the two arms of the study. The study populations were adult patients’ ≥ 18 years who have been enrolled on treatment for ≥ 3months. The intervention group received an unasked for single short message service reminder, sent 48 hours before their scheduled appointments and continued with standard care, while the control group received standard care without any reminder. The study participants were blinded to their study group. Also, research assistants involved in collecting baseline and outcome data were blinded to study participants study group. Baseline data was collected through a structured questionnaire. Study participants were followed up for four consecutive scheduled ARV pick up appointments. The following outcome data were collected at each follow up visit; number of days late after scheduled appointment, adherence measured by pill count and 3 days self-report recall of adherence. Main results: The pre-intervention survey revealed that only 60% of the study participants were willing to be reminded of their medication pick up appointment. Overall, the SMS reminder improved adherence to medication pick up appointments by 1.6 times as compared to no reminder and also reduced the risk of missing medication pick appointments by 22% as compared to no SMS reminder. Study participants that received a reminder were also two times more likely to achieve optimal adherence to their medication, compared to those who received no reminder. The SMS reminder improved adherence to antiretroviral medication by 11% in this study, while the mean difference in the number of days late to collect antiretroviral medication was significantly reduced by about 4 days by the intervention. Participants that are employed were more likely to adhere to antiretroviral medications as compared to the unemployed. Ironically participants that were on ART for less than one year and those that had treatment supporters reminding them of their medication appointments were significantly less likely to honour their medication pick up appointments. Conclusion: Being employed was significantly associated with attaining optimal adherence to antiretroviral medication. There were no other significant associations between the patients socio- economic and demographic characteristics and adherence to scheduled medication pick up appointments, or to adherence to medication. Recommendations: The Ministry of Health and Social Services should consider rolling out SMS reminders to ART sites with similar settings as Swakopmund State Hospital ART Clinic. Patients that are willing to receive the reminder should be targeted in the scaling up of the roll out. Late and missed medication pick up appointments could be used as an easy proxy measurement for assessing adherence to ART.

Magister Scientiae Dentium - MSc(Dent) / Introduction: South Africa has an estimated HIV prevalence rate of 29.5%, in Gauteng province, the prevalence rate in women attending ante-natal clinic is 28.7% and in the Johannesburg Metro District, the prevalence rate is 41%. The early identification of HIV in the HIV positive well patient or HIV positive unwell patient can lead to the commencement of early intervention and treatment, thus resulting in a higher quality of life for the patient and lower treatment costs for the State. Aim: To determine the oral health knowledge, practices and treatment patterns of nurses at ARV clinics in Johannesburg Metro District. Materials and Methods: The study design was a convenient cross-sectional survey conducted between May 2014 and January 2015 in the Johannesburg Metro District. The study population comprised of nursing staff at ARV clinics in the Johannesburg Metro District. 147 questionnaires were distributed among the nurses that were in contact with the patients. Only 100 (n=147) questionnaires came back completed. The data collected was entered into Microsoft Excel and imported to STATA 13.1 to determine statistical significance using chi-squared test. A p-value was regarded significant if <0.05. Results: The results of the study depicted poor knowledge on oral manifestations of HIV/AIDS from the nursing staff at the ARV clinics in the district. Although 85% could describe the oral lesions found in the oral cavity and 66% perceived that they could identify Oral Candidiasis (OC), only 47% could correctly identify the lesion. 57% perceived knowing the condition associated with OC and only 46% correctly named the condition (p- value=0.001). Only two thirds of 43% of nurses could manage OC using drugs from the protocol accessible at the clinics, 25% referred and 32% did not know how to manage the OC (p-value=0.001). Only 40% (n=100) of the nurses referred patients for oral health promotion. Almost all the nurses (81%) indicated repeatedly that they need more training on oral health and oral health promotion. Conclusions: There is a need to include the oral manifestations of HIV in the nursing curriculum. Continued professional development should include Oral Health Promotion. Further research is needed to explore means of incorporating an oral health and disease module in the nursing curriculum.

Magister Public Health - MPH / Background: The recognition of HIV/AIDS as a chronic life-long condition globally in recent years has demanded a different perception and an alignment to its association with other chronic diseases. Both HIV and other chronic non-communicable diseases are significant causes of morbidity and mortality. Their combined DALY contributions for Botswana would be significant if research and strategies in controlling these conditions are not put in place. Natural aging and specific HIV-related accelerated aging of patients who are on antiretroviral treatment means that age-related diseases will adversely affect this population. Princess Marina Hospital Infectious Diseases Care Clinic has been in operation since 2002. The clinic has initiated over 16 000 patients on anti-retroviral treatment (ART) since 2002. The current study estimated the prevalence of non-AIDS defining conditions (NADCs) in the attendees of the clinic in 2013. The majority of patients that attended the clinic had been on treatment for over three years with some patients more than ten years. These ART experienced patients were more likely to be susceptible to chronic non-communicable diseases, including non-AIDS defining conditions. The nomenclature used in classification of NADCs in the current study was appropriate for resource-limited settings; because the study setting offered HIV treatment under resources constraints. Aim: The current study characterised non-AIDS defining conditions, and determined their associations with virologic treatment failure in a cohort of patients that were enrolled at Princess Marina Hospital antiretroviral clinic in Gaborone, Botswana. Methods: A retrospective cross sectional study of records of patients who attended the Princess Marina Infectious Diseases Care Clinic in 2013. Stratified random sampling of a total of 228 patients’ records was achieved from a total population of 5,781 records. Data was transcribed into a Microsoft Excel Spreadsheet and then exported to Epi-Info statistical software for analysis. Results: Eighty (35%) cases of NADCs were reported/diagnosed in the study sample; with 27% (n=62) of the patients having at least one condition, 6.7% (n=17) two conditions, and 0.4% (n=1) three conditions. The top prevalent conditions were hypertension (n= 40), hyperlipidaemia (n=7) and lipodystrophy (n=7). The prevalence of NADCs on the various categories of patients compared with the total sample population was as follows: active patients (prevalence ratio= 0.70), transferred out patients (prevalence ratio = 1.24), patients who died (prevalence ratio=2.04) and patients who were lost to follow-up (prevalence ratio =2.86). The prevalence of NADCs was significantly associated with increasing age (p<0.001); having social problems (p=0.028); having been on treatment for over three years (p=0.007); an outcome of death (p = 0.03) and being lost to follow-up (p=0.007). The study showed that being controlled on second line or salvage regimen (p=0.014) and the presence of adherence problems in the past was associated with virologic failure (p=0.008). There was no association of presence of NADCs to virologic failure. Conclusions: There was significant morbidity of non-AIDS defining conditions in the Princess Marina Infectious Diseases Care Clinic shown by a prevalence of NADCs in the clinic of 35% in 2013.The significant associations of the presence of NADCs and virologic failure with outcomes of death and loss to follow-up illustrate the adverse effects that NADCs are having, and calls for strategies to address multi-morbidities in HIV patients on antiretroviral treatment.

Magister Public Health - MPH / The introduction of antiretroviral therapy (ART) brought new hope to HIV patients as it has transformed a fatal disease to a chronic manageable condition. In 2009 there were over 920,000 Malawians infected with HIV and 110,000 new infections. Malawi like other countries in the sub-Saharan Africa has made great strides in ensuring access to ART. The government of Malawi introduced free antiretroviral therapy (ART) in June 2004. By 2010, a total of 250,987 patients in the country were receiving ART. The success of ART requires, amongst others, a sustained adherence rate to medication of more than 95% to prevent viral replication and the development of drug resistant HIV strains. Identifying the factors that influence adherence is essential for the long-term success of public ART programmes. This study explored patient, socio-economic, cultural, and religious and health systems factors that influence adherence to ART in Zomba district in Malawi. An explorative qualitative study was conducted amongst ART patients and health workers in four health facilities in Zomba district of the Southern Region of Malawi. Data collection was through individual in-depth interviews with 25 ART patients and semi-structured key informant interviews with 13 health workers that were actively involved in the ART programme. Data was audio-recorded and transcribed verbatim. Thematic and content analysis of transcribed data was done. The study found high individual commitment, having social support from family and friends and continuous good counselling to be facilitators to adherence to ART. HIV-related stigma and discrimination, none disclosure of HIV status, lack of partner support, travelling to attend funerals and religious beliefs were noted barriers to adherence. Health system factors such as congestion in the clinic, negative staff attitudes and a lack of privacy at the pharmacy were also identified as barriers to clinic attendance and keeping appointments. Although pill burden was not mentioned, patients reported drug reactions as a barrier to adherence. Although there is good road network in the district, transport cost was still mentioned as a hindrance to treatment adherence. Treatment success was reported to be both a facilitator and a barrier to adherence. HIV-related stigma and discrimination among people need to be addressed to increase support to PLWHIV and encourage disclosure of HIV status. The improvement of the socio-economic status of ART patients needs to be addressed to reduce dependence on support from other people and provide money to make follow-up appointments. The health systems need to reduce clinic congestion and waiting times so that patients are not deterred from accessing ART.

Magister Public Health - MPH / Evaluation of health programmes is essential to assist programme managers in decision-making and accountability to the population they serve. Additionally, regular monitoring and evaluation of TB/HIV collaborative activities are used as a means to assess quality, effectiveness and coverage of services; yet little attention has been given to this in most developing countries. In the southern region of Ethiopia, since the inception of the TB/HIV collaborative activities in 2005, there has not been any formal evaluation pertaining to the implementation status of integrated TB/HIV services at routine program level. However, a series of TB/HIV reviews underlined many challenges that have adversely affected the implementation nationally. However, studies conducted on the quality of TB and HIV/AIDS services tend to be broad and not targeted to the integrated TB/HIV program and therefore, it was necessary to assess the implementation status in a more focused way with a vision to determine its adequacy or otherwise and make appropriate recommendations to improve integrated TB/HIV services in the town. Aim: To assess the implementation of integrated TB/HIV activities in the health facilities of Hawassa town administration Study design: Cross sectional study Study population: All health facilities, health managers, and records of TB and HIV patients in Hawassa town administration Sample population: The study population encompassed TB and HIV clinics, managers of each health facility, and sampled records of individual clients/patients enrolled in the HIV/AIDS/TB treatment and care program, from each health facility in the year 2009/10. Data collection: Face-to-face interviews with facility managers, observation of the rooms in which TB/HIV services are rendered and a review of patient records, were undertaken. Analysis: Descriptive statistics with frequencies and percentages were used for analysis of facility based resource inputs, TB case finding and management, and HIV case finding and management practices. Indicator variables extracted from the record review were transformed into scales (0 or 1) and weighted to reflect the levels of TB/HIV service quality, integration and resources input. After weighting, experts' opinion was used to set a cut off level (75%) to categorize the relative service quality received by individuals and the level of integrated care provided by facilities into "adequate" or "inadequate". Bivariate analysis was done to assess the effect of independent predictor variables on outcome variables. We used a– P value of 0.1 on bivariate analysis as the cut off point for inclusion of variables into the multivariate analysis. Prevalence ratios, adjusted prevalence odds ratios, and 95% confidence intervals were used to present outcomes. Results: Availability of resource inputs for HIV/AIDS care was inadequate in half of the facilities in Hawassa town whereas, laboratory infrastructure for TB/HIV care was adequate in all facilities. Most (91%) HIV/AIDS patients had their CD4 count and weight (96%) measured at baseline. However, the trend declined over time and the practice was better in hospitals than in health centres. HAART status was a strong predictor of CD4 count improvement and improvement in CD4 count was found to be a strong predictor of body weight gain. TB case finding and management practices in HIV/AIDS clinics were found to be adequate in the health facilities in Hawassa town. Ninety five percent and 86% of HIV positive patients were screened for TB at baseline and at the last clinical visit respectively, of which 98%, 93% and 81% of patients co infected with TB and HIV were provided with DOTS, CPT and ART respectively. However, only 11% of HIV positive patients without active TB were provided with IPT. Only HAART status was found to be a strong predictor of TB case finding. Quality of HIV/AIDS care in health facilities in Hawassa town was adequate. Availability of at least a minimum number of staff and being on HAART were found to be strong negative and positive predictors of quality respectively. Overall, 91% of patients on HAART were retained in care at the end of the year (alive and on treatment), 6% were retained and 3% died. Resources for the TB program were deficient in our study area. Three out of four facilities had inadequate overall input resources required for good quality TB care and the fourth barely managed to achieve adequate status. However, laboratory infrastructure and availability of forms and registers were adequate in all the facilities. There was a high degree of HIV case finding and a high prevalence (17%) of HIV among TB patients. Despite this, the overall HIV care provided was inadequate, with only 64% and 73% of TB/HIV co-infected patients being provided with HAART and co-trimoxazole respectively and 22% of TB/HIV co-infected patients not enrolled in HIV care. Among sputum positive TB patients good quality TB care was found to be a strong predictor of successful treatment outcome Our study also showed consistently very high quality TB service provision in the town despite the lack of required resources. Conclusion and Recommendations: The study showed that there was relatively good quality provision of TB and HIV services despite inadequate input resources and that quality of care was positively associated with good outcomes. The study also indicated that HAART benefited patients substantially and hence earlier initiation could be the way forward. We recommend that to further improve quality of care one stop shopping services (availing both anti-TB and HIV care at the same service point within a clinic) be established. In addition, we recommend improved patient monitoring, especially for Pre-ART patients, be established.

This study set out to explore and describe adolescent learners’ experiences of HIV/AIDS programmes presented at their schools. The rationale was that an understanding of how learners experience HIV/AIDS programmes might afford insight into the ways in which adolescents manage HIV/AIDS-related issues every day. Subsequent understanding could perhaps contribute to the body of knowledge on HIV/AIDS education, and possibly inform future HIV/AIDS education curriculum development. The conceptual framework constituted the impact of HIV/AIDS on society, education and adolescents; theories on experiences and adolescent development; relevant Department of Education policies and curriculum plans; as well as national and international research concerning HIV/AIDS education programmes. A qualitative research approach was followed from an interpretivist epistemology, with sensitivity given to criteria of credibility, transferability and dependability. An instrumental case study was conducted at three secondary schools (cases), using focus groups and written essays as the methods for data collection from 90 diverse participants, Grade 11 learners. Responses were audio-taped, transcribed and analysed from a constructivist grounded theory perspective. Results were interpreted by means of literature control. Six prominent themes emerged. Learners experienced that they were changed positively by knowledge on HIV/AIDS. In this regard they were more open and motivated to communicate, their views and perceptions altered and they were motivated to behave responsibly. However, learners also experienced HIV/AIDS knowledge negatively. They felt bombarded with HIV/AIDS information and they experienced some HIV/AIDS information as upsetting. Learners’ experiences still reflected some stereotyping and persisting misconceptions. Learners associated poverty and lack of education with higher HIV infection rates, as well as a lack of support from parents and/or family. Learners’ experiences reflected that they would appreciate their parents’ participation in HIV/AIDS programmes. Learners voiced a need for improved communication with their parents regarding HIV/AIDS, and experienced their parents as ignorant, shy, stubborn or scared in this regard. Learners’ accounts reflected that parents’ initial negativity towards the programme later changed into positive support. The learners also had positive and negative experiences regarding their friends and the HIV/AIDS programmes. They expressed that their peer-relationships improved in terms of ability to communicate and render support. In addition they expressed that their friends still had a great influence in their lives. Some issues, such as risk behaviour and the HIV-status of their peers, shocked learners. The learners indicated that they thought HIV/AIDS education was necessary, but recommended certain amendments for future HIV/AIDS programmes. Their experiences suggested smaller gender-specific groups; an outsider-presenter; parent/caregiver involvement; variety in programme format; long-term HIV/AIDS education; HIV/AIDS care, support and treatment information in addition to that of prevention; addressing values and life skills content in HIV/AIDS education; as well as fear-provoking real-life contexts. Several recommendations were made in terms of HIV/AIDS education and programme development. Integration between HIV/AIDS education, life skills education and values education in the formal curriculum is supported by findings and recommended for curriculum development and educational practice. Correspondingly, it is recommended that multiple views on poverty be incorporated into HIV/AIDS education to address persisting stereotypes and misconceptions. Furthermore, cognisance of learners’ suggestions in terms of format and content regarding future HIV/AIDS programme development is recommended. Findings queried existing premises regarding adolescents and (ir-)responsibility in developmental theory, establishing a foundation for further research. Existing silences in the data relating to gender, orphans, violence, non-governmental organisations, condom-use in the context of HIV/AIDS also requires further research. Establishing that the use of open-ended methods with adolescents resulted in access to rich and descriptive data signified a methodological contribution. Theoretically this study contributes to the existing body of knowledge related to HIV/AIDS education by giving voice to adolescent learners’ experiences of HIV/AIDS programmes. Contributions in the realm of HIV/AIDS educational practice and curriculum development include learners’ views of what they found beneficial and lacking in existing programmes, as well as their recommendations regarding format and content for future HIV/AIDS programmes directed at adolescents. / Thesis (PhD (Educational Psychology))--University of Pretoria, 2006. / Educational Psychology / unrestricted

No abstract available / Dissertation (MA(Theology))--University of Pretoria, 2008. / Practical Theology / unrestricted

No abstract available / Dissertation (MA (Research in Practical Theology))--University of Pretoria, 2007. / Practical Theology / unrestricted