Thesis (PhD)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Introduction In the era of antiretroviral therapy (ART), people living with Human Immunodeficiency Virus (HIV) now have prolonged life spans. An emerging trend of non- acquired immune deficiency syndrome (AIDS) related complications now prevails in the aging HIV infected population. Increased levels of inflammation and chronic immune activation are associated with HIV infection. In the era of ART people living with HIV are at an increased risk of cardiovascular disease (CVD). Platelets play a pivotal role in both inflammation and immune activation and upon activation platelets degranulate and secrete various inflammatory, coagulatory and adhesion molecules. Activated platelets express surface P-selectin (CD62P) and are a key component of the coagulation pathway and serve as a link between inflammation and thrombosis. Activated platelets have been implicated in inflammatory and cardiovascular disease and have been identified as immune cells that play a crucial role in pathogen recognition and modulation of immune cells during infections. Several antiviral and antibacterial properties of platelet alpha granule contents have been established. Platelet aggregometry remains the most widely used technique to evaluate platelet function even though this technique is limited by many pre-analytical variables. Platelet flow cytometry on the other hand offers a rapid measurement of platelet function in their physiological environment with minimal artefactual activation. Few studies have however reported on standardized methods to evaluate platelet function in the context of HIV. Platelet function remains unclear and data on HIV infected treatment naïve individuals remains scarce. The aim of this project was to examine the relationship between platelet function and immune activation in patients with HIV Materials and methods This study consisted of five sub-studies, firstly platelet indices and levels of platelet activation were determined in a cohort of 330 participants (185 HIV infected ARV naïve and 145 uninfected healthy controls) using; flow cytometry and haemotology analyzers. The relationship between these indices and markers of platelet activation, disease progression and immune activation were assessed. Furthermore, levels of platelet activation and aggregation were evaluated in a cohort of 82 participants (41 HIV infected (ARV naïve) individuals and 41 uninfected healthy controls), using a novel whole blood flow cytometry based functional assay. These baseline levels were then correlated with markers of immune activation and disease progression in HIV. In a subsequent study, platelet function in a cohort consisting of 58 HIV infected (ARV naïve) and 38 uninfected controls was evaluated using flow cytometry. Platelet response was measured post stimulation with adenosine diphosphate (ADP) at concentrations known to induce reversible (0.04mM) and irreversible (0.2mM) platelet aggregation. In order to assess platelet function in HIV, platelet response was evaluated in a cohort consisting of 58 HIV infected (ARV naïve) and 38 uninfected controls. Platelets were activated using varying concentrations of ADP, arachidonic acid (AA) and collagen and platelet function was measured using flow cytometry. Levels of circulating platelet leukocyte aggregates (PLAs) were also measured using flow cytometry in a cohort consisting of 35 HIV-infected (ARV naïve) individuals and 32 uninfected healthy controls. Associations between PLAs, immune activation and disease progression in HIV infected individuals were determined. The final study evaluated platelet aggregates, platelet derived microparticles (PMPs) and microparticles (MPs) in a cohort consisting of 46 HIV infected (ARV-naïve) and 40 uninfected healthy controls. Associations between MPs, PMPs, platelet aggregates and markers of immune activation and disease progression were evaluated. Results HIV infected individuals showed decreased mean platelet volume levels (HIV mean 7.91 ± 0.85 vs. 8.52 ± 1.12, p<0.0001) that directly correlated with CD4 counts (r=-0.2898, p=0.0075) and viral load (r=0.2680, p=0.0177). Platelet distribution width (PDW) levels directly correlated (r=0.3455, p=0.0362) with active coagulation and inversely correlated (r=-0.3666, p=0.0463) with platelet aggregation. HIV infected individuals showed increased levels of platelet activation (%CD62P median 11.33[5.96-29.36] vs. control group 2.48[1.56-6.04], p=0.0001). In HIV, platelet function is retained and platelets showed increased response to submaximal concentrations of endogenous agonists. HIV infected individuals showed increased levels of circulating platelet monocyte aggregates (25.26[16.16-32.28] vs. control group 14.12[8.36- 18.83], p=0.0001) that directly correlated with markers of immune activation; %CD38/8 (r=0.54624, p=0.0155), viral load (r=0.633, p<0.009). Furthermore we report on increased levels of circulating MPs (median %MPs 1.7[0.95-2.83] vs. Control group 1.12[0.63-1.57], p=0.0160); PMPs (median %PMPs 26.64[11.33-36.62] vs. Control group 20.02[18.08-26.08], p=0.0133); activated PMPs (median CD62P MFI 3.81[3.46-4.54] vs. Control group 3.41[3.16-3.6], p=0.0037) and platelet aggregates (Median %CD62P 14.10[5.49-39.94] vs. Control group 0.17[0.10-10.99], p= 0.0097) in HIV infected asymptomatic individuals. Conclusion This study supports the potential use of the MPV and PDW as readily available markers of platelet activation and immune activation in HIV. We also showed elevated levels of activated platelets in HIV infected individuals that were hyper responsive to endogenous agonists in a concentration dependent manner. Platelet flow cytometry is a rapid and valuable technique in the evaluation of platelet function in HIV. The measurement of platelet function using flow cytometry allows the evaluation of platelet signalling pathways that may be modified in HIV infected individuals. Lastly we describe an optimized whole blood flow cytometry based assay for the evaluation of circulating microparticles (MPs), platelet derived microparticles (PMPs) and levels of activated platelets and aggregates which mimics the in vivo physiological environment of MPs. To the best of our knowledge, this study is the first to report on a novel approach in evaluating platelet function in HIV using a series of optimised whole blood flow cytometry based platelet assays. In addition, minimal work has been performed previously on platelet function in the context of HIV-infection; and particularly in a cohort of asymptomatic, untreated patients as defined for this study. / AFRIKAANSE OPSOMMING: Inleiding In die era van antiretrovirale terapie (ART), het mense wat met die menslike immuniteitsgebreksvirus (MIV) leef, het nou 'n verlengde lewensduur. 'N opkomende neiging van nie-verworwe immuniteitsgebreksindroom (vigs) heers nou in die verouderende MIV-besmette bevolking. Verhoogde vlakke van inflammasie en chroniese immuun aktivering word geassosieer met MIV-infeksie en in die era van ART loop mense wat met MIV leef, 'n verhoogde risiko van kardiovaskulêre siekte (KVS). Plaatjies speel 'n belangrike rol in beide inflammasie en immuun aktivering en met aktivering degranulate en skei plaatjies verskeie inflammatoriese, coagulatory en adhesie molecule af. Geaktiveerde plaatjies druk oppervlak P-selectin (CD62P) is 'n belangrike komponent van die stollings weg en dien as 'n skakel tussen inflammasie en trombose. Geaktiveerde plaatjies is in beide inflammasie en kardiovaskulêre siekte betrokke en is geïdentifiseer as immuun selle wat 'n deurslaggewende rol speel in die patogeen erkenning en modulasie van immuun selle tydens infeksies. Verskeie antivirale en antibakteriese eienskappe van plaatjie alpha korrel inhoud is vasgestel. Plaatjie aggregometry bly die mees gebruikte tegniek om plaatjie funksie te evalueer, alhoewel hierdie tegniek is beperk deur baie pre-analitiese veranderlikes. Plaatjie vloeisitometrie aan die ander kant bied 'n vinnige meting van plaatjie funksie in hul fisiologiese omgewing met 'n minimale artefactual aktivering. Min studies het egter berig op gestandaardiseerde metodes om plaatjie funksie in die konteks van MIV te evalueer. Plaatjie funksie is steeds onduidelik en data oor MIV besmet behandeling naïef individue bly skaars. Die doel van hierdie projek was om die verhouding tussen die plaatjie funksie en immuun aktivering in pasiënte met MIV te ondersoek. Materiaal en metodes Hierdie studie het bestaan uit vyf sub-studies. In die eerste plekis plaatjie indekse en vlakke van plaatjie aktivering bepaal in 'n groep van 330 deelnemers (185 MIV-besmette ARV naïef en 145 onbesmette gesonde kontrole) met behulp van vloeisitometrie en hematologie ontleders. Die verhouding tussen hierdie indekse en merkers van plaatjie aktivering, die siekte se progressive en immuun aktivering is beoordeel. Verder is die vlakke van plaatjie aktivering en samevoeging in 'n groep van 82 deelnemers (41 MIV-besmette (ARV naïef) individue en 41 onbesmette gesonde kontrole) geëvalueer, met behulp van 'n nuwe vol bloed vloeisitometrie gebaseerde funksionele toets. Hierdie basislyn vlakke is dan gekorreleer met merkers van immuun aktivering en die progreessie van die siekte in MIV. In 'n daaropvolgende studie, is plaatjie funksie in 'n groep wat bestaan uit 58 MIV besmet te (ARV naïef) en 38 onbesmette beheer geëvalueer met behulp van vloeisitometrie. Plaatjie reaksie is na stimulasie gemeet met adenosine diphophate (ADP) by konsentrasies bekend omkeer (0.04mM) te oorreed en onomkeerbaar (0.2mm) plaatjie aggregasie. Ten einde plaatjie funksie in MIV te evalueer, is plaatjie reaksie in 'n groep wat bestaan uit 58 MIV-besmette (ARV naïef) en 38 onbesmette kontrole geëvalueer. Die plaatjies is geaktiveer deur gebruik te maak van wisselende konsentrasies van ADP, is aragidoonsuur (AA) en kollageen en plaatjie funksie gemeet met behulp van vloeisitometrie. Vlakke van sirkulerende plaatjie leukosiet gemiddeldes is ook gemeet met behulp van vloeisitometrie in 'n groep wat bestaan uit 35 MIV-positiewe (ARV naïef) individue en 32 onbesmette gesonde kontrole. Assosiasies tussen leukosiet gemiddeldes, immuun aktivering en die progressive van ie siekte in MIV-besmette individue is ook bepaal. Die finale studie het plaatjie-gemiddeldes, plaatjie afgelei mikrodeeltjies en mikrodeeltjies geëvalueer in 'n groep wat bestaan uit 46 MIV besmet (ARV-naïewe) en 40 onbesmette gesonde kontrole. Assosiasies tussen mikrodeeltjies, plaatjie afgelei, plaatjie gemiddeldes en merkers van immuun aktivering en die siekte se progressie is geëvalueer. Resultate MIV-besmette individue het gedaalde gemiddelde plaatjie volume vlakke getoon (HIV gemiddelde 7,91 ± 0,85 8,52 ± 1,12 teen, p <0,0001) wat direk gekorreleer het met CD4-tellings (r = -0,2898, p = 0,0075) en virale (r = 0,2680, p = 0,0177). Plaatjie verspreiding breedte vlakke het direk gekorreleer met (r = 0,3455, p = 0,0362) met 'n aktiewe koagulasie en omgekeerd gekorreleer (r = -0,3666, p = 0,0463) met plaatjie aggregasie. MIV-besmette individue het verhoogde vlakke van plaatjie aktivering getoon (% CD62P mediaan 11,33 [5,96-29,36] teen kontrole groep 2,48 [1,56-6,04], p = 0,0001). In MIV, was plaatjie funksie behou en plaatjies het 'n verhoogde reaksie op submaksimale konsentrasies van endogene agoniste getoon. MIVbesmette individue het verhoogde vlakke van sirkuleer plaatjie monosiet-gemiddeldes gedemonstreer (25.26 [16,16-32,28] teen kontrole groep 14,12 [8,36-18,83], p = 0,0001) wat direk gekorreleer het met merkers van immuun aktivering; % CD38 / 8 (r = 0,54624, p = 0,0155), virale lading (r = 0,633, p <0,009). Verder rapporteer ons op verhoogde vlakke van sirkulerende mikrodeeltjies (mediaan% LP 1.7 [0,95-2,83] teen kontrole groep 1,12 [0,63-1,57], p = 0,0160); PMPs (mediaan% PMPs 26,64 [11,33-36,62] teen kontrole groep 20,02 [18,08-26,08], p = 0,0133); geaktiveer PMPs (mediaan CD62P MFI 3,81 [3,46-4,54] teen kontrole groep 3,41 [3,16- 3,6], p = 0,0037) en plaatjie gemiddeldes (Mediaan% CD62P 14,10 [5,49-39,94] teen 0.17 [0,10- 10,99], p= 0.0097) in MIV besmet asimptomatiese individue. Gevolgtrekking Hierdie studie ondersteun die potensiële gebruik van die MPV en PDW as waardevolle geredelik waardevolle merkers van plaatjie aktivering en immuun aktivering in MIV. Ons het ook getoon verhoogde vlakke van geaktiveer de plaatjies in MIV-besmette individue getoon wat hyper reageer op endogene agoniste was in 'n konsentrasie-afhanklike wyse. Plaatjie vloeisitometrie is 'n vinnige en waardevolle tegniek in die evaluering van plaatjie funksie in MIV. Die meting van plaatjie funksie gebruik vloei cytometry maak die evaluering van plaatjie sein paaie wat in MIVgeïnfekteerde individue verander moontlik. Laastens het ons beskryf 'n hele bloed vloeisitometrie gebaseer de toets vir die evaluering van sirkulerende mikrodeeltjies, plaatjie afgelei mikrodeeltjies en vlakke van geaktiveer plaatjies en gemiddeldes wat lyk soos die in vivo fisiologiese omgewing van MP's. Na die beste van ons kennis, is hierdie studie die eerste om te rapporteer oor 'n nuwe benadering in die evaluering van plaatjie funksie in MIV met behulp van 'n reeks van new hele bloed vloeisitometrie gebaseer de plaatjie toetse. Daarbenewens is minimale werk voorheen uitgevoer op die plaatjie funksie in die konteks van MIV-infeksie; en veral in 'n groep van asimptomatiese, onbehandelde pasiënte soos vir hierdie studie. Hierdie projek het bewyse bygevoeg tot die teorie dat plaatjies, in MIV, kan 'n skakel wees tussen die aktiewe inflammatoriese reaksie en die toename in die aantal trombotische en kardiovaskulêre siekte waargeneem in pasiënte wat met hierdie siekte saamleef.

Background: During the 1980s, the fear of HIV spread over the world. Health professionals'attitudes to patients with HIV, was negatively impacted because of their fear to be infected.Patients with HIV have therefore,during disease history's first two decades, experienced stigma and discrimination in the response from health professionals. Because of the increasing knowledge of HIV it is of interest to study patients' contemporary experiences of the encounter with health professionals. Aim:To explore how patients with HIV experiencing the meeting with health professionals. Method:Literature study with seven qualitative and three quantitative articles. Results:Two themes were found; to be discriminated and to be powerless and extradited. To be discriminated describes that patients in several cases been treated differently than others, by health professionals.To be powerless and extradited describes that patients are not allowed tobe involved in their care and they have distrust to health care providers.Conclusion:Patients with HIV experience discrimination, excessive precautions and ignorance which cause a care suffering. It is important that the nurse is aware of the deficiencies in the treatment to work towards a good care relationship.There is a great need for further research regarding to explore how patients with HIV experiencing the treatment from health professionals.

Bakgrund: Hiv är ett folkhälsoproblem som cirka 30-35 miljoner människor runt om i världen lever med. I Sverige rapporteras 400-500 nya fall varje år. Att ha hiv kan leda till att människor utsätts för stigmatisering från omgivningen. Syfte: Syftet med denna litteraturöversikt är att belysa upplevelser av stigmatisering hos människor som har hiv. Metod: En litteraturöversikt genomfördes där tio vetenskapliga artiklar valdes med både kvalitativa och kvantitativa studier. Resultat: Resultatet presenterades i fyra huvudteman: Upplevelsen av social stigmatisering, Självstigmatisering hos människor som lever med hiv, Fysiskt avstånd och Att uppleva psykisk ohälsa. Diskussion: Resultatet har diskuterats utifrån omvårdnadsteoretikern Katie Eriksson om den caritativa vårdteorin samt fyra konsensusbegrepp som hon har beskrivit: den mångdimensionella hälsan, lidande- en del av hälsan, vårdande- att lindra patientens lidande och den unika människan. Resultatet har även diskuterats genom Erikssons tolkning av: försoning och värdighet. / Background: HIV is a public health problem that about 30-35 million people live with around the world. HIV. 400-500 new cases are reported each year in Sweden. Having HIV can lead to stigmatization from people around you. Aim: The experience of stigmatization in people who are living with HIV. Method: The literature review was based on ten scientific articles, both qualitative and quantitative studies. Results:  The results were presented in four main themes: Experiences of social stigmatization, Self-stigmatization with people who are living with HIV, Physical distance and Experiences of mental illness. Discussion: The result has been discussed based on nursing theorist Katie Eriksson´s theory about the caritative theory and the four consensus concepts she mentioned: the multi-dimensional health, suffering- a part of health, care- to relieve the patient´s suffering and the unique human. The result has also been discussed through Eriksson´s important concepts such as: atonement and dignity.

Thesis (MScMedSc)--Stellenbosch University, 2012. / Bibliography / ENGLISH ABSTRACT: Background: In the era of antiretroviral therapy (ART), the risk of acquired immune deficiency syndrome (AIDS) related deaths has decreased and people living with Human Immunodeficiency Virus (HIV) now have prolonged life spans. However, an increasing trend of non-AIDS associated deaths has been reported despite adequate control of viral loads. HIV infection is established as a chronic inflammatory condition which is associated with an increased risk for thrombosis. Thus HIV infected patients are at a higher risk of developing cardiovascular disease (CVD) and other inflammatory-associated complications. Inflammation is linked with thrombosis and promotes the formation of thrombin, which plays an important role in platelet activation. Furthermore, activated platelets have been shown to play a key role during infection and the inflammatory process, particularly by mediating interactions between cells of innate immunity. Soluble markers of platelet activation have been shown to be increased in HIV-infection. However, these have not been well documented by flow cytometry. P-selectin CD62P is stored in the alpha granules of platelets and is expressed on the surface only upon platelet activation. This facilitates interaction with other blood cells and the endothelium. Activated platelets may play a role in HIV-induced atherosclerosis through the expression and release of mediators that induce endothelial activation and support the adhesion of leukocytes to the inflamed vessel wall. Fibrinogen is a precursor of the blood coagulatory protein fibrin and the degradation of fibrin to D-dimer is a measure of the formation and the subsequent dissolution of blood clots. In HIV infected patients, chronic inflammation induces the up-regulated expression of tissue factor (TF) on monocytes which triggers the activation of the clotting cascade and increases the level of D-dimers. Methods: This pilot study consisted of ART naïve patients and all platelet flow analyses were carried out on whole blood. In this study, a total of 57 adult South Africans were recruited from a clinic in the Western Cape. These included 32 HIV positive patients and 25 HIV negative individuals. The levels of platelet activation and platelet function were investigated using a novel platelet cytometry assay. The method was optimized to ensure minimal platelet activation: no centrifugation or red blood cell (RBC) lysis steps were performed. The platelet-specific markers CD41a and CD42b were used to ensure gating on platelets only. CD62P expression was used to evaluate platelet activation and these levels were correlated with Fibrinogen, hsCRP, Ddimer, CD4 counts and viral load. Furthermore, platelet function was evaluated by investigating the response of platelets to endogenous agonists which included adenosine diphosphate(ADP) and arachidonic acid (AA) at varying concentrations. Results:This study demonstrated higher baseline levels of CD62P expression in treatment naïve HIV positive patients as compared to uninfected controls (mean %CD62P 71.74 ± 2.18 vs control 54.52 ± 2.42; p=<0.0001). In addition it was shown that %CD62P expression correlated directly with platelet counts (r=0.374, p=0.042). Platelet counts showed an inverse correlation with viral loads (give values) Fibrinogen levels correlated with the absolute WCC (r=0.659, p=0.0021); absolute neutrophil count (r=0.619, p=0.0105); absolute monocyte count (0.562, p=0.0235) and hsCRP (r=0.688 p=0.0011). In addition, fibrinogen showed a strong negative correlation with CD4 counts (r=-0.594, p=0.0014) and therefore, may be a valuable marker of both disease progression and risk of thrombosis in treatment naïve HIV positive patients. HsCRP levels correlated with the absolute neutrophil counts (r=0.392, p=0.0005). The HIV Group showed an overall hyper-response to ADP at a concentration 0.025 μM as compared to uninfected controls (62.34 ± 9.7 vs control 36.90 ± 5.7, p=0.0433). Conclusions: In this study we describe a novel Flow Cytometry technique that may be used to evaluate the levels of platelet activation and platelet function in HIV infected patients. In addition we report a cost-effective panel in the form of fibrinogen, WCC and platelets that may be valuable in predicting the progression of HIV infection to AIDS or other inflammatory- associated complications in treatment naïve HIV infected patients. Platelet counts showed an inverse correlation with viral loads and a direct correlation with the level of activated platelets. These findings taken together suggest the potential prognostic value of platelet activation and platelet counts in the context of asymptomatic HIV infected patients. Our findings suggest WCC and Fibrinogen may be used to evaluate the inflammatory profile of individual HIV infected patients. This may have a direct impact on HIV patient management prior to initiation of antiretroviral therapy and valuable in monitoring responses to treatment. Further, we present a novel flow cytometry based platelet functional assay and suggest the use of ADP at a concentration of 0.025 μM to evaluate platelet function optimally in HIV infected patients. The utilization of the novel Flow Cytometry technique as described in this study would add significant value in the assessment of thrombotic risk and disease progression in HIV infected patients and may additionally prove to be of value in other chronic inflammatory conditions. / AFRIKAANSE OPSOMMING: Voorkennis: In die era van antiretrovirale terapie (ART), het die risiko van vigs-verwante sterftes verminder en mense wat nou met volle naam (MIV) leef, het ‘n verlengde lewensduur. Nogtans, word 'n toenemende neiging van nie-vigs geassosieer sterftes berig wat hoofsaaklik toegeskryf word aan trombotiese toestande. MIV-infeksie word as 'n chroniese inflammatoriese toestand beskou met ʼn verhoogde trombose risiko geassosieer word. Dus, MIV-besmette pasiënte het 'n hoër risiko om kardiovaskulêre siekte (CVD) te ontwikkel ongeag of hulle ARV naïef is of op behandeling is nie. Inflammasie word geassosieer met trombose en bevorder die vorming van trombien, wat 'n belangrike rol in plaatjie aktivering speel. Verder, word daar bewys dat geaktiveerde bloedplaatjies 'n belangrike rol speel tydens infeksie en die inflammatoriese proses.Hulle bemiddel interaksies tussen die selle van ingebore immuniteit. Daar word bewys dat oplosbare merkers van plaatjie aktivering verhoog is in MIV-infeksie, maar die bewyse is nie so goed gedokumenteer deur vloeisitometrie nie. P-selectin (CD62P) word gestoor in die alfa korrels van plaatjies en word uitgedruk op die oppervlak slegs wanneer plaatjies geaktivering word; daardeur fasilitering dit die interaksie met ander bloedselle en die endoteel. Geaktiveerde plaatjies kan ook 'n rol in MIV-geïnduseerde aterosklerose speel deur middel van die uitdrukking en vrylating van bemiddelaars wat endoteel aktivering induseer asook die adhesie van leukosiete aan die ontsteekte vat wand ondersteun.. Fibrinogeen, 'n voorloper van die bloed koagulatories proteïen fibrin en die degradasie van fibrin na D-dimeer is' n maatstaf van die vorming en die daaropvolgende ontbinding van bloedklonte. Kroniese inflammasie in MIVbesmette pasiënte, induseer die op-gereguleerde uitdrukking van weefsel faktor (TF) op monosiete wat die aktivering van die stolling kaskade inisieer en die D-dimere vlakke verhoog. Metodes: Hierdie loodsstudie bestaan uit ART naïewe pasiënte en al die plaatjie vloei ontleding was op vol bloed uitgevoer. In hierdie studie, 'n totaal van 57 volwasse Suid-Afrikaners was van' n kliniek in die Wes-Kaap gewerf. Dit sluit 32 MIV-positiewe pasiënte en 25 MIV negatiewe individue in. Die vlakke van plaatjie aktivering en plaatjie funksie was ge ondersoek deur middel van 'n nuwe plaatjie sitometrie toets. Die metode was geoptimaliseer om minimale plaatjie aktivering te verseker: dus geen sentrifugering of volle naam (RBS) liseer stappe was gebruik nie. Die plaatjie-spesifieke merkers, CD41a en CD42b was gebruik om te verseker dat slegs bloedplaatjes gekies word. Die uitdrukking van CD62P was gebruik vir die evaluering van plaatjie aktivering en hierdie vlakke was gekorreleer met fibrinogeen, hsCRP, D-dimeer, CD4- tellings en virale lading. Verder, was plaatjie funksie geëvalueer deur die reaksie van plaatjies aan endogene agoniste wat ADP en AA by wisselende konsentrasies insluit te ondersoek. Results: Hierdie studie het getoon hoër basislyn vlakke van CD62P uitdrukking in behandeling naïewe MIV-positiewe pasiënte in vergelyking met onbesmette beheermaatreëls (beteken% CD62P 71,74 ± 2,18 vs beheer 54,52 ± 2,42, p <0.0001). Daar is ook getoon dat% CD62P uitdrukking direk gekorreleer met plaatjie tellings (r = 0,374, p = 0,042). Plaatjie tellings het 'n omgekeerde korrelasie met virale ladings (gee waardes) fibrinogeen vlakke korreleer met die absolute WCC (r = 0,659, p = 0,0021), absolute neutrofiel telling (r = 0,619, p = 0,0105); absolute monosiet telling (0,562, p = 0,0235) en hsCRP (r = 0,688 p = 0,0011). Daarbenewens, fibrinogeen het 'n sterk negatiewe korrelasie met 'n CD4-tellings (r = -0,594, p = 0,0014) en daarom kan 'n waardevolle merker van beide die siekte en die risiko van trombose in behandeling naïewe MIV-positiewe pasiënte. HsCRP vlakke gekorreleer met die absolute neutrofiel tellings (r = 0,392, p = 0,0005). Die MIV-groep het 'n algehele hiper-reaksie op die ADP by 'n konsentrasie 0,025 μM in vergelyking met onbesmette beheermaatreëls (62,34 ± 9,7 vs beheer 36,90 ± 5.7, p = 0,0433). Gevolgtrekkings: In hierdie studie beskryf ons 'n roman vloeisitometrie tegniek wat gebruik kan word om die vlakke van Plaatjie aktivering en plaatjie funksie in die MIV-besmette pasiënte te evalueer. Verder het ons 'n verslag van 'n koste-effektiewe paneel in die vorm van fibrinogeen, WCC en plaatjies wat waardevol kan wees in die voorspelling van die vordering van MIVinfeksie tot VIGS of ander inflammatoriese-verwante komplikasies in die behandeling naïewe MIV-besmette pasiënte. Plaatjie tellings het 'n omgekeerde korrelasie met die virale laste en 'n direkte verband met die vlak van geaktiveerde bloedplaatjies. Hierdie bevindinge saam, dui op die moontlike prognostiese waarde van Plaatjie aktivering en die plaatjie tel in die konteks van die asimptomatiese MIV-geïnfekteerde pasiënte. Ons bevindinge dui daarop WCC en fibrinogeen kan gebruik word om die inflammatoriese profiel van individuele MIV-geïnfekteerde pasiënte te evalueer. Dit kan 'n direkte impak op MIV pasiënt vooraf aan die inisiasie van antiretrovirale terapie en waardevolle in die monitering van die reaksie op behandeling. Verder bied ons 'n roman vloeisitometrie gebaseer plaatjie funksionele toets en dui op die gebruik van die ADP teen 'n konsentrasie van 0,025 μM plaatjie funksie optimaal te evalueer in MIVgeïnfekteerde pasiënte. Die benutting van die roman vloeisitometrie tegniek soos beskryf in hierdie studie sal 'n beduidende waarde toevoeg in die beoordeling van die die trombotiese risiko en die siekte in MIV-geïnfekteerde pasiënte en kan addisioneel bewys van waarde te wees in 'n ander chroniese inflammatoriese toestande. / National Reserach Foundation

Bakgrund: På världsbasis lever 36,7 miljoner människor med sjukdomen Humant Immunbrist Virus (HIV). Då forskningen och behandlingen gått framåt från att vara en dödlig till kronisk sjukdom med rätt behandling, kan patienter idag leva ett helt liv. Trots detta bemöts patientgruppen många gånger med stigmatiserande attityder då kunskapen om sjukdomen visat sig vara bristfällig hos hälso-och sjukvårdspersonal. Syftet: Var att beskriva hur patienter med diagnosen HIV upplever bemötandet inom hälso-och sjukvården, samt att granska undersökningsgrupperna i de inkluderade artiklarna. Metod: Litteraturstudie med deskriptiv design. Sökningar utfördes i PubMed och CINAHL. Totalt 14 artiklar med kvalitativ design och två med mixad metod, där endast den kvalitativa delen presenteras i resultatet. Analysmetoden som användes till studien var Evans beskrivande modell. Resultat: Två huvudteman identifierades i studien kunskapsnivå och attitydernas betydelse i mötet. Studien visade att kunskapsnivån har betydelse för bemötandet. Patienterna upplevde att när personal hade högre kompetens och positivare attityder resulterade det i bättre bemötande. Däremot okunskap hos personalen visade sig i form av negativa attityder och rädsla för patientgruppen,vilket resulterade i onödigt lidande och inget förtroende för vården. Undersökningsgruppen presenterades utifrån ålder, kön, antal år med HIV samt geografisk tillhörighet. Slutsatser: Negativa attityder i form av stigmatisering och diskriminering återstår inom hälso-och sjukvården av HIV positiva patienter. Positiva attityder visade sig vara starkt sammankopplat med kunskapsnivån hos personalen. Ämnet behöver därför belysas för att omvårdnaden ska utvecklas och ett professionellt förhållningssätt upprätthållas. / Background: In global basis 36, 7 million people living with the disease Human Immuno deficiency Virus (HIV). As the research and treatment progressed from being a fatal to chronic disease, with proper treatment, patients can now live a full life. Despite this the patient group are treated many times with stigmatizing attitudes as knowledge of the disease shown to be deficient among healthcare personnel. Purpose: Was to describe how patients diagnosed with HIV experiencing the meeting with healthcare personnel, as well as to review the study groups in the included articles. Method: Literature study with descriptive design. Searches were carried out in PubMed and CINAHL. A total of 14 articles with qualitative design and two with mixed method, where only the qualitative part is presented in the results. The analytical method used for this study was Evans descriptive model. Findings: Two main themes were identified in the study, knowledge level and attitude of the significance of the meeting. The study showed that the level of knowledge is important for the meeting. Patients experienced that when personnel had higher skills and more positive attitudes this resulted in better treatment. In contrast, ignorance of the personnel turned out in the form of negative attitudes and fear of the patient group, resulting in unnecessary suffering and no confidence in health care. The study group presented based on age, sex, number of years with HIV and geographic affiliations. Conclusions: Negative attitudes in the form of stigma and discrimination remains in health care of HIV positive patients. Positive attitudes were shown to have a strong correlation level with expertise of the health care personnel. The subject needs to be highlighted in order to developing care and maintain a professional attitude.

Στην παρούσα μεταπτυχιακή εργασία αξιολογήθηκε η συνδυαστική θεραπευτική φαρμακευτική αγωγή των HIV οροθετικών ασθενών βασιζόμενη σε 2 δείκτες: 1) στο ιϊκό φορτίο VL (Varial Load, copies/ml) που εκφράζει τις συγκεντρώσεις του RNA του HIV στο αίμα και 2) στον αριθμό των CD4 Τ-λεμφοκυττάρων (κύτταρα/mm3) που εκφράζει των αριθμό των κυττάρων τα οποία βοηθούν τον ασθενή να καταπολεμήσει την λοίμωξη. Συγκεντρώθηκαν δεδομένα από 278 ασθενείς και 32 ‘παλιούς’, από όλη την Ελλάδα, για το χρονικό διάστημα 1990-2006 (Πανεπιστημιακό Νοσοκομείο Ρίο). Για καθέναν από τους ασθενείς ελήφθησαν δεδομένα σε φύλλα του excel, μη κατηγοριοποιημένα, και για καθέναν υπήρχαν από 20 έως 100 μετρήσεις. Μια τόσο εκτεταμένη συγκέντρωση δεδομένων για HIV οροθετικούς ασθενείς γίνεται για πρώτη φορά στην Ελλάδα. Η θεραπεία για τον HIV περιλαμβάνει συνήθως 3 ή περισσότερα φάρμακα (HAART). Στην παρούσα μελέτη χρησιμοποιήθηκαν 3 κατηγορίες αντιρετροϊκών φαρμάκων: 1. Νουκλεοσιδικοί αναστολείς της ανάστροφης μεταγραφάσης (NRTIs) (ομάδα πράσινη), (10 φάρμακα) 2. Mη νουκλεοσιδικοί αναστολείς της ανάστροφης μεταγραφάσης (NNRTIs) (ομάδα κίτρινη), (3 φάρμακα) 3. Αναστολείς των πρωτεασών (PIs) (ομάδα μπλέ) (11 φάρμακα) Οι ασθενείς ανάλογα με την αγωγή της πρώτης θεραπείας τους κατηγοριοποιήθηκαν σε ομάδες (4) και σε υποομάδες με βάση τα επιμέρους φάρμακα κάθε ομάδας: Ομάδα πράσινη (ΝRTIs) (72 ασθενείς) Ομάδα πράσινη- μπλε (ΝRTIs-PIs) (139 ασθενείς)και 8 επιμέρους υποομάδες Ομάδα πράσινη- κίτρινη (ΝRTIs-NΝRTIs) (35 ασθενείς)και 2 επιμέρους υποομάδες Ομάδα πράσινη-κίτρινη-μπλε (ΝRTIs-NΝRTIs- PIs) (3 ασθενείς) Οι ασθενείς των ομάδων και υποομάδων μελετήθηκαν ξεχωριστά, χωρισμένοι σε μη-πεπειραμένους (naïve) και σε πεπειραμένους (experienced). Η αξιολόγηση της θεραπείας των ασθενών (κατά ομάδες και υποομάδες) έγινε με βάση:  το % ποσοστό που πέτυχαν ‘μη-ανιχνεύσιμο’ VL≤50, καθώς και VL≤200 και VL≤500, ανά τρείς μήνες (διαγραμματική παρουσίαση).  Το ποσοστό των ασθενών που δεν πέτυχαν VL≤50.  Τον μέσο χρόνο που πέτυχε VL≤50 το 50% των ασθενών (ταχύτητα ανταπόκρισης στη θεραπεία).  Τη συσχέτιση των τιμών VLέναρξης και CD4έναρξης που είχαν οι επιτυχημένοι ασθενείς κατά την έναρξη της θεραπείας (κατηγοριοποίηση σε κλίμακες), καθώς και του CD4 την στιγμή επίτευξης VL≤50, με ταυτόχρονο υπολογισμό των %μεταβολών των VL και CD4. Με βάση τα παραπάνω προέκυψαν τα ακόλουθα: Η λήψη αποκλειστικά NRTIs (ποσοστό αποτυχίας VL≤50 78,5%) ήταν λιγότερο αποτελεσματική σε σχέση με συνδυαστική αγωγή NRTIs-ΡIs (επιτυχία 81,8%), ή με NRTIs-NNRTIs (επιτυχία 81,6%). Για να δράσει η αγωγή με αποκλειστικά NRTIs, απαιτείται μεγαλύτερο διάστημα, στο οποίο μπορεί η τιμή του VL να ελαττωθεί <500, αλλά είναι λιγότερο πιθανό να πέσει <200. Μεταξύ των NRTIs-PIs & NRTIs-NNRTIs λαμβάνοντας υπόψη και τον χρόνο που πέτυχε το 50% των ασθενών, η αγωγή NRTIs-NNRTIs ήταν πιο αποτελεσματική αφού επιτεύχθηκε VL≤50 σχεδόν στο 1/3 του χρόνου. Όσον αφορά τις επιμέρους υποομάδες (NRTIs-PIs & NRTIs-NNRTIs) οι naïve ασθενείς έφταναν ταχύτερα σε μη ανιχνεύσιμα επίπεδα VL σε σχέση με τους experienced (μικρότερη ταχύτητα ανταπόκρισης), με όλα τα ΡΙs που συνδυαζόταν με NRTIs, και είχαν μικρότερα ποσοστά αποτυχίας. Οι experienced ασθενείς (ποσοστά αποτυχίας 11 έως 87%) είχαν ως πιο επιτυχημένες αγωγές την πράσινο-μπλε4 (NRTIs-NLF), την πράσινο-μπλε3 (NRTIs-IND), ακολουθούμενη από την πράσινο-μπλε5 (NRTIs-SAQ) και λιγότερο επιτυχημένη την πράσινο-μπλε1 (NRTIs-RIT), ενώ για τις πράσινο-μπλε8 (ΝRTIs-ΑΒΤ), πράσινο-μπλε1,2 (ΝRTIs-RIT-ΙΝV) και πράσινο-μπλε1,3 (ΝRTIs-RIT-ΙΝD) δεν προέκυψαν ασφαλή συμπεράσματα. Στους naïve ασθενείς υπήρχαν διαφορές στην ταχύτητα ανταπόκρισης ανάλογα με τον ληφθέντα PI. Ταχύτερη ανταπόκριση παρατηρήθηκε με την αγωγή της πράσινο-κίτρινο (συνδυασμός NRTIs-EFV & NRTIs-VIR). Όσον αφορά την αγωγή NRTIs-ΡΙ, πιο αποτελεσματική ήταν η πράσινο-μπλέ4, ακολουθούμενη από την πράσινο-μπλέ5, ενώ αντίθετα οι συνδυασμοί πράσινο-μπλέ8 και πράσινο-μπλέ2 ήταν οι λιγότερο επιτυχημένοι. Υψηλή τιμή του CD4έναρξης και χαμηλή του VLέναρξης βοηθά στην επίτευξη VL≤50. Οι περισσότεροι naïve ασθενείς είχαν χαμηλό VLέναρξης 1.000-10.000 και υψηλό CD4έναρξης (όπως και οι περισσότεροι experienced) 300-550. Οι naïve ασθενείς της πράσινο-μπλε2 (μεγαλύτερα ποσοστά αποτυχίας) είχαν σχετικά χαμηλό VLεν (<50.000) και CD4εν>100. Οι ασθενείς της πράσινο-μπλε4, είχαν τα μεγαλύτερα ποσοστά επιτυχίας πιθανόν λόγω χαμηλού VLεν (1.000-50.000) και υψηλού CD4εν (300-750 και >750). Το 85% των ασθενών της πράσινο-μπλε5 (επιτυχημένη), είχαν VLεν <10.000 και μάλιστα όταν ήταν <1.000 η ταχύτητα ανταπόκρισης ήταν η μισή σε σχέση με όταν ήταν 1.000-10.000. Οι ασθενείς της πράσινο-μπλε8, (επιτυχημένοι ακόμα και στις υψηλές κλίμακες VLεν), είχαν μεγάλο χρόνο ανταπόκρισης. Οι περισσότεροι (n=20) ασθενείς της πράσινο-κίτρινο3, είχαν VLεν 1.000-50.000 και υψηλό CD4εν 300-550 και πέτυχαν σε μεγαλύτερο χρόνο απ’ ότι της πράσινο-κίτρινο1. Για τους experienced ασθενείς της πράσινο-μπλε2, αν και υπήρχαν ευνοϊκές συνθήκες (VLεν 1.000-50.000 και CD4εν 300-550) είχαν μεγάλο ποσοστό αποτυχίας. Οι ασθενείς της πράσινο-μπλε5 (επιτυχημένη) είχαν VLεν<10.000 και όταν το CD4εν ήταν 550-750, η ταχύτητα ανταπόκρισης ήταν 4 φορές μεγαλύτερη. Οι επιτυχημένοι ασθενείς της πράσινης ομάδας κατά την επίτευξη VL≤50 (Μ.Ο.~47 μήνες) είχαν CD4 κατά ~33% αυξημένο σε σχέση με το CD4εν. Οι επιτυχημένοι ασθενείς της πράσινο-μπλε είχαν CD4 όταν VL≤50 (Μ.Ο.~27 μήνες) αυξημένο κατά ~125% σε σχέση με το CD4εν και VLεν~80πλάσιο (Μ.Ο.~86.000). Οι επιτυχημένοι ασθενείς της πράσινο-κίτρινο είχαν επίσης ανάλογο αριθμό CD4εν, αλλά ο Μ.Ο. CD4 όταν VL≤50 ήταν μικρότερος (αυξημένος κατά 21,6% έναντι 125%). Πέτυχαν σε μόλις κατά Μ.Ο. 15 μήνες, έχοντας πολύ υψηλό Μ.Ο. VLεν (~129.000) και με ποσοστό επιτυχίας ανάλογο με αυτό της πράσινο-μπλέ ομάδας (~81,6%). Οι επιτυχημένοι naïve ασθενείς των υποομάδων πράσινο-μπλε, που είχαν τις υψηλότερες τιμές VLεν κατά σειρά αποτελεσματικότητας ήταν: Π-Μπλέ1,3(3 ασθενείς)> Π-Μπλέ1>Π-Μπλέ8. Τα CD4 των επιτυχημένων ασθενών της πράσινο-μπλέ4 την στιγμή που πέτυχαν (Μ.Ο.~22 μήνες), ήταν τα πιο υψηλά (Μ.Ο. 720). Οι επιτυχημένοι ασθενείς της πράσινο-μπλέ5 είχαν τις χαμηλότερες τιμές VLεν (Μ.Ο.~ 7.000) και CD4 την στιγμή που πέτυχαν υψηλά (Μ.Ο. ~600). Οι επιτυχημένοι ασθενείς των υποομάδων πράσινο-κίτρινο, είχαν υψηλές τιμές VL έναρξης (Μ.Ο.~130.000). Οι επιτυχημένοι experienced ασθενείς που είχαν τις υψηλότερες τιμές VLεν ήταν της πράσινο-μπλέ1 (Μ.Ο.~162.000), (αποτυχία~62%), της πράσινο-μπλέ2 (αποτυχία~87%) (Μ.Ο.~90.000), καθώς και των επιτυχημένων πράσινο-μπλέ3 και πράσινο-μπλέ4 (Μ.Ο.~86.000-130.000), ενώ της επιτυχημένης πράσινο-μπλέ5 είχαν χαμηλό VLεν (Μ.Ο.~3.000). / -