Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to a State-aided District Hospital in Durban, South Africa in 2007. Introduction: A proportion of the many patients who have advanced AIDS in South Africa present for the first time requiring admission to hospital, the number of which are limited by the availability of beds. Novel ways were developed to offer subacute inpatient care at Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate antiretroviral therapy (ART) (exposed) for patients with advanced disease before their discharge (ART group) . Different components of palliative care were offered for those who did not enter the inpatient ART programme or who were terminally ill (non-ART group) (non-exposed) . Aim: The aim of the study is to describe the clinical condition, inpatient case management and outcomes before discharge of people living with HIV admitted to Siyaphila in order to assist in developing appropriate protocols for inpatient care. Methods: This was an observational, analytic, cohort study using a convenience sample of all patients consecutively admitted to Siyaphila during nine months in 2006/2007. Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one stage of care to another and outcomes for the two groups before discharge were determined. Univariate and multivariate logistic regression analysis was performed on the ART group to identify risk factors for mortality before discharge. A comparison between the ART and non-ART group was also undertaken. Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251; 62%) was the most common opportunistic infection followed by cryptococcal meningitis (68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The median time from initial admission until discharge was 13 days in the non-ART group and 18 days in the ART group. The mortality before discharge among the non-ART group was 24% compared to 6% among the ART group. (p =0.001). The median number of days before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome was diagnosed in seven patients (4%) among the admissions but caused no deaths. In the multivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1 (95% Confidence Interval: 0.01 - 0.9). Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART uptake after discharge. The findings of this study should be adopted as the best clinical practice for PLHIV and AIDS admitted in the late stages of the disease. 0Nords 423) Title: Case Management and Clinical Outcomes of People Living with HIV and Admitted to a State-aided District Hospital in Durban, South Africa in 2007. Introduction: A proportion of the many patients who have advanced AIDS in South Africa present for the first time requiring admission to hospital, the number of which are limited by the availability of beds. Novel ways were developed to offer subacute inpatient care at Siyaphila, a facility linked to McCord Hospital in Durban to provide expedited or immediate antiretroviral therapy (ART) (exposed) for patients with advanced disease before their discharge (ART group) . Different components of palliative care were offered for those who did not enter the inpatient ART programme or who were terminally ill (non-ART group) (non-exposed). Aim: The aim of the study is to describe the clinical condition, inpatient case management and outcomes before discharge of people living with HIV admitted to Siyaphila in order to assist in developing appropriate protocols for inpatient care. Methods: This was an observational, analytic, cohort study using a convenience sample of all patients consecutively admitted to Siyaphila during nine months in 2006/2007. Prevalence of AIDS defining conditions at Siyaphila, time taken to progress from one stage of care to another and outcomes for the two groups before discharge were determined. Univariate and mUltivariate logistic regression analysis was performed on the ART group to identify risk factors for mortality before discharge. A comparison between the ART and non-ART group was also undertaken. Results: Among the cohort of 405 PLHIV enrolled at Siyaphila during the study period only 171 (42%) were initiated on ART immediately. In all patients, tuberculosis (251; 62%) was the most common opportunistic infection followed by cryptococcal meningitis (68; 17%) and Pneumocystis pneumonia (28; 7%). The mean baseline CD4 cell count was 84 celis/uL for the non-ART group and 55 celis/uL for the ART group. (p <0.01) The median time from initial admission until discharge was 13 days in the non-ART group and 18 days in the ART group. The mortality before discharge among the non-ART group was 24% compared to 6% among the ART group. (p =0.001). The median number of days before ART was initiated was 14 days. Immune reconstitution inflammatory syndrome was diagnosed in seven patients (4%) among the admissions but caused no deaths. In the mUltivariate analysis, the odds ratio for mortality for patients under 40 years was 0.1 (95% Confidence Interval: 0.01 - 0.9). Conclusions: Subacute care offered at Siyaphila provides an entry point into the ART programme for non-ambulatory patients who in the KwaZulu-Natal context have low ART uptake after discharge. The findings of this study should be adopted as the best clinical practice for PLHIV and AIDS admitted in the late stages of the disease. (Words 423) / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.

Thesis (Ph. D.)--University of Texas at Austin, 2008. / Vita. Includes bibliographical references.

Thesis (MBA (Business Management))--University of Stellenbosch, 2009. / ENGLISH ABSTRACT: By understanding the costs of HIV/AIDS, businesses can understand the incentives for preventing and treating the disease better. This report primarily investigates whether there is a difference in the relationship between HIV/AIDS prevalence rates and related costs in different sectors in South Africa. With an HIV prevalence ratio of approximately 10:1 for the mining and financial sectors, it is difficult to motivate that more research should be done on the impact of HIV/AIDS on the financial sector. However, if the study indicates a higher cost ratio between the two sectors it could increase the priority of the epidemic in the financial sector, giving rise to a bigger incentive to fight the epidemic. The estimated HIV/AIDS-related cost of an infected manager is R120 000 compared to the cost of R4 600 for an infected unskilled employee. From this analysis it is estimated that the HIV prevalence ratio between highly skilled and semi- and unskilled labour is 1:2.5, while the HIV cost ratio between the different skill levels is 1:0.2. This clearly indicates that there could be a significant difference between the HIV prevalence ratio and the HIV cost ratio for different levels of skills. From the Absa and AngloGold average salary information reviewed, the assumption was made that the Absa employees are more skilled than the AngloGold employees. With the knowledge of this difference in skill levels between the two companies in the different sectors, and the information above regarding the difference in HIV/AIDS-related costs for different skill levels, it is possible that the HIV/AIDS-related costs in the financial sector could be in line with the costs in the mining sector. Using HIV prevalence as an indication of the impact of the disease on the financial sector, a high-level cost estimate could be R150.9 million, compared to R3 985 million if the difference in the relationship between HIV/AIDS prevalence and related costs are taken into account. These materially different estimates could cause companies in the financial sector to make incorrect decisions regarding HIV/AIDS budgets for HIV/AIDS prevention and treatment, as incorrect indicators of the impact of the epidemic on the profit of the organisation are used. / AFRIKAANSE OPSOMMING: Deur die koste van MIV/vigs te verstaan, kan besighede die dryfvere vir die voorkoming en behandeling van MIV/vigs beter verstaan. Die verslag ondersoek hoofsaaklik of daar ’n verskil is in die verhouding tussen die voorkomsyfer en verwante koste van MIV/vigs in verskillende sektore in Suid Afrika. Met die MIV-voorkomsverhouding van ongeveer 10:1 vir die mynwese en finansiële sektore, is dit moeilik om verdere navorsing oor die impak van MIV op die finansiële sektor te regverdig. Indien hierdie studie egter ’n hoër kosteverhouding tussen die twee sektore aantoon, kan dit die prioriteit van die epidemie in die finansiële sektor verhoog, wat sal lei tot dryfvere om die epidemie te beveg. Die beraamde MIV/vigs-verwante koste van ’n besmette bestuurder is R120 000, vergelykend met die koste van R4 600 vir ’n besmette ongeskoolde werknemer. Uit ontledings kan beraam word dat die MIV-voorkomsyfer tussen hoogs geskoolde en half- en ongeskoolde werknemers 1:2.5 is, terwyl die MIV-kosteverhouding tussen die verskillende vlakke 1:0.2 is. Die inligting toon dat daar beduidende verskille tussen die MIV-voorkomsverhouding en die MIV-kosteverhouding vir verskillende vlakke van geskooldheid kan wees. Volgens Absa en AngloGold se inligting oor gemiddelde salarisse is die aanname gemaak dat Absa-werknemers meer geskoold is as AngloGold-werknemers. Met die kennis van hierdie verskil in vaardigheidsvlakke tussen die twee maatskappye in die onderskeie sektore en die inligting hierbo rakende die verskil tussen MIV/vigs-koste vir verskillende vaardigheidsvlakke, is dit moontlik dat die MIV/vigs-verwante koste in die finansiële sektor in ooreenstemming met dié in die mynwesesektor kan wees. As MIV-voorkoms as ’n aanwyser van die impak van die koste op die finansiële sektor gebruik word, kan ’n hoëvlak-kosteberaming R150.9 miljoen wees, vergelykend met R3 985 miljoen, as die verskil in die verhouding tussen MIV/vigs-voorkoms en verwante koste in berekening gebring word. Die wesenlik verskillende beramings veroorsaak dat maatskappye in die finansiële sektor foutiewe besluite rakende MIV/vigs-begrotings vir MIV/vigs-voorkoming en -behandeling maak, aangesien foutiewe aanwysers van die impak van die epidemie op die wins van die organisasie gebruik word.

Studies on knowledge, attitudes and practices among healthcare workers involved in HIV and AIDS care have often revealed the lack of knowledge about HIV and AIDS. Nurses‘ knowledge may compromise the quality of care and attitudes towards patients living with HIV/AIDS. Special nursing knowledge and skills have been suggested as a prerequisite for taking care of patients with HIV. The purpose of this study was to assess nurses‘ knowledge, attitudes and practices towards patients with HIV and AIDS in Kumasi, Ghana. A quantitative cross-sectional study was conducted among 247 nurses at five selected health facilities in Kumasi. Data was collected by means of a structured self-administered questionnaire and analysed using SPSS version 23.0. Results were presented using charts and tables. Knowledge of HIV and AIDS was satisfactory but some of the nurses still hold erroneous beliefs and misconception about HIV transmission. A majority demonstrated favourable attitudes. Nurses had fears of contracting the virus, which resulted in the display of negative attitudes by some. Their practice of universal precautions was satisfactory; however, there was evidence of noncompliance among some of them. More studies should be conducted throughout the country to further assess nurses‘ knowledge, attitude and practices towards HIV and AIDS / Health Studies / M.A. (Nursing Science)

Background: Despite advances in HIV medication, many people living with HIV (PLWH) do not link to care upon diagnosis, do not remain engaged if linked, and do not achieve viral suppression through consistent ART adherence. Not achieving viral suppression is associated with low CD4-cell counts, preventable hospitalizations, frequent emergency room usage, risk of developing a drug resistance, and excess morbidity and mortality. Despite extensive literature that explores barriers to care, these disparities remain, particularly among racial, ethnic and sexual minority groups. Mistrust of health care systems and/or providers is thought to provide a partial explanation for why racial and ethnic minority groups are less likely to access outpatient HIV care. One form of health-related mistrust, referred to as “conspiracy beliefs” in the literature and in popular culture, is particularly associated with racial and ethnic minority people. HIV-related “conspiracy beliefs” can include the ideas that the government created HIV to target specific minority groups, that antiretroviral medication is used to experiment on vulnerable groups, or that a cure is being withheld or delayed by pharmaceutical companies and/or the government. Although many studies have assessed the prevalence of such beliefs, little is known about the possible relationship between endorsing these ideas and engagement from HIV care/ART adherence among PLWH. Moreover, the extant literature has provided equivocal findings that point to the need for further research on the relationship between these beliefs and managing one’s HIV. Methods: Over the course of one year, 27 semi-structured, in-depth interviews were conducted with low income PLWH of color living in the NYC area that are currently, or were recently, disengaged from outpatient HIV medical care. Additionally, a brief questionnaire was administered to obtain demographic and engagement/medication adherence data to describe the sample of participants. Findings: This analysis revealed the variation, texture and diversity related to people’s beliefs about the origin and treatment of HIV. Beliefs about the pharmaceutical industry and the government highlighted both the racism and classism experienced by low income who belong to racial and ethnic minority groups. Notably, HIV care providers did not appear to be perceived as part of the government-pharmaceutical power complex. This suggests that while many people may endorse these types of ideas, endorsement does not necessarily directly impact engagement in care. However, endorsing positive beliefs about the efficacy of ART, and the belief that HIV can be a chronic disease if treated consistently, helped participants remain adherent or desire to re-commit to taking it consistently. Participants also appreciated, and desired, providers that engaged in patient-centered medicine. Recommendations: It may be that public health does not necessarily need to endeavor to dislodge origin or pharmaceutical/cure-related beliefs; rather, interventions can focus on building trust between health care providers and populations that have been experienced both historically and ongoing marginalization. Participants’ emphasis on wanting to manage their ART-related challenges with their providers suggests that HIV providers have an instrumental role in not only lowering viral loads and achieving viral suppression, but also helping their patients feel agentic and able to manage their HIV. Implementing patient-centered medicine will also engender trust, thereby helping patients internalize the belief that consistent engagement and ART adherence makes HIV a chronic, manageable illness.

Vulnerable populations comprise a growing number of people living with HIV/AIDS and are at increased risk for poorer health outcomes. The purpose of this research was to approximate the effect of the Ryan White CARE Act on the health status of people living with HIV/AIDS who were receiving medical care in the United States. The vulnerable populations model was utilized to identify appropriate variables for analysis as well as to provide a sequencing for the testing of models. Data analyzed in this study came from the 1996 Baseline Survey of the HIV Cost and Services Utilization Study (HCSUS), a cooperative study between RAND and the Agency for Health Care Policy and Research (now known as the Agency for Health Care Quality and Research). Three analyses sequences, using different dependent variables, to estimate health status were conducted. In the first analysis, health status was measured by CD-4 count and stage of illness. In the second analysis, only CD-4 counts were used for health status. In the final analysis, health status was estimated based on AIDS diagnosis. Each of the three analyses included the same independent variables: race, gender, education, sexual orientation, income, insurance status, region of the country, receipt of case management, perceived health, and level of antiviral therapy. The three analyses suggested similar results. Specifically, that African Americans and women had better health status as compared to whites and men, respectively. Additionally, insurance, case management, and antiviral therapy were associated with poorer health status. Factors such as education, income, and region of the country yielded inconsistent results between models. To better understand the effect of the Ryan White CARE Act on health outcomes for people living with HIV/AIDS, future research should consider inclusion of a variable that more directly measures the CARE Act, such as payer source for medical care.

The purpose of the study was to describe the effects of an EMR on patient management in selected HIV clinics in Johannesburg. A quantitative, descriptive, cross-sectional study was undertaken in four HIV clinics in Johannesburg. The subjects (N=44) were the healthcare workers selected by stratified random sampling. Consent was requested from each subject and from the clinics in Johannesburg. Data was collected using structured questionnaires. Median age of subjects was 36, 82% were female. 86% had tertiary qualifications. 55% were clinicians. 52% had 2-3 years work experience. 80% had computer experience, 86% had over one year EMR experience. 90% used the EMR daily, 93% preferred EMR to paper. 93% had EMR training, 17% used EMR to capture clinical data. 87% perceived EMR to have more benefits; most felt doctor-patient relationship was not interfered with. 89% were satisfied with the EMR’s overall performance. The effects of EMR benefit HIV patient management. / Health Studies / MA (Public Health)

No description available.

Text in English / Lack of knowledge and skills among health care providers for provision of integrated TB/HIV activities for better health outcomes for co-infected patients is a public health concern. A qualitative, non-experimental, explorative and descriptive research design based on the phenomenological philosophical tradition by Heidegger to broaden hermeneutics was conducted. The study was conducted at Mopani district to explore and describe the experiences of eligible nurse managers relating to the implementation of the TB/HIV activities at management level. A purposive sample of 14 participants was recruited and consent form obtained. An unstructured interview guide, with a grand tour question, was used to conduct face to face individual interviews. Tesch’s method of analysis was employed until two themes, five categories and ten subcategories emerged from the data. The major findings were on challenges experienced by nurse mangers such as shortage of resources, poor planning, lack of support by management and patient related challenges. Recommendations were based on the findings to encourage staff retention strategies, adequate funding for TB control programs, support by management, co-joint planning, team work and effective tracing strategies. / Health Studies / M.A. (Health Studies)

The purpose of the study was to describe the effects of an EMR on patient management in selected HIV clinics in Johannesburg. A quantitative, descriptive, cross-sectional study was undertaken in four HIV clinics in Johannesburg. The subjects (N=44) were the healthcare workers selected by stratified random sampling. Consent was requested from each subject and from the clinics in Johannesburg. Data was collected using structured questionnaires. Median age of subjects was 36, 82% were female. 86% had tertiary qualifications. 55% were clinicians. 52% had 2-3 years work experience. 80% had computer experience, 86% had over one year EMR experience. 90% used the EMR daily, 93% preferred EMR to paper. 93% had EMR training, 17% used EMR to capture clinical data. 87% perceived EMR to have more benefits; most felt doctor-patient relationship was not interfered with. 89% were satisfied with the EMR’s overall performance. The effects of EMR benefit HIV patient management. / Health Studies / MA (Public Health)