Thesis (Ph. D.)--University of Washington, 2007. / Vita. Includes bibliographical references (leaves 146-154).

Health Studies / M.A. (Health Studies)

This study deals with the impact of HIV/AIDS on women living in chronic poverty. The question arises: Do we focus on their HIV/AIDS stories only or do we include their other lived experiences? This phenomenological study, on two sets of three generations of women infected and affected by HIV/AIDS and living in poverty, is an attempt at understanding the way the women experience their lifeworlds, not only their HIV/AIDS stories. One set includes a grandmother, her daughter who is living with full-blown AIDS, and her granddaughter, while the other includes a grandmother, her daughter and her granddaughter infected with HIV. The initial focus of the study was on the women’s HIV/AIDS narratives. However as the study progressed, especially during the interviews, it became apparent that the women’s generational poverty or chronic poverty was of greater concern to them than the HIV/AIDS that they were experiencing. Of the six participants, only one woman centred her life story on HIV/AIDS. This finding echoes other studies on HIV/AIDS among poor women: that chronic poverty is more threatening to the women than the risk or reality of AIDS. As a phenomenological researcher my aim was to focus on the participants’ own interpretations of the studied phenomenon. However, this was inadequate in accounting for the role that social structures play in shaping and informing the women’s subjective consciousness and experience. For this reason, I used feminist ideas to understand and interpret the women’s patriarchal experiences.

Magister Public Health - MPH / Since the introduction in 2005 of prevention of mother-to-child transmission of HIV (PMTCT) services in Akwa Ibom State in Nigeria the PMTCT programme has faced several challenges including that of poor male participation in the PMTCT programme. To date no research has focused on the issue of male participation in PMTCT programmes in Akwa Ibom State, and there is thus a limited understanding of why so few male partners of HIVpositive pregnant women participate in the State's PMTCT programme. It is therefore important to explore the factors affecting male involvement in PMTCT programmes in Akwa Ibom State, so that strategies can be put in place to help improve the overall health of their families and themselves. The overall aim of the study was thus to explore the factors affecting male participation in the PMTCT programme at a primary health care center in West Itam, Akwa Ibom State, in Nigeria. This explorative study was conducted using a descriptive qualitative research approach. The research study approach helped to understand the perspectives of the male partners of HIV positive pregnant women who received the PMTCT intervention, as well as key informants in the Primary Health Care (PHC) facility where these PMTCT services are offered. The study population consisted of all males living within the catchment area of the West Itam PHC, Akwa Ibom State, Nigeria. In the research study, 11 men were purposively sampled: five of whom were the partners of HIV-positive women who had attended, or were currently attending the PMTCT services at the West Itam PHC with their partner. The other six interviewees were local male community members – who would be eligible to potentially accompany their partner to PMTCT services at the facility. The data was collected through individual, in-depth interviews with the male partners and community members using a semi-structured interview guide. One focus group discussion (FGD) was conducted with key personnel working in the West Itam PHC using a semistructured interview guide. All interviews and the FGD were tape-recorded and transcribed. Thematic analysis was used to analyse the data. Ethical approval was first obtained from the UWC Research Ethics Committee and the Ethics Committee of the Akwa Ibom State Ministry of Health before proceeding with the study. From this study, it is suggested that most of the respondents knew that PMTCT services are offered at the PHC West Itam. They knew their partner's next antenatal appointment, but only very few accompany their pregnant partners to the antenatal clinic. The striking reason being a lack of time/being busy. The key means of support of the partners' antenatal visits was giving their pregnant partners money for transport, and money for food/snacks (at the clinic). Inter-spousal communication was found to be good, and there appeared to be a perception by the men that antenatal clinic (ANC)/PMTCT is not only for women, with most of the men agreeing that it is useful for men to participate in PMTCT. The barriers to male participation in the PMTCT programme that were elicited in this study include lack of belief about HIV/AIDS and lack of awareness about PMTCT and the perception of PMTCT as a "women's affair". Another barrier to male participation in the PMTCT programme was the men being busy with their jobs/lack of time, and fear. Facility-based barriers include delays/time wasting at the clinic, and the nurses, who were identified as having an unaccommodating attitude towards the clients. Finally, the fact that the nurses and counsellors at the PHC West Itam were all female was a problem for men. It is recommended that there is need for advocacy and education to raise awareness about HIV/AIDS, and encourage male participation in PMTCT. It is also important to encourage the disclosure of HIV status by the women to their male partners. Furthermore, a separate male counselling unit needs to be created, as well as ensuring the employment of male nurses and counsellors. Additionally, the female nurses at the facility need to be trained/re-trained on proper attitude and confidentiality, and efforts must be made to avoid delays at the clinic.

Magister Public Health - MPH / Disclosure of HIV positive status to male partners is well established as a key element in the success of prevention of mother to child transmission of HIV programmes, as it helps improve adherence to ARVs by the women within these programme. However, partner notification rates remain low in the urban areas of Lusaka, Zambia against a high HIV prevalence of 25%. The purpose of this study was to explore the timing of disclosure as part of the process of disclosure amongst women who were part of the PMTCT services at Kaulu health centre in Lusaka. An exploratory descriptive study using qualitative research methods was conducted. 15 women, who were attending the Kaulu health centre PMTCT programme, were requested to participate in a semi-structured interview. The women, who were purposively selected with the aid of the health centre‟s PMTCT focal point nurse, had to have disclosed their HIV positive status to their partner, either before or during the course of their pregnancy or after delivery. To increase rigour, individual interviews were conducted with 5 health workers associated with the PMTCT programme so as to obtain their perspective and experiences on the issue of HIV disclosure amongst their PMTCT patients. Participation in the study was voluntary and all information obtained during the course of the interviews remained confidential and secure. Potential participants were each provided with an explanation of the purpose and process of the study and their informed written consent obtained before the researcher embarked on the interviews. Content analysis of the transcripts was done so as to develop coding categories and identify emerging themes. Disclosure to male partners is an important step in PMTCT and facilitates adherence to HIV care for the family and should be done as early as possible after the woman receives her HIV test result, though there exists a range of alternative times when it can be done. The relationship existing between a couple is very important in determining the timing of when a woman chooses to disclose. PMTCT services need to provide ongoing counselling for HIV positive women during pregnancy and after giving birth that supports, informs and equips them with the necessary skills to make an informed and timely decision about disclosure to a partner. In addition, the PMTCT service providers need to be encouraged to implement couple counselling as a strategy to facilitate disclosure as well as establishment of a peer support network for HIV positive pregnant women. The study findings will be used to contribute to health workers‟ capacity to support women manage the disclosure process to their male partners, thus helping to increase the disclosure rate and also contributing to improving the positive effect of the PMTCT services, in Lusaka, Zambia. / South Africa

Uganda has experienced substantive shifts in HIV prevention and treatment resulting in marked declines in HIV incidence and mortality rates across the country despite being among the top 5 highest new prevalence rates for HIV transmission and infection among women (Uganda Ministry of Health, 2019). Prior research has revealed that fear of stigma and discrimination, disclosure of HIV status, and quality of services are key factors in women’s healthcare decisions and care-seeking behaviors (Akatukwasa et al. 2021; Lancaster et al., 2016; Grossman & Stangl, 2013). Yet, there continue to be significant knowledge gaps regarding the mechanisms through which intersectional stigma exacerbates health outcomes for people living with HIV. This dissertation draws on baseline data, from the Kyaterekera project an efficacy trial testing the effects of a structural intervention on the HIV-health outcomes of women engaged in sex work within the Masaka region, Uganda. Using an explanatory sequential mixed method design, this study utilized Structural Equation Modeling (SEM) to test the direct and indirect effects of intersectional stigma on mental health, while also evaluating mechanisms (i.e., social support and quality of care) through which stigma impacts mental health, treatment adherence and subsequent viral load. There were no direct or indirect effects of intersectional stigma on mental health, but intersectional stigma was positively associated with social support. Additionally, depression and adherence were negatively associated with viral load. Next, in-depth interviews (n=52) explored personal and community-level factors that may influence women’s care-seeking attitudes and overall health decisions. The following themes were most salient for women: 1) disclosure risk, 2) Intersectional community stigma permeates marginalized women’s health decisions, 3) adaptive behaviors and coping strategies are essential to maximizing care experiences, and 4) the Care Seeking Cost-Benefit Tradeoff. Through an integrative framework, quantitative and qualitative findings were then juxtaposed through a joint display and found to be predominantly complementary (McCrudden, M. T., Marchand, G., & Schutz, P. A., 2021). Findings suggest that a positive association between intersectional stigma and social support may underscore the significant long-term effects of living with HIV. Moreso, holding other stigmatized social statuses. Moreso, this link between intersectional stigma and social support may be due to women anticipating the likelihood of experiencing community-level/interpersonal stigma with HIV disclosure and extensive contact with their social support network. Also, more contact with social networks, particularly those in which stigma norms and discriminatory attitudes are pervasive on the community/ interpersonal level (or perceived to be so) may account for the positive associations between HIV stigma and social support. Sex work had a higher degree of concealability than HIV. As such, sex work was disclosed less frequently than HIV to healthcare providers, family, and friends due to anticipatory community stigma. Despite the finding that the explanatory sequential design produced no direct or indirect effects of intersectional stigma on mental health or viral load via SEM, the exploratory analysis provides substantive insights into the negative impact of HIV-related intersectional stigma on women’s care-seeking experiences and broader health decisions. Women’s care-seeking attitudes and behaviors reveal the intrinsic adaptive skills, strength, and resilience they possess to address individual health needs despite known barriers to care. Overall, this study provides further support for holistic interventions that can enhance and build resilience and successful adaptive strategies to mitigate the effects of HIV-related intersectional stigma.

The purpose of the study was to determine the effect of antenatal health education on postnatal care (PNC) among Human Immunodeficiency Virus (HIV) positive women in Francistown city, Botswana. This study followed a quantitative research paradigm. Data was collected with the aid of a questionnaire from eligible women who consented in writing to participate in the study. Forty-five percent (45%) (n=45) HIV positive women came with babies for 6 weeks PNC and 55% (n=55) brought 8 weeks old babies either for weighing or for the two months immunisation from 28 April to 10 June 2014. The responses regarding the source of health education received were as follows: 40% lay counselors, 31% midwives, 15% doctors, 5% nurses without midwifery, 5% cadre unknown, 2% both lay counselors and midwives, 1% by a health education assistant and 1% was not health educated at all. Conclusion: The study revealed that HIV positive pregnant women received health education from different cadres of health and mostly by lay counselors. Literature indicates that lay counselors may give health information but at a very superficial level. / Health Studies / M.A. (Health Studies)

The purpose of the study was to determine the effect of antenatal health education on postnatal care (PNC) among Human Immunodeficiency Virus (HIV) positive women in Francistown city, Botswana. This study followed a quantitative research paradigm. Data was collected with the aid of a questionnaire from eligible women who consented in writing to participate in the study. Forty-five percent (45%) (n=45) HIV positive women came with babies for 6 weeks PNC and 55% (n=55) brought 8 weeks old babies either for weighing or for the two months immunisation from 28 April to 10 June 2014. The responses regarding the source of health education received were as follows: 40% lay counselors, 31% midwives, 15% doctors, 5% nurses without midwifery, 5% cadre unknown, 2% both lay counselors and midwives, 1% by a health education assistant and 1% was not health educated at all. Conclusion: The study revealed that HIV positive pregnant women received health education from different cadres of health and mostly by lay counselors. Literature indicates that lay counselors may give health information but at a very superficial level. / Health Studies / M. A. (Health Studies)

Thesis (M. Tech. (Biomedical technology)) - Central University of technology, Free State, 2013 / Breastfeeding is a major source of childhood nutrition and protection, but with South Africa having one of the highest HIV prevalence in the world the risk of HIV transmission from mother to infant through breastfeeding becomes a major issue. Infant mortality due to malnutrition and infections is also of great concern. Exclusive breastfeeding and giving antiretroviral drugs to the HIV-infected mother and the HIV-exposed infant is one of the most significant ways to improve infant survival rates and reduce transmission of HIV through breastfeeding. Whether HIV disease progression and its metabolic impact on the mother will affect the nutrient composition of breast milk is a question that arises. The aim of this study was to determine the possible association between the stage of HIV disease, as measured by the immunological markers, and the nutrient composition of breast milk. The study population consisted of 60 HIV infected female volunteers who were divided into two groups. Milk and blood samples were obtained from 30 HIV-positive women that was not on any ARV treatment and from 30 HIV-positive women that was on ARV treatment. Their HIV status and treatment regime were obtained from their files. Participants were also asked to complete a questionnaire. Macro-nutrients that were measured included lactose, proteins, fat, total solids and the energy content of the breast milk. This was done on the MIRIS Human milk analyser. The micro-nutrients that were measured were calcium and phosphate on the DXC 800 chemistry analyser. Blood analysis was included to determine the stage of HIV disease progression in the HIV-positive mothers and comprised of a CD4/CD8+ T cell count, viral load and a full blood count. CD4/CD8+ T cells were determined using flowcytometry on the BD FACScalibur. The COBAS AmpliPrep/COBAS TaqMan HIV-1 Test was used for the determination of the viral load and the full blood count was done using a Sysmex XT2000i haematology analyser. When comparing the analysed haematological variables, the white blood cells and red blood cells indicated a significant difference between the two groups. Both of the groups were anaemic. The CD3+ T cell count was higher and the CD4+ T cell count was lower than the reference range in both groups. The median CD4+ T cells and HIV-1 viral load for the HIV with treatment group was higher than the HIV-infected without treatment group. The analyzed milk data yielded no p-value of great significance, suggesting that there was no statistically significant difference recorded of the measured nutrients between mothers receiving treatment and those who did not receive any treatment for HIV. The Spearman Correlation Coefficient was used to determine if HIV disease progression would have an influence on the nutrients that were measured. For the HIV-infected without treatment group, a significant correlation was found between the HIV-1 viral load and percentage total solids in breast milk. For the HIV-infected with treatment group the only positive correlation was between the CD4+ T cell count and the percentage total solids and energy content of the breast milk. No strong positive correlation could be established between the immunological markers of HIV disease progression and the analysed nutrients in the breast milk. Taking this into consideration, HIV-positive mothers can breastfeed their babies even if their HIV status is at a more advance phase, but the emphasis should be placed on exclusive breastfeeding and getting the needed support to breastfeed.

Thesis (M. Tech. (Biomedical technology)) - Central University of technology, Free State, 2013 / Thirty-one years after the discovery and isolation of the human immunodeficiency virus (HIV) by French and American scientists, much progress has been made in basic research, clinical treatment, and public heath prevention. Although, much evidence of mother-to-child-transmission (MTCT) of HIV has been amassed since then, not much of it describes the effects of HIV on the nutrient composition of breast milk. The aim of this study was to determine the effects of HIV on the nutrient composition of breast milk, by studying two groups of adult lactating respondents from the same socio-economic background, who were chosen randomly and participated voluntarily. The study population consisted of 60 breastfeeding mothers, divided into two groups of 30 mothers each. Group one represented the control group of HIV non-infected mothers whereas group two consisted of HIV-infected mothers who did not receive any treatment. After a registered medical nurse took blood and breast milk samples, analysis was done on ethylenediamine tetra-acetic acid (EDTA) whole blood to determine the haematological and immunological parameters and breast milk was analyzed for nutrient composition. Standard laboratory operating procedures (SOP) were followed, throughout, to determine the parameters of the blood and breast milk samples. Results showed that associations between the socio-economic statuses (SES) of the two respondent groups could be established. Albeit differences were not significant, some were, however, detected in the number of people contributing to the household income of the respondents (p = 0.0051), their employment status (p < 0.0001) and the availability of water sources (p = 0.1124). It is believed that factors, such as the prevalence of HIV, if related to the different levels of SES may play an important role in the outcome of the health statuses of individuals at different levels of society. By implication, it is not the different levels of SES, but rather factors related to the different levels of SES that have an impact. Significant differences could be seen in the haematological variables between the two respondent groups: Red blood cell count (RBC) (p < 0.0001), hemoglobin (Hb) levels (p = 0.0119), hematocrit (Hct) (p = 0.0031), mean corpuscular volume (MCV) (p = 0.0005), mean corpuscular hemoglobin (MCH) (p = 0.0043) and monocyte count (p = 0.0275). These differences, however, were not significant to this study. Other differences that were significant were immunological parameters between the two respondent groups: CD4 cell count (p < 0.0001) and viral load, done only on the blood of the HIV-infected respondent group. The CD4 cell count is used as a guideline for the initiation of treatment for HIV-infected persons and is required to accurately assess the immune status of any patient at any given time. The viral load has long been established as a strong predictor of the rate of disease progression. The only significant difference in the breast milk composition was reflected in the following variables between the two groups: percentage (%) proteins (p < 0.0001) and calcium levels (p = 0.0081). The median and mean values of the percentage proteins were elevated in the subject group of mothers living with HIV, while calcium levels in the same group showed a decrease in both median and mean values. The lack of significant differences between the groups might be due to the small study population. If nothing else, this study highlights the need for further trials to evaluate the true effects of HIV on the nutrient composition of breast milk.