Introduction: The burden of disease due to HIV/AIDS and tuberculosis remains great for many countries around the world. Continuing attention must be devoted to these epidemics if we ever hope to one day contain their devastating effects on humankind. The objective of this study is to; to evaluate and compare cohort treatment outcomes of HIV infected TB patients and HIV infected non-TB patients treated with HAART at the Themba Lethu Clinic between 1st April 2004 and 1st April 2007. To measure outcomes in CD4, viral load, hemoglobin, liver function tests, weight, BMI, loss to follow up and death and to compare this outcomes between HIV patients who have had TB and HIV patients who have never had TB. Materials and Methods: information collected of patients for three years shall be used to carry out analysis. A total of 5818 patients were included in the cohort sample. 19.23% (1,048) of the patients had been diagnosed with TB at some point in time while 80.77% (4,770) had never been diagnosed with TB. Mean baseline CD4 cell counts were 113.47cells/mm3 for non TB patients and 88.85cells/mm3 for those who have ever had TB. This baseline CD4 counts are considered 2 months prior to ARV start and 1 month post the start of ARV. Baseline means for weight, BMI, AST and ALT were also taken into consideration by the two patient groups. Clinical out come was assessed and evaluated by comparing incidence of designated end points either as survival or failures. Incidence of deaths and loss to follow up was also compared in the two groups of patients. Results: Among HIV non TB patients, incidence rate of them having CD4 counts greater than 200 was at 36.47 persons per 10000 person days while for the patients who had been diagnosed with TB incidence of CD4 rising to above x 200 was lower at 34.19persons per 10000 person days. A rate ratio of 0.94 (95% CI 0.85 - 1.03) showed no true difference in the two groups. When looking at deaths in the two groups of patients, incidence in those who had TB was 3.84 deaths per 100 patient years and 4.16 deaths per 100 patient years for the non TB group with RR 0.93 and CI 0.66 - 1.28. Differences in incidence and outcomes were noticed in Hb gain, weight and BMI change, Liver function test changes over time and loss to follow up “defaulters”. Survival curves were modeled to show trend of change and log rank test were used to ascertain equality of survival curves. Where log rank p. values < 0.05 were noticed among survival curves of weight, BMI, AST, ALT, Hb and Loss to follow up. This again showed differences in weight, BMI, hemoglobin, AST, ALT and loss to follow up while no statistical differences were recognized between the two groups of patients when considering changes in CD4, deaths and Viral load over time as log rank test failed to reject the null hypothesis of similar curves. Conclusion: Data indicated that similarity and differences between HIV TB patients and HIV non TB patients could vary along certain outcomes. But one sure point is both groups of patients had an equal chance of staying alive when properly treated with ARV/HAART.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine Johannesburg, 2014 / Human immunodeficiency virus (HIV) associated thrombotic microangiopathy (TMA) is thought to be a common form of the disorder in South Africa with a severe clinical presentation and poor prognosis; it remains however poorly characterized. This study was undertaken to evaluate the presentation and prognosis of HIV-associated TMA through retrospective analysis of a cohort of HIV positive and negative subjects diagnosed with and treated for TMA at a single center (Helen Joseph Hospital) from 1/1/2001 to 31/12/2009. HIV-associated TMA was the dominant form of the disorder in this series and was associated with advanced HIV infection and a more severe presentation than TMA in HIV negative subjects. Although mortality was non-significantly more frequent, response to plasmapheresis was more rapid and recurrence less common in HIV positive subjects. This study adds to available literature on a rarely studied disorder. Despite its aggressive nature, timeous diagnosis and intervention facilitate satisfactory outcomes in HIV-associated TMA.

A research report submitted to the School of Public Health , University of Witwatersrand Johannesburg in partial fulfillment of the requirements for the degree of Masters of Science in Epidemiology and Biostatistics, November 2013 / Malaria in HIV-infected (HIV+) persons is associated with reduced immunity due to a decrease in CD4+ cells count and an increase in viral load, and immunity becomes more compromised in HIV-infected ART-naïve patients. However, the relationship between treatment of HIV infection with antiretroviral therapy (ART) and malaria among HIV coinfected individuals has not been widely reported in Africa, in particular amongst Rwandan women. In this study, the investigator examined malaria incidence and its associated potential risk factors in a cohort of HIV-uninfected, HIV-infected on ART and HIV-infected naïve Rwandan women. Method The data used in this research consists of 936 women enrolled in the Rwandan Women's Inter-association Study and Assessment (RWISA) study. Follow-up visits were carried out every 6 months for a period of 5 years. Incidence of malaria was considered as self-reported if it occurred during the 6 months prior to the study visit. Incidence rates (IRs) and Hazard ratios (HRs) with 95% CI were determined in HIV-uninfected, HIV-infected ART-naïve and HIV-infected on ART groups. Predictors of malaria incidence in these groups were estimated by Hazard ratios (HR, 95% CI) using Cox regression adjusted for potential confounders. Results Of the 936 women enrolled in the study (226 HIV-uninfected and 710 HIV-infected), almost 90% of the women reported malaria during the follow-up period. At the baseline visit, the median age of the participants was lower among HIV-infected women at 34 years ([IQR] 30- 39), compared to that of HIV-uninfected women at 43 years ([IQR] 34-49), P<0.01. In both groups of HIV-infected and HIV-uninfected women, a large number were widowed i.e. 49% vs. 42%, P<0.01 The HIV-infected women had lower educational status (67% vs. 57%, P<0.01) and lower employment opportunities (68% vs 72%, P=0.002) than HIV-uninfected women. Of the HIVuninfected women, 174 (77%) and of HIV-infected women 596 (84%) reported that they did not have enough food to eat. Malaria incidence was higher in HIV-infected ART-naïve women [adjusted HR= 1.2, 95% CI (1.01-1.36), P=0.03], when compared to HIV-infected women on ART. However, when malaria incidence was compared according to HIV status, HIV-infected women showed a significantly lower incidence when compared to their HIV-uninfected counterparts [adjusted HR= 0.8, 95% CI (0.69- 0.97), P=0.02]. The independent predictors of malaria incidence in the cohort were unemployment, lower level of education, age and season. Conclusion HIV-infected antiretroviral-naïve women in malaria-endemic areas are at higher risk of malaria than HIV-infected women on antiretroviral therapy. In countries where both diseases overlap, the indirect effect of HIV treatment with combination antiretroviral therapy could reduce malaria burden. These findings suggest that additional malaria prevention efforts should be aimed at the untreated HIV-infected population.

Limited research has been conducted on children’s understanding of HIV/AIDS despite its widespread practice in South Africa today. This study aimed to explore this area, specifically investigating institutionalised children’s understanding of HIV/AIDS Increased mortality rates have been seen as a result of the pandemic. In addition, children are seen as vulnerable to the impact of HIV/AIDS. While some children are directly affected by HIV/AIDS, having lost their parents to the epidemic, other children are infected with the virus. Taking this into account, it was deemed useful to explore how children have made sense of HIV/AIDS. The participants for the current study were between the ages of 8 and 14 years, and they were drawn from a children’s institution in a black community within South Africa. The participants engaged in story telling and drawing as means of communicating their understanding of HIV/AIDS. They participated in the following activities: Draw A Person (DAP), Kinetic Family Drawing (KFD), Draw a picture of a person infected with HIV/AIDS, Drawing a picture of HIV/AIDS, and completing Incomplete Sentences in relation to their understandings of HIV/AIDS. They also answered relevant questions in relation to all their drawings. Thematic content analysis was used to analyse data, together with methods adopted from a study conducted by Wiener and Figueroa (1998). It was found that children have a basic understanding of HIV/AIDS, based on information they obtained from their educators, guardians, peers, and the media. Prominent themes arising from the findings are as follows: the visibility of HIV infection, the impact of HIV on relationships, HIV changing lives, preoccupation with death and dying, confusion about HIV/AIDS, and HIV and Morality. Generally, respondents were found to have a negative perception of HIV/AIDS. It was also found that although respondents seem to have some understanding of HIV/AIDS regarding modes of transmission, and ways of preventing transmission, confusion about HIV/AIDS was dominant.

M.Sc. (Physiotherapy), Faculty of Health Sciences, University of the Witwatersrand, 2008. / Paediatric Human Immunodeficiency Virus (HIV) remains a significant challenge to children and caregivers in South Africa. Although the availability of antiretroviral (ARV) therapy has improved, it is not yet universally accessible. Rates of transmission from mother to child thus remain high and the virus widely uncontrolled. One aspect affecting children infected with HIV is that of muscle strength. For children weakness has been inferred by way of developmental studies in young children infected with HIV. Impaired performance in activities such as standing, walking, stair-climbing and jumping have been noted. These gross motor activities require higher muscle outputs and strength against gravity. This study sought to ascertain the feasibility of a full study on muscle strength in children infected with HIV. It analysed the effect of HIV on muscle strength, height and weight of those children receiving and not receiving highly active antiretroviral therapy (HAART). Children were recruited from Harriet Shezi Children’s HIV Clinic at Chris Hani Baragwanath Hospital, Soweto, Gauteng Province, South Africa. The study population included a group of children receiving HAART (n=16) and a group of children not receiving HAART (n=16). A once off test of muscle strength was administered to each child using a hand-held dynamometer. A demographic questionnaire and the Household Economic and Social Status Index (HESSI) were administered to their primary caregiver. Results showed the sample population to be of low socio-economic status (average score=54%) and the children to be underweight and short for their age (p<0.001). The CD4 count of the group on HAART was significantly higher than the group not receiving HAART (p<0.05). The group not receiving HAART was significantly stronger than the HAART group (p<0.05). Length of time having received HAART and muscle strength showed no significant correlation (p=0.647). No significant correlation was shown between CD4 count and muscle strength in the group receiving HAART (p>0.1). A significant negative correlation was shown between CD4 count and muscle strength in the group not receiving HAART (p<0.05). As statistically significant normative muscle strength data for children not infected with HIV in this age group fails to exist, the study was unable to ascertain a quantitative measure of weakness in these children. Comparison of those values available, however, showed normative values to be double that of children who participated in the study. The implications of these findings are that as one observes this group of children’s CD4 count drop, so too does their muscle strength. HAART, once initiated, stems the decrease in muscle strength over a period of time but does not reverse it. Furthermore, children and caregivers who participated in this study were faced with the adversities of poor socioeconomic status, limited access to medication and ARV treatment and inadequate nutritional intake, most of which were largely beyond their immediate control. This pilot study has indicated the feasibility and importance of a full study to investigate the muscle strength of children infected with HIV. Further research is needed to establish the impact of earlier administration of HAART on muscle strength. The effect of exercise on the muscle strength of children who are infected with HIV has yet to be documented. The implication of these factors on gross motor development in children infected with HIV has yet to be investigated.

ABSTRACT: Worldwide, social responses to the HIV/AIDS epidemic have been largely negative, with widespread revulsion to the illness manifesting in hatred, discrimination, rejection, exclusion, marginalisation and fear of those infected, such that witch-hunts, harsh criminal legislation, seclusion camps and other extreme reactions to the illness have been seen (Cameron, 2005). South Africa, despite having enacted a number of laws and policies to protect the rights of people living with HIV/Aids, has not been immune from the negative social response to the disease, with many HIV-positive South Africans having recounted stories of how being HIV-positive has led to alienation from family and friends, difficulties in accessing education and healthcare services, job loss, emotion and verbal abuse, and even physical violence (Campbell, 2003; Preston- Whyte, 2004; Stadler, 2004; Stein, 2004). Negative social responses to HIV/AIDS can be seen as having a detrimental effect on the ability of affected communities to deal with the challenges posed by the disease. For example, fear of the shame and disgrace attached to HIV/AIDS is often at the root of the failure of people to undergo testing, to reveal their HIVpositive status, to seek out treatment and routinely take medication. Cases have been cited of HIV-positive women who continue to breastfeed, despite the knowledge that this may endanger their child, in order to avoid being identified as having HIV, and of HIV-positive people who continue to engage in unprotected sex, for the same reason (Campbell, 2003; Preston-Whyte, 2004). Thus, it is important to tackle the challenge represented by negative social responses to people infected with HIV/AIDS. In order to do so, it is necessary to understand the nature, causes and consequences of responses to the disease. Towards this, this research study has attempted to examine the factors shaping negative social responses to HIV/AIDS among a selected group of white South Africans. Factors that emerged as influential include notions of blame, deviance and morality, as well as pre-existing prejudices, particularly along racial lines.

Stavudine (d4T), a nucleoside reverse transcriptase inhibitor (NRTI) used to treat infection by the human immunodeficiency virus (HIV), is associated with the development of peripheral neuropathy and pain in HIV-positive patients. The mechanisms of this toxic neuropathy are poorly understood, primarily due to a lack of relevant animal models of the neuropathological process initiated by d4T. I investigated whether daily oral or subcutaneous administration of d4T produces neuropathological changes. Compared to previous descriptions of mechanical hypersensitivity induced by daily oral administration of d4T to rats at a dose of 50 mg.kg-1over a four week period, I found that this dosing regimen did not result in hyperalgesia to blunt and punctuate mechanical stimuli applied to the gastrocnemeus muscle. In agreement with the lack of hyperalgesia, oral administration of d4T at 50 mg.kg-1 over a four week period did not induce significant myelinated nerve fibre loss or morphological changes in the sciatic nerve. I then investigated whether administering 100 mg.kg-1 d4T subcutaneously, and therefore avoiding first-pass metabolism, to rats for four weeks causes hyperalgesia and neuropathological changes in nerve morphology. Daily subcutaneous injections of d4T at 100 mg.kg-1 over a four week period did not induce the development of hyperalgesia to a punctate mechanical stimulus applied to the tail or significant neuropathology. My studies demonstrate that multiple administrations of d4T at 50 mg.kg-1 orally or 100 mg.kg-1 subcutaneously over a four week period do not induce hyperalgesia or nerve fibre pathology in rats. Thus, developing a robust animal model of d4T-induced neuropathy may be challenging in the absence of HIV-infection, such that occurs in infected patients. Key words: HIV, ART, d4T, hypernociception

A research report submitted to the Faculty of Health sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Science in Medicine in Epidemiology and Biostatistics 30th May 2012 / Introduction The burden of HIV/AIDS is higher in the sub-Saharan region and multiple sexual partnerships are among the sexual behaviors that put people at risk of HIV transmission. The main aim of this study was to determine the prevalence and associated demographic, socio-economic and behavioral factors of multiple sexual partnerships among men in Zimbabwe. Materials and Methods This was an analytical cross-sectional study that used data from the Zimbabwe Demographic Health Survey 2005-06. Negative binomial regressions were fitted to identify factors associated with multiple sexual partnerships among men in Zimbabwe. Results The prevalence of multiple sexual partnerships was 13.5 %, 12.9%, and 11.2% among the formerly, never and currently married men respectively. Among the formerly married men, the risk factors significantly associated with multiple sexual partnerships included access to newspapers (RR= 1.28; 95% CI:1.02 , 1.60). Formerly married men aged 35-44 years had lower risk of engaging in multiple sex partnerships (RR = 0.59, 95%CI: 0.42, 0.83) than the other age groups. Relative to formerly married men in Manicaland, formerly married men in Mashonaland East region had lower risks of having more sexual partners. Age at first intercourse and sexual attitude were also significantly associated with multiple sexual partnerships among the formerly married men iv Among the never married men, the risk factors associated with multiple sexual partnerships included employment status (RR = 1.33%; 95%CI: 1.17, 1.52), Watching TV (RR = 1.33%; 95%CI: 1.05, 1.69) and sexual attitude (RR = 1.37%; 95% CI: 1.05, 1.79). Relative to never married men in Manicaland, the never married men in Mashonaland East and Mashonaland West had lower risks of having multiple sexual partners. Among the married men, the risk factors associated with multiple sexual partnerships included first intercourse at the age of 19 years or below (RR = 1.07%; 95% CI: 1.04, 1.11) and sexual attitude (RR = 1.16%; 95% CI: 1.09, 1.23). Protective factors included higher level of education (RR = 0.87%; 95% CI: 0.77, 0.98), being 35-44 (RR = 0.94%; 95% CI: 0.89, 0.99) or 45-54 years old (RR = 0.93%; 95% CI: 0.88, 0.99) and being from Mashonaland East (RR= 0.89%; 95%CI: 0.85, 0.93) region. Discussion and Conclusions The results show that after adjusting for potential confounders in the multivariate negative binomial regression analysis; age, geographical region, education, working status, frequency of reading newspapers/magazines/TV, age at first intercourse and sexual attitude remained significantly associated with MSP. However, the extent to which each of these factors was associated with multiple sex partnership varied among marital status groups, therefore HIV/AIDS intervention programs should be designed accordingly.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Science in Physiotherapy Johannesburg, 2014 / Stroke is a significant contributor to disease worldwide and is the second highest cause of death in both men and women. Importantly, stroke is not only a common cause or mortality but also morbidity. This increased risk of suffering a stroke could lead to an increased number of individuals with functional limitations. The main objective in stroke rehabilitation is seen as aiding the patient to achieve their highest physical and psychological performance, with the ultimate goal of a stroke survivor being one of functional independence allowing them to return to their home and reintegrate into their community. The aim of this study is to describe the differences in functional abilities between patients with stroke who are HIV positive and those who are HIV negative admitted to Witrand rehabilitation unit in the North-West province of South Africa. This is a retrospective longitudinal study utilizing the review of subject records. All subject files dating back to 21 April 2005 to December 2010 were analysed. Functional ability of patients with stroke was scored using the Beta assessment tool.The Beta assessment tool is one of three platform level tools designed by the South African Database for Functional Medicine (SADFM).It is an evidence – based scoring system which can convert a patient’s functional abilities and behaviour into quantifiable data. Scores on admission and discharge were recorded to determine the presence of change in functional ability after having received rehabilitation. Demographic information and clinical characteristics of subjects were captured using a self-designed questionnaire. Data were analysed using both a two sample t-test and descriptive statistical tests. Over the period, 2005 – 2010, 173 stroke survivors were admitted to the Witrand rehabilitation unit.Data from 32 patient files was excluded for not meeting the inclusion criteria; leaving data from 141 files to form our study group (n). The study group included 53.2% male and 46.8% female stroke survivors, with the mean age for stroke at 54.4 years and52.4 years for males and females respectively. Ischaemic strokes were more prevalent than haemorrhagic strokes (74.5% and 25.5% respectively) with hypertension asthe most common (31.9%) stroke risk factor. The mean age of stroke onset for a HIV positive individual was 39.6 years and 54.9 years for an individual without HIV.This study found that HIV positive individuals required on average 7.5 days less to rehabilitate than an individual with HIV. This discrepancy could be a result of the notably younger HIV positive group. After receiving rehabilitation from a multidisciplinary team, the HIV positive group improved with an average of 40 points and the individuals without HIV by 38 points. When performing the various statistical tests there were in fact no significant differences between the two different clinical groups. Despite the statistically insignificant findings when comparing the HIV positive and HIV negative group, when taking a closer look at the study groups demographics and clinical characteristics this study yielded interesting results. It could be argued that a majority of the HIV positive group were generally younger than the HIV negative group and perhaps the advantage of age on recovery could result in this group in gaining, on average, a similar number of points on the beta scale with those individual without HIV.Prior to their commencement of rehabilitation it should be taken into account that neurological recovery requires a degree of brain reorganization and that with age comes a certain degree of neuronal loss. Neuroplasticity is the ability of the central nervous system to respond to internal and external stimuli by reorganizing its structure, function and connections. Normal ageing is associated with a decline in and reduced plasticity. These negative changes can be experienced as reductions in processing speed, working memory and peripheral nervous system functions; all of which can be associated with poorer rehabilitation outcomes. Neural plasticity is crucial for functional recovery and this occurs more effectively and efficiently in younger individuals.However, in general the age for stroke onset was younger than that of developed countries thus stroke should no longer be considered an ‘old-age’ disease in developing countries. Keywords: Stroke; Human Immunodeficiency Virus (HIV); Functional abilities

A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfillment of the requirements for the degree of Doctor of Philosophy Johannesburg, 2014 / Background: Individuals infected with the human immunodeficiency virus (HIV) are living longer due to effective disease management with highly active antiretroviral therapy (HAART). International literature suggest that mortality in people living with HIV and AIDS (PLWHA) is shifting to non-AIDS defining diseases such as cardiovascular disease. It is suggested that PLWHA are at an increased risk for developing ischemic heart disease (IHD) due to HIV mediated processes, traditional risk factors of IHD and factors related to HAART exposure. In the South African context risk factors for IHD are reported to be on the increase in the general population but published information regarding the risk factors for IHD in PLWHA is limited. Human immunodeficiency virus infection is a significant Sub-Saharan Africa challenge with 5.26 million people living in South Africa (SA) reported to be infected with HIV. Only Swaziland, Lesotho and Botswana report higher prevalence rates of HIV infection. Due to the high prevalence rate of HIV in SA, the reported increase in risk factors for IHD in the general population and the suggested increased risk for IHD in PLWHA, screening these risk factors in PLWHA in the South African context may be necessary. Innovative prevention strategies for IHD are also required to manage the risk for IHD in PLWHA in SA due to the high prevalence rate. A home-based education and pedometer walking programme could be such a strategy. The aims of the research project were therefore firstly to screen selected risk factors for IHD in PLWHA attending a primary care clinic and secondly to evaluate said individuals’ self-perception regarding their risk of IHD. Lastly the project set out to determine the effects of an individualised education and home-based pedometer walking programme on the risk of IHD as a potential prevention management strategy for IHD in PLWHA. Methodology: The research project consisted of four studies divided into phase 1 (study 1, 2, 3) and phase 2 (study 4). The study aims, methods and data analysis approaches were: Study 1: Aimed to screen a sample of PLWHA (on HAART) for physical activity and selected risk factors of IHD using the Yamax SW200 pedometer and other appropriate methods respectively. This study was an observational study and data analysis consisted of descriptive analysis and reviewing associations with univariate logistic regression analysis. A p–value less than 0.05 was considered statistically significant. Study 2: Aimed to evaluate participants’ self-perception and behaviour in relation to the risk of IHD using a semi-structured interview and card sort technique. This study was a qualitative study and data analysis consisted of descriptive and conventional content analysis. Study 3: Aimed to develop the education physical activity diary that was used in phase 2. The methodological processes included a literature review, a review of the education material to be included in the physical activity diary by an academic peer–review panel, review by a clinician working with PLWHA and a sample of PLWHA. Following these activities the diary was constructed and translated into isiZulu. Study 4: Aimed to assess the effects of an education and home-based pedometer walking programme on the risk factors of IHD in a sample of PLWHA (on HAART) with an increased risk for IHD as determined in study 1. The study was a randomised controlled trial consisting of an intervention and control group. Assessments were done at baseline, six and 12 months. Control participants continued with standard clinic care and were phoned once a month for five months during the baseline and six month interval. The intervention participants received a Yamax SW200 pedometer, an education physical activity diary, individualised walking programme and had once a month face-to-face education sessions in the baseline to six month interval. Intervention participants were instructed to continue with their physical activity modification programme during the six to 12 months period. No contact was made with control or intervention participants during this time. Intention-to-treat analysis was the primary approach for study 4. Data analysis consisted of descriptive analysis (mean [±SD] and frequencies [percentages]) and randomisation to group allocation was assessed using a two sample/ independent t-test or Wilcoxon rank–sum (Mann– Whitney) for non-normally distributed continuous data. Categorical data were evaluated with the Pearson Chi Square test. A p–value less than 0.05 was considered statistically significant. To evaluate the effect of time on outcomes assessed, repeated measures ANOVA for within-group changes were performed. To evaluate the effect of the programme on outcomes assessed, repeated measures ANCOVA with baseline values as co-variates were performed to highlight the between-group effect. To assess the associations between dependent variables and the time and intervention/control interaction the pedometer data were log-transformed due to skewness. The generalised estimation equation (GEE) and mixed effects model (MEM) approaches were used to fit the univariate and multivariable models. The correlation structure selected was the exchangeable option with the identity link function suitable for Gaussian data. The relationship between high sensitivity C-reactive protein (hs-CRP) at baseline and evaluated risk factors for IHD was assessed with the Pearson correlation coefficient and univariate logistic regression in MEM respectively on log-transformed hs-CRP. Results: Study 1: Two hundred and five PLWHA (on HAART) were screened for selected risk factors for IHD. The demographic characteristics of participants consisted of the following: mean age (38.2 [±9.5] years), gender (men [n=47; 22.9%] and women [n=158; 77.1%]), most participants had a secondary educational level (n=95; 46.3%), were employed (n=115; 56.1%) and were supporting dependents (n=158; 85.4%). The majority of participants perceived their general health as good (n=120; 58.5%), but felt their body shape had changed in the last six months (n=123; 60%). This was mostly due to a reported increase in weight (n=132; 64.4%). The mean time on HAART was 8.7 (±2.3) months, with the majority of participants being diagnosed as HIV positive between 2009 to 2011 (n=134; 66%). The majority of participants were on Lamivudine, Efavirenz and Tenofovir (n=139; 67.8%) therapy with a mean CD4 count of 285.1 (±157) cells/mm3 and viral load of 12 513.2 (±59 710.6) copies/ml. The physical activity levels of participants were reduced with the mean pedometer step count per day found to be 7 673.2 (±4 017.7) with men being more active (10 076.3 [±4 885.6] steps per day) than women (6 993.3 [±3 462.6] steps per day). The majority of study participants (n=150; 77%) took less than 10 000 steps per day. Taking less than 10 000 steps per day was related to waist circumference (WC) (odds ratio=1.04; 95% CI: 1.00–1.08; p=0.03) when adjusted for age and gender. Eight participants (3.9%) participated in formal sporting activities that were supervised and 123 participants (60%) tried to incorporate exercise into their daily lives. The preferred activity method for exercise was walking (n=56; 45.5%) and running (n=33; 26.8%). Perceived stress was moderately high with a mean Cohen’s Perceived Stress score at 19.2 (±7.8) with women reporting higher levels of stress (20 [±7.1]) than men (16.9 [±9.1]). A family history of IHD was low in participants (n=29; 14.2%) as well as a known diagnosis of diabetes mellitus (n=1; 0.005%), hypertension (n=19; 9%) and current smoking status (n=33; 16.1%). The majority of participants reported not being able to consume fish weekly (n=114; 55.6%) and reported weekly consumption of fruit and vegetables (n=110; 53.7%). Few participants were able to consume three to five vegetables and fruit combined per day (n=68; 33.2%). The mean resting heart rate (RHR) of the sample was slightly elevated (82.7 [±11.4] bpm) with having a RHR ≥ 80 bpm related to diastolic blood pressure (DBP) (odds ratio=1.07; 95% CI: 1.03–1.11; p<0.00) and physical activity (odds ratio=0.99; 95% CI: 0.99–0.99; p=0.02) as adjusted for age and gender. The sample as a whole was overweight with a mean body mass index (BMI) of 25.6 (±1.4) kg/m2. Having a BMI ≥ 25 kg/m2 was related to systolic blood pressure (SBP) (odds ratio=1.07; 95% CI: 1.04–1.10; p<0.00), WC (odds ratio=1.34; 95% CI: 1.22–1.46; p<0.00), hip circumference (odds ratio=1.53; 95% CI: 1.38–1.75; p<0.00) and CD4 count (odds ratio=1.00; 95% CI: 1.00–1.01; p=0.01) as adjusted for age and gender. Study 2: Thirty PLWHA (on HAART) were purposefully sampled according to the following criteria: individuals had to be on HAART for six to 12 months, between the ages of 20 and 65 years and ambulatory without an assistive device with no pre-existing history of cardiovascular disease, mental illness, current acute infection, current pregnancy or breast-feeding women. The demographic details of participants were as follows: median age 36.5 (31.8–45.0) years; women (n=25; 83.3%) and men (n=5; 16.7%); the majority of participants (n=16; 53.3%) had a secondary school education, were employed (n=17; 56.7%) and were supporting dependents (n=26; 86.7%). Knowledge and understanding related to IHD, insight into own risk for IHD and health character in the HIV context were identified as three prominent themes. An important finding that the study highlighted was that participants did not perceive themselves to be at risk for IHD due to being HIV+ or using HAART in any way. The majority of participants (n=15; 50%) did not perceive themselves to be at risk for IHD due to reporting having adequate coping behaviour and living a healthy lifestyle. Twelve (40%) participants did however perceive a risk for IHD due to physical symptoms experienced and their behaviour consisting of a poor diet, elevated stress levels and lack of exercise. Three (10%) participants were unsure concerning their risk for IHD in the future. Study 3: A selection of pages from the education physical activity diary can be found in Appendix 31. Study 4: Eighty four PLWHA (on HAART) participated in study 4. The education and home-based walking programme implemented in study 4 was successful in improving physical activity levels in both the control and intervention groups, as participants’ pedometer-determined step-count increased from baseline. The within-group change at six months were statistically significant (p=0.03) for both groups but not so for the 12 month period (control group [p=0.33] and intervention group [p=0.21]). It was however of clinical value in the intervention group, due to the group exceeding the step count aim of the programme, that being 3 000 steps above baseline at each assessment point. Translating the step count into time, would amount to approximately 30 minutes of added walking per day. The group therefore reached the Public Health recommendations for physical activity. Social support in the form of encouragement, motivation and participation from friends and family was noted as important enablers that assisted intervention participants to adhere to their programme. No significant differences were observed in the sociodemographic profile, HIV related clinical markers and antiretroviral therapy and IHD risk factors evaluated at baseline. The study highlighted that inflammation (hs-CRP) was a significant risk factor for IHD in the study cohort due to mean baseline values of 8.6 (±8.4) mg/l in the intervention and 5.4 (±6.5) mg/l in the control group. Inflammation (hs-CRP) was related to perceived stress (Pearson correlation [r=0.23; p=0.03] and MEM univariate logistic regression [log B=0.04; 95% CI: 0.0004– 0.08; p=0.03]), weight (Pearson correlation [r=2.8; p=0.01] and MEM univariate logistic regression [log B=0.02; 95% CI: 0.01–0.04; p=0.01]), BMI (Pearson correlation [r=0.35; p<0.00] and MEM univariate logistic regression [log B=0.07; 95% CI: 0.03–0.12; p<0.00]), WC (Pearson correlation [r=0.28; p=0.01] and MEM univariate logistic regression [log B=0.03; 95% CI: 0.06–0.36; p=0.01]) and hip circumference (Pearson correlation [r=0.28; p=0.01] and MEM univariate logistic regression [log B=0.02; 95% CI: 0.01–0.04; p=0.01]). The risk for IHD according to Framingham Risk Score (FRS) calculation was low as baseline FRS points were 3.3 (±6.5) points in the control group and 2.5 (±6.5) points in the intervention group. The education and home-based walking programme was effective in increasing physical function capacity (six-minute walk test mean difference: 15.70 [±9.33] meters), reducing waist: hip ratio (mean difference of -0.003 [±0.01] cm), reducing glucose level (mean difference of -0.12 [±0.09] mmol/l) and increasing HDL (mean difference of 0.07 [±0.05] mmol/l) as evaluated during betweengroup analysis. The within-group analysis indicated that a significant reduction in SBP occurred in both groups at the six months time period (control group: p=0.03 and intervention group: p<0.00). A slight increase in BMI occurred in both groups at the six and 12 month period that were statistically significant (p<0.00). A significant reduction in total cholesterol (p=0.04) and LDL (p<0.00) at the 12 month period were also noted in the control group. The log-transformed univariate logistic regression model highlighted many associations between the interaction (time and treatment: control or intervention group effect) and secondary outcomes assessed. The inverse associations between perceived stress levels (p<0.00) and BMI (p=0.02) with the six month time interval of the control and intervention groups compared to baseline control findings were confirmed during multivariable analysis in the log-transformed GEE model. Additionally an inverse association between perceived stress levels (p<0.00), BMI (p<0.00), LDL (p=0.01) and triglycerides (TG) (p=0.01) at the six month time interval of the intervention group compared to baseline control findings were confirmed in the multivariable analysis in the logtransformed MEM model. Conclusion: This project showed that physical inactivity, elevated perceived stress levels, inadequate diet of fruit, vegetable and fish intake, elevated RHR, increased BMI and raised hs-CRP were risk factors for IHD in the study cohort. These risk factors screened indicated an elevated risk for IHD in the future even though the FRS demonstrated a low risk for IHD. An IHD predictive model that incorporate hs-CRP when evaluating risk for IHD and which has been validated for use in PLWHA is therefore necessary to adequately evaluate the risk for IHD in this population. This is especially of relevance in the South African context considering the prevalence of HIV infection in women and the association of female gender with hs-CRP as indicated in the literature. The project highlighted that an elevated stress level was a significant risk factor for IHD in the study cohort and was also given as one reason why participants perceived themselves to be at risk for IHD. The positive association between perceived stress and hs-CRP was also of value. The stress lowering effect of the education and home-based pedometer walking programme was therefore of significant importance as it could manage this risk factor. Additionally if stress declines it could potentially also influence hs-CRP in the long term. The study therefore contributes to the body of knowledge related to the effects of exercise on psychological parameters in PLWHA. Additionally the project confirmed that an optimistic bias in individuals living with HIV is present regarding their future possibility for developing IHD. Their perception for the risk for IHD did not always align with the risk factors present as screened. This might be due to the fair application of knowledge related to IHD when evaluating their risk for IHD. It also confirmed that education strategies are needed to explain the risk factors for IHD and how HIV infection and HAART influence these risk factors of IHD. Lastly the project found that an education and individualised home-based pedometer walking programme was able to influence physical activity levels positively and was successful in reducing the risk of some factors for IHD in PLWHA at primary care level. Such a programme can be implemented as an innovative method to manage risk factors for IHD in PLWHA by physiotherapists especially in regions where physiotherapy numbers are low and HIV prevalence high.