A Research Report submitted to the School of Public Health, University of the Witwatersrand in partial fulfillment of the requirements for the degree of Master of Public Health. May 27, 2015 / Introduction: Studies across Sub-Sahara have established transactional sex as one of the of the keys factors contributing to young people’s risk of HIV infection. However, there are few studies that have explored the dynamics of transactional sex among young people in Malawi. The aim of this study was to investigate the extent of, and risk factors associated with transactional sex among (in and out of school) young men and women of ages 18 – 23 years in urban informal settlements in Blantyre, Malawi. Methods: This was a secondary analysis of data from a cross-sectional study conducted in 2013 on sexual risk-taking among young people aged 18 – 23 years in urban informal settlements in the city of Blantyre, Malawi. The analysis was restricted to sexually active young men and women (those respondents who reported ever having sexual intercourse in the primary study). Bivariate and multivariate analyses were conducted to detect associations between socio-demographic factors (i.e. age, socio-economic status, relationship status and education, as well as behavioral factors (i.e. sexual debut, number of partners, age disparity with sexual partner, coercive sex and alcohol consumption), and transactional sex. Results: The majority (60.06%) of the study population reported involvement in transactional sex. Stratified by sex, 67.10% of young men had ever given cash or material goods in order to get sex, and 53.45% of young women had ever received cash or material goods in exchange for sex. Half (50.75%) of the transactional sex reported was in exchange for cash and consumption/lifestyle goods and from this, over half of the young women (58.67%) reported receiving consumption and lifestyle goods in exchange for sex, and slightly over a quarter (26.32%) of the young men reported giving survival needs in exchange for sex. Among men, household structure (AOR 2.07, 95% CI 1.37 – 3.13) and severe food insecurity (AOR 1.67, 95% CI 1.05 – 2.67) emerged as important socio-demographic predictors of transactional sex, and number of sexual partners (AOR 2.67, 95% CI 1.78 – 4.08) and age disparity (AOR 0.34, 95% CI 0.21 – 0.57) were shown to be the behavioral factors that influence giving cash/material goods for sex. Among young women, only age at sexual debut (AOR 2.07, 95% CI 1.37 – 3.13) and number of sexual partners (AOR 3.02, 95% CI 1.65 – 5.52), were significantly associated with receiving cash or goods in exchange for sex. Conclusions: Overall, the study findings show that transactional sex is a common practice among young men and women, and that both young and women exchange luxury or aspirational items more than survival items for sex. Among young men, household structure, food security, age at sexual debut, number of sexual partners and age differentials with sexual partner were associated with giving material goods or money for sex. Among women on the other hand, age at sexual debut and number of sexual partners were associated with receiving material goods or money in exchange with sex. These findings suggest that young people in poor urban settings engage in risky sexual behavior such as Transactional sex, and highlight the need for HIV prevention interventions to deliberately target this group. Programmers should consider designing interventions that suit the needs of the different gender groups. The study findings also highlight the importance of targeting young women with behavioral change interventions before sexual debut, and integrating transactional sex interventions with those focused on reduction of multiple sexual partnerships may have beneficial implications for transactional sex among young people in poor urban settings. Further research should explore the influence of materialist and consumeristic cultures on transactional sex among young people.

A research report submitted in submissible format to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of MSc in Child Health (Community Paediatrics) 20 June 2017 / Background: HIV antiretroviral therapy (ART) is associated with breast abnormalities in adults, especially efavirenz (EFV). Little is known about the prevalence of these adverse effects among adolescents receiving ART. Methods: A retrospective record review describing breast conditions in adolescents receiving ART at three facilities in Johannesburg, South Africa was conducted. Patients aged 10-19 years who presented from 1 January to 31 December 2014 were included. Analyses were conducted to determine whether EFV use was associated with an increase in breast conditions. Results: A total of 631 patient records were reviewed, 37 (6%) had an abnormal breast event documented of whom 24/37 (65%) were male. Patients with abnormal breast conditions developed them 1.5 years later than patients with normal breast development (p<0.0005). Forty-one abnormal breast events were observed in thirty-seven patients with twenty being described as gynaecomastia or lipomastia (49%). 44% had concurrent generalised lipodystrophy (n=19). Of those with an abnormal breast event, 71% of patients had CD4 counts >500 cells/μl and were virologically suppressed (n=29). Those on EFV had a significantly higher prevalence of breast abnormalities compared to other regimens (p=0.016) and all had been exposed to EFV before. No other ART drug was associated with breast abnormalities in this cohort. Sixteen patients had substitution of EFV and three breast events resolved once substituted from EFV. Breast abnormalities in adolescents on ART Conclusion: Six percent of patients had an abnormal breast condition in this study. Use of EFV and increasing age were associated with breast abnormalities in this population. Further research is needed to better understand this phenomenon. / MT2017

MMed (Otorhinolaryngology), Faculty of Health Sciences, University of the Witwatersrand / HIV/AIDS continues to be an important public health challenge in sub Saharan Africa. It is estimated that approximately 68% of people living with HIV in the world are from this region [1]. South Africa has the largest infected population in the world, the adult (15-49 years) HIV prevalence is estimated at 17.64% [2]. It has been estimated that 40 - 70% of such HIV positive individuals present with head and neck manifestations, which include infection, inflammation and tumours, and are often the only and initial presenting sign [3,4]. Peritonsillar abscess is the most common deep infection of the head and neck in young adults and can occur in all age groups, but the highest incidence is in adults 20 to 40 years of age [5]. The aim of this study was to assess the relationship between peritonsillar abscess and the HIV status of patients. Method: An analytical cross sectional study utilising retrospective clinical data from ward registers, patient records, treatment registers and National Health Laboratory System (NHLS) databases. This study was conducted in the adult ENT ward at the Chris Hani Baragwanath Hospital and sample consisted of patient records over a 4 year period from January 2005 to December 2008. All patients admitted to the ENT ward with the discharge diagnosis of peritonsillar abscess that have been tested for HIV were included in this study. In this study period 450 patient files were reviewed of which 291 fulfilled the inclusion criteria. The demographic details, clinical presentation which included head and neck manifestations of HIV, the HIV status, management and complications of peritonsillar abscess were recorded. This data was analysed using STATA-10 software. Results: The age ranged from 15 to 63 years with a mean (SD) 29.3 years (9.58). From the 291 patients, 86 (29.55%) were HIV positive. This is significantly higher than the adult (15-49years) HIV prevalence rate of 17.64% [6]. The male: female ratio of HIV positive patients 1:1.53. Forty-nine (16.84%) patients presented with cervical lymph nodes of which 65.31% were HIV positive (P< 0.001). From the 86 HIV positive patients oral candida was present in 15.12% (P<0.001), lymphoma in 6.98% (P<0.001), oral hairy leukoplakia in 2.33%, Kaposi’s sarcoma in 1.16% and complications (parapharyngeal abscess) 3.48%. There was no statistical significance in the management of HIV positive patients, however hospital stay was longer with a mean of 3.802 days (P<0.001). From this study sample the HIV prevalence of 29.55% suggests that peritonsillar abscess may be an early clinical marker of HIV infection. Due to the high incidence of head and neck manifestations in HIV positive patients identifying a clinical marker (quinsy) in the earlier stages of HIV infection would allow for better screening, earlier diagnosis and treatment of HIV infection.

MMed, Haematology, Faculty of Health Sciences, University of the Witwatersrand / Background: Mycobacterium tuberculosis (MTB) infection remains a serious public health challenge in sub-Saharan Africa. Rapid and early diagnosis is critical in the successful control of this eminently treatable infection. This study compared the diagnostic usefulness of culture, bone marrow trephine biopsy granulomata, bone marrow trephine biopsy Ziehl-Neelsen (ZN) stain and bone marrow mycobacterial polymerase chain reaction (PCR) in establishing the diagnosis of mycobacterial infection in HIV infected patients. Materials and methods: The trephine biopsies of HIV positive patients done for the investigation of suspected tuberculosis were reviewed for granulomata and stained with ZN stain. The corresponding bone marrow aspirates were subjected to DNA real-time PCR analyses using LightCyler TB Kit® (Roche Diagnostic). Culture results were used as diagnostic gold standard. Results: Of the 60 patients studied, 24 were culture negative. Of the 34 culture positive, 62% were Mycobacterium tuberculosis and 38% were Mycobacterium avium intracellulare. Using the culture method as a gold standard, the sensitivities and specificities were 97% and 23% for bone marrow trephine biopsy granulomata, 65% and 58% for bone marrow trephine biopsy ZN staining and 50% and 73% for bone marrow aspirate PCR analysis respectively. Ninety-seven percent of all trephine biopsies with positive ZN stain had granulomata. Conclusion: The presence of granulomata in bone marrow trephine biopsies of HIV infected patients appear to have a high diagnostic yield whilst mycobacterial PCR has the lowest yield but highest specificity. These results should be confirmed in a prospective case controlled study because the sample size in this study was small, and the study was a retrospective one.

Highly active antiretroviral therapy has successfully limited HIV-1 disease progression to AIDS, but is consistently compromised by the emergence and transmission of HIV-1 drug resistant strains. As a result, a continued search for novel anti-HIV-1 agents with improved pharmacological profiles has become fundamental. Chrysotherapy has been in use since the early 1920s in treatment of rheumatoid arthritis, and has since been investigated for various ailments including HIV/AIDS. This study evaluated 45 synthetic gold compounds for drug like properties using theoretical and experimental techniques with the aim of generating sufficient data to considerably aid the rational design of new anti-HIV agents. Theoretical techniques applied included the Osiris Property Explorer and the Lipinski’s Rule of Five which assessed drug-likeness and bioavailability respectively. In vitro studies included aqueous solubility assays, cytotoxicity (PM1 cell lines and PBMCs) assays, antiviral assays in PBMCs, direct enzyme (RT and IN) inhibition, and the effect of serum protein binding and biological stability on antiviral efficacy. An overall low druglikeness score and an intermediate bioavailability were predicted by the Osiris Molecular Property Explorer. Low drug-likeness was suggested to be due to a high frequency of foreign fragments in the synthetic gold compounds, while their high molecular weight reduced bioavailability. In general gold compounds exhibited cytotoxicity properties and moderate aqueous solubility in vitro. Overall, the 45 synthetic gold compounds did not show activity against HIV-1 replication in vitro. Seven compounds (AB05-AB11) exhibited direct HIV-1 RT inhibition, and compounds AB39 and AB04 demonstrated moderate direct HIV-1 IN inhibition, but this activity was abrogated in PBMC inhibition assays. Serum binding, compound stability and cytotoxicity were all implicated in the lack of HIV-1 inhibition in PBMCs. To this end, data obtained was sufficient to aid in the future rational design of second generation HIV RT and IN inhibitors with acceptable pharmacological properties.

A contentious area of clinical practice in the discipline of surgery, with ethical implications, relates to disclosure of clinician HIV status to patients, specifically where exposure prone procedures, performed in a confined body space using sharp instruments without full vision of the operative area, carrying a technical risk of blood borne pathogen transmission are being performed by HIV positive surgeons. Within the context of patient informed consent, it has been proposed that surgeons who are HIV positive make their status known to patients on whom they would perform such procedures. Failing which it is proposed that surgeons who are HIV positive should refrain from such procedures. It has been counterargued that such disclosure is an infringement on clinician privacy and that curtailing the scope of practice is prejudicial to both surgeon and patient. The former in terms of employment prospects and the latter based on the lack of data supporting a significant risk of clinician to patient transmission with a resultant unnecessary loss of surgical skills. Existing recommendations appear to be informed more by sentiment than science and are thus potentially unsatisfactory, more so in that they do not seem to confer benefit to either patients or clinicians. Further, whilst such policies emanate from developed countries they may not address the clinical realities or sentiment of the South African situation. Where such policies do exist, it is not clear to what extent the recommendations accord with clinician views. Against this background the current study surveyed views of practicing South African surgeons regarding aspects of this issue i.e. HIV and surgeons. Some of the salient findings included the view that a patient centred approach requiring HIV status disclosure to patients would be discriminatory to surgeons whilst not clearly of benefit to patients. Further that HIV positive surgeons should determine their own scope of practice. Certainly it appears that patient centered approaches and restrictive policies, related to this issue, do not appear to accord with clinician sentiment. In the absence of any comparable data either locally or internationally, the current study provides a preliminary indication of clinician views with implications for the development of locally relevant guidelines.

ABSTRACT Incidence estimation and calibration from cross-sectional data of acute infection HIV-1 seroconvertors. May 2007 Eustasius Musenge Masters in Medicine in the Field of Biostatistics and Epidemiology Supervised by: Mr E Marinda and Dr A Welte Background: The HIV-1 incidence (a very important measure used as a proxy for disease burden) can be estimated from a cross-sectional study. This incidence estimate has the advantage of reducing on costs and time, thus enabling more timely intervention; it is also ideal for developing nations. A common procedure used in making this estimate utilizes two antibody tests (Sensitive/Less sensitive tests). Due to the long window period of such tests (at least three months), persons classified as recently infected would have been infected more than three months prior to the test date. Detecting acute HIV-1 infection is very important since this is the most infectious stage of the disease. This research report explores a method of estimating incidence using an antibody test and a virological test, Polymerase Chain Reaction Ribonucleic Acid (PCR-RNA).The cross-sectional data used are from the Centre for the AIDS Programme of Research in South Africa (CAPRISA). Methods: Actual follow-up cohort data from CAPRISA acute infection cohort (AIC), comprised of 245 sex workers, were used to estimate the incidence of HIV-1 using a PCR-RNA ,virology test based, incidence formula. The result obtained was compared to the incidence estimate obtained by the classical method of estimating incidence the AIDS Programme of Research in South Africa (CAPRISA). Methods: Actual follow-up cohort data from CAPRISA acute infection cohort (AIC), comprised of 245 sex workers, were used to estimate the incidence of HIV-1 using a PCR-RNA ,virology test based, incidence formula. The result obtained was compared to the incidence estimate obtained by the classical method of estimating incidence (prospective cohort follow-up). As a measure to reduce costs inherent in virological tests (PCR-RNA), multistage pooling was discussed and several pooling strategies simulations were proposed with their uncertainties. Point estimates and interval estimates of the window period, window period prevalence and incidence from crosssectional study of the AIC cohort were computed. Findings: The mean window period was 6.6 days 95% CI: (2.7 – 13.0). The monthly window period prevalence was 0.09423 percent 95 % CI: (0.0193 – 0.1865)%. The incidence from the prospective cohort follow-up was 5.43 percent 95% CI: (3.9 – 9.2) %. The incidence estimate from cross-sectional formulae was 5.21 percent 95% CI: (4.1– 4.6). It was also shown by use of simulations that an optimum pool sample size is obtained when at least half the samples are removed on every run. Interpretation and recommendations: The PCR-RNA test is very sensitive at detecting acute HIV-1 infected persons. The incidence estimate from the crosssectional study formulae was very similar to that obtained from a follow-up study. The number of tests needed can be reduced and a good estimate of the incidence can still be obtained. The calibration was not accurate since the samples used were small and the window period duration was too short, hence, it was difficult to extrapolate to the whole population. Further work still needs to be done on the calibration of the proposed incidence formulae as it could be a very useful public health tool.

A growing body of research exists that examines the nature of i n tervent ions aimed at educa ting adolescents in t e rms of HIV and AIDS (Campbell, 2003; Campbell & McPhail, 2002; Van Dyk, 2001). However, there appears to be a grave pauci ty of l i t e rature that explor es the impact of HIV and AIDS on adolescents’ psychological and emotional functioning. Adolescents who live in the af t e rmath following the death of a parent, or parents often have to deal with rejection from thei r community, and are often confronted with significant emo t ional, educa tional and psycho-social challenges. These cha llenges continue to pose enormous threat to the development of a healthy s e lf-concept (Foster & Germann, 2002). These adolescents continue to be marginalized as their voices remain largely s i l e n t in contemporar y research . Using a combination of Art therapy, and narr ative creation, twenty-eight adolescents participated in a group intervention intended to facilitate, empower and encourage meaning making processes, and to f ac i l i t at e both oral and wr i t ten communica tion about the i r exper iences of living wi th HIV and AIDS. Findings suggest that while adolescents living with HIV and AIDS continue to have significant emotional, physiological, and social cha l lenges on a daily basis, their stories espouse great hope, determination and resilience.

M.Sc. (Med.), Faculty of Health Sciences, University of the Witwatersrand, 2011 / Human Immunodeficiency Virus type 1 (HIV-1) is the causal agent of AIDS, and currently infects 33.3 million individuals worldwide. The gradual depletion of CD4+ T lymphocytes is a characteristic feature of a progressive HIV-1 infection. During HIV-1 infection the number of infected CD4+ T lymphocytes is fewer than the number of CD4+ T lymphocytes that are depleted, therefore suggesting a role for HIV-mediated apoptosis of uninfected bystander CD4+ T lymphocytes. Apoptosis, also known as programmed cell death, is a highly regulated, normal physiological process that results in the disposal of unwanted or corrupted cells such as virally infected cells. Several HIV-1 proteins are involved in HIV-1-mediated apoptosis, of which the envelope (Env) glycoprotein gp120 subunit is the most effective. However, the true mechanism of gp120-mediated apoptosis of uninfected CD4+ T lymphocytes is not fully understood and remains controversial. Furthermore, research focusing on HIV-1 subtype C Env-mediated apoptosis is limited. This study compared the ability of CCR5-utilizing soluble monomeric HIV-1 subtype C gp120 (gp120ZM651), monomeric HIV-1 subtype B gp120 (gp120BaL) and trimeric/oligomeric HIV-1 subtype C gp140 (gp140AncC) to induce apoptosis of uninfected Jurkat T lymphocytes and activated CD4+ T lymphocytes via CD4 and CD4/CCR5 signalling, respectively. All three Env glycoproteins were expressed in HEK 293T cells, purified by lectin affinity chromatography and characterized by assessing their binding capabilities to monoclonal antibodies IgGb12, 17b (in the presence and absence of soluble CD4) and 2G12. Purified recombinant gp120BaL, gp120ZM651 and gp140AncC were found to v be functional and conformationally intact and subsequently added in different concentrations to uninfected Jurkat T lymphocytes and activated CD4+ T lymphocytes. Apoptosis was detected by flow cytometry using Annexin V/7-AAD staining for up to 48 hours post treatment, and further confirmed by TUNEL analysis at 65 hours post treatment. Recombinant gp120BaL, gp120ZM651 and gp140AncC induced low levels of apoptosis in the Jurkat T lymphocytes (6.1%, 5.0% and 6.8%, respectively) and higher levels of apoptosis in the activated CD4+ T lymphocytes (13.3%, 15.6% and 11.5%, respectively) via TUNEL analysis of chromosomal DNA fragmentation. Moreover, comparable levels of apoptosis were observed between the monomeric gp120 and trimeric/oligomeric gp140 forms in both cell types. Interestingly, the subtype C gp140AncC induced higher levels of apoptosis than subtype C gp120ZM651 and subtype B gp120BaL in activated CD4+ T lymphocytes during the Annexin V/7-AAD analysis while the subtype C gp120ZM651 induced higher levels of apoptosis than subtype C gp140AncC and subtype B gp120BaL in activated CD4+ T lymphocytes during the TUNEL analysis. Overall, these results suggest that soluble gp120 is able to mediate low levels of apoptosis via CD4 signalling only in Jurkat T lymphocytes, and these levels are enhanced in activated CD4+ T lymphocytes, possibly due to engagement of gp120 with CD4 and the CCR5 co-receptor on the surface of the target cell.

Background: A novel, isothermal nucleic acid amplification method, RT-LAMP, presents potential for nucleic acid amplification-based diagnostics in resource-limited settings. Low-cost HIV-1 viral load monitoring will improve access to ART for HIV-1-infected individuals present in settings where on-site viral load testing is unavailable. Aim: The aim of this dissertation was to develop an RT-LAMP HIV-1 viral load assay by combining the RT-LAMP reaction with colorimetric amplification detection by hydroxy-naphthol blue dye. Methods: Different approaches for HIV RNA extraction from patient plasma and culture supernatant were studied to obtain template for RT-LAMP. Reaction products for 4 different RT-LAMP primer sets were analysed using agarose gel electrophoresis and restriction digestion. Results: The first 3 primers sets produced persistent off-target amplification. The fourth primer set, designed against culture supernatant DU179, produced a target-specific colour change from violet to blue after 1 hour, following optimisation of amounts of Mg2SO4 and AMV RT. Further studies showed HNB detection sensitivity to template copy number. Conclusions: Initial reaction conditions pertaining to an RT-LAMP based, colorimetric HIV-1 viral load assay were established. Further work is required to determine the reaction duration at which the colour change represents a viral load of ≥1000 copies HIV RNA per ml plasma.