Magister Public Health - MPH / Aim: This study aimed to evaluate the effectiveness of the Mobile HIV/AIDS Treatment Teams in initiating and treating patients with HAART at fixed primary health care clinics Amajuba District.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The objective was to understand the significance for the family caregiver before of the child care that has HIV / AIDS in antiretroviral therapy (ART). It was phenomenological qualitative research based on theoretical-philosophical - methodological Martin Heidegger. The subject were family caregivers of children that realize monitored in the pediatric clinic at the Hospital Universitário de Santa Maria (HUSM / RS / BRAZIL). The data production occurred in the period of January to July 2013 through phenomenology interviews with 10 family caregivers. It was developed Heidegger's analysis and in the vague understanding and median the family of child with HIV / AIDS in ART unveiled that the experience of care means that once started therapy the child have a normal life, doing all that other children do. It follows a routine, it have time to give the medication and other care. In the begin it was difficult until we hit the medication and it had difficulties with the intake. It was difficult to live with the disease not knowing where to turn, it needed of the help of family members and professionals. With time it observes, learns and starts calm because the child takes the medicine. It has afraid of prejudice, why hide the diagnosis of both the child and of other family. It has to pay more attention to the child than himself. In interpretive analysis the family reveals being caregiver, it shows that the child is and does everything who the others revealing the way of being to be in the impersonality. It establishes a routine to keep the treatment and health of the child remaining committed to the world of occupations. It is shown in the mode of curiosity when he observes the daily care of the child and he learns and it proves to be quiet when the child accepts and asks the drug. So the child has a normal life that keeps her in the public interpretation of the impersonal. Given the fact of to live with the disease, the experience of being - family - caregiver unfolds in the mode of factuality because it is before a fact launched and show-be-with when counts with the help of other family members. This experience is shown in the layout mode of fear, permeating through fear, horror and terror when think in the diagnostic revelation in the consequences that can result in the child's daily life and prejudice, concealing the child's diagnosis, remaining in the stillness. The be - family - caregiver engage with the child care and it leave to care for themselves, losing himself in the mode of being of inauthenticity. The inauthenticity present in the everyday care bears the be - family - caregiver to do as others think that has to be done, It does not revealing in its uniqueness. It was highlight the need of health professionals to develop dialogue aimed not only to medication and treatment, but also that facilitate the understanding of situation through educational groups, consultations and workshops. It is suggested to stimulate the involvement of others people next to the child that can realize and divide this care with the family caregiver. / O objetivo foi compreender a significação para o familiar cuidador diante do cuidado à criança que tem HIV/aids em terapia antirretroviral (TARV). Investigação qualitativa fenomenológica fundamentada no referencial teórico-filosófico-metodológico de Martin Heidegger. Sujeitos da pesquisa foram familiares cuidadores de crianças que realizam acompanhamento no ambulatório de pediatria no Hospital Universitário de Santa Maria (HUSM/RS/BRASIL). A produção dos dados ocorreu no período de janeiro a julho de 2013, por meio de entrevista fenomenológica com 10 familiares cuidadores. Desenvolveu-se análise heideggeriana, sendo que, na compreensão vaga e mediana o familiar da criança que tem HIV/aids em TARV, desvelou que a vivência do cuidado significa que depois que iniciou a medicação a criança leva uma vida normal, faz tudo o que as outras crianças fazem. Obedece a uma rotina, tem hora certa para dar a medicação e para os demais cuidados. No começo foi difícil enquanto não acertaram a medicação e tinham dificuldades com a ingesta. Foi difícil conviver com a doença, não saber a quem recorrer, precisou da ajuda dos familiares e dos profissionais. Com o tempo observa, descobre, aprende e fica tranquilo, pois a criança aceita o remédio. Tem medo do preconceito, por isso oculta o diagnóstico tanto da criança quanto da família e dos outros. Tem que dar mais atenção à criança do que a si mesmo. Na análise interpretativa o familiar se revela sendo cuidador mostra que a criança é e faz tudo como todas as outras, desvelando-se no modo de ser da impessoalidade. Estabelece uma rotina para manter o tratamento e a saúde da criança mantendo-se empenhado no mundo das ocupações. Se mostra no modo da curiosidade quando observa o cotidiano do cuidado à criança e assim aprende e com isso, revela-se tranquilo quando a criança aceita e solicita o medicamento. Isso faz com que a criança tenha uma vida normal o que a mantém na interpretação pública do impessoal. Diante do fato de ter que conviver com a doença, a vivência de ser-familiar-cuidador se desvela no modo da facticidade, pois está diante de um fato lançado e se mostra ser-com quando conta com o auxílio dos demais familiares. Nessa vivência se mostra no modo de disposição do medo, perpassando pelo pavor, horror e terror quando pensa na revelação do diagnóstico, nas consequências que isso possa acarretar no cotidiano da criança e no preconceito, assim, acaba ocultando o diagnóstico da criança, permanecendo na silenciosidade. O ser-familiar-cuidador ao se ocupar com os cuidados com a criança deixa de cuidar de si, perdendo-se no modo de ser da inautenticidade. A inautenticidade presente na cotidianidade do cuidado carrega o ser-familiar-cuidador para fazer como os outros acham que tenha que ser feito, não se revelando na sua singularidade. Salienta-se a necessidade dos profissionais de saúde em desenvolver diálogo voltado não apenas à medicação e tratamento, mas também que facilitem a compreensão da situação por meio de grupos educativos, consultas e oficinas. Sugere-se estimular o envolvimento de outras pessoas próximas à criança que possam realizar e dividir esse cuidado com o familiar cuidador.

Depuis la description des premiers cas de SIDA pédiatriques en 1983, d’importants progrès ont été réalisés dans la compréhension des mécanismes de transmission, puis dans la prévention de celle-ci, et dans la connaissance de l’histoire naturelle de l’infection par le VIH chez l’enfant. Depuis 1996 les multithérapies ARV ont permis une diminution considérable de la transmission verticale et de la morbidité et mortalité des enfants infectés par le VIH.<p>Les buts de ce travail ont été :<p>• d’évaluer, dans le contexte de l’offre de soin mise en place dans un centre de référence,<p>l’impact de l’administration prophylactique des traitements ARV pendant la grossesse sur la transmission verticale du virus.<p>• de déterminer si l’instauration précoce d’un traitement ARV chez les enfants infectés à la naissance et encore asymptomatiques améliorait le devenir de l’enfant.<p>• de contribuer à l’évaluation de l’impact de l’exposition à la maladie maternelle et aux traitements ARV sur le devenir des enfants non infectés nés de mères infectées par le VIH.<p><p>Une étude rétrospective portant sur les enfants nés de mères infectées par le VIH et suivis à l’hôpital St-Pierre entre 1986 et 2002, nous a permis de comparer 3 cohortes de naissance correspondant à différents types de prise en charge. Nous avons pu montrer que le taux de transmission a diminué globalement de 10% durant la période précédant l’administration de prophylaxie ARV à 5% durant la troisième période où les multithérapies étaient recommandées en prophylaxie durant la grossesse. Nous avons montré<p>que chez les mères qui ne bénéficiaient pas de prophylaxie ARV le taux de transmission avait augmenté significativement entre 1986 et 2002; le plus souvent suite à une prise en charge trop tardive de la grossesse, à un dépistage tardif de la séropositivité maternelle, ou à une mauvaise compliance au traitement.<p>Chez le nouveau-né infecté par le VIH, la multiplication virale est beaucoup plus importante<p>et prolongée que lors de la primo-infection chez l’adulte. Parallèlement, l’évolution clinique de l’infection peut être rapide dans un quart des cas, et aboutir au SIDA ou au décès avant l’âge de 1 an, sans qu’il existe de bons facteurs prédictifs de cette évolution défavorable en début de vie. Jusqu’en 2007, les différentes recommandations internationales indiquaient de débuter un traitement chez les nourrissons infectés lors d’apparition de symptômes cliniques ou d’immunodépression. Cependant dès 1996, certains centres dans des pays industrialisés, dont l’équipe de pédiatrie du CHU St Pierre, ont décidé d’initier un traitement ARV chez tous les nourrissons infectés dès confirmation du diagnostic. En 2006, nous avons initié une étude rétrospective multicentrique incluant 13 cohortes européennes visant à étudier l’impact du traitement précoce sur l’évolution clinique et biologique de l’enfant. Les données de 210 enfants,nés entre 1996 et 2004 et infectés à la naissance ont été analysées, et ont permis de dé4<p>montrer que les enfants traités avant l’âge de 3 mois avaient un risque de développer un sida ou de décéder 5 fois inférieur aux enfants traités après cet âge. Des résultats similaires ont été observés dans une étude randomisée réalisée en Afrique du Sud et publiée simultanément. Depuis, les recommandations internationales ont été revues<p>et préconisent la mise sous traitement de tous les nourrissons infectés. L’analyse des données biologiques a permis de montrer que la réponse virologique immédiate était plus rapide avec un pic de charge virale moins élevé et que la chute des lymphocytes CD4 était moins prononcée lorsque le traitement était débuté précocement.<p>Avec la généralisation de la prophylaxie ARV pendant la grossesse, le nombre d’enfants exposés in utero au VIH mais indemnes de l’infection a considérablement augmenté.<p>Des études, menées principalement dans des pays en développement, ont révélé un risque accru de morbidité et de mortalité infectieuse ainsi que la survenue d’infections sévères inhabituelles chez ces enfants. Nous avons été frappés durant le suivi de ces enfants par la survenue d’un nombre élevé d’infections néonatales causées par le streptocoque du groupe B (GBS). La comparaison avec le taux d’infection observé dans une population contrôle (estimé sur base des naissances survenues pendant la même période dans le même hôpital) nous a permis de décrire une incidence 19 fois supérieure d’infection à GBS chez les enfants exposés au VIH et non infectés que chez les enfants contrôles. Il s’agit du premier travail publié évoquant une susceptibilité accrue aux infections des enfants exposés non infectés dans un pays industrialisé.<p>En conclusion, la prophylaxie ARV pendant la grossesse et en début de vie a permis de diminuer considérablement la transmission verticale de l’infection à VIH. Un dépistage manqué, une prise en charge tardive de la grossesse, ou la mauvaise adhérence au traitement sont encore responsables d’infection du nouveau-né. Lors de confirmation<p>d’infection du nourrisson par le VIH, il est très important de débuter un traitement le plus rapidement possible afin de contrôler rapidement la multiplication virale, de maintenir une bonne immunité et de prévenir le développement de la maladie. Enfin, en l’absence d’infection du nourrisson par le VIH, il est important de poursuivre le suivi pendant les premières années de vie puisqu’il semble que les enfants exposés au<p>VIH et non infectés soient plus susceptible aux infections sévères. Ceci a été démontré en ce qui concerne les infections néonatales à GBS. / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Background: IPT is an effective, safe and feasible disease prevention scheme that should be administered for all PLHIV living in areas with high latent TB prevalence. Objective: To assess the impact of isoniazid in the incidence of tuberculosis among HIV infected individuals in Addis Ababa. Methods: A case control study design was undertaken among 489 HIV and TB infected patients in Addis Ababa from January 2008 to December 2010. Results: Tuberculosis incidence rate among those who developed TB after completing 6-9 month isoniazid preventative therapy was17.14 PYO compared to 10.28 PYO among those who were not. Isonizide reduced the chance of developing tuberculosis among HIV infected patients (OR= 0.072; 95% CI 0.044, 0.12). Age (AOR= 0.14; 95% CI 0.03, 0.97) and sex (AOR= 1.86; 95% CI 1.02, 2.23) of the patient, CD4 count at HIV diagnosis (AOR= 0.21; 95% CI 0.13, 0.31), clinical stage of HIV illness (AOR= 1.22; 95% CI 1.09, 1.84) and past tuberculosis history (AOR = 1.97; 95% CI 1.24, 3.67) were major factors associated with tuberculosis incidence. Conclusions: INH prophylaxis was associated with lower incidence of tuberculosis among PLHIV. / Health Studies / M. Public Health

Objetivo: Evaluar si existe asociación entre el abandono con la falla terapéutica en inmigrantes venezolanos con infección por el virus de inmunodeficiencia humana (VIH) que reinicien tratamiento antirretroviral de gran actividad (TARGA). Métodos: Llevamos a cabo una cohorte retrospectiva en el Hospital Nacional Arzobispo Loayza. Incluimos pacientes que reiniciaron tratamiento TARGA. La variable de resultado fue la falla terapéutica (FT), compuesta por falla inmunológica (FI), virológica (FV) y clínica (FC). La variable de exposición fue el abandono terapéutico, aquellos que no recibieron tratamiento por 30 días, de 30 días a seis meses y de seis meses a más. Las variables control fueron el sexo, la orientación sexual, el nivel de instrucción, la edad y comorbilidades. Utilizamos modelos lineales generalizados de Poisson con errores estándar robustos para calcular riesgo relativo a nivel crudo (RR) y ajustado por criterio estadístico (RRa1) y epidemiológico (RRa2). Resultados: Incluimos 294 pacientes, 47,7% de ellos abandonaron TARGA, 32,7% abandono menos de seis meses, 15% abandonó mas de seis meses y el 27,9% tenían FT. Comparado con aquellos que no abandonaron, un abandono menor a 6 meses [RRa1: 1,98 (IC95%: 1,27 a 3,09);] y de seis meses a más [RRa1: 3,17 (IC95%: 2,02 a 4,95);] incrementó el riesgo de FT. El abandono de hasta seis meses [RRa1: 2,32 (IC95%: 1,40 a 3,84)] y de seis meses a más [RRa1: 3,93 (IC95%: 2,39 a 6,45)]; aumentó el riesgo de FV. En el caso de la FC [RRa1: 1,96 (IC95%: 0,67 a 5,79)] y la FI [RRa1: 2,99 (IC95%: 0,87 a 10,30)] no encontramos evidencia estadística de asociación con el abandono terapéutico. Conclusiones: El abandono del TARGA incrementa el riesgo de FT y FV en pacientes inmigrantes venezolanos. Dentro de la valoración integral que los pacientes con VIH debe explorarse el abandono como una variable de alta a importancia. / Objective: To evaluate the association between antiretroviral treatment interruption with the treatment failure in adults with human immunodeficiency virus (HIV) infection that reinitiates (HAART). Methods: We carried out a retrospective cohort study at the Hospital Nacional Arzobispo Loayza. We included immigrant patients who reinitiate HAART. The outcome was treatment failure (TF) may be immunological (IF), virological (VF), and clinical (CF) failure. The exposure variable was antiretroviral treatment interruption. The control variables measured were sex, sexual orientation, educational level, age, and comorbidities. We performed linear Poisson models with robust standard errors to calculate relative risk at the crude level (RR) and adjusted by statistical and epidemiological criteria. Results: We included 294 in the analysis. 47.7% of them defaulted treatment, 32.7% abandoned less than six months, 15% abandoned more than six months and 27.9% did TF; 24.6% VF; 6.8% IF, and 6.4% CF. A treatment interruption less than 6 months [aRR: 1.98 (95% CI: 1.27 to 3.09);] and from six months to more [aRR: 3.17 (95% CI: 2.02 to 4.95)] increased the risk of TF. Likewise, treatment interruption of up to six months [aRR: 2.85 2.32 (95% CI: 1.40 to 3.84)] and from six months to more [aRR: 3.93 (95% CI: 2.39 to 6,45)]; increased the risk of VF concerning patients who did not abandon treatment. In the CF [aRR: 1,96 (IC95%: 0,67 a 5,79)] and IF [aRR: 2,99 (IC95%: 0,87 a 10,30)] case, we did not find statistical evidence of an association with the abandonment time. Conclusions: The HAART treatment interruption is associated with the development of therapeutic and virologic failure. Treatment interruption should be explored as a variable of high importance in the assessment of patients with HIV. / Tesis

MPH / Department of Public Health / Background: South Africa presently has a very high HIV burden. It has adopted the UNAIDS “90-90-90 targets” to curb its HIV burden. This target aims to attain sustained viral suppression in 90% of all persons receiving antiretroviral therapy. This is supported by several studies. Studies to observe if patients are achieving and sustaining viral suppression in Limpopo, South Africa, are few. Objective: To investigate the viral and immunologic responses of patients in Vhembe District to highly active antiretroviral therapy (HAART) between the 1st of January 2004 and 31st of July 2016. Methodology: This was a retrospective medical record review conducted in Vhembe District in rural Limpopo. It included the medical records of 1247 individuals from Thohoyandou Community Health Centre. Analysis was done using SPSS 24.0. To model the factors associated with virologic and immunologic responses, each independent variable was tested for association with the dependent variable (viral suppression and CD4 count increase of ≥ 50 cells/μL from baseline to 6 months). The independent variables included age, year of initiation, gender, marital status, baseline BMI, haemoglobin, clinical stage and estimated creatinine clearance. The Pearson Chi square (X2) was used for all categorical independent variables and the t-test, for all continuous independent variables, to test for association. The estimate used was a 95% confidence interval, and a p-value of < 0.05 was considered significant. Results: The study showed that 52.6% of individuals were in clinical stage I at baseline. Viral suppression (viral load < 50 copies/ml) at 6 months was 64% (n = 648), 72% (n =193) at 60 months and 94% (n = 16) at 132 months. Fifty-nine percent had consistent viral suppression for a period of at least 6 months. Consistent viral suppression (viral load < 50 copies/ml on at least one consecutive occasion without any intervening viral load > 50 copies/ml) for at least 54 months was only 14%, while 2.3% had a delay in switching from a failing regimen. The mean CD4 count at baseline was 227 cells/μL, and 538 cells/μL at 60 months. The mean CD4 cell count increase from baseline to 6 months was 190 cells/μL. The immuno-virologic discordance was 27%. Patients with higher baseline CD4 count and females were significantly (p = 0.001 and 0.031 respectively) more likely to achieve viral suppression at 6 months. Those below 45 years and females were v significantly (p = 0.011 and 0.043 respectively) more likely to achieve adequate CD4 count increase at 6 months. Conclusions: The proportion of individuals with viral suppression in the District increased from 6 months onwards, and is fairly adequate. However, sustainability of viral suppression, once attained, is low. Adequate immunologic response, however, seems high. Males and age group above 45 years appear to have poorer responses to HAART.

Alemtuzumab exerts its clinical efficacy by its specific pattern of depletion and repopulation of different immune cell subsets. Recently, single cases of multiple sclerosis patients who developed severe exacerbation after the first alemtuzumab application, accompanied by re-appearance of peripheral B cells, were reported. Here we present a case with underlying B cell-driven multiple sclerosis that impressively improves after alemtuzumab, although peripheral B cell repopulation took place. Our detailed clinical, histopathological, imaging and immunological data suggest that alemtuzumab can act as an effective rescue treatment in highly active B cell-driven and antibody/complement-mediated multiple sclerosis type II patients.

Purpose: The purpose of this study is to assess risk factors associated with TB co-infection in HIV/AIDS patients taking antiretroviral therapy (ART). Methodology: An observational, analytic, case-control and quantitative study was conducted on a randomly selected 367 HIV and AIDS patients of whom 92 of them were TB co-infected. Data collection was done by using self-structured questionnaire. Result: In this study, educational status, waste disposal system, monthly income, contact history with a patient of active tuberculosis or presence of a family member with active tuberculosis, drug adherence, knowledge on tuberculosis prevention and history of exposure to substance were factors independently associated with the occurrence of active tuberculosis among HIV and Aids patients taking ART. Conclusion: The findings highlight the need for on-going educational, informational and other interventions to address the risk factors of tuberculosis in HIV and Aids patients in order to decrease the rate of TB co-infection / Health Studies / M.A. Public Health

Poor decision making among clinicians to transferring human immune deficiency virus (HIV) patients into second-line antiretroviral therapy (ART) has led to an increase in morbidity and mortality to people living with HIV (PLHIV). No clear barriers are known for clinicians not switching their patients. This is a descriptive qualitative research aimed to discover obstacles that influence clinicians' decision making to transferring patients into second-line ART despite higher level resistance to first-line ART. The researcher applied a participatory action research framework to solve the identified barriers with clinicians. Using the research questions the researcher explored reasons, perceived barriers and enabling factors for clinicians delay in making decision to transferring HIV patients into second-line ART. In-depth semistructured interviews were conducted with 30 participants. Six thematic areas (a) clinicians' capacity to diagnose treatment failure, (b) laboratory investigations, (c) availability, access, and tolerability to second-line ART, (d) clinicians' perceptions on ARV medicines, (e) clients' readiness for ARV medicines, and (f) adherence and retention to ARV medicines were analysed using STATA. Readiness, adherence and retention to ART, knowledge, competence and experience on ART , lack of viral load testing, and shortage of second-line ART were the common major barriers for clinicians in determining transferring patients into second-line ART. The government of Tanzania should acknowledge and create participation, responsibility, and commitment strategies to reduce the observed barriers. Findings of this study generates knowledge and provide actionable plans to help clinicians easily identify HIV patients who are in need of second-line ART.

This study attempted to identify personal (patient-related) factors influencing anti-retroviral therapy (ART) adherence in Addis Ababa, Ethiopia. A quantitative, descriptive, cross-sectional and analytical design was used. Structured interviews were conducted with 355 ART patients. The findings revealed that stigma, discrimination, depression and alcohol use negatively affected patients’ ART adherence levels. However, patients’ knowledge levels had no influence on their ART adherence levels, contrary to other researchers’ reports. Addressing stigma and discrimination at community levels might enhance patients’ abilities to take their medications in the presence of others. Healthcare professionals should be enabled to diagnose and treat depression among ART patients during the early stages. Non-adherent ART patients should be counseled about possible alcohol abuse. / Health Studies / M.A. (Public Health with specialisation in Medical Informatics)