Purpose of the study - Identify predictors of mortality and develop a related care plan for patients who are on antiretroviral therapy (ART) in Gondar, Ethiopia. Design - A quantitative, retrospective cohort study was conducted analysing medical records of HIV patients who presented to Gondar University Hospital (GUH), Gondar, and started ART between 1 January 2007 and 30 June 2010. Results - In defining the predictors of mortality, the findings in bivariate analysis revealed: female sex, CD4 cell count ≤ 50/μl, CD4 cell count 51-199/μl, a haemoglobin concentration ≤8g/dl, a history of oral candidiasis, tuberculosis and Cryptococcus meningitis were all statistically significant. A female sex, CD4 cell count ≤ 50/μl and CD4 cell count 51-199/μl maintain their significance level in the multivariate analysis. Conclusions - The study therefore recommends that clinicians and case managers be vigilant of these predictors of mortality while managing HIV patients who are on ART / Health Studies / M.A. (Public Health)

NTRODUÇÃO: Embora haja cada vez mais provas de que a co-infecção pelo HCV piora a evolução da hepatotoxicidade relacionada ao HIV, as influências dos diferentes fatores associados a este permanecem mal compreendidas. Este estudo está destinado a avaliar os dados epidemiológicos, laboratoriais e HAART e sua associação com a evolução da taxa de progressão da fibrose (FPR), em doentes co-infectados acompanhados em centros de referência para o tratamento de HIV/VHC na cidade de São Paulo, Brasil. MÉTODOS: 938 prontuários de patientes coinfectados foram revisados para este estudo e 102 preencheram os critérios de inclusão. Um estudo transversal, avaliando os aspectos sócioepidemiológicos, laboratoriais e biópsia hepática foi realizado e correlacionado o grau de fibrose hepática e a FPR encontrada. RESULTADOS: A população foi caracterizada por indivíduos homens (83,3%), de meia-idade (42,9 anos), brancos (53,9%), com o principal fator de risco de aquisição de ambas as infecções foi através da utilização de drogas ilícitas (72,5%), principalmente intravenosa e presença de consumo de álcool (75,5%), com predominância do genótipo 1 de HCV (56,9%) e tempo médio de uso de antirretrovirals de 7,9 anos (DP = 3,6 a). A avaliação histológica não mostrou qualquer relação entre maior grau de fibrose na biópsia hepática relacionados com a exposição da antirretrovirals ou mesmo na FPR. Abuso de drogas ilícitas, incluindo cocaína inalada e intravenosa relacionam-se com taxas mais elevadas fibrose hepática e FPR. CONCLUSÃO: Os resultados enfatizam a necessidade de incentivar a retirada do consumo de drogas ilícitas da população de pacientes coinfectados HIV/VHC em uso de qualquer regime antirretroviral. O nosso estudo não encontrou nenhuma relação entre a utilização de regimes baseados em IP ou NNRTI e um pior prognóstico da fibrose hepática ou FPR na população avaliada. / BACKGROUND: Although there\'s growing evidence that the co-infection with HCV worsens the evolution of the HIV-related hepatotoxicity, the influence of the different factors associated to this remains poorly understood.This study intended to evaluate the epidemiological, laboratorial and HAART associated to the evolution of the fibrose progression rate (FPR) in co-infected patients followed in reference centers for the treatment of HIV/HCV in the city of São Paulo, Brazil. METHODS: 938 medical charts of co-infected patientes were reviewed for this study.and 102 fullfilled the inclusion and exclusion criteria to participate. A cross-sectional study evaluating socio-epidemiological aspects, laboratorial assesment and liver biopsy was performed and correlated with the fibrosis rate and the fibrosis progression rate (FPR). RESULTS: The population was characterized by male (83,3%), middle-age (42,9 years), white (53,9%) individuals, with a main risk factor of adquisition of both the infections trough illicit drugs-use (72,5%), mainly intravenous and alcohol consumption (75,5%), with predominance of HCV genotype 1 (56,9%) with a medium time of use of antiretrovirals of 7,9 years (SD=3,6 y). Histologic evaluation showed no relation between higher fibrosis degree in the liver biopsy related to the exposure of the antiretrovirals or even in the fibrosis progression rate (FPR). Illicit drugs abuse, including inaled and intravenous cocaine , were related to higher liver fibrosis rates and FPR. CONCLUSION: Our results emphasize the necessity of encourage the withdraw of ilicit drugs consumption in the HIV/HCV co-infected population in use of any antiretroviral regimen. Our study does no find any relation between the use of IP or NNRTI-based regimens and the poor prognosis of the liver fibrosis in this population.

Orientadores: Marcos Tadeu Nolasco da Silva, Rubens Nelson Amaral de Assis Reimão / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T23:19:37Z (GMT). No. of bitstreams: 1 Gazini_CarinaCaires_M.pdf: 1252210 bytes, checksum: 00b55ba57c9260460ffa328a2940bdb8 (MD5) Previous issue date: 2011 / Resumo: INTRODUÇÃO: O sono é fator indispensável para a saúde integral. Sua má qualidade, em adolescentes, pode resultar em alterações cognitivas, psicológicas e clínicas. Crianças e adolescentes infectados pelo Vírus da Imunodeficiência Humana (HIV) são vulneráveis a apresentar distúrbios do sono, como consequência de alterações imunológicas e emocionais. Com base neste contexto, este estudo teve o objetivo de avaliar as características do sono de adolescentes infectados pelo HIV e verificar a associação entre aspectos psicossociais, clínicos, imunológicos e virológicos e alterações no padrão e na qualidade do sono. CASUÍSTICA E MÉTODOS: Estudo observacional, analítico, prospectivo, do tipo corte transversal. Foram avaliados 222 adolescentes de ambos os gêneros, com idade a partir de 10 anos, sendo 102 infectados pelo HIV (59 rapazes) e 120 estudantes (73 garotas) presumidamente saudáveis. Para a coleta de dados aplicaram-se: Escala de distúrbios do sono em crianças (SDSC), Escala de Sonolência de Epworth (ESE) e Questionário genérico sobre Qualidade de Vida Pediátrica (PedsQLTM4.0). Dados clínicos, imunológicos e virológicos foram retirados dos prontuários médicos. Na análise estatística, utilizaram-se os testes de Mann-Whitney, Qui-Quadrado e o Coeficiente de Correlação de Spearman. Resultados foram considerados estatisticamente significativos se P ? 0,05. O estudo foi aprovado pelo Comitê de Ética em Pesquisa em Seres Humanos da Faculdade de Ciências Médicas da Universidade Estadual de Campinas. RESULTADOS: Verificou-se prevalência de distúrbios do sono, com base nos escores SDSC, de 77,4% nos pacientes e 75% nos controles (P = 0,67). Pacientes infectados pelo HIV apresentaram maior pontuação do escore SDSC nos distúrbios respiratórios do sono com medianas de 3 (3 - 15) vs 3 (3-11) (P = 0,05), e maior pontuação de sonolência diurna excessiva pela ESE, com medianas de 6 (0 - 17) vs 5 (0 - 14) (P = 0,02). Houve correlação entre os escores SDSC e PedsQL em ambos os grupos, com rs = -0,46 no grupo infectado (P < 0,001) e rs = -0,37 no grupo controle (P < 0,001). Não se observaram associações estatisticamente significativas entre os indicadores de qualidade do sono e variáveis clínicas, imunológicas ou virológicas, no grupo infectado. CONCLUSÃO: Os adolescentes infectados pelo HIV apresentaram qualidade do sono semelhante à população saudável, porém com alta prevalência de distúrbios do sono, ocorrendo associação entre qualidade de sono e qualidade de vida em ambos os grupos. Não foram identificados fatores clínicos, imunológicos ou virológicos associados à qualidade do sono, no grupo infectado. Tais resultados decorrem provavelmente da gradual melhora de condições de vida dos adolescentes infectados, resultante do sucesso da terapia antirretroviral, bem como das vulnerabilidades que potencialmente afetam a qualidade do sono em adolescentes brasileiros / Abstract: INTRODUCTION: Sleep is an indispensable feature of integral health. It's bad quality, in adolescents, may result in cognitive, psychological and clinical disturbances. Children and adolescents infected with Human Immunodeficiency Virus (HIV) are vulnerable to present sleep disturbances, due to immunological and emotional abnormalities. Within the above setting, this study aimed to evaluate sleep characteristics of HIV-infected adolescents and to verify the association between psychosocial, clinical, immunological and virological issues and abnormalities in pattern and quality of sleep. PATIENTS AND METHODS: Observational, analytical, prospective, cross-sectional study. Two hundred and twenty-two adolescents from both genders were evaluated, aged 10 or more years-old. One hundred and two (59 boys) were HIV-infected, and 120 (73 girls) were presumedly healthy students. The following tools were used for data collection: Sleep Disturbance Scale for Children (SDSC), Epworth Daytime Sleepiness Scale (EDSS) and Generic Pediatric Quality of Life Questionnaire (PedsQLTM4.0). Clinical, immunological and virological data were retrieved from medical records. For statistical analysis, the Mann-Whitney and Qui-Square tests, and Spearman Correlation Coefficient were used. Results were considered statistically significant if P ? 0.05. The study was approved by the Committee of Ethics in Research in Human Beings from the Faculty of Medical Sciences, State University of Campinas. RESULTS: The prevalence of sleep disturbances, based on SDSC scores, was 77.4% in patients and 75% in controls (P = 0.67). HIV-infected patients showed higher SDSC scores in the respiratory sleep disturbances domain, with medians of 3 (3 - 15) vs 3 (3-11) (P = 0.05), and higher scores in EDSS, with medians of 6 (0 - 17) vs 5 (0 - 14) (P = 0.02). A correlation was observed between SDSC and PedsQL scores in both groups, with rs = -0,46 in the infected group (P < 0.001) and rs = -0.37 in the control group (P < 0.001). No statistically significant associations were observed between quality of sleep markers and clinical, immunological or virological variables, in the infected group. CONCLUSION: HIV-infected adolescents showed similar quality of sleep when compared to the healthy control population, yet with high prevalence of sleep disturbances in both groups. An association between quality of sleep and quality of life was observed in both groups. No clinical, immunological or virological issues were identified in the HIV-infected group in association to sleep quality. Such results are probably due to the gradative improvement of conditions of life in HIV-infected adolescents, as a result of successful antiretroviral therapy, and also to the vulnerabilities which potentially affect the quality of sleep in Brazilian adolescents / Mestrado / Saude da Criança e do Adolescente / Mestre em Saude da Criança e do Adolescente

Orientador: Marcos Tadeu Nolasco da Silva / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-18T22:53:13Z (GMT). No. of bitstreams: 1 Ernesto_AlineSantarem_M.pdf: 2616267 bytes, checksum: 8169b5c577c4b73c8dedf740de1f15b9 (MD5) Previous issue date: 2011 / Resumo: Introdução: A Síndrome de Imunodeficiência Adquirida (Aids) é atualmente uma doença crônica, controlável graças à Terapia Antirretroviral de Alta Atividade (TARV). Em um contexto de acesso universal ao tratamento, a adesão do paciente torna-se um fator limitante e desafiador. Este estudo teve como objetivo avaliar a prevalência da nãoadesão à TARV em uma coorte de crianças e adolescentes com o uso de instrumentos complementares, bem como identificar e compreender os fatores associados a ela. Casuística e Métodos: Estudo analítico, observacional, prospectivo do tipo corte transversal. A população foi composta por 108 pacientes infectados pelo Vírus da Imunodeficiência Humana (HIV) em TARV (60 meninos), com idades entre 8 e 19 anos. A adesão foi avaliada por meio de um questionário padronizado, consulta a registros de dispensação de farmácia (RDF) e uma escala de auto-eficácia. Foram entrevistados os responsáveis pela administração da medicação, cuidadores ou pacientes. Indivíduos que receberam menos de 95% das doses prescritas nas 24 horas ou nos 7 dias anteriores à entrevista, ou que apresentaram um intervalo maior que 37 dias no RDF nos três meses anteriores à entrevista, foram considerados não-aderentes. A escala de auto-eficácia forneceu um escore contínuo, com amplitude de 0 a 100. Foi avaliada a associação de variáveis independentes ligadas a condições demográficas, clínicas, imunológicas, virológicas, e psicossociais aos desfechos de adesão. Na análise estatística univariada foi utilizada a determinação de Odds Ratios (OR) para a comparação entre variáveis categóricas, o teste de Mann-Whitney para a comparação entre variáveis contínuas e categorias, e determinado Coeficiente de Correlação de Spearman (rs) para a comparação entre variáveis contínuas. Resultados foram considerados significativos com valor de p _ 0,05. Para o controle de variáveis de confundimento, foi utilizada a análise multivariada com o uso de regressão logística. O estudo foi aprovado pelo Comitê de Ética em Pesquisa em Seres Humanos da Faculdade de Ciências Médicas da Universidade Estadual de Campinas. Resultados: A prevalência de não-adesão variou entre 11,1% (pacientes não aderentes por 3 instrumentos), 15,8% (auto-relato de 24 horas), 27,8% (auto-relato semanal), 45,4% (RDF) e 56,3% (ao menos um dos 3 desfechos). Os auto-relatos de 24 horas e 7 dias, quando comparados ao RDF, mostraram baixa sensibilidade (29% e 43%, respectivamente) e alta especificidade (95% e 85%, respectivamente). As seguintes variáveis independentes apresentaram associação estatisticamente significativa com a não-adesão na análise univariada, de acordo com o instrumento: Auto-relato de 24 horas: dificuldade de administração pelo cuidador (OR = 9,11; IC95% = 2,87 - 28,98); paciente não-praticante de religião (OR = 2,76; IC95% = 0,92 - 8,32); intolerância à medicação (OR=4,61; IC95% =1,47 - 14,42); renda per capita (medianas de US$ 137,91 vs US$ 208,33; p = 0,016); número de ITRNs com mutações de resistência (medianas de 6 vs 1; p = 0,016); Auto-relato de 7 dias: dificuldade de administração pelo cuidador (OR = 2,91; IC95% = 1,05 - 8,12; administração da TARV pelo paciente (OR = 3,59; IC95% = 1,47 - 8,78); cuidador com 8 ou menos anos de escolaridade (OR = 3,25; IC95% = 1,03 - 10,30); paciente com mais de 8 anos de escolaridade (OR = 3,70; IC95% = 1,41 - 0,70); idade do paciente (medianas de 13,94 vs 12,94; p = 0,03); renda per capita (medianas de US$ 131,67 vs US$ 201,39; p = 0,009); Registro de dispensação de farmácia: dificuldade de administração pelo cuidador (OR = 3,19; IC95% = 1,11 - 9,17); administração da TARV pelo paciente (OR = 2,70; IC95% = 1,15 - 6,33); falha de controle virológico (OR = 3,70; IC95% = 1,67 - 8,33); falta a consulta nos últimos 6 meses (OR = 3,27 IC95% = 1,38 - 7,78); paciente nãopraticante de religião (OR = 2,47 IC95% = 1,10 - 5,57); cuidador não-praticante de religião (OR = 3,19; IC95% = 1,36 - 7,50); cuidador com emprego fora do domicílio (OR = 2,27; IC95% = 1,05 - 4,92); renda per capita (medianas de US$ 166,67 vs US$ 222,22; p = 0,014); As seguintes variáveis independentes apresentaram associação estatisticamente significativa com a não-adesão na análise multivariada, de acordo com o instrumento: Auto-relato de 24 horas: intolerância à medicação (OR = 9,11; IC95% = 2,87 - 28,98); Auto-relato de 7 dias: dificuldade de administração pelo cuidador (OR = 2,91; IC95% = 1,05 - 8,12); administração da TARV pelo paciente (OR = 3,59; IC95% = 1,47 - 8,78); classe socioeconômica C+D (3,54; 0,97 - 2,85); Registro de dispensação de farmácia: falha de controle virológico (OR = 3,73; IC95% = 1,68 - 8,31); falta a consulta nos últimos 6 meses (OR = 3,27 (IC95% = 1,38 - 7,78); cuidador não-praticante de religião (OR = 3,19; IC95% = 1,36 - 7,50); O escore de auto-eficácia teve mediana de 95,20 (11,90 - 100) e mostrou associação significativa com dificuldade de administração da medicação pelo cuidador (mediana de 78,5 vs 95,2; p = 0,001), falha de controle virológico (mediana de 90,4 vs 100; p = 0,001), administração da TARV pelo paciente (mediana de 89,8 vs 95,2; p = 0,05), falta à consulta nos últimos seis meses (mediana de 86,3 vs 100, p < 0,001), categoria clínica N, A ou B (mediana de 90,47 vs 100; p = 0,018), paciente não praticante de religião (mediana de 90,4 vs 95,2, p = 0,037), orfandade (mediana de 95,2 vs 90,4 p = 0,05), relação CD4/CD8 (rs = 0,220; p = 0,025), número de classes de antirretrovirais com resistência viral (rs = 0,583; p < 0,001), número de ITRNs com resistência viral (rs = 0,44; p = 0,009), renda per capita (rs = 0,302; p = 0,001), Escore PedsQL domínio emocional (rs = 0,265; p = 0,007). Conclusão: Na população estudada, observou-se alta prevalência de falha de adesão à TARV, com maior sensibilidade de detecção pela análise da retirada de medicamentos na farmácia. Adicionalmente, observou-se associação entre os escores de auto-eficácia e as categorias de adesão. Os instrumentos utilizados mostraram-se complementares na identificação de fatores de risco para a não-adesão. Com o objetivo de eliminar variáveis de confundimento, sete fatores foram identificados como associados a dificuldade de adesão: intolerância à medicação, dificuldade de administração da medicação pelo cuidador, responsabilidade de administração medicação pelo próprio paciente, classe socioeconômica mais baixa, ausência de controle virológico, cuidador não praticante de religião e faltas às consultas / Abstract: Background: The Acquired Immunodeficiency Syndrome (Aids) is currently a chronic disease, manageable by Highly Active Antiretroviral Therapy (HAART). In a setting of universal access to treatment, patient adherence arises as a limiting and challenging issue. This study aimed to evaluate the prevalence of nonadherence to HAART in a cohort of children and adolescents, using complementary instruments, and also identify and understand associated factors. Patients and Methods: Observational, analytical, prospective, cross-sectional study. The study population comprised 108 Human Immunodeficiency Virus (HIV) -infected patients on HAART (60 boys), from 8 to 19 years-old. Adherence was evaluated by a standardized questionnaire, pharmacy refill data (PRD) and a self-efficacy scale. Patients or caregivers were interviewed (whoever was in control of medicine administration). Patients who received less than 95% of prescribed doses in the 24 hours of 7 days before the interview, or who had a record of an interval of more than 37 days between refills, were considered nonadherent. The self-efficacy scale provided a continuous score, varying from 0 to 100. The association between adherence outcomes and independent variables related to demographical, clinical, immunological, virological and psychosocial conditions was estimated. Statistical analysis was performed with the use of Odds Ratios (OR) for comparison between categorical variables, Mann-Whitney test for comparison between continuous variables and categories, and Spearman Correlation Coefficient (rs) for comparison between continuous variables. Results were considered statistically significant if p _ 0.05. Confounding variables were controlled by multivariate analysis with logistic regression. The study was approved by the Human Research Ethics Committee of the State University of Campinas Faculty of Medical Sciences. Results: Nonadherence prevalence varied from 11.1% (nonadherent patients in 3 instruments), 15.8% (24-hour self-report), 27.8% (7-day self-report), 45.4% (PRD) and 56.3% (at least one of the outcomes). Self-reports from 24 hours and 7 days, when compared to PRD, showed low sensitivity (29% and 43%, respectively) and high specificity (95% and 85%, respectively). The following independent variables showed statistically significant association with nonadherence on univariate analysis, according to each instrument: Twenty-four hour self-report: difficulty of ministration by caregiver (OR = 9.11 ; 95%CI = 2.87 - 28.98); lack of religious practice by patient (OR = 2.76; 95%CI = 0.92 - 8.32); medication intolerance (OR=4.61; 95%CI =1.47 - 14.42); per capita income (median US$ 137.91 vs US$ 208.33; p = 0.016); number of nucleoside/nucleotide analogues (NRTIs) with resistant mutations (median 6 vs 1; p = 0.016); Seven-day self-report: difficulty of ministration by caregiver (OR = 2.91; 95%CI = 1.05 - 8.12; HAART ministration by the patient (OR = 3.59; 95%CI = 1.47 - 8.78); caregiver with 8 or less years of school attendance (OR = 3.25; 95%CI = 1.03 - 10.30); patient with 8 or more years of school attendance (OR = 3.70; 95%CI = 1.41 - 0.70); patient age (median 13.94 vs 12.94; p = 0.03); per capita income (median US$ 131.67 vs US$ 201.39; p = 0.009); Pharmacy refill data: difficulty of ministration by caregiver (OR = 3.19; 95%CI = 1.11 - 9.17); HAART ministration by the patient (OR = 2.70; 95%CI = 1.15 - 6.33); lack of virological control (OR = 3.70; 95%CI = 1.67 - 8.33); missed consultations in the former 6 months (OR = 3.27 (95%CI = 1.38 - 7.78); lack of religious practice by patient (OR = 2.47 (95%CI = 1.10 - 5.57); lack of religious practice by caregiver (OR = 3.19; 95%CI = 1.36 - 7.50); caregiver working outside the home (OR = 2.27; 95%CI = 1.05 - 4.92); per capita income (median US$ 166.67 vs US$ 222.22 ; p = 0.014); The following independent variables showed statistically significant association with nonadherence on multivariate analysis, according to each instrument: Twenty-four hour self-report: medication intolerance (OR = 9.11; 95%CI = 2.87 - 28.98); Seven-day self-report: difficulty of ministration by caregiver (OR = 2.91; 95%CI = 1.05 - 8.12); HAART ministration by the patient (OR = 3.59; 95%CI = 1.47 - 8.78); socioeconomical classes C+D (3.54; 0.97 - 2.85); Pharmacy refill data: lack of virological control (OR = 3.73; 95%CI = 1.68 - 8.31); missed consultations in the former 6 months (OR = 3.27 (95%CI = 1.38 - 7.78); lack of religious practice by caregiver (OR = 3.19; 95%CI = 1.36 - 7.50); The self-efficacy score had a median of 95.20 (11.90 - 100) and showed significant association with difficulty of ministration by caregiver (median 78.5 vs 95.2; p = 0.001), lack of virological control (median 90.4 vs 100; p = 0.001), HAART ministration by patient (median 89.8 vs 95.2; p = 0.05), missed consultations in the former 6 months (median 86.3 vs 100, p < 0.001), clinical categories N, A or B ( median 90.47 vs 100; p = 0.018), lack of religious practice by patient (median 90.4 vs 95.2, p = 0.037), being orphan (median 95.2 vs 90.4 p = 0.05), CD4/CD8 ratio (rs = 0.220; p = 0.025), number or antiretroviral classes with resistance (rs = 0.583; p < 0.001), number of NRTIs with resistance (rs = 0.44; p = 0.009), per capita income (rs = 0.302; p = 0.001), PedsQL score, emotional domain (rs = 0.265; p = 0.007). Conclusion A high prevalence of HAART nonadherence was observed in the study population, being pharmacy refill data the most sensitive measurement. Additionally, an association was observed between adherence outcomes and self-efficacy scores. The instruments employed showed complementarity in the recognization of nonadherence risk factors. Aiming to eliminate confounding variables, seven factors were identified as associated to lack of adherence: medication intolerance, difficulty of ministration by the caregiver, ministration of medicines by the patient, lower socioeconomic class, lack of virological control, lack of religious practice by the caregiver and missed consultations / Mestrado / Saude da Criança e do Adolescente / Mestre em Ciências

Magister Public Health - MPH / Antiretroviral regimens have side effects that can threaten adherence by patients resulting in evolution of viral resistance due to suboptimal drug levels. Studies have shown that drug adherence of at least 80% can result in viral load suppression. There is no literature on the association between the level of adherence to antiretroviral therapy and the degree of virological suppression in Namibia. The aim of the present study was to determine the therapeutic and virological outcomes in HIV/AIDS patients at 6 and 12 months after initiation of highly-active antiretroviral therapy (HAART) in an urban population in Namibia. The distribution of viral load results showed a low uptake (35%) of virological monitoring at 6 month time point and even lower (12%) at 12 months. A conservative viral load threshold for virological response is required in the Namibian setting. The current adherence level of &gt;80% encourage increased ARV therapy rollout. Poor virological outcome was associated with self-reported adherence. / South Africa

Magister Public Health - MPH / Antiretroviral therapy (ART) improves the quality of lives of people living with HIV/AIDS by suppressing HIV replication and improving the patient’s immunity. An improved immunity will help prevent patients from contracting opportunistic infections. Adherence to ART is vital to obtain good clinical outcome for patients. Defaulting ART leads to increase in viral load, decreased host immunity, development of HIV drug resistant strains, exposure to opportunistic infections and ultimately death. HIV positive patients who are on ART face many challenges in adhering to their medications, these challenges act as barriers to their adherence to treatment. This study explores the barriers that adult patients in a hospital in Eastern Cape of South Africa face while on treatment. These barriers include individual factors, socio-economic factors, health service factors, medical regimen factors.

South Africa, with an estimated 5.7 million people living with HIV, continues to have one of the largest epidemics in the world. The introduction of HAART resulted in prolonged and improved quality of life of many infected patients. However, adverse effects caused by these drugs have become a major concern as they affect the adherence of patients and in some cases even result in the death of patients. Although much research has been and is still being conducted in the area of understanding, preventing and management of ARV adverse effects, there is still a need for patients to be actively involved in self-monitoring for adverse effects. This will assist health care professionals in early identification of serious or potentially serious ARV effects. This study aimed at evaluating the usefulness of strategies developed and employed in the identification, recording and monitoring of adverse effects. The study was conducted with patients receiving HAART from a private HIV and AIDS clinic in Uitenhage, Eastern Cape, South Africa. The research project was approved by the Nelson Mandela Metropolitan University Research and Ethics Committee and the research site. This was an experimental, randomized controlled study carried out over a period of three months (August to October 2009), with a sample size of 160 patients divided into four study groups of 40 patients each. Two monitoring strategies, namely an ARV adverse effect monitoring tool and a patient self-monitoring diary were developed and used for the identification and recording of adverse effects. The four study groups included a Control group, a Tool group, a Diary group and a Tool-Diary group. Willing patients, after signing an informed consent form, were randomly assigned to one of the four groups by participating health care workers at the study site. Data was retrieved from the patient files by the researcher. Descriptive statistical analysis of the findings of the study was conducted using SPSS®. One hundred and forty nine patients were included in the final data analysis. Of the 80 diaries handed out to patients, only 33 were returned and due to errors only 31 were suitable for analysis. Monitoring tools were completed and analysed for 36 patients. The tool was found to be more effective in identifying adverse effects of a physical nature (such as peripheral neuropathy and lipodystrophy) than the usual methods of monitoring employed by the clinic, whilst the diary, used alone, was found to be less effective. Use of the tool and diary combined resulted in the most significant identification and recording of central nervous system related adverse effects and physical adverse effects. However due to the low return rate of the diaries and the majority of the monitoring tool not being completed in many instances the results of this study may not be generalisable. The study results did however suggest that combining the tool and the diary methods of adverse effect identification, yielded the most favourable results when compared to each method alone. This may be attributed to the fact that the tool is useful in identifying objective symptoms and the diaries subjective symptoms, particularly in instances where the patients forget to report their symptoms to healthcare professional whilst at the clinic. The diaries were also reported to improve adherence for more than 90 percentage (n=31) of the patients. More research would be needed in order to verify the exact significance of the tool and the diary in identifying and recording adverse effects and symptoms of adverse effects.

This research focuses on the psychosocial factors that affect adherence to highly active antiretroviral therapy (HAART) amongst HIV/AIDS patients at Kalafong Hospital. Even though the development of such regimens has helped turn HIV infection in the United States into a relatively manageable, though still serious chronic disease, compliance remains one of the major challenges in managing medication for those patients living with HIV/AIDS. This is particularly relevant given the high adherence rate (95%) required to obtain a successful long-lasting effect. In South Africa non-compliance to HAART is an under-explored phenomenon. Consequently, an understanding of factors influencing compliance is still incomplete. A qualitative study that investigates non-adherence to medication in HIV/AIDS patients was undertaken at Kalafong Hospital. This study aimed to understand patients’ psychosocial difficulties resulting in non-adherence. The study was approached in terms of the health belief model (HBM), which addresses individual characteristics pertaining to change, the transtheoretical change model (TTM) and the motivational interviewing model (MI), which address both individual and social contexts pertaining to change. The findings are designed for use by healthcare professionals as a proactive compliance enhancement tool. Participants were recruited through referrals by the medical staff to the researcher. The criteria included that participants had relapsed due to non-compliance with drug therapy. Participants that were currently experiencing difficulties with adherence were also included in the study. Males and females aged between 20 and 40 were included in the study. Fifteen participants between the ages of 20 and 40 participated in the study (13 females and two males). The data were collected by means of semi-structured interviews and follow-up unstructured questions. The interviews were audio recorded and field notes were taken. Data were analysed qualitatively. Sixteen themes emerged and were further classified into two categories: individual and social context. The themes were then compared and integrated with the literature. The study concludes that psychosocial factors such as support from family, friends and healthcare workers was found to be of utmost importance in encouraging adherence. Medication can only prolong a patient’s life if the psychosocial context in which the patient is embedded is considered in the treatment plan. / Dissertation (MA)--University of Pretoria, 2008. / Psychology / unrestricted

Human immunodeficiency virus (HIV) infection has reached epidemic proportions in South Africa. The availability of highly active anti-retroviral therapy (HAART) prolongs life in HIV-infected persons, who may subsequently present with chronic manifestations of HIV-infection. The respiratory morbidity attendant to HIV-infection, even in the presence of HAART is high, the aftermath of which is lung tissue destruction and bronchiectasis. As a consequence of the political decision not to offer HAART to HIV-infected children, a number of children in South Africa have been left with severe consequences of uncontrolled HIV-infection. Bronchiectasis is one of those and because children with this devastating condition were numerous in the Pretoria region, the author and her colleagues began a Chronic Lung Disease Clinic in that region. This prompted the idea of investigating both the epidemiological profiles of these children and an attempt to intervene with both standard bronchiectasis guideline care and the use of a form of therapy commonly employed in other forms of bronchiectasis. This thesis explores those ideas. Important new and novel findings that were consequent were; that bronchiectasis is diagnosed late in HIV-infected children at a mean age of 6.9 years. The predominant organisms cultured from the airways are Haemophilus influenzae and parainfluenzae in 49% of samples. Pseudomonas aeruginosa (PA), common in cystic fibrosis (CF)-bronchiectasis is an uncommon pathogen in HIV-related bronchiectasis; isolated in only 2% of specimens. Tuberculosis (TB), at least as reported, is a significant antecedent of bronchiectasis, reported in 48.5%of children. A further 21.2% of the patients had received more than two courses of anti-TB treatment. However, proof of TB infection has been lacking. Respiratory morbidity is significant with the mean forced expiratory flow in one second (FEV1) of 53%, in this cohort at the time of presentation. Thirty-six percent of all children were exposed to environmental tobacco smoke, although this was not correlated with disease severity or HIVdisease progression. There is elevation of immunoglobulins in HIV-related bronchiectasis, with a mean IgE of 79 kU/l. This was not, though, associated with HIV disease progression as previously described in adult studies, nor with the presence of allergic bronchopulmonary aspergillosis (ABPA). The elevation in IgE was also not associated with an elevation of T helper-2 mediated cytokines, confirming the lack of association with atopy. The predominant cytokine, identified is interleukin (IL)-8, both systemically and locally (in airway secretions). There was elevation of other T helper-1 driven cytokines, reflecting an ability to mediate adequate inflammatory responses, which was independent of the level of immunosuppression. With the presence of HAART, there was a decline in the pro-inflammatory cytokines over time, which may be attributed to the ongoing effect of HAART that ties in to, or goes beyond the restoration of T cell numbers. Soluble triggering receptor expressed on myeloid cells (sTREM), an innate immune marker, is elevated in children with HIV-related bronchiectasis when compared to a control group of children with cystic fibrosis-related bronchiectasis. sTREM is not associated with the presence of exacerbations and the level of immunosuppression. The use of an anti-inflammatory drug erythromycin also did not impact the sTREM values. There was also no relationship between sTREM and pro and antiinflammatory cytokines and chemokines. Fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET) could not reliably predict the presence of pulmonary exacerbations. Its diagnostic value was limited to identifying disease activity in acute pneumonia. 18F-FDG PET also had no significant correlation with CRP, inflammatory cytokines or markers of HIV disease activity. In a randomised controlled trial of erythromycin, a cost-effective immunomodulatory drug, compared to placebo, erythromycin was ineffective in reducing the number of pulmonary exacerbations. Erythromycin also failed to demonstrate any effect on systemic and local pro- and anti-inflammatory cytokines/chemokines. With access to anti-retroviral therapy, airway clearance, nutritional rehabilitation and vigilant follow up there was an improvement in pulmonary function parameters and stability of the degree of bronchiectasis that we propose is probably in keeping with an organ system disease modifying effect that may be, an as yet, undefined and undescribed byproduct of HAART. / Thesis (PhD)--University of Pretoria, 2012. / Paediatrics and Child Health / unrestricted

AIM The objective of this study is to determine factors that may contribute to hospital admissions in a cohort of medically insured South African patients in the era of HAART. METHODS This was a retrospective cohort of all HIV-positive adult and paediatric patients enrolled on a medical aid disease management programme in South Africa over a period of three years. Patient-specific demographic and clinical information were obtained from the medical aid records. Survival analysis was used to analyse time to first admission looking at admissions occurring after enrolment to the programme, during the study period of between 01 January 2006 and 31 December 2008. Only the right censored cases were included in the analyses. Descriptive analyses were conducted on the key prognostic factors. Variables that were significant in the univariate were considered in the multivariate Cox proportional hazards model. RESULTS A total of 8440 patients were included in the analysis. Half of these patients had at least one admission during the observation periods with 43.28% having had 2 or more admissions. The average admission rate was 2 admissions per patient over the 36 month observation period. Young children, adolescents and the very old (> 60 years) were significantly more likely to be admitted than the middle age groups, HR = 1.30 [95%CI 1.21 -1.40] p<0.01, 1.24 [95%CI 1.10 – 1.41] and 1.13 [95% CI 1.10 – 1.27] p<0.01 respectively. Low CD4 cell counts of < 200 cells/ µL were significantly associated with a higher likelihood of hospitalizations with hazard ratios even greater for CD4 cell counts of less than 100 cells/ µL, HR= 1.34 [95%CI 1.29 – 1.39], p<0.01. Cases were more likely to be admitted by a clinical haematologist or gynaecologist than by other specialist categories.HR =1.58 [95%CI 1.29 –1.94] and 1.17[95%CI 1.08 – 1.27] respectively with p<0.01. CONCLUSION Factors that are associated with hospital admissions in this private sector, medically insured population are a younger and older age, low CD4 cell counts and admission by a clinical haematologist and gynaecologist. These results suggest that disease management strategies should be intensified for the younger and older age groups. All HIV-positive patients should be closely monitored for CD4 deterioration so that treatment is initiated timeously. Routine haematological investigations should be recommended for all HIV-positive patients in order to pick up and treat haematological conditions before they result in a hospital admission. Evidence based guidelines, outlining the place of caesarian section deliveries in the HIV population, should be developed for use by gynaecologists specifically in the private sector. Copyright / Dissertation (MSc)--University of Pretoria, 2011. / Clinical Epidemiology / unrestricted