A research report submitted to the School of Public Health, University of the Witwatersrand (Johannesburg, South Africa) in partial fulfilment of the requirements for the degree of Master of Public Health for the year 2014 / Introduction: After 12 years of implementing the national Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme in South Africa, interventions to prevent MTCT of HIV are now offered in more than 95% of public antenatal and maternity facilities country-wide free of charge (MRC, 2010), even though HIV/AIDS-related diseases are said to be a major cause of death in young children (UNICEF, 2011). The context within which women make decisions about PMTCT participation depends on, amongst other things, the level of their knowledge about HIV/AIDS (Leonard et al, 2001; Sematimba et al, 2004). The concept of behavior-based programming is central to a behavior change approach to reducing Mother-to-Child Transmission of HIV. This places behaviours at the centre of the program design process (Moore, 2003). Understanding the providers and users of the PMTCT interventions’ knowledge and experience on HIV and PMTCT is therefore important to ensure appropriate interventions to address beliefs, attitudes, myths and misunderstandings. Methodology: Semi-structured interviews were conducted with users of the PMTCT programme, while structured survey questionnaires were collected with the providers of the PMTCT programme in early 2012. Users of the PMTCT programme were asked questions regarding HIV knowledge, experience of HIV testing in pregnancy, PMTCT knowledge and experience of the PMTCT programme. We also asked questions on infant feeding choices and practices. Forty six interviews were carried out with participants at three ANC Clinics with PMTCT services in Soweto - Gauteng. Thirty were users of PMTCT programme and sixteen were providers of PMTCT service. Results: All participants understood that HIV was a virus that affected the immune system. Results show that there is generally a good understanding of HIV and how it is transmitted. In addition there was a good understanding on methods to prevent acquiring HIV. There was a general feeling that a lot of people were afraid of being tested. Interestingly, most participants believed that people who were pregnant or sick had no choice but to get tested. Most of the participants believed that education should be a tool used to motivate more people to get tested for HIV. Most users in this study disclosed their HIV status and PMTCT programme use. Overwhelmingly the decision to participate was based on the desire not to infect their infants. Women had been informed that mixed feeding increased the risk of transmission by breast feeding. There were a few participants who believed that HIV infected women should not breastfed. It was found that almost two-thirds of the women in this study were formula feeding their infants. Reason cited for formula feeding was that they did not want to infect their infants. As far as PMTCT knowledge was concerned, it was found that almost all health care providers knew that the most common route of HIV acquisition was through heterosexual sexual practices. All the HCWs knew that prolonged breastfeeding increased the risk of transmission. Reassuringly all HCWs knew not to use invasive delivery procedures and that risk of transmission was decreased with low maternal viral load. Only 50% of the HCWs indicated that the first choice of WHO- recommended mother-to-child regimen for antiretroviral prophylaxis in PMTCT was Zidovudine (ZDV) and Nevirapine (NVP) (WHO, 2012). The HCWs understood that infant formula did not provide superior nutritional support or antibody protection. They also knew that formula feeding carried increased risk of diahorrea or bacterial infections. There was confusion regarding the duration of exclusive breast feeding. Only half of the HCWs stated that post-natal infant-feeding counselling and follow-up are required whenever a mother decides to change her feeding practice. HCW participants felt that most patients fail to adhere to their medication requirements. This was cited to be mainly due to the fact that patients may not have disclosed their HIV status to the household members. Baby feeding choices are cited as the strongest barriers to the success of the PMTCT programmes. Mothers who have not disclosed their HIV status to their household members find it difficult to comply with the chosen feeding choices especially bottle feeding; they therefore opt for exclusive breastfeeding –which family members attempt to interrupt with mixed feeding practices for a number of reasons. Conclusion: Contrary to studies cited in the literature review, health systems failure was not a major problem in Soweto and therefore was not a factor that could impact on either the knowledge or the experience of users and providers. Even though disclosure rates were high amongst the users interviewed in this study, participants believed that the biggest barrier to people participating in the PMTCT programme was because of stigma, ignorance, and fear that they may be recognised while accessing services by people they may know. Although women had been provided with information on exclusively breastfeed, most users of the PMTCT programme interviewed were bottlefeeding – not due to stigma, but due to fear of transmission. In terms of barriers – adherence was noted as a major problem by providers. This linked to issues of feeding practices - if mothers bottle-feed they are stigmatised and opt for exclusive feeding, but are then forced by family to supplement with the bottle for various reasons. Mothers do not reveal their status, which jeopardises their success on the programme

This research investigated the ethical and legal issues that impact on the urgent implementation of Nurse Initiated and Managed Anti-Retroviral Treatment (NIMART) in South Africa, which is part of the task-shifting strategy recommended by the World Health Organization (WHO) to deal with the human resource shortage that has negatively impacted access to Anti-Retroviral Treatment (ART) in developing countries (WHO;2006). The objectives were to review and analyse the existing legal framework and provisions for NIMART in South Africa; and to identify ethical issues and implications of NIMART within the current legal framework. It analysed the legal issues that impact on the implementation of NIMART within the public health service in South Africa, as well as the ethical basis and implications of NIMART on the practice of nurses in the scale-up of Anti-Retroviral Treatment in Primary Health Care (PHC). A comparative analysis was done with case studies of task-shifting in other developing countries and evidence-based recommendations for an enabling and long-term sustainable ethico-legal approach to task-shifting were established. The research concluded that despite the existing legal framework for NIMART in South Africa being firmly founded in the Constitution and further enabled by health policy, challenges exist in implementation of certain critical aspects of the enabling legislation relating to nurse training and accreditation required for full authorization to practice NIMART and that these technical challenges if not attended to could threaten the long-term sustainability of NIMART.

Background Cardiovascular disease in the context of human immunodeficiency virus infection has become a major clinical concern in recent years. In the current report we assess hospitalizations due to cardiovascular disease in human immunodeficiency virus patients in a Social Security reference hospital in Peru. Methods A retrospective study was carried out between January 1996 and December 2012 in a General Hospital in Lima, Peru. Results We included 26 patients hospitalized due to cardiovascular disease. Mean age was 46.3 years (SD 12.5), predominantly male (57.7%). Ten patients (38.4%) were in Acquired Immunodeficiency Syndrome stages. Seventeen (65.4%) received high-active-antiretroviral therapy. Eleven (42.3%) had cardiac involvement and 15 (57.7%) had non-cardiac vascular involvement. The most frequent causes of cardiac involvement were pericardial effusion and myocardial infarction. On the other hand, deep vein thrombosis and stroke were the most frequent for non-cardiac vascular involvement. Conclusions Cardiovascular disease is an important cause of hospitalization in Peruvian human immunodeficiency virus patients, with differences between immunosuppression stages. Further studies analyzing associated factors are warranted. / germanvrodriguez@yahoo.com / Revisión por pares

nÃo hà / Desde que a SÃndrome da ImunodeficiÃncia Adquirida (AIDS) comeÃou a ser reconhecida como problema de saÃde pÃblica, tem havido preocupaÃÃo crescente com o papel desempenhado pelos usuÃrios de drogas na disseminaÃÃo global do VÃrus da ImunodeficiÃncia Adquirida (HIV), sendo esta, atualmente, a segunda causa de morte entre eles. O estudo apresenta como objetivo geral promover, por meio dos CÃrculos de Cultura, espaÃo crÃtico-reflexivo acerca da prevenÃÃo do HIV/aids junto aos jovens usuÃrios de cocaÃna/crack. Trata-se de pesquisa-aÃÃo, realizada de janeiro a setembro de 2012. Os sujeitos do estudo foram dez jovens usuÃrios de cocaÃna/crack, do sexo masculino, com idade entre 18 e 24 anos, acompanhados para tratamento de dependÃncia na comunidade terapÃutica Desafio Jovem do CearÃ. Os instrumentos e as tÃcnicas utilizados para coleta das informaÃÃes foram: entrevista semiestruturada, observaÃÃo-participante, registro fotogrÃfico, gravaÃÃo dos discursos e registro em diÃrio de campo. Como mÃtodo e tÃcnica para articular a dimensÃo coletiva e interativa da investigaÃÃo proposta pela pesquisa-aÃÃo, utilizou-se o CÃrculo de Cultura. Deste modo, foram realizados seis CÃrculos de Cultura construÃdos de acordo com as seguintes etapas: o conhecer do universo individual e coletivo, seleÃÃo dos temas, dinÃmicas de sensibilizaÃÃo e problematizaÃÃo, reflexÃo teÃrico-prÃtica, construÃÃo coletiva do conhecimento e avaliaÃÃo de cada cÃrculo. Neste sentido, os jovens discutiram e refletiram sobre: o viver dos jovens com as drogas, a vulnerabilidade do usuÃrio de drogas ao HIV/aids, a relaÃÃo da Aids com as drogas, a prevenÃÃo e a transmissÃo do HIV/aids e o que aprendemos sobre Aids? Os resultados dessas discussÃes foram os seguintes: no inÃcio dos cÃrculos, os jovens demonstraram conhecimento sobre a aids bastante incipiente e desarticulado, com predominÃncia de mitos; relataram nunca terem feito uso de drogas injetÃveis, porÃm se consideravam vulnerÃveis Ãs DST/aids visto que o compartilhamento de canudos e cachimbos para o uso da cocaÃna/crack e a perda da consciÃncia favoreciam ao nÃo uso do preservativo durante as relaÃÃes sexuais e à multiplicidade de parceiros; os amigos desses jovens foram os principais fatores de risco para que viessem a experimentar as drogas; as festas, as âravesâ eram lugares propÃcios para o inÃcio do uso de drogas, porÃm casas abandonadas, escolas, e casas dos amigos, tambÃm foram incluÃdas como opÃÃes para o consumo de drogas, e que a religiÃo era muito importante para que os jovens decidissem nÃo usar mais as drogas e iniciassem o tratamento para dependÃncia. O processo educativo despertou nos nossos jovens o interesse e a necessidade de conversar com seus pares acerca da problemÃtica que envolvia as DST/aids e as drogas, e alÃm disso ensinou vÃrias maneiras de trabalhar a questÃo das drogas nas escolas com crianÃas e adolescentes que ainda nÃo sÃo usuÃrios, ratificando que o cÃrculo possibilita a reflexÃo e a transformaÃÃo do sujeito e do meio no qual ele està inserido. Diante do exposto, o enfermeiro pode trabalhar com metodologias dialÃgicas e participativas, como a de Paulo Freire, para favorecer a reflexÃo crÃtica do educador e educando em prol da prevenÃÃo de DST/aids em usuÃrios de cocaÃna/crack.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / A violÃncia sexual caracteriza-se como um grave problema de saÃde pÃblica que acarreta distÃrbios no desenvolvimento biopsicossocial e sexual de suas vÃtimas, principalmente quando essa agressÃo ocorre na fase da adolescÃncia, pois esses sujeitos se encontram numa etapa da vida marcada por mudanÃas e adaptaÃÃes, especialmente no Ãmbito da sexualidade. Portanto, as crenÃas e valores das vitimas de violÃncia sexual precisam ser compreendidas para promover a adoÃÃo de comportamentos sexuais saudÃveis. Objetivou-se compreender como as crenÃas e valores das adolescentes vitimas de violÃncia sexual influenciam no comportamento de prevenÃÃo das DST e da AIDS com base no Modelo de CrenÃas em SaÃde (MCS) . Trata-se de uma pesquisa qualitativa, descritiva, realizada numa InstituiÃÃo de Acolhimento no Municipal de Fortaleza, no perÃodo de maio a julho de 2011, com oito adolescentes vitimas de violÃncia sexual. Foram utilizados como instrumentos e procedimentos para a coleta de informaÃÃes: a observaÃÃo participante de todos os encontros, que foram registrados no diÃrio de campo; todo o material produzido durante os grupos focais, como cartazes, desenhos, entre outros; e a transcriÃÃo da gravaÃÃo dos diÃlogos durante as estratÃgias de grupo e do roteiro de entrevista semiestruturada. As informaÃÃes foram organizadas conforme as dimensÃes do MCS. Todos os aspectos legais e Ãticos da pesquisa envolvendo os seres humanos foram respeitados. Inicialmente, foi necessÃrio caracterizar as participantes do estudo e observou-se que as histÃrias de vida dessas adolescentes estavam condizentes com a literatura. Em relaÃÃo Ãs categorias criadas conforme o MCS: as adolescentes tem um dÃfice de conhecimento em relaÃÃo a essas doenÃas e nÃo se consideraram susceptÃveis as DST/AIDS por acreditarem que nÃo irÃo se relacionar sexualmente com homens, mesmo identificando a maior vulnerabilidade da mulher a essas patologias; em relaÃÃo à percepÃÃo da gravidade, elas classificaram essas doenÃas como graves, incurÃveis e que alteram o convÃvio social, demonstrando medo de contrair uma dessas patologias; identificaram como benefÃcios e barreiras do mÃtodo preventivo ser de fÃcil acesso e utilizaÃÃo e prevenir tanto doenÃas como gravidez, mas interferem no prazer sexual; e seu uso està relacionado com questÃes culturais e sociais, ressalta-se tambÃm, que o abuso de Ãlcool e drogas intervÃm na adoÃÃo de comportamentos saudÃveis. Conclui-se que as crenÃas e valores dessas adolescentes as tornam vulnerÃveis a DST/AIDS, sendo necessÃrio refletir sobre as consequÃncias da violÃncia sexual na vida dessas adolescentes para a elaboraÃÃo de estratÃgias e aÃÃes preventivas voltadas para esse publico-alvo no que concerne ao desenvolvimento da sexualidade de forma segura, minimizando traumas e sofrimentos advindos dessa experiÃncia na vida dessas adolescentes, tornando-as conscientes dos seus direitos sexuais e reprodutivos. / Sexual assault is characterized as a serious public health problem that leads to disorders in the bio-psychosocial and sexual development of the victims, especially when the aggression happens in adolescence, because these subjects are in a stage of life marked by changes and adaptations, especially concerning sexuality. Therefore, the values and beliefs of the victims of sexual assault must be understood to promote the adoption of a healthy sexual behavior. It was aimed to understand how beliefs and values of adolescent victims of sexual assault influence the behavior of prevention of STD/AIDS based on the Health Belief Model. It is a qualitative descriptive research carried out at a Host Institution in the City of Fortaleza from May to July 2011 with eight adolescent victims of sexual assault. Using as tools and procedures for data collection: participant observation of all meetings, which were registered in a field diary; all the material produced during the focus groups, such as posters, drawings, among others; and the transcription of the dialogue recording during the group strategies and semi-structured interviews. The information was organized according to the Health Belief Model dimensions. All legal and ethical aspects of researches involving human beings were respected. Initially, it was necessary to characterize the study participants and it was found that the life stories of these adolescents were consistent with the literature. Regarding the categories created according to the Health Belief Model: the adolescents lack knowledge about these diseases and don't considered them susceptible to STD/AIDS because they believe that they will not relate sexually with men, in spite identifying the greater vulnerability of women to such pathologies; concerning the perception of gravity, they classified these diseases as serious, incurable, and that changes social life, demonstrating fear of contracting these diseases; they identified as benefits and barriers of preventive method: it is easy to access and use, and prevents both diseases as pregnancy, but interferes with sexual pleasure; and its use is related to cultural and social issues, we also emphasize that the abuse of alcohol and drugs interferes in the adoption of healthy behaviors. We conclude that the beliefs and values of these adolescents make them vulnerable to STD/AIDS, being necessary to reflect on the consequences of sexual violence in their lives to build strategies and preventive actions aimed at this target audience in terms of a safe development of sexuality, minimizing trauma and suffering resulting from this experience in their lives, making them aware of their sexual and reproductive rights.

hesis (M.Sc. (Nutrition))--North-West University, Potchefstroom Campus, 2007.

Objective: A neglected issue in literature on nutrition and HIV/AIDS is how other health professionals view their role in that arm. The purpose of this study was to understand professional nurses' perception regarding their ability to render effective nutritional care to people living with HIV/AIDS (PLWHA). Design: A qualitative approach was used. Twenty-three, in-depth, semi-structured interviews were conducted with nurses (mean age 38) working in eight (five rural and three urban) Wellness clinics within public hospitals providing antiretroviral therapy (ART) in North West Province, South Africa. Brief structured demographic questionnaires were also administered. All interviews and focus group discussions were recorded for transcription and open-coding. NVivo was used for open coding, whilst descriptive statistics were done using SPSS for windows (version 14, SPSS Inc., Chicago. IL). A research team of professionals and researchers collaboratively analysed data for emerging themes. Results: All the hospitals that participated had at most three nurses, having at least one professional nurse working in the Wellness clinic for PLWHA. More than half of the participants interviewed were diploma holders, eight (35%) were degree holders and three (13%) had certificates in nursing. Five main themes (previously guided by the interview questions) emerged during the analysis of data and these portrayed participants' perceptions regarding their ability to render effective nutritional care to PLWHA. The themes were 1) challenges faced by nurses dealing with PLWHA on a daily basis, 2) concerns of PLWHA, 3) nurses’ perception on the importance of nutrition in HIV/AIDS care, 4) nurses’ perceived ability to deal with nutritional issues in HIV/AIDS, 5) the role of traditional healers, traditional medicine in HIV/AIDS. Thirty five percent of participants mentioned poor socio-economic status of PLWHA as a barrier to the participants to talk about good nutrition to people that are food insecure. Furthermore, 13% of participants indicated that they are constantly facing the dilemma of PLWHA mixing traditional medicines and ART. Participants perceived the following skills to be important in the area of nutrition and HIV/AIDS: communication, listening and knowledge. Although knowledge could be debated as it is not a skill per se, the participants believed that on needs to acquire nutrition knowledge first and then improve on the communication and listening skills with more exposure and training. Ten (41%) of the participants interviewed rated themselves as average, 11 (48%) participants as good whilst only 4%, representing one participant, felt they were very good at giving out nutrition education. Sixty one percent of participants said they would require more knowledge, whilst 39% said they would need to acquire communication and listening skills for them to be able to render effective nutritional cart to PLWHA. In this study, participants perceived nutritional care to PLWHA as their responsibility and that lack of knowledge was influencing their inability to offer this service effectively. All the participants indicated a need for collaboration with nutrition professionals, ill-service training us well as exposure to clear communication channels for nutrition and HIV/AIDS information. Participants were concerned with the lack of policy implementation regarding nutrition and policy documents. Of the 23 participants interviewed, only two (9%) confirmed having seen and rend the South African Guidelines on Nutritional Care for People Living with TB, HIV/AIDS and other Chronic Debilitating Conditions. Conclusion: All participants interviewed believed that nutrition knowledge in the area of HIV/AIDS can be improved if poor people who are infected and affected by HIV/AIDS are food secure. Concerning practice, it is recommended that nutrition and HIV/AIDS as a topic be introduced in both undergraduate mid postgraduate training for nurses. The lack of policy implementation, level of qualification and years spent in the nursing profession may have influenced participants' perception regarding their ability, as well as confidence, to render nutritional care to PLWHA. Possible interventions to improve policy implementation could be the development of user-friendly information, education and communication materials for health institutions as these may serve as constant reminders to health care service providers. It was found that participants' perceptions regarding their ability to render effective nutritional care to PLWHA was affected by a complex number of factors which emerged as themes that need to be addressed. Participants' experience suggests that more research and inquiries are needed into traditional medicines and traditional healing, as the issue of ARVs and traditional medicine is becoming a public health dilemma, riot only to the nurses, but to every stakeholder involved in the field of HIV/AIDS. Furthermore, a need exists for nurse-specific outreach, collaboratively done by nutrition professionals and other stakeholders. This work thus provides a foundation for further exploring ways to improve the ability of other health care workers such as nurses in the nutritional care of PLWHA which will ultimately improve the quality of life of PLWHA. / Thesis (M.Sc. (Nutrition))--North-West University, Potchefstroom Campus, 2007

Objective: A neglected issue in literature on nutrition and HIV/AIDS is how other health professionals view their role in that arm. The purpose of this study was to understand professional nurses' perception regarding their ability to render effective nutritional care to people living with HIV/AIDS (PLWHA). Design: A qualitative approach was used. Twenty-three, in-depth, semi-structured interviews were conducted with nurses (mean age 38) working in eight (five rural and three urban) Wellness clinics within public hospitals providing antiretroviral therapy (ART) in North West Province, South Africa. Brief structured demographic questionnaires were also administered. All interviews and focus group discussions were recorded for transcription and open-coding. NVivo was used for open coding, whilst descriptive statistics were done using SPSS for windows (version 14, SPSS Inc., Chicago. IL). A research team of professionals and researchers collaboratively analysed data for emerging themes. Results: All the hospitals that participated had at most three nurses, having at least one professional nurse working in the Wellness clinic for PLWHA. More than half of the participants interviewed were diploma holders, eight (35%) were degree holders and three (13%) had certificates in nursing. Five main themes (previously guided by the interview questions) emerged during the analysis of data and these portrayed participants' perceptions regarding their ability to render effective nutritional care to PLWHA. The themes were 1) challenges faced by nurses dealing with PLWHA on a daily basis, 2) concerns of PLWHA, 3) nurses’ perception on the importance of nutrition in HIV/AIDS care, 4) nurses’ perceived ability to deal with nutritional issues in HIV/AIDS, 5) the role of traditional healers, traditional medicine in HIV/AIDS. Thirty five percent of participants mentioned poor socio-economic status of PLWHA as a barrier to the participants to talk about good nutrition to people that are food insecure. Furthermore, 13% of participants indicated that they are constantly facing the dilemma of PLWHA mixing traditional medicines and ART. Participants perceived the following skills to be important in the area of nutrition and HIV/AIDS: communication, listening and knowledge. Although knowledge could be debated as it is not a skill per se, the participants believed that on needs to acquire nutrition knowledge first and then improve on the communication and listening skills with more exposure and training. Ten (41%) of the participants interviewed rated themselves as average, 11 (48%) participants as good whilst only 4%, representing one participant, felt they were very good at giving out nutrition education. Sixty one percent of participants said they would require more knowledge, whilst 39% said they would need to acquire communication and listening skills for them to be able to render effective nutritional cart to PLWHA. In this study, participants perceived nutritional care to PLWHA as their responsibility and that lack of knowledge was influencing their inability to offer this service effectively. All the participants indicated a need for collaboration with nutrition professionals, ill-service training us well as exposure to clear communication channels for nutrition and HIV/AIDS information. Participants were concerned with the lack of policy implementation regarding nutrition and policy documents. Of the 23 participants interviewed, only two (9%) confirmed having seen and rend the South African Guidelines on Nutritional Care for People Living with TB, HIV/AIDS and other Chronic Debilitating Conditions. Conclusion: All participants interviewed believed that nutrition knowledge in the area of HIV/AIDS can be improved if poor people who are infected and affected by HIV/AIDS are food secure. Concerning practice, it is recommended that nutrition and HIV/AIDS as a topic be introduced in both undergraduate mid postgraduate training for nurses. The lack of policy implementation, level of qualification and years spent in the nursing profession may have influenced participants' perception regarding their ability, as well as confidence, to render nutritional care to PLWHA. Possible interventions to improve policy implementation could be the development of user-friendly information, education and communication materials for health institutions as these may serve as constant reminders to health care service providers. It was found that participants' perceptions regarding their ability to render effective nutritional care to PLWHA was affected by a complex number of factors which emerged as themes that need to be addressed. Participants' experience suggests that more research and inquiries are needed into traditional medicines and traditional healing, as the issue of ARVs and traditional medicine is becoming a public health dilemma, riot only to the nurses, but to every stakeholder involved in the field of HIV/AIDS. Furthermore, a need exists for nurse-specific outreach, collaboratively done by nutrition professionals and other stakeholders. This work thus provides a foundation for further exploring ways to improve the ability of other health care workers such as nurses in the nutritional care of PLWHA which will ultimately improve the quality of life of PLWHA. / Thesis (M.Sc. (Nutrition))--North-West University, Potchefstroom Campus, 2007

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2005. / Härtill 4 uppsatser.

Thesis (Ph. D.)--University of Arizona, 1993. / Also issued in print.