Includes bibliographical references (leaves 60-64). / Although national guidelines in South Africa recommend starting antiretroviral therapy (ART) mainly to outpatients with WHO stage four disease and/or CD4 count of 200 cells/uL, immediate ART initiation after opportunistic infection (OI) treatment in the inpatient wards at several international sites has been shown to reduce the adverse outcomes of AIDS progression and death. Current South African policies of discharging patients after hospital admission for management of OIs for follow up and initiation of ART at ARV clinics result in poor patient outcomes as described by reports from South Africa. In contrast, this study demonstrates the feasibility and effectiveness, under routine programme conditions, of a rapid, supervised inpatient ART initiation. Further research is needed to reduce the high rate of early mortality among patients with advanced HIV disease.

Includes bibliographical references (leaves 34-39). / Since 1948, when the World Health Organization (WHO) defined health as being not only the absence of disease and infinity but also the presence of physical, mental, and social well-being (Constitution of the World Health Organization, 1952), quality of life issues became more apparent. The aim of the research undertaken was to establish whether the hospital palliative care team (HPCT) at the Johannesburg General Hospital was making a difference to referred hospital patients' quality of life. The HPCT was started at the Johannesburg General Hospital in 2001. The team functions as an advisory body on pain and symptom control. Palliative Care is an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. The method used was the FACT G questionnaire, which was completed by the patient group initially, and thereafter HPCT intervention. The questionnaire is used to measure quality of life (QOL). The study is a descriptive cohort design. The first 24 patients completed the informed consent prior to completing the questionnaire. The pre QOL questionnaire served as the baseline QOL scores prior to HPCT intervention. The initial QOL scores were then compared to the post QOL scores after HPCT intervention. Seven subjects were excluded from the research as six patients were discharged from hospital early due to a bed shortage and one patient died. The seven patients' results from the pre FACT G questionnaire were discarded and all subsequent calculations did not include their results. The increase in the total percentage scores (45.53 to 63.35) was statistically significant (p< 0.001) using the paired t-test. Thus the results show a significant difference between pre and post assessment QOL scores. The research demonstrates significant improvements in patients' quality of life (p<0.001) after HPCT intervention. It is hoped that future research would continue to show the value of HPCT and their effect of benefiting patients' quality of life.

Includes bibliographical references (leaves 70-75). / This study set out to document quality of life in the industrialized setting of HIV infected South African gold minders who are on highly-active anti-retroviral therapy, by administering the MOS SF-36, and to determine which categorical variables impact on QOL in this study cohort. It also intended to promote routine quality of life measurements, as an index of programme performance, and to strengthen the case for widened access to anti-retroviral treatment. A cross sectional survey of 202 outpatients was carried out at the central clinic at the health service hospital owned by Anglogold in the Northwest Province. Scores of eight scales of the MOS SF-36 measuring different aspects of quality of life were calculated. Demographic and laboratory data were collected from a separate case report form and the clinic database, as part of the categorical variables. Results showed that more than 59% of all respondents achieved scores of 100 for all subscale domains, and that the only categorical variables that showed statistically significant impact was age, with QOL scores on the physical function domains decreasing with age. This decrease in function was thought to be more attributable to age, than HIV status, stage or progression. The sample population was noted to have a high level of health care, and exhibited both the well-worker and survival cohort effect, as a result of a stringent pre-employment selection, on-going occupational fitness assessments and medical boarding in the case of sub-standard fitness.

Includes bibliographical references. / This research aimed to explore the perceived needs of support required by paediatric staff caring for children with LL and LTIs in the Paediatric Department in DNH and set out the following objectives: 1) To identify the need for educational support; 2) To explore the emotional impact on Health Care Professionals HCPs caring for children with LL and LTI; 3) To identify the kind of support required for staff in order to offer the best possible care to these paediatric patients and their families.

Includes bibliographical references (leaves 48-52). / The study aimed to explore the causes of death, the costs involved in these deaths as well as the places where these deaths occurred. As all patients had access to ART once registered with the disease management company, AfA, most patients would have received ART, once the criteria for starting treatment were met.

Includes bibliographical references / Background: WHO has been advocating for provision of palliative care for all who need it according to needs and context. Though significant advances have been achieved in providing palliative care for adults in Sub Saharan Africa, very little progress has been made in providing paediatric palliative care. Coverage of paediatric palliative care services have remained low and there is lack of evidence on child specific palliative care needs and tools for assessing these needs. This study tested applicability of some tools for assessing palliative needs in children in the Zambian context and reports palliative care needs of children and their families attending the University Teaching Hospital (UTH) in Lusaka, Zambia Methodology: This was a mixed study with quantitative and qualitative components. The quantitative component assessed and applied 2 new research tools for assessing palliative care needs in children attending University teaching hospital in Lusaka, Zambia. The tools assessed included the Needs Evaluations questionnaire (NEQ) and the paedsQL4 questionnaire. Cronbach's alpha was used to determine reliability while factor analysis was used to identify relevant factors. Focus group discussions were conducted with selected group of parents/legal guardians of children. In-depth interviews were conducted with key informants. All participants were purposely selected to take part in the study and were informed about the voluntary nature of the study. Results: The NEQ and the paedsQL4 questionnaires were both found to be reliable for assessing palliative care needs for children in the Zambian context (Cronbach's alpha >0.8). Generally there were very high need gaps across all hospital wards with 15/23 items having need gap of >50%. Overall the largest need gap was in the information domain. The HIV ward had least need gap with only 8/23 items having a need gap of > 50%. Results from the paedsQL4 showed that there were significant mean differences across the three categories of patients in all domains of functioning with oncology patients performing worst. In physical functioning domain, the items showed that 6/7 items had significant mean differences (p<0.05).Confirmatory factors analysis showed that 2 items were loading highly on the physical functioning factor. These were running and participating in sports (0.896).In the emotional functioning domain, 2 items loaded highly on factor analysis, feeling sad (0.842 and angry (0.666).In the social functioning domain, highest loading were in 2 items, both related to making friends. In the school domain missing school to go to hospital loaded highly on factor analysis (0.842) followed by difficulty paying attention in class (0.716) Qualitative results supported findings from quantitative data. Several needs were highlighted by the parents/guardians and health workers. The major family needs focused on economic/financial and bereavement support. Most families were referred to the UTH from very far off places without any form of support. In line with quantitative findings, there was high demand for information for families which health workers did not adequately provide. One major barrier identified to provision of palliative care was poor coordination of services with most patients missing out on services which were already available. While social workers were available, poor funding negatively affected this service. There were very few trained health workers in palliative care. Pain management remained poor with many clinicians still not comfortable to prescribe stronger analgesia such as morphine for severe pain. Conclusion: This study applied two quantitative tools for assessing palliative care needs in Children. The results showed that the tools were fairly reliable and applicable in the Zambian context. The findings indicate huge needs gap for child palliative care services in Zambia. The major family needs were economic and bereavement support. There was high demand for information for families which health workers did not adequately provide. Pain control remained sub-optimal especially for children with cancer. One major barrier identified to provision of palliative care was poor coordination of services.

Includes bibliographical references. / Sedation in the context of terminal care has been a hotly debated topic for many years. There are two main reasons for this. Firstly, the wide variation in its reported use leads to doubts about the appropriateness of the care available in areas with a high percentage of sedation, and secondly, there is the suspicion that terminal sedation is actually a euphemism for euthanasia. Ventafridda's report in 1990 that 52% of moribund patients required sleep-inducing sedation to control physical suffering, stimulated a lot of discussion in palliative care circles with many physicians being surprised at the apparent high percentage of patients needing terminal sedation. This was followed by the publication of studies from various centres throughout the world in an effort to determine current international practice.

Includes bibliographical references. / Terminal illness affects the family as a social group severely, impacting on all aspects of the family's functioning. The burdens and stressors experienced by families coping with terminal illness has been well described, and included physical, emotional and spiritual components. Recognising the interconnectedness of the patient and his/her family and friends, and facilitating the process of coping is the challenge and privilege of Palliative Care Teams. Family Conferences are an intervention with which to aid and facilitate the recovery of 'balance' within a family, by providing for their needs for information, support, good communication from and relationship with the Palliative Care Team.

Includes abstract. / Includes bibliographical references (leaves 62-68). / To determine the demographics and the physical, psychosocial and spiritual needs and expectations for the palliative care of a homeless community in an HIV Care Centre, located in the inner city of Johannesburg.

Includes bibliographical references. / Do any validated dementia screening tools exist for use in palliative care populations in sub-Saharan Africa? Around the world populations have increased life expectancies. The tendency to develop dementia increases with age. By 2040, it is projected that more than 80 million people worldwide will suffer from dementia. Effective and validated dementia screening tools are used for screening and identifying people with dementia at an early stage, allowing for the possibility of earlier intervention. Validated tools are used internationally, but there is a need to determine if such tools have been validated for use in a sub-Saharan African palliative care population, which presents with the distinct challenges of literacy, language and culture. There is also a high incidence of HIV in sub-Saharan Africa, with a concomitant high prevalence of HIV-associated dementia. Sub-Saharan Africa therefore needs a unique, validated dementia screening tool for use in a palliative care population. Dementia causes a high burden of suffering for patients, their families, and communities. There is a similarity between many of the symptoms of cancer and dementia, although patients with dementia have a longer life expectancy. Palliative care is the cornerstone in the management of cancer patients and is therefore clearly ideal for people suffering from dementia. The World Health Organization, in their publication: "Palliative Care for Older People: Better Practices", state that people who suffer from dementia are in urgent need of improved palliative care services 2.2. Aim The aim of this systematic review was to identify validated dementia screening tools, and of those tools, to determine, specifically, whether they had been validated in a palliative care population in sub-Saharan Africa. This was done by following 3 objectives: Page 14 1. To identify which validated dementia screening tools are available. 2. To identify and isolate those tools which have been validated in sub-Saharan Africa. 3. To determine from those tools validated in sub-Saharan Africa, which have been validated in a palliative care population. To clarify, the aim of the study was to identify the validated tools, for dementia screening in sub-Saharan Africa, in a palliative care population. This study did not endeavor to conduct an in-depth analysis of the psychometric properties of the identified tools. 2.3. Methods The EBSCO, PUBMED, SCOPUS, Medline, Psych INFO, CINAHL and Africa-Wide Information databases were searched to identify dementia screening tools. The comprehensive search strategy focused on search terms in the categories of dementia, screening tools and subSaharan Africa. Included were all tools used to screen dementia in an adult population, provided the tools met one of the following validity criteria: face validity, or content validity, or concurrent validity as well as internal consistency. An abstract had to be available. The tool had to be peer reviewed, for use with human subjects, and in English. Exclusion criteria for the validated tools were: grey literature and the screening of children. 2.4. Results Stage 1 was to identify validated dementia screening tools internationally using the electronic databases listed above under methods. This search identified 116 articles written on global dementia screening tools. Stage 2 was performed on the same electronic databases to determine if any tools had been validated in sub-Saharan Africa. This search identified 8 articles on dementia screening tools validated in sub-Saharan Africa. The 3rd stage was to determine if any of the dementia screening tools from stage 2 had been validated in a palliative care population. In stage 3, 3 articles were identified all pertaining to the same dementia screening tool. The International HIV Dementia Scale (IHDS) was the only validated dementia r a g " I s screening tool found that had been validated in sub-Saharan Africa in an HIV population but not in a palliative care population. HIV can be seen as being included in a palliative care population. 2.5. Conclusion No validated tool was identified for the broad-based screening of dementia in sub-Saharan Africa in a palliative care population. The IHDS has been validated for use in screening for HIV-associated dementia in this region. This tool can still be used in the HIV population, but the author is of the opinion that the IHDS, as a screening tool for dementia, is not adequate in the general palliative care population. In the current clinical setting, the international gold standard tool for dementia screening, the Mini Mental State Examination (MMSE), is regularly used, and despite certain limitations associated with its use in the sub-Saharan Africa setting, the author recommends its continued use. The author recommends that the MMSE be revalidated for use in the sub-Saharan Africa palliative care population.