In South Africa, the highest HIV prevalence is amongst young people, who may have the greatest potential to contribute to the country’s economy. South Africa has one of the world’s largest antiretroviral (ARV) rollout programs. Like all medications, ARVs need to be taken as prescribed to be safe and effective. Excellent adherence is necessary to ensure that drug resistance does not develop. HIV cannot be cured, and at present ARVs must be taken for the rest of the patient’s life. In the ARV clinic in Knysna, an unanticipated category of patients has been identified: those who “bounce” in and out of long term therapy. Not only do these patients put their own health at risk, but the development and transmission of drug resistant HIV threatens the potential treatment options of the whole community. One of the problems identified in recurrently defaulting patients, is the difficulty in maintaining long term adherence to an ARV treatment program, while in full time employment. This is because as time goes on, patients need to balance the need for ARV care, which has rigorous clinic attendance parameters, with work attendance. Many employees have only twelve days of paid sick leave per annum, and patients require an average of eleven clinic visits in the first six months of treatment. This qualitative study gauges whether the services provided to HIV positive people living in Knysna meets the needs of their employers. The study interviewed both employees and employers to gauge the effects of HIV on local businesses, and explored the knowledge and attitudes of employers towards services provided by the Knysna ARV program. Employers were asked to suggest ways in which the services could be improved to better meet their needs, and ultimately, the needs of their employees.

M.Med.(Anaesthesia), Faculty of Health Sciences, University of the Witwatersrand, 2008 / BACKGROUND HIV infection is common in South Africa. The disease often remains clinically latent, despite the patient having severe immune compromise. Clinical preoperative assessment may result in patients with this severe systemic disease going unnoticed. OBJECTIVES The primary objective was to determine the relationship between the preoperative physical status of HIV-positive patients presenting for anaesthesia and the CD4- count. The secondary objectives were to determine the prevalence of HIV infection in this group of patients, to determine the prevalence of HIV infection in selected subgroups, to ascertain what proportion of patients presenting for anaesthesia know their HIV status, and to ascertain what proportion of HIVpositive patients are receiving highly active antiretroviral therapy (HAART). METHOD A sample of 350 adult patients presenting for anaesthesia at Chris Hani Baragwanath Hospital was selected. Patients were interviewed preoperatively and were examined, and in doing so their ASA physical status grading was determined. Blood was sampled, and in those who were confirmed HIV-positive, vi a CD4-count was checked. Further data were collected: age, gender, the type, nature, urgency and time of day of surgery, the patient’s knowledge of their HIV status, and whether the patient was receiving HAART or not. RESULTS HIV-positive patients were more likely to be classified as ASA 1 or 2 than ASA 3 or 4 (OR 2.1). HIV-positive patients with CD4-counts above 200 cells.mm-3 were also more likely to be ASA 1 or 2 than ASA 3 or 4 (OR 3.88). However, within the group of HIV-positive patients with CD4-counts below 200 cells.mm-3, significantly more patients were classified as ASA 1 or 2 than ASA 3 or 4 (p<0.0001). Three patients with CD4-counts below 50 cells.mm-3 were classified as ASA 1 or 2. The overall prevalence of HIV infection was 29.4%. Within the various subgroups, the groups with higher disease prevalence rates were females, patients presenting for obstetric surgery, and the younger age groups. The highest prevalence of HIV infection was found in patients aged 30-39 years (43.0%), and the lowest prevalence was found in patients aged 60 years or older (7.7%). CONCLUSIONS Routine clinical preoperative assessment in patients from a population with a high HIV prevalence rate may result in asymptomatic, severe immune compromise secondary to HIV infection being missed in a significant number of patients. Further study into the perioperative outcomes of these patients is warranted.

M.Dent.(Community Dentistry), Faculty of Health Sciences, University of the Witwatersrand, 2009 / Title: Knowledge, Attitudes and Practices of caregivers about oral lesions in HIV positive patients in NGOs /CBOs in Region 8, Johannesburg, Gauteng. Background: The HIV pandemic continues to be a major public health problem in South Africa where 11% of people were infected with HIV in 2005(HSRC, 2005).The care and support of these patients as they eventually become ill will necessitate the increase in use of community-based/homebased/ hospice institutions. The City of Johannesburg (CoJ), one of the metropolitan municipalities (local government) in Gauteng Province-SA, has been planning the development and implementation of programmes related to the prevention, care and support for people infected and affected by HIV/AIDS. Care and support has been limited to 18 NGOs/ CBOs. Four of these institutions provide palliative care and are staffed by 64 caregivers. Studies done throughout the world indicate that oral lesions associated with HIV occur in over half of HIV/AIDS patients. These oral lesions seriously impair the oral-health-related-quality of life in affected individuals and necessitate the need to provide services to alleviate them and improve patient comfort. The caregivers in the NGOs/CBOs are therefore pivotal in offering care and support in the management of HIV including the management of oral lesions. In order for the caregivers in the NGOs/CBOs to be able to manage the disease in its entirety; they need optimal knowledge of the infection/illness including the oral manifestations associated with the ailment. Objectives: (1.) To determine the knowledge of the caregivers in the NGOs/CBOs providing palliative care in Region 8, CoJ, Gauteng regarding common oral manifestations associated with HIV. of the caregivers in the NGOs/CBOs . (2.) To assess the attitudes of the caregivers in the NGOs/CBOs providing palliative care in Region 8, CoJ, Gauteng on common oral manifestations associated with HIV. (3.) To determine the practices of the caregivers in the NGOs/CBOs in Region 8, CoJ, Gauteng, pertaining to the common oral manifestations associated with HIV. (4.) To determine the sociodemographic profile of the caregivers providing palliative care in the NGOs/CBOs in Region 8, CoJ, Gauteng. Methods: A descriptive cross-sectional study was conducted where all caregivers providing care and support in the four NGOs/CBOs were invited to participate in the study. Data was collected by a customised questionnaire to obtain information on demographics, knowledge, attitudes and practices on providing for HIV positive patients. Results: The results were grouped according to training in oral health care (TOHC) and no training (NTOHC). The mean age was 43.5 years for TOHC and 30.8 years NTOHC and was statistically significant (p<0.005). There were statistical significant differences in the gender proportions in within groups in the both groups, employment status, work experience as a caregiver and training in general home-based care (p<0.05). Most (72.2%) of those NTOHC had little experience (<1 year) of care giving compared to 41.1% (p=0.03) and 33.3% were providing care without training in homebased care (HBC) compared to 100% (p=0.00). The caregivers trained in oral health care had knowledge levels shown by higher knowledge levels on four of seven variables compared to those who were not trained in oral health care (p< 0.05, Table 3.3 p.21). The majority of caregivers NTOHC reported that caring for the mouth of HIV positive patients is an ‘unpleasant difficult task and poses an infection risk to the caregivers’ while these concerns were expressed by the minority of caregivers TOHC (p<0.05). Practices performed by caregivers NTOHC were appropriate for dry mouth, difficulty in swallowing but was inappropriate for bleeding gums and bad breath while those caregivers TOHC provided appropriate advice/practices for oral thrush, bad breath, bleeding gums, dry mouth with statistical difference. Conclusion: The caregivers TOHC had fairly better knowledge, attitudes and practices regarding oral lesions in HIV compared to those NTOHC. There was strong likelihood of knowledge variables and training in oral health care. Recommendations: Bearing in mind the limitations of KAP surveys and the cross sectional nature of the study, it is recommended that training in oral health care and refresher courses for those trained must be incorporated into the programme of all caregivers working in palliative institutions because it will provide specialised knowledge about oral health and oral lesions in HIV improve their knowledge, attitudes and practices and thus provide a better service to their patients.

Objective To determine the reasons for the change or modification in the first line HAART regimen (1a and 1b) in HIV positive patients at the Thusong CCMT site. Methods This study is a quantitative descriptive study using a standardized data collection tool to extract retrospective data from medical records. Subjects Subjects for this study included patients 18 years or older attending the Thusong CCMT site, which were started on HAART regimens 1a or 1b and were on treatment for at least 6 months. The final sample size evaluated was 257 patients. Results There was a high rate (43%) of change or modification of the first line HAART regimen. Majority of the patient’s (72%) had their regimen modified due to side effects of the drugs and only a small number (9.7%) of patients had a complete change in the regimen due to virological failure. Stavudine (d4T) associated lipodystrophy was the most common side effect (45.5%) followed by peripheral neuropathy (16.7%), leading to treatment modification. Conclusion The rate of modification or change of first line HAART regimen, at Thusong CCMT, was fairly high (42.6%), and the most common reason for the modification or change was drug side effect of stavudine (d4T).

Thesis (M.Cur.) --University of Limpopo, 2013 / Previous research about people living with HIV and AIDS has highlighted social support as an important determinant of health outcomes; i.e. perceived support to be associated with adjustment and coping in relation to HIV diagnosis, as well as its potentially chronic and disability course . The purpose of the study is to determine the effects of HIV and AIDS on the socio-economic status of people infected with HIV and AIDS at the village of Ga-Mathabatha in the Capricorn District of the Limpopo Province, South Africa. In this study, a qualitative, descriptive, exploratory and contextual design is used. A non-probability purposive sampling technique was used to carefully select the sample based on the knowledge that the participants had about the phenomena studied. Semi-structured, one-on-one, in-depth interview with a schedule guide were conducted until saturation of data was reached. To initiate each interview, a central question was was asked: “Describe the effects that HIV and AIDS have on your socio-economic status”. Participants were given an opportunity to describe their experiences with regard to the effects of HIV and AIDS on their socio-economic status. Field notes of semi-structured, one-to-one, in-depth interview session were recorded. A voice recorder was used to capture all the semi-structured, one-to-one, in-depth interviews. The recorded interviews were transcribed verbatim, using Tesch’s qualitative data analysis method. Trustworthiness was ensured by using Guba’s model criteria; i.e. credibility, transferability, confirmability, and dependability. The results indicate that HIV and AIDS have an effect on the socio-economic status of HIV-positive people. Ethical standards for nurse researchers were adhered to, namely permission to conduct the study was obtained from the Medunsa Research and Ethics Committee. Permission to conduct the research project was granted by the Limpopo Turfloop Campus, Limpopo Provincial Department of Health and Social Development, and the ART clinic management at the Ga-mathabatha Relebogile Wellness and ART Clinic. To ensure confidentiality and anonymity, written informed consent was obtained from each participant before he/she could participate in the study. The quality of the research was also insured. Five themes and their sub-themes, and the literature control are presented in the discussion of the research findings. The findings of this study have a central story line which reveals that participants are sharing similar experiences in terms of socio-economic factors after they have tested HIV-positive which are related to several factors; including the involvement of family and friends in their care, changes encountered which affect their social life, household income, and their living conditions. The following five themes and their sub-themes have emerged during data analysis: Theme 1: Different sources of income of HIV-positive people; Theme 2: Living conditions of HIV-positive people; Theme 3: Consequences related to HIV and AIDS disease progression; Theme 4: Support and care to HIV-positive people; and Theme 5: Disclosure versus non-disclosure of HIV-positive status. The results of this study are limited to the Relebogile Wellness and ART Clinic in the Ga-Mathabatha area of the Capricorn District in the Limpopo Province, South Africa. The study findings cannot be generalised to all clinics that are issuing ARVs in the Capricorn District. Study conclusions emphasise the fact that there is a need for HIV and AIDS positive patients to receive continuous support from family, friends, and the community with the purpose of enabling them to cope emotionally, socially, and economically. It also reveals the importance of participants to take their treatment as prescribed with the aim of improving their immune systems. The recommendations emphasise the fact that there is a need for HIV and AIDS patients to receive continuous support from family, friends, and the community with the purpose of enabling them to cope emotionally, socially, and economically. TERMINOLOGY Human Immunodeficiency Virus (HIV) HIV is a virus which has a known and distinct capacity to cause Acquired Immune Deficiency Syndrome once it has entered the body. It attacks a person’s immune system (Kaushik, Pandey & Pande, 2006:43) Acquired Immunodeficiency Syndrome (AIDS) It is the fourth stage of HIV infection and it is usually characterised by a CD4 count of less than 200. It is not a specific illness but rather a collection of illnesses that affect the body to such an extent that the weakened immune system struggles to respond effectively (Kaushik et al., 2006:43) Effects Effects are consequences that are brought about by a cause (Kaushik, Pandey & Pande, 2006:56). Examples of effects are changes in the health status, and standard of living of a population as a result of a programme, project or activity. In this study, effects refer to changes in the socio-economic status of a population that have occurred as a result of the breadwinner in a family who has become unable to go to work due to a weakened immune system that results from HIV and AIDS. Epidemic It is the occurrence of cases of an illness (or an outbreak) in a specific population with a frequency clearly in excess of the normal probability (Giesecke, 2007:19). In this study, an epidemic refers to the effect HIV and AIDS has on the population. Socio-economic status Socio-economic status refers to the standardised way of grouping a population in terms of parental occupation, income, power, prestige, and education (Kirsh, 2006:287). In this study, socio-economic status defines a person’s monthly income, education, and occupation. Family A group of people living together in a permanent arrangement, separated from the rest of the world by the walls of the family dwelling and by societal guarantees of family privacy (Bachmann & Booyens, 2006:4). In this study, a family denotes those people who are living under the same roof with a breadwinner who is HIV-positive.

Thesis (MSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Efavirenz is an antiretroviral drug used in the treatment of HIV-positive patients as part of first line triple-highly active antiretroviral therapy. Treatment response varies among individuals and adverse drug reactions tend to occur, as a result of the variation in the rate of efavirenz metabolism among individuals. This is partly caused by genetic variation; therefore the study of genes involved in the metabolism of efavirenz, such as CYP2B6, could potentially enhance treatment success. The effect of CYP2B6 SNP 516G>T (part of the CYP2B6*6 allele) is particularly important, as individuals homozygous for the minor allele of this SNP have significantly increased efavirenz levels. Furthermore, nuclear receptors, specifically constitutive androstane receptor, encoded by NR1I3, and pregnane X receptor, encoded by NR1I2, are involved in the regulation of the genes responsible for efavirenz metabolism and could therefore indirectly influence the pharmacokinetics of efavirenz. The current study identified variants in the NR1I3 and NR1I2 genes through in silico analysis, bi-directional sequencing and literature searches. A total of nine NR1I3 and ten NR1I2 target variants were subsequently genotyped in 132 HIV-positive female patients from the Xhosa and Cape Mixed Ancestry populations. The resulting genotype and allele frequencies were statistically analysed to search for correlations between genetic variations and available efavirenz levels in hair samples, treatment outcome as measured by viral load, and the occurrence of adverse drug reactions. The minor allele of a NR1I2 5’-upstream SNP, rs1523128 (6334A>G), was significantly associated with decreased efavirenz levels. From analysis of the effect of composite SNPs, NR1I3 5’-upstream SNP rs55802895 (258G>A) in conjunction with CYP2B6*6, was significantly associated with efavirenz-levels. It was found that the minor allele of rs55802895 inhibited the effect of CYP2B6*6, resulting in normal efavirenz levels for individuals homozygous for the minor allele of both SNPs. Additionally, when the target NR1I3 and NR1I2 variants were analysed in conjunction with six SNPs from CYP1A2, CYP2A6, CYP3A4 and CYP3A5, 11 compound genotypes were shown to be statistically associated with mean EFV plasma levels. The study emphasises the complexity of efavirenz metabolism, and the importance of transcriptional regulation in xenobiotic metabolism. / AFRIKAANSE OPSOMMING: Efavirenz is ‘n antiretrovirale middel wat gebruik word in die behandeling van HIV-positiewe pasiënte as deel van drievoudige hoogs-aktiewe antiretrovirale terapie. Reaksie op behandeling verskil tussen individue en nadelige newe-effekte, wat veroorsaak word deur die verskil in tempo waarteen efavirenz gemetaboliseer word, neig om voor te kom. Hierdie verskille word gedeeltelik veroorsaak deur genetiese variasie; dus kan die studie van gene betrokke by die metabolisme van efavirenz, soos CYP2B6, moontlik die sukses van behandeling verhoog. Die effek van CYP2B6 SNP 516G>T (deel van die CYP2B6*6-alleel) is veral belangrik, want individue wat homosigoties is vir die minderheids-alleel het betekenisvol hoë efavirenz-vlakke. Nukleêre reseptore, spesifiek konstitutiewe androstane reseptor, deur NR1I3 gekodeer, en pregnane X reseptor, deur NR1I2 gekodeer, is betrokke by die regulering van die gene verantwoordelik vir efavirenz-metabolisme en kan dus die farmakokinetika van efavirenz beïnvloed. Die huidige studie het variante in NR1I3 en NR1I2 identifiseer deur in silico-analise, bi-direksionele volgordebepaling en ’n literatuurstudie. Nege NR1I3 en tien NR1I2-variante in totaal is vervolglik gegenotipeer in 132 HIV-positiewe vroulike pasiënte van Xhosa en Kaapse Gemengde Afkoms populasies. Die gevolglike genotipe- en alleelfrekwensies is statisties geanaliseer om vir korrelasies tussen genetiese variasies en beskikbare efavirenz-vlakke in haarmonsters, uitkoms van behandeling gemeet in virale lading en die voorkoms van nadelige newe-effekte te soek. Daar is gevind dat die minderheids-alleel van ’n NR1I2 5’-stroomop SNP, rs1523128 (6334A>G), betekenisvol geassosieer is met ’n daling in efavirenz-vlakke. Vanuit die saamgestelde SNPs, is die NR1I3 5’-stroomop SNP rs55802895 (258G>A), tesame met CYP2B6*6, betekenisvol geassosieer met efavirenz-vlakke. Daar is gevind dat die minderheids-alleel van rs55802895 die effek van CYP2B6*6 demp, en gevolglik normale efavirenz-vlakke in individue homosigoties vir die minderheids-allele van albei SNPs veroorsaak. Addisioneel is die teiken NR1I3 en NR1I2 variante gemeenskaplik met ses SNPs van CYP1A2, CYP2A6, CYP3A4 en CYP3A5 geanaliseer en 11 gekombineerde genotipes is statisties geassosieer met gemiddelde EFV plasma vlakke. Hierdie studie beklemtoon die kompleksiteit van efavirenz-metabolisme en die belangrikheid van transkripsionele regulering in xenobiotiese metabolisme. / National Research Foundation (NRF)

Introduction: Decentralization of antiretroviral therapy (ART) services faces decreasing quality when increasing ART coverage. This study compares nurse initiated and managed patients to doctor managed patients under these circumstances, using retention in care as a crude measure of quality of care. Methods: This was an observational retrospective cohort study. A simple data abstraction tool was used to collect baseline patient data from medical records of HIV positive patients (N=871) initiating ART at Mbabane Government Hospital and four of its outreach clinics, between 1st January and 30th June 2011. Descriptive summary statistics and comparison of the two cohorts using multivariate analysis was done. Results There was no statistically significant difference in retention rates between the doctors and nurses cohorts at 69.1% and 70.9%, respectively (P was 0.56). After adjusting for sex, haemoglobin, CD4 cell count, weight and WHO stage, the odds of being retained in care were similar between the two groups, adjusted OR: 1.11(95% CI: 0.72, 1.69), with a p value of 0.64. Haemoglobin and weight were positively associated with retention in care, while male sex was negatively associated with retention in care. Discussion: The similar retention rates between the two cohorts suggest that in terms of retention in care the service provided by the nurses was comparable to that provided by doctors. This is important to ART program managers as they scale-up ART decentralization. Conclusion: Task-shifting of ART initiation from doctors to nurses is feasible as nurse initiated and managed antiretroviral therapy is comparable to doctor initiated and managed treatment. / Dissertation (MSc)--University of Pretoria, 2014. / gm2014 / Clinical Epidemiology / unrestricted

Objective: The objective of this cross sectional study was to compare the clinical presentation and response to treatments, in HIV positive and TB smear positive patients treated during the pre-Highly Active Antiretroviral Therapy (HAART) and Highly Active Antiretroviral Therapy (HAART) era (2004 and 2007), in St Joseph’s hospital Roma Lesotho. Comparison was done in terms of age, sex, sputum conversion at 2months and 6months end of TB treatment, baseline and 6 months end of TB treatment weight, weight gained and radiological presentation and resolution. Method : It was a cross sectional study design. Data was captured from the TB/HIV register, for pre-HAART era data of patients registered in the 2004 TB/HIV was captured and for the HAART era data of patients registered in the 2007 TB/HIV was captured. Cases were individuals with sputum smear positive tuberculosis and confirmed HIV infection, presenting in the pre HAART era (2004) and in the HAART era (2007). For inclusion in the HAART era, an individual had to be on HAART for at least2 weeks or more. A total of 113 Patients were analysed and 85 patients the HAART era. Comparison of continuous measurements was done with a t-test and categorical measurement was done with a chi-square test. Multivariable logistic regression was used to detect differences between the pre-HAART and HAART era Result: One hundred and thirteen (113) patients were analysed in the pre-HAART era and eighty five (85) in the HAART era. Mean age of presentation was lower in the pre-HAART era 36.1 years compared to HAART era 39.3 years with statistically significant result (p=0.0362). Pattern of sex distribution was similar in both era, (p-value=0.85). Sputum conversion showed statistically significant differences at 2 months, 95.2% of the HAART patients had sputum reverted whereas, 83.2% of the pre-HAART had sputum reversion (p-value=0.009), but no statistically significant result was seen at 6 months (p-value=0.38). Weight did not differ significantly between the two time periods, but there was a statistically significant difference in terms of mean weight gained in Haart era. Patients in the HAART era gained 0.92kg at the end of treatment compared to pre HAART era (p-value=0.001). Radiological presentation and resolution did not differ significantly between the two time periods. (p-value= 0.36). Conclusion : Smear positive TB/HIV co-infected patients in the HAART era were older at presentation, had better sputum conversion at 2 months and improved weight gain at 6 months end of TB treatment. Comparison with a historical control group alone however does not conclusively prove that this effect is due to HAART. Copyright / Dissertation (MSc)--University of Pretoria, 2010. / School of Health Systems and Public Health (SHSPH) / Unrestricted

Health Studies / (M.P.H. (Health Studies))

Stigma and discrimination (SAD) attached to Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) has been recognised as a major obstacle to HIV prevention, treatment, care and support throughout the world. SAD is more devastating when it occurs in health care settings where it is least expected. Health care providers (HCPs) are supposed to provide physical, social and psychological support to people living with HIV (PLWHA) but HIV and AIDS-related SAD has been extensively documented among the HCPs. Different studies have pointed out that there are three major actionable causes of HIV-related SAD in health care settings. These are lack of awareness among HCPs, fear of casual contacts and associating the SAD to immoral behaviour. The main objective of the current study is to determine the magnitude of HIV and AIDS-related SAD and its associated factors in hospitals and then to propose appropriate SAD reduction-intervention strategy in the health care settings. The study employed pre-test-post-test design with non-equivalent control group. Two paradigms were used in this study including quantitative and qualitative approaches. The sampling method for the quantitative part of the study was probability sampling in which the respondents were randomly selected using stratified sampling technique. The study was able to determine the magnitude of HIV and AIDS-related SAD among the HCPs. Moreover, the study has identified the factors that are attributed to the prevalence of SAD in the hospitals. The major factors identified for causing the SAD in the hospitals were sex, age, work experience, low level of knowledge, negative attitudes and percieved risk of HIV infection of some HCPs toward the PLWHA. The intervention made on the respondents in the treatment group was able to reduce the overall prevalence of the SAD among the HCPs. The study suggests that to reduce the SAD, HIV and AIDS-related trainings before and after graduation is critical to improve the knowledge, attitudes and practices of the HCPs. Besides, ensuring the availability of the protective supplies in hospitals is crucial in reducing the fear of HIV infection among the HCPs while providing care for HIV positive patients. Effective implementation of the hospital policies, strategies, guidelines and protocols along with good institutional support is also vital in creating safe and user-friendly hospitals for PLWHA. / Health Studies