Thesis (MPH) -- University of Limpopo, 2012. / No Summary

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Background: The HIV/AIDS epidemic is continuing to impact negatively on the health of populations globally. The region most affected by this epidemic is sub-Saharan Africa, with two-thirds of people living with HIV/AIDS located in this region. In order to combat this epidemic, countries are putting up efforts to scale-up the provision of antiretrovirals to affected individuals. South Africa faces challenges similar to other sub-Saharan countries in the scaling-up of antiretrovirals, such as cost of drugs, inadequate laboratory infrastructure and the low and declining number of health professionals. Therefore, the contribution of private general practitioners as part of the overall strategy to combat the HIV/AIDS epidemic needs to be considered. However, the performance of antiretroviral programmes in the private sector are unknown and there is therefore a need to explore patient outcomes in antiretroviral programmes being run by general practitioners in the private sector. The findings of this study will add to understanding what the outcomes of ARV programmes by GPs in private practice could be in a public-private partnership. Aims: The main aim of the study was to evaluate patient outcomes in an antiretroviral programme in the setting of a solo private general practitioner. Methods: This was a cross-sectional study using retrospective data from March 2005 to February 2008. A total of 170 patient records from a private general practitioner’s rooms were examined. The data were analysed using the using the median, interquartile and proportions. The Chi square was used to test for association between baseline characteristics and patient outcomes in the univariate analysis. Results: The increase in median CD4 count was 242 cells/μl and 265 cells/μl at 6 months and 12 months respectively. The proportion of patients who achieved viral suppression at 6 months and 12 months was 75% and 73% respectively. Rate of loss to follow-up was 29% and 38% at 6 months and 12 months respectively, which was much higher than in other settings. Although there were no statistically significant associations established by the study, the patterns emerging from the study showed that the baseline characteristics that were a risk for poor virological outcomes during the period of the study were female gender, younger age group, higher WHO clinical staging, lower CD4 count and higher viral load. Baseline characteristics that were a risk for loss to follow-up during the period of the study were male gender, younger age group, higher WHO clinical staging, lower CD4 count and higher viral load. Conclusion: Patient outcomes in an antiretroviral programme in the setting of a solo private general practitioner are comparable with patient outcomes in antiretroviral programmes in public sector settings in terms of immunological and virological outcomes. However, the lost to follow-up rate was much higher than in public sector settings.

A research report submitted in submissible format to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of MSc in Child Health (Community Paediatrics) 20 June 2017 / Background: HIV antiretroviral therapy (ART) is associated with breast abnormalities in adults, especially efavirenz (EFV). Little is known about the prevalence of these adverse effects among adolescents receiving ART. Methods: A retrospective record review describing breast conditions in adolescents receiving ART at three facilities in Johannesburg, South Africa was conducted. Patients aged 10-19 years who presented from 1 January to 31 December 2014 were included. Analyses were conducted to determine whether EFV use was associated with an increase in breast conditions. Results: A total of 631 patient records were reviewed, 37 (6%) had an abnormal breast event documented of whom 24/37 (65%) were male. Patients with abnormal breast conditions developed them 1.5 years later than patients with normal breast development (p<0.0005). Forty-one abnormal breast events were observed in thirty-seven patients with twenty being described as gynaecomastia or lipomastia (49%). 44% had concurrent generalised lipodystrophy (n=19). Of those with an abnormal breast event, 71% of patients had CD4 counts >500 cells/μl and were virologically suppressed (n=29). Those on EFV had a significantly higher prevalence of breast abnormalities compared to other regimens (p=0.016) and all had been exposed to EFV before. No other ART drug was associated with breast abnormalities in this cohort. Sixteen patients had substitution of EFV and three breast events resolved once substituted from EFV. Breast abnormalities in adolescents on ART Conclusion: Six percent of patients had an abnormal breast condition in this study. Use of EFV and increasing age were associated with breast abnormalities in this population. Further research is needed to better understand this phenomenon. / MT2017

MA, School of Human and Community Development, Faculty of Humanities, University of the Witwatersrand / HIV/AIDS remains a global pandemic that is affecting millions of people. The advent of antiretroviral medication in the late 1980s has led to major advances in clinical treatment that has turned the deadly disease into a chronic condition for those who are infected. However, adherence to antiretroviral medication remains problematic. Whilst extensive international research has been done to identify various variables that contribute to rates of non-adherence, there is not much research being done in South Africa that provides a reliable prediction of non-adherence or generates a theoretical understanding of the issue. The main aim of this study was to ascertain the barriers and facilitators that contribute to the level of adherence to antiretroviral treatment. This was done from a biopsychosocial perspective that takes into account not only the biomedical factors that may have an impact on antiretroviral treatment levels but also includes the various psychological and socio-political factors that contribute to non-adherence. The qualitative research methodology was used. Data was collected from 14 participants using semi-structured interviews. The participants included 3 medical practitioners, 1 nutritionist, 2 counsellors, 2 treatment activist, 2 caregivers to PLWHA and 4 people on treatment. Interviews were audio-recorded and transcribed. Thematic content analysis was used to generate themes. Themes were categorised under individual, interpersonal level and systemic level barriers and facilitators to ARV treatment which included biomedical, psychological as well as social-political factors that facilitate non-adherence. The main findings in this study suggest that there is a complex web of interaction between the various biomedical, psychological and socio-political factors that impact on adherence levels. Additionally, the response by PLWHA to their illness and subsequently to ARV treatment is more complex than a mere conforming to a set of medical standards and instructions. As such intervention that looks to increase adherence levels cannot be a one-dimensional or onesided endeavour and requires a multifaceted approach.

Background: The government of South Africa rolled out free anti-retroviral treatment in 2004 but many people living with HIV still present late for treatment while others choose to die rather than accessing this free treatment. This qualitative study was done at Potchefstroom Provincial Hospital Wellness Clinic to establish why many people living with HIV in Potchefstroom present late for treatment. Aim: To establish why people living with HIV/AIDS in Potchefstroom delay in accessing antiretroviral therapy. Objectives: 1.To conduct interviews with selected patients, in order to understand why they delayed accessing antiretroviral treatment. 2. To assess the demographics of patients who delayed in accessing antiretroviral treatment. Methods: This is a qualitative study carried out at the Wellness clinic of the Potchefstroom provincial hospital in the North West province of South Africa. Eight adult participants (3 females and 5 males) were interviewed individually in English, in one-on-one free attitude interviews and the conversations were audio-taped by the researcher. All the respondents were from the nearby black township of Ikageng. The respondents were selected after meeting the inclusion criteria of the study. The researcher asked the respondents to freely describe the reasons why they started antiretroviral treatment late. In addition, a semi-structured open ended questionnaire was also used by the researcher to prompt responses. Interviews went on until saturation point was reached. The audio-taped interviews were transcribed verbatim and the responses were analyzed. Responses from the different participants which bore similarity were assigned a similar color code. By using the cut and paste method, all responses bearing the same color code were pasted on one page resulting into the themes. Results: Four broad themes emerged as the reasons responsible for the late accessing of ART by the respondents. These themes were: 1. Stigma and discrimination, 2. Ignorance and lack of perceived risk of infection, 3. Denial, and 4. Health care system constraints. Conclusions: This small study though not exhaustive by any means, has highlighted some of the reasons why people living with HIV present late for help. The study was done using participants from only one peri-urban population. It is therefore not easy to generalize the results to the whole of South Africa, a country with a lot of social and economical diversities among its people. A bigger study over a wider geographical area might reveal different findings.

Research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree MASTER OF MEDICINE (MMED.) (PAEDIATRICS AND CHILD HEALTH). Department of Paediatrics and Child Health Johannesburg, South Africa, 2012 / Cardiovascular disease is a common complication of advanced HIV disease in both paediatric and adult patient groups and may present with left ventricular (LV) dysfunction. Introduction of Highly Active Antiretroviral Therapy (HAART) has improved outcomes in patients presenting with LV dysfunction. However, mitochondrial toxicity, a complication of HAART, may present with myocardial dysfunction.

M.P.H., Faculty of Health Sciences, University of the Witwatersrand, 2011 / Background Few results are available concerning long-term clinical outcomes in ART treatment programs. The objective of this study was to describe clinical and laboratory outcomes for adult patients commenced on ART in Selebi Phikwe, Botswana from June 2004 to June 2005 within one year of commencement of ART. Methods Cross-sectional descriptive study of clinical and laboratory outcomes for 904 adult patients initiated on ART in Selebi Phikwe, Botswana, from June 2004 to June 2005. Data from ART services statistics was analyzed using descriptive statistical methods. Results Most patients had low a basal CD4 cellular count with a median count of 25 cells, which rose to 147 after 12 months of treatment. Of the 84 (9%) deaths, 75 (89%) had a basal CD4 count of less than 10 cells and 48 (57%) died within three months of commencing of ART Conclusion Good clinical and laboratory outcomes for patients on ART in resource limited are achievable. Mortality commonly occurs among patients with low CD4 counts and within three months of commencement of therapy.

M.Sc.(Med.), Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, 2011 / Background The therapeutic goal of HAART is sustained immune recovery and viral suppression. However some patients still have poor CD4 count responses despite achieving viral suppression. Such discordance immune response has been associated with poor clinical outcomes. We describe the prevalence of discordant immune response during the first 6-months of HAART and determine risk factors associated with this discordance at two large public sector clinics in South Africa. Methods We analysed data from 6 460 HIV-infected adults initiated onto first-line HAART at Goba and Phola Park clinics, in Johannesburg, South Africa between November 2008 and December 2009. Multivariable logistic regression models were used to estimate adjusted odds ratios (AOR) for associations between discordant immune response and clinical and demographic factors. Models were adjusted for WHO clinical stage, baseline CD4 count, education level and HAART regimen. Results At initiation of HAART, most patients were female 592(64.6%) and 803(87.6%) were initiated on 3TC-d4T-EFV/NVP. The mean CD4 count was 155 cells/mm3 (±118.4 sd), mean age was 38.5 years (±8.7 sd) and most patients had haemoglobin >11g/dL (n=645, 71.2%). By 6-months after initiation of HAART, 24% (n=220) of patients had a discordant immune response, 7% (n=67) discordant virologic 5 response and 21% (n=1359) had been lost to follow-up. In multivariable analysis, higher baseline CD4 cell count (CD4≥200cells/mm3): AOR=3.02; 95%CI 2.08-4.38; p<0.001) and moderate anemia (8-9.4 g/dL) at baseline (AOR=2.30; 95%CI 1.25-4.59; p=0.007) were the strongest predictive factors for development of discordant immune response. Conclusions We found a significant proportion of patients with discordant immune response 6-months after initiating HAART. Simple algorithms utilizing baseline characteristics can be developed for use in clinics in order to identify those patients at risk of development of discordant immune responses. Intensive monitoring of individuals at risk may improve clinical outcomes.

Background Potential causes of poor antiretroviral therapy (ART) treatment outcomes can be patient or health system related. Data on the effect of health system on ART outcomes is scarce. Objective: To compare treatment outcomes of HIV positive adults (≥18 years) initiating ART in either private or public HIV clinics in Johannesburg, South Africa. Methods: A retrospective cohort analysis was conducted on HIV positive, ART naïve adults initiating ART at a public (Themba Lethu Clinic) or private HIV clinic in Johannesburg between 01 January 2005 and 31 December 2011. Treatment outcomes included mortality, loss to follow up (LTFU; defined as >90 days since last scheduled visit date), failure to suppress viral load (>400copies/ml) at 6 and 12 months and absolute change in CD4 count from baseline until 6 and or 12 months after ART initiation. Survival analysis was performed using Kaplan Meir curves. Multivariate Cox proportional hazards models were used to assess predictors of mortality and LTFU. Generalized estimation equations were used to determine predictors of failure to suppress viral load while absolute change in CD4 count was analysed using the Wilcoxon rank sum test. Results: A total of 11690 patients initiated ART at the public clinic compared to 574 at the private clinic. Patients were similar in terms of age, gender and baseline viral load. Private clinic patients were less likely to die [aHR=0.39;95% CI 0.14-1.06] or to be retained on ART [aHR=1.59;95% CI 0.94-2.70], although both estimates lacked statistical significance. Public clinic patients presented with advanced HIV [WHO stage 3 or 4, p<0.001] compared to the private clinic. However, private clinic patients were 63% more likely to have a detectable viral load at 12 months of follow up [RR=1.63;95% CI 1.15-2.32]. There were no differences in the absolute CD4 changes between the private and public clinic at 6 months (median 99 IQR 43-78 vs. 103 IQR 52- 168; p=0.584) respectively. Conclusion: This study demonstrates that health systems have an influence on ART outcomes. The private sector is commended for early initiation of treatment and the availability of a variety of ARV drugs. However there is need for standardization of prescribing practices and care. Better virological responses amongst public patients can be attributed to better adherence to treatment and reduced LTFU rates compared to the private sector. Public-private partnerships are thus encouraged to address shortcomings of either sector.