In November 2003, the Department of Health launched the Operational Plan for Comprehensive Care, Management and Treatment (CCMT) for South Africa. This policy has as its central goal universal access to antiretroviral therapy to 1 million people living with HIV by the end of 2007. National implementation of the operational plan began in April 2004 and as at the end of October 2006, South Africa had initiated 213 828 people onto ART through the Plan, making it the biggest programme in the world. Of these, 55 580 people had been placed on treatment in Gauteng Province. Despite these early achievements, there are concerns as to whether the South African public health sector can rise to the challenge of universal access while achieving good clinical outcomes and programme performance. As Venter (2006: 298) states, “the health sector is buckling under the current load, and currently does not have the capacity to do anymore than dent the numbers needed to treat, unless a radical restructuring of health services occurs.” A crucial factor in providing a comprehensive approach to HIV/AIDS is the reorientation of service delivery from acute to chronic disease care. In addition to the shift in focus to chronic disease management of HIV/AIDS, health system constraints need to be addressed. These include inadequate health system infrastructure and human resources. This study aimed to comprehensively assess organisational capacity to provide antiretroviral therapy (ART) in two public sector CCMT sites in Gauteng Province and the influence of these organisational factors on follow-up and adherence to ART, with the view to understanding whether public sector CCMT sites are able to deal with new challenges posed by the Plan. The objectives were to assess: (1) levels of follow-up and adherence in patients registered at the CCMT site, (2) dimensions of organisational capacity, drawing on internationally recognised chronic disease care frameworks, namely the Wagner Chronic Care Model (CCM) and Innovative Care for Chronic Conditions (ICCC). These dimensions were: presence of motivated and adequately staffed teams; delivery systems design; the quality of support systems; and facility information systems. 3) the similarities and differences between the two sites with respect to organisational capacity, follow-up and adherence. The two sites were selected through a stratified (CHC and hospital) random sample of CCMT sites in Region A of the province, excluding the long–standing and well-established academic hospital CCMT sites in the sampling frame. The two sites, located in a District Hospital in the West Rand and a Community Health Centre (CHC) in Central Witwatersrand, were visited between May and July 2006. They had initiated 540 and 1001 patients on ART respectively since October 2004. A multi-method health service evaluation of capacity in the HIV related services (ART/Wellness, VCT, PMTCT, and TB) was conducted. This consisted of 11 semi-structured interviews with facility and programme managers; review of registers and routine facility data; an observation checklist and mapping to assess the physical infrastructure of the facility, presence of management and health information systems; 35 self administered questionnaires to assess the levels of motivation of nursing staff at each site. Data on self-reported adherence and viral loads were obtained from a separate study involving exit interviews with 356 patients who had been attending the services for at least four months in the two sites.1 Of the 540 and 1001 patients enrolled in the two services, 69.8% and 69.3% were still in the service after 18 months at the hospital and CHC, respectively. The monthly drop-out rate at the hospital had risen fairly sharply towards the end of the 18 month period, attributed by the staff to growing difficulties in access to the site by new enrolments. Nevertheless, based on self-reports (3- day recall period), viral load measures, and loss to follow-up, adherence levels at both sites appeared to be in line with national and international best practice. The percentage of patients with undetectable virus was 76.2% and 74.4% at the hospital and CHC, respectively. Staffing of the CCMT sites matched the pre-requisites outlined by the National Department of Health for a ‘core’ health care team treating 500 patients. The CHC CCMT site, however, had more than 500 patients on ART and moreover was providing two services within one unit, i.e. ART/Wellness and VCT thus increasing the patient load. Sites were reaching saturation and this was due to the lack of sufficient space coupled with the high volumes of patients, shortage of certain scarce skills (in particular pharmacy staff), and the multiple responsibilities of nursing staff. In general, the staffing situation at the hospital appeared better. More staff had joined than left the hospital over the year prior to March 2006, and clinical workloads both in the ambulatory services and the CCMT site were less than at the CHC. Vacancy rates were low, at 13.8% and 4.8% for the hospital and CHC, respectively. Strong leadership of CCMT sites by motivated ART programme managers was displayed; site managers were highly respected and revered by staff. Based on ratings in a self-administered questionnaire, overall levels of motivation and organisational commitment at both sites appeared good, although, worryingly, a sizeable proportion of respondents in both sites agreed with statement “I intend to leave this hospital/clinic.” Lack of external support (from the HIV/AIDS, STI, TB Programme) and debriefing systems for programme managers and nursing staff was identified as weaknesses. With some exceptions, both sites showed evidence of strong ‘horizontal’ mechanisms of referral and coordination between HIV and AIDS related services within sites; however the PMTCT programme at the hospital was less co-ordinated and networked with other services. In addition, ART and PMTCT programme managers at the hospital indicated that the relationship between hospital services and surrounding clinics was poor. Apart from the lack of space at the CHC CCMT site, support systems were adequate. There were no reported drug stock outs and supply of drugs and general supplies was good at both sites. Both sites were able to offer a range of routine and HIV specific tests. A combination of paper and electronic based information systems were used at both sites, however, the hospital CCMT site used a mixture of standard and locally designed data collection forms compared to the CHC which mainly used standard Department of Health forms. The information systems were adequate in monitoring and evaluating patients and programme performance; however, the study highlighted the absence of a clear patient register for individual and programme monitoring and only cross sectional patient data was reported. There was also considerable duplication at the hospital in collecting and compiling patient information. The findings of the study suggest that the two sites, located in the ‘routine’ public sector environment of Gauteng Province have demonstrated ability to build organisational capacity for ART provision, through a degree of systems integration and design, decision support systems, generation and local use of information and motivated local champions. Through these elements of organisational capacity, both sites have achieved good adherence rates. The key factors to achieving this good programme performance were motivated local champions who drove programmes forward and good working relationships between the CCMT and other players. In light of the weaknesses identified, the following key recommendations are proposed: Review sites to identify the reasons for the high-drop out rate and address these issues Due to evidence of early saturation at the CHC, it is suggested that additional roll-out sites be established, or alternatively increase staffing and space at the CHC to meet the needs of the high patient load. In addition, well patients should be decanted to lower level services e.g. community based care organisations, thus reducing the burden on the site Pay attention to the physical infrastructure needs of clinic based sites, especially as they become saturated Foremost, the current Employee Assistance Programme (EAP) implemented in Gauteng Province should be strengthened and marketed so that staff members are more aware of the service and make use of it accordingly. Alternatively, a culture of “caring for the caregivers” should be cultivated, through for example, specialist assistance, debriefing sessions, and better external programme support from HIV/AIDS, STI, TB (HAST) managers Improve support and supervision of ART programmes by facilitating greater communication and feedback between sites and district, national and provincial levels of government. Adopt a strategy of “task shifting”, through better use of lay workers, counsellors, and mid level workers such as pharmacy assistants. Facilitate greater integration and coordination between the PMTCT programmes and other services, including the provision of VCT and training of staff. In addition, it is imperative that there is good integration between services provided by local and provincial Departments of Health Simplify and standardise information systems, particularly the development of clear patient registers to allow for cohort analysis.

Despite the improved survival of human immunodeficiency virus (HIV) infected individuals with the introduction of highly active anti-retroviral therapy (HAART) in the South African public sector in 2004, new challenges have been brought to the fore. These include drug-related toxicities, particular those of stavudine, which remains in common use within developing countries. A prospective analysis of 9040 HIV-1-infected adults initiated on HAART from 2004 to 2007 at the Themba Lethu Clinic, Helen Joseph Hospital in Johannesburg, confirmed the ability to roll out a successful HAART programme in a resource limited environment with a high retention rate of 70%. Nearly 30% of patients switched to non-stavudine based regimens due to side effects - predominantly peripheral neuropathy, symptomatic hyperlactataemia and lipoatrophy. In an attempt to look for safer options, a prospective randomized controlled trial comparing standard and low dose stavudine with tenofovir was undertaken in 2009. Sixty patients were randomized 1:1:1 to either standard (30-40 mg), low (20-30 mg) dose stavudine or tenofovir (300 mg) each combined with lamivudine and efavirenz. Adipocyte mitochondrial DNA (mtDNA) levels, gene expression, anthropometry, markers of inflammation, lipid and glucose metabolism were assessed at various time intervals. Results demonstrate early mitochondrial depletion among black South African patients receiving low and standard doses of stavudine, with preservation of gene expression levels, except for NRF1 and MTCYB, when compared to patients on tenofovir. Mitochondrial toxicities occurred in both the stavudine arms. Immunological and virological outcomes were similar for all three arms. Both drugs caused lipid changes, but tenofovir had a more favourable effect on anthropometry and adipokines. Both stavudine regimens increased fasting insulin and C-peptide levels, with the higher stavudine dose also causing increased fasting glucose and HOMA levels. This study demonstrates an early association between mitochondrial depletion and stavudine therapy in the black South African population and shows that tenofovir has a minimal effect on mitochondrial numbers. Only two of eight adipocyte genes were significantly affected by stavudine therapy when compared with tenofovir, but this was only seen with the standard dose. This study highlights the occurrence of significant metabolic abnormalities with both drugs. Therefore, awareness of the potential increased cardiovascular risk should be of concern with tenofovir and stavudine, although toxicity is lower in the low dose compared to the standard dose stavudine regimen with no attenuation of anti-retroviral effectivity.

Research Report submitted in fulfillment of the requirements for the degree of Master in Public Health (MPH) at the University of the Witwatersrand. April 2015 / Introduction: Antiretroviral therapy (ART) is a lifesaving clinical intervention for people living with HIV (PLHIV). An important barrier to accessing therapy is the shortage of the health workforce particularly doctors. In order to mitigate the shortage, a nurse driven ART delivery approach known as Nurse Initiated and Managed Antiretroviral Therapy (NIMART) has been implemented in the public sector in South Africa and in other countries. NIMART enables professional nurses to initiate HIV positive persons on ART and manage their care at primary health care clinics. This study sought to explore and describe perceptions of operational managers, facility managers and professional nurses on the facilitators and barriers to the implementation of NIMART in the City of Joburg (CoJ) clinics. Methodology: This was an exploratory descriptive qualitative study which used in-depth interviews with a variety of respondents in order to gain insights into their perceptions of the implementation of NIMART in the CoJ clinics. In total, 26 respondents, comprising of operational managers, facility managers and professional nurses participated in the study. Thematic content analysis was used to analyse data drawing from the Donabedian structure-process-outcome framework. Results: The respondents identified the adequacy of NIMART training and mentoring; the availability and use of NIMART guidelines and the integration of NIMART into Primary Health Care (PHC) services as structural facilitative factors for NIMART implementation. The shortage of the health workforce, shortage of antiretrovirals (ARVs), poor referral feedback, food insecurity and the mobility of patients were identified as key structural and process barriers to the implementation of NIMART. Respondents perceived the improvement in quality of life of NIMART patients and the clinics’ ability to retain patients in care as indicative of the success of iii NIMART implementation. Finally, respondent’s suggestions for improving NIMART implementation in CoJ clinics focussed on improving shortage of the health workforce, improving the availability of ARV drugs and providing opportunities for continuing education for professional nurses. Discussion, conclusion and recommendations: In order to mitigate the barriers identified in this study, recommendations were that the City of Joburg should utilize lower level health care cadres such as nursing assistants and lay counsellors to reduce the professional nurses’ workload and thus improve access to treatment. In addition, the City of Joburg should revise the antiretroviral drug allocations to clinics and revise delivery schedules to ensure that clinics do not run out of ARV drugs. The referral feedback process should be strengthened through the referring clinic and the referral hospital jointly developing referral protocols that should be used by both institutions. Finally, the City of Joburg should consider conducting consultative discussions with professional nurses prior to introduction of new programmes and provide opportunities for regular updates for operational managers, facility managers and professional nurses. Future research could look at the role of PHC qualification in the implementation of NIMART.

Thesis (D Phil. (Medical Virology))--2008. / Background and Objectives: South Africa is one of the countries highly affected by human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infections. Some drugs (e.g. lamivudine) used as part of combination antiretroviral regimens for HIV treatment have dual activity against HBV and HIV. Despite high infection rate with both viruses, routine screening for HBV before initiation of treatment for HIV is not yet a standard practice. This study undertook to investigate: (1) the burden of HBV co-infection in HIV-positive patients enrolling for highly active antiretroviral therapy (HAART) at Dr George Mukhari hospital, (2) the impact of anti-HBV containing HAART regimens on HBV during the management of HBV/HIV co-infected patients, (3) the co-evolution of HBV and HIV drug-resistant strains, and (4) the correlation of HBV genotypes with response to anti-HBV containing HAART regimens. Study Population and Methods: To investigate the burden of HBV/HIV co-infections, a cohort of 192 HIV patients who were candidates for ARV treatment at Dr George Mukhari hospital were studied by screening for HBV serological markers (HBsAg, anti-HBs and anti- HBc) (Elecsys 2010, Roche Diagnostics) and HBV DNA with an in-house nested PCR assay targeting HBV polymerase gene. Quantitation of HBV DNA positive samples was performed with Roche Cobas Taqman HBV test 48 assay. To investigate the impact of lamivudine-containing HAART regimens on HBV during the management of HBV/HIV co-infected patients, as well as the coevolution of HBV and HIV drug-resistant strains, a total of 78 patients were studied. HBV virological response against lamivudine containing-HAART regimens [1a (lamivudine, stavudine and efaverenz); 1b (lamivudine, stavudine and neviripine)] was measured (Cobas Taqman HBV test 48, Roche diagnostics). HBV direct sequencing targeting HBV polymerase gene was performed on all baseline samples (n=78) and additional samples collected at various time points (n = 45). Direct sequencing was also performed on 30 HIV baseline samples targeting the HIV reverse transcriptase and protease genes (Spectru-Medix SCE 2410 Genetic Analysis System and ABI PRISM® 3100 Genetic Analyzer version 3.7). To explore the genetic diversity of HBV and HIV strains circulating in Pretoria and surrounding areas, as well as the correlation of HBV genotypes with response to lamivudine-containing-HAART regimens in co-infected patients, all baseline and follow-up HBV and HIV sequences were analysed, compared and correlated with treatment. Sequence alignments and phylogenetic studies for both HBV and vi HIV were conducted with MAFFT, Mega 4 and neighbour joining phylogenetic trees generated with the PHYLIP programme. Results: Three significant findings were observed in this study. Firstly, the majority of South African HIV patients enrolling for HAART were exposed to HBV infection and either had acute or chronic HBV infections. A total of 63.0% of patients were found to have one or more HBV markers, with 40.6% having detectable HBV DNA as an indication of replication. The study also detected 22.9% with positive HBsAg, and 23% of 77% HBsAg-negative patients having occult hepatitis B infection. Secondly, HBV/HIV co-infected patients do benefit during the management of HIV infections with lamivudine-containing HAART regimens. A total of 68.4% of patients responded to HAART, with undetectable HBV DNA during 18 to 24 months of follow-up. A total of 91.3% of HIV patients also responded to HAART with an undetectable HIV viral load during 6 to 12 months of follow-up. However, a total of 18% of patients had persistent HBV DNA, yielding various HBV virological responses against lamivudine containing-HAART regimens. This proportion of patients poses a question regarding the management of HBV and HIV coinfections, as guidelines on the use of HAART with anti-HBV activity from developed countries, may not necessarily be followed in developing countries. The results further showed that baseline drug-resistance was more frequent with HIV than HBV in this cohort of patients. The following HIV primary drug resistant mutants were observed: nine major NRT's primary mutants, M41L (1/30), E44A (1/30), V75M (1/30), F77L (1/30), V118I (1/30), M184V (1/30), L210S (1/30), T215Y (1/30) and V90I (1/30), and five major NNRT’s primary mutants were also detected, K103N (3/30), Y318CFSY (1/30), E138Q (1/30), P225H (1/30) and K238T. However, all followup samples had undetectable HIV viral load. In contrast to HIV, only one patient was detected with HBV mutant, M204I, at baseline. The mutant reversed to wild type during 6 months and other follow-up (12, 18 and 24 months). Finally, this study indicated that the HBV genotype A is still the most prevalent genotype circulating in South Africa. Of the 78 HBV sequences, 77 were genotype A and 1 sequence was genotype G. This is the first report from Africa of the detection of HBV genotype G. HIV subtype C remains the predominant prevailing subtype in South Africa. HBV genotype or HIV subtype C was not observed to influence any treatment outcome following treatment with vii lamivudine-containing HAART regimens. The study also indicated that patients on lamivudinecontaining HAART regimens do benefit not only by suppressing HIV and HBV viral load, but also improving immunity (i.e. CD4 cells count increases). Conclusion: Overall, the present study highlights the need for screening HBV before initiation of any HAART containing anti-HBV regimens in HBV/HIV co-infected patients. It necessitates the use of molecular assays for effective laboratory in diagnosis of occult HBV infections in HIVpositive patients, especially in developing countries where these assays are not widely available. While lamivudine-containing HAART regimens do benefit both HBV and HIV patients in co-infected individuals, however, whether HBV virological response is temporary or sustained is unknown at this stage. What is certain is that these patients require an effective monitoring programme as (1) a small percentage experience variable HBV virological responses (partial, reactivation, or no response), and (2) hepatitic flares are likely to develop if HAART is terminated (e.g. by patient), or the current HAART regimen is switched to another regimen without anti-HBV activity. HBV genotype A remains the dominant genotype in South Africa, but novel genotypes can be detected. HIV subtype C was found to be the prevalent subtype. HBV genotype or HIV subtype C were not seen to influence any treatment outcome following treatment with lamivudine-containing HAART regimens. Recommendations: HIV patients should be screened for HBV before initiation of anti-HBV containing HAART regimens. The screening of HBV in HIV patients is also important since some drugs included as part of HAART (e.g. nevirapine) may cause hepatotoxicity and exacerbate HBV infections leading to increased morbidity and mortality due to liver complications. Immunization and immune boosters of HIV patients with low (< 10IU/L) or no immunity against HBV should be done as this could be beneficial, although these patients may not respond optimally, or their immunity may wane faster due to immunocompromised status. Monitoring of both HBV and HIV resistant strains should be conducted for timely detection for the occurrence of multiple resistant mutations, which could limit future therapeutic option for both viruses.

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

Made available in DSpace on 2014-06-11T19:31:28Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-05-25Bitstream added on 2014-06-13T20:02:00Z : No. of bitstreams: 1 gil_nlm_dr_botfm.pdf: 336399 bytes, checksum: eb6b6028092afa89e83fd18fa36b0e6a (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Universidade Estadual Paulista (UNESP) / O “HIV/aids - Quality of life” (HAT-Qol) é um instrumento específico multidimensional utilizado para mensurar a Qualidade de Vida de indivíduos infectados pelo HIV. É dividido em nove domínios, a saber, atividade geral, atividade sexual, preocupação com sigilo sobre a infecção, preocupação com a saúde, preocupação financeira, conscientização sobre o HIV, satisfação com a vida, questões relativas à medicação e confiança no médico. O presente estudo analisou a qualidade de vida de indivíduos com infecção pelo HIV ou aids atendidos no Programa de DST/Aids no município de Maringá (PR), relacionando com o uso ou não de terapia anti-retroviral (TARV) e as características sócio-demográficas, epidemiológicas e clínicas. A coleta de dados foi realizada, pela análise retrospectiva dos prontuários dos 1.200 pacientes cadastrados no Serviço e, a seguir, foi aplicado o instrumento HAT-Qol, no momento anterior à consulta médica ambulatorial de rotina. Preencheram os critérios de inclusão 169 pacientes com diagnóstico confirmado de infecção pelo HIV, que foram divididos em dois grupos de estudo, G1 com 118 indivíduos em uso de TARV e G2 com 51 sem uso de TARV. Na análise dos resultados, quanto às características sócio-demográficas, observou-se que, não houve influência nas respostas, em nenhum Domínio, em relação a gênero, grau de escolaridade e opção sexual. Houve influência da faixa etária em relação ao Domínio que avalia a satisfação com a atividade sexual e do estado civil em relação ao Domínio que avalia a conscientização sobre o HIV, nos quais obtiveram menor índice nas respostas ou pior qualidade de vida, respectivamente, os homens de 50 a 69 anos e os pacientes sem parceiros fixos em relação aos casados ou amasiados. Observou-se, ainda, que o tempo de diagnóstico da doença exerceu... / The “HIV/aids – Quality of life” (HAT-Qol) is a specific multifunctional instrument used to measure the Quality of life of HIV infected people. It’s divided in nine domains that are, general activity, sexual activity, concern about the infection secrecy, concern about health, financial concern, awareness about HIV, satisfaction with life, issues about medications and belief in the doctor. The current study has analyzed the quality of life of HIV or aids infected individuals attended in the DST/Aids Program in Maringá city, Paraná state, in relation with the use or not of antiretroviral therapy (TARV) and the social-demographic, epidemiological and clinical characteristics. The data collect was performed, by the retrospective analysis of the 1200 prontuaries of patients registered in the Service and, then, the HAT-Qol instrument was applied right before the routine ambulatory medical consultation. 169 patients had fit the inclusion criteria of HIV infection diagnosis confirmed, which were divided in two groups of study, G1 with 118 individuals in use of TARV and G2 with 51 individuals not using TARV. In the analysis of the results, in respect of the social-demographic characteristics, it was observed that it didn’t influence the answers in any Domain, in respect of the gender, educational degree and sexual option. The age rate influenced the Domain which evaluates the satisfaction with the sexual activity and of the marital status in relation with the Domain that evaluates the awareness about HIV, in which they had the lowest response index or the worst quality of life, respectively, the men between 50 and 69 years-old and the patients who didn’t have regular partners compared with the ones who were married or concubine. It was observed yet that the time of the disease’s diagnosis influenced the Domains... (Complete abstract click electronic access below)

Orientador: Lenice do Rosário de Souza / Banca: Lucilene Ruiz Resende Silva / Banca: Alcyone Artioli Machado / Resumo: A aids é uma doença causada pelo HIV, que compromete o sistema imune do organismo. O advento da terapia antirretroviral (TARV) altamente eficaz promoveu melhora substancial do prognóstico dessa doença e da qualidade de vida dos pacientes com HIV/AIDS. Durante seu tratamento prolongado notam-se algumas alterações hematológicas, como anemia e macrocitose, bem como carências de micronutrientes como a vitamina B12 e ácido fólico. O objetivo do presente trabalho é determinar a relação entre macrocitose e anemia e o uso de ARV ou a deficiência de vitamina B12 ou de ácido fólico. Foram avaliados 110 pacientes HIV-positivos, comparando-se aqueles em uso de TARV com AZT (G1), em TARV sem AZT (G2) e sem o uso de TARV (G3). Os pacientes dos três grupos não apresentaram variações significativas quanto aos níveis de hemoglobina (p=0,584). Os pacientes do G1 apresentaram VCM aumentado quando comparados aos do G3 (p<0,05), bem como os do G2 em relação aos do G3 (p<0,001). As dosagens de vitamina B12 do G1 e G3 foram menores do que as encontradas pelo G2 (p=0,008). As dosagens do ácido fólico não apresentaram diferença estatística entre os grupos (p=0,956). Conclui-se que os indivíduos em uso de TARV apresentaram macrocitose, embora esta não pudesse ser relacionada ao tipo de TARV ou à deficiência de vitamina B12, como também a deficiência de ácido fólico não esteve relacionada ao uso de TARV nem à macrocitose / Abstract: AIDS is a chronic disease characterized by HIV infection and results in immunodeficiency. HAART is an effective approach to this disease, substantially improving quality of life and prognostic factors. It has become frequent the occurrence of hematologic disorders such anemia and macrocytosis, as well as micronutrients deficiency with the outcome of the treatment. The objective of this study is to correlate macrocytosis, anemia and HAART collateral effects with B12 vitamin and folic acid deficiencies. 110 HIV positive patients were included and divided in 3 groups: HAART with AZT (Group 1), HAART without AZT (Group 2) and without any antiretroviral treatment (Group 3). All groups did not have difference related to hemoglobin level (p=0,584). G1 had higher VCM levels than G3 (p<0,05), as well as G2 than G3 (p<0,001). G1 and G3 Vitamin B12 levels were smaller than those from G2 (p=0,008). Folic acid measurements did not differ among groups (p=0,956). We conclude that patients in HAART treatment had macrocytosis, even though this could not be related to an specific drug among HAART treatment or vitamin B12 deficiency. However, folic acid deficiency was not related neither to HAART nor macrocytosis / Mestre

Magister Public Health - MPH / Introduction: Zambia is among the countries in the sub-Saharan African region most severely affected with HIV/AIDS. Approximately 1.2 million (14%) Zambians were living with HIV in 2010. Zambia introduced antiretroviral therapy (ART) in the public sector in 2002, starting with two pilot sites, and rolling it out throughout the country in 2004 and 2005. To date,approximately 350,000 people have accessed HIV treatment. The long-term success of ART programs depends on optimal adherence to ART by patients.In 2010 Livingstone General Hospital (LGH), the setting for the current research had over 7,000 enrolled for HIV care of whom 3,880 patients were on ART. By the end of June 2011, it was reported that 343 patients in this hospital were between 2 to 30 days late for their medication refill appointments. This meant that these patients had missed more than one dose, and thus not meeting the required 95% of medication for viral suppression. This study explored the barriers to medication adherence experienced by ART patients at Livingstone General Hospital (LGH). Methodology: An exploratory qualitative study was conducted. Six focus group discussions(FGD) were conducted with 42 patients on ART, and follow up semi-structured interviews with 7 patients identified during the FGDs. FGDs and semi-structured interviews were audio-tape recorded and transcribed verbatim. Thematic and content analysis of transcribed data was done. Results: The study found that the barriers to ART adherence included socio-economic factors such as poverty, use of traditional complementary and alternative medicines (TCAM) and religious beliefs. Patient related factors reported to negatively affect adherence were HIV related-stigma and discrimination, alcohol use, low literacy and education levels, busy daily schedules and forgetfulness. Regimen related factors included experiencing side effects to medication and complexity of treatment regimen. Negative staff attitudes, traveling long distances to health facility, long waiting times, lack of confidentiality, poor health information and poor patient-health provider relationships were the health system factors that negatively impacted on ART adherence. Conclusion: The combination and complexity of factors affecting adherence identified in this study have posed a challenge to adherence to ART. People have been forced to make adjustments to their routine lives in order to accommodate ART. The most problematic factor identified was the use of TCAM in combination with ART or as replacement of ART.

Thesis (MPH.) -- University of Limpopo, 2015 / Purpose / Aim: To find out determinants affecting adherence to antiretroviral therapy in patients receiving free treatment from the wellness clinic at Bela Bela District Hospital in Limpopo province of South Africa. Objectives: To identify the determinants which affect the adherence to ART treatment among patients living with HIV and AIDS and to determine which of these determinants are significant predictors of adherence among HIV and AIDS patients. Methodology: a descriptive retrospective, quantitative research. Sampling: A population of 800 patients existing in the recording book was retrieved from the patients’ records at the wellness clinic. Out of 800 a sample of 260 was derived using a simple size calculator tool. Analysis: data were analysed by SPSS Windows Version 21.0. Descriptive statistics means and frequencies were calculated. Chi-Square tests were done in order to test the association between variables (such as age groups, gender, weight groups, regimens and WHO stages). Logistic regression was run to assess the effect of different determinants on the adherence to ART (e.g. viral load affected the adherence contrary to age, gender and others). Results: Female (65%) was more compliant to their male counterpart (35%). Most of the patients (47.3%) in the study belonged to the age group 21 to 35 years and only (2.7%) in the age group less or equal to 20 years. Most patients were categorised into WHO stage I (31.2%). Only 9.2% of the patients were categorised into WHO Stage IV. Most of the patients in group 2 (41.3%) had a weight between 40kgs and 54kgs and group 1 (4.2%) with patients whose weight was less than 40kgs. One of the patients has no record on weight. The majority of patients (44.2%) had CD4 count, less or equal to 100. Only 2.7% had CD4 count 300 and more. After 6 months of treatment, 37% of patients had CD4 count from 300 and above; 9.7% of the patients had CD4 countless than 200. For 136 (52.3%) of the patients in the sample the information on CD4 count at 6 xi months was missing. The majority of patients (72.7%) in the sample had low viral load and only (27.3%) of the patients had high viral load. Majority of patients (48.5%) were on New 1a Regimen instead of Regimen 1a (30.8%) because of the side effects the latter has on them. Some patients (11.2%) were on Regimen 1b, followed by patients (8.1%) on Regimen New 1b. The remaining patients were on Regimen 1c, Reg 2 and Truvada (1.6%). Findings: The majority of patients were young females; in the age-group of 21-35 years. This is reproductive age with many challenges: earlier exposed to infection, more vulnerable than males, stigmatisation, rape, fear of isolation. Majority of patients were in the WHO stage 1 and 2. The WHO stage does not depend on the level of CD4 count. It is important to consider the weight of the patient before to initiate the treatment. More than the half patients had a CD4 count required to start with ART. After 6 months they were more adherent. Most of them were on regimen Reg (New 1a) because of less side effects. The findings showed also different types of associations with some variables were significant determinants such as CD4 count had significant associations with gender, viral load, regimen, WHO staging, the p-value was lesser than 0.05. Conclusion: The results showed that viral load was the only determinant affecting adherence in the current study. The number of males in this study population was lower than females from the age group of less than 20 and age group of 21 to 35, and females than males in age group 36 to 50 and 51 or more. The lower infectivity of males is linked to the state of denial and not testing for HIV. The lower number in females can be due to their positive trends to the ART in their old age. The reasons for the low number need to be investigated. Awareness campaigns should be intentioned towards males. There should be publicity about the equality of both male and female genders.

Includes bibliographical references / Over the past decade, antiretroviral therapy (ART) programmes have rapidly expanded in resource-limited settings. Access to ART has been accelerated through a public health approach to reduce morbidity and mortality, thereby transforming HIV from a humanitarian crisis to a chronic disease. However, the benefits of ART to patients and communities are dependent on patients being retained in care. This thesis investigates loss to follow-up (LTFU) after ART initiation, in the context of scale-up and limited resources and evaluates models of ART delivery to improve retention. After a brief introduction that offers orientation to the key issues and concepts in the field, Chapter 2 provides a comprehensive literature review discussing the public health concerns related to LTFU in ART programmes, as well as the methodological concerns encountered in studying LTFU. Six results chapters (Chapters 3-8) are presented using complementary cohort data from two collaborative datasets (one from programmes in resource-limited settings and one including only South African cohorts) and from a single ART programme at a community health centre. How to define LTFU is the focus of Chapter 3, demonstrating that definitions can have an appreciable impact on estimates of LTFU. In Chapter 4, temporal factors related to the expansion of ART programmes are investigated, with evidence that the risk of patient LTFU increases with each successive calendar year of ART initiation, and that the rate of programme expansion has a stronger association with the risk of LTFU than absolute programme size. Analyses in Chapter 5 suggest that patients initiating ART at higher CD4 cell counts, above 300 cells/μl, may have an increased risk of LTFU compared to patients initiating ART with lower CD4 cell counts. Taken together, these findings underscore the notion that LTFU is a burgeoning threat to the long-term successes of ART programmes in South Africa and other resource-limited settings. Chapters 6-8 report on the implementation and outcomes from innovative models of ART delivery for stable ART patients. Patient outcomes from (i) a nurse-managed ART service and then (ii) community-based 'Adherence Clubs' highlight that comparable and, in some cases, favourable patient outcomes may be achieved when ART delivery is decentralised. This thesis concludes that LTFU is a significant challenge faced by ART programmes. In the context of ambitious targets and evidence of the potential benefits of ART for individuals and communities, concurrent changes to the health system are necessary to support retention in care. The successes of ART programmes in treating a chronic condition in resource-limited settings can be built upon by expanding community-based ART provision and potentially integrating management of other adulthood illnesses.