Magister Public Health - MPH / In recognition of high dual burden of tuberculosis (TB) and Human Immunodeficiency virus(HIV) in Sub-Saharan Africa, the World Health Organization (WHO, 2004) provided guidance for implementing integrated HIV/TB services. This strategy has been implemented using different models ranging from partial to fully integrating, and evaluations of these models have been conducted to determine their effectiveness. The aim of this study was to describe and contrast the effectiveness of different models of implementation of HIV and TB integration at primary care level within the Tuberculosis (TB) programme in Livingstone District, Zambia The specific objectives of the study included; 1. To describe the models of integrated HIV and TB services that are currently implemented at four health facilities within the TB programme in Livingstone District at primary health care level. 2. To describe and contrast the coverage and quality of HIV diagnosis in the Tuberculosis(TB) programme achieved in the different facilities representing fully and partially integrated models of service delivery. 3. To describe and contrast the coverage and quality of HIV prevention activities in the Tuberculosis (TB) programme achieved in the different health facilities representing fully and partially integrated models of service delivery. 4. To describe and contrast the coverage and quality of HIV care activities received by coinfected clients in the Tuberculosis (TB) programme in the different facilities representing fully and partially integrated models of service delivery. 5. To describe the quality and outcomes of TB diagnosis and treatment in the different facilities representing fully and partially integrated models of service delivery. A research design using quantitative methodologies: a cross sectional survey and structured observations or review of patient records (quantitative) were used. The records of 814 TB clients notified in 2010 served as the study population while the sample of 464 (232 from partially and 232 from fully integrated) were randomly selected. Two data collection tools namely: patient record and HIV/TB register review; facility staff interviews (key informant interviews) were used and the results were analyzed using Epi info statistical package. In the study, all respondents gave informed consent and no personal information was collected from the retrospective record review. The HIV prevention interventions in this study were rated below 30% except for of HIV education (97%). Statistically significant differences (p-value<0.001) existed for condom provision at facility level. Poor performance reported for STI screening (below 2%) and PMTCT information (below 15%). The HIV testing rate was 94% among TB clients which was higher than the counseling coverage of 88%. Statistically significant differences (p value <0.001) at facility level existed for clients who received HIV test results. Sixty three percent (63%) of TB clients were also co- infected with HIV. ART assessment for TB clients was below 40% and statistically significant differences (p value=<0.001) between facilities were identified for this indicator. ART assessment of TB clients at the same facility they tested for HIV was above 50% for all facilities. The continuation of cotrimoxazole was poor at 38% and statistically significant differences (p value=<0.001) were identified for this indicator between facilities. Sputum testing was 85% while the cure rate was poor at 28% average for all facilities. Statistically significant differences (p-<0.001) were noticed at model level for clients cured. Although HIV prevention and care services were introduced in the TB program in Livingstone,they were not comprehensive enough to respond to the high HIV and TB co-infectivity. For HIV prevention, other than HCT and HIV education, the rest of the critical interventions such as condom provision, STI screening and treatment, and PMTCT intervention were neglected. The HIV care services such as ART assessment and CPT implementation were also poor. There is need to put in place systems to improve these services in the district to improve treatment outcomes. The differences that were noted in performance for the majority of the indicators were mainly at facility level as being a fully integrated facility did not guarantee effective integration or better performance.

Magister Public Health - MPH / The HIV prevalence rate in Zimbabwe has been estimated at 15% (15 years old and above), which is one of the highest in the world, and HIV/AIDS remains a significant public health problem. The focus of HIV prevention strategies has been on heterosexual transmission since this is the primary driver of the HIV epidemic in Zimbabwe. Heterosexual serodiscordant couples represent an important subpopulation for HIV prevention but are not well studied in Zimbabwe. In Harare almost all serodiscordant couples participating in the HPTN 052 study reported correct and consistent condom use. However, rates of STIs and pregnancies showed that couples in the study continued to have unprotected sex, in-spite of intensive couples’ counselling, quarterly follow up visits and provision of condoms. The aim of this qualitative study was to explore barriers to condom use by these serodiscordant couples in which one partner was on ART in Harare, Zimbabwe. It used a two stage qualitative approach with semi-structured interviews being the primary method of data collection. These interviews were conducted on a sample of five study staff, 15 serodiscordant couples and individuals enrolled in the HPTN 052 study in Harare, Zimbabwe after consent was obtained. Thematic analysis was used to analyse data collected.The study findings showed that partners were in a fairly large age range (30 to 50+ years) with males being slightly older than females. Seven males and five females were HIV positive. Couples had a wide variation in the length of their relationships, from one month to over 15 years as a couple. The study findings also showed that individuals in serodiscordant relationships understood serodiscordance. Problems unique to these couples were identified and broadly categorized as dealing with an HIV positive result, accepting serodiscordance, and difficulty of disclosing serodiscordance to family. Couples also showed understanding of the importance of condom use in a discordant relationship. The most common reason for using condoms was to prevent transmission of HIV to the uninfected partner. The main barriers to condom use were the strong desire to have children, male partner reluctance to use condoms and the influence of the negative partner in determining condom use. Based on these findings, a nuanced approach to prevention strategies, such as condom use and couples counselling and testing, is required. The aim should be to increase understanding of serodiscordance, risk and condom use at all sessions or contacts with couples.

Magister Public Health - MPH / Background: The hallmark of HIV infection is immunosuppression which predisposes to unusual infections and malignancies generally known as opportunistic diseases (ODs). Globally, ODs are the major cause of morbidity and mortality in people living with HIV (PLHIV). Since the advent of Highly Active Antiretroviral Therapy (HAART), a significant decline in AIDS progression and ODs has been observed globally. However, most of the evidence suggesting sustained decline in AIDS progression and ODs has come from high-income settings with relatively less burden of ODs in the pre-HAART era. The findings of studies in high-income settings may not be generalizable to resource-limited settings. Lack of information regarding the burden of ODs in HAART-experienced populations in Nigeria and the risk factors for their occurrence has made it difficult to fully assess the sustained efficacy of HAART in the country. The aim of this study was to investigate the prevalence of and risk factors for HIV-related opportunistic diseases amongst HAART patients at the Federal Medical Centre (FMC) in Owerri, Nigeria. Study design and setting: A quantitative, cross-sectional descriptive and analytical study was conducted with 354 adult HIV-infected patients 15 years and above, who were on HAART for a minimum of 12 weeks at the HIV clinic of the FMC, Owerri, South-east Nigeria. Patients currently manifesting an OD whose onset ante-dated the commencement of HAART were excluded. The participants were recruited by simple random sampling. Data collection: Using a structured questionnaire, data was collected by clinicians through interviews, physical and laboratory examinations for patients that provided informed consent and met the study criteria. The questionnaire captured patient’s socio-demographic information and other relevant clinical/laboratory data. Data Analysis: The data was analysed using Epi info version 3.5.1 and Open Epi Version 2.2.1. Descriptive statistics for HIV-related ODs were carried out using percentages and frequencies tables for categorical variables and means (SD) or medians (IQR) for numerical variables. In univariate analysis, the Chi-square test was used to determine significance of association between OD and socio-demographic and clinical variables while the Student "t"-test was used to compare group means. Logistic regression model (multivariate analysis) was used to determine the independent risk factors for the occurrence of ODs using parameters that had a p-value of <0.25 on univariate analysis. All reported p-values <0.05 were considered statistically significant. Results: The mean age of the participants was 41.1 ± 10.0 years; and females were in the majority (65.8%). Over 40% of them were rural dwellers, 50.4% belonged to the lower socioeconomic class, and 55% had a monthly household income less than 20,000 Naira. Fifty percent (50%) of them had advanced immunosuppression at first presentation. The median duration of HAART (3 years) paralleled the median duration of HIV diagnosis (3.4 years) and HAART adherence rate was 78%. The overall prevalence of ODs was found to be 22.4%. Among the 76 patients diagnosed with ODs, the leading conditions were candidiasis (38.2%), TB (34.2%), dermatitis (25%), chronic diarrhoea (6.6%) and sepsis (6.6%). The independent risk factors for the occurrence of ODs were household income less than 20,000 Naira (Adjusted odds ratio [AOR] = 2.4, 95% CI 1.1-5.1), HIV duration of less than 3 years (AOR= 2.1, 95% CI 1.1- 4.2), advanced WHO clinical stage at baseline (AOR= 8.1, 95% CI 4.0-16.4), baseline haemoglobin less than 10 g/dl (AOR= 2.9, 95% CI 1.3-56.1), current CD4 cell count less than 200 cells/μl (AOR= 3.0, 95% CI 1.14-6.2), and HAART non-adherence (AOR= 5.4, 95% CI 2.6-11.2). Past history of TB was found to be a strong predictor of TB (AOR= 5.3, 95% CI 1.4-20.2). Conclusions: Opportunistic diseases are common in patients receiving HAART in Nigeria and candidiasis and TB remain the leading conditions. Late presentation and HAART non-adherence are among the strongest risk factors for ODs in patients receiving HAART. Others include duration of HIV diagnosis less than 3 years, presence of anaemia at the time of first presentation and having a low CD4 cell count while on HAART. Beyond these clinical risk factors, poverty increases the risk of developing an OD during HAART and may emerge a strong determinant of HIV-related ODs in developing countries. Recommendations: A high index of suspicion for ODs remains necessary in HAART patients. Health education on HIV screening and early presentation should be intensified. PLHIV who are anaemic before commencement of HAART, those with low CD4 cell count despite HAART use, and low-income earners should become target groups for a more aggressive evaluation for ODs. Prophylaxis for TB and fungal infections in the absence of active disease should be widely implemented in developing countries. HAART adherence should be intensified.

Master of Public Health - MPH / Poor adherence to antiretroviral therapy (ART) among paediatric and adolescent patients remains a big concern to health workers at Onandjokwe CDC clinic in Oshikoto Region of Namibia. Despite successes in the scale up of ART in Oshikoto Region the clinic experienced high prevalence of poor adherence to ART among adolescent patients. Out of 631 adolescents alive and on ART in this clinic, 154 (24%) had records of poor drug adherence between Jan 2015 and August 2015; which compared poorly to only 4 % of 7289 adults currently on ART who have records of poor adherence during the same period. The aim of the current study was to explore barriers to adherence to antiretroviral therapy among these adolescents. Among the study population of 631 adolescents on ART in Onandjokwe, a sample population of 154 had records of poor adherence (scored below 85%) to ART between June 2015 and August of the same year were considered for the study but among them 16 adolescents were recruited as the study sample. Additionally, 5 caregivers of adolescents on ART, 6 Healthcare Providers were selected as key informants. A voice recorder and field notes were being used during data collection. Two 2 sessions of Focus Group Discussions (FGD) were held with adolescents while 2 FGD sessions held with 5 caregivers and 6 healthcare providers to elicit expert opinions. Lastly, 5 In-depth interviews were conducted with individual adolescents who missed ART medicine follow up for 1 month or more between January and August of 2015. Data Analysis was performed using hand manipulation by grouping responses into main study objectives/themes. Data cleaning, translation of voice transcription from Oshiwambo to English language and incorporating of non-verbal expressions was also done. The results indicate that factors contributing to poor ART adherence among adolescents are patient and family related, socio-economic, and related to substance abuse, stigma and discrimination, health care and health systems, as well as the environment and weather.

Aim To determine the demographic and socio-economic characteristics of patients accessing antiretroviral treatment, in the public sector in Zambia. Methods A descriptive cross-sectional survey, using a pre-structured interview questionnaire, with patients on antiretroviral treatment. A total of 200 patients receiving antiretroviral treatment at the 2 national referral hospitals and seven provincial hospitals providing ART were included in the study Data was analyzed using STATA version 8. Analysis was by frequency tables and summary statistics. Results The majority of the patients on antiretroviral treatment were females at 61.5 percent. Most of the patients were in the age group 40 - 44 years old. Most of the patients were married followed by those who were widowed, who were predominantly female. The net monthly income was generally low for most patients and the forty thousand Kwacha monthly contributions for ARVs was high for most patients. Higher levels of education were associated with increased access to antiretroviral treatment. Conclusion and Recommendations There were more females than males accessing antiretroviral treatment in the public sector in Zambia. The majority of patients have a low income and the forty thousand Kwacha monthly contributions towards ARVs was high for most patients. It is recommended that antiretroviral treatment be provided for free or at a highly subsidized cost and also that the Ministry of Health increases the ART centers if the goal to put 100,000 on treatment by the end of 2005 is to be achieved. / Dissertation (MPH)--University of Pretoria, 2009. / School of Health Systems and Public Health (SHSPH) / Unrestricted

Background: Given the rapid expansion of antiretroviral therapy (ART) services in South Africa, there is growing recognition of the importance of fertility intentions, contraceptive use and childbearing among women living with HIV (WLHIV). With the integration of family planning services in the prevention of mother-to-child transmission of HIV (PMTCT) services, understanding fertility intentions and contraceptive use is crucial in evaluating such programs. We investigated the relationship between future fertility intentions, contraceptive use and repeat pregnancies among WLHIV in Cape Town, South Africa. Methodology: We analyzed data from the MCH-ART study conducted at the Gugulethu Midwife Obstetric Unit (MOU) in Cape Town, South Africa, which followed women initiating ART during pregnancy through 36-60 months postpartum. Self-report data were collected using standardized questionnaires at repeated study visits. Data on repeat pregnancies were abstracted from the Western Cape Provincial Data Centre. Associations between maternal characteristics and repeat pregnancies were examined using Cox proportional hazards models. Results: Overall, 109 incident repeat pregnancies were recorded among the 471 women included in this analysis. The median time at risk per individual was 4.27 years. The rate of repeat pregnancies was 5.72 per 100 person-years (PY). This rate was significantly lower among women aged 35-45 years (2.11/100PY) compared to women aged 18-24 years [7.56/100 PY; adjusted hazard ratio (aHR), 0.26: 95% confidence interval [CI], 0.09, 0.81). A total of 333 women contributed data on future fertility intentions and contraceptive use at 12 months postpartum, with 9% reporting that they wanted another child in the future, and 82% reporting current contraceptive use; 16% (n=54) reported not wanting another child but no contraceptive use. The rate of repeat pregnancies was 3 folds higher among women who reported wanting a child in the future (12.59/100 PY) compared to women who did not want 5 a child in the future (4.31/100 PY; aHR, 3.46: 95% CI, 1.83, 6.50). Contraceptive use at 12 months postpartum was not associated with repeat pregnancies. Women who did not want a child and used contraceptives had a 45% decreased hazard of repeat pregnancies compared to women who did not want a child and did not use contraceptives (aHR 0.55: 95% CI [0.32, 0.94]. Conclusion: Among women initiating ART during pregnancy, a repeat pregnancy incidence rate of 5.72/100 PY was observed through 36-60 months postpartum, with the incidence lower among older women. At 12 months postpartum, a notable proportion of women reported not wanting another child but no contraceptive use. Wanting a child in the future was associated with a higher rate of repeat pregnancy, but contraceptive use at 12 months postpartum was not associated with repeat pregnancies. These results highlight the importance of understanding factors associated with the dissonance between fertility intentions and contraceptive use and childbearing to ensure delivery of quality integrated reproductive health services in the PMTCT framework.

Master of Public Health - MPH / Background: Zimbabwe has one of the highest HIV prevalence rates in sub-Saharan Africa, with the adult prevalence rate at 15%. The HIV prevalence is highest among adult women, at 18%. Mother-to-child transmission is the second leading cause of HIV in Zimbabwe. Therefore, provision of anti-retroviral therapy to pregnant women is important in reducing mother-to-child transmission. In 2012, the World Health Organisation formally adopted ART guidelines known as "Option B Plus", where triple therapy is provided to pregnant women for life, regardless of CD4 count. Zimbabwe subsequently adopted Option B Plus in September 2013. However, the success of ART depends on adherence to treatment. Lack of adherence to treatment leads to an increased risk of opportunistic infections and drug resistance, which is costly to treat. The aim of the study was to explore pre-and post-partum barriers to anti-retroviral therapy for HIV-positive women initiated onto Option B Plus in Harare, Zimbabwe. Methodology: Descriptive qualitative methods were used to explore the barriers to ART adherence for pre-and post-partum HIV-positive women initiated onto Option B Plus in Harare, Zimbabwe. In-depth, semi-structured interviews were conducted in Shona with 20 non-adherent pre-and post-partum HIV-positive women and four key informants who are health workers from two identified health facilities (Edith Opperman Polyclinic and Kuwadzana Polyclinic). The interviews were recorded, transcribed and translated into English. The data was analysed using inductive thematic analysis. Results: Health facility and individual factors emerged as barriers to adherence. Heavy workload and staff shortages, negative health worker attitude, cost of accessing health facilities, medicine shortages and detrimental health facility policies were all health facility related barriers identified by both key informants and the women. Individual barriers were related to difficulty in navigating the early days after diagnosis and treatment, stigma, intimate partner dynamics and religion. Conclusion: Despite free, decentralised provision of ART, barriers to adherence still exist. Many of the barriers have been articulated in previous research that focused on prevention of- mother-to-child transmission regimens, as well as ART regimens for the general population. The fact that the barriers remain suggests that the barriers are complex and addressing them will require tackling social constraints such as stigma and gender roles that pose a significant barrier to adherence.

Philosophiae Doctor - PhD / The HIV/AIDS pandemic has been a torment to the African developmental agenda, especially the Southern African Development Countries (SADC), for the past two decades. The disease and condition tends to affect the productive age groups. Children have also not been spared from the severe effects associated with the disease. The advent of antiretroviral treatment (ART) has brought a great relief to governments and patients in these regions. More people living with HIV/AIDS have experienced a boost in their survival prospects and hence their contribution to national developmental projects. Survival analysis methods are usually used in biostatistics, epidemiological modelling and clinical research to model time to event data. The most interesting aspect of this analysis comes when survival models are used to determine risk factors for the survival of patients undergoing some treatment or living with a certain disease condition. The purpose of this thesis was to determine prognostic risk factors for patients' survival whilst on ART. The study sought to highlight the risk factors that impact the survival time negatively at different survival time points. The study utilized a sample of paediatric and adult datasets from Namibia and Zimbabwe respectively. The paediatric dataset from Katutura hospital (Namibia) comprised of the adolescents and children on ART, whilst the adult dataset from Bulawayo hospital (Zimbabwe) comprised of those patients on ART in the 15 years and above age categories. All datasets used in this thesis were based on retrospective cohorts followed for some period of time. Different methods to reduce errors in parameter estimation were employed to the datasets. The proportional hazards, Bayesian proportional hazards and the censored quantile regression models were utilized in this study. The results from the proportional hazards model show that most of the variables considered were not signifcant overall. The Bayesian proportional hazards model shows us that all the considered factors had different risk profiles at the different quartiles of the survival times. This highlights that by using the proportional hazards models, we only get a fixed constant effect of the risk factors, yet in reality, the effect of risk factors differs at different survival time points. This picture was strongly highlighted by the censored quantile regression model which indicated that some variables were significant in the early periods of initiation whilst they did not significantly affect survival time at any other points in the survival time distribution. The censored quantile regression models clearly demonstrate that there are significant insights gained on the dynamics of how different prognostic risk factors affect patient survival time across the survival time distribution compared to when we use proportional hazards and Bayesian propotional hazards models. However, the advantages of using the proportional hazards framework, due to the estimation of hazard rates as well as it's application in the competing risk framework are still unassailable. The hazard rate estimation under the censored quantile regression framework is an area that is still under development and the computational aspects are yet to be incorporated into the mainstream statistical softwares. This study concludes that, with the current literature and computational support, using both model frameworks to ascertain the dynamic effects of different prognostic risk factors for survival in people living with HIV/AIDS and on ART would give the researchers more insights. These insights will then help public health policy makers to draft relevant targeted policies aimed at improving these patients' survival time on treatment.

This study emanates from the need to understand the socio-economic factors that might have contributed to the patients dropping out of the MASA antiretroviral therapy programme in Botswana. The aim of the study was to explore the socio-economic factors that are involved in compliance to antiretroviral therapy. It is crucial to know what these factors are and the strategies that can be deployed to address them. This will assist in the achievement of the programme goals. The type of research that was used is applied research. One of the primary rationales of applied research is that the study may have some practical use. The purpose of applied research is to contribute knowledge that will help people understand the nature of the problem in order to intervene, and this was the main motivation for this study. Since the MASA programme was launched, there were some patients who were ‘lost to follow-up’. As a result, there was a need to understand the reasons behind this phenomenon, so that the patients who are enrolled on the programme are retained. In order to gain an in-depth understanding of how the socio-economic factors affect compliance with antiretroviral therapy, phenomenology was used as a research strategy. Using the phenomenological strategy helps in understanding the nature or meaning of the respondents’ everyday experiences and to transform experiences into consciousness. The sampling method that was used is probability sampling, utilising availability sampling. The population for this study was HIV positive adults who had dropped out of the MASA Programme at Princess Marina Hospital, IDCC clinic in Botswana. The data collection instrument that was used was the interview schedule. From the conclusions, it is apparent that the socio-economic factors are crucial and should therefore be given more attention if better compliance is to be realised. In the same breath, patients require counselling that will focus, not only on the medical aspects of HIV/AIDS but also on the socio-economic factors. As shown in this study it is predominantly the socio-economic factors that led to patients dropping out of the programme. Social workers can play a critical role in this regard as they are equipped with counselling skills. Lastly, the conclusions and recommendation arising from this study are provided. / Dissertation (MA (Social Health Care))--University of Pretoria, 2007. / Social Work and Criminology / unrestricted

Introduction An estimated 11.4% of South Africans are infected with HIV. As of 2007, 1.7 million people required antiretroviral therapy (ART) and only 460 000 were reported to be on ART. ART can improve the quality of life and socio-economic status for HIV positive patients. This study aimed at evaluating the role played by the different factors in influencing treatment adherence among HIV patients on ART. Methods The study was conducted on patients receiving out-patient ART in two district hospitals (one urban and the other rural) of Mpumalanga Province, South Africa. The study project was approved by the Research and Ethics Committee of the University of Pretoria as well as by the Mpumalanga Provincial Department of Health. This was an analytical, cross-sectional study. The sample size for the study was 490 (245 per site). Facility-based patient appointment registers for the period June-August 2008 were used as the sampling frame. The respondents were selected through systematic random sampling. An interviewer directed standardised questionnaire was administered to the respondents after securing voluntary informed consent. Data were also extracted from the attendance registers in the two facilities. Adherence was measured using the Patient Medication Treatment Adherence Questionnaire. The Pearson chi-square test of association and binary logistic regression analysis were used for identifying significant predictors of non-adherence variables. Results Four hundred and twenty nine questionnaires of the 488 returned questionnaires were analysed. Sixty one questionnaires were disqualified due to incompleteness of data. The response rate was 99.7% in both study areas and participants reported adherence was 92.54%. The median age of the respondents was 36 (IQR, 13), gender distribution was 21.13% males and 78.87% females. The median duration of treatment (in months) with ART was 15 months (IQR, 18). Treatment adherence was higher in the urban than in the rural hospital. The variables that were significantly associated with non-adherence were ‘urban residence’ (OR 0.39 [0.2-0.8]); ‘lack of social support’ (OR 2.74 [1.3-5.7]); Discussion There were also some qualitative variables that had a bearing on quality of healthcare services that could explain differences between the rural and urban sites. Social support and urban residence demonstrated association with treatment adherence. Copyright / Dissertation (MMed)--University of Pretoria, 2010. / School of Health Systems and Public Health (SHSPH) / Unrestricted