Magister Public Health - MPH / HIV/AIDS remains a major public health issue that is affecting all population groups and communities in Zambia. Among the most affected groups are key populations (KPs) such as female sex workers. KPs are considered at high risk of contracting HIV but have limited access to HIV services and retention in care due to internalized stigma, discrimination, criminalization, and negative attitudes towards HIV treatment. Under the USAID Open Doors project in Zambia, KPs access comprehensive HIV prevention, care and treatment services. The test and treat strategy is implemented by the project in support of the UNAIDS 90-90-90 targets by 2020 to diagnose 90% of people living with HIV, put 90% of them on treatment, and for 90% of them to have suppressed viral load.

In sub-Saharan Africa, women are disproportionately affected by HIV. Sustained adherence to lifelong antiretroviral therapy (ART) is needed to ensure their own health and prevent transmission of HIV to their partners and their children. However, non-adherence to ART remains a substantial challenge with many associated risk factors. Travel is often reported in the qualitative literature as a barrier to ART adherence among women living with HIV, but few quantitative studies have explored this association. This research aimed to describe travel in the past year among mothers living with HIV in the Long-term Adherence and Care Engagement (LACE) study, to explore factors associated with travel, and to investigate the associations between travel and i) self-reported adherence, and ii) HIV viral load. Part A of this dissertation is the study protocol that introduces the need for this research and presents how the research will be carried out. Part B is a narrative literature review. The review summarises and synthesises existing research relating to HIV treatment and travel in sub-Saharan Africa, giving context to the dissertation. Part C is the journal “ready” manuscript. This section presents an analysis of data from the LACE study, a cross-sectional survey of women living with HIV approximately four years after they had started ART during pregnancy in Gugulethu, Cape Town. At the LACE study visit, data on short-term travel patterns (stayed away from home for 3 or more nights) in the past year and self-reported adherence in the past 30 days (using a validated three-item scale) were collected through structured questionnaires, and a blood specimen was tested for HIV viral load. Poisson regression models with robust standard errors were used to explore factors associated with travel (any versus none), self-reported adherence (100% versus <100%), and viral suppression (≤50 copies/mL). Results were reported as crude risk ratios (RR) and adjusted risk ratios (aRR) with 95% confidence intervals (CI). The results showed that among 353 women enrolled in the LACE study (mean age 32.6 years, 48% employed, 38% married/cohabiting, median 44 months postpartum) 23% (n=81) reported travelling in the past year. Of the women who travelled, most went to the Eastern Cape (90%) and travelled 1-2 times during the year (93%). Women who travelled were more likely to be married/cohabiting than women who had not travelled (aRR = 1.45; 95% Cl: 0.97 - 2.16). Only 9% of women who travelled (7 of 81) reported difficulty with ART adherence due to travel. Overall, 59% of women reported 100% adherence in the past 30 days: 52% of women who had travelled in the past year versus 61% of those who had not travelled (aRR = 0.83; 95% Cl: 0.66-1.04). Only 56% of the cohort were virally suppressed: 60% and 55% of those who had and had not travelled in the past year, respectively (aRR = 1.10; 95% Cl: 0.89-1.36). Travel in the past year was not significantly associated with self-reported adherence or viral suppression in crude or adjusted analyses. These results highlight that poor adherence and viremia were very common in this cohort of women, four years after starting ART in pregnancy. Almost a quarter of women reported travel in the past year but only a v few reported difficulties with adherence related to travel and we found no association between travel in the past year, self-reported adherence in the past 30 days or viremia. Further research is needed to understand adherence patterns during periods of travel and interventions are clearly needed to support women's long-term adherence to ART.

Includes bibliographical references / Introduction: Tuberculosis (TB) notification in South Africa has increased six fold over the last two decades mainly because of the Human Immunodeficiency Virus (HIV) epidemic. Globally, it was estimated that 73% of the TB cases were co-infected with HIV with more than 25% of this global co-infection burden being in South Africa alone. In 2012, globally 1.3 million deaths occurred due to TB; moreover 0.3 million were HIV-associated TB death. In 2010 TB was the leading cause of natural deaths in the population aged 15 to 24 years accounting for 14% of the total deaths in South Africa. In 2013 the proportion of patients with TB who were co-infected with HIV was extremely high at 62%.The outcome of co-infected patients was poorer than the outcome of HIV negative TB patients. However, there is little information available on the risk factors associated with TB treatment outcomes and the influence of co-infection. Method: A cross sectional study analysed Electronic TB Register (ETR.net) data from the Metro East Geographic Service Area (GSA) of the Cape Town Metro district. The dataset included adult patients aged 15 years or more, who initiated TB treatment between 1st July 2011 and 30th June 2012. In the descriptive analysis we analysed death separately but for the regression we merged death with unfavourable treatment outcome. Relative risks were used for measures of association. Univariate and multivariate analyses were performed using a generalized linear regression model. Statistically significant variables in the univariate analysis were included in the multivariate analysis. Findings: TB case notification in Eastern GSA was 922 per 100 000 population. Of the 12672 TB patients registered, 50% were co-infected with HIV. The incidence of death in co-infected was 5% versus 3% in uninfected, treatment success 67% versus 73% and unfavourable treatment outcome 28% versus 24%. The Khayelitsha sub-district had the highest proportion of the TB burden (37%) and of co-infection (65%). Fourteen percent of patients had extra-pulmonary TB (EPTB), 66% of whom were co-infected with HIV. In the multivariate analysis HIV (RR 1.2), retreatment (RR 1.4) and sputum smear microscopy not done (RR 1.4) were significantly associated with unfavourable treatment outcome. The sub districts Eastern (RR 0.9) and Northern (RR 0.7) were less likely to develop unfavourable outcome compared to Khayelitsha. In the stratified analysis, retreatment (RR 1.3) and smear not done (RR 1.3) were significant risk factors for an unfavourable treatment outcome in co-infected patients. Amongst HIV negative patients retreatment (RR 1.6) and smear not done (RR 1.6) were significant risk factors for an unfavourable treatment outcome. Conclusions: The incidence of TB is extremely high in the Eastern GSA of Cape Town however the prevalence of co-infection varies across the sub-districts. Although treatment outcomes have been improving, co-infection, retreatment and smear microscopy not done pre-treatment were factors significantly associated with an unfavourable treatment outcome. Eastern and Northern sub-districts were significantly more likely to have favourable treatment outcomes compared to Khayelitsha, where both TB incidence and HIV co-infection were greatest.

Magister Public Health - MPH / In 2018, it was estimated that 33,000 adolescent girls and 4,200 adolescent boys were HIV-positive in South Africa. The Free State province reports that 89% of people living with HIV are diagnosed; 72% of those diagnosed are receiving antiretroviral therapy (ART); of which 93% have achieved viral suppression (< 1000 RNA copies/mL). Thabo Mofutsanyane District has the highest HIV prevalence in the Free State province. A retrospective, quantitative cross-sectional study was conducted to determine the predictors of viral suppression among adolescents on ART in Thabo Mofutsanyane District Municipality, Free State province, South Africa. Data for all adolescents, aged 10–19 years, receiving ART in 2019 (N = 6 300) was extracted from Tier.net electronic database into an Excel spread sheet and exported into Statistical Package for the Social Sciences – Version 26 (SPSS v 26) for analysis.

Indiana University-Purdue University Indianapolis (IUPUI) / Background: Many authors have indicated that HIV-infected patients mortality risk is higher immediately following the start of Antiretroviral Therapy. However, mortality rate of HIV-infected patients is expected to decrease after starting Antiretroviral Therapy (ART) potentially complicating accurate statistical estimation of patient survival and, more generally, effective monitoring of the evolution of the worldwide epidemic. Method: In this thesis, we determine if mortality of HIV-patients increases or decreases after the initiation of ART therapy using flexible survival modelling techniques. To achieve this objective, this study uses semi-parametric statistical models for fitting and estimating survival time using different covariates. A combination of the Weibull distribution with splines is compared to the usual Weibull, exponential, and gamma distribution parametric models, and the Cox semi-parametric model. The objective of this study is to compare these models to find the best fitting model so that it can then be used to improve modeling of the survival time and explore the pattern of change in mortality rates for a cohort of HIV-infected patients recruited in a care and treatment program in Uganda. Results: The analysis shows that flexible survival Weibull models are better than usualoff-parametric and semi-parametric model fitting according to the AIC criterion. Conclusion: The mortality of HIV-patients is high right after the initiation of ART therapy and decreases rapidly subsequently.

A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of MSc (Med) Johannesburg, 2011 / Peripheral sensory neuropathy is a common neurological complication of antiretroviral therapy, typically occurring within 6-months of starting Highly Active Antiretroviral Therapy (HAART) which includes stavudine. Therefore, the primary aim of the study was to determine the 6-month incidence of ATN in patients free of neuropathy and beginning stavudine-based HAART for the first time. Also, we examined whether initiating stavudine-based HAART altered the symptoms of patients who had a pre-existing, virus-mediated distal symmetrical polyneuropathy (HIV-DSP). Seventy-five HIV-positive patients were screened for neuropathy, at the Chris-Hani Baragwanath Hospital, using the AIDS Clinical Trials Group neuropathy screening tool. The bilateral presence of atleast one sign (decreased vibration sense in the great toe or absent ankle reflex) and one symptom (pain, paraesthesia or numbness) in the feet was indicative of neuropathy. On recruitment, 52 patients presented without neuropathy and 13 patients presented with HIV-DSP. After 3- months of follow-up (n=46), 23% (10/46) of patients had developed peripheral neuropathy, and by 6-months (n=44), 41% (18/44) of patients had developed neuropathy. Greater disease severity was the only risk factor significantly associated with the development of neuropathy. Eleven (61%) of the 18 patients that developed neuropathy, developed painful symptomatic neuropathy, and only 6 (55%) of these patients were receiving treatment for symptom relief. In patients with HIV-DSP, numbness was the most common symptom reported at baseline and was the only symptom to reduce in frequency across the 6-months. In conclusion, we found that the development of neuropathy is common in the first 6-months of patients initiating stavudine-based HAART.

The Human Immunodeficiency Virus (HIV) which causes Acquired Immunodeficiency Syndrome (AIDS) has caused a global scare with mainly poor African countries suffering the greatest burden. Treatment of HIV is more of palliation rather than cure such that there is no room for treatment interruption if treatment goals are to be met. Antiretroviral treatment is associated with short term and long term side effects which have the potential to negatively impact on the high levels of adherence to treatment that is required to maintain virological suppression and may eventually lead to development of drug resistance and treatment failure. This research aims to identify the extent to which these side effects, through possible poor adherence, impact on treatment successes by measuring the risk that side effects contribute towards treatment failure. Methods Secondary data analysis was conducted on a cohort of patients who initiated ART between 2004 and 2010 at a large tertiary facility in Johannesburg. Patients who were switched to second line ART due to treatment failure were identified. Assessment of side effects on adherence was done. The hazards of side effects among patients switching and not switching to second line were calculated using Cox proportional hazards regression adjusting for other socio-demographic and clinical predictors for treatment failure. Interaction between side effects, gender, age and that of side effects and adherence was investigated. Time dependent covariates were also investigated. Confounding was controlled using multivariate Cox regression analysis. Results There were 5285 patients in the baseline cohort with multiple entry points who contributed 16035 person-years of follow up. The cohort consisted of 63.2% females and 36.8% males. Of these 85.9% were initiated on stavudine (d4T)- based regimen, 7.1% on tenofovir (TDF), 6.3% on zidovudine (AZT)-based regimen and 0.7% on other regimens. The median and mean time at risk per subject was 2.2 and 2.3 years respectively. A total of 770 episodes of side effects due to first line ART were experienced with some patients recording multiple side effects at different time points. Adherence data were found to be missing and incoherent in some of the regimen dosages and could not be used to objectively compare patients. There were 430 patients who were switched to second line ART due to treatment failure. Relative to the group of no side effects, the adjusted hazard ratios for mild, moderate and severe side effects were 1.40 (95% CI=0.94-2.09) p=0.10; 1.72 (95% CI=1.35-2.20) p<0.01 and 1.24 (95% CI=0.65-2.35) p=0.52 respectively. Therefore, overally side effects did not seem to play a role in the time to switch to second line ART. Sex, baseline CD4 cell count, the period during which ART was initiated and the time between date of testing HIV positive and date of initiating were significantly associated with the time to switching to second line ART. Conclusion The study informs that side effects overally may not play a significant role in switching patients from first line to second line ART with the exception of moderate side effects. However, patients who experience side effects should be closely monitored and adequately counselled to help them cope with the side effects so that optimal adherence levels are maintained. Availability of adherence scores or additional information on pills that should have been taken on periods during which pills were reported to have been missed would have made the research more valuable by allowing objective comparison of adherence among patients.

The roll-out of antiretroviral drugs in South Africa started in March 2004. In Mopani district, a rural district of Limpopo Province, the roll-out programme commenced in October 2004. While many resources were invested in this program, no study has assessed the clinical outcomes in this rural district. In addition, most studies conducted in South Africa were conducted in urban and tertiary settings. Assessing clinical outcomes is important in determining whether the program is making the desired clinical difference in the lives of the patients and may serve as feedback into the program for quality improvement purposes. Methodology The study was a retrospective record review of patients who were initiated on antiretroviral (ARV) treatment between December 2007 and November 2008. A structured questionnaire was used to collect data from 124 patient’s files and data was collected up to November 2011. The data collected included patients’ socio-demographic characteristics, clinical outcomes (CD4 count, viral load, presence of opportunistic infections, adverse effects and hospital admissions recorded at 6, 12, 24 and 36 months), the number of patients who were still attending the ARV clinic at 36 months and the reasons why patients are no longer attending the clinic. Data was analysed with Epi-Info and STATA. Results Of the 124 patients, 69% were females, 28% males and 3% did not have their sex specified. The majority of the patients were between 30 and 49 years. There was a significant improvement in CD4 count and viral load between baseline and all timeperiods after the initiation of ARV treatment. The mean CD4 count at baseline was 128The roll-out of antiretroviral drugs in South Africa started in March 2004. In Mopani district, a rural district of Limpopo Province, the roll-out programme commenced in October 2004. While many resources were invested in this program, no study has assessed the clinical outcomes in this rural district. In addition, most studies conducted in South Africa were conducted in urban and tertiary settings. Assessing clinical outcomes is important in determining whether the program is making the desired clinical difference in the lives of the patients and may serve as feedback into the program for quality improvement purposes. Methodology The study was a retrospective record review of patients who were initiated on antiretroviral (ARV) treatment between December 2007 and November 2008. A structured questionnaire was used to collect data from 124 patient’s files and data was collected up to November 2011. The data collected included patients’ socio-demographic characteristics, clinical outcomes (CD4 count, viral load, presence of opportunistic infections, adverse effects and hospital admissions recorded at 6, 12, 24 and 36 months), the number of patients who were still attending the ARV clinic at 36 months and the reasons why patients are no longer attending the clinic. Data was analysed with Epi-Info and STATA. Results Of the 124 patients, 69% were females, 28% males and 3% did not have their sex specified. The majority of the patients were between 30 and 49 years. There was a significant improvement in CD4 count and viral load between baseline and all timeperiods after the initiation of ARV treatment. The mean CD4 count at baseline was 128 The roll-out of antiretroviral drugs in South Africa started in March 2004. In Mopani district, a rural district of Limpopo Province, the roll-out programme commenced in October 2004. While many resources were invested in this program, no study has assessed the clinical outcomes in this rural district. In addition, most studies conducted in South Africa were conducted in urban and tertiary settings. Assessing clinical outcomes is important in determining whether the program is making the desired clinical difference in the lives of the patients and may serve as feedback into the program for quality improvement purposes. Methodology The study was a retrospective record review of patients who were initiated on antiretroviral (ARV) treatment between December 2007 and November 2008. A structured questionnaire was used to collect data from 124 patient’s files and data was collected up to November 2011. The data collected included patients’ socio-demographic characteristics, clinical outcomes (CD4 count, viral load, presence of opportunistic infections, adverse effects and hospital admissions recorded at 6, 12, 24 and 36 months), the number of patients who were still attending the ARV clinic at 36 months and the reasons why patients are no longer attending the clinic. Data was analysed with Epi-Info and STATA. Results Of the 124 patients, 69% were females, 28% males and 3% did not have their sex specified. The majority of the patients were between 30 and 49 years. There was a significant improvement in CD4 count and viral load between baseline and all timeperiods after the initiation of ARV treatment. The mean CD4 count at baseline was 128 cells/mm3; it increased to 310 cells/mm3 at 6 months, 380 cells/mm3 at 12 months and 470 cells/mm3 at 24 months. By 6 months, 67% of the patients had achieved viral suppression, but at 24 months, patients started having viral rebound. During the study, 20 patients fell pregnant and four patients fell pregnant twice. Overall, pregnant patients had a significantly higher viral load compared to non-pregnant patients (p-values = 0.015 at 6 months, 0.002 at 12 months and 0.027 at 24 months). Seventy two percent of patients were retained in the program at 36 months. Of the 28% that were no longer attending the clinic, 11.3% were transferred to other institutions, 6.5% were down referred to clinics, 3.2% died, 3.2% defaulted and 3.2% were lost to follow-up. Conclusion This study shows that good clinical outcomes can be achieved within an antiretroviral rollout program in a rural hospital. The biggest magnitude of clinical benefits was observed in the first six months after the initiation of ARV treatment with threats of viral rebound thereafter. There was good patient retention at 36 months after initiation of ARV treatment and a significant difference in viral load between pregnant and non-pregnant patients. The high rate of unplanned pregnancy signifies the need to place closer attention to family planning among female patients on antiretroviral treatment.

Carcinoma of the cervix is frequently diagnosed in the department of Radiation Oncology in Charlotte Maxeke Johannesburg Academic Hospital(CMJAH). It is therefore is a condition of priority and there is scarce literature in the management of HIV positive patients. OBJECTIVES: The primary objective of the research is to determine the overall survival of 2yrs and more, as well as to determine acute and late toxicity for patients completing prescribed radiation treatment. The secondary objective was to determine the impact of highly active antiretroviral therapy on survival and toxicity. The study is limited to HIV positive women presenting with cervical cancer. DESIGN & METHOD: The study is a retrospective study of patients treated at Charlotte Maxeke Johannesburg Academic Hospital between 2008-2009. Inclusion criteria: Females between the ages of 18 and 70, Stages IB2 – Stage IIIB carcinoma of the cervix who have completed planned radiation therapy with or without chemotherapy. The sample size was 151 patients. RESULTS: The mean age was 42.7yrs. The median CD4 count was 309 and 26.2% had CD4 counts below 200.The majority of patients had either Stage IIB (55.0%) or IIIB (31.8%). The total dose to Point A was a median dose of 74Gy. The majority of patients had either Grade II (38.4%) or III (31.1%) toxicity. Significant association between these adverse events and HAART status was rated as p=0.0008. The most common late complication was cystitis (15.9%). Overall survival at 2 years was 100% for Stage I, 92.8% for Stage II and 96% for Stage III. CONCLUSION: The median age was lower than in the HIV negative patients. The acute complications for those not on HAART, were higher in comparison to patients on HAART. The overall survival at 2 yrs. was above 90% for all stages in this study / GR2018

No description available.