Magister Public Health - MPH / Namibia is severely affected by the HIV/AIDS epidemic, with an estimated HIV prevalence of 17.8%. A comprehensive, public HIV/AIDS treatment and care programme was established in 2003 by the government of Namibia in association with its development partners. The introduction of antiretroviral therapy [ART] has dramatically decreased HIVrelated mortality and morbidity, improved quality of life, revitalized communities and transformed perceptions of HIV/AIDS from a plaque and death sentence to a manageable chronic condition. Intermediate Hospital Oshakati (IHO) in the Oshana region, is one of the six pilot hospitals where highly antiretroviral therapy (HAART) was initiated. Adherence to antiretroviral therapy (ART) is a key factor in ensuring optimal clinical outcomes and is associated with improved survival among HIV and AIDS patients. Sustained high levels of adherence (taking 95% or more of medication as prescribed) are essential for treatment success. Suboptimal adherence to treatment has been associated with virologic, immunologic and clinical failure, and may increase the risk of resistance to first-line ART drugs. Studies conducted in various parts of the country including the Oshakati district, report small proportions of patients defaulting on ART. Defaulting from treatment raises questions about adherence to ART as it can be assumed that poor adherence would precede defaulting from treatment. This study explored factors that influence poor adherence to ART among patients at Intermediate Hospital Oshakati. / South Africa

Magister Scientiae Dentium - MSc(Dent) / The initiation of highly active antiretroviral therapy has shown to result in successful suppression of viral replications followed by an increase in CD4 lymphocytes, a partial recovery of T-cell specific immune responses and decrease susceptibility to opportunistic pathogens. Aim: The aim of the present study was to determine the prevalence of oral lesions in patients before and after undergoing HAART. Methods: The study design was longitudinal and descriptive, investigating the prevalence of oral lesions presenting in HIV/AIDS patients at baseline, 3 and 6 months after taking HAART. A convenience sample size of 200 participants was targeted. Results: 210 HIV positive patients participated at baseline. At 3 months, 96 (46%) and at 6 months, 52 (25%) were available for review respectively. At baseline 210 HIV positive patients were recruited into the study from three hospitals. Two infectious disease hospitals belonged to the City of Harare and the other is a government hospital. Just over two thirds were female (64.3%) and the age ranged as follows: 21-30 (17%); 31-40 (44%); 41-50 (26% and 51-60 (9%).Discussion: HAART appears to be effective in reducing the prevalence of oral lesions in persons with AIDS likely due to the immunological reconstitution. Oral candidiasis remains the most prevalent oral opportunistic infection in immuno-suppressed individuals and hence its important predictive value for immuno-suppression defined as CD4-cell count level <200/mL of blood. All oral lesions strongly associated with HIV infection with the exception of non-Hodgkin’s lymphoma were diagnosed at baseline. CD4 cell count level increased after initiation of HAART. T-lymphocytes that are formed after the introduction of HAART may not provide sufficient protection against some lesions like parotid gland disease and HPV conditions (planar warts). HAART failure was detected in some patients who had negative CD4-cell count at 6 months compared to the baseline parameters. Conclusions: HIV-positive patients experience oral pain during the course of their disease, eating, drinking and swallowing. Further longitudinal studies are required in order to ascertain the prevalence of these lesions at three and six months and the effect of HAART.

Magister Public Health - MPH / At the end of 2008, Nigeria had the third largest number of people living with HIV/AIDS(PLWHA) in the world, with an estimated 2.95 million people and an average prevalence rate of 4.6%. According to the 2008 prevalence survey, prevalence rates in Nigeria’s 36 states and capital ranges between 1.0% in Ekiti State, to 10.6% in Benue.In Benue State, as at December 2008, only 12% of those requiring treatment were enrolled in an ART programme and only about half of the 23 Local Government Areas (LGAs) had a health centre providing ART services. There are several possible causes for poor coverage of ART services. This study explores some of the barriers preventing PLWHAs from accessing treatment in Benue State.The study utilized a qualitative case study design to explore the problem of poor access to ART in Benue State. PLWHAs, policy makers, program managers and health workers were involved in an effort to describe the factors influencing access to ART in the State. Semi structured interviews, exit interviews and focus group discussions were used.To analyse the findings, categorization was done into facilitators and barriers to access, in addition to the ways respondents believe these barriers can be overcome. Other sub-themes were also identified and sorted. Themes were linked to direct quotes from the respondents. Additional literature review was done to review available information on the themes identified. Facilitators of access included free cost and increased number of sites; beneficial effects of ART;disclosure, membership in a support group and having a treatment partner. Barriers included stigma and discrimination; hunger, poverty, transportation and opportunity costs; hospital factors; non-disclosure; inaccurate knowledge and perceptions about HIV and ART; certain religious beliefs and advice; coverage, capping of services and fear of non-availability of ART.In addition to stigma, patients bypass closer ART access points to further away hospitals because of business opportunities; financial assistance; perceived better standard of care and hope that a cure, when found, will be more accessible to patients in bigger hospitals.In conclusion, improving health worker attitudes through training; reselection of non-ARV drugs used in HIV management to ensure an uninterrupted supply; highlighting the importance of membership in a support group through patient enlightenment; working with religious leaders to reduce stigma and improve access; income-generating programs for patients; decentralization of ART services and upgrading of primary healthcare centres are important strategies to improve ART access in the state.

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.

The introduction of highly active antiretroviral therapy (HAART) has resulted in a significant decrease in the mortality and morbidity associated with the acquired immunodeficiency syndrome (AIDS). Several problems are associated with HAART and include high costs of treatments, poor availability of drugs in low-income countries, poor compliance, severe adverse effects and drug resistance. Therefore, the focus of current research is the development of new antiretroviral drugs, improved treatment strategies and the discovery of new drugs derived from plants. Green tea (GT) and its active constituent epigallocatechin gallate (EGCg) have been found to be protective against cancer, cardiovascular and neurodegenerative diseases and were found also to have antimicrobial, antimalarial and more importantly antiviral activity. EGCg, in vitro has been shown to inhibit the human immunodeficiency virus (HIV) viral enzymes reverse transcriptase and protease, destroy viral particles and interfere with the attachment of gp120 to cellular receptor CD4. The aims of this study were firstly to investigate the in vitro antiretroviral activity of GT and EGCg on the LP-BM5 defective murine leukemia virus (MuLV) that induces a disease in C57BL/6 mice similar to AIDS in humans and secondly to investigate the effects of GT and EGCg on the in vitro cytotoxicity and antiretroviral activity of current antiretroviral drugs zidovudine (AZT), indinavir (IDV), hydroxyurea (HU) and chloroquine (CQ). To achieve the above aims an in vitro model that represents cell-to-cell spreading of the LP-BM5 MuLV was developed. Firstly the presence of the LP-BM5-defective virus in the BM5 cell line was confirmed using transmission electron microscopy (TEM) to identify viral particles, PCR and RT-PCR were used to determine the presence of viral DNA and RNA respectively and viral infectivity was confirmed in C57BL/10 mice. The cytotoxicity of each drug and combination was evaluated with the MTT assay in the SC-1 cell line, the predominant cell type in the in vitro cell culture model. GT was the least cytotoxic, followed by AZT, IDV, EGCg, HU and CQ. Co-cultures (BM5:SC-1, 1:10000) that represented cell-to-cell transmission of the virus were established. Real time PCR for proviral DNA revealed that IDV, AZT and HU completely suppressed, CQ dose dependently reduced while GT and EGCg had no effect on viral transmission. Findings using AZT and IDV thus validated the use of this in vitro co-culture model for first line screening of new drugs and plant extracts. The effect of GT or EGCg in combination with AZT, IDV, HU or CQ was also evaluated as GT or EGCg could enhance the antiretroviral effects or decrease cellular toxicity of these drugs. For GT with AZT a mix of synergism and antagonism on cell toxicity was observed with little to no effect on the antiretroviral activity of AZT. Antagonism on cell toxicity was observed for GT with IDV, with no effect on the antiretroviral activity of IDV. In contrast EGCg significantly reduced the antiretroviral activity of IDV. A strong antagonistic effect was observed for GT with HU, with GT reducing the antiretroviral effect of HU. For combinations of AZT with EGCg and HU with EGCg a similar effect was observed as for AZT and HU respectively combined with GT. Synergism in cytotoxicity was observed between GT and CQ associated with a significant decrease in viral loads while EGCg combined with CQ had an opposite effect at higher concentrations. In conclusion, the in vitro co-culture model of BM5 and SC-1 cells was successfully used to evaluate combinations of GT and EGCg with AZT, IDV, HU and CQ. Interesting and often contradicting effects were observed, such as seen for IDV in combination with GT and EGCg as well as CQ in combination with GT and EGCg. These effects may be of clinical relevance and further investigation is warranted. / Dissertation (MSc)--University of Pretoria, 2009. / Anatomy / unrestricted

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

Charles University Faculty of Pharmacy in Hradec Králové Department of Pharmacology & Toxicology Student: Kateřina Erbenová Supervisor: PharmDr. Martina Čečková, Ph.D. Title of diploma thesis: Study of interactions antiretroviral drug maraviroc with drug transporters ABCB1 and ABCG2. Maraviroc is inhibitor of CCR5 HIV virus entry into the cells representing one of the important components of antiretroviral therapy. To optimize the treatment strategies and minimize the therapeutic risks of maraviroc-containing combination antiretroviral therapy, it is important to know the interactions of this drug with other antiretrovirals. In particular, interaction on membrane transporters may affect pharmacokinetics and thereby the tissue concentrations of administered drugs, leading to insufficient efficacy of the therapy or increased toxicity. The aim of this study was to experimentally evaluate interaction of maraviroc with the two most important active drug transporters of the ABC transporter superfamily, ABCB1 (P-glycoprotein) and ABCG2 (BCRP). Using in vitro methods employing cell lines we aimed to fulfil two main goals: (1) to evaluate the inhibitory effect of maraviroc on ABCB1 and ABCG2 transporters and (2) to study if any of these transporters could transfer maraviroc as their substrate. The data...

Due to the increasing availability of ART (antiretroviral therapy),HIV is starting to be seen as a chronic disease. This has several effects on families, one of which is the need to disclose their HIV status to children who were born with the illness. Potential barriers and available support structures with regards to paediatric HIV disclosure need to be considered before specific guidelines can be given to caretakers and health care providers. This study aimed to explore and describe the patterns of paediatric HIV disclosure or non-disclosure using a sample of caretakers or parents of children/adolescents who were born with HIV. The Disclosure Decision Making Model (DDMM) was used as a framework to understand the decision-making process that leads to either disclosure or non-disclosure. Qualitative data was gathered by means of in-depth, semi-structured interviews, conducted in English. Ten participants were recruited from a community health care centre that offers HIV counselling and testing in the Nelson Mandela Bay Health District. Data gathered was transcribed and analysed using thematic analysis. Lincoln and Guba’s model was used to determine the trustworthiness of the data. The two themes that emerged from the study were (1) caretakers wish to disclose HIV status to the child but identified barriers to doing this and, (2) caretakers identified factors that helped them to disclose the child’s status. This study provides a more in-depth understanding of the factors that influence disclosure in a resource-limited setting in the Eastern Cape.

Desde a sua descoberta, no início da década de 80, o HIV/aids, constituiu-se como uma doença que ultrapassa os limites da dimensão biomédica, apresentando diversos desafios à sociedade. No Brasil, estima-se que aproximadamente 734 mil pessoas vivem com HIV/aids. Foram desenvolvidas diferentes classes de drogas antirretrovirais para seu tratamento; as quais são eficazes para o controle parcial da replicação viral. Sem a descoberta da cura, é imprescindível que as pessoas vivendo com HIV/aids sigam as recomendações da equipe de saúde, aderindo ao tratamento proposto; aumentando sua qualidade de vida, bem como contribuindo para a diminuição da transmissão do vírus. Durante o tratamento, algumas dificuldades podem surgir, determinando momentos de maior ou menor adesão ao mesmo e os profissionais de saúde, dentre eles, os farmacêuticos, devem estar atentos a estes momentos. Este estudo transversal teve como objetivo analisar a retirada do TARV nos últimos 24 meses e investigar os possíveis fatores que levam a retirada desta medicação de forma irregular na Unidade Especial de Tratamento de Doenças Infecciosas (UETDI) do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo. Participaram 250 pessoas que vivem com HIV/aids que retiram a medicação na Farmácia do local do estudo. Os participantes foram separados em dois grupos: Grupo em Atraso e Grupo Controle segundo seus históricos de dispensação da TARV nos vinte e quatro meses anteriores a realização das entrevistas. Predominaram participantes do sexo masculino (57,6%), com mais de 40 anos (76%), brancos (51,6%), com baixa escolaridade (48,4%), sem parceiro fixo (52,4%), residentes em Ribeirão Preto (63,6%). Todas as variáveis foram relacionadas em um estudo univariado e aquelas com um valor de \"p\" igual ou menor que 0,2 foram selecionadas para análise multivariada. As associações entre variáveis selecionadas e a retirada irregular comparada com a retirada regular, foi estimada pela estimativa com intervalo de confiança de 95%. As variáveis que mostraram associação com a retirada da TARV em atraso foram: fazer uso de outro medicamento além da TARV, apresentar resultado de exame de carga viral como detectável, ter, no início do período analisado, contagem de linfócitos T CD4 menor que 200 células /mm3 e ter baixa adesão como resultado do Teste de Morisky- Green / Since its discovery in the early 80s, HIV / AIDS was established as a disease that pushes the boundaries of biomedical dimension, presenting many challenges to the society. In Brazil, there are almost 734,000 people carrying HIV / AIDS. Different classes of antiretroviral drugs were developed for their treatment, which are effective in partial control of viral replication. Yet incurable disease it is essential that people living with HIV / AIDS follow the recommendations of the health care agents, adhering to the proposed treatment, increasing their quality of life, and contributing to the reduction of transmission of the virus. During treatment, some difficulties may arise, determining moments of greater or lesser adherence, and pharmacists among other health professionals, should be aware of these moments. This cross-sectional study aimed to analyze the withdrawal of ART in the last 24 months, and investigate the possible factors that lead the medication withdrawal erratically on Special Treatment of Infectious Diseases Unit (UETDI) of the Clinics Hospital - School of Medicine of Ribeirao Preto, University of São Paulo. Two hundred and fifty people living with HIV / AIDS got medication in the study site pharmacy. Participants were divided into two groups: Group Control and Group Delay, according to their historical dispensing of ART in twenty-four months prior to the interviews; predominant male participants (57.6%) with more than 40 years (76%), white (51.6%), with low education (48.4%), with no steady partner (52.4%), residents in Ribeirão Preto (63.6%). All variables related in a univariate analysis, and those with a value of \"p\" equal to or smaller than 0.2 were selected for multivariate analysis. The associations between selected variables, and the irregular removal compared to regular withdrawal were estimated with 95% confidence interval. The variables that were associated with the withdrawal of ART arrears, and making use of another drug in addition to HAART, presented results of viral load test as detectable, having the beginning of period analyzed, CD4 lymphocyte count less than 200 cells / mm3, and have low compliance as a result of Morisky- Green test.