Magister Commercii (Information Management) - MCom(IM) / In South Africa, public health facilities provide free antiretroviral treatment (ART) mainly via primary healthcare (PHC) nurses. To streamline data collection an electronic HIV information system (TIER.Net), was introduced in 2010. Data originates in paper-based records completed by clinicians with the data from these paper systems then being captured into TIER.Net by clerical data capturers. TIER.Net is designed to effectively monitor outcomes of the ART programme and generate information for planning, management and decision making. For Enock Mgijima subdistrict to attain these functions, it is imperative that data collected at the 21 PHC facilities in the sub-district be of good quality. There has been uncertainty around the quality levels of the data collected through the paper records and TIER.Net, and it was unclear which factors promote or inhibit improved data quality.

Fléau mondial depuis des millénaires, la tuberculose (TB) a régressé dans la deuxième moitié du 20ème siècle avant de connaitre une résurgence à partir des années 1980 à la faveur de la pandémie du VIH. Les deux maladies se potentialisent mutuellement et forment un « couple infernal ». En Afrique, la TB est la première cause de mortalité des adultes infectés par le VIH, quel que soit leur niveau d’immunité. Une des mesures pour lutter contre la TB associée au VIH est la chimioprophylaxie, consistant à traiter une infection tuberculeuse latente pour prévenir l’évolution vers une TB maladie. La mieux évaluée, consiste à prescrire 6 à 12 mois de monothérapie d’isoniazide (Isoniazid Preventive Therapy, IPT). Depuis 1993, l’OMS recommande la prescription de 6 mois d’IPT chez toutes les personnes infectées par le VIH sans signe de TB active. Malgré des preuves scientifiques solides à l’appui de cette recommandation, l’utilisation de l’IPT est toujours restée faible. Avant notre travail, trois raisons expliquaient cette faiblesse : (i) la crainte qu’une chimioprophylaxie mal appliquée ne favorise l’émergence de résistances ; (ii) le fait que les essais avaient démontré l’efficacité de l’IPT pour réduire l’incidence de TB, pas pour réduire la mortalité ; (iii) le fait que les essais d’IPT avaient eu lieu en majorité avant l’ère des antirétroviraux (ARV), chez des personnes très immunodéprimées. Les ARV permettant également de réduire le risque de TB en faisant régresser l’immunodépression, certains considéraient que l’IPT était devenue inutile. Dans cette thèse nous faisons d’abord un rappel des connaissances essentielles sur l’infection par le VIH, la TB, l’association TB/VIH, et le concept de chimioprophylaxie antituberculeuse. Puis nous exposons les résultats de l’analyse du suivi prolongé de l’essai randomisé Temprano ANRS 12136, qui s’est déroulé entre 2008 et 2015. Cet essai a suivi 2056 adultes infectés par le VIH dans 9 centres de soins à Abidjan. Les participants qui avaient des CD4 élevés (moyenne 477/mm3) étaient randomisés en 4 bras pour étudier deux interventions : 6 mois d’IPT (reçu vs. non reçu) et ARV (début immédiat vs. début différé). Les participants ont été suivis pendant 4,9 ans en moyenne. 89% d’entre eux ont débuté des ARV. Pendant le suivi, il y a eu 86 décès, 34 dans le groupe avec IPT (probabilité à 6 ans : 4,1% ; IC95% 2,9–5,7) et 52 dans le groupe sans IPT (probabilité à 6 ans: 6,9% ; 5,1–9,2). Le Hazard ratio de décès dans le groupe avec IPT par rapport à l’autre groupe était 0,63 (95% CI 0,41-0,97). Il n’y avait pas d’interaction entre IPT et ARV précoce, ni entre IPT et le temps. Ces résultats ont été publiés dans The Lancet Global Health. Enfin nous discutons ces résultats avec ceux des essais d’IPT précédents, dans une revue critique de la littérature analysant les données d’efficacité et de tolérance, les déterminants de l’efficacité, et les risques de résistance. Nous montrons que l’essai Temprano complète et élargit le spectre des connaissances, et que les preuves scientifiques accumulées depuis 1993 jusqu’à l’essai Temprano inclus suggèrent que les ARV modifient certains paramètres de l’IPT qu’on pensait solidement établis. Avant l’ère des ARV on considérait que l’efficacité de l’IPT était forte chez les personnes avec IDR positive mais très faible voire inexistante chez les personnes avec IDR négative, qu’il y avait une perte d’efficacité de l’IPT au cours du temps et que l’IPT n’avait pas d’effet sur la mortalité. Avec les ARV, on voit que l’IPT est efficace quel que soit le résultat des tests tuberculiniques, que cette efficacité est prolongée, et qu’elle se traduit non seulement par une réduction de la TB mais aussi de la mortalité. L’IPT reste donc une intervention d’une grande actualité à l’ère des ARV. Ces résultats devraient convaincre les pays jusque-là réticents à appliquer les recommandations de l’OMS. / Tuberculosis (TB) has been a worldwide scourge for millennia. It has regressed in the second half of the 20th century before resurging in the 1980s because of the HIV pandemic. Both diseases potentiate each other and form a "cursed duet". In Africa, TB is the leading cause of mortality among HIV-infected adults, regardless of their level of immunity. One of the measures to fight HIV-associated TB is chemoprophylaxis, which consists in treating latent TB infection to prevent the progression to TB disease. The most evaluated chemoprophylaxis, referred to as "Isoniazid Preventive Therapy" (IPT), consists in prescribing 6 to 12 months of isoniazid monotherapy. Since 1993, WHO recommends the prescription of 6 months of IPT in all HIV-infected persons who do not have evidence of active TB. Despite strong scientific evidence to support this recommendation, the use of IPT has remained low. Before our work, there were three reasons for this:(i) people feared that chemoprophylaxis might favor the emergence of resistance to TB drug; (ii) the IPT trials demonstrated the effectiveness of IPT in reducing TB incidence, not in reducing mortality; (iii) most IPT trials took place before the antiretroviral treatment (ART) era, in highly immunocompromised individuals. As ART also reduces the risk of TB by decreasing immunosuppression, some people considered that IPT had become useless. In this work, we first go over the basic knowledge about HIV infection, TB, the combination of the two diseases, and the concept of antituberculous chemoprophylaxis. Then we present the results of the long-term follow-up of the Temprano ANRS 12136 randomized trial, which took place between 2008 and 2015. This trial followed 2056 HIV infected adults in 9 care centers in Abidjan. Participants with high CD4 counts (mean: 477 cells/mm3) were randomized into 4 arms to study two interventions: 6 months of IPT (received vs. not received) and early ART (immediate initiation vs. delayed initiation). Participants were followed for an average of 4.9 years. Eighty nine percent of participants received ART. During follow-up, there were 86 deaths, 34 in patients randomized to IPT (6-year probability: 4.1%, 95% CI 2.9-5.7) and 52 in those randomized to no-IPT (6-year probability: 6.9%, 5.1-9.2). The Hazard ratio of deaths among those randomized to IPT compared to others was 0.63 (95% CI 0.41-0.97). There was no interaction between IPT and early ART, nor between IPT and time. These results were published in The Lancet Global Health. Finally, we discuss these results with those of previous IPT trials, after reviewing all available randomized-controlled evidence on efficacy, safety, efficacy determinants and risks of resistance. We show that the Temprano trial complements and widens the spectrum of evidence accumulated since 1993 and that ART modifies some key parameters of IPT previously thought to be strongly established. Prior to the ART era, evidence suggested that the efficacy of IPT was high in people with positive Tuberculin Skin Test (TST) but very low in those with negative TST; that there was a loss of IPT efficacy over time; and that IPT had no effect on mortality. With ART, IPT appears to be effective regardless of TST results, have prolonged efficacy, and reduce not only TB but also mortality. IPT remains a very topical intervention in the ART era. These results should convince IPT-reluctant countries to implement WHO recommendations.

HIV and AIDS pandemic have been declining in South Africa. HIV and AIDS affect individuals, families, organizations and the communities at large. While the roll out of the antiretroviral treatment (ART) has brought much excitement and hope to both patients and the health practitioners, it has also brought challenges (Maskew, Macphail, Menez & Rubel, 2007:853). In order for ART to be effective patients need to adhere to antiretroviral treatment, thus adherence is a critical component of ART. Patients who discontinue treatment are at high risk of illness and death because of AIDS related diseases or developing drug resistant virus. With a better understanding of the reasons for defaulting antiretroviral treatment interventions can be designed to improve adherence to antiretroviral treatment. Thus the purpose of this study was to explore the reasons why HIV and AIDS infected patients default antiretroviral treatment because adherence to ART is of utmost important. Within the context of qualitative and applied research the researcher utilized the collective case study design. Semi structured interviewing was used as data collection method to elicit qualitative information on the reasons why patients default ART. The main research question that was put forward to all participants was: What are your reasons for defaulting ART? The participants in this study were patients who have default their ART during 2012. By using systematic sampling fourteen participants from Thekganang ARV Clinic in Seshego District Hospital, Limpopo province, were selected to form a sample for this study. Some conclusions based on the findings were that: The participants were knowledgeable about the basic facts of HIV and AIDS and they had a good understanding about the importance of adherence even though they defaulted their antiretroviral treatment. The use of ART may also be challenging to individuals. The findings of this study were that not all participants in the study experienced challenges with taking ART. Those who experienced challenges included fear of disclosing HIV status, fear of stigmatization and physical challenges due to ill health. Regarding the reasons for defaulting ART, participants’ reasons for defaulting antiretroviral treatment were similar although some of the reasons applied to only one participant. Participants’ reasons for treatment default were classified into socio-economic factors, patient related, psychological related and medication related factors. Socio- economic factors included shortage of food in the household and lack of money for transport to attend clinic appointments. Patient related factors included substance abuse, lost appointment cards, participants were too busy with personal issues and relocation to another area of residence. Psychological factors that contributed to non-adherence to treatment were depression and denial. Medical related factor voiced was that participant was too confused about the drug regimen. Most participants were satisfied with the services in Thekganang ARV clinic although some participants raised concerns about staff attitudes and long queue. The findings will assist the hospital management and the clinic staff to make informed decisions about the management of defaulters in the clinic. The study was concluded with the relevant recommendations to the ART facilities. The recommendations included implementation of the multi-disciplinary centred approach, establishing patient education programmes and on-going support services to patients who fail to adhere to treatment. Future research studies should determine the prevalence of drug resistant HIV patients in the ART facilities and the development of a systematic method of capturing ‘‘lost to follow up’’ patients who pass away within hospitals. / Dissertation (MA)--University of Pretoria, 2014. / lk2014 / Social Work and Criminology / MA / Unrestricted

The aim of the study was to evaluate the effect of human immunodeficiency virus infection (HIV) and antiretroviral treatment on the retinal nerve fibre layer (RNFL). The RNFL hickness defined by standard parameters(TSNIT average, Superior average and Inferior average) was assessed in 48 HIV positive patients using scanning laser polarimeter, GDx VCC device. Results were compared to normal values and tested against factors suspected to affect the RNFL thickness. The mean values of the RNFL standard parameters were for TSNIT average, Superior average and Inferior average, 57,65 ± 6,18  m, 69,38 ± 8,34  m, 68,89 ± 9,50  m respectively, in our cohort. The RNFL thinning was not confirmed in our HIV positive group compared to values on healthy population. No significant correlation between the RNFL thickness and the immune profile or antiretroviral therapy was detected. However, a significant negative correlation between the RNFL thickness with increasing duration of HIV infection was foundin our study that is hypothesized to be possibly on an immune pathological basis. Powered by TCPDF (www.tcpdf.org)

Magister Curationis / The National Programme of Prevention of Mother to Child transmission (PMTCT) in relation to HIV/AIDS was introduced by the Department of Health in different sites per province in South Africa in 2001. The number of women has a chance to access antenatal clinic services during pregnancy but they start to attend usually in late gestation.

Master of Public Health - MPH / Background: HIV remains a global concern. Consequently, global institutions such as the World Health Organisation (WHO) and United Nations Programme on HIV and AIDS (UNAIDS) continue to work towards ending HIV/AIDS by facilitating innovative strategies to improve service delivery of antiretroviral therapy (ART). In 2016 WHO issued the ‘test and treat’ policy recommendation in line with the UNAIDS 2020, 90-90-90 target of reaching 90% people to know their HIV status, get 90% of these on ART treatment and to have 90% of those on treatment virally suppressed. Differentiated Care Models (DCMs) has been put in place for all stakeholders, from global, institutes, government departments and civil society to improve patient access to treatment and retention in care. While various evaluation studies have shown that DCMs improve the retention in care and adherence to medication behaviours of patients on ART, little is known about the patients’ experiences and preferences. The aim of the current study was to explore and compare the experiences of patients in three DCMs (Facility Adherence Clubs [FAC], Community Adherence Club [CAC] and Quick Pharmacy Pick-up [QPUP]) in a community health care facility in a township in Cape Town, South Africa. Methods: An exploratory qualitative study design was used. Data were collected through semi-structured interviews (12) and focus group discussions (6) with purposively selected participants from six DCMs. Thematic analysis was done using Atlas.ti version 8.0. Results: Patients found DCMs easily accessible and convenient and presented positive experiences in relation to the National Health Services (NHS) patients experience principles. FACs and CAC presented attributes of patient-centeredness as prescribed by the NHI. We found that the QPUP model fell short on attributes of patient-centeredness such as coordination and integration of care, information sharing, communication and education, and emotional/psychological support. Conclusions: The principles of DCMs acknowledge the diversity and preference of PLHIV in addressing the barriers they face in accessing ART while empowering these patients to self-manage their disease. Understanding the experiences of patients using DCMs could improve our understanding of how DCMs promote self-management among PLHIV (or not) and some of the challenges faced by the patients using these care models. This understanding could inform strategies to tailor ART delivery services that suit the patients’ needs and enhance their abilities to achieve optimal retention in care and viral suppression.

Includes bibliographical references (leaves 81-85). / HIV and AIDS are still affecting many people in Brazil, South Africa and across the world, even though much has been done to mitigate against its further spread. Often Brazil and South Africa are compared to each other because of their economic position in the world and also because of their similar political histories. This research compares the Brazilian and the South African HIV and AIDS National Strategic prevention policies and it also aims to find out why the HIV and AIDS prevalence rates took significantly different patterns in the respective countries. The study includes a policy comparison and qualitative in-depth interviews with 14 organisation directors whose main focus is HIV prevention in Brazil and South Africa. The mains findings revealed that one of the main reasons for the different prevalence rate in both countries was because the civil society in Brazil played a major role in pressurizing the government to respond to the pandemic, while in South African the civil society did not play a major role. The Brazilian government thus started responding to HIV at least 9 years before the South African government did. Also, the Brazilian National HIV and AIDS prevention policy has an action plan for each goal, while the South African Policy does not have action plans for their goals. The Brazilian policy is also decentralized to municipal level, while the South African policy is decentralized only to Provincial level. Another finding was that in Brazil the NGO sector was directly involved in formulating the policy while in South Africa the NGO sector was not. In Brazil the respondents had a good knowledge and understanding of the policy, while in South Africa the respondents did not have a good knowledge of the policy. In Brazil NGOs have formed partnerships between themselves in order to deliver better services and to make their voices stronger when pressurising the government. Respondents in Brazil also knew what other organisations were doing. In South Africa organisations did not know what other organisations were doing and the NGOs did not have strong partnerships between themselves.

Background: HIV is a condition that requires lifelong treatment. Treatment options currently consist of oral antiretroviral therapies (ART) taken once or twice daily. Long-acting injectable HIV treatments are currently in development to be administered monthly or every other month. Preferences for route of administration could influence treatment adherence, which could affect treatment outcomes. The purpose of this study was to examine patient perceptions of oral and injectable routes of administration for ART. Methods: Qualitative thematic analysis was conducted to examine 5122 online discussion threads by people living with HIV (PLHIV) in the POZ Community Forums from January 2013 to June 2018. Analysis focused on identifying perceptions of oral or injectable routes of administration for ART. Relevant threads were extracted and imported into the qualitative data analysis software package ATLAS.ti.8 so that text could be reviewed and coded. Results: Analyses identified 684 relevant discussion threads including 2626 coded quotations from online posts by 568 PLHIV. The oral route of administration was discussed more frequently than injectable (2516 quotations for oral; 110 injectable). Positive statements on the oral route of administration commonly mentioned the small number of pills (276 quotations), dose frequency (245), ease of scheduling (153), and ease of use (146). PLHIV also noted disadvantages of the oral route of administration including negative emotional impact (166), difficulty with medication access (106), scheduling (131), and treatment adherence (121). Among the smaller number of PLHIV discussing injectable ART, common positive comments focused on dose frequency (34), emotional benefits of not taking a daily pill (7), potential benefits for adherence (6), overall convenience (6), and benefits for traveling (6). Some comments from PLHIV perceived the frequency of injections negatively (10), and others had negative perceptions of needles (8) or appointments required to receive injections (7). Conclusions: Qualitative analysis revealed that route of administration was frequently discussed among PLHIV on this online forum. While many expressed positive views about their daily oral medication regimen, others perceived inconveniences and challenges. Among PLHIV who were aware of a possible monthly injectable treatment, many viewed this new route of administration as a convenient alternative with potential to improve adherence.

With great appreciation, I would like to accentuate the substantial contributions of the following people who made this project possible: To Dr. CMT Fourie (my supervisor), Prof. JM van Rooyen (my co–supervisor) and Prof. AE Schutte (my co–supervisor) whose gracious advise, patient guidance, commitment and support have enabled me to plan, analyse, interpret and write this project in a scientific manner. It has been an educational experience for me, thank you. To Mr. LS Wyldbore for the language editing of this dissertation. I thank all the participants, researchers, field workers and supporting staff of the PURE study. The financial assistance of the National Research Foundation (DAAD–NRF) towards this research is hereby acknowledged. A special thanks to my parents, sister, Albert, family and friends, thank you for the never–ending love, support, patience and understanding that you gave me throughout this project. Last, but not the least, a special thank to God for giving me the opportunity, talent, determination and endurance to complete this project. / Thesis (M.Sc. (Physiology))--North-West University, Potchefstroom Campus, 2012.

With great appreciation, I would like to accentuate the substantial contributions of the following people who made this project possible: To Dr. CMT Fourie (my supervisor), Prof. JM van Rooyen (my co–supervisor) and Prof. AE Schutte (my co–supervisor) whose gracious advise, patient guidance, commitment and support have enabled me to plan, analyse, interpret and write this project in a scientific manner. It has been an educational experience for me, thank you. To Mr. LS Wyldbore for the language editing of this dissertation. I thank all the participants, researchers, field workers and supporting staff of the PURE study. The financial assistance of the National Research Foundation (DAAD–NRF) towards this research is hereby acknowledged. A special thanks to my parents, sister, Albert, family and friends, thank you for the never–ending love, support, patience and understanding that you gave me throughout this project. Last, but not the least, a special thank to God for giving me the opportunity, talent, determination and endurance to complete this project. / Thesis (M.Sc. (Physiology))--North-West University, Potchefstroom Campus, 2012.