This thesis examines HIV disease natural history and response to antiretroviral treatment (ART) in patients from The TREAT Asia HIV Observational Database (TAHOD), a mulitcentre, prospective observational cohort of HIV-infected patients from countries in the Asia-Pacific region. By September 2005, 2979 patients have been recruited to TAHOD from 15 participating sites. The majority were male (73%), median age 37 years. Chinese (37%), Thai (25%) and Indian (17%) were the main ethnicities. Most patients reported HIV infection through heterosexual (59%) and homosexual contact (23%); 5% injecting drug use. At baseline, 41% of patients were diagnosed with AIDS defining illness, and 77% were being treated with highly active antiretroviral therapy (HAART). Baseline and retrospective data suggest that the overall response to HAART in TAHOD is similar to that seen in western cohorts, with mean CD4 count increase of 115 cells/μL and 69% achieving a viral load less than 400 copies/mL six-month after HAART initiation. Baseline CD4 count was the strongest predictor of short-term disease progression. Prognostic models based on routine clinical data and haemoglobin gave a good estimation of disease progression. The rate of new AIDS defining illness was 26% in the first 90 days after HAART initiation, which may partly be due to immune reconstitution syndrome occurring shortly after treatment. The most frequently used first-line ART combination was stavudine/lamivudine/nevirapine. Approximately 22% of patients receiving this treatment changed or stopped at least one drug in the first year, with adverse effect (including lipodystrophy, hepatitis, rash and peripheral neuropathy) the major reasons. The rates of discontinuation of efavirenz or nevirapine as part of HAART were similar (16 vs. 20/100 person years). Older age and positive HCV antibody were associated with an elevated liver function (ALT) test. Both prevalence of HBV and HCV coinfection with HIV were approximately 10%. The impact of hepatitis coinfection on immunological and virological responses to ART and HIV disease progression was not statistically significant. Both HBV and HCV remained independently associated with elevated ALT in the multivariate models. The overall HIV disease progression and response to ART in TAHOD patients were similar to those seen in the western countries.

Parkinson's Disease can be treated by a micro-electrode guided neurosurgery called a Pallidotomy or Deep Brain Stimulus. A new software program, called Onetrack, is being developed and incorporates a three dimensional virtual model of the brain, a advanced digital signal processor and a knowledge based system (KBS). This thesis discusses the design and development of this KBS. The purpose of the KBS is to assist the surgical team in identifying the different anatomical structures and neuronal cell types of the brain. Therefore, improving the efficiency of the procedure.

Stress has been shown to exacerbate cell death and cognitive deficits after ischemic injury in rodents, however, little is known of the effects of stress on motor recovery. The objective of this present thesis is to examine the effects of chronic stress on skilled motor recovery after devascularization lesion in rats. It was found that pre-lesion stress induced the most behavioural impairments, while post-lesion stress exacerbated infarct volume. The effects of chronic multiple stress on skilled motor recovery after lesion was also examined. Chronic multiple stress did not modulate skilled motor recovery nor did it have any influence on infarct volume. Additionally, stress had effect on edema after devascularization lesion. The present thesis suggests that the time of exposure to chronic stress in respect to the ischemic lesion, in addition to the type of stress, will differentially affect recovery and compensation in rats. / xii, 122 leaves : ill. ; 29 cm.

The development of health systems in sub-Saharan Africa has been seriously challenged in the last two decades by the rise of HIV/AIDS. In this thesis I argue that the interface between health policy and HIV/AIDS in South Africa is poorly understood and that this has been to the detriment of fairly radical health care reforms as well as more general health systems development. The research problem outlined above is two-fold, requiring different types of enquiry and analysis. Firstly, there is a gap in our understanding of the impact of HIV/AIDS on health systems. Empirical evidence is presented from research on health facilities and health management structures in Ugu district, KwaZulu-Natal to address this concern. Secondly, it is asserted that our limited understanding of the impact of HIV/AIDS and the nature of the epidemic have prevented a true appreciation of its significance for health policy. This dimension of the problem is addressed through an analysis of South African health policy from 1994 through to the present, as well as a more theoretical look at the potential future influence of the antiretroviral therapy programme on the health system. Both quantitative and qualitative methodologies are employed in this research to acquire empirical insights. Health service utilisation trends are assessed retrospectively by quantitative analysis of key indicators from district and provincial information systems. Meanwhile, the prospective component of the quantitative research can best be described as repeat cross-sectional surveys of a selection of health facilities in Ugu district. These surveys capture data on the profile of patients seeking care and the resource requirements for managing these patients. Qualitative methodologies (predominantly semi-structured interviews) are used at facility level to gain insight into human resource issues and at the management level to better understand health system functioning in relation to HIV/AIDS. One would expect the increasing HIV prevalence and burden of AIDS illness in South Africa to translate into a higher demand for health care. However, this has not occurred in Ugu district, largely because of difficulties with access to care. Despite this, at lower level health services, namely clinics and district hospitals, HIV-related service provision has outpaced an increase in resources. Specifically, the introduction of the antiretroviral therapy programme and the decentralisation of a range of HIV/AIDS services are causing new strains on the system. In essence, the epidemic has created a need to address barriers to accessing care and to expand support for district health services. HIV/AIDS not only increases the demand for health care, but on the supply side erodes the capacity of the health system to deliver care. My research demonstrates that health care workers in KwaZulu-Natal are being severely impacted by the epidemic, with the nature of their work contributing to both their susceptibly and vulnerability. Not only is HIV/AIDS increasing absenteeism and attrition through escalating morbidity and mortality, but it is also working in more subtle ways to contribute to a range of 'push' factors driving health workers from the public health sector. None of these issues have been addressed because of the narrow definition of 'human resource management', despite the obviously heightened need to monitor attrition trends and develop creative retention strategies. My research looks not only at the impact of HIV/AIDS impact on health services in Ugu district, but also at the impact of the epidemic on higher levels of the health system which constitute management structures. At these levels, the health system is challenged by an urgency to deliver HIV/AIDS services, as well as an increasing involvement of donors and partners such as civil society organisations or faith based organisations. This has resulted in trends towards more centralised control of planning and management and, in some instances, a deflection of resources towards HIV/AIDS issues and programmes. This context has called for a strong focus on capacity development and means to ensure the integration of health programmes. Many of the trends in Ugu district demonstrate the insidious nature of HIV/AIDS impact and give some insight into why these trends have not been adequately addressed by South African health policies. My analysis suggests that despite the appropriateness of the overarching direction of health reforms, some concerns arising from the HIV/AIDS epidemic have received little attention. These include a need to: 1) manage human resource impacts, 2) develop home community based care and establish a continuum of care, and 3) lead and direct the involvement of donors and partners in the health sector. On the other hand, there have been some beneficial policy developments, such as the elimination of user fees for certain services and the attention paid to the way in which a focus on HIV/AIDS care can potentially weaken the health system. Unfortunately, in many instances HIV/AIDS has also widened the gap between policy and implementation and opportunities have been missed to develop the health system in an appropriate manner. The South African antiretroviral therapy programme, launched in 2003, is a source of uncertainty regarding the future development of health policy in the country. My analysis makes use of scenarios to explore the potential future impact of the programme. I consider the ways in which the programme is steering us away from our post-apartheid vision of an equitable and well functioning national health system and towards 'AIDS exceptionalism'. I look to Botswana, the first country in southern Africa to provide antiretroviral therapy in the public health sector, for early lessons as to what we might expect. My case study of this programme suggests that HIV/AIDS care can be integrated with time, so limiting damage to the development of fragile health systems. Only through ongoing reassessment of the South African situation will it become apparent whether such lessons are transferable. Nonetheless, forward thinking should allow us to move from a crisis-orientated response to one that is more strategic. This thesis concludes with four key messages (or recommendations) emerging from both the empirical research and the health policy analysis. Firstly, there is a clear need to establish systems that can provide comprehensive and timely information concerning the impact of HIV/AIDS on public health services. Secondly, trusting relationships have to be built between academics/researchers and health policy makers so that research informs policy. Thirdly, there is a need to (re)establish a shared vision of the national health system and maintain a focus on achieving this vision. Finally, priority programmes and resources allocated to these must be used to strengthen our national health system in creative ways. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2007.

In the midst of hope and suffering due to the challenges posed by HIV and AIDS in South Africa, communities have literally witnessed a glimmer of hope in women volunteers who have readily and willingly provided care and support to people living with HIV and AIDS (PLWHA) and their families. Policy-makers have maintained that if the care of sick people is to be both comprehensive and cost-effective, it must be conducted as much as possible in the community, with hospitalization only when it is necessary. However, the strains on those caring for people with HIV and AIDS are enormous. This paper argues that neo-liberal policies are reinforcing the divide between the 'haves' and the 'have-nots', by placing strain on women volunteers in the field of community home-based care. The study was conducted in the area of Mpophomeni Township, in KwaZulu-Natal province. The research participants consisted of 10 community home-based care (CHBC) volunteers and their supervisor, 3 CHBC trainers, and 1 counselling trainer. Using a qualitative design, this study examines a specific CHBC training course and how effectively it prepares voluntary caregivers for the challenges experienced in individual homes. Ascertaining how the training helped caregivers to confront their own fears and problems before dealing with those of others, and exploring how community caregivers coped with the stress inherent in their jobs was the primary focus of this study. For these purposes, a qualitative methodology was deemed most appropriate for it allowed me to gain in-depth information through observations, semistructured interviews, a review of relevant documents, and training materials. Inspired by feminist perspectives, the findings revealed that already overburdened and poor people provide the bulk of voluntary services in the area of CHBC. Consequently, they are unable to provide quality care for people living with HIV and AIDS without external support from the government. The findings further established a mismatch between the training content and the reality of work of caregivers. The training puts more emphasis on practical aspects, by providing basic nursing care, often only relevant in helping a bedridden patient. However, many voluntary caregivers reported that the demands placed on them do not end with the death of the patient. This poses a challenge for those in the CHBC training environment as they need to offer relevant and well-researched information linked to the reality of voluntary caregivers' work. The study also highlighted a need to consider the personal long-term goals of volunteer caregivers and begin to realize the importance of using the training to put them on a career path. I therefore argue that the burden of care for people living with HIV and dying from AIDS in resource-poor settings cannot be shifted entirely to communities with the false assumption that they are able to cope. As we continue to grapple with moral and ethical issues in the context of HIV and AIDS, we also need to be concerned about moving women volunteers' efforts from invisibility to visibility through a social transformation agenda. / Thesis (M.Ed.)-University of KwaZulu-Natal, Pietermaritzburg, 2006.

This thesis examines HIV disease natural history and response to antiretroviral treatment (ART) in patients from The TREAT Asia HIV Observational Database (TAHOD), a mulitcentre, prospective observational cohort of HIV-infected patients from countries in the Asia-Pacific region. By September 2005, 2979 patients have been recruited to TAHOD from 15 participating sites. The majority were male (73%), median age 37 years. Chinese (37%), Thai (25%) and Indian (17%) were the main ethnicities. Most patients reported HIV infection through heterosexual (59%) and homosexual contact (23%); 5% injecting drug use. At baseline, 41% of patients were diagnosed with AIDS defining illness, and 77% were being treated with highly active antiretroviral therapy (HAART). Baseline and retrospective data suggest that the overall response to HAART in TAHOD is similar to that seen in western cohorts, with mean CD4 count increase of 115 cells/μL and 69% achieving a viral load less than 400 copies/mL six-month after HAART initiation. Baseline CD4 count was the strongest predictor of short-term disease progression. Prognostic models based on routine clinical data and haemoglobin gave a good estimation of disease progression. The rate of new AIDS defining illness was 26% in the first 90 days after HAART initiation, which may partly be due to immune reconstitution syndrome occurring shortly after treatment. The most frequently used first-line ART combination was stavudine/lamivudine/nevirapine. Approximately 22% of patients receiving this treatment changed or stopped at least one drug in the first year, with adverse effect (including lipodystrophy, hepatitis, rash and peripheral neuropathy) the major reasons. The rates of discontinuation of efavirenz or nevirapine as part of HAART were similar (16 vs. 20/100 person years). Older age and positive HCV antibody were associated with an elevated liver function (ALT) test. Both prevalence of HBV and HCV coinfection with HIV were approximately 10%. The impact of hepatitis coinfection on immunological and virological responses to ART and HIV disease progression was not statistically significant. Both HBV and HCV remained independently associated with elevated ALT in the multivariate models. The overall HIV disease progression and response to ART in TAHOD patients were similar to those seen in the western countries.

Thesis (MSc)--Stellenbosch University, 2002. / ENGLISH ABSTRACT: The aim of this study at the Brooklyn Chest Hospital (BCH) was to assess the change in the oral carriage of Candida species in twenty-nine patients co-infected with the Human Immunodeficiency Virus (HIV) and Tuberculosis (TB), before and after anti-fungal treatment. Each patient accepted onto the study underwent a comprehensive oral and peri-oral examination where the presence, site and clinical features of all oral and peri-oral lesions were recorded. The purpose of the examination was to provide a clinical diagnosis of oral candidasis. Each patient was also asked to provide a sample of oral fluid for laboratory analysis. This was collected using an oral rinse. The results of a variety of laboratory investigations were used to identify the species of Candida obtained from the oral rinse. Both the oral and peri-oral examination and the oral rinse procedure were repeated after one month and at three months. A sample from each oral rinse was inoculated on CHROMagar Candida chromogenic medium (CHROMagar Candida, France, Paris). CHROMagar is used for the isolation and presumptive identification of Candida sp. from other yeasts on the basis of strongly contrasted colony colours, which are produced by the reactions of species-specific enzymes with a proprietary chromogenic substrate. After forty-eight hours the CHROMagar plate was examined for growth, when a record of colony morphology and colour was made. A single sample from each different colour-coded colony was taken and streaked onto a Sabouraud plate (Oxoid, Basingstake, England) and then incubated for forty eight hours at thirty-seven degrees centigrade. A variety of laboratory investigations were subsequently carried out on a single colony taken from the Sabouraud agar plate (Oxoid). The results of these tests were used to identify the individual species of Candida isolated from each oral rinse. Oral candidasis was the most prevalent oral lesion observed on admission and at three months. Six different species of Candida were identified during this study, namely Candida albicans, Candida dubliniensis, Candida krusei, Candida glabrata, Candida parapsilosis, and Candida tropicalis. C.albicans was the most commonly identified species in study population. Candida dubliniensis was isolated and identified for the first time in a South African HIV population. Each specimen of Candida sp. identified by laboratory analysis was tested for sensitivity to Nystatin, Amphotericin B and Fluconazole anti-fungal agents. An additional sensitivity test was performed using Ajoene and Allicin (extracts of garlic) to assess the comparative antifungal properties of these compounds. / AFRIKAANSE OPSOMMING: Die doelwit van hierdie studie by die Brooklyn Borshospitaal (BCH) was om die verandering in orale draerstatus van die Kandida spesies in nege-en-twintig HIVfTB koïnfekteerde pasiënte vas te stel, voor- en na antifungale behandeling. Elke pasiënt in die studie het 'n volledige intra- en ekstra-orale ondersoek ondergaan. Die teenwoordigheid, area en kliniese voorkoms van alle letsels is noteer. Die doel van die ondersoek was om 'n kliniese diagnose van orale kandidiase te verkry. 'n Monster orale vloeistof is geneem van elke pasiënt vir laboratorium analise. Die monster is in die vorm van 'n mondspoel geneem. Verskeie toetse is gedoen om die verskillende Kandida spesies in elke monster te identifiseer. Die orale- en ekstra-orale ondersoek sowel as die mondspoelmonster is na 1 en 3 maande herhaal. Elke mondspoelmonster is op CHROMagar Kandida chromogene medium (CHROMagar Candida, France) inokuleer. CHROMagar word gebruik vir die vermoedelike identifikasie en isolasie van Kandida spesies teenoor ander swamme. Dit word gedoen op die basis van kontrasterende koloniekleure, wat teweeggebring word deur spesie-spesifieke ensiemreaksies op 'n chromogene substraat. Die CHROMagar plate is na 48 uur ondersoek vir groei en die kolonie-morfologie en - kleur is noteer. 'n Enkel monster. is geneem van elke verskillende kolonie (geskei op kleur) en is uitgestreep op 'n Saboraud plaat (Oxoid, Basingstoke, England). Dit is dan vir 48 uur inkubeer teen 37°C. Verskeie laboratorium ondersoeke is daarna uitgevoer op 'n enkel kolonie geneem vanaf die Saboraud agar plaat (oxoid). Die resultate van die ondersoeke is gebruik om individuele spesies van Kandida te identifiseer. Orale Kandidiase was die mees algemene orale letsel geïdentifiseer by toelating en 3 maande ondersoeke. Ses verskillende spesies Kandida is identifiseer tydens die studie, naamlik: Kandida albicans, K.dubliniensis, K.Krusei, K.glabrata, K.parapsilosis en K.tropicalis. K.albicans was die mees algemeen identifiseerde spesie in die studiepopulasie. K.dubliniensis is vir die eerste keer in Suid-Afrika in 'n HIV<+lpopulasie isoleer en geïdentifiseer. Elke monster van identifiseerde Kandida spesies is getoets vir sensitiwiteit teenoor Nistatien, Amfotensien B en Flukonasool. Addisioneel is ook getoets vir sensitiwiteit teenoor Ajoene en Allicin (knoffelekstrakte).

Thesis (MFamMed)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Background: A national roll-out of antiretroviral therapy in the public sector was started in 2004, and Paarl was one of the first sites to start these services in the Western Cape. Operational research is required to guide the continuous improvement of such services. This research aimed to describe the characteristics of the treatment cohort started at TC Newman CDC’s ARV clinic in Paarl, to determine the retention in treatment rate and to assess the clinical and virological outcomes. Methods: A retrospective descriptive and observational study was done at the TC Newman ARV clinic in Paarl. All adult HIV positive patients that were started on antiretroviral therapy in the given time period were included. Patient and treatment data had been collected in an electronic database (e-register) and were extracted and analysed. Results: Starters: Out of the 2469 patients that were enrolled for ARV treatment between February 2004 and December 2010, 2254 started locally (the rest transferred in). 64% of them were female (decreasing rate over the years). Strugglers: By June 2011 51.5% of patients were still on ARVs, 6.9% patients had died, 16.7% had been ‘transferred out’and 24.7% were reported as ‘Lost to Follow-up’. 40% of the attrition of the cohort occurred in the first 6 months, 70% in the first 18 months. Stayers: Of the 1172 patients retained after start at TC Newman CDC, 1023 (87.3%) were still on Regime 1 and 149 (12.7%) on Regime 2. Conclusions: The results of this treatment cohort (mortality, treatment retention and regimen durability) equal those in other published treatment cohorts, although very limited comparable data are available. However, the high ‘lost to follow-up’ rate is of concern and needs further investigation. Changes in the programme structure and environment tend to have an immediate effect on initiation numbers of new patients.

Thesis (MPhil)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: NACOSA had an eventful history spanning 22 years. The first phase between 1992 and 2001 is labeled Great Expectations as the composite multi-sectoral structure started a groundbreaking initiative on HIV and AIDS in South Africa and believed that the first AIDS plan drafted by them would be implemented as planned. Expectations came to nothing as government struggled to find its feet through a decade of blunders leading to the demise of the structure by end 2001. The next phase between 2001 and 2010 is labeled Starting Over as the Western Cape branch of NACOSA reinvented itself as a community mobilisation network for the province. Within a period of ten years Western Cape NACOSA developed into a successful national network with a large membership fully involved through its networking, capacity building and promoting dialogue functions. The third phase between 2010 and 2015 is labeled Rapid Growth as NACOSA developed into a large training and grant management agency with strong systems providing funding to its members through sub-granting. Networking continued at a slower pace but is still highly important for the organisation. The network contributes to localised social capital through shared learning and collaboration. NACOSA‟s sustainability has been developed through the ability to raise long-term funds for network activities, capacity building of members and coordinated service delivery on the ground. NACOSA also has a culture of identifying and acting fast on opportunities and adapting to change when it is needed. Strategic factors attributing to the success of NACOSA are a sector based approach promoting diversity in its membership; a consistently focused and shared purpose throughout the years; a community agent approach believing in and advocating for community systems strengthening; obtaining a mandate from network members for main strategy changes; strategic partnerships; a strong capacity building approach focussing on organisational and programmatic competencies; not competing with network members but acting as main weaver; creating specialist networks for specific HIV-related causes; a committed representative executive committee and skilled staff; bringing groups together on a regular basis for discussions and strategising; a variety of social media; and a network mindset intent on a culture of learning and building trust between member organisations. / AFRIKAANSE OPSOMMING: NACOSA het 'n gebeurtenisvolle geskiedenis wat strek oor 'n periode van 22 jaar. Die eerste fase tussen 1992 en 2001 word genoem Groot Verwagtinge, verwysende na die saamgevoegde multi-sektorale struktuur wat ontstaan het as die eerste groot MIV en VIGS inisiatief in Suid-Afrika. Hulle het verwag dat hul eerste VIGS-plan geïmplementeer sou word soos wat hulle dit beplan het. Hul verwagtinge het egter skipbreuk gely as gevolg van die regering wat oor die dekade heen hul voete gesleep en foute gemaak het wat uiteindelik gelei het tot die struktuur se ondergang in 2001. Die volgende fase tussen 2001 en 2010 word genoem Oorbegin verwysende na die Wes-Kaap tak van NACOSA wat hulself herskep het as „n gemeenskapsmobiliseringsnetwerk. Wes-Kaap NACOSA het binne tien jaar weer ontwikkel in 'n suksesvolle nasionale netwerk met 'n groot ledetal wat volledig ingeskakel is by die organisasie se netwerk, kapasiteitsbou en bevordering van dialoogaktiwiteite. Die derde fase tussen 2010 en 2015 word genoem Snelle Groei verwysende na NACOSA se ontwikkeling in 'n groot opleidings- en fondsbestuursagentskap met sterk stelsels wat befondsing aan hul lede verskaf. Netwerkskakeling het voortgeduur teen 'n stadiger pas maar is steeds baie belangrik vir die organisasie. Die netwerk dra by tot die bou van plaaslike sosiale kapitaal deur middel van samewerking en saam leer. NACOSA se volhoubaarheid het ontwikkel deur hul vaardigheid om langtermynfondse in te samel vir netwerkaktiwiteite, kapasiteitsbou en gekoördineerde dienslewering op grondvlak. NACOSA het ook 'n kultuur om geleenthede vinnig te identifiseer en daarop te reageer, asook om aan te pas by veranderinge wanneer nodig. Strategiese faktore wat bygedra het tot NACOSA se sukses sluit in 'n wye sektorbenadering met diverse lidmaatskap; 'n konsekwente gedeelde doelwit oor die jare; die bevordering van sterk gemeenskapstelsels; die verkryging van 'n mandaat by netwerklede vir strategie-veranderinge; strategiese vennootskappe; 'n sterk kapasiteitsboubenadering wat fokus op organisatoriese en programmatiese vaardighede; geen kompetisie met lede-organisasies maar eerder die rol van “hoofwewer”; skep van spesialisnetwerke vir spesifieke MIV-verwante kwessies; 'n toegewyde raad en vaardige personeel; gereelde bymekaarbring van groepe vir dialoog en strategie bou; 'n verskeidenheid van sosiale media; en 'n netwerk denkpatroon gefokus op 'n leerkultuur en die bou van vertroue tussen lede.

The questionnaire text in English, Afrikaans and Native language / The aim of the study was to minimise non-adherence to antiretroviral (ARV) treatment amongst HIV/AIDS adult patients at a hospital in Namibia thereby promoting successful outcomes in patients on ARV treatment. A quantitative cross-sectional descriptive study was conducted on a sample of 112 non-adherent adults. Data collection was through structured interviews and patients’ records review. Data analysis was by descriptive statistics. Rate of non-adherence was 36.7%. Characteristics common in the sample were, being a woman, age of 31-45 years, being unmarried, low educational status, lack of HIV status disclosure, feeling that taking ARVs reminded one of HIV and experience of ARV side effects. Reasons for missed doses included forgetting, alcohol use, access to care, work commitments, lack of food, stress and travelling. Of the respondents, 86.6% had unsupressed viral loads. Recommendations include use of reminders, automated SMS, establishing treatment supporters and collaborative efforts in reducing active substance use to improve adherence. / Health Studies / M.A. (Nursing Science)