Magister Curationis - MCur / Early infant diagnosis (EID) programmes offer diagnosis of HIV, which facilitates provision of life-saving care to infants infected with HIV. Implementing programmes for EID and treatment has proved challenging in Malawi. Many infants access EID late or not at all. Previous studies have shown that lack of knowledge among health care providers (HCPs) is a challenge to effective EID. Little is known on the knowledge and skills of health care providers in Malawi. Aim: The aim of the study was to investigate the knowledge and skills of HCPs on EID of HIV in Mzuzu, Malawi. Objectives: (i) to examine the knowledge of HCPs on EID of HIV; and (ii) to determine the skills of HCPs on EID of HIV. Methods: A descriptive cross-sectional survey design with a quantitative approach was used. The study was conducted in three hospitals in Mzuzu, Malawi. The population was HCPs (doctors, nurses/midwives, clinical officers and medical assistants) working in maternity, paediatric wards and under-five clinics. A total of 68 HCPs participated in the study. A closed-ended self-administered questionnaire was used to collect data. Data were analysed using the Statistical Package for Social Science version 23. Descriptive statistics were used to present the frequency tables of observations. Ethical approval was sought from the University of the Western Cape Senate Research Committee and Malawi National Health Research Council. Results: The results on the knowledge of HCPs demonstrate that 38% of them had a score of <69% (poor), 25% scored within 70–79% (fair), and 37% scored >80% (good). Results on the skills showed that 69% of the HCPs scored <69% (poor), 15% scored within 70–79% (fair), and 16% scored >80% (good). The results also showed a correlation between the knowledge of HCPs and their level of education achievement (certificate, diploma and degree) as well as the skills of HCPs and their department of work. Conclusion: The study found that more than one-third of the HCPs lacked knowledge and skills on EID of HIV. These findings reflect the need to address the practical challenges of EID service delivery. Recommendations: There is a need to increase the efforts that are being put in place to train HCPs on EID of HIV in order to scale up EID. Training should assess the needs of HCPs regarding the knowledge and skills required in the delivery of EID services.

Magister Public Health - MPH / Background: The advent of antiretroviral therapy (ART) has significantly redefined the course of the HIV pandemic making HIV, a chronic illness rather than a death sentence. To maximize the efficacy of ART in improving survival rates of HIV/AIDS patients, lowering the incidence of opportunistic infections, reducing HIV transmission and minimizing the possibilities of developing drug resistance, long-term retention in care is critical. In South Africa, poor retention in care of 32% has been noted in women who were initiated on ART during pregnancy as compared to 13% in non-pregnant women initiated on ART. However, little is known in Swaziland about the retention in care in women who were initiated on ART during pregnancy and the factors that influence retention in care among this category of women. Aim: To determine the factors associated with poor retention in care among women initiated on ART during pregnancy at King Sobhuza II Public Health Unit (PHU) in Swaziland. Methodology: A quantitative, retrospective cohort review of 316 medical records of women who were initiated on ART during pregnancy from January 2012 to December 2013 was conducted. A data extraction sheet was used to collect data from the files of patients who were initiated on ART during pregnancy. The dataset was imported into IBM SPSS Statistic 20 Software for analysis. Bi-variate analysis was done to determine risk factors associated with retention in ART care at ART initiation and on the last ART refill visit. Kaplan-Meier analysis was used to determine retention in care at 6, 12, 24 and 36 months. Cox proportional hazards models were then used to determine factors associated with poor retention. Results: The overall retention rate of women who were initiated on ART during pregnancy at the PHU after a median duration on ART of 25.80 months [interquartile range (IQR): 16.70 – 30.98] of follow up was 74.1% (n=316). Most women initiated on ART during pregnancy (52.4%) became lost to follow up after giving birth as compared to 47.6% who became lost to follow up before giving birth. After 6 months on ART, the lost to follow up rate was 16.5% (n=316); but increased to 20.9% (n=316), 23.5% (n=243) and 26.9% (n=52) after 12, 24 and 36 months respectively. On the ART initiation visit, the factors associated with retention in care for pregnant women included being married, having the partner on ART, disclosing one’s HIV status to the partner, not drinking alcohol, being a non-smoker and reporting no financial challenges. In addition, on the last ART refill visit, the risk factors for retention in care for women initiated on ART during pregnancy were having the ART regimen changed, having regular CD4 cell count done, rise in CD4 cell count, good adherence on ART and use of contraceptive other than the condom for family planning after delivery. Conclusion: The retention in care for women who were initiated on ART during pregnancy was found to be lower than in the general adult population. However, the study findings on retention in care are similar to what has been found in other settings. The factors influencing poor retention also mirror those found in the other parts of sub-Saharan Africa. Whilst decentralisation of ART services improves ART coverage it should be coupled with strategies aimed at improving patient retention.

Magister Public Health - MPH / Background and Rationale: Antenatal care (ANC) is vital for accessing prevention of mother to child transmission (PMTCT) services. The timing of the first ANC visit is critical for HIV infected pregnant women to access antiretroviral (ARV) prophylaxis as recommended. In addition pregnant women access other interventions like syphilis screening and treatment, provision of ferrous iron supplements, malaria prevention and treatment, health education, identification and management of risk factors. There is however paucity of information on factors associated with the timing and adequate use of ANC services in Chitungwiza Township, Zimbabwe. Aim: This study aimed to determine the factors associated with early access to and adequate use of ANC services among women attending ANC in the four polyclinics in Chitungwiza Township.Method:The study included a retrospective record review of women who registered for ANC in 2010 and a cross sectional study of pregnant women attending ANC clinic for the first time during the current pregnancy during the survey period. Data on gestation age at first ANC visit, number of ANC visits, age, gravidity, parity, tetanus, iron sulphate, rhesus results, HIV test result, WHO clinical stage, CD4 count, cotrimoxazole, PMTCT option accepted, date of initiation of AZT or ART; partner HIV test results; and infant feeding adherence done was abstracted into an MS Excel spreadsheet from the 2010 ANC registers in the four primary health care clinics. Every fourth record was captured. Exit interviews were also conducted on all women attending ANC for the first time during the current pregnancy using a structured questionnaire. Questions on socio-economic status, pregnancy history, reasons for seeking ANC, knowledge and belief about ANC services and their perception of the service received were asked. The outcome variables were gestation age at first ANC visit and the number of ANC visits. The spreadsheet was imported into Epi Info 7.0.9.7 and STATA 11 for analysis. The questionnaires were captured into an Epi Info 7 database exported to STATA 11 for analysis. A sample of 1,236 of first ANC visit records were abstracted from the 2010 ANC registers in the four primary care clinics and 80 women coming for ANC were interviewed in three clinics. The prevalence of pregnant women attending ANC for the first time at gestation age less or equal to 14 weeks and the prevalence of women with less than 4 ANC visits were computed. Pearson Chi-square tests were used to determine the strength of the relationships between the dependent variable (gestation age at the time of the first visit) and independent variables of age, marital status, level of education, parity, gravidity. All statistical tests were performed at 5% significance level and estimates were calculated at 95% confidence interval. Multiple logistic regression analysis was used to investigate the association between the outcome and the independent variables. Model interpretation was done using odds ratios (OR). Levels of knowledge and perception about ANC services as well as service content during the visit were also summarized. Results: Less than 1% of the women who attended ANC in 2010 came for 1st visit at week 14 or less, while of the women interviewed, 2.5% came at similar gestation age. Thirty-nine percent of women attending ANC in 2010 had at least four visits. Lower parity and tetanus immunization were significantly associated with early ANC initiation, while tetanus immunization and syphilis screening were associated with the number of visits.Among the interviewed women (n=80), 72.1% believed that a pregnant women should start ANC at 14 weeks or earlier. Most women (61.7%) cited having no money for booking as the reason for not coming earlier. Need for husband or partners permission, procrastination and not having any health problems with previous pregnancies were also a barrier to access. Uptake of HIV testing was very high at 94.7% of the women. However partner testing was very low at 2.1%. Knowledge of the appropriate time of the first ANC visit was somewhat high but not universal. Conclusions and Recommendations: Timely and adequate uptake of ANC services is very low in Chitungwiza Township. The user-fees appeared to be a major barrier to accessing ANC timely. While correct knowledge about when to go for ANC and the health problems women face during pregnancy and childbirth is prevalent,other factors like the need for permission from spouse or partner and procrastination were barriers to seeking service. Abolishing maternity fees should be seriously considered in order to increase access to timely ANC services. Sustainable means of financing services without reducing quality should be sought. There was variable uptake of various interventions in the ANC package due in part to supplies stock outs. There is need for strengthening the procurement and distribution systems so as to ensure continuous supplies at service delivery level.

Magister Public Health - MPH / Background: Although great strides have been made in reducing mother-to-child transmission of HIV (MTCT) in Namibia, the universal target of less than 5% by 2015 has not yet been achieved. In an effort to scale-up services in the programme, a comprehensive family centred approach which broadens HIV prevention activities and considers HIV as a family disease was instituted. However its success has been affected by low male partner participation in the programme. Study aim: To investigate factors influencing male partner involvement in MTCT-plus programme in Gobabis District, Omaheke Region, Namibia. Study design and data collection: This was a cross sectional descriptive study that wasconducted using a qualitative research methodology. Data was generated through focus group discussions (FGDs) and in-depth interviews. Four same sex FGDs were conducted with men and pregnant women. The study participants were HIV positive pregnant women and HIV positive women in their postnatal period purposefully selected from the PMTCT clients. A few male participants were partners of the female participants and other men conveniently sampled from the community. Seven in-depth interviews were conducted to gather information from key informants who were programme managers and midwives. Thematic analysis was used for the data analysis. Results: Men were generally knowledgeable and appreciated the importance of participating in the MTCT-plus programme but the majority of them did not participate. They cited several barriers to actively supporting their partners. Men‘s participation in the MTCT-plus programme was affected by lack of trust in the health workers and cultural practices that shift the role of taking care of their partners to the biological parents. The other barriers included HIV related stigma, unfriendly environment at the antenatal care clinics, time and work related constraints, having many sexual partners and gender and power imbalances in relationships that affect patterns of communication on HIV related matters. Discussion: Participation in the MTCT-plus programme is well supported by men. However, few men put this into practice because of complexities surrounding their specific role in women reproductive health issues, as well as cultural practices and health facilities organizational structures that preclude men from participation in the MTCT-plus programme. Given the positive attitude by men towards participation in this programme, creating a male friendly space within the MTCT-plus programme and empowering men to participate in them should be prioritized for the programme to achieve its goals.

Magister Public Health - MPH / Background: One study on estimating rates of mother to child transmission of HIV (MTCT) in program settings in Zambia showed significant reduction in the MTCT rate with some specific prevention of mother to child transmission of HIV (PMTCT) interventions. Prolonged breastfeeding and mixed feeding practices by HIV positive mothers increased the MTCT rate by more than double by the time the infant reached 6 to12 months of age. Although the study did not assess the quality of PMTCT counselling in antenatal care settings, literature shows that poor quality of counselling on PMTCT reduces the effectiveness of PMTCT interventions. Study aim: To evaluate the quality of PMTCT counselling offered to pregnant women attending antenatal care (ANC) services in four public health facilities in Kitwe, Copperbelt province of Zambia. Study design and data collection: This was a cross sectional descriptive study. Data was generated using qualitative research methods including document analysis and individual interviews with 22 participants using non-participant observations, client exit interviews and focus group discussions (FGDs) to collect data. The study participants were ANC attendees and PMTCT providers. Two FGDs were conducted with a total of 98 counselling observations done and 16 ANC client exit interviews. Client exit interviews were done immediately after the mothers had undergone PMTCT counselling. Results: Content for group health education (GHE) varied across the facilities. Individual pre-test, post-test and follow up counselling sessions were very short and lacked depth. A total of 41 (83.7%) pre-test observations took between 1 and 5 minutes to be conducted. In addition, several key topics including major modes of HIV transmission, MTCT and the "window period" were omitted. The counsellors' interpersonal skills were generally good but they did not consistently summarize the main issues. The 16 mothers interviewed had limited knowledge of PMTCT with only one client knowing all the MTCT modes correctly. Discussion: Quality of PMTCT counselling did not meet expectations. With a lot of key topics omitted, outcomes of PMTCT interventions may not be as good as expected. Facilities are faced with serious staff shortages and limitations with space. The few members of staff available are overworked and are not able to provide quality PMTCT counselling. Conclusion: While the PMTCT uptake was good and clients felt satisfied, the quality of PMTCT counselling is compromised. There is need to improve it and ensure optimal effectiveness of PMTCT services.

Philosophiae Doctor - PhD / The epidemiological interconnectedness of tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics is well documented. Although international agencies such as the World Health Organisation (WHO) have been advocating for the implementation of collaborative TB/HIV activities at all levels in order to mitigate the impact of the dual epidemic on communities, health care delivery and programme management, its implementation has been very slow, particularly in countries highly burdened with TB/HIV infection, such as South Africa. Provision of integrated TB/HIV services has been partial and sub-optimal at community level. This requires innovative interventions that go beyond health facility boundaries such as engaging community care workers (CCWs). This thesis presents ways of engaging community members such as CCWs in collaborative TB/HIV activities including prevention of mother-to-child transmission of HIV (PMTCT). Methods: Both action research and health systems strengthening research were used as theoretical frameworks. The study was conducted in three phases which consisted of: a situational analysis; design and implementation of the intervention; and evaluation of the intervention. Mixed method research using both quantitative and qualitative research methods in one study was conducted, and various research designs were used depending on the research questions and the study phases. Results: The findings of Phase I of this study highlight partial integration of TB/HIV/PMTCT services at facility and community levels, and sub-optimal provision of integrated services, particularly at community level where only 10% of TB and HIV patients needing care at community level were supported by CCWs. Most TB-HIV co-infected patients were managed at the primary health care (PHC) clinic level of care, compared to other levels (p<0.05), and less than 50% of PHC clinic staff were trained in TB and HIV management. This phase also indicates poor linkage between facility and CCWs through the nongovernmental organizations (NGOs) managing CCWs. In addition, it identifies various health systems barriers that impede the implementation of collaborative TB/HIV/PMTCT activities and involvement of CCWs in the mainstream of the primary health care system. The findings of Phase II and III show that integrating different CCW cadres into one cadre and expanding their scope of practice to provide a comprehensive package of care for TB/HIV/PMTCT is a feasible and an effective intervention to accelerate the implementation of collaborative TB/HIV activities, including PMTCT, at community level. In addition, the findings suggest that up-skilled CCWs contribute significantly to bridging the current service delivery gaps in vertical TB, HIV and PMTCT services by increasing coverage for case finding of TB (38%) and sexually transmitted infections (STIs) (40%), PMTCT services (infant feeding, referral for PCR and AZT adherence support) (30%), and TB and antiretroviral treatment (ART) adherence (30%, 28%). The increase in uptake of TB/HIV/PMTCT services was statistically significant (p<0.05). Provision of home-based HIV counseling and testing by CCWs proved to be acceptable and feasible. Of 684 people offered home based HCT, 634 (82%) accepted to be tested and 45 (7%) tested HIV positive. However, other PHC care services such as integrated management of childhood illnesses (IMCI) and referrals to social welfare were poorly provided. Conclusion and Recommendations: The findings indicated that up-skilling CCWs resulted in improvement of CCW's performance in provision of integrated TB/HIV/PMTCT services, particularly for TB and STI symptom screening, HCT, infant feeding counselling and AZT treatment support for PMTCT, and treatment adherence support for TB and ART. However, this study emphasised the need for addressing contextual and health systems issues such as structural, organisational and managerial constraints. There is a need to reorganise the PHC system to ensure that CCWs are integrated as part of the PHC system. Systematic skills building and consistent CCW supervision, with reliable referral and monitoring and evaluation (M&E) systems are required for efficiency and sustainability of any community based intervention. It is also necessary to ensure that other PHC activities, such as referral for social welfare and IMCI, are not compromised when additional activities are added to the CCW care package. / This research was made financially possible by the, African Doctoral Dissertation Research Fellowship (ADDRF) of the African Population and Health Research Centre, in partnership with the International Development Research Centre and Ford Foundation. South African Tuberculosis AIDS Training (SATBAT): a South African/US research training collaboration funded by Fogarty International Center Grant 1U2RTW007370-01A1).

Magister Public Health - MPH / Dual protection is protection against unwanted pregnancy, HIV and other sexually transmitted infections and a means of achieving safer sex and birth control (WHO, 2012). It is one of the essential tools promoted by the WHO for preventing unintended pregnancies and sexual transmitted infections among HIV-positive women to reduce dual risk of unintended pregnancies, re-infections and transmission of HIV in the cases of sero-discordant couples. However, the use of dual method use among HIV-positive women in Zimbabwe is poorly described. Hence to fill in the existing research gap, this study aims to explore the factors influencing dual protection use by HIV- positive women participating in a prevention of mother-to-child transmission (PMTCT) program in an urban setting in Zimbabwe. Methodology: A qualitative exploratory study design with a combination of qualitative research methods including interviews and focus group discussions was conducted. A total of five focus group discussions (FGDs) each consisting of 8-12 participants was conducted with a total of 51 women. Five in-depth interviews were conducted with key informants. All interviews and FGDs were audio recorded using a digital voice recorder. The interviews were conducted in Shona and translated into English. Data analysis was done manually using thematic coding. Codes emerged from the data using an inductive approach. Ethical principles of research and rigour were observed throughout the study. Results: Dual protection use was low among the HIV-positive women. Absolutely non-use of contraceptive was reported by some women. The main methods of contraceptives were the pill, depo provera and condoms. Inconsistent condom use was mentioned among the few women who reported using condoms. Many barriers to contraceptives use among HIV-positive women in Zimbabwe were identified. However there were a few facilitating factors too. Health system factors associated with health care workers (HCWs) related factors and service delivery processes were reported as major barriers to contraceptive use. Women expressed negative attitude towards condom use associating them with unfaithfulness. Facilitators of contraceptive use identified were couples' HIV testing and counselling, women's increase in CD4 count result, fear of vertical transmission and HIV sero-discordance between couples. Conclusion and Recommendations: In conclusion, dual protection use among HIV-positive women in this community was low. Health system factors were the main barriers to contraceptives use whilst health related factors were the main facilitators. HIV-positive women still face challenges in accessing and utilisation of contraceptives. Hence the barriers to contraceptive use needs to be addressed at the same time promoting the facilitators.

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

Passive immunization with neutralizing antibodies (nAbs) may prevent mother-to-child transmission (MTCT) of HIV-1 and/or impact HIV-1 exposed infant outcomes. This study compared plasma neutralizing activity against heterologous HIV-1 variants and the quasispecies present in the infected mothers among exposed uninfected infants (HEU) to infants that eventually acquired infection and between transmitting versus non-transmitting mothers. HEU (n = 42), compared to those that eventually acquired infection (n = 21), did not possess higher nAb responses against heterologous envelopes (p = 0.46) or their mothers’ variants (p = 0.45). Transmitting as compared to non-transmitting mothers, however, had significantly higher plasma neutralizing activity against heterologous envelopes (p = 0.03), although these two groups did not have significant differences in their ability to neutralize autologous strains (p = 0.39). Furthermore, infants born to mothers with greater neutralizing breadth and potency were significantly more likely to have a serious adverse event (p = 0.03). These results imply that pre-existing anti-HIV-1 neutralizing activity does not prevent breast milk transmission. Additionally, high maternal neutralizing breadth and potency may adversely influence both frequency of breast milk transmission and subsequent infant morbidity. In addition to neutralization, passively acquired maternal antibodies that mediate antibody dependent cellular cytotoxicity (ADCC) may impact both breast milk transmission and infant outcomes. To date, no study has rigorously compared ADCC activity against a broad panel of heterologous strains or circulating maternal viruses among HEU versus infants that eventually acquire infection and among transmitting versus non-transmitting mothers. We developed a high-throughput assay that measures the lysis of infected reporter target cells in the presence and absence of antibodies. This assay yields similar results as other methods that use decreases in reporter signal from target cells or lysis of primary cells estimated by flow cytometry. In contrast to other ADCC methods, we show that our assay allows assessment of ADCC breadth and potency in a relatively high throughput manner because it uses novel target cells that are susceptible to infection by diverse HIV-1 variants. Estimating ADCC breadth and potency and activity against maternal strains will have important insights about the impact of passively acquired maternal antibodies on MTCT.

Effectiveness of services for Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) depends on viable and efficient health systems, adherence to and utilization of services. Despite strategies to provide access to PMTCT of HIV services, utilization of these services remain low in Nigeria thereby increasing child morbidity and mortality from HIV-related causes. Adherence to comprehensive HIV/AIDS care, for both the mother and baby, remain a challenge for HIV positive women. Utilizing the Health Belief Model and Social Support Theory, this qualitative study explores factors influencing utilization and adherence to PMTCT services by mothers living with HIV/AIDS in Rivers State, Nigeria. Purposive sampling procedures were used to select 40 study participants including 20 HIV positive mothers and 20 health care workers as key informants. Findings indicate that high self-perceived susceptibility to HIV influences utilization and adherence to PMTCT services among mothers living with HIV and AIDS in Rivers State. Although utilization and adherence to PMTCT were reported very high among this population, there were however challenges and barriers to optimal utilization of PMTCT. These include unavailability of test kits, antiretroviral medication stock-outs, and inadequate human resources for health. High transport, PMTCT and antenatal care costs were identified as the major socio-economic barriers to PMTCT administration as well as the high financial burden of formula feeding for women that preferred exclusive formula feeding. In addition to increased numbers of health care workers trained in PMTCT service delivery, recommendations for a public health approach to service delivery and a streamlined primary care strategy are proposed. These include social and community activities to address HIV/AIDS stigma, improving awareness of PMTCT facts, addressing gender relations and encouraging male participation. Inter-ministerial collaborations and targeted partnerships are also recommended for expanding coverage and ensuring optimal utilization of PMTCT services.