<p>The study aimed to assess the level of adherence and to identify the barriers to adherence and the motivations for good adherence to antiretroviral therapy, amongst women who commenced treatment while pregnant at research clinics in Molepolole, Mochudi, Lobatse and Gaborone.</p>

La transmission mère-enfant du VIH-1 (TME) représente le principal mode d’infection chez l’enfant et se produit durant la grossesse (in utero, IU), l’accouchement (intrapartum, IP) ou l’allaitement (postpartum, PP). Les mécanismes qui sous-tendent le passage du VIH-1 à travers le placenta et les muqueuses intestinales du nouveau-né sont encore très peu décrits. « Dendritic cell-specific ICAM-grabbing non-integrin » (DC-SIGN) et son homologue DC-SIGN « related » (DC-SIGNR) sont des récepteurs d’antigènes exprimés au niveau du placenta et capables de capter et de transmettre le VIH-1 aux cellules adjacentes. Ils pourraient donc participer au passage trans placentaire du VIH-1 et le polymorphisme génétique affectant l’expression ou modifiant l’interaction avec le virus aurait une influence sur la TME du VIH-1. Afin d’explorer cette hypothèse, nous avons procédé à une analyse exhaustive du polymorphisme de DC-SIGN et DC-SIGNR dans la population du Zimbabwe. Par la suite, nous avons déterminé l’association entre le polymorphisme de DC-SIGN et DC-SIGNR et la TME du VIH-1 dans une cohorte d’enfants nés de mères VIH-positives à Harare, au Zimbabwe. Enfin, nous avons défini l’impact fonctionnel des mutations associées. Les enfants homozygotes pour les haplotypes H1 et H3 dans le gène de DC-SIGNR sont 4 à 6 fois plus à risque de contracter le VIH-1 par voie IU et IP. H1 et H3 contiennent la mutation du promoteur p-198A et la mutation de l’intron 2, int2-180A, et des études fonctionnelles nous ont permis de démontrer que p-198A diminue l’activité transcriptionnelle du promoteur de DC-SIGNR et l’expression des transcrits d’ARNm dans le placenta, alors que int2-180A modifie le répertoire d’isoformes de DC-SIGNR vers une proportion diminuée d’isoformes membranaires. Les enfants porteurs des haplotypes H4 et H6 de DC-SIGN sont 2 à 6 fois plus à risque de contracter le VIH-1 par voie IU. Ces haplotypes contiennent deux mutations du promoteur (p-336T/C et p-201C/A) et quatre mutations codant pour un changement d’acide aminé dans l’exon 4 (R198Q, E214D, R221Q ou L242V) associées à un risque augmenté de transmission IU, IP et PP du VIH-1. Des études fonctionnelles ont démontré que les mutations du promoteur diminuent l’expression de DC-SIGN dans les macrophages placentaires. Toutefois, l’exposition IU au VIH-1 module le niveau d’expression de DC-SIGN, résultant en des niveaux d’expression similaires entre les macrophages des porteurs des allèles sauvages et mutés. Les mutations de l’exon 4 augmentent l’affinité de DC-SIGN pour le VIH-1 et sa capacité à capturer et à transmettre le virus aux lymphocytes T, favorisant possiblement la dissémination du VIH-1 à travers le placenta. L’association entre les mutations de DC-SIGN et la transmission IP et PP du VIH-1 suggèrent qu’il aurait aussi un rôle à jouer dans les muqueuses intestinales de l’enfant. Notre étude démontre pour la première fois l’implication de DC-SIGN et DC-SIGNR dans la TME du VIH-1. L’augmentation des capacités de capture et de transmission de DC-SIGN résulte en une susceptibilité accrue de l’enfant à l’infection au VIH-1 et concorde avec un rôle dans la dissémination transplacentaire. Toutefois, la diminution préférentielle des transcrits membranaires de DC-SIGNR au placenta augmente la TME du VIH-1 et laisse croire à son implication via un autre mécanisme. Ces mécanismes pourraient aussi s’appliquer à d’autres pathogènes reconnus par DC-SIGN et DC-SIGNR et transmis de la mère à l’enfant. / Mother-to-child transmission (MTCT) is the main cause of HIV-1 infection in children worldwide. MTCT of HIV-1 can occur during pregnancy (in utero, IU), delivery (intrapartum, IP) or breastfeeding (postpartum, PP). Dendritic cell-specific ICAM-grabbing non-integrin (DC-SIGN) and its homolog DC-SIGN related (DC-SIGNR) are attachment receptors for HIV-1 and are expressed in the placenta. They have been implicated in viral capture and transmission to T cells. To investigate the potential role of DC-SIGN and DC-SIGNR in MTCT of HIV-1, we carried out a genetic association study in a well-characterized cohort of 197 HIV-infected mothers and their infants recruited in Harare, Zimbabwe. Infants harbouring two copies of DC-SIGNR H1 and/or H3 haplotypes (H1-H1, H1-H3, H3-H3) had a 4-fold increased risk of IU and 6-fold increased risk of IP HIV-1 infection after adjusting for a number of maternal factors. The implicated H1 and H3 haplotypes share two single nucleotide polymorphisms (SNPs) in promoter region (p-198A) and intron 2 (int2-180A) that were associated with increased risk of both IU and IP HIV-1 infection. The promoter variant reduced transcriptional activity in vitro. In homozygous H1 infants bearing both the p-198A and int2-180A mutations, we observed a 4-fold decrease in the level of placental DC-SIGNR transcripts, disproportionately affecting the expression of membrane-bound isoforms compared to infant noncarriers. Infants carrying H4 and H6 haplotypes in DC-SIGN gene were more likely to be HIV-1-infected during pregnancy. These haplotypes contain promoter variants (p-336T/C and p-201C/A) and exon 4 variants (R198Q, E214D, R221Q and L242V) that were all significantly associated with increased risk of MTCT of HIV-1. Compared with wild-type sequence, the promoter variants reduced both the DC-SIGN transcription in vitro and expression (2-fold) in placental macrophages of HIV-1-unexposed infants. However, in HIV-1-exposed infants, the level of DC-SIGN expression in placental macrophages was similar in infants carrying either the promoter wild-type or variant sequences. Exon 4 variants increased HIV-1 capture and transmission to T cells in vitro. Association between DC-SIGN SNPs and HIV-1 IP and PP infection also suggests that DC-SIGN plays an important role in intestinal mucosa. This is the first study reporting on functional impact of DC-SIGN and DC-SIGNR natural polymorphisms on HIV-1 transmission from mother-to-child. Decreased levels of expression of membrane DC-SIGNR isoforms at the placental endothelial cell surface increased child susceptibility to HIV-1. Presence of DC-SIGN variants increasing its affinity for the virus augmented child susceptibility to HIV-1 and may favour viral dissemination across the placental barrier. This study provides compelling evidence to support an important role of DC-SIGN and DC-SIGNR in various modes of MTCT of HIV-1 and shed light on the possible mechanisms involved in HIV-1 passage from mother-to-infant. These findings raise the possibility that similar mechanisms may operate with other human pathogens known to interact with DC-SIGN and DC-SIGNR.

The prevention of mother-to-child transmission is one of the most powerful tools in human immunodeficiency virus type 1 (HIV-1) prevention and has huge potential to improve both maternal and child health. In the absence of any preventative measures, infants born to and breastfed by their HIV-positive mothers have roughly a one-in-three chance of acquiring the infection themselves. HIV can be passed on from mother-to-child during pregnancy, during labor and delivery, and even after during breastfeeding. Intrapartum and neonatal single-dose nevirapine (sd-NVP) is the foundation of preventing mother-to-child transmission in lower resource settings where it has been used alone or as part of combination regimens. Both its simplicity and its long plasma half-life contribute to the success of sd-NVP based therapy. However, sd-NVP frequently results in HIV-1 viral resistance in mothers and children who become HIV infected despite prophylaxis. Sd-NVP leads to the development of non-nucleoside reverse transcriptase inhibitors (NNRTI) drug resistance, compromising the success of treatment of mother and child with subsequent antiretroviral combinations. Resistance to NNRTIs is particularly worrisome in lower resource settings since many subsequent regimens for maternal and infant antiretroviral therapy include a NNRTI drug.

Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--Stellenbosch University, 2008. / Objective: Primary: To investigate the effect of pasteurisation on the composition of expressed breast milk from HIV positive mothers and its adequacy in relation to the growth of their VLBW premature infants. Methods: A descriptive, prospective case-controlled pilot study was performed in 3 regional state hospitals in the Western Cape, South Africa. The control and study groups consisted of 12 HIV negative and 11 HIV positive mothers, with their VLBW premature infants, respectively. All mothers (19 - 35 years old) belonged to the Xhosa ethnic group. All infants were born <34 weeks gestation and birth weight <1500g. Eight breast milk samples were collected on days 6, 7, 13, 14, 20, 21, 27 and 28 from all mothers during the first 28 days after birth. Breast milk was expressed by hand or pump from either the right or left breast. Half of each breast milk sample was kept raw. The remaining sample was Pretoria pasteurised, after which both samples were subdivided into 3 or 4 aliquots to determine energy, protein, carbohydrate, fat, folate, calcium, phosphorus, magnesium, sodium, otassium, iron, copper, zinc content and HI viral load (study group only). The mothers’ dietary intake during pregnancy and lactation was obtained by means of a quantitative food frequency questionnaire and repeated 24-hour recall respectively. The infants’ dietary intake was recorded daily. Mothers’ anthropometric measurements taken at study entry and exit were weight, height and mid-upper arm circumference. All infants’ daily weight, as well as length and head circumference at birth and on day 28 postpartum was obtained. Biochemical analysis was performed on the blood samples obtained at study entry and exit from all mothers and infants. For statistical analysis, Statistica® (release no 7, 2006) was used for repeated measures analysis of variance (ANOVA) to determine the effect of HIV, pasteurisation, milk expression and time on the composition of the breast milk. Results: There was no significant difference in the studied macro- and micronutrient composition between raw or pasteurised expressed breast milk from HIV positive and HIV negative mothers with premature infants. A significant decline in breast milk protein (p<0.01), magnesium (p=0.045), potassium (p=0.002), zinc (p<0.01) and copper (p=0.03) content was observed for the whole study population over time, while folic acid content increased significantly (p=0.012) over time. The sodium/potassium ratio of both groups remained strongly indicative of the presence of sub-clinical mastitis. A significant (p=0.03) greater mean volume of milk was obtained with pump [42.5 Standard Deviation (SD) 18.1 ml], compared to hand expression [36.7 (16.7) ml]. Method of expression did not result in a significant difference in breast milk composition for any of the nutrients studied. Eight (35%) infants were born SGA while 21 (91%) infants were SGA on day 28. The infants gained a mean of 16.37 (4.5) g/kg/day (i.e. 91% of the recommended growth rate of >18g/kg/day) from the day on which birth weight was regained. The control and study group infants respectively consumed a mean of 3.27 (1.36) and 3.21 (1.36) g protein/kg/day and 138.1 (33.8) and 142.3 (33.8) kcal total energy/kg/day. This corresponds to a PER of 2.6 (control group) and 2.5 (study group) respectively, which cannot provide for the increased growth needs of the SGA infant in need of catch-up growth. Six infants experienced an incident of Grade 1 NEC which resolved and all completed the study. Two (18%) HIV-exposed infants were found to be HIV positive at 28 days post delivery. Four participating infants died. No adverse event or mortality was related to the study protocol as no intervention was undertaken. Conclusion: HIV positive Xhosa mothers provide as nutritious breast milk to their VLBW premature infants as HIV negative Xhosa mothers. Maternal nutrient intake during pregnancy and lactation did not have a significant effect on the nutritional composition of breast milk, except for folate content.

225 leaves printed on single pages, preliminary pages i- xxiii and numbered pages 1-203. Includes bibliography, list of abbreviations, list of definitions, list of tables and figures and list of appendices. / Digitized at 330 dpi color PDF format (OCR), using KODAK i 1220 PLUS scanner. / Thesis (MNutr (Interdisciplinary Health Sciences))--University of Stellenbosch, 2005. / ENGLISH ABSTRACT: "A comprehensive package of care for the Prevention of Mother- To-Child Transmission (PMTCT) of HIV" states that all mothers participating in the PMTCT Programme should receive education that will enable them to make informed decisions about infant feeding options. Rapid, same-day HIV testing and results that are available immediately, enable health care workers to be responsible for providing pre- and post-test counselling (which includes infant feeding options) on the same day. This could place a tremendous workload and time pressure on the health care workers. The aim of this study was to determine how "informed" is the literate mother's decision regarding infant feeding options, who participated in the PMTCT Programme, in the Gert Sibande District, Mpumalanga, South Africa. Method: Data was collected from health care workers and mothers on the PMTCT Programme at 23 PMTCT sites in the Gert Sibande District, with the help of 6 field workers and the PMTCT site manager at each PMTCT site, by means of once-off, self-administered questionnaires, which had been previously tested and validated. Results: Health care workers' attitude towards the PMTCT Programme was positive, although some (14%) indicated that what was expected of them was not achievable in their working environment. The most prominent change relating to the personal preferences of health care workers regarding infant feeding options for HIV-infected mothers, after attending the 5-day PMTCT course, was from formula-feeding to breast-feeding. Most (65%) indicated it was possible to stay neutral in a counselling session regardless of personal preference for infant feeding and 60% of those who could not stay neutral, still thought it was in the mother's best interest to be counselled by them. Most (98%) agreed mothers had the right to make informed decisions and 80% agreed mothers were able to make such a decision. Most (67%) health care workers indicated that not enough staff was stationed at PMTCT sites, only 53% used the feeding option cards when counselling mothers and indicated that more educational material was needed. Sixty one percent of the health care workers demonstrated the preparation of the formula to the mothers and allowed the mothers to demonstrate back to them. Between 49-82% and 37-56% of the health care workers knew the correct answers to knowledge questions relating to breastfeeding and formula-feeding, respectively. Not one health care worker, nor mother, knew all the steps in preparing a formula feed. Most (80%) mothers made decisions based on information provided to them by health care workers and only a small (13%) percentage were influenced by the community to practise a different feeding option than what they had chosen. Conclusions: The attitude, personal preferences, knowledge of and resources available to health care workers, influenced the decision made by mothers regarding infant feeding options and seeing that most mothers made their decision, based on information provided by health care workers, it is concluded that mothers can only make an informed decision about infant feeding options if they are advised appropriately by well trained, equipped and informed health care workers. / AFRIKAANSE OPSOMMING: "A comprehensive package of care for the Prevention of Mother-To-Child Transmission of HIV", vermeld dat moeders, wat deelneem aan die Voorkoming van Moeder-Tot-Kind Oordrag (VMTKO) progam, voorligting behoort te ontvang ten opsigte van voedingsopsies vir hul babas, sodat hulle in staat sal wees om 'n ingeligte keuse te maak. Gesondheidswerkers is verantwoordelik om voorligting voor en na die HIV toets te gee, wat die voedingsopsies vir babas insluit, op dieselfde dag. Dit kan 'n ontsaglike werkslading op die gesondheidswerkers plaas. Die doel van die studie was om te bepaal hoe "ingelig" is die geletterde moeder se keuse ten opsigte van voedingsopsies, wat deelneem aan die VMTKO program, in die Gert Sibande distrik, Mpumalanga, Suid-Afrika. Metode: Die data is ingesamel by 23 VMTKO-klinieke en -hospitale in die Gert Sibande distrik onder gesondheidswerkers en moeders op die VMTKO-program, met behulp van 6 veldwerkers en VMTKO-bestuurders, deur middel van eenmalige, selfvoltooide vraelyste, wat van tevore getoets en gevalideer was. Resultate: Die gesondheidswerkers se houding teenoor die VMTKO-program was positief, alhoewel 14% aangedui het dat wat van hulle verwag word nie prakties of moontlik is in hul werksomgewing nie. Die prominentste verandering rakende die persoonlike voorkeure van die gesonheidswerkers teenoor voedingsopsies vir HIV -geinfekteerde moeders, na die 5-dag VMTKO kursus, was van formulevoeding na borsvoeding. Meeste (65%) het aangedui dit is moontlik om neutraal te bly gedurende 'n voorligtingssessie, ten spyte van persoonlike voorkeure vir voedingsopsies en 60% van die wat nie neutraal kon bly nie, het steeds gedink dit is in die beste belang van die moeder om deur hulle voorgelig te word. Meeste (98%) het saamgestem dat dit die moeder se reg is om 'n ingeligte keuse te maak en 80% het saamgestem dat die moeder wel in staat is om so 'n besluit te neem. Meeste (67%) gesondheidswerkers het aangedui dat personeel tekorte bestaan by die VMTKO klinieke en hospitale. Slegs 53% gebruik die voedingsopsie kaarte gedurende 'n voorligtingsessie met die moeder en het aangedui dat meer voorligtingsmateriaal benodig word. Een en sestig persent van die gesondheidswerkers het die voorbereiding van die formulevoeding aan die moeders gedemonstreer en het moeders toegelaat om ook die demonstrasie te doen. Nege en veertig tot twee en tagtig persent en 37-56% van die gesondheidswerkers kon die korrekte antwoorde verskaf vir vrae oor borsvoeding en formulevoeding, afsonderlik. Nie een gesondheidswerker of moeder kon al die stappe vir die voorbereiding van die formulevoeding noem nie. Meeste (80%) moeders maak keuses gebaseer op inligting wat aan hulle verskaf word deur die gesondheidswerkers en slegs 'n klein persentasie (13%) word beinvloed deur familielede om die teenoorgestelde voedingsopsie te praktiseer as wat hulle gekies het. Gevolgtrekking: Die houding, persoonlike voorkeure, kennis van en hulpbronne beskikbaar aan die gesongheidswerkers, beinvloed die besluit wat moeders neem ten op sigte van voedingsopsies en aangesien die moeders hulle besluit baseer op inligting wat deur die gesondheidswerkers aan hulle gegee word, word die gevolgtrekking gemaak dat moeders slegs 'n ingeligte keuse aangaande voedingsopsies kan maak indien hulle voorligting ontvang deur goed opgeleide en ingeligte gesondheidswerkers.

Breast-feeding by Human Immunodeficiency Virus (HIV) positive mothers poses a risk of transmitting HIV infection from the mother to the baby. This study attempted to describe and explore the knowledge of antenatal women in Gaborone, Botswana on the transmission of HIV through breast-feeding. The research results, obtained from interview schedules, revealed that the respondents had: a greater knowledge of transmission of HIV in adults than mother-to-child-transmission (MTCT); a moderate understanding of infant feeding methods; poor understanding of the risk of HIV transmission through different infant feeding methods and feelings that infant feeding method reveals ones HIV status, which indicate stigma and discrimination. The study findings may assist health care providers to intensify educational programmes and counselling in the antenatal clinics and communities to reduce MTCT. / Health Studies / M. A. (Health Studies)

The importance of adequate completion of clinical records and data collection tools at a health care facility is widely acknowledged. This study was conducted in order to explore and describe the completion of the ante-natal care (ANC) register by midwives in Tshwane Metsweding District, Gauteng Province, South Africa. A sequential mixed method approach consisting of quantitative and qualitative phases was employed. To collect quantitative data, 155 entries of variables completed in the ANC register were assessed using a checklist. Subsequently, qualitative data were collected through two focus group discussions with midwives to understand their experience regarding the completion of the register. The findings revealed that the completion of the ANC register is generally poor. Midwives indicated that the register is a good data collection tool. Recommendations to improve record-keeping such as the implementation of an electronic ANC register were made. / Health Studies / M.A. (Health Studies)

Vertical transmission of HIV is still a growing concern in South Africa. Breastfed infants are still at risk as HIV is present in breast milk, leaving HIV-positive mothers unsure of the best feeding option for their infants. However, there are various infant feeding techniques that HIV-positive mothers can use to supplement breastfeeding and flash-heat is one of them. Flash-heat is heat treating expressed breast milk to deactivate HIV for infant feeding. This study explored the possibility of HIV-positive mothers to practice flash-heating method for their infants exclusively for four months as a strategy to prevent vertical transmission of HIV. A descriptive, explorative and contextual design using a mixed method was used to obtain data from mothers in a post natal ward at Tembisa hospital. The mixed method used was useful in identifying the number of HIV-positive mothers who would adopt the flash-heat technique, the characteristics of mothers whom the technique could be promoted to, the factors that influence/affect the choice of infant feeding for these mothers, as well as their feelings associated with the feeding technique. Most (74%) mothers had a positive response to the flash-heat technique compared to 10% who were uncertain. They believed that heat treating their breast milk would result in their infants being HIV-free. In addition they believed that this method was cheaper than formula feeding and expressed positive feelings about touching their breast milk while expressing with no adverse feelings of expressing into a glass jar. Furthermore, findings of this study indicated that HIV-positive mothers in a public health facility would adopt flash-heat as an alternative infant feeding method. Thus practical guidelines to promote this feeding method were proposed. The proposed draft guidelines which promote the use of the flash-heat infant feeding method for HIV-positive mothers in public sector facilities will be communicated to relevant authorities such as the National Department of Health. These guidelines support the new policy shift to exclusive breastfeeding as a child survival strategy in South Africa. / Health Studies / D.Litt. et Phil. (Health Studies)

Study Objective The objectives of this study are: (1) to explore the impact of the national consolidated guidelines for Option B+ PMTCT on the work of healthcare professionals at both clinical and management levels (including nurses, physicians and management) (2) to understand pregnant HIV-positive women views and experiences with ART for life, as a way to better manage the Option B+ PMTCT programme within state hospitals Research Questions The following research questions will be used to explore both perceptions of healthcare professionals and patients: 1.How have the national consolidated guidelines for Option B+ PMTCT affected the work of healthcare professionals? 2.What are pregnant HIV-positive women’s views and experiences about going on lifetime treatment with ARVs? / ABSTRACT Background. South Africa’s National Department of Health has adopted World Health Organization’s (WHO) 2013 consolidated guidelines on the use of ARVs for treatment and prevention of HIV infection. The guidelines include changes for prevention of mother to child transmission (PMTCT) through Option B+. Option B+ aims to reduce the HIV prevalence rate amongst these women by placing them on ART for life, no matter their CD4 count. As a result, in January 2015, these guidelines were implemented for the PMTCT programme at RMMCH. Little is known about the impact of these new guidelines on the work of healthcare professionals in state hospitals. Most importantly, no research has focused on how these changes have affected adherence for the patients. Purpose. The purpose of this research project is (1) to explore the impact of the Option B+ PMTCT programme on the work of healthcare professionals, and (2) to understand pregnant HIV-positive women views and experiences with ART for life, as a way to better manage the Option B+ PMTCT programme. Methods. A qualitative study design is used with a phenomenological approach. The methodology uses demographic questionnaires and semi-structured interviews with healthcare professionals and patients. The study is situated in Johannesburg, South Africa. Findings. The findings demonstrate that work has changed and become difficult to manage for all healthcare professionals because of (1) the need for strengthening indicators for tracking to decrease loss to follow-up (LTFU); (2) inconsistency in delivery of counseling and support services and the need for communication across clinical departments; and (3) the lack of compassion and understanding by service providers. The difficult healthcare environment has affected overall views and experiences of pregnant HIV-positive women going on ART for life. All 55 patient participants responded that they chose to take the fixed-dose combination (FDC) for life to protect the health of the baby and felt ART for life can be stopped after giving birth. Conclusion. Implications for future research include the need to address changes within the healthcare system at both clinical and management levels. It is crucial to incorporate the perspective of patients in policy implementation; uptake and adherence are key indicators in informing whether the Option B+ PMTCT programme is being adapted into state hospitals effectively. There needs to be extensive research on how to strengthen indicators for long term scalability and sustainability of the programme. Future evaluations need to address, will interdisciplinary collaboration within hospitals improve the management and understanding of Option B+? / Thesis / Master of Science (MSc)

Evidence-informed health policy making contributes to improved health outcomes by strengthening health systems. In addition, health policy decisions should take into consideration the needs and priorities of users of healthcare services. However, little research has been done to find best ways to facilitate evidence-informed and participatory health policymaking, particularly in low- and middle-income countries. This thesis is written based on three studies done in Ethiopia to fill this knowledge gap. In the first study, we examined whether, how and under what conditions evidence was used and service-users participated during the agenda-setting and policy formulation phases of selected policies in the ‘prevention of mother-to-child transmission of HIV’ program in Ethiopia using a multiple-case study design. In the second study, we identified strategies to facilitate evidence-informed health policy making using an online survey. In the third study, we identified strategies to facilitate participatory health policy making using a combined paper-based and Internet-based Delphi approach. The thesis does not have direct theoretical contribution. However, it will draw on two theoretical frameworks, namely Kingdon’s framework and the 3I+E framework. and use them in a setting from where they were originally developed. This thesis has two substantive and three methodological contributions. Substantively, the first study provides empirical evidence about the current practice of evidence-informed and participatory health policy making in a low-income, ‘revolutionary’ democratic country (Ethiopia). In addition, the studies have identified strategies to concretize the constitutional and policy provisions for evidence-informed and participatory health policy making in Ethiopia. The thesis has the following three methodological contributions. First, the studies explored the use of Kingdon’s multiple-streams framework and the 3I+E framework in predicting factors influencing agenda-setting and policy formulation phases, respectively, and in explaining the use of research evidence in informing these two phases in a ‘revolutionary’ democratic country where they have not previously been used. Second, the thesis has shown that paper-based and Internet-based Delphi could be combined in contexts with limited resources. Third, the thesis has demonstrated the possibility of training service-users as ‘peer’ researchers to collect and analyze data to inform their participation and maximize their contribution in surveys, forming a pyramid of participation. / Thesis / Doctor of Philosophy (PhD) / Evidence-informed health policy making can contribute to improved health outcomes by strengthening health systems. In addition, health policy decisions ultimately affect users of healthcare services. Thus, such decisions should take into consideration their needs and priorities. However, little research has been done to find best ways to facilitate evidence-informed and participatory health policymaking, particularly in low- and middle-income countries. This thesis is written based on three studies done in Ethiopia. In the first study, we examined whether, how and under what conditions evidence was used and service-users participated in the ‘prevention of mother-to-child transmission of HIV’ program in Ethiopia. In the second and third studies, we identified strategies to facilitate evidence-informed and participatory health policy making. In addition, we explored the possibility of combining Internet- and paper-based methods for consensus-building among policymakers, program managers, researchers, healthcare providers and service-users in settings with limited resources.