The benefits of breastfeeding are well known. It has been shown that HIV is transmitted through breast milk. The HIV epidemic is threatening exclusive breastfeeding in South Africa. It is important that mothers make the right infant feeding choice. There are three basic infant feeding methods available for HIV infected mothers namely; breastfeeding, replacement feeding or formula feeding and heat treatment of breast milk. There are many risk factors for the transmission of HIV through breast milk. Exclusive breastfeeding may reduce the risk of mother-to-child-transmission, compared with mixed feeding. This can only take place when breastfeeding is done safely and not mixed with other food or drinks. There are many factors that influence a mother's decision to breastfeed, for example personal, social, cultural factors, facilities, environmental factors, knowledge about breastfeeding, mass media and friends. There are also many sources of information about infant feeding methods. The aim of this study was to determine which factors influence the decision on the early infant feeding choice of women who delivered at the Lower Umfolozi District War Memorial Hospital in Empangeni, KwaZulu-Natal. This may help to understand what factors health professionals should focus on in promoting appropriate infant feeding methods. A structured questionnaire was completed by a 100 women and focus group discussions were held with 22 women who delivered at the Lower Umfolozi District War Memorial Hospital. Most of the mothers (72%) did choose breastfeeding, and 58% of these mothers intended to breastfeed for only six months. The majority of the women (97%) received counseling about their infant feeding method, mostly from a health care worker at the clinic. One-third of the women (33%) were influenced by health care professionals on deciding on their infant feeding method and 44% of the participants indicated that no-one influenced them and that they decided themselves. In the focus group discussions the fear of transmission of HIV through breast milk was stated as an important reason why mothers should choose replacement feeding. In conclusion the most important results are that significantly more HIV-infected mothers chose replacement feeding as infant feeding method, and mothers who chose breastfeeding were significantly older than mothers who selected replacement feeding and they made their infant feeding decision significantly earlier than those who chose replacement feeding. According to the focus group discussion results the communities also felt that the HIV-infected mothers should not breastfeed their infants due to the fact that the virus can be transmitted through breast milk. Health professionals should still provide all the necessary information about exclusive breastfeeding for the first six months, even where the prevalence of HIV is high. In most of these areas replacement feeding will not be acceptable, feasible, affordable, sustainable and safe, due to lack of safe water, sanitation and the poor socio-economic status of these people. The dangers of mixed feeding should be emphasized. Most of the women in this study received information from health care workers and family. It is important that family members are included when information is given to women of child-bearing age. Health care workers need appropriate training to ensure that they give the right messages about safe infant feeding to the mothers. / Thesis (M.Sc. (Dietetics)--North-West University, Potchefstroom Campus, 2009.

South Africa recently changed infant feeding policy within Prevention of Mother to Child Transmission (PMTCT) of HIV from free formula to recommendation of breastfeeding for all. The country is evaluating the role of Community Health Workers (CHWs) in supporting mothers and newborns. The aim of this thesis is to explore perceptions of household members on the value given to and the social forces behind formula feeding in light of the recent policy change, and to assess the effect of a community-based package of maternal and newborn care delivered by CHWs on HIV-free survival and exclusive and appropriate infant feeding up to 12 weeks of age. Studies were conducted in a high HIV prevalence township. Focus group discussions were performed (grandmothers, fathers and teenage mothers) and in-depth interviews with HIV-positive and HIV-negative mothers. Perceptions of household members on the formula policy change were explored and the value household members place on formula feeding and circumstances that drive it. In a cluster-randomized trial (15 intervention, 15 control clusters) CHWs provided two antenatal and five post-natal home visits to support and promote PMTCT activities. There were misunderstandings by community members on the free formula policy change. Mothers transferred the motherhood role to their mothers while partners provided inadequate financial support, leading to risky mixed feeding. Teenage mothers rarely breastfed their infants due to perceived constraints including embarrassment, sagging breasts and loss of freedom and boyfriends. At 12 weeks of age the intervention had doubled exclusive breastfeeding (EBF) (28% vs. 14%) and slightly increased infant weight and length. No difference was seen between study arms in HIV-free survival. The effect on EBF at12 weeks did not differ with maternal education or wealth levels, but was higher among HIV-negative mothers.  Focusing on teenage mothers breastfeeding challenges, involvement of grandmothers and fathers in infant feeding decision-making, improving communication strategies on policy change and breastfeeding to the community and health workers and CHWs home visits supporting PMTCT activities are important for infant feeding and child health.

GB virus C (GBV-C) is a common, apathogenic virus that can inhibit human immunodeficiency virus (HIV) replication in vitro. Persistent coinfection with GBV-C has been associated with improved survival among HIV-infected adults while loss of GBV-C viremia has been associated with poor survival. If GBV-C does inhibit HIV replication, it is possible that GBV-C infection may reduce mother-to-child-transmission (MTCT) of HIV. This study investigated whether maternal or infant GBV-C infection was associated with reduced MTCT of HIV infection. The study population consisted of 1,783 pregnant women from three Bangkok perinatal HIV transmission studies (1992-94, 1996-7, 1999-2004). We tested plasma collected at delivery for GBV-C RNA, GBV-C antibody, and GBV-C viral genotype. If maternal GBV-C RNA was detected, the four- or six-month infant specimen was tested for GBV-C RNA. Rates of MTCT of HIV in GBV-C-infected and GBV-C-uninfected women and infants were compared using multiple logistic regression as were associations with MTCT of GBV-C and prevalence of GBV-C infection. The prevalence of GBV-C infection (i.e. presence of RNA or antibody) was 33% among HIV-infected women and 15% among HIV-uninfected women. Forty-one percent of GBV-C-RNA-positive women transmitted GBV-C to their infants. Only two of 101 (2.0%) GBV-C-RNA-positive infants acquired HIV infection compared to 162 (13.2%) of 1,232 of GBV-C-RNA-negative infants (RR 0.15, p<0.0001). This association remained after adjustment for maternal HIV viral load, antiretroviral prophylaxis, CD4+ count and other covariates. MTCT of HIV was not associated with presence of maternal GBV-C RNA or maternal GBV-C antibody. Maternal receipt of antiretroviral therapy was associated with increased MTCT of GBV-C, as was high GBV-C viral load, vaginal delivery and absence of infant HIV infection. GBV-C infection among women was independently associated with more than one lifetime sexual partner, intravenous drug use and HIV-infection. We observed a higher prevalence of GBV-C infection among HIV-infected compared to HIV-uninfected pregnant women in Thailand, likely due to common risk factors. Antiretroviral therapy appears to increase MTCT of GBV-C. Infant GBV-C acquisition, but not maternal GBV-C infection, was significantly associated with reduced MTCT of HIV. Mechanisms for these later two associations are unknown. / Bhanich Supapol W, Remis RS, Raboud J, Millson M, Tappero J, Kaul R, Kulkarni P, McConnell MS, Mock PA, Culnane M, McNicholl J, Roongpisuthipong A, Chotpitayasunondh T, Shaffer N, Butera S. 2008. Reduced mother-to-child transmission of HIV associated with infant but not maternal GB virus C infection. J Infect Dis 197(10):1369-1377. Bhanich Supapol W, Remis RS, Raboud J, Millson M, Tappero JW, Kaul R, Kulkarni P, McConnell MS, Mock PA, McNicholl JM, Vanprarar N, Asavapiriayanont S, Shaffer N, Butera ST. 2009. Mother-to-child transmission of GB virus C in a cohort of women coinfected with GB virus C and HIV in Bangkok, Thailand. J Infect Dis 200:227-235.

<p>Increased uptake of VCT services by pregnant women may be attributed to the development of counseling services and increased availability of rapid tests at the study clinics by the Namibian Health and Social Services. A high knowledge and understanding of HIV and VCT services by pregnant women also probably contributed.</p>

A principal via de infecção pelo HIV-1 em crianças é a transmissão materno-infantil (TMI). Estimativas para taxas de TMI do HIV-1 são de 3% entre gestantes sob terapia antirretroviral e de 25 a 30% para as não tratadas. Apesar da exposição viral durante a gestação, a maioria dos recém-nascidos não são verticalmente infectados, o que sugere a existência de barreiras protetoras à TMI do HIV-1. Diversos fatores podem estar associados com a TMI do HIV-1. Polimorfismos genéticos são descritos em associação com a infecção pelo HIV-1, incluindo os dos antígenos leucocitários humanos (HLA). A molécula HLA-G tem sido implicada nas interações imunológicas materno-fetais e é expressa em células da placenta, especificamente nos citotrofoblastos extravilosos, que formam a camada responsável pela interface entre os tecidos fetais e maternos. Este estudo avaliou os polimorfismos de inserção e deleção de 14pb do HLA-G na TMI do HIV-1. Participaram do estudo, 86 duplas de mães e filhos, sendo 58 duplas de mãe-filho em que a TMI do HIV-1 não ocorreu e 28 duplas em que a TMI ocorreu. Os resultados mostraram maior frequência de genótipo deleção/deleção em mães pertencentes ao grupo TMI positiva, sem utilização de antirretrovirais (p=0,05). Foi observada associação significante entre conhecimento prévio da soropositividade, realização de pré-natal, utilização de antirretrovirais na gestação e não amamentação com a prevenção da TMI (p<0,05). Nesse contexto, a enfermagem pode contribuir com ações que envolvem o pré-natal, parto e puerpério, por meio de aconselhamento quanto à realização do teste anti- HIV-1 no pré-natal, utilização adequada de antirretrovirais e promoção de práticas ideais de alimentação infantil. Adicionalmente, o estudo contribui para a ampliação de conhecimentos da enfermagem sobre a temática do HLA-G na TMI, e destaca a importância de que a enfermagem, fundamentada em ciências biológicas, esteja envolvida na produção de conhecimentos e tecnologias, o que reflete na melhoria da prestação do cuidado ao paciente. / The main way of HIV-1 infection in children is mother-child transmission (MTCT). TMI rates estimates for HIV-1 are 3% in pregnant women in antiretroviral therapy and 25 to 30% for untreated ones. Despite the viral exposure during pregnancy, most newborns are not vertically infected, suggesting the existence of protective barriers to TMI of HIV-1. Several factors may be associated with MTCT of HIV-1. Genetic polymorphisms are described in association with HIV-1, including the human leukocyte antigens (HLA). The molecule HLA-G has been implicated in maternal-fetal immune interactions and is expressed in placenta cells, particularly in extravillous cytotrophoblasts, forming the layer responsible for the interface between fetal and maternal tissues. This study evaluated the HLA-G 14pb insertion and deletion polymorphisms in MTCT of HIV-1. Participated in the study 86 mother-child pair, 58 mother-child pairs in which the MTCT did not occur and 28 doubles in which the MTCT occurred. The results showed a higher frequency of genotype deletion/deletion in mothers in which MTCT occurred belonging to the group without using antiretroviral (p=0.05). Significant association was observed between prior knowledge of seropositivity, conducting prenatal, use of antiretroviral during pregnancy and not breastfeeding to the prevention of MTCT (p <0.05). In this context, nursing can contribute to actions involving prenatal, birth and postpartum, conducting counseling for the conduct of HIV testing during prenatal care, proper use of antiretroviral and promotion of optimal infant feeding practices. Additionally, the study contributes to the expansion of nursing knowledge about the topic of HLA-G in MTCT, and highlights the importance of nursing, grounded in basic sciences, is involved in the production of knowledge and technology, which reflects improvement in the provision of patient\'s care.

As medidas preventivas da transmissão vertical do HIV podem efetivamente reduzir as taxas da infecção nas crianças. No entanto, são necessárias a participação e adesão das mães ao tratamento. Buscando compreender as crenças que influenciam o comportamento das mães portadoras do HIV em relação às medidas profiláticas da transmissão vertical, desenvolvemos este estudo qualitativo. Foram entrevistadas 14 mulheres portadoras do HIV cujos filhos nasceram no município de Ribeirão Preto e tinham no mínimo 6 meses de vida. Os dados foram tratados de acordo com o método da Análise de Conteúdo e interpretados utilizando-se como referencial teórico o Modelo de Crenças em Saúde (Rosenstock, 1974), composto pelas dimensões susceptibilidade percebida, severidade percebida, benefícios percebidos e barreiras percebidas. Na análise emanaram categorias que evidenciam as contradições da epidemia da aids: na susceptibilidade percebida emergiram “invulnerabilidade antes da gravidez”, “o pré-natal” e “susceptibilidade da criança”; quanto à severidade da doença – “subestimação do HIV” e “medo da morte”; “crescer saudável” e “não ser como eu”, foram os benefícios percebidos pelas mães; em relação às barreiras possíveis, encontramos a “descrença na existência do vírus”, “dificuldades financeiras” e “omissão do diagnóstico”. Alguns aspectos das crenças podem ser considerados tanto como facilitadores como dificultadores da adesão materna, dependendo do contexto sócio-econômico e cultural em que vive a mãe. Conhecer a percepção das mães acerca das crenças que motivam os seus comportamentos proporciona aos profissionais de saúde maior compreensão desses comportamentos, permitindo ainda a possibilidade de elaboração de um planejamento mais efetivo de cuidados dentro de um contexto culturalmente significativo, com maior probabilidade de promover a adesão da clientela. / Prevention measures for the mother-to-child transmission of the HIV virus may effectively reduce infection rates in children. However, for such effectiveness to come true, mothers have to comply with the treatment. This study was carried out aiming to understand the beliefs which influence the HIV positive mothers’ behaviors towards prevention methods against mother-to-child transmission. Fourteen HIV infected women whose children were at least 6 months old and all born in Ribeirão Preto county were interviewed. Data were studied according to the Content Analyses method and interpreted using as a theoretical reference the Health Belief Model (Rosenstock, 1974), formed by the following dimensions: perceived susceptibility, perceived severity, perceived benefits and perceived obstacles. As we analyzed those data we came up with some under categories showing the AIDS epidemic paradox: in the perceived susceptibility appeared: “invulnerability prior to pregnancy”; “pre delivery”; “a child’s susceptibility” as for the disease seriousness. “Underestimation of the HIV virus”;” fear of death”; “healthy growing up”; and “not the same as me” were the benefits mentioned by the mothers. As for the possible barriers, we found things like: “disbelief in the virus existence”; “financial problems”; “diagnosis omission”. Some aspects of the beliefs may be considered both helpers and trouble-makers for a mother’s adhesion, varying according to the social, economic and cultural environment the mother lives in. Getting to know a mother’s perception regarding the beliefs motivating their behaviors provides the health professionals a higher understanding of such behaviors, allowing the possibility of making up an effective care plan within the context culturally meaningful, with a higher probability of promoting patients’ adhesion.

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.