Magister Public Health - MPH / Disclosure of HIV positive status to male partners is well established as a key element in the success of prevention of mother to child transmission of HIV programmes, as it helps improve adherence to ARVs by the women within these programme. However, partner notification rates remain low in the urban areas of Lusaka, Zambia against a high HIV prevalence of 25%. The purpose of this study was to explore the timing of disclosure as part of the process of disclosure amongst women who were part of the PMTCT services at Kaulu health centre in Lusaka. An exploratory descriptive study using qualitative research methods was conducted. 15 women, who were attending the Kaulu health centre PMTCT programme, were requested to participate in a semi-structured interview. The women, who were purposively selected with the aid of the health centre‟s PMTCT focal point nurse, had to have disclosed their HIV positive status to their partner, either before or during the course of their pregnancy or after delivery. To increase rigour, individual interviews were conducted with 5 health workers associated with the PMTCT programme so as to obtain their perspective and experiences on the issue of HIV disclosure amongst their PMTCT patients. Participation in the study was voluntary and all information obtained during the course of the interviews remained confidential and secure. Potential participants were each provided with an explanation of the purpose and process of the study and their informed written consent obtained before the researcher embarked on the interviews. Content analysis of the transcripts was done so as to develop coding categories and identify emerging themes. Disclosure to male partners is an important step in PMTCT and facilitates adherence to HIV care for the family and should be done as early as possible after the woman receives her HIV test result, though there exists a range of alternative times when it can be done. The relationship existing between a couple is very important in determining the timing of when a woman chooses to disclose. PMTCT services need to provide ongoing counselling for HIV positive women during pregnancy and after giving birth that supports, informs and equips them with the necessary skills to make an informed and timely decision about disclosure to a partner. In addition, the PMTCT service providers need to be encouraged to implement couple counselling as a strategy to facilitate disclosure as well as establishment of a peer support network for HIV positive pregnant women. The study findings will be used to contribute to health workers‟ capacity to support women manage the disclosure process to their male partners, thus helping to increase the disclosure rate and also contributing to improving the positive effect of the PMTCT services, in Lusaka, Zambia. / South Africa

Magister Public Health - MPH / Since the advent of the HIV pandemic, efforts have been made to find and implement interventions to reduce the risk of transmission of the infection in various risk groups. Mother to child transmission is responsible for a great majority of childhood HIV infections. Interventions have been developed which reduce considerably the risk of mother to child transmission to babies born to women who are infected. To be able to access these interventions, pregnant women first have to know their status by being tested at antenatal clinics. Initial testing protocols in most countries were based on the opt-in, client-initiated approach. However, in many countries, this did not result in many women getting tested and being able to access interventions. Accordingly, many countries have now adopted the routine opt-out approach as a way of increasing testing rates among women attending antenatal clinics. Ghana has had a PMTCT programme since 2004 initially based on opt-in testing. In 2007, there was a change in this testing regimen to the opt-out approach. The aim of this study was to assess the quality, acceptability and factors influencing the acceptability of the use of routine verbal opt-out strategy for HIV testing during pregnancy for women attending antenatal clinics in the Kassena-Nankana district of northern Ghana. A cross-sectional analytical study design was used in this study. The study was conducted in the Kassena-Nankana district of northern Ghana using a structured questionnaire in face to face exit interviews with pregnant women after they had completed their first antenatal clinic visit. A total of 251 women aged between 15-49 years were interviewed after informed consent had been obtained from them. Data was captured with Epidata and analysed with EpiInfo. Cross-tabulations and logistic regression analyses were done. Of the 251 respondents who were interviewed in this survey, 85% of them were aware of MTCT, 82% knew at least one PMTCT strategy, 92% felt they had experienced good quality counselling that day at the ANC and 81% thought that the opt-out testing was acceptable. The perception of the women in the study about the quality of counselling they were given, their exposure to radio and their ethnicity were significantly associated with their acceptability of opt-out testing for HIV. While majority of the respondents felt that the quality of the counselling they received was good and a majority also felt that the opt-out strategy was acceptable, there were concerns about the quality of counselling provided. Recommendations include the need to improve counselling practices in the antenatal clinics by providing more structured information to the women. The District Health Management Team also needs to provide more information to people in the communities about PMTCT using radio as a medium.

No description available.

The study sought to determine the meaning and interpretation by facility managers and nurses on utilisation of expanded programme on immunisation and integrated management of childhood illnesses (EPI and IMCI) programmes for follow-up and antibody testing of HIV-exposed infants (HEI) at 18 months. Also to understand the factors within the health systems that influence the follow-up and antibody testing. The study setting selected was six facilities in Steve Tshwete subdistrict in Nkangala district of Mpumalanga province in South Africa. The study used a hermeneutic phenomenology using in-depth interviews for collecting data from 4 facility managers and 12 nurses. The major themes that emerged from the interviews were referral, defaulting, integration, stigma, and off-site ART initiation within the health system. These were found to influence the utilisation of HEI and IMCI services for follow-up and management of HEI. It was also found that the importance of integrating the management of HEI into the EPI and IMCI cannot be overemphasised. It was concluded that the Health Department needs to be vigilant and use all available resources to manage HEI to meet the MDG 4 of prevention of infant mortality / Health Studies / M.A. (Nursing Science)

Thesis (MCurr)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: HIV infection poses a major obstacle in breastfeeding as it represents the most common way by which children acquire HIV. Exclusive breastfeeding has been discovered as the most effective intervention in preventing mother-to-child transmission of HIV, mortality and promotion of HIV free survival. The main objective was to evaluate the evidence on the effectiveness of exclusive breastfeeding versus formula feeding and/ or mixed feeding in the prevention of HIV-1 transmission from mother to child. To identify the studies, an electronic search was conducted using PUBMED/MEDLINE, CINAHL, CENTRAL and EMBASE databases. Electronic journals, which include the Southern African Journal of HIV medicine (SAJHIV), HIV Medicine Journal and American Journal of Public Health, were also accessed. Manual searches were carried out. In addition, relevant experts were contacted in order to locate more data. There were no limitations with regards to date and language. The review considered studies on infants who were vertically HIV-1 exposed (mother HIV positive during pregnancy, birth and breastfeeding). These infants were exclusively breastfed for six months with administration of antiretroviral prophylaxis and were compared to infants exclusively formula fed. The outcomes measured were vertically acquired HIV infection; mortality and HIV free survival up to 24 months of age. Two reviewers independently selected articles which met the inclusion criteria. They independently extracted the data using a data extraction tool. Disagreements were solved by discussion. Data was then meta-analysed using Rev Man 5.1.0. Methodological quality of each trial was assessed by the reviewers using the Cochrane assessment tool for risk of bias. Two randomised clinical trials and one intervention cohort study (n=2112 infants) comparing exclusive breastfeeding with exclusive formula feeding were included. HIV infection was associated with exclusive breastfeeding as compared with exclusive formula feeding (Risk ratio 1.67, 95% CI 1.26 to 2.23, p=0.0005). Exclusive formula feeding was associated with high mortality from infections (Risk ratio of 0.67 95% CI 0.43 to 0.83, p=0.002 Chi²= 1.30, p=0.52, I²=0%). There were no statistically significant differences in HIV free survival between exclusive breastfeeding and exclusive formula feeding as measured by trialists at 9, 18 and 24 months (Risk ratio 1.19, 95% CI, 0.92 to 1.54, p=0.19, Chi²= 3.15, p=0.21, I²=36 % 3 studies, 1012 infants). None of the studies included reported on mixed feeding. Complete avoidance of breastfeeding is effective in preventing mother-to-child transmission of HIV. HIV infection during breastfeeding might be an indicator of mixed feeding and poor adherence. Formula feeding is only applicable in settings where formula milk is accessible, feasible, acceptable, safe and sustainable (AFASS) because formula feeding carries a high risk of mortality from causes other than HIV. If the AFASS criteria cannot be met, mothers should be encouraged to exclusively breastfeed and ensure that their infants completely adhere to the antiretroviral prophylaxis because they decrease the rate of vertical HIV-1 transmission. / AFRIKAANSE OPSOMMING: MIV besmetting veroorsaak ‘n groot struikelblok vir borsvoeding, omdat dit die mees algemene manier is waarop babas met MIV besmet word. Eklusiewe borsvoeding is as die mees effektiewe intervensie ontdek in die voorkoming van moeder na kind oordrag van MIV, morbiditeit en die bevordering van MIV vrye oorlewing. Die hoofdoelwit is om die effektiwiteit van eksklusiewe borsvoeding teenoor formule-voeding en of gemengde voeding in die voorkoming van MIV oordrag van moeder na kind te evalueer. Elektroniese navorsing is gedoen deur gebruik te maak van PUBMED/MEDLINE, CINAHL, CENTRAL en EMBASE databasisse. Elektroniese joernale wat die Southern African Journal of HIV medicine (SAJHIV), HIV Medicine Journal and American Journal of Public Health insluit, is ook gebruik. Handnavorsing is ook gedoen, asook relevante data van kenners op die gebied, is verkry. Geen beperking is geplaas op taal of tyd nie. Studies op babas wat blootgestel is aan die MIV-1 (moeder MIV positief gedurende swangerskap en borsvoeding) is in die oorsig oorweeg. Hierdie babas is eksklusief vir 6 maande gerborsvoed, met of sonder anti-retrovirale behandeling, en is vergelyk met eksklusiewe formule-voeding. Die resultaat was dat almal tot op 24 maande gemeet is aan MIV besmetting, mortaliteit en MIV vrye oorlewing. Twee resensente het onafhanklik artikels geselekteer wat aan die ingeslote kriteria voldoen het. Hulle het onafhanklik data geselekteer deur van ’n selekteringsinstrument gebruik te maak. Misverstande is deur besprekings opgelos. Data was daarna gemeet en gemetaanaliseer deur Rev Man 5.1.0. Die metadologiese kwaliteit van elk proeflopie is geassesseer deur die resensente wat gebruik gemaak het van die Cochrane evalueringsinstrument om die risiko van onewewigtigheid uit te skakel. Twee ewekansige kliniese proewe en een intervensie kohort studie (n = 2112 babas) wat eksklusiewe borsvoeding vergelyk met 'n eksklusiewe formule-voeding is ingesluit. MIVinfeksie wat verband hou met 'n eksklusiewe borsvoeding is vergelyk met eksklusiewe formule-voeding (risiko verhouding van 1.67, 95% CI 1.26 tot 2,23, p=0.0005). Eksklusiewe formule-voeding hou verband met 'n hoë mortaliteit van infeksies met ’n risiko verhouding van 0.67, 95% CI 0.43 tot 0.83, p = 0.52, Chi ² = 1.30, p = 0.52, I ² = 0%. Daar is geen statisties beduidende verskille in MIV-vrye oorlewing tussen eksklusiewe borsvoeding en eksklusiewe formule-voeding nie wat deur die proefnemers gemeet is op 9, 18 en 24 maande (risiko verhouding 1.19, 95% CI, 0.92 tot 1.54, p = 0,19, Chi ² = 3,15, p = 0.21, I ² = 36% 3 studies, 1012 babas). Nie een van die ingeslote studies het verslag gedoen oor gemengde voeding nie. Algehele vermyding van borsvoeding is effektief in die voorkoming van Moeder na Kind oordrag van MIV. MIV-infeksie gedurende borsvoeding mag ’n aanduiding van gemengde voeding en swak nakoming wees. Formule voeding is alleenlik van toepassing in situasies waar formule-melk toeganklik, uitvoerbaar, veilig en volhoubaar is, want formule-voeding dra ’n hoë risiko van mortaliteit weens ander oorsake buiten MIV. Indien daar nie aan hierdie kriteria voldoen kan word nie, behoort moeders aangemoedig te word om eksklusief te borsvoed en seker te maak dat hulle babas die antiretrovirale profilaksie getrou neem, want dit verlaag die koers van vertikale MIV-1 oordrag.

La problématique de la neutralisation par les anticorps constitue un enjeu majeur dans la perspective de la conception d’un vaccin efficace contre le VIH et les connaissances récemment acquises conforte NT l’absolue nécessité de maintenir une recherche cognitive fondamentale sur le sujet. L’un des objectifs de ce travail de thèse a été de documenter les propriétés biologiques en terme de sensibilité à la neutralisation de variants présents chez certains patients asymptomatiques à long terme (ALT) et présentant des caractéristiques particulières. Nous avons pu identifié certains déterminants moléculaires associés à la sensibilité ou à la résistance à l’anticorps monoclonal 2G12 tels le site potentiel de glycosylation (PNGS) en position N302 et la longueur de la boucle V1V2 du gène env. Nous avons ensuite caractérisé la relation entre l’évolution du gène env et la sensibilité à la neutralisation dans un contexte d’évolution tardive chez un patient ALT. Ces travaux ont permis de mettre en évidence une poursuite de l’évolution du gène env plus de 10 ans après l’infection et ceci malgré la présence d’anticorps largement neutralisants et d’une réponse autologue croissante au cours du temps. Le contexte de la transmission mère enfant (TME) constitue un modèle de choix afin d’étudier le rôle des anticorps neutralisants. Afin d’identifier d’éventuels corrélats de protection, mon travail a consisté à étudier la réponse neutralisante dans une population de 114 couples mères-enfants. Nous avons pu confirmer que le spectre de neutralisation des sérums maternels n’était pas associé à une moindre TME du VIH-1, mais que les anticorps neutralisant certains isolats pourraient constituer des indicateurs d’intérêt associé à un moindre risque de transmission. L’ensemble de ces travaux souligne à nouveau la complexité et la pertinence à poursuivre les investigations relatives à l’identification d’éventuels corrélats de protection. / Basic research on neutralizing antibodies. still remains relevant in term of HIV vacccine development. One of the aim of this thesis was to document the neutralization sensitivity of particular HIV-1variants from long term non progressor (LTNP) patients. We first identified molecular signatures associated with sensitivity to 2G12, such as a potential N-linked glycosylation site (PNGS) at N302 and a longer V1V2 loop of gp120. We also studied the relationship between long-term evolution of the virus and neutralization sensitivity in a LTNP patient. We showed that HIV-1 may continue to evolve in presence of both broadly neutralizing antibodies and increasing autologous neutralizing activity more than 10 years post-infection. Mother-to-child transmission provides a natural model for studying the role of neutralizing antibodies. In previous studies, we showed that the presence or high titers of neutralizing antibodies against a CRF01_AE strain, MBA, was associated with a lower rate of HIV-1 intrapartum transmission in Thailand (Barin et al., 2006; Samleerat et al., 2009). In order to confirm this observation and to identify potential correlates of protection in the MTCT context, we examined the breadth and levels of neutralizing antibodies in 57 transmitting and 57 non-transmitting untreated HIV-1 infected mothers. Our study confirmed that the breadth of maternal neutralizing antibodies was not associated with protection of infants from infection, but that neutralizing antibodies to particular strains might be associated with a lower rate of MTCT of HIV-1.

Als ein Grund für die vertikale Transmission von HIV von der Mutter auf das Kind während der Schwangerschaft bzw. der Geburt wird der Transport von HIV durch die Eihaut diskutiert. Hierbei handelt es sich wahrscheinlich um einen rezeptorvermittelten Transport, der auf einer Interaktion zwischen einer Lektin-bindenden Domäne auf dem viralen Oberflächenglykoprotein gp120 und einem Rezeptor auf der epithelialen Oberfläche beruht. In der vorliegenden Arbeit konnte die in den Transport von zellfreien HIV-1 durch epitheliale Zellen beteiligte Domäne auf gp120 erstmals näher charakterisiert werden. Überlappende Oligopeptide –basierend auf der Aminosäurensequenz von gp120– wurden zur Hemmung der Transzytose von HIV-1 durch humane Amnionzellen verwendet. Vier dieser Oligopeptide inhibierten die Transzytose von HIV-1 signifikant. Ein synthetisches Peptid (Env362-420) mit einer Länge von 59 Aminosäuren, welches die Sequenz der inhibierenden Oligopeptide darstellt, reduzierte die Menge an transportierten Viren ebenfalls, unabhängig vom HIV-1 Subtyp. Im Weiteren konnte der Transport von HIV-1 durch polyklonale Antikörper in Seren HIV-Infizierter, die mit Env362-420 reagierten, und durch Seren, die durch eine Immunisierung von Kaninchen mit Env362-420 gewonnen wurden, inhibiert werden. Antikörper gegen die in den Transport involvierte Domäne konnte in Seren HIV-Infizierter zu jedem Stadium der Infektion nachgewiesen werden. Bei einer Expression der Antikörper in der frühen Infektionsphase wäre ein positiver Einfluss auf die Prognose der Krankheit vorstellbar. Ob ein Zusammenhang zwischen einer Antikörperexpression gegen Env362-420 in HIV-infizierten Schwangeren und der Wahrscheinlichkeit einer HIV-Transmission auf das Kind besteht, muss noch geklärt werden. Env362-420 kann zur Identifizierung des Rezeptors auf der epithelialen Oberfläche, welcher in die Transzytose von HIV involviert ist, und zur Entwicklung von Inhibitoren der Mutter–Kind-Übertragung von HIV herangezogen werden. / The transport of HIV through the fetal membranes is discussed as one possible reason for the vertical transmission of HIV from mother to child during pregnancy or labor. HIV can penetrate epithelial barriers by a receptor-mediated transport mechanism involving interaction of a lectin-like domain on the viral glycoprotein gp120 and a receptor on the epithelial surface. In this study the domain on gp120 involved in transcytosis of cell-free HIV-1 through epithelial cells was characterized in more detail. Overlapping oligopeptides of gp120 were used to inhibit transcytosis of HIV 1 through an amnion cell monolayer. Four oligopeptides significantly inhibited transcytosis of HIV 1. A synthetic oligopeptide (Env362-420) with a length of 59 amino acids representing the sequence of the four inhibiting oligopeptides significantly reduced the transport of HIV, independent of the HIV 1 subtype. Furthermore, human HIV-positive sera with antibodies reacting with the domain Env362-420 and rabbit sera raised against the oligopeptide Env362-420 also inhibited the transport of HIV-1. Antibodies directed against the transcytosis domain could be detected in sera from every stage of infection. The development of these antibodies in the early stage of infection might play a role in the outcome of the HIV disease.It has to be investigated whether HIV 1-infected women who developed these antibodies show a lower rate of HIV transmission to their offspring than those without such antibodies. Env362–420 can also be used as a tool to identify the receptor involved in transcytosis on the epithelial cell surface and to develop inhibitors that could help prevent mother-to-child transmission of HIV during pregnancy or labor.

This dissertation examines the effectiveness of interventions related to family planning and the uptake of HIV-related preventive services among women in low-income settings. Women in low-income settings and living with HIV face many barriers to care, including limited access to services for family planning and HIV-related preventive care. At the same time, national, regional, and global efforts are looking for interventions to help control rapid population growth, create an HIV-free generation, and provide adequate preventive care for those living with HIV. This dissertation cuts across these issues and can help to inform debate and policies to address these issues. This dissertation comprises three discrete papers. Paper 1 (chapter 1) examines the effectiveness of a national scale-up of community-based distribution of family planning services on contraceptive use in Malawi’s rural areas during the period 2005-2016. The national-scale up of the intervention followed the success of a pilot of a similar intervention implemented in the period 1999-2004. As in the pilot, the scaled-up program distributed condoms and oral contraceptives and provided family planning education. Further, because education and income are important determinants of individual contraceptive use, the paper also examines whether the effectiveness of the national scale CBDs varies over these dimensions. The paper uses the Malawi Demographic and Health Surveys. The study finds that the intervention increased contraceptive use by 6.8 percentage points and the effects were greater among uneducated and low-income women. Paper 2 (chapter 2) conducts a cost-effectiveness analysis of a trial of cash incentives aimed at increasing the uptake of services for the prevention of mother-to-child transmission (PMTCT) of HIV. The trial was conducted in the Democratic of the Congo (DRC) as part of an effort to find ways of increasing uptake of PMTCT services in sub-Saharan Africa where uptake of these services remains low. The study is conducted from the societal perspective, relies on multiple sources within and outside of the DRC for cost data, and reports economic costs in 2016 International Dollars (I$). At a threshold of 3*GDP per capita for the DRC (I$2409), the study finds that the intervention is cost-effective. Paper 3 (chapter 3) examines the guideline concordance of the time to follow-up anal cancer screening in women living with HIV at high risk for anal cancer. In the US, the incidence of anal cancer in women living with HIV has increased significantly in the past 2-3 decades. However, early detection of anal cancer, through regular screening, can lead to effective secondary prevention of the disease. While guidelines for anal cancer screening exist, very little is known about the guideline concordance of the time to follow-up anal cancer screening in women at high risk of acquiring anal cancer. Hence this study. The study uses Medicaid Analytic eXtract files which compile claims of individuals enrolled in Medicaid—a public health insurance program largely for eligible low-income adults and the largest single payer for HIV/AIDS in the US. The study finds that time to follow-up screening is not guideline-concordant for most women living with HIV, particularly those with one of the two risk factors for anal cancer: a history of abnormal cervical test results or a history of genital warts.

<p>This thesis assesses the uptake of the national Prevention of Mother to Child Transmission of HIV (PMTCT) programme in South Africa, and the challenges of achieving safe infant feeding practices in the context of HIV. The research studies contained in this thesis utilised a variety of quantitative and qualitative research methods in order to provide a full understanding of the challenges of moving from efficacy to effectiveness in PMTCT programmes. The first paper utilised a cross-sectional approach to a programme evaluation, papers two and three utilised qualitative methodologies, and paper four was based on a longitudinal cohort study design. The findings highlight the low uptake of PMTCT interventions and inappropriate infant feeding choices. The experiences of women with HIV provide an important insight into the difficulties of operationalising the WHO/UNICEF HIV and infant feeding recommendations in real life settings, where rates of HIV disclosure are low and mixed feeding is the norm. Several personal and environmental characteristics were identified that contributed to success in maintaining exclusive infant feeding practices. The research provides some guidance on the definition of appropriateness in infant feeding choices, and highlights the poor outcomes associated with formula feeding under unsafe conditions. Modifying infant feeding practices is essential in order to reduce postnatal HIV transmission and improve child survival. Interventions to improve infant feeding need to include improving the quality of counselling and support provided by health workers, with more structured assessments used to guide infant feeding choices. Efforts are also needed at the community level to increase rates of disclosure and to promote exclusive infant feeding as a norm.</p>

<p>&nbsp / </p> <p align="left">This study explores the challenges faced by nurse counselors in the implementation of HIV and Infant Feeding Policy in Amathole District of the Eastern Cape. <b><font face="Times New Roman">Objectives: </font></b><font face="Times New Roman">To describe the demographic characteristics of the study population / Toexplore the challenges faced by nurse counselors in the implementation of current HIV and infant feeding policy and guidelines / &nbsp / To establish the nurse counselors&rsquo / perspectives on the infant feeding policy and guidelines for HIV positive mothers / To examine the support system available to the nurse counselors who give infant feeding advice to HIV positive mothers.</font></p>