Dissertations / Theses on the topic 'Antiretroviral (ARV) drugs'

Acquired Immunodeficiency Syndrome (AIDS) is characterized by the progressive destruction of a person’s immune system and is the latest and most serious stage of Human Immunodeficiency Virus (HIV) infection. Botswana currently has the highest estimated prevalence of HIV infection in the world. Botswana has a relatively young population structure, with about 60% of the approximately 1,8 million people aged less than 45 years. HIV prevalence for pregnant women aged 15–45 years in Botswana did, however, decrease marginally from 36,2% in 2001 to 35,4% in 2002. It is estimated that about 258 000 Botswana are now living with HIV and AIDS, and high morbidity and mortality rates due to HIV/AIDS have seen Botswana slip down the United Nations Development Plan (UNDP) Human Development Index rankings from 71 in 1996, to 122 in 1999/2000. In 2002 Botswana initiated public antiretroviral therapy (ART) at four sites initially to provide treatment to HIV/AIDS patients before expanding the programme to the rest of the country. The specific objective of the study was to investigate the prescribing patterns of ARV drugs at Sekgoma Memorial Hospital ARV therapy clinic (SMH–IDCC) in the central district of Botswana for a two–year period from 2005 to 2006. Data from 1717 patients were obtained from the SMH–IDCC electronic database regarding ARV drugs prescribed during the study period, CD4–Tcell count (cells/?L) at the commencement of therapy and after six months from the commencement of therapy and side effects necessitating change of therapy for the study period 2005 until 2006. The study showed that there were eight antiretroviral therapy (ART) regimens prescribed: zidovudine plus lamivudine plus efavirenz (AZT/3TC/EFV), zidovudine plus lamivudine plus nevirapine (AZT/3TC/NVP), Combivir® plus efavirenz (CBV/EFV), Combivir® plus nelfinavir (CBV/NFV), Combivir® plus nevirapine (CBV/NVP), stavudine plus lamivudine plus efavirenz (D4T/3TC/EFV), stavudine plus lamivudine plus nelfinavir (D4T/3TC/NFV), and stavudine plus lamivudine plus nevirapine (D4T/3TC/NVP). The most prescribed ART regimen for adult patients was Combivir® plus efavirenz (CBV/EFV) (51,37%). This was broken down as 17,20% of females and 34,17% of males. The second most prescribed ART regimen was Combivir® plus nevirapine (CBV/NVP)(36% of the total study population (N=1717). This represented 34,17% of females and 1,98% of males. The most prescribed ART regimen in children was zidovudine plus lamivudine plus efavirenz (AZT/3TC/EFV) (3,73% of the total population), broken down as 1,05% of females and 2,68% of males. The second most prescribed regimen in this group was zidovudine plus lamivudine plus nevirapine (ZDV/3TC/NVP) (3,50% of total population). The findings from this study indicated that all eight the ART regimens prescribed at the study site were in accordance with the Botswana national ART guidelines. There were thirteen different types of side effects necessitating change of therapy, including pregnancy, treatment failure and poor adherence. The average CD4–Tcell count change (155.63 cells/?L, ± 204.08 cells/?L) for the study population was more than 100% after six months from commencement of therapy, indicating success of therapy in terms of CD4–Tcell count.
Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2011.

HIV/AIDS is the most threatening and challenging infectious diseases of our time, with the highest increase of newly infected cases reported. This infectious disease was discovered in the early eighties under homosexual men and was later to be discovered in heterosexuals. HIV is a systemic immunosuppressive disorder which causes a depletion of CD4+ T cells and develops into the acquired immunodeficiency syndrome - AIDS. Africa is the continent most affected by HIV/AIDS with the southern parts of Africa having the highest prevalence rates compared to the rest of Africa. Statistics indicate that AIDS is responsible for 3% of deaths in children worldwide - one in seven people dying of an HIV-related illness is a child under the age of 15 years. It was stated by the WHO that countries should develop improved antiretrovirals regimes for the prevention of mother-to-child transmission. Difficulties in administering antiretrovirals (ARVs) to patients (especially children) are the strict dosage regimes and the severe adverse reactions. These factors complicate patient adherence. The list of problems in treating patients is endless and includes the distribution, stability as well as the low efficacy of these drugs. Most of the above mentioned problems and obstacles related to ARVs and ARV treatment could be minimized or eliminated by the use of a stable and effective drug delivery system. Enhancing ARV treatment may be accomplished by the use of the Pheroid™ drug delivery system. Pheroids™ consists mainly of fatty acids and sterile nitrous oxide gassed water. Pharmacological active substances are entrapped into submicron and micron sized structures called Pheroids™. Research showed promising results and advantages in delivering drugs through oral and transdermal routes using Pheroid™ technology. The focus of this study was to test the possible enhancement of the efficacy of antiretrovirals using Pheroid™ technology. The assays used to study this possible enhancement were a modified neutral red and a modified 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium (MTT) assay. These assays confirmed and illustrated the toxic and protective properties of the tested ARVs (stavudine, lamivudine and nevirapine). An MT-2 cell line was used and infected with an HIV-1 strain, SW7-TCL. Applying Pheroid™ technology in these assays resulted in massive cell death, due to increased ARV toxic levels within the cells. Viability tests proved that Pheroids™ had no effect on the viability of cells at the concentration typically used. This confirmed the enhancing properties of Pheroids™ in the delivery of drugs into the cells. The MTT assay was further adapted from a seven day incubation period to a three day incubation period. By using a low concentration series and a three day incubation period the loss of cells through toxicity was partially overcome. One of the problems that arose form this study was the non-reproducibility of the results. Absorbance levels fluctuated at specific concentrations of the same ARV, which cause difficulties in comparing results. This result was repeatedly confirmed in this syncytium forming infection model. In conclusion, Pheroid™ technology enhanced the delivery of ARVs into the cells although it resulted in cell death. Both the neutral red and MTT assays were found to be inaccurate but further development, research and assay optimization could result in improved in vitro studies. The article format was used for this thesis, as described in the general academic rules in section A.13.7.3 of the North West University. Chapter 1 deals with HIV/AIDS related problems, statistics and treatment obstacles. Chapter 2 is a summary of the cell viability assays used in this study. Pheroid™ technology and its application to ARV treatment are dealt with in chapter 3. The proposed article for submission in the journal Cell Death and Differentiation has been included in chapter 4. Some of the results from the study are reported in the article and annexures, whilst other results are shown and discussed in Chapter 5. Chapter 6 gives a conclusion and final summary of this study. All other experimental methods and results are enclosed in the annexures, as is the "Guide for authors" for the article.
Thesis (M.Sc. (Pharmaceutics))--North-West University, Potchefstroom Campus, 2008.

Thesis (MMed) -- Stellenbosch University, 2010.
Bibliography
Objective: The objective of this retrospective cohort study is to assess whether demographic and anthropometric parameters, laboratory tests, co-morbidity, co-infection, treatment regimen, IRIS and adherence to treatment predict the expected response to HAART and differences if any, in the pattern of response as measured by CD4 count, weight gain and haemoglobin levels in two cohorts of patients in Roma, The Kingdom of Lesotho. Method: Data were collected randomly from a computerised database of the Antiretroviral Centre of the hospital and two cohorts of 151 subjects in each of the two arms of the study were identified from hospital records from January 2008. Each of these subjects was followed up over a period of 12 months with data obtained for at least 2 visits within the 12 month span. Data were obtained at baseline, 3 months and also at 6 and 12 months marks. Data on characteristics were compared between the two arms. Variables that may be potential confounders were identified and univariate and multivariate logistic regression analyses were carried out to establish differences independent of confounding factors for the combined endpoints as well as for each endpoint separately. Results: In all 302 patients had their records analysed and comparison of clinical and immunological response patterns in patients taking AZT and TDF-containing ART regimens and the possible prediction of which the regimen would be better and within which population. Despite the perceived mismatch between two NRTIs it can be concluded from the results of this study that, overall, the inclusion of AZT in treatment regimen showed a modest protective effect over the TDF counterpart as measured by the endpoints of the discriminative powers of the Receiver Operating Curves of the explanatory variables being 66% , 77% and 66% for CD4, Haemoglobin and Weight respectively, and 63%, 70% and 65% for the same variables in the AZT and TDF arms of the study respectively. Conclusion: In a population of HIV patients on treatment in resource-limited settings AZT-containing regimens appear to show a slight improvement over the TDF-containing ones.

Thesis (M Med Pharmacy)--University of Limpopo, 2011
Most pharmaceutical agents can result in side effects and toxicities that in some instances may be life threatening, especially if there is delay in their recognition. For various reasons it is therefore imperative to study adverse events associated with antiretroviral agents (ARVs). The aim of this study was to study the adverse events in adult HIV-infected patients receiving antiretroviral therapy at a public health treatment site, and to quantify the frequency of adverse events in different population subgroups. A retrospective cohort study was conducted in a sample of 99 patients (i.e. 70% females and 30% males) from a public health clinic providing antiretroviral drugs to more than 1500 patients. The reported adverse events were neurological disorders (33%), rash (17%), gastrointestinal toxicity (16%), lactic acidosis (14%), hepatitis (7%), lipodystrophy (7%), pancreatitis (5%), IRIS (3%), anaemia (1%), and gynaecomastia (1%). Based on the analysis of the presented data in this report, age, weight, gender, and pCD4 count are not the predictors for the development of lactic acidosis, pancreatitis, and peripheral neuropathy. The duration of treatment was found to be the predictor for the development of lactic acidosis, pancreatitis, and peripheral neuropathy in this study sample. More frequent and closer monitoring of the reported adverse events will be necessary for patients treated longer on ART. Information bias is possible as case data for all reported adverse effects were collected retrospectively from hand-written patient records which were not consistent and standardised.

Magister Public Health - MPH
Background:HIV is a worldwide pandemic with an estimated 2.5 million children under the age of 15 living with HIV in the world in 2009. Children account for approximately 14% of all HIV-related deaths around the world. Several studies have shown that the use of antiretroviral drugs greatly improve the lives of HIV-1 infected individuals, however, most of these studies report on outcomes of ART programmes in developed world and for adult patients. Very few settings have published outcomes of paediatric ART programmes.Objectives This research was aimed at describing the long term (at least one year) treatment outcome of HIV-1 infected children in the HIV/AIDS Prevention Group (HAPG) program in Bela-Bela in the Limpopo province of South Africa.Study design and methods: A quantitative approach involving a retrospective cohort design was used for the study. The study included all children under the age of 15 that were enrolled in the HATG treatment programme in Bela-Bela between February 2004 and December2009.Immunological, virological, clinical outcomes and loss to follow-up were determined for this cohort. Mortality and survival was also determined. Results: The median age of children in this study was 5 years (IQR: 2-7) with 14% (10/71) of them being less than 18 months. Median CD4 count at commencement of ART, viral load and weight were 358 cells/mm3 (IQR 203.5-, 125673 RNA copies/μL (IQR 58094-328424.5) and 14.5Kg (IQR: 11.0-18.35) respectively. CD4 counts and weight showed increase within the study period, and there was also a decline in viral load. Loss to follow-up was 7.04% while mortality was 19% with 21.43% of mortality cases being children who were ≤18months. Mortality occurred within the first year of ART initiation and occurred in cases that had advanced disease.Conclusion: This study shows that the ART program in Bela-Bela has a positive outcome on HIV positive children.The high mortality rate was due to children starting ART at an advanced disease stage. Despite the good outcome, it is recommended that a system be put into place that will aid in identifying children at an early stage of the disease and treatment initiated promptly.

Thesis (MSc)--Stellenbosch University, 2012.
Background: While Selection of reverse transcriptase (RT) mutation has been reported frequently, protease (PR) mutations on antiretroviral therapy (ART) including boosted Protease inhibitor (PI) have not been reported as much in Zambia. Affordable in-house genotyping assays can been used to expand the number of patients receiving drug resistance geno-typing, which can aid in determining prevalence of RT/PI emerging mutations. Methods: A previously published drug resistance genotyping assay was modified and used to genotype RT and PR genes. 19 patients virologically failing first-line regimen and 24 failing second-line regimen were studied to determine resistance patterns. Virological failure was defined as failing to maintain <1000 copies/mL during ART. Only major and minor RT and PR mutations (IAS-USA 2010) were considered for analysis. The in-house assay was validated by comparing sequence data of 7 previously ViroSeq tested samples and 5 randomly selected samples to determine reproducibility. Results: The in-house assay efficiently amplified all 12 validation samples with the lowest sample scoring 99.4% sequence homology. The most common RT mutation was M184V (79% n=19) and (71% n=24) first and second-line respectively. No significant differences were reported in all the other RT mutations between first-line and secondline regimens. Drug resistant PI mutations (I54V, M46I and V82A all present 20.8%) were only found in the second-line regimen and were insignificant, p= 0.0562. Conclusion: The in-house assays can be used as alternatives for commercial kits to genotype HIV-1C in Zambia without compromising test quality. The insignificant PI drug resistant mutations which were found, despite virological failure in patients, could indicate a possibility of other mutations within the HIV-1 genome that could reduce PI susceptibility.

Background: According to the United Nations AIDS Reference Group (2010) and World Health Organization (2010:2), approximately 33 million people in the world had HIV/AIDS in 2009 of which 2.6 million were children. More than 30 million of these individuals resided in low– and middle–income countries. South–Africa had the highest prevalence of HIV/AIDS in the world with an estimated 5.2 million patients in 2009 (Statistics South Africa, 2010:2). Although the prevalence of human immunodeficiency virus (HIV) infection among children is reported to be high, little is known about other medication administrated concomitantly with their antiretroviral drugs. Objective: The general objective of this study was to investigate possible changes in the medicine prescribing patterns of HIV/AIDS and non–HIV/AIDS children. Methods: A quantitative, retrospective drug utilisation review was performed utilising medicine claims data of a South African pharmacy benefit management company. Data for a four–year period (Jan 1, 2005 to Dec 31, 2008) were analysed. The study population consisted of all children <=12 years divided into those receiving ARVs (designated HIV positive) and those without (designated HIV negative). Descriptive statistics such as average mean, standard deviation, t–test, d–values, and two way frequency tables were used to describe the results. Data were analysed using the Statistical Analysis System ® SAS 9.1 ® programme. Results: The study population (children <= 12 years) represented 16.2% (n = 197 323) of the total population in 2005, 15.4% (n = 193 346) in 2006, 15.6% (n = 142 049) in 2007 and 13.3% (n = 98 939) in 2008. Children with HIV/AIDS represented 0.2% (n = 197 323) of the study population in 2005 and increased to 0.4% (n = 98 939) in 2008, whereas the percentage of children without HIV/AIDS decreased from 99.8% (n = 197 323) in 2005 to 99.6% (n = 98 939) in 2008. The total number of HIV/AIDS children that also received other medication concomitantly with their ARVs increased from 96.5% (n = 402) in 2005 to 97.2% (n = 427) in 2008. Males with HIV/AIDS who used other medication represented 52.6% (n = 388) in 2005 and increased to 53.3% in 2008 while female HIV/AIDS patients represented 47.4% in 2005 and decreased to 46.7% in 2008. Prescriptions containing three ARV items represented 69.5% (n = 2 969) of the total number of prescriptions received by HIV/AIDS patients in 2005 and decreased to 67.7% in 2008. The combination of lamivudine, nevirapine and stavudine were the three products that appeared most frequently on prescriptions for HIV/AIDS children in the age group 0 <= 1 years and 1 <= 5 years from 2005 to 2008. In the age group 5 <= 12 years the combination most frequently prescribed was lamivudine, nevirapine and zidovudine. HIV positive children received 6.2 ± 4.62 prescriptions for other medication (non–ARVs) per year during 2005 compared to HIV negative children with 3.9 ± 3.71 (p < 0.0001, d = 0.5). In 2008 HIV positive children received 6.4 ± 5.02 prescriptions per year compared to HIV negative patients who received 4.36 ± 4.05 prescriptions (p < 0.0001, d = 0.5) in 2008. HIV negative children received more central nervous system items, endocrine items and autacoids than HIV positive children, whereas HIV positive children received more respiratory system agents, dermatological, ear, nose throat and antimicrobials items. Conclusion: The study showed that HIV positive children received significantly more prescriptions for other medication per year compared to their HIV negative counterparts. The top pharmacological groups mostly prescribed to both groups were respiratory agents, antimicrobials, analgesics, dermatological and ear, nose and throat items.
Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2012.

Antiretroviral drugs are successful in controlling HIV/AIDS and reducing disease progression. Antiretroviral regimens are stopped in up to 25% of all patients during their initial treatment therapy as a result of adverse drug effects, failing treatment and nonadherence within the initial eight months of treatment (Sharma et al., 2007: 235). A pharmacovigilance surveillance system makes it possible for physicians, pharmacists and other healthcare providers to report suspected ADRs. The purpose of this system is to operate as a guide in identification of new ADRs and predisposing risk factors to known ADRs. The objective of this study was to assess the prevalence and documentation of adverse drug reactions (ADR) in the private and public antiretroviral clinics in Maseru district, with special reference to zidovudine (AZT) and tenofovir (TDF) - based regimens. The empirical investigation was divided into two phases. The first phase was a cross-sectional quantitative retrospective drug utilisation review study which focused on the occurrence of adverse drug reactions in patients taking zidovudine (AZT) and tenofovir (TDF). The second phase, a survey in a form of questionnaires for the health professionals. Drug utilisation review: The sample size of patients was 300. Of the 44 patients who experience ADRs, 72.73% (n = 32) were female and 27.27% (n = 12) were male. A greater number of patients who experienced ADRs were females with 43.18% (n = 19) presenting with skin rash, 27.27% (n = 12) with nausea/vomiting, and 2.27% (n = 1) with diarrhoea. In male patients, 2.27% (n = 1) had peripheral neuropathy, 18.18% (n = 8) skin rash, 2.27% (n = 1) Fanconi syndrome, 2.27% (n = 1) nausea/vomiting, and 2.27% (n = 1) diarrhoea. Patients whose ART regimen changed due to ADRs were five. 60% (n = 3) of the patients were females and 40% (n = 2) were males. There was an estimated increase of 0.0025 cell/mm³, 0.0026 cell/mm³, 0.0024 cell/mm³, 0.0025 cell/mm³, and of 0.0019 cell/mm³ in CD4 cell count per day according to sex, age group, weight group, initial ART regimen, and ADRs, respectively. An estimated increase of 0.00021 g/dL, 0.00022 g/dL, 0.00018 g/dL, 0.00022 g/dL, and of 0.00020 g/dL in Hb profile per day occurred according to sex, age group, weight group, initial ART regimen, and ADRs, respectively. There was an estimated increase of 0.000062%, 0.000046%, 0.000068%, 0.000062%, and of 0.00017% in neutrophil count according to sex, age group, weight group, initial ART regimen, and ADRs per day, respectively. There was an estimated increase of 0.000044 IU/L, 0.000043 IU/L, 0.000046 IU/L, and of 0.000028 IU/L in ALT according to sex, age group, weight group, and initial ART regimen per day, respectively. An estimated decrease of 0.000013 IU/L in ALT according to ADRs per day also occurred. There was an estimated decrease of 0.00038 μmol/L, 0.00039 μmol/L, 0.00040 μmol/L, 0.00040 μmol/L, and of 0.00028 μmol/L in serum creatinine per day according to sex, age group, weight group, initial ART regimen, and ADRs, respectively. There was an estimated decline of 0.00023 mmol/L, 0.00022 mmol/L, 0.00023 mmol/L, 0.00024 mmol/L, and of 0.00015 mmol/L per day in urea according to sex, age group, weight group, initial ART regimen, and ADRs, respectively. Health professional’s questionnaire: 49 health professionals responded to the questionnaire. 100% (n= 49) of the participants showed that they did not use the yellow card scheme to report ADRs. 34.65% (n = 17) use the individual case safety reports. 57.14% (n = 28) used the structured databases to report ADRs. 85.71% (n = 42) documented in the patient bukana, and 6.12% (n = 3) used the HIV/AIDS ART card to document ADRs occurrence. 91.84% (n = 45) of the health professionals never filled the ADR reporting form in their working environment. In conclusion, adverse drug reactions occurring in a hospital or healthcare facility should be recorded and reported by the medical practitioners, nurses, pharmacists, and the pharmacy technicians. Therefore, it is important to assess the continuous evaluation of the benefits and harm of medicines which will help in achieving the ultimate goal of making safer and more effective treatment available for patients. As well as to help the health professionals to participate in the very important process of continuous surveillance of safety and efficacy of pharmaceutical products used in clinical practice.
MPham (Pharmacy Practice), North-West University, Potchefstroom Campus, 2014

The purpose of this study was to assess the impact of virologic monitoring frequencies on treatment failure, adherence to therapy, and the emergence of drug resistance in HIV-1 infected patients. A quantitative, meta-analysis was conducted to investigate the virologic outcomes of infrequent and frequent Viral Load (VL) testing among patient on combination antiretroviral therapy (cART). Data was collected through a self-designed data collection form. Two comparison groups emerged being guided by the VL monitoring frequency. In group I, the health outcomes were compared for (≥3 VLs per year) versus (≤2 VLs per year) and (2 VLs per year) versus (≤1 VLs per year) for group II. Data were analysed using the Cochrane's statistical software, RevMan v5.3. The findings support (2 VLs per year) as the optimal VL monitoring strategy for stable and virologically suppressed patients and there is nothing to be gained by (≥3 VLs per year).
Health Studies
M.P.H.

This non-experimental, retrospective, descriptive and correlational study investigated adherence to antiretroviral drugs among HIV positive patients at Mpilo Central Hospital in Bulawayo Zimbabwe. Data among 118 patients was extracted from clinic registers and patient facility held medical records to determine level of adherence to ART using pharmacy refills (a non-immunological adherence parameter) and compared to CD4 cell count ( an immunological adherence parameter). Adherence levels obtained in this study using pharmacy refills was low (62.7%) and a relatively high non-adherence level of 37.3%. The pharmacy refill adherence level obtained was comparable to CD4 cell count adherence level of 64.6% (as indicated by a 50% CD4 cell count gain). These findings would seem to indicate the need for more education on the importance of adherence and further the need for better adherence monitoring systems
Health Studies
M.A. (Public Health)

Stavudine (d4T), a nucleoside reverse transcriptase inhibitor (NRTI) used to treat infection by the human immunodeficiency virus (HIV), is associated with the development of peripheral neuropathy and pain in HIV-positive patients. The mechanisms of this toxic neuropathy are poorly understood, primarily due to a lack of relevant animal models of the neuropathological process initiated by d4T. I investigated whether daily oral or subcutaneous administration of d4T produces neuropathological changes. Compared to previous descriptions of mechanical hypersensitivity induced by daily oral administration of d4T to rats at a dose of 50 mg.kg-1over a four week period, I found that this dosing regimen did not result in hyperalgesia to blunt and punctuate mechanical stimuli applied to the gastrocnemeus muscle. In agreement with the lack of hyperalgesia, oral administration of d4T at 50 mg.kg-1 over a four week period did not induce significant myelinated nerve fibre loss or morphological changes in the sciatic nerve. I then investigated whether administering 100 mg.kg-1 d4T subcutaneously, and therefore avoiding first-pass metabolism, to rats for four weeks causes hyperalgesia and neuropathological changes in nerve morphology. Daily subcutaneous injections of d4T at 100 mg.kg-1 over a four week period did not induce the development of hyperalgesia to a punctate mechanical stimulus applied to the tail or significant neuropathology. My studies demonstrate that multiple administrations of d4T at 50 mg.kg-1 orally or 100 mg.kg-1 subcutaneously over a four week period do not induce hyperalgesia or nerve fibre pathology in rats. Thus, developing a robust animal model of d4T-induced neuropathy may be challenging in the absence of HIV-infection, such that occurs in infected patients. Key words: HIV, ART, d4T, hypernociception

A Thesis submitted to the Faculty of Health Sciences (Internal Medicine), University of the Witwatersrand, in fulfillment of the requirements for the degree of Doctor of Philosophy. Johannesburg, 2017
South Africa has the largest ARV treatment programme in the world, wherein highly active antiretroviral treatment (HAART) has improved the health related quality of life (HRQoL) in HIV/AIDS patients. On the contrary, cancers not previously associated with HIV/AIDS (non-Aids defining cancers; NADCs) have been shown to be increasing, compared to the AIDS defining cancers (ADCs). Lung cancer, as a NADC has been documented in the HIV/AIDS population as a leading malignancy. The poor understanding of the association between ARV drugs and lung cancer places a burden on public health, both globally and in South Africa (SA). Furthermore, the deregulation of the cell-cycle is one of the hallmarks of cancer, including lung cancer. The main aim of this study was to elucidate the effects of HAART components Efavirenz (EFV) and Lopinavir/ritonavir (LPV/r) on cell-cycle related genes in an in vitro lung cancer model. To achieve this, cellular based, molecular and Bio-Informatics approaches were employed. First, the cytotoxic effects of EFV (at 4, 13, 26, 50 μM) and LPV/r (at 10, 32, 50, 80 μM), for 24h, 48h and 72h on normal lung fibroblasts (MRC-5) and lung adenocarcinoma (A549) cells, were evaluated using the Alamar Blue (AB) assay. This was then followed by cell-impedance “xCELLigence” real-time cell analysis (RTCA) assay. This was done to determine the effects of EFV (at 4, 13, 50 μM) and LPV/r (at 10, 32, 80 μM) on cell viability, cell death and proliferation. Cell-cycle analysis using propidium iodide (PI) by Fluorescence-activated cell sorting (FACS) was done to quantify DNA present at each of the cell-cycle stages of the cell-cycle in response to ARV treatment. Subsequently, an apoptosis assay using Annexin V FITC and Propidium iodide (PI) dual staining by FACS was carried out to confirm and quantify the ARVs potential apoptotic effects. Then, 4′,6-diamidino-2-phenylindole (DAPI) staining was used to assess changes in nuclear morphology exerted by the ARVs’ effects. A more in depth interrogation of the cell-cycle was performed using a focussed gene array panel of some 84 human cell-cycle related genes. First, total RNA was isolated from both treated and untreated MRC-5 and A549 cells and reverse transcribed to cDNA for use as template in the PCR array reactions. From the array gene expression results, by convention a ±2 fold up-or-down-regulation was used as the basis of target selection. Following this, a real-time quantitative PCR (RT-qPCR) validation of selected genes of interest was done to quantify and confirm the PCR array results. This was followed by in-silico Bio-informatics analysis to map the molecular pathways regulated by the identified targets. For this purpose, STRING, Database for Annotation, Visualization and Integrated Discovery (DAVID), Reactome and Ingenuity Pathway Analysis (IPA) databases were used. Interestingly, double-edged oncogenic properties of both EFV and LPV/r at different concentrations were identified. The proliferative effects of EFV at 4, 13μM and LPV/r at10 μM, were elucidated, while 26, 50μM of EFV, and 32μM of LPV/r had slight inhibitory effects on cell proliferation. LPV/r at concentrations of 50 and 80μM exerted cytotoxic effects on the cells, as demonstrated by the AB and xCELLigence RTCA assays. Cell-cycle analysis using PI staining, particularly showed cell-cycle arrest at 32μM LPV/r, and a shift to G2/M by 13μM EFV, plasma relevant doses, compared to the untreated cells. An increasing apoptosis percentage was observed with increasing LPV/r concentrations, that is, 80μM LPV/r raised the apoptosis percentage almost two-fold compared to 32μM. This was coupled by necrosis, observed in a time-dependant manner. DAPI staining confirmed loss of nuclear integrity post ARV exposure, suggesting that both EFV and LPV/r impose damage to the genomic DNA. To further assess the observed changes in nuclear morphology, the effects of EFV and LPV/r on the expression of an arrayed panel of human cell-cycle genes in cancer and normal lung cells was determined. Significantly differentially expressed targets were identified and further quantified and confirmed by RT-qPCR. Such targets included ATM, p53, cyclin-dependant kinase inhibitors (CDKIs), such as, p21, aurora kinase B (AURKB), Mitotic Arrest Deficient-Like 2 (MAD2L2) and the apoptosis related gene, caspase 3 (CASP3). Bio-Informatics analyses revealed close and direct protein-protein interactions (PPIs) between these targets, notably, with change in interaction between the gene products involved in DNA repair mechanisms, observed between ARV treated and untreated groups, as illustrated by STRING interactions. DAVID, Reactome and IPA analysis showed changes in expression of genes related to stress and toxicity and DNA damage response genes. In particular, ATM, p53 and its downstream targets such as GADD45A (growth arrest and DNA damage inducible alpha) gene were up-regulated by ARV treatment, while cyclin/CDK activity was down-regulated, resulting in reduced cell proliferation. Thus in summary, both EFV and LPV/r altered the expression levels of cell-cycle related genes, influencing overall cellular health, acting to either inhibit or stimulate cell proliferation. This suggests EFV’s and LPV/r’s proliferative and inhibitory roles in the proliferation of lung cells. Moreover, future directions can include the transfection of lung cells with HIV provirus followed by treatment of the cells with the same ARVs under study. This could be substantiated by including HIV positive patient samples on and off ARV drug treatment with lung cancer, including HIV negative patients with cancer as one of the controls.
MT2018

A dissertation submitted to the Faculty of Science, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Genetics. Johannesburg, South Africa 2017
Background: Stavudine (d4T) use is associated with the development of sensory neuropathy (SN), several mechanisms may underlie d4T-induced toxicity, including: (1) Inter-patient genetic variability in the genes modulating the deoxynucleotide triphosphate (dNTP) pool sizes. (2) Variation in intracellular ARV drug concentrations due to genetic variation in drug transporters. In our study we examined the genetic variation in four stavudine transporter genes and seven genes regulating the deoxythymidine triphosphate (dTTP) synthesis and their associations with d4T-induced SN or CD4+ T cell count or mtDNA copy number. Methods: We examined a cohort of HIV-positive South African (SA) adults exposed to d4T, including 143 cases with SN and 120 controls without SN. 26 single nucleotide polymorphisms (SNPs) from the literature were chosen, prioritised on being tagSNPs with minor allele frequency >5% in Kenyan Luhya (a proxy population for the SA Black population); SNP functional effects and suitability for multiplex analysis on the genotyping platform. Genotyping was performed using Sequenom mass spectrometry. A qPCR assay was used to measure the mtDNA copy number. Association of sensory neuropathy, CD4+ T cell count and mtDNA copy number with genetic variants was evaluated using PLINK. Results: All 26 SNPs were in Hardy-Weinberg equilibrium (HWE) in both the cases and controls. SNP rs8187758 of the SLC28A1 transporter gene and a 3-SNP haplotype ABCG2 were significantly associated with CD4+ T cell count after correction for multiple testing (p = 0.043 and p=0.042 respectively), but were not significant in multivariate testing. No SNP remained significantly associated with SN or mtDNA copy number, after correction for multiple testing. Conclusion: Variation in genes encoding molecular transporters of d4T may influence CD4+ T cell counts after ART. This study presents a positive step towards achieving personalized medicine in SA.
MT 2018

The role of therapeutic drug monitoring in pediatric antiretroviral therapy is unclear. A little pharmacokinetic datum from clinical practice exists beyond controlled approval studies including clinically stable children. The aim of this study is to quantify LPV exposure of critically ill infants in an ICU and-by identifying risk factors for inadequate exposure-to define sensible indications for TDM in pediatric HIV care; in addition, assume total drug adherence in ICU to compare LPV exposure with a setting of unknown adherence. In this prospective investigation, 15 blood samples from critically ill infants in the pediatric ICU at Tygerberg Hospital were analyzed for LPV-serum concentrations. They were then compared to those of 22 blood samples from out-patient children. Serum-level measurements were performed with an established high-performance liquid chromatography method. All LPV-serum levels of ICU patients were higher than a recommended Ctrough (= 1.000 ng/ml), 60% of levels were higher than Cmax (8.200 ng/ml). Partly, serum levels reached were extremely high (Maximum: 28.778 ng/ml). Low bodyweight and age correlated significantly with high LPV concentrations and were risk factors for serum levels higher than Cmax. Significantly fewer serum levels from infants in ICU care (mean: 11.552 ng/ml ± SD 7760 ng/ml) than from out-patient children (mean: 6.756 ng/ml ± SD 6.003 ng/ml) were subtherapeutic (0 vs. 28%, p = 0.008). Under total adherence in the ICU group, there were no subtherapeutic serum levels, while, in out-patient, children with unknown adherence 28% of serum levels were found subtherapeutic. Low bodyweight and age are risk factors for reaching potentially toxic LPV levels in this extremely fragile population. TDM can be a reasonable tool to secure sufficient and safe drug exposure in pediatric cART
Die Rolle des Therapeutischen Drug Monitorings (TDM) in der antiretroviralen Therapie bei Kindern ist unklar. Es existieren nur wenige pharmakokinetische Daten - insbesondere von kleinen Kindern – abseits der kontrollierter Zulassungsstudien an klinisch stabilen Patienten. Es ist das Ziel dieser Untersuchung, die Lopinavir-Exposition kritisch kranker Säuglinge auf einer pädiatrischen Intensivstation zu quantifizieren und durch die Identifikation von Risikofaktoren für inadäquate Exposition sinnvolle Indikation für einen Einsatz von TDM in der pädiatrischen HIV-Versorgung zu definieren. Des Weiteren verglichen wir unter Annahme totaler Adhärenz auf die Lopinavir-Exposition auf einer Intensivstation mit der einer ambulanten Versorgungsstruktur. In dieser prospektiven Studie untersuchten wir 15 Serum Proben kritisch kranker Säuglinge auf der pädiatrischen Intensivstation des Tygerberg Hospitals im Hinblick auf LPV-Serumkonzentrationen. Sie wurden verglichen mit 22 Konzentrationen von ambulant betreuten Kindern. Die Messungen wurden mit einer etablierten HPLC-Methode durchgeführt. Alle LPV-Konzentrationen der Intensiv-Patienten waren höher als die empfohlene Talspiegel (Ctrough = 1.000 ng/ml), 60% waren höher als Cmax (8.200 ng/ml). Es wurden zum Teil extrem hohe Konzentrationen erreicht (Max. 28.778 ng/ml). Ein geringes Körpergewicht und Alter korrelierten signifikant mit hohen LPV-Konzentrationen und waren Risikofaktoren für Spiegel, die über Cmax lagen. Signifikant weniger Konzentrationen von Intensivpatienten (MW: 11.552 ng/ml ± SD 7760 ng/ml) waren subtherapeutisch als von ambulant betreuten Kindern (mean: 6.756 ng/ml ± SD 6.003 ng/ml) (0 vs. 28%, p = 0.008). Unter totaler Adhärenz in der Intensiv-Gruppe waren keine subtherapeutischen Konzentrationen festzustellen, während 28% der ambulant betreuten Kinder subtherapeutischen Spiegel aufwiesen. Ein geringes Körpergewicht und Alter sind Risikofaktoren für das Erreichen potenziell toxischer Konzentrationen von Lopinavir in dieser extrem fragilen Population. TDM kann helfen LPV-Toxizität von anderen klinischen Erscheinungen zu differenzieren. TDM kann ein sinnvolles Hilfsmittel sein, um eine sichere und effektive antiretrovirale Therapie bei Kindern zu garantieren

The purpose of the study was to evaluate the IMB skills model for its relevance to the Ethiopian context. According to the model, adherence-related information and motivation work through adherence-related behavioural skills to affect adherence to ART. Quantitative, analytical, observational, cross-sectional, institution-based study was conducted to evaluate the model by assessing those patients who have and do not have the right information, motivation, and behavioural skills whether they have or do not have good adherence to ART. Data was collected using structured questionnaires where a total of 400 randomly selected participants provided data on adherence-related information, motivation and behavioral skills as well as adherence behavior per se. Data was analysed using the Statistical Package for Social Sciences (SPSS) version 20.0. Both descriptive and inferential statistics used in the study. Only 90.75 % of the total sample population reported ART adherence rate of more than or equal to 95% in this study. Free and restricted model tests, through bivariate and multivariate analyses, used to assess the propositions of the IMB model of ART adherence and provided support for the interrelations between the elements proposed by the model. The study has supported the applicability of the IMB model of adherence to the Ethiopian context highlighting its application in adherence-promotion intervention efforts. The findings revealed the need for on-going educational, informational and other interventions to address the knowledge, motivation and adherence behavioural skills of patients in order to improve the current levels of ART adherence behaviour.
Health Studies
D. Litt. et. Phil. (Health Studies)

Purpose: The purpose of this study is to assess risk factors associated with TB co-infection in HIV/AIDS patients taking antiretroviral therapy (ART). Methodology: An observational, analytic, case-control and quantitative study was conducted on a randomly selected 367 HIV and AIDS patients of whom 92 of them were TB co-infected. Data collection was done by using self-structured questionnaire. Result: In this study, educational status, waste disposal system, monthly income, contact history with a patient of active tuberculosis or presence of a family member with active tuberculosis, drug adherence, knowledge on tuberculosis prevention and history of exposure to substance were factors independently associated with the occurrence of active tuberculosis among HIV and Aids patients taking ART. Conclusion: The findings highlight the need for on-going educational, informational and other interventions to address the risk factors of tuberculosis in HIV and Aids patients in order to decrease the rate of TB co-infection
Health Studies
M.A. Public Health

Health communication is a vital part of health care and treatment. For patients living with HIV, effective health communication is crucial. This study aimed at describing health communication from the perspective of HIV-positive patients by uncovering their experiences as they interacted with various medical staff members at Stanger Hospital. Guided by a review of various health communication models, data were collected via individual interviews and non-participant observation. The findings showed that interactive communication was favoured by all the respondents, especially communication that was patient-centred. Such communication encompassed education on how to live and cope with HIV. Obstacles to effective communication such as power differentials, lack of time and privacy at public health care clinics were identified. The study found that the different medical staff members at the clinic to various degrees addressed distinctive communication needs of HIV-positive patients. This study contributed to effectively understating the communication process as a whole.
Sociology
M.A. (Social Behaviour Studies in HIV/AIDS)

This study attempted to identify personal (patient-related) factors influencing anti-retroviral therapy (ART) adherence in Addis Ababa, Ethiopia. A quantitative, descriptive, cross-sectional and analytical design was used. Structured interviews were conducted with 355 ART patients. The findings revealed that stigma, discrimination, depression and alcohol use negatively affected patients’ ART adherence levels. However, patients’ knowledge levels had no influence on their ART adherence levels, contrary to other researchers’ reports. Addressing stigma and discrimination at community levels might enhance patients’ abilities to take their medications in the presence of others. Healthcare professionals should be enabled to diagnose and treat depression among ART patients during the early stages. Non-adherent ART patients should be counseled about possible alcohol abuse.
Health Studies
M.A. (Public Health with specialisation in Medical Informatics)