Academic literature on the topic 'Highly active antiretroviral therapy – Tuberculosis – Botswana'

Thesis (MPH)--University of Limpopo, 2013.<br>Statistics from Pigg’s Peak Hospital, in Swaziland, continue to show an improvement in the uptake of HIV testing among TB patients, as well as a very high rate of HIV co-infection among the TB patients. The unit’s reports also show a low uptake of antiretroviral therapy among the HIV co-infected TB patients, and high death rates. Most of these deaths occur among HIV co-infected TB patients who have not yet initiated ART despite being on TB treatment. Anecdotal evidence suggests that there is reluctance and refusal by a considerable proportion of TB/HIV co-infected patients to take TB treatment and ART concurrently, and that they prefer to commence ART after completing TB treatment. No study has ever been conducted in Swaziland to determine the reasons for refusal of ART initiation prior to the completion of TB treatment among HIV co-infected TB patients. Aim The aim of this study was to explore the reasons for refusing antiretroviral therapy among HIV co-infected tuberculosis patients, prior to the completion of tuberculosis treatment, at Pigg’s Peak Hospital, in Swaziland. Methods A qualitative descriptive study was conducted in order to generate information on the subjects’ experiences and views on the concurrent taking of tuberculosis and antiretroviral medicines. A sample of nineteen HIV co-infected TB patients was purposefully selected to answer the research question. Results The most common reasons given by the respondents for refusing ART initiation during TB therapy were their un-readiness for ART, especially because ART must be taken for life, the perception that one was still in good health, the fear of adverse outcomes being precipitated by combining ART with TB medicines, a preference of traditional medicines, and health systems-related problems. Other reasons were: a lack of food, substance abuse, a fear of the increased pill burden, a denial of the HIV-positive status, and problems related to treatment supporters. Conclusion In TB/HIV co-infection care settings, comprehensive Pre-ART counseling must be integrated with interventions that address the specific barriers to ART initiation faced by clients; to improve the acceptability of ART initiation during TB therapy to these HIV/TB co-infected patients.

The emergence of the Human Immuno-Deficiency Virus (HIV) and Acquired Immuno-Deficiency Syndrome (AIDS) has resulted in many children being perinatally-infected. Some die before reaching adolescence, while others survived into adolescence due to the introduction of Highly Active Antiretroviral Therapy (HAART). Amongst countries of sub-Saharan Africa, Botswana has the highest estimated prevalence rate of HIV and AIDS which is 18.5% of a total population of 2 038 228. In 2002, Botswana became the first country in sub-Saharan Africa to launch a free national HAART programme in the public health sector. The country has achieved more than a 96% coverage rate of HAART. Despite availability of HAART, adolescence is a complex developmental phase marked with psychological, behavioural, physiological and cognitive changes. Hence, the goal of the study has been to identify barriers to HAART adherence amongst HIV-infected adolescents in a government hospital, in Botswana. A qualitative research approach and a phenomenological research design have been utilised to explore and describe factors that inhibit HIV-infected adolescents from adhering appropriately to HAART. The study participants are twelve HIV-infected adolescents (males and females) aged 13 to 17 years who receive HAART from a government hospital in Botswana. Simple random sampling had been used to select these study participants. Unstructured, one-on-one interviews had been conducted utilising an interview schedule and the data that had been collected from the interviews has been transcribed and thematically analysed using Tesch s framework. A bio-ecological perspective has been applied to enhance understanding of this phenomenon. The following themes emerged from the study: knowledge about HIV and AIDS and the importance of HAART adherence, contextualising and conceptualising HAART adherence amongst adolescents, factors contributing towards non-adherence to HAART amongst HIV-infected adolescents, coping strategies and recommendations. The study findings reveal that participants displayed adequate knowledge regarding HIV and AIDS, its transmission, prevention and treatment. However, participants showed inadequate knowledge regarding the myths of HIV and AIDS. The study findings reveal further that participants are knowledgeable of the benefits of HAART adherence, methods that are being utilised to assess adherence and consequences of non-adherence. Hospital, school, home, radio, television, pamphlets, teen club and church are the major sources of information for the knowledge displayed. The results of the study show that a significant number of participants started treatment at a younger age and have been on treatment for lengthier periods. The main barriers to HAART adherence are individually-related factors, regimen or medication side effects, social stigma from school and community, and lengthy waiting times in the health facility during medication refills. However, disclosure of HIV positive status, support from family, teen club or peers, hospital, school, church and various individual strategies were utilised as coping mechanisms. Moreover, majority of the participants were adamant that continuous education on the importance of HAART adherence by healthcare workers and caregivers is essential. They also added that medication supervision is a key strategy in enhancing adherence amongst non-adherent HIV-infected adolescents. Recommendations include the imperativeness of a multi-sectoral approach towards strengthening education on HIV and AIDS, including the importance of HAART adherence, as well as addressing stigma and discrimination surrounding HIV and AIDS. Last of all, future research should include caregivers and healthcare workers particularly, in studies of this nature to strengthen the findings. It should also consider the effectiveness of initiatives that have been outlined to promote HAART adherence.<br>Mini Dissertation (MSW)--University of Pretoria, 2015.<br>Social Work and Criminology<br>MSW<br>Unrestricted

Thematic Paper (M.C.T.M. (Clinical Tropical Medicine))--Mahidol University, 2007.<br>LICL has E-Thesis 0024 ; please contact computer services. LIRV has E-Thesis 0024 ; please contact circulation services.

Magister Public Health - MPH<br>Background: The hallmark of HIV infection is immunosuppression which predisposes to unusual infections and malignancies generally known as opportunistic diseases (ODs). Globally, ODs are the major cause of morbidity and mortality in people living with HIV (PLHIV). Since the advent of Highly Active Antiretroviral Therapy (HAART), a significant decline in AIDS progression and ODs has been observed globally. However, most of the evidence suggesting sustained decline in AIDS progression and ODs has come from high-income settings with relatively less burden of ODs in the pre-HAART era. The findings of studies in high-income settings may not be generalizable to resource-limited settings. Lack of information regarding the burden of ODs in HAART-experienced populations in Nigeria and the risk factors for their occurrence has made it difficult to fully assess the sustained efficacy of HAART in the country. The aim of this study was to investigate the prevalence of and risk factors for HIV-related opportunistic diseases amongst HAART patients at the Federal Medical Centre (FMC) in Owerri, Nigeria. Study design and setting: A quantitative, cross-sectional descriptive and analytical study was conducted with 354 adult HIV-infected patients 15 years and above, who were on HAART for a minimum of 12 weeks at the HIV clinic of the FMC, Owerri, South-east Nigeria. Patients currently manifesting an OD whose onset ante-dated the commencement of HAART were excluded. The participants were recruited by simple random sampling. Data collection: Using a structured questionnaire, data was collected by clinicians through interviews, physical and laboratory examinations for patients that provided informed consent and met the study criteria. The questionnaire captured patient’s socio-demographic information and other relevant clinical/laboratory data. Data Analysis: The data was analysed using Epi info version 3.5.1 and Open Epi Version 2.2.1. Descriptive statistics for HIV-related ODs were carried out using percentages and frequencies tables for categorical variables and means (SD) or medians (IQR) for numerical variables. In univariate analysis, the Chi-square test was used to determine significance of association between OD and socio-demographic and clinical variables while the Student "t"-test was used to compare group means. Logistic regression model (multivariate analysis) was used to determine the independent risk factors for the occurrence of ODs using parameters that had a p-value of <0.25 on univariate analysis. All reported p-values <0.05 were considered statistically significant. Results: The mean age of the participants was 41.1 ± 10.0 years; and females were in the majority (65.8%). Over 40% of them were rural dwellers, 50.4% belonged to the lower socioeconomic class, and 55% had a monthly household income less than 20,000 Naira. Fifty percent (50%) of them had advanced immunosuppression at first presentation. The median duration of HAART (3 years) paralleled the median duration of HIV diagnosis (3.4 years) and HAART adherence rate was 78%. The overall prevalence of ODs was found to be 22.4%. Among the 76 patients diagnosed with ODs, the leading conditions were candidiasis (38.2%), TB (34.2%), dermatitis (25%), chronic diarrhoea (6.6%) and sepsis (6.6%). The independent risk factors for the occurrence of ODs were household income less than 20,000 Naira (Adjusted odds ratio [AOR] = 2.4, 95% CI 1.1-5.1), HIV duration of less than 3 years (AOR= 2.1, 95% CI 1.1- 4.2), advanced WHO clinical stage at baseline (AOR= 8.1, 95% CI 4.0-16.4), baseline haemoglobin less than 10 g/dl (AOR= 2.9, 95% CI 1.3-56.1), current CD4 cell count less than 200 cells/μl (AOR= 3.0, 95% CI 1.14-6.2), and HAART non-adherence (AOR= 5.4, 95% CI 2.6-11.2). Past history of TB was found to be a strong predictor of TB (AOR= 5.3, 95% CI 1.4-20.2). Conclusions: Opportunistic diseases are common in patients receiving HAART in Nigeria and candidiasis and TB remain the leading conditions. Late presentation and HAART non-adherence are among the strongest risk factors for ODs in patients receiving HAART. Others include duration of HIV diagnosis less than 3 years, presence of anaemia at the time of first presentation and having a low CD4 cell count while on HAART. Beyond these clinical risk factors, poverty increases the risk of developing an OD during HAART and may emerge a strong determinant of HIV-related ODs in developing countries. Recommendations: A high index of suspicion for ODs remains necessary in HAART patients. Health education on HIV screening and early presentation should be intensified. PLHIV who are anaemic before commencement of HAART, those with low CD4 cell count despite HAART use, and low-income earners should become target groups for a more aggressive evaluation for ODs. Prophylaxis for TB and fungal infections in the absence of active disease should be widely implemented in developing countries. HAART adherence should be intensified.

The purpose of the study was to describe factors contributing to mortality among HIVinfected people on Isoniazid Preventive Therapy (IPT) in Botswana. A quantitative, explorative, descriptive study was used and 80 records of deceased IPT respondents were reviewed through the use of a checklist. The demographic factors, baseline physical examination, hospitalisation and drug history were taken into consideration. Out of the deceased patients, 75% were female. The major findings showed that 100% (N=80), the most highly indicated causes of death were gastroenteritis (18.75%), cryptococcal meningitis (17.5%) andpneumonia (16.25%). Of the patients (28.75%) who died before completing the six months of IPT. The causes of death were gastroenteritis (21.7%), symptoms and signs of bacterial pneumonia (17.4%), cryptococcal meningitis (13%), Pulmonary Tuberculosis (PTB) (13%), septicaemia (13%), and murder (13%). It has been recommended that there should be reorganisation of services of care for HIV-infected persons, such as provision of Cotrimoxazole Prophylaxis Therapy (CPT) and Antiretroviral Therapy (ART) to ensure holistic approach care. The future study should include HIV-infected children on IPT using the same or modified objectives. The conclusion drawn was that disintegrated interventions of IPT, CPT and ART and lack of holistic care for PLHIV lead to opportunistic infections that caused mortality on patients on IPT.<br>Department of Health Studies<br>M.A. (Public Health)

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree Master of Family Medicine, October 2013<br>Botswana has one of the highest HIV prevalence rates in the world, with 32% of pregnant women and 24% of adults in the general population living with HIV. Although antiretroviral therapy (ART) or HIV/AIDS treatment is widely available in the public sector in Botswana, not all treatment-eligible patients utilise the services in a timely manner. The study aims to identify the factors associated with the intention of already screened HIV positive/AIDS patients, who met the government criteria, to enrol into the HIV treatment programme in Lobatse, Botswana. Methods: A Cross-sectional descriptive study was used, conducted at the Infectious Disease Control Clinic, Athlone Hospital, Lobatse over a 6-month period. A questionnaire was administered on systematically sampled participants, who met Botswana National antiretroviral treatment or HIV/AIDS treatment guidelines. Results: A total of 342 participants were enrolled, mostly female (67.3%) and single (50%). Majority of the participants were age 35-44 years (17%), attained up to primary level education (44%) and were mostly unemployed (54%). A majority (59%) intended to enroll into ART or HIV/AIDS treatment programme due to sickness, while others were motivated by voluntary testing and counseling (24%). The majority of the respondents received post-test counseling (97.3%) and most was motivated to seek ART or HIV/AIDS treatment (88.3%). Only (60%) disclosed their status to their relative. Although most participants (59.6%) were willing to be linked to care and support, most (65.1%) were ignorant of support groups and services available for them. Discussion: Although there is increasing access to ART or HIV/AIDS treatment, most participants still wait until they are sick or have symptoms before they enroll into ART. Supportive post-test counseling and conducive family environment were some of the enabling factors. Distance to health facilities and long queues are barriers to accessing care as well as stigma and discrimination. The most significant reasons for not continuing with the treatment were health facilities being far from place of residence and queuing for a long time to see a doctor and or collect medications. Conclusion: Sickness, public education, supportive family environment and effective post-test counseling were found to be significant motivators for intention to enroll into ART. Perceived barriers to accessing treatment include distance and time spent in the health facilities. Interventions are required to reduce stigma, bring health facilities nearer to the people, and increase efficiency in health facilities and increase access and utilization of the care and support groups.

M.P.H., Faculty of Health Sciences, University of the Witwatersrand, 2011<br>Background Few results are available concerning long-term clinical outcomes in ART treatment programs. The objective of this study was to describe clinical and laboratory outcomes for adult patients commenced on ART in Selebi Phikwe, Botswana from June 2004 to June 2005 within one year of commencement of ART. Methods Cross-sectional descriptive study of clinical and laboratory outcomes for 904 adult patients initiated on ART in Selebi Phikwe, Botswana, from June 2004 to June 2005. Data from ART services statistics was analyzed using descriptive statistical methods. Results Most patients had low a basal CD4 cellular count with a median count of 25 cells, which rose to 147 after 12 months of treatment. Of the 84 (9%) deaths, 75 (89%) had a basal CD4 count of less than 10 cells and 48 (57%) died within three months of commencing of ART Conclusion Good clinical and laboratory outcomes for patients on ART in resource limited are achievable. Mortality commonly occurs among patients with low CD4 counts and within three months of commencement of therapy.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Masters of Public Health in the field of Health Measurement 22nd February, 2012<br>Introduction: Barriers associated with good adherence to Antiretroviral Therapy (ART) among human immunodeficiency virus (HIV) infected adolescents are multiple and complex. Those barriers contribute to low adherence levels putting infected adolescents at risk of developing resistance and decreasing their survival time. Patients care givers psychosocial and demographic variables, medication related factors and health care delivering factors are among the barriers that correlate with non adherence to antiretroviral drugs (ART’s) among HIV infected adolescents. Those barriers vary across individuals within the same population of adolescents. This study was conducted to determine the level of adherence among HIV infected adolescents on ART and to identify barriers associated with non adherence among this population attending the Botswana Baylor Children’s Clinical Center of Excellence (COE) in Gaborone, Botswana. Materials and methods: A cross sectional analytical study using quantitative data was performed. A structured, self administrated questionnaire adapted from the AIDS Clinical Trials Group (ACTG) was used to identify the barriers while the socio-demographic and clinical data were retrieved from study participants’ medical records. The adherence level was estimated using the pharmacy pill count technique. The adolescents aged 13 to 18 years receiving ART for more than 6 months and attending the ART National Program at the time of the study and who did assent and had their care givers consent to participate in the study were included in the analysis. Results: A high adherence level (75.6%) was reported among the study participants. Besides gender, no other socio-demographic and clinical variables showed association with non adherence. Male adolescents were found to be 70% less likely to adhere to their medication than their counterpart females [p= 0.020, OR=0.30, 95% CI (0.10 – 0.85)]. Furthermore adolescents v who missed a dose because their pills were not collected from the pharmacy either by themselves or by their care givers were 77 % less likely to adhere to their ART medication than those who did not miss a dose because they had their medication collected [p= 0.019, OR= 0.23, 95%CI (0.064 – 0.837)]. Conclusion: A high proportion of HIV infected adolescents attending the Baylor Center of Excellence ART National Program were adherent to their medication. Despite the high level adherence to ART among this age group, interventions to improve adherence level should be designed with a focus on male adolescents and to reinforce counseling of care givers and adolescents about the hazards of poor adherence to treatment. Further research is however, needed to elucidate more about the two main barriers that were found to be significantly associated with non adherence among adolescents at Botswana Baylor Children’s Clinical Center of Excellence: male-gender and medication collection from the pharmacy.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment for the degree Masters of Medicine in Paediatrics (MMed) Johannesburg 2012<br>Introduction: Highly active antiretroviral treatment (HAART) programs in heavily HIV-TB burdened countries may reduce the risk of TB in children directly by improving the immune system of HIV-infected children; and indirectly by reducing the force of transmission from the adult population. The incidence of childhood TB is a sentinel measure of the control of infectious adult TB cases in the community. Objective: We evaluated the impact that scaling-up of the HAART program in Soweto had on the incidence of hospitalization for culture-confirmed TB in children. Methods: The study was undertaken in Soweto, where the prevalence of HIV was 4-5% in children between 2005 and 2009. The estimated HAART coverage increased from 43% in 2005 to 84% by 2009 in children with HIV/AIDS. Hospitalized cases of culture-confirmed TB in children 3 months to 14 years of age were identified through laboratory and clinical electronic databases. Results: Overall, the incidence (per 100 000) of hospitalization for culture-confirmed TB declined by 58% (95%CI 49.3-65.2) from 2005 (71.4) compared to 2008-9 (30.0); p<0.0001. This included a 67% (95%CI 58.5-74.8) reduction in incidence among HIV-infected children from 2005 (1 601) compared to 2008-9 (517; p<0.0001). v In addition, a 33% reduction was observed in HIV-uninfected children (incidence 19.3 vs 12.9; p=0.016). Fifty-six percent of TB episodes, across all study periods, occurred in HIV-infected children who were mainly (76%) severely immunocompromised. Conclusions: Up-scaling of the HAART program in South Africa has been associated with decline in the incidence of culture-confirmed TB, more so in HIV-infected than HIV-uninfected children. Severely immunocompromised HIV-infected children, however, need to be identified and targeted with HAART and other strategies to further reduce the burden of TB in this group.