Tesi sul tema "Hive Monitoring"

L'objectif de cette thèse est de développer des solutions de smart sensing à bas coût, permettant d'améliorer des capteurs peu onéreux grâce à des corrections logicielles. Plutôt que de concevoir des capteurs performants mais coûteux, cette approche vise à créer des capteurs low cost qui sont ensuite corrigés et optimisés via des algorithmes embarqués. Les architectures électroniques récentes offrent désormais une puissance de calcul suffisante pour effectuer ces corrections directement au plus proche de la mesure, edge computing, tout en conservant une consommation énergétique extrêmement faible rendant les systèmes sur batterie viables.Deux approches de correction logicielle sont explorées : une méthode basée sur un algorithme déterministe, et une seconde méthode s'appuyant sur l'intelligence artificielle. Après avoir conçu une architecture de collecte de données adaptée aux ruches d'abeilles, ces deux approches sont mises en œuvre. La première approche, déterministe, est utilisée pour corriger les données provenant des jauges de contrainte dans le cadre d'une balance à ruches. La seconde méthode est appliquée à des capteurs audio MEMS, afin d'extraire des métriques de santé des colonies d'abeilles grâce à des techniques de machine learning
The objective of this thesis is to develop low-cost smart sensing solutions, enhancing inexpensive sensors through software-based corrections. Rather than designing high-performance but expensive sensors, this approach aims to create low-cost sensors that are then corrected and optimized via embedded algorithms. Recent electronic architectures now offer sufficient computational power to perform these corrections directly at the measurement source, known as edge computing, while maintaining extremely low energy consumption, making battery-powered systems viable.Two software correction approaches are explored: a method based on a deterministic algorithm, and a second method relying on artificial intelligence. After designing a data collection architecture suited for beehives, both approaches are implemented. The first, deterministic approach is used to correct data from strain gauges in the context of a hive scale. The second method is applied to MEMS audio sensors, to extract bee colony health metrics using machine learning techniques

Uganda has registered more than a million deaths since the HIV virus was first offi¬cially reported in the country over 3 decades ago. The governments in partnership with different groups have implemented different programmes to address the epidemic. The support from different donors and reduction in prices of treatment resulted in the focus on antiretroviral therapy access to those affected. Presently only a quarter of the approximately 1 million infected by HIV in Uganda are undergoing antiretroviral therapy. The number of patients pause a challenge in monitoring of therapy given the overall resource needs for health care in the country. Furthermore the numbers on antiretroviral therapy are set to increase in addition to the stringent requirements in tracking and monitoring of each individual patient during therapy. This research aimed at developing a framework for adopting knowledge engineering in information systems for monitoring HIV/AIDS patients. An open source approach was adopted due to the resource constrained context of the study to ensure a cost effec¬tive and sustainable solution. The research was motivated by the inconclusive literature on open source dimensional models for data warehouses and data mining for monitor¬ing antiretroviral therapy. The first phase of the research involved a situational analysis of HIV in health care and different health care information systems in the country. An analysis of the strengths, weaknesses and opportunities of the health care system to adopt knowledge bases was done. It proposed a dimensional model for implementing a data warehouse focused on monitoring HIV patients. The second phase involved the development of a knowledge base inform of an open source data warehouse, its simulation and testing. The study involved interdisciplinary collaboration between different stakeholders in the research domain and adopted a participatory action research methodology. This involved identification of the most appropriate technologies to foster this collabora¬tion. Analysis was done of how stakeholders can take ownership of basic HIV health information system architecture as their expertise grow in managing the systems and make changes to reflect even better results out of system functionality. Data mining simulations was done on the data warehouse out of which two machine learning algorithms (regression and classification) were developed and tested using data from the data warehouse. The algorithms were used to predict patient viral load from CD4 count test figures and to classify cases of treatment failure with 83% accu¬racy. The research additionally presents an open source dimensional model for moni¬toring antiretroviral therapy and the status of information systems in health care. An architecture showing the integration of different knowledge engineering components in the study including the data warehouse, the data mining platform and user interac-tion is presented.

The benefits of immunologic and virologic monitoring for the management of HIV-positive individuals are well established. However, the optimal frequency with which CD4 cell count and HIV RNA should be monitored remains unknown. In this dissertation, we use observational data from two collaborations of prospective cohort studies from high-income countries to estimate the effect of CD4 cell count and HIV RNA monitoring strategies on clinical, virologic, and immunologic outcomes in virologically suppressed HIV-positive patients. In Chapter 1, we compare three CD4 cell count and HIV-RNA monitoring strategies applied to virologically suppressed individuals on combined antiretroviral therapy (cART) without AIDS: once every (i) 3±1 months, (ii) 6±1 months, and (iii) 9-12 ±1 months. We find that monitoring frequency can be decreased from every 3 months to every 6, 9, or 12 months in the short term with respect to clinical outcomes. In Chapter 2, we compare strategies corresponding to three CD4 cell count thresholds at which monitoring frequency is decreased from every 3-6 months to every 9-12 months: 200 cells/µl, 350 cells/µl, and 500 cells/µl. We find that decreasing monitoring from every 3-6 months to every 9-12 months while CD4 cell count>200 cells/µl does not worsen the short-term clinical and immunologic outcomes of HIV-positive, virologically suppressed individuals on cART without AIDS. Our estimates also suggest that decreasing monitoring frequency when CD4 cell count>200 cells/µl compared with when CD4 cell count>500 cells/µl may result in an increased risk of virologic failure at 24 months of follow-up. In Chapter 3, we compare joint monitoring and treatment switching strategies. The strategies expand on those described in Chapter 2 by including two HIV-RNA threshold at which individuals should switch to a new antiretroviral regimen: 200 copies/ml and 1,000 copies/ml. We find that the studied monitoring-switching strategies have little impact on the short-term clinical outcomes of HIV-positive individuals on cART. In summary, we illustrate an approach to compare monitoring strategies in HIV-positive individuals, and provide estimates of the comparative effectiveness of strategies used in clinical practice. Since effects of different monitoring strategies could take years to materialize, longer follow-up is needed to fully evaluate this question.

Disease surveillance is the continuous collection, analysis, and interpretation of health-related data. Information gained from routine HIV disease surveillance is vital to national program managers deciding to implement new prevention or treatment programs. In this dissertation, we describe methods for estimation of HIV incidence and the prevalence of HIV drug resistance.

HIV antiretroviral therapy spans several different drug classes, meant to combat various aspects of viral infection and replication. Many authors have argued the benefits of therapeutic drug monitoring (TDM) for the HIV patient including compliance assurance and assessment of appropriate drug concentrations; however, the array of drug chemistries and combinations makes TDM an arduous task. HPLC-UV and LC-MS/MS are both frequent instruments for the quantification of HIV drugs in biological matrices with investigators striving to balance sensitivity and affordability. Plasma, the dominant matrix for these analyses, is prepared using protein precipitation, liquid-liquid extraction or solid-phase extraction depending on the specific complement of analytes. Despite the range of polarities found in drug classes relevant to HIV therapeutics, most chromatographic separations utilize a hydrophobic column (C18 ). Additionally, as the clinically relevant samples for these assays are infected with HIV, along with possible co-infections, another important aspect of sample preparation concerns viral inactivation. Although not routine in clinical practice, many published analytical methods from the previous two decades have demonstrated the ability to conduct TDM in HIV patients receiving various medicinal combinations. This review summarizes the analytical methods relevant to TDM of HIV drugs, while highlighting respective challenges.

Includes bibliographical references (leaves 57-65).
This programme aims to ensure that all students and staff are aware of their HIV status and encourages the reduction of high-risk behaviours. Furthermore, UCT's VCT programme provides access to both medical care and social support at HIV positive individuals. The focus of this implementation evaluation was to determine the extent to which UCT's VCT programme was operating effectively and in keeping with UCT's mission.

Background: Antiretroviral therapy (ART) services have expanded over the past decade, providing treatment to over 15 million people globally. It is imperative that this scale-up of ART provision be accompanied by optimal treatment response monitoring strategies to timely and accurately detect treatment failure. Routine viral load (VL) monitoring is the preferred ART response monitoring tool and its use has been increasing across Africa; however, there are few insights into VL monitoring practices during pregnancy. This thesis describes public sector VL testing practices in a cohort of HIV-infected pregnant women who initiated ART before pregnancy in Cape Town, South Africa. Methods: This study was conceived in 2015 as a sub-analysis of the first phase of an on-going prospective trial: the Strategies to optimize antiretroviral therapy services for maternal and child health (MCH-ART) Study, being conducted in Gugulethu, Cape Town, South Africa. Consecutive HIV-infected pregnant women on ART before pregnancy and making their first visit to a primary care antenatal clinic between March 2013 and June 2014 were enrolled into the study. Pre-existing demographic, obstetric and ART history data collected during enrolment into the MCH-ART study were used. In addition, HIV VL results were obtained from the National Health Laboratory Service (NHLS) system from 15 months prior to the estimated date of conception to delivery. VL testing and VL results were described for the two periods: (i) before conception (from estimated date of conception to 15 months prior) and (ii) during pregnancy (from estimated date of conception to delivery). Results: Among 520 women the median age was 31 years [Interquartile range (IQR), 28-35 years] and the median duration of ART use was 2.7 years [IQR, 1.5-5.1 years]. Before conception, 66% (n=311) of women had at least one VL test done in routine adult ART services, and 9% of these results (n=29) were >1000 copies/mL. During the pregnancy, 80% (n=415) of women had at least one VL test done and 12% (n=49) of these results were >1000 copies/mL. Pregnant women with elevated VL >1000 copies/mL were more likely to have been on ART for longer (p=0.049), report at least 2 missed ART doses in the preceding 30 days (p=0.043) and be on a protease inhibitorbased regimen (p=0.016). Among women with VL >1000 copies/mL during pregnancy, 59% (n=29) had a repeat VL done at a median of 3.5 months after the initial test (IQR, 2.1-4.4 months) with 52% (n=15) of these women having a VL >1000 copies/mL on this second test. Conclusion: While coverage of VL monitoring appears high in this setting, a substantial fraction of women with elevated VL in pregnancy were never retested. With increasing numbers of HIV positive women using ART, greater attention is needed to design and implement effective strategies for VL monitoring in pregnancy.

Today, antiretroviral therapy is potent, convenient and usually well tolerated, capable of reducing human immunodeficiency virus (HIV) blood concentration to undetectable values within a few weeks from treatment initiation and of inducing a robust and sustained CD4 T-cell gain. Despite these unquestioned successes, the problem is far from being solved: even in countries with full access to ntiretroviral treatment, life expectancy of people under ARV therapy remains lower with respect to that of uninfected people. Furthermore, large populations of HIV infected individuals who are not diagnosed remain untreated or enter treatment at a very late stage of diseases. Undiagnosed and untreated population represents an infected reservoir that increases HIV transmission. Patient with HIV/Acquired Immunodeficiency Syndrome (AIDS) disease face many problems when commencing antiretroviral therapy also called as highly active ntiretroviral therapy (HAART). In addition to understanding their HIV disease, they are prescribed with combination antiretroviral therapy and have a higher risk of developing adverse drug reactions. Consequently, patients feel that HIV treatment is a burden and turn non-adherent to HAART. One important tool for better patient compliance towards HAART is optimizing therapy for minimal side effects by therapeutic drug monitoring. In the present PhD research work entitled “Traditional and novel therapeutic approaches for the personalized therapy in HIV patients co-infected with opportunistic infections and other co-morbidities” we studied the role of therapeutic drug monitoring in HAART therapy for personalized patient care. The experimental section of the thesis is broadly categories as follows • HPLC UV assay method development for ARV drugs quantification • LC-MS/MS assay method development for ARV drugs quantification • Pharmacokinetics of ARV drugs dosing at conventional doses • Association between antiretroviral pharmacokinetics and drug-related metabolic disorders • Pharmacokinetic interaction between raltegravir and anti HCV drugs in an HIV-HCV liver transplant recipientIn conclusion we developed and validated HPLC-UV and LC-MS/MS methods which are accurate, reproducible and able to simultaneously quantify nineteen antiretroviral agents in plasma by a single assay. Good extraction efficiency and low limit of quantification make these methods suitable for use in clinical trials and for TDM. This method has been successfully applied for our routine TDM and PK studies in HIV-infected patients. When applied these methods for routine therapeutic drug monitoring of antiretroviral drugs we were able to document that a significant proportion of patients treated with some of the antiretrovirals at marketed doses had plasma concentrations exceeding the upper therapeutic threshold. Such selected patients, who might have the highest risk of experiencing drug-related complications, may benefit from therapeutic drug monitoring -driven adjustments in antiretroviral doses with potential advantages in terms of costs and toxicity. In case of atazanavir, a protease inhibitor, we documented that significant proportion of patients treated with conventional atazanavir dosages had plasma concentrations exceeding the upper therapeutic threshold. A likely possibility is an inherited deficit in atazanavir clearance and/or atazanavir metabolism; in particular, atazanavir is a dedicated CYP3A substrate, which includes 3A4 and 3A5, two polymorphic genes. The administration of unboosted atazanavir to healthy subjects carrying the defective CYP3A5*3 resulted in significantly higher ATV concentrations compared with values measured in patients expressing CYP3A5 . Assuming that over 90% of patients in our study were Caucasians with a high prevalence of carriers of CYP3A5*3, it is likely that the observed overexposure to atazanavir concentrations is the result of excessively high dose of ritonavir- boosted atazanavir or of needless boosting with ritonavir. This is a first important conclusion of our study that raises concerns on the need of full dose of ritonavir-boosted atazanavir in caucasian patients and opens new questions about the atazanavir dosages that should considered correct (or in label and off label in Europe). We found the positive correlation of atazanavir concentration with hyperbilirubinemia and lipid dystrophy. We confirmed that the overexposure to ATV is associated with increased risk of nephrolitiasis. We also found that such patients have the highest risk of experiencing atazanavir -related complications and may benefit from therapeutic drug monitoring -driven adjustments in atazanavir dosage with potential advantages in terms of costs and toxicity. At the end when we monitored raltegravir concentration in HIV infected patient co-infected with hepatitis C virus we observed a threefold increase in exposure of raltegravir concentration. HIV-HCV co-infected liver transplant recipients was simultaneously taking ombitasvir, dasabuvir and paritaprevir/ritonavir (3D regimen) for recurrent Hepatitis C virus infection. Such suspected interaction, which might be clinically relevant in selected patients, is easily manageable through therapeutic drug monitoring of raltegravir concentrations, eventually improving the safety of this drug.

Thesis (MPH) --University of Limpopo, 2009
The aim of the study was to determine the challenges of scaling up and strengthening quality-assured laboratory services for diagnosis and monitoring tests for HIV / AIDS patients on Anti- retroviral Therapy (ART). The objectives of the study were to: review the current national HIV/AIDS/STI/TB policy, Laboratory policy, ART strategic plan and guidelines on the implementation of ART services in Zambia; assess the knowledge, attitudes, and practices (KAP) of medical doctors/clinicians and knowledge and practices of laboratory staff in the diagnosis and monitoring tests for HIV / AIDS patients on ART; assess the quality of laboratory services for diagnosis and monitoring tests of HIV / AIDS patients on ART in Zambia compared to WHO standard guidelines; quantify the time taken for CD4 count results to reach the ART centres and determine the difference between the knowledge, attitudes and practices (KAPs) of medical doctors/clinicians in the ART centres with and without laboratory services for diagnosis and monitoring tests for HIV/AIDS patients on ART in Zambia. The study design was a cross-section descriptive survey of one hundred and thirty-seven (137) ART centres in the public health sector of the nine (9) provinces in Zambia. The study population consisted of six directors and managers from the Ministry of Health at national level, medical doctors/clinicians, laboratory staff, district directors of health, in charge of ART centres, and data-entry clerks in charge of Health Information Management Systems (HIMS) from one hundred and thirty-seven (137) ART centres in the public health sector in Zambia. The study findings indicated that only 23% of public sector laboratories were offering a full complement package of quality-assured laboratory services to support the ART programme in Zambia. The HIV/AIDS policy, Laboratory policy, Laboratory Standard Operating Procedures (SOPs) and guidelines on ART scale-up implementation plans exist at national level but had not been fully disseminated to all the ART centres. The average number of qualified laboratory staff at district hospitals surveyed was one (1) qualified laboratory personnel which is lower than the WHO recommendation of four (4) staff per district hospital. Most of the laboratories had no CD4 count machines to support ART V services. Unfortunately, CD4 count results took more than a week to reach the ART centres. Laboratories surveyed indicated a lack of equipment maintenance plans and service contracts. External Quality Assessment for diagnosis and monitoring tests for HIV/AIDS patients on ART was not yet well established. The findings also indicated that Medical Doctors/Clinicians working in the ART centres with laboratory services to support ART programme had better prognosis and treatment of patients on ART compared to those working in the ART centres without laboratory services. There was no difference in the knowledge, attitude and practices of Medical Doctors/Clinicians in the diagnosis and monitoring tests for the management of HIV/AIDS patients on ART in ART centres with and without laboratory service to support the ART programme in Zambia. In conclusion, the Ministry of Health should improve and increase accessibility to fully functional laboratory services to support ART programmes in order to reduce turn-around time for the CD4 count results to reach the ART centres. CD4 count machines should be provided to all the laboratories in ART centres and include service maintenance contracts to support ART services. The policy and decision makers should improve and strengthen the quality of laboratory services by disseminating the National HIV/AIDS policy, Laboratory policy, Laboratory SOPs and guidelines on ART scale-up implementation plan. The recruitment, training and improvement of redistribution of qualified staff should be accelerated to accommodate the current high workload, range of tests performed and an increase in laboratory operations with ART scale-up programme. A standard format of recording and reporting CD4 count results should be put in place (i.e. computerised or manual system). The Ministry of Health should develop guidelines and establish quality assurance systems and affiliate the laboratories to participate in the &ADC regional External Quality Assurance for accreditation such as the South African National Accreditation Systems (SANAS), to support the ART programme.

Record numbers of new diagnoses of HIV infection have been recorded in the UK in recent years. However, whether these are historic infections now being diagnosed or evidence of ongoing HIV transmission is unclear from these data. The Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) is a generic term for .a number of different laboratory techniques that can be used to distinguish recent HIV infections occurring in the 4-6 months prior to sampling from long standing HIV infections. When these data are analysed with appropriate demographic data it is possible to estimate the rate of acquisition ofHIV infection or incidence . . However the method has many .limitations. This thesis identifies and examines the confounding factors that limit the applications of the STARHS technologies or alter its accuracy. It quantifies the degree of misclassification of specimens as recent HIV infections due to use of effective anti-retroviral therapy in patients and proposes uses of ST ARHS data in populations where multiple HIV subtypes circulate. and incidence estimates are difficult to determine. Having excluded confounding factors, the STARHS 'detuned' appr~ach is useq to determine HIV Incidence in men who·have sex with men attending Sexually Transmitted Infection (STI) clinics in the UK as part of an unlinked anonymous HIV prevalence monitoring programme. This demonstrated that ongoing transmission of HIV is occurring in this population and that despite widespread use of anti-retroviral therapies the rate of HIV transmission has shown no decline. This thesis adds new insight to and understanding of the complex mechanisms that limit the application of laboratory techniques for identifying recent HIV infection. Furthermore, it demonstrates that the STARHS teclmique, when used appropriately, is able to provide reliable and sensitive estimates of HIV incidence, thus improving understanding of recent trends in the HIV epidemic.

Thesis (S.M.)--Massachusetts Institute of Technology, Sloan School of Management, 2011.
Cataloged from PDF version of thesis.
Includes bibliographical references (p. 65-66).
Health care delivery organizations bear the burden of meeting monitoring and evaluation requirements set by numerous external organizations often at the cost of implementing internally defined management needs. Monitoring and evaluation in global health delivery has received increasing attention over the last few years. For instance, the World Health Organization and UNAIDS have published guidelines and provided technical assistance for HIV/AIDS monitoring and evaluation programs. In doing so, they establish international standards for performance measures, defining success metrics and related data indicators. Donor organizations, such as the President's Emergency Plan For AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosk and Malaria (GFATM), and the World Bank's Multi-Country AIDS Program (MAP), have also contributed to defining HIV/AIDS success measures and data indicators in the way that they require funding recipients to report on performance. The multitude of players at the global level has made monitoring and evaluation in HIV/AIDS management confusing with regards to coordination, priority-setting, authority, and information clarification. Health care delivery organizations that act as local service providers must balance fulfilling donor requirements with addressing internal management priorities, which considers beneficiary needs, internal strategy, and available resources. This thesis discusses the challenge of obtaining this balance by comparing data indicators set at the global level with data monitoring priorities at the enterprise level. A case study of Kyetume Community Based Health Care Programme, a health care delivery organization in Mukono, Uganda, is presented to illustrate management complexity of data monitoring at the enterprise level. The application of basic data management solutions at a local service provider shows how business management practices can be applied towards improving health care delivery processes. Drawing upon the case study as well as the concepts presented about global and enterprise level contributions to monitoring and evaluation, this paper discusses stakeholder incentives and the implications on monitoring HIV/AIDS care delivery.
by Terry Hu.
S.M.

Monitoring patient health in low and middle-income country HIV care programmes is challenging, as, without evidence, measurement tools derived from high-income country studies have been adapted and paper-based monitoring systems quickly developed. An accurate understanding of the population in care may be compromised. This thesis examines aspects of HIV care: access to Cotrimoxazole preventive therapy (CPT), prevalence of common mental disorders (CMD), and tools used to measure outcomes on antiretroviral therapy (ART). CPT access is frequently cited as being as low as 4% with few studies estimating long-term access. Estimated prevalence of CMD varies widely as little standardisation in measurement tools exists. And, while international ART programme monitoring recommendations exist, no study has compared the concordance, or otherwise, between information collected in different countries. The first study in this thesis, in Ugandan and Tanzanian patients, estimates time from HIV diagnosis to CPT initiation, time spent on CPT and associated factors. These estimates are compared to reported data. CPT coverage and time on CPT were poor. The absence of unique patient identifiers means monitoring data cannot distinguish patients who were diagnosed and initiate CPT in different reporting periods. Furthermore, no long-term data are officially reported. The second study estimates CMD prevalence and associated factors among HIV-positive Ugandans, and validates measurement tools for this. Prevalence was around 10% but no routinely-collected data identified at-risk patients. Measurement tool validity was poor, and their use substantially overestimates prevalence. The third study compares ART programme monitoring systems in Malawi, Uganda, Ukraine and Tanzania. There was little concordance with international recommendations, and discordance in additional data-items and paediatric age-groupings. This signalled a lack of understanding of how best to monitor the health of treated populations. Finally, a fourth study is proposed with the aim of assessing the validity and predictive value of existing programmatic monitoring systems.

Since the early 1980s in sub-Saharan Africa (SSA), substantial human and financial resources have been dedicated to monitoring the HIV/AIDS epidemic. Throughout, surveillance data collected at antenatal care (ANC) clinics have been a key data source. ANC surveillance data are well-known to be biased when quantifying population HIV prevalence levels in SSA. Nonetheless, a routinely-accepted, although rarely-tested assumption has been that the data are representative of population-level HIV prevalence trends. More recently, HIV testing data from prevention of mother-to-child transmission (PMTCT) programmes have been proposed as a substitute for ANC surveillance, although these data can be subject to temporal biases too. The primary objective of this thesis is to add to the limited evidence regarding the representativeness of HIV testing data from pregnant women to monitor population-level HIV prevalence trends. Empirical analyses from repeated household-based population surveys and ANC surveillance were done for seven countries in SSA from 2000 to 2010 and among youth aged 15 to 24 years in Manicaland, Zimbabwe from 1985 to 2003. Also, a mathematical model was used to explore temporal bias in ANC surveillance trends in epidemics similar to those in Botswana, Côte d’Ivoire and rural Zimbabwe from 1985 to 2030. Finally, PMTCT programme data were assessed for their representativeness as compared to ANC surveillance data in Manicaland, Zimbabwe from 2006 to 2008. Results showed the representativeness of ANC surveillance data to vary by time period and setting, although trends among youth were more robust than those among adults aged 15 to 49 years across settings, and particularly so among men. Representativeness in the ART-era depends on coverage and scale-up, the setting, and the potential for changing fertility patterns among ART users. PMTCT data for surveillance purposes was of limited use in Manicaland, Zimbabwe from 2006 to 2008. In summary, caution is needed when using HIV testing data from pregnant women to monitor population HIV prevalence trends in SSA.

Philosophiae Doctor - PhD
There are number of Non-Governmental Organisations (NGOs) in South Africa that use sport as a tool to respond to HIV/AIDS mainly among young people, however, little is reported about the outcomes and impact of these programmes. The aim of this study is to contribute to a generic monitoring and evaluation framework by improving the options for the use of outcome indicators of sport-based HIV/AIDS awareness programmes of selected NGOs in South Africa. The research followed a qualitative multiple case study design using multiple data collection instruments. The overall findings revealed that the sport-based HIV/AIDS awareness programmes of five selected NGOs examined in this study focus on similar HIV prevention messages within the key priorities highlighted in the current National Strategic Plan for HIV/AIDS, STIs and TB of South Africa. The HIV prevention messages of selected NGOs are also in line with the commitments and targets of the 2011 UN Political Declaration on HIV/AIDS. The sport-based HIV/AIDS programmes target youth with messages that raise awareness of HIV/AIDS, HIV risk behaviours and HIV stigma. Furthermore messages that promote uptake of health services such as HIV Counselling and Testing (HCT) and Voluntary Medical Male Circumcision (VMMC). However, evaluating outcomes and impact of such programmes remains a challenge. Descriptive information and outputs are more recorded rather than information about the actual outcomes which occurred as a result of sport-based HIV/AIDS awareness programmes. The use of multiple data collection instruments in conjunction with approaches of the ten-step model to a result-based monitoring and evaluation systems enables this study to propose a total of fifty one generic outcome indicators. These generic outcome indicators focus on measuring change in the knowledge of HIV/AIDS and change in attitude and intention towards HIV risk behaviours. In addition, this study further proposed a total of eight generic outcome indicators to measurepredictors of HIV risk behaviour. The selected NGOs can adapt the proposed generic outcomes and indicators based on the settings of their programmes. It can be concluded that the proposed generic outcome indicators are able to assist the NGOs to improve monitoring and evaluation of their sport-based HIV/AIDS awareness programmes. A collaborative approach by all stakeholders is required, from international organisations, funders, governments, NGOs and communities to strengthening monitoring and evaluation of sport-based HIV/AIDS awareness programmes including other development programmes.

South Africa, with an estimated 5.7 million people living with HIV, continues to have one of the largest epidemics in the world. The introduction of HAART resulted in prolonged and improved quality of life of many infected patients. However, adverse effects caused by these drugs have become a major concern as they affect the adherence of patients and in some cases even result in the death of patients. Although much research has been and is still being conducted in the area of understanding, preventing and management of ARV adverse effects, there is still a need for patients to be actively involved in self-monitoring for adverse effects. This will assist health care professionals in early identification of serious or potentially serious ARV effects. This study aimed at evaluating the usefulness of strategies developed and employed in the identification, recording and monitoring of adverse effects. The study was conducted with patients receiving HAART from a private HIV and AIDS clinic in Uitenhage, Eastern Cape, South Africa. The research project was approved by the Nelson Mandela Metropolitan University Research and Ethics Committee and the research site. This was an experimental, randomized controlled study carried out over a period of three months (August to October 2009), with a sample size of 160 patients divided into four study groups of 40 patients each. Two monitoring strategies, namely an ARV adverse effect monitoring tool and a patient self-monitoring diary were developed and used for the identification and recording of adverse effects. The four study groups included a Control group, a Tool group, a Diary group and a Tool-Diary group. Willing patients, after signing an informed consent form, were randomly assigned to one of the four groups by participating health care workers at the study site. Data was retrieved from the patient files by the researcher. Descriptive statistical analysis of the findings of the study was conducted using SPSS®. One hundred and forty nine patients were included in the final data analysis. Of the 80 diaries handed out to patients, only 33 were returned and due to errors only 31 were suitable for analysis. Monitoring tools were completed and analysed for 36 patients. The tool was found to be more effective in identifying adverse effects of a physical nature (such as peripheral neuropathy and lipodystrophy) than the usual methods of monitoring employed by the clinic, whilst the diary, used alone, was found to be less effective. Use of the tool and diary combined resulted in the most significant identification and recording of central nervous system related adverse effects and physical adverse effects. However due to the low return rate of the diaries and the majority of the monitoring tool not being completed in many instances the results of this study may not be generalisable. The study results did however suggest that combining the tool and the diary methods of adverse effect identification, yielded the most favourable results when compared to each method alone. This may be attributed to the fact that the tool is useful in identifying objective symptoms and the diaries subjective symptoms, particularly in instances where the patients forget to report their symptoms to healthcare professional whilst at the clinic. The diaries were also reported to improve adherence for more than 90 percentage (n=31) of the patients. More research would be needed in order to verify the exact significance of the tool and the diary in identifying and recording adverse effects and symptoms of adverse effects.

Effective antiretroviral therapy (ART) is essential for viral suppression (VS) in HIV-infected patients. However, there is a lack of nationally representative data on types of ART regimens used and their impact on VS. This thesis used self-reported interview and abstracted medical record from 2009 Medical Monitoring Project (MMP) to study ART regimen type and related health outcomes. Results showed that 88.6% of HIV-infected adults in care was prescribed ART, and about half took regimens designated as ‘preferred’ according to U.S ART guidelines. Among MMP participants prescribed ART, 62.7% achieved durable VS, 77.8% achieved recent VS, 83.5% were 100% dose-adherent, and 17.1% reported side effects. Multivariate regression analyses revealed that although ART was critical for VS, there were minor differences in health outcomes among the major ART classes in the U.S. ART guidelines or six most-commonly used regimens. This study could be potentially useful for future strategic planning of HIV care.

Background: At the end of 2012, worldwide, approximately 35.5 million people were living with HIV. 1 HIV mortality rates, in resource limited settings are now starting to improve as antiretroviral therapy (ART) is becoming universally available. Now, these settings need to improve the care provided to patients. Good quality care requires timely detection, staging and initiation of therapy. CD4+ cell counting, point-of-care (POC) devices could improve the quality of care in resource limited settings, by allowing for the decentralization of HIV care. As a result, these POC CD4+ cells assays could circumvent patient barriers to care, and relieve building pressure on regional laboratories. Several POC CD4+ devices are available, but an independent comparison of performance has not yet been done. The aim of this thesis is to evaluate the current evidence for POC CD4+ cell counting technologies and determine whether their performance would allow them to be used interchangeably with the current gold standard.Methods: To attain our objective we completed a systematic review and meta-analysis of the evidence relating to POC CD4+ cell assays. Our populations of interest were global populations of adults with a HIV+ status. Our outcome of interest was to the absolute Bland Altman mean bias, which represents the agreement between the POC device and the gold standard. We systematically searched 19 databases, relevant conferences and grey literature for the period 2000 to 2013. Of 4154 citations found, 16 articles were selected. A Bayesian hierarchical normal-normal model was used to meta-analyze data.Findings: POC devices appear to perform best in capillary samples. Only sufficient data was available to allow for a meta-analysis of the PIMA device; a smaller BA mean bias in capillary blood vs. venous specimens was found (-3.0 cells/μL; 95% CrI: -28•2 to 22•8 vs. -26•5 cells/μL; 95% CrI: -46•7 to -6•8). Insufficient data was available for other POC devices (the MiniPOC and the MBio) to allow for a meta-analysis; however they also appear to perform well when considered graphically in a forest plot.Conclusion: The PIMA CD4 device was comparable to flow cytometry as the estimated difference between the CD4+ cell count of the device and the reference fell within a range of acceptable accuracy (+/- 30 cells/μL). The miniPOC and the MBio devices also appear to perform well. Devices appear to better estimate capillary specimens compared to venous specimens. POC CD4+ cell count devices are a rapidly developing field and so providers need reliable evidence for technology selection decisions. The synthesis of evidence relating to the accuracy of POC CD4+ cell counting devices may be of interest for initiatives that are scaling up the use of these devices globally.
Contexte : À la fin de 2012, il y avait 35,5 millions de personnes à travers le monde vivant avec le VIH.1 Le taux de mortalité du VIH dans des milieux à faibles ressources commence maintenant à s'améliorer avec la disponibilité de la thérapie antirétrovirale (TAR) qui est en train de devenir universelle. Maintenant ces milieux doivent améliorer les soins donnés aux patients. Les soins de bonne qualité nécessitent un dépistage, une détermination du stade et un début de traitement rapides. Les appareils de diagnostic qui comptent les cellules CD4+ au point de service (POC) pourraient améliorer la qualité des soins dans les milieux à faibles ressources en permettant la décentralization des soins VIH. Par conséquent, ces tests effectués par ces dispositifs POC de diagnostic et de comptage de cellules CD4+ pourraient contourner les obstacles aux soins des patients et atténuer la pression de devoir construire des laboratoires régionaux. Plusieurs dispositifs POC de diagnostic de CD4+ sont disponibles mais une comparaison indépendante de leur performance n'a pas encore été faite. Le but de cette thèse est d'évaluer les éléments dont on dispose déjà concernant les technologies POC comptage de cellules CD+4 et de déterminer si leur performance leur permettrait d'être utilisées de façon interchangeable avec la norme de référence actuelle.Méthodes : Afin d'atteindre notre objectif nous avons procédé à un examen méthodique et à une méta-analyse afin d'évaluer les tests POC comptage de cellules CD4+. Notre résultat d'intérêt était selon le biais moyen absolu de Bland Altman, qui représente l'accord entre le dispositif POC et la norme de référence. Nous avons examiné systématiquement 19 bases de données, ainsi que des conférences et de la littérature grise pertinentes datant de 2000 à 2013. 16 articles ont été sélectionnés sur 4154 citations. Nous nous sommes servis d'un modèle bayésien hiérarchique de distribution normale-normale afin de faire la méta-analyse des données.Résultats : les dispositifs POC semblent fonctionner mieux avec des prélèvements de sang capillaire. Il y avait seulement des données disponibles pour effectuer une méta-analyse du dispositif PIMA ; on a trouvé un plus petit biais moyen Bland Altman dans les prélèvements de sang capillaire par rapport aux échantillons de sang veineux (-3,0 cellules/ μL; 95% CrI : de -28,2 à 22,8 contre -26,5 cellules/ μL; 95% CrI : de -46,7 à -6,8). Les données disponibles pour les autres dispositifs POC (le MiniPOC et le MBio) n'étaient pas suffisantes pour permettre une méta-analyse, pourtant ces dispositifs semblaient bien fonctionner selon la représentation graphique en forêt.Conclusion : Le dispositif PIMA CD4 était comparable à la cytométrie en flux parce que la différence estimée entre le comptage de cellules CD4 du dispositif et de la référence a donné une précision suffisante (+/- 30 cellules/ μL). Les dispositifs miniPOC et MBio semblent bien fonctionner aussi. Il semble que les dispositifs donnent une meilleure estimation de prélèvements de sang capillaire que pour les prélèvements de sang veineux. Les dispositifs POC de comptage de cellules CD4+ font partie d'un secteur en pleine croissance, donc les fournisseurs de soins de santé ont besoin de preuves fiables pour la prise de décision en matière de technologie. La synthèse des données probantes portant sur l'exactitude des dispositifs POC de comptage de cellules CD4+ pourrait intéresser les initiatives qui intensifient l'utilisation de ces dispositifs à l'échelle mondiale.

South Africa is one of the countries hardest hit with the Human Immunodeficiency Virus (HIV) and Acquired Immuno Deficiency Syndrome (AIDS) epidemic. In response to the epidemic, the South African government adopted the Comprehensive HIV & AIDS Care, Management and Treatment programme strategic plan (CCMT) in 2000 (1) and developed the Operational Plan for CCMT for antiretroviral therapy rollout in 2003 (2). In order to monitor the progress of the implementation of CCMT, the National Department of Health (NDOH) adopted the Monitoring and Evaluation (M & E) framework in 2004 (3). The aim of this study was to assess the HIV & AIDS programme in Grahamstown‘s public sector health care system by using the national M & E indicators of the HIV & AIDS programme. The national M & E framework was used as the data collection tool and available information was collected from various sources such as the District Health Office (DHO), Primary Health Care (PHC) office, accredited antiretroviral sites and the provincial pharmaceutical depot. Group interviews were conducted with key stakeholder health care professionals at the District Health Office, Primary Health Care office, Settlers Hospital and the provincial Department of Health personnel. A one-on-one interview was conducted with the Deputy Director of HIV & AIDS Directorate, monitoring and evaluation in the National Department of Health. Available indicators such as budget and expenditure including antiretroviral procurement; human resources; nutrition-related indicators; prevention care and treatment indicators were collected. A group interview was conducted to document current practices, or where there was a lack of documentation, for indicators such as traditional medicines and pharmacovigilance. Most of the national M & E indicators are not required to be collected or collated by the district because the reporting format designed by the provincial Department of Health is different. Facilities, districts and provinces in South Africa are at different levels of implementation of the antiretroviral programme and hence a common format of the M & E indicators is not used by all provinces. Uniform data collection is not achieved due to human resources‘ constraints and other challenges such as continued use of manual reporting systems by the clinics. Districts are expected to report according to the formats drawn up by the provincial Department of Health (DOH) and there is a lack of awareness regarding the national M & E document amongst the Grahamstown Health Care Professionals. There is a need for training on the use of the M & E national framework so that the HCPs at the primary and secondary levels of the health care system are proficient with the process of M & E, and can provide inputs as well as take ownership of the process. The establishment of an M & E unit in Grahamstown is essential so that data collection and submission of the HIV & AIDS programme in the public sector according to the National M & E framework is addressed. However, despite all constraints and challenges in the public sector health care system in Grahamstown, available human and financial resources are being used effectively to maintain the HIV & AIDS programme.

This thesis assesses factors associated with a number of short and long-term outcomes in HIV-infected patients receiving antiretroviral treatment in Asia. Analyses in this thesis were based on two cohorts of HIV-infected patients; The Treat Asia HIV Observational Database (TAHOD), a multi-centre prospective observational cohort from countries in Asia-Pacific region, and the HIV Netherlands Australia Thailand (HIV-NAT) collaboration cohort, a cohort of patients treated with antiretroviral treatments at HIV-NAT in Bangkok, Thailand. We examined factors associated with time to immunological failure endpoints, such as CD4≤ 200 cells/??L, CD4≤ 100 cells/ ??L, and CD4 return to baseline, and with the virological failure endpoint, detectable viral load defined as a value greater than 500 copies/mL. Multivariate Cox proportional hazard models were used. Results showed that CD4 count at baseline and changes in CD4 strongly predicted immunological failure. For virological failure, detectable viral load at baseline was the strongest predictor. As a step to developing simplified monitoring strategies, in which patients with a low risk of failure could have their monitoring CD4 count and viral load tests deferred, we developed predictive models for each immunological and virological failure endpoint. Models were developed on the HIV-NAT cohort, and validated on the independent TAHOD cohort. For predictive models, the complementary log-log transformation for each endpoint was fitted appropriate to the interval censored nature of the data. To assess goodness-of-fit, cut-offs were defined for the predicted risks that separated patients from low risk to high risk. Overall, the observed versus expected failures from HIV-NAT data agreed quite well across all endpoints, probably reflecting that the HIV-NAT database was the data we built the models upon. Not only did these models fit the HIV-NAT database well, they also discriminated patients from low to high risk groups. When we validated models with TAHOD data, the observed and expected failures agreed well only in the model for CD4 count return to baseline. For most of the endpoints, the predictive models overestimated the number of failures, with predicted values larger than observed. However, the proportions of failures were lowest in the low risk group and highest in the high risk group, indicating that our models did discriminate between patients at high and low risk, and that the predictive models might still be of use for the purpose of simplified monitoring strategies. With CD4 count and viral load monitoring tests now comprising a large component of the cost of HIV treatment in resource limited settings, we developed and assessed a simplified monitoring strategy that aimed to reduce the numbers of monitoring tests performed. The predictive models developed earlier were used to calculate the probabilities of failure in TAHOD patients. We assumed that patients would have their CD4 and viral load assessments annually, at baseline and at one year, predicted risk of failure at ensuing clinical visits, week 12, 24 and 36. For patients at low predicted risk of failure at ensuing clinical visits, we assessed the effect of deferring monitoring tests, both in terms of blood tests avoided, and in terms of delaying detection of failure in some patients. A number of levels for the predicted risk of failure that lead to deferral of testing were evaluated. The results suggested that predicted probabilities of failure of 10% - 20% gave the best results across all failure endpoints. These cut-offs could save a median of 598 (51.6%) (range 37 (2.6%)_-1,218 (81.9%) ) blood tests over the first year of treatment, but would fail to detect 29 (18%) (range 10 (7.4%) - 128 (39.3%) ) failures. The median time from failure to detection in those patients who did fail and had deferred monitoring tests was 28 weeks. Rates of antiretroviral treatment change in TAHOD were examined. We identified patterns and factors associated with the rate of treatment change. Median time to the first treatment change was 3.2 years. Factors predicting rate of treatment change in TAHOD were treatment combination, being on second or third combination, number of drugs available in each site and being an injecting drug user. The overall rate of treatment change in TAHOD was 29 per 1OO-person-year. Around 30% of patients stopped their treatment due to adverse events. These rates of treatment change are lower than have been seen in patients in western countries. This may be due to patients in developing countries having access to fewer antiretroviral drugs than patients in developed countries.

Includes bibliographical references
BACKGROUND: A viral load monitoring algorithm in the 2013 Western Cape Department of Health PMTCT guidelines include VL measurement in women who are antiretroviral (ART)-experienced at presentation for antenatal care, the timing of subsequent VL measurements and criteria for regimen change. The study evaluates the implementation of the algorithm in women who are virologically nonsuppressed and determines the outcomes of virological resuppression and infant PCR status. METHODS: This retrospective cohort study focused on all ART-experienced women who presented for antenatal care at one of two primary level Maternity Obstetric Units (MOUs) in Khayelitsha, Cape Town between July 2013 and June 2014. The study used routine data from facility registers, clinical records and electronic monitoring systems at the MOU, and referral ART sites and hospitals. Data collected included age, ART clinic, start date and regimen, and maternal VL and infant PCR results. RESULTS: Forty percent of the 1412 HIV-positive pregnant women, were ART-experienced, of whom 14.1 % were VNS. Predictors of being VNS included a duration on ART of more than 4 years (p= 0.04), attending an ART clinic other than that in the facility (p= 0.02), being on a second-line ART regimen (p=0.07) and being younger than 25 years (p= 0.05). The algorithm was correctly followed in up to 87.5% of women identified as VNS. The rate of virological resuppression by three months postpartum was 70.0% to 82.3%. Excluding three neonates who died, all of the 82.2% of infants tested were PCR negative. CONCLUSIONS: Nearly 15% of ART-experienced women were virologically nonsuppressed on presentation for antenatal care. Levels of adherence to the guideline, and virological resuppression rates of up to 82.3% are encouraging. The implementation of the VLM algorithm could be improved by the integration of obstetric and ART care, the adoption of a single electronic monitoring system and the use of standardised integrated clinical stationery.

Bureaucratic management practices increasingly dominate global development and global public health systems. The contemporary approach to managing development programs is a 'results-based' , 'New Public Management', which focuses on the measurement of targets, and a linear logic from 'input' to 'impact'. There has been little attention to the experience of the 'frontline' workers of such management systems, which appear to be designed from a donor, rather than from a worker point of view. The possibility of more participatory or empowering Monitoring & Evaluation (M&E) methods has received little attention. India' s response to its HIV epidemic has emerged through government and private philanthropy channels, both increasingly adopting approaches of New Public Management. This thesis is concerned with M&E practices in the context of HIV prevention interventions in India. While the literature contains numerous reports of evaluations of interventions in this context, there is no literature which reflects on or problematizes the actual practices of monitoring and evaluation, and how these practices have effects on the ground. Critical development literature and theory highlight the discrepancies which often exist between ideal policies and their actual implementation on the ground. This thesis draws on community psychology, practice theories, and Alvesson and Spicer's (2012) concept of an 'economy of persuasion', to understand the 'mess', particularly the unintended consequences that come about at the interface between bureaucratically-rational M&E processes and complex humanintervention practices.

WHO guidelines recommend viral load monitoring for all HIV-1 positive patients on antiretroviral therapy (ART). However, few low-income countries have virological monitoring widely available, and patients may remain on virologically failing regimens. This could compromise future ART through the accumulation of drug resistance mutations and result in worse long-term clinical outcomes. The DART trial was conducted in Uganda and Zimbabwe and compared clinically driven monitoring with or without routine CD4 measurement in ART-naïve adult patients. Annual plasma viral load was retrospectively measured for 1,762 patients. This thesis investigates how no laboratory monitoring impacts virological failure and the development of drug resistance. Time to persistent virological failure was analysed, and analytical weights were calculated to correct for non-random sampling. The long-term durability of first-line ART was remarkable; 21% of patients on an NRTI-NNRTI regimen and 40% on a triple-NRTI regimen experienced persistent virological failure by 240 weeks. Routine CD4 monitoring did not reduce virological failure. Deaths after 48 weeks of ART are widely assumed to be due to virological failure or non-adherence. Analyses revealed that a surprisingly high number of these deaths (40%) occurred without virological criteria for treatment switch being met. Routine CD4 monitoring reduced the rate of death with virological failure but did not impact deaths with virological suppression. Cross-sectional analyses quantified HIV-1 drug resistance at the end of first-line ART. On NRTI-NNRTI regimens, 88% had NRTI resistance, and 66% had NNRTI resistance. Routine CD4 monitoring did not reduce the prevalence or extent of drug resistance. The order and rate of HIV-1 drug resistance mutations were explored using repeated genotypes within patients. On NRTI-NNRTI regimens, NRTI and NNRTI mutations developed at a rate of 0.96 and 0.21 per year respectively. Mutagenic tree models demonstrated that ART regimen influenced the order and rate in which mutations occurred.

Yes
This briefing paper reports on research exploring detailed case studies of HIV/AIDS livelihoods-oriented interventions operating in Uganda, Lesotho and South Africa. The interventions were analysed through an audit of sustainable livelihood `principles¿. This revealed general lessons both about the practical opportunities and challenges for employing sustainable livelihoods approaches to the design, implementation, monitoring and evaluation of development interventions and also about the changing format of development interventions.
Department for International Development

It is approaching 35 years since human immunodeficiency virus (HIV)-1 was first identified in Western Australia (WA) and 20 years since introducing highly active antiretroviral therapy (HAART) transforming HIV management, in the majority of cases, by maintaining ‘undetectable’ HIV-1 RNA and restoring CD4 T cell counts to healthy levels. Despite these advances patients are at increased risk of developing age-associated diseases. This thesis therefore investigates whether expanding laboratory approaches to incorporate aspects of the disease process, that are currently 'invisible' in clinical practice but may be prognostically important or which may inform treatment and prevention strategies at a population level, is warranted. The following aims were addressed; 1) analysing determinants of HIV-1 RNA residual viraemia; 2) investigating monocyte activation during chronic HIV-1 infection and; 3) assessing HIV-1 diversity from large scale sequences throughout WA and Australia, including the collaboration and formation of the Australian Molecular Epidemiology Network (AMEN). The main findings demonstrated HIV-1 residual viraemia was powerfully associated with the pre-treatment level of viraemia even after 10-15 years of starting HAART. Analysis of monocyte activation revealed multiple pathways involved in chronic immune activation responses to HIV-1, by altering CD16+ monocyte expression and elevated levels of sCD14 (previously associated with all-cause mortality), that were not corrected by HAART and therefore prognostically significant. In contrast, levels of other biomarkers (e.g. CXCL10 and sCD163) declined with HAART. Investigations of HIV-1 genetic diversity within the WA cohort (n=1021) and the Australian cohort (n=4873) revealed new challenges for HIV-1 prevention due to significant increases in HIV-1 non-B-subtypes, consistent with an increasing impact of migration, while local transmissions were predominantly HIV-1 B-subtypes. Overall, this thesis provides evidence for possible new approaches that may enhance HIV-1 laboratory practice that could aid clinical management, improve long-term health outcomes for those living with HIV-1 infection and guide effective preventative strategies.

This thesis is devoted to general practice (GP) networks in Belgium, their development and their activities within the Belgian health system context. These networks are specific research tools for the repeated or continuous collection and analysis of data related to diseases and other health events observed in general practice, including interventions of general practitioners. The thesis focuses on three not-for-profit general practice research networks which are operational today: (1) the national Network of Sentinel General Practices (SGP), coordinated by the Federal research institute Sciensano; (2) the Flemish Intego network, coordinated by the Academic Center for General Practice of Catholic University Leuven; (3) the network of the Fédération des maisons médicales et des collectifs de santé francophones (FMM) with its Monitoring Chart (Tableau de bord), which collects data from Wallonia and the Brussels-Capital Region. The thesis is divided into a general introduction, three main parts and a final discussion with concluding remarks. The general introduction outlines the importance of data from general practice and the contribution of GP networks to research. Furthermore, it points out the importance of general practice for the control of sexually transmitted infections (STIs), a specific field of action. The first main part of the thesis investigates the research question of how the three GP research networks developed within the specific context of the Belgian health system. It is based on the interpretation of written sources such as project reports, annual network reports, research publications, parliamentary documents, relevant websites and the existing research literature. The context analysis included a comparison with the Netherlands since the latter have strong traditions with regard to the position of the general practitioner in the health system (gatekeeper to secondary care, whereas in Belgium the patient generally chooses his/her health provider, and a Global Medical File administered by the general practitioner is not mandatory in Belgium), to general practice research networks and computerisation. It could be shown (1) that Belgium has held a middle position in the European Union regarding GP computerisation; (2) that, contrary to the Netherlands, an operational national GP network based on data from electronic health records (EHRs) could not be established; and (3) that Belgian health system computerisation, which advanced substantially in the last decade, put the issue of health data collection and storage by a new digital service on the agenda. Subsequently, three sub-chapters focus on the development of the three GP networks from their foundation until today. They demonstrate that the SGP and Intego were founded as innovative tools originating from Flemish general practice research, whereas the Monitoring Chart originated from the dynamism of Integrated Primary Health Care Centres (IPHCCs, Maisons médicales) in French-speaking Belgium. Acting as health observatories was both part of the mission of the IPHCCs and the demand of the Regional governments. With time, the research designs of the three GP networks became more sophisticated. Furthermore, European cooperation of the SGP with other GP networks since the late 1980s stands out, since the vision to establish a European sentinel general practice network led to joint influenza surveillance as one of its lasting achievements. In continuation of the developments described above, the second main part of the thesis addresses the missions and the organisation of the three GP networks today as well as their respective strengths and limitations in comparative perspective. It is based on network publications and reports, relevant websites and informal information from the networks themselves. The comparison shows that there is little overlap between the activities of the three GP networks, given the different areas of investigation and the complementarity of supplementary information collected by the SGP versus routine data extraction from EHRs in the other two networks. Furthermore, Intego and the Monitoring Chart essentially cover different parts of the country. The prospective research design of the SGP allows formulating hypotheses and designing research questionnaires with precise definitions of diagnoses before the start of a new research topic in order to minimise inter-observer variability, whereas the diagnosis in the other two networks is the result of the general practitioner's clinical judgement. The Intego network disposes of a substantial number of routine parameters collected over more than two decades by now. With these data, the researchers can design retrospective cohort studies without recording or recall bias by the GP who does not know during his/her daily routine for which research questions his/her data may be used later. The Monitoring Chart stands out by its comparatively strong presence in the Brussels-Capital Region and its data from the less well-to-do part of the population. The third main part of the thesis focuses on STIs which provided a research opportunity, given that Belgian public health efforts to control them have increased in recent years and that the three GP networks engaged in research activities in this regard. The first sub-chapter addresses challenges for the surveillance and monitoring of STIs due to the nature of the pathogens, followed by a sub-chapter about characteristics of STI surveillance and monitoring in Belgium. Afterwards, a sub-chapter describes health policy efforts in order to establish the Belgian HIV Plan 2014-2019. The development of the HIV Plan was analysed by applying the policy streams model of John Kingdon. The analysis was based on published government statements, parliamentary documents, and websites of stakeholders, and showed that the Federal Ministry of Health initiative to achieve the HIV Plan was characterised by a coordinating role with a participatory approach towards the other Belgian governments and stakeholders. The 2013 protocol agreement of the Belgian governments committed them to principles, actions, and cooperation regarding HIV prevention, testing, treatment of persons living with HIV and care for their quality of life, but not to budgets, priorities or target figures. The implementation of the plan, highlighting aspects relating to general practice, is addressed in the subsequent sub-chapter. Two further sub-chapters are based on the analysis of retrospective cohort studies with Intego data from 2009 to 2013, based on EHR routine registration by over 90 general practitioners in Flanders. In the first sub-chapter, the frequencies of gonorrhoea and syphilis diagnoses were investigated. Case definitions were applied. Due to small case numbers obtained, cases were pooled and averaged over the observation period. Frequencies were compared with those calculated from mandatory notification. A total of 91 gonorrhoea and 23 syphilis cases were registered. The average Intego annual frequency of gonorrhoea cases obtained was 11.9 (95% Poisson confidence interval (CI) 9.6; 14.7) per 100,000 population, and for syphilis 3.0 (CI 1.9; 4.5), respectively, while mandatory notification was calculated at 14.0 (CI: 13.6, 14.4) and 7.0 (CI: 6.7, 7.3), respectively. In spite of limitations such as small numbers and different case definitions, the data suggests that the general practitioner was involved in the large majority of gonorrhoea cases, while the majority of new syphilis cases did not come to the knowledge of the general practitioner. The second sub-chapter deals with the prescription of antibiotics to treat gonorrhoea in general practice in Flanders 2009-2013. Belgian guidelines recommended ceftriaxone or alternatively spectinomycin from 2008 onwards and azithromycin combination therapy since 2012. The study investigated to which extent contemporary gonorrhoea treatment guidelines were followed. Ninety-one gonorrhoea cases with ten chlamydia and one genital trichomonas coinfections in 90 patients were registered between 2009 and 2013. The proportion of cases with ceftriaxone and/or spectinomycin prescriptions rose from 13% (two of 15 cases) in 2009 to 56% (nine of 16 cases) in 2013. Combination therapy of ceftriaxone and/or spectinomycin together with azithromycin rose from 0 of 15 cases (0%) in 2009 to 7 of 16 cases (44%) in 2013. Although numbers are small, the results suggest that gonorrhoea therapy guideline adherence improved between 2009 and 2013. Future opportunities, recommended in the final discussion, include (1) extending provider-led STI testing in Belgium, with a prominent role for general practitioners; (2) investigating barriers and facilitators for the achievement of the Global Medical File, notably if sensitive and potentially stigmatising issues such as STIs or mental health are involved; (3) making task delegation by the general practitioner towards other primary health care providers more attractive; (4) facilitating general practitioners' tasks by the introduction of support features into the EHR in order to improve registration and quality of care in general; (5) eliciting Regional government support in order to investigate the diagnostic profiles of the patient population of IPHCCs; and (6) establishing an extended network for the collection and analysis of "production data" (such as the number of contacts, interventions, referrals, prescriptions and diagnostic requests) from general practitioners and other primary health care providers, proceeding from the know-how and the experience of the three investigated GP networks.
Doctorat en Sciences de la santé Publique
info:eu-repo/semantics/nonPublished

Introdução: A AIDS (Síndrome da Imunodeficiência Adquirida) é caracterizada por uma disfunção grave no sistema imunológico causada por uma infecção por HIV (Human Immunodeficiency Virus). A quantificação da viremia (carga viral) é uma ferramenta muito útil no monitoramento dos pacientes infectados pelo HIV, sendo um marcador de progressão da doença e eficácia do tratamento. A estimativa incorreta da carga viral pode levar à decisão terapêutica equivocada, portanto métodos acurados de quantificação se fazem necessários. Diversas técnicas comerciais estão disponíveis para a quantificação da carga viral do HIV-1: a maioria destas se baseiam na detecção de ácidos nucléicos e outras na detecção de enzimas e antígenos. O grau de automação varia nas diferentes técnicas assim como os procedimentos de isolamento, amplificação e detecção. A correlação e a concordância entre estas técnicas têm sido estudadas e há relatos de discordância entre os valores de carga viral produzidos por diferentes métodos. O conhecimento sobre o efeito das variações entre as técnicas se faz necessário para assegurar a interpretação adequada dos resultados. A interpretação dos resultados correta é particularmente importante quando estes estão próximos a pontos de corte utilizados para definições de rebote viral e falha virológica. Objetivos: O objetivo deste estudo é comparar as técnicas de PCR (Cobas AmpliPrep TaqMan HIV-1 v2.0) e b-DNA (Siemens Versant HIV-1 RNA 3.0) para quantificação do HIV-1. Métodos: 1000 amostras recebidas no HIV/GUM Research Laboratory do Chelsea and Westminster Hospital para quantificação da carga viral do HIV-1 durante os meses de Dezembro de 2009 e Janeiro de 2010 foram testadas pelos métodos de PCR (Cobas AmpliPrep TaqMan HIV-1 v2.0) e b-DNA (Siemens Versant HIV-1 RNA 3.0). Resultados: Uma superquantificação sistemática foi observada nos resultados testados por PCR. Esta superquantificação ficou evidente nos resultados entre 50 e 250 cópias. Uma concordância elevada foi observada na análise dos pontos de corte de 500 e 1000 copias/mL. Uma correlação linear forte foi observada entre estas técnicas na análise das amostras que obtiveram resultados dentro do limite comum de detecção de ambas as técnicas, porém o nível de concordância foi insatisfatório. Conclusão: A superquantificação observada nos resultados obtidos pelo Cobas AmpliPrep TaqMan HIV- 1 v2.0 em relação ao bDNA Siemens Versant HIV-1 RNA 3.0 é provavelmente o resultado de uma sensibilidade aumentada desta técnica. Nós recomendamos cautela quando resultados de duas metodologias diferentes são comparados, especialmente quando se comparam metodologias convencionais com aquelas baseadas em PCR em tempo real.
Introduction: AIDS (Acquired Immunodeficiency Syndrome) is characterised by a severe immune dysfunction caused by the HIV (Human Immunodeficiency Virus). The HIV viral load quantification is an essential tool to monitor HIV-infected patients. The HIV quantification is a disease progression marker and it is a key indicator in treatment efficacy. Inaccurate viral RNA values may subsequently lead to inappropriate treatment decisions hence accurate quantification methods are necessary. Several different methodologies are available to quantify the HIV viral load: a number of them are based on nucleic acid detection and others in detection of enzymes and antigens. Automation is also variable among these methods in addition to differences in isolation, amplification and detection. Several studies have been carried out to evaluate their correlation and agreement and some have evidenced discordant viral load values assessed by different assays. The knowledge about these differences should be taken in to account when analysing viral load results, particularly when low-level viraemia is concerned or those close to endpoints employed for definition of virological failure. Objectives: In this study, two methods to quantify viral load are evaluated: one is based on real-time PCR (AmpliPrep TaqMan HIV-1 v2.0) and the other is based on branched-DNA technology (Siemens Versant HIV-1 RNA 3.0). Methods: 1000 plasma samples received at the HIV/GUM Research Laboratory within Chelsea and Westminster Hospital for HIV-1 viral load quantification between December 2009 and January 2010 were tested by both Cobas AmpliPrep TaqMan HIV-1 v2.0 and Siemens Versant HIV-1 RNA 3.0 methods. Results: Results obtained show that Cobas AmpliPrep TaqMan HIV-1 v2.0 PCR systematically overquantifies the viral loads results when compared to bDNA Siemens Versant HIV-1 RNA 3.0. Conclusion: The overquantification by Cobas AmpliPrep TaqMan HIV-1 v2.0 over bDNA Siemens Versant HIV-1 RNA 3.0 is likely to be a result of its increased sensitivity. We recommend caution when comparing results from different methodologies, especially when a conventional assay and a real-time PCR assay are concerned.

Le diagnostic et le suivi des infections par le VIH, VHB et VHC restent un défi dans les pays à faibles ressources qui sont par ailleurs les plus touchés. Il est urgent de pouvoir disposer d'outils de biologie simples, fiables et peu chers pour le contrôle de ces infections virales. Le défi est immense d'un point de vue clinique et politique de santé. L'objectif de ce travail de recherche effectué dans le cadre de la présente thèse est de développer et valider des stratégies et de nouveaux outils de biologie adaptés au diagnostic et au suivi des hépatites virales et de l'infection VIH dans les pays à ressources limitées. Dans un premier temps, nous avons investigué sur les résultats de sérologie VIH discordants, car en biologie et en pratique clinique, il est important d'établir le statut sérologique réel des personnes dépistées avec des résultats clairs pour une prise de décision adéquate à l'échelle individuelle. Dans ce travail, nous avons trouvé que les résultats discordants par l'algorithme de dépistage des femmes enceintes au Burkina Faso, étaient dans 94% des cas de faux positifs dus au test Determine™ HIV-1/2 et 4% de faux négatifs liés au test Genie II™ HIV-1/HIV-2. En matière de santé publique, les femmes présentant ce type de résultat peuvent être considérées comme séronégatives dans les centres où des investigations supplémentaires ne sont pas possibles, surtout dans les pays comme le Burkina Faso où la prévalence de l'infection est basse avec une faible diversité génétique. Dans un second temps, nous avons focalisé nos travaux sur la faisabilité d'une stratégie de dépistage qui combine la détection des trois infections (VIH, VHB et VHC) sur une seule carte DBS. Dans cette étude pilote, nous avons démontré que le DBS collecté en parallèle au test rapide VIH dans un centre de dépistage volontaire permet d'une part de faire la confirmation du VIH par immunoblot, et d'autre part de compléter par le diagnostic des hépatites B et C par ELISA suivi de western blot et PCR pour la confirmation pour le VHC. Cette stratégie peut servir de modèle pour promouvoir et vulgariser le dépistage des hépatites virales B et C dans les pays à ressources limitées. Le DBS peut servir de contrôle et de confirmation du diagnostic du VIH, VHB et VHC. Par la suite, nous avons évalué la performance de deux tests de 4ème génération immunoluminométriques (Elecsys® HIV Combi PT assay, Roche Diagnostics et Liaison® XL Murex HIV Ab/Ag test, DiaSorin) sur des échantillons séchés sur papier filtre en comparaison au test de diagnostic rapide et aux échantillons de sérum frais prélevés chez les patients en primo-infection VIH. Ces travaux ont clairement montré que les deux tests de 4ème génération réalisés sur papier filtre offrent de bonnes performances dans le diagnostic de la primo-infection par rapport aux tests de diagnostic rapide sur sérum frais. Cette méthode peut être utilisée pour détecter précocement le VIH chez les personnes difficiles à atteindre et les populations vivant dans des zones périphériques des pays à ressources limitées. Enfin, nous avons mis au point une technique de PCR en temps réel de détection et de quantification de l'ADN du VHB. A cet effet, nous sommes partis de deux PCR « maison » ciblant deux régions génomiques différentes (gène X pour la qPCR 1 et gène S pour la qPCR 2) en comparaison à un test commercial de charge virale (Cobas AmpliPrep/Cobas TaqMan HBV Test, version 2.0, Roche Diagnostics). La qPCR 2 avec un seuil de détection à 91 UI/ml (vs 104 UI/ml pour la qPCR 1) a montré une meilleure performance dans la quantification de l'ADN du VHB. Cette qPCR 2 peu chère est aujourd'hui produite sous forme de kit par une start-up appelée OMUNIS. Ce kit en développement fera l'objet d'une évaluation multicentrique en France, en Afrique et en Asie du Sud-Est à travers un réseau de laboratoires sous la promotion de l'ANRS
Diagnosis and management of hepatitis B, hepatitis C and HIV infections are a real challenge in middle and low-income countries. There is an urgent need for simple, reliable and inexpensive tools to control these infections in high prevalence sittings like Africa and Asia. The challenge is immense in clinical and public health policy hands. The main goal of this research work performed for our PhD is the development and validation of strategies and tools to diagnose and monitor HIV, HBV and HCV infections in resource-constrained countries. At a first step, we investigated the results of HIV discordant results, since it is important to establish the real HIV status of people tested with clear results for appropriate decision-making in biological and clinical practice. This work show that discordant results obtained in the algorithm of HIV screening among pregnant women in Burkina Faso, are false positive results in 94% of cases due to the Determine™ HIV-1/2 immunochromatographic test and false negative results in 4% of cases due to the Genie II ™ HIV-1 / HIV-2 test. In public health practice, women with this type of result can be considered as negative for HIV testing in centers where additional investigations are not possible, especially in countries like Burkina Faso with a low incidence and a low genetic diversity of HIV.In a second step, we focused our work on the feasibility of a screening strategy that detects HIV, HBV and HCV infections into a single card of DBS. In this pilot study, we demonstrated that DBS collected in parallel to HIV rapid testing in a voluntary counseling and testing center allows HIV confirmation using immunoblotting, and an additional testing by diagnosing HBV and HCV using ELISA followed by immunoblotting and PCR for HCV confirmation. This strategy can serve as a model to promote and scale-up the screening of HBV and HCV in resource-limited countries. DBS can be served as control and confirmation of HIV, HBV and HCV diagnosis. Furthermore, we evaluated the performance of two 4th generation chemiluminescent immunoassays (Elecsys HIV Combi PT assay, Roche Diagnostics and Liaison XL Murex HIV Ab/Ag test, DiaSorin) tested on filter paper samples in comparison to rapid diagnostic test and fresh serum samples from patients with acute HIV infection. These studies have clearly shown that the two 4th generation tests performed on filter paper offer good performance in terms of sensitivity for the diagnosis of HIV infection in its early phases compared with rapid diagnostic tests. This approach may be used in combination with HIV rapid tests in hard-to-reach individuals and populations living in remote areas of when an early HIV infection is suspected since rapid tests do not offer appropriate performance in this case.Finally, we developed a real-time PCR for HBV DNA detection and quantification. In this study, we evaluated two in-house PCR targeting two different regions of HBV genome (X gene for qPCR 1 and S gene for qPCR 2) in comparison with a commercial Roche HBV DNA test (Cobas AmpliPrep / Cobas TaqMan HBV Test, version 2.0, Roche Diagnostics) as a gold standard. The qPCR 2 with a low detection limit of 91 IU/ml (vs 104 IU/ml for 1 qPCR) showed a better performance in HBV DNA quantification. This inexpensive qPCR with best performance characteristics is producing by a start-up called OMUNIS. This kit will be evaluated in France, in Africa and in South and East Asia in a research study funded by ANRS (France REcherche Nord & sud Sida-hiv Hépatites)

The school environment presents a valuable opportunity for the identification, monitoring and support of children made vulnerable by HIV/AIDS and poverty. Many children are caring for parents suffering from AIDS related illnesses and/or they are the main breadwimnner of the household. As a reult of HIV/AIDS and poverty therefore, children might be dropping out of school, or their ability to performadequately at school might be significantly reduced. The main aim of this study was to use a case study approach to explore and describe support provision in a South African formal school, examining in particular, the relative significance of leadership, organisational development and gender-related matters in addressing the needs of children made vulnerableby HIV/AIDS and poverty.The availability and quality of this support is analysed within the context of the Western Cape Education Department (WECD) transforming itself from a system focussed on controlling schools to a system focused on supporting schools.

BACKGROUND AND RATIONALE Acute HIV infection (AHI) is the period between the acquisition of the human immunodeficiency virus (HIV) and the development of HIV-specific antibodies that define seroconversion. AHI is characterised by high HIV viral replication and, in most cases, a transient non-specific febrile illness that typically occurs around 2 weeks after the HIV- transmission event. Primary HIV infection (PHI) is generally considered the period up to 6 months after infection and is a rapidly evolving phase characterized by the stepwise gain in positivity for the detection of HIV-RNA and HIV-specific antibodies. Different HIV antigen specificities appear in sequence after HIV transmission as do immunoglobulin G (IgG) subclass responses. As such, using different diagnostic tools, PHI has been categorised into ‘Fiebig stages’ that are useful in approximating infection date with relative accuracy. As a result of high viremia in bodily fluids, individuals are considered hyper-infectious during AHI. In areas of high HIV incidence, this phenomenon could contribute greatly to fuelling the worldwide HIV pandemic. Despite the importance of early diagnosis and treatment to reduce onward transmissions and prevent substantial irreversible immunological damage, AHI represents a ‘window period’ during which persons infected with HIV are commonly undiagnosed. Routine second generation HIV-rapid test algorithms provide negative or indeterminate results for up to 6-8 weeks after infection. During this time, HIV can only be diagnosed by detecting the presence of the virus itself. The current gold-standard test for confirming viremia is HIV-RNA viral load (VL) testing. However, technical and financial constraints make this technique very limited in low-income areas such as Sub-Saharan Africa, where the prevalence of AHI among febrile patients may reach 3%. VL testing is also used to monitor the efficacy of anti-retroviral treatment (ART). Achieving effective ART monitoring is a key determinant to ensure viral suppression and reach the UNAIDS 90-90-90 targets. Although considerable international efforts have resulted in a dramatic increase in ART coverage in the last years, relatively little progress has been achieved in the development of simple, accurate and affordable tools that allow proper surveillance of ART efficacy. VL monitoring is important for timely diagnosis of virological failure (VF) to allow early adherence interventions, prevent further transmissions and avoid delays in regimen switches that could lead to disease progression or emergence of drug resistances. Detecting virological failure depends on VL testing; whose availability is very limited in low and middle-income countries (LMIC) due to cost and operational constraints. The alternative to VL has often been clinical and/or immunological monitoring, which frequently results in patients remaining on failing ART as well as unnecessary regimen switches. Indeed, recent cross-sectional surveys reported that around 25%-35% of individuals on ART in Mozambique had detectable HIV viremia levels. As viremia increases during PHI, there is a striking cascade response of inflammatory cytokines. Significant efforts have been made to characterise host and viral proteins present during AHI aiming to identify biomarkers of progression or key pathological pathways that could be targeted to minimize HIV-induced immune damage over the course of infection. Subsets of T cells can be defined by their specificity, surface phenotype or degree of maturation, and any or all of these parameters can be affected by HIV infection. During PHI, many cells of the immune system show signs of extensive activation and a progressive loss of resting subsets. Generally, untreated HIV-infection is characterized by progressive CD4 T- cell depletion and CD8 T-cell expansion. The profound CD4 T-cell depletion is linked directly to the risk for opportunistic infections and mortality, while CD8 T-cell activation and exhaustion have been observed to be strong correlates of disease progression. Such alterations of CD4 and CD8 homeostatic mechanisms lead to progressive loss of the naïve and memory T-cell pool, resulting in an imbalance in T-cell phenotypes. Similarly, after HIV infection, accelerated aging of T cells or immunosenescence has been also associated with risk of adverse clinical events in HIV infected individuals. The challenges of identifying individuals during the AHI phase have resulted in a lack of critical information that constrains the development of therapeutic interventions. In this thesis, we provide a longitudinal characterization of T-cell subsets and the expression of soluble inflammatory biomarkers over the first year after PHI in a cohort of Mozambican adults and compare these changes with Chronic HIV-infection (CHI). Additionally, we assess the predictive power of these soluble biomarkers as surrogates of viremia for detection of AHI in seronegative febrile individuals and for identification of virological failure in ART- treated subjects. METHODS This thesis is based on research conducted at the Barcelona Institute for Global Health (ISGlobal)/ Hospital Clinic-Universitat de Barcelona in Spain, the AIDS Research Insitute/ Germans Trias i Pujol Research Institute (IGTP) and at the Centro de Investigaçao em Saude de Manhica (CISM) in Mozambique. To longitudinally analyze individuals during PHI, a screening based on reported-fever and pooled VL- testing was used to identify AHI in HIV-seronegative adults presenting at the Manhiça District Hospital (MDH), Mozambique. HIV-uninfected and chronically HIV infected individuals, both ART-naïve and on first-line ART, were also recruited at MDH in the context of the study. Plasma levels of inflammatory and immune biomarkers were subsequently determined by Luminex and ELISA, anti-HIV antibodies were analysed by flow-cytometry and Western Blot (WB) and T-cell phenotyping was performed through multi-panel flow- cytometry analysis. To evaluate biomarkers in treated HIV infected individuals, samples from a resistance survey study performed in 2013 were retrospectively analysed. The thesis is presented as a collection of four articles, of which three are accepted for publication in peer-reviewed international journals, and one is under review for publication. KEY RESULTS The findings from the studies that constitute this thesis provide a further characterization of the dynamics of immune response biomarkers over the different stages of HIV infection among adults in Mozambique. Immune response biomarkers across Fiebig staging at primary HIV infection A total of 85 AHI individuals were identified in our cohort as seronegative or indeterminate for rapid test and positive for plasma HIV-RNA among Mozambican adults seeking health care at the MDH. This represents an AHI prevalence of 3% among seronegative individuals reporting febrile illness. Soluble biomarkers, including inflammatory cytokines and general and HIV-specific antibody subtypes, were determined over different Fiebig stages at PHI, together with clinical and immunological characteristics. We compared cytokine levels between individuals at pre- (Fiebig I-IV) and post-seroconversion stages (Fiebig V-VI) at the screening visit. Thus, we identified a signature of four cytokines composed of BAFF, MCP-1, sCD163 and MIG that is highly associated with the PHI phase prior to development of the HIV-specific humoral response as determined by standard Western Blot serology. Longitudinal analysis of soluble and cellular biomarkers along the HIV infection process After longitudinal follow up of the PHI individuals, T-cell subsets and the expression of soluble inflammatory and immune biomarkers were characterized over the first year after of infection. Although plasma HIV viremia, CD4 and CD8 T cell counts undergo a rapid stabilization after HIV infection, several immunological parameters, including Th1Th17 CD4 T cells and activation or exhaustion of CD8 T cells continue to decrease even after 9 months post-infection. Importantly, no sign of immunosenescence was detected over the first year of HIV infection and no significant changes were observed in the Tregs population. Levels of IP-10, MCP-1, BAFF, sCD14, TNFR2 and TRAIL were significantly overexpressed at the first month of infection and underwent a prompt decrease in the following months. However, MIG and CD27 levels started to increase 1 month after infection and remained over- expressed for almost one year post-infection. Early levels of plasma TNFR2, sCD27, BAFF, IL- 10 and sCD14 cytokines were significantly associated with later levels of exhausted CD4 T- cells or with CD8 T-cell activation. Biomarkers as an accurate tool to identify acute HIV infection in febrile individuals In order to evaluate whether levels of a single or a combination of biomarkers had predictive accuracy to identify AHI among HIV-seronegative adults presenting with reported fever at the MDH, plasma levels of 49 inflammatory biomarkers from AHI (n=61) and non- HIV infected outpatients (n=65) were compared. The cytokine IP-10 demonstrated the best predictive accuracy for AHI detection (AUC=0.88 [95%CI 0.80-0.96]). A cut-off value of IP- 10≥161.6pg/mL provided a sensitivity of 95.5% (95%CI 85.5-99.5) and a specificity of 76.5% (95%CI 62.5-87.2) for AHI identification. Thus, an IP-10-based screening for subsequent AHI identification with VL could reduce the number of VL determinations necessary by 75%. After a cost-effectiveness analysis of this IP-10-based approach, we concluded that the implementation of an IP-10 screening test could avert from 21 to 84 new infections and save from US$176,609 to US$533,467 to the health system per 1,000 tested patients. IP-10 predictive power to detect virological failure in treated patients Due to the strong association with VL, we hypothesized that plasma IP-10 levels could be a surrogate marker of detectable viremia in ART-treated individuals. Consequently, we found that IP-10 levels were significantly higher in ART-treated subjects with detectable VL (108.2 pg/mL) as compared to those with undetectable VL (38.0 pg/mL) (U-test p<0.0001) in a cohort of 316 HIV-infected individuals on ART for more than a year. An IP-10 univariate model demonstrated high accuracy for prediction of detectable viremia (AUC=0.85 [95% Confidence Interval (CI) 0.80-0.90]). Using a cut-off value of IP-10≥44.2 pg/mL, the IP-10 model identified viremic ART-treated subjects with 91.9% sensitivity (95% CI 83.9-96.7) and 59.9% specificity (95% CI 52.0-67.4). Accordingly, we found that such IP-10 screening for potential virological failure would reduce by 43% the number of VL determinations required to monitor the same number of patients and this approach could potentially save 38% of VL-derived costs to the health system. CONCLUSIONS AND RECOMMENDATIONS AHI prevalence in febrile seronegative adults presenting at the MDH was found to be 3% as reported in 2008, having thus remained unchanged in this population in the last 5 years. After quantification of the soluble biomarkers across the different Fiebig stages described in PHI, we identified a signature of four cytokines composed of BAFF, MCP-1, sCD163 and MIG that was highly associated with the pre-seronversion phase as determined by WB serology. These effectors could provide clues for the development of vaccine or immunomodulatory strategies aimed at reducing the irreversible immune damage inflicted during PHI. Throughout characterization of cellular and soluble immune biomarkers along the different phases of HIV infection, we found that activated and effector memory CD8 T-cells together with Th1Th17 cells continued to decay several months after control of viremia. These findings indicate that balance in the T-cell compartments occurs months after viremia or CD4 count stabilize, suggesting persistent immune dysfunction in many different T cell subsets and raises the potential need for early initiation of therapy that could limit immunological damage. From the 49 soluble biomarkers that were assessed in febrile seronegative individuals, IP-10 demonstrated the best predictive power for AHI detection, providing a sensitivity of 95.5% and a specificity of 76.5%. Implementation of an IP-10-based screening for subsequent AHI diagnosis with VL is a cost effective strategy that could avert up to 84 new infections and save up to US$500,000 to the health system per 1,000 tested patients. IP-10 is also an accurate biomarker to screen individuals on ART for virological failure (VF), identifying 91.9% of patients with detectable viremia with a specificity of 59.9%. Employing IP-10 as a screening tool to target the individuals on ART most likely to require VL testing would reduce by 43% the number of VL determinations required to control viral suppression and it could save 38% of VL-derived costs to the health system. Thus, IP-10 quantification could be developed as a screening tool to identify both AHI in febrile seronegative individuals and VF in patients on ART with subsequent viral load testing. The implementation of these algorithms would facilitate AHI diagnosis and ART- monitoring in LMIC, as sub-Saharan Africa. Nevertheless, further research is necessary to explore the impact of other common HIV comorbidities on HIV-induced levels of IP-10, validate the IP-10 predictive power and optimize model cut-off values in other populations.
NTRODUCCIÓ: La fase aguda de la infecció pel virus de la immunodeficiència humana (VIH) és el període comprès entre l'adquisició del virus i el desenvolupament d'anticossos específics que defineixen la seroconversió i es coneix com AHI per les seves sigles en anglès (Acute HIV Infection). La AHI es caracteritza per un alt nivell de virus en els fluids corporals i, en la majoria dels casos, un quadre transitori de febre no específica. Com a resultat, els individus es consideren híper-infecciosos durant l'AHI i en zones o poblacions vulnerables d'alta incidència de VIH, aquest fenomen podria contribuir en gran manera a la pandèmia mundial del VIH. El diagnòstic precoç i l'inici primerenc del tractament són intervencions clau per reduir les potencials transmissions i prevenir un substancial dany immunitari irreversible. Malgrat la seva importància, el AHI representa un "període finestra" que pot durar fins a 2 mesos durant el qual les persones infectades només pot ser diagnosticades mitjançant la prova de càrrega viral (CV), que consisteix a detectar el ARN del virus en sang. La prova de CV també és necessària per al monitoratge de l'eficàcia del tractament antiretroviral. No obstant això, les restriccions logístiques, tècniques i financeres fan que aquesta prova de CV sigui d'accés molt limitat a les zones d'escassos recursos com l'Àfrica Subsahariana. OBJECTIUS: En aquesta tesi, es proporciona una caracterització longitudinal dels subconjunts de cèl·lula del sistema immune i l'expressió de biomarcadores inflamatoris solubles durant el primer any d'infecció en una cohort d'adults moçambiquesos i es comparen amb els nivells en la fase crònica de la infecció. A més, també s'avalua el poder predictiu d'aquests biomarcadores solubles per a la detecció de la AHI en individus seronegatius amb febre i per a la identificació de fallada terapèutica en individus tractats. RESULTATS: Es van testar un total de 4011 adults a l'Hospital Distrital de Manhiça (Moçambic), dels quals 3% dels individus seronegatius que van reportar símptomes febrils es trobaven en fase de AHI. Dels 49 biomarcadores solubles que es van avaluar, IP-10 va demostrar tenir el millor poder predictiu per a la detecció de AHI, proporcionant una sensibilitat del 95.5% i una especificitat del 76.5%. La implementació d'un cribratge de pacients amb simptomatologia febril basat en IP-10 per al posterior diagnòstic de AHI amb CV és una estratègia rendible que podria evitar fins a 84 noves infeccions en països d'alta incidència de VIH i estalviar més de 500,000US$ al sistema de salut per cada 1,000 pacients analitzats. L'IP-10 va demostrar també ser un biomarcador precís per detectar els casos de fallada terapèutica entre individus en tractament, identificant el 91.9% dels pacients amb viremia detectable amb una especificitat del 59.9%. CONCLUSIONS: La quantificació de la proteïna IP-10 podria desenvolupar-se com una eina per identificar tant AHI en individus seronegatius febrils com fallada terapèutica en pacients tractats mitjançant confirmació posterior per CV. La implementació d'aquests algorismes facilitaria el diagnòstic de AHI i el monitoratge del tractament en àrees d'escassos recursos, com l'Àfrica sub-Sahariana.
INTRODUCCIÓN: La fase aguda de la infección por el virus de la inmunodeficiencia humana (VIH) es el periodo comprendido entre la adquisición del virus y el desarrollo de anticuerpos específicos que definen la seroconversión, y se conoce como AHI (en inglés Acute HIV Infection). La AHI se caracteriza por un alto nivel de virus en los fluidos corporales y, en la mayoría de los casos, un cuadro transitorio de fiebre no específica. Como resultado, los individuos se consideran híper-infecciosos durante la AHÍ y en zonas o poblaciones vulnerables de alta incidencia de VIH, este fenómeno podría contribuir en gran medida a la pandemia mundial del VIH. El diagnóstico precoz y el inicio temprano del tratamiento son intervenciones clave para reducir las potenciales transmisiones y prevenir un sustancial daño inmunitario irreversible. A pesar de su importancia, el AHI representa un "periodo ventana" que puede durar hasta 2 meses durante el cual las personas infectadas sólo puede ser diagnosticadas mediante la prueba de carga viral (CV), que consiste en detectar el ARN del virus en sangre. La prueba de CV también es necesaria para la monitorización de la eficacia del tratamiento anti-retroviral. Sin embargo, las restricciones logísticas, técnicas y financieras hacen que esta prueba sea de acceso muy limitado en las zonas de escasos recursos como el África Subsahariana. OBJETIVOS: En esta tesis, se proporciona una caracterización longitudinal de los subconjuntos de células del sistema inmune y la expresión de biomarcadores inflamatorios solubles durante el primer año de infección en una cohorte de adultos mozambiqueños y se compara estos cambios con la infección por el VIH en la fase crónica. Además, también se evalúa el poder predictivo de estos biomarcadores solubles para la detección de la AHI en individuos seronegativos con fiebre y para la identificación de fallo terapéutico en individuos tratados. RESULTADOS: Se testaron un total de 4011 adultos en el Hospital Distrital de Manhiça, de los cuales 3% de los individuos seronegativos que reportaron síntomas febriles se encontraban en fase de AHI. De los 49 biomarcadores solubles que se evaluaron, IP-10 demostró tener el mejor poder predictivo para la detección de AHI, proporcionando una sensibilidad del 95.5% y una especificidad del 76.5%. La implementación de un cribado de pacientes con sintomatología febril basado en IP-10 para el posterior diagnóstico de AHI con CV es una estrategia rentable que podría evitar hasta 84 nuevas infecciones en países de alta incidencia de VIH y ahorrar más de 500,00US$ al sistema de salud por cada 1,000 pacientes analizados. El IP-10 demostró también ser un biomarcador preciso para detectar los casos de fallo terapéutico entre individuos en tratamiento antirretroviral, identificando el 91.9% de los pacientes con viremia detectable con una especificidad del 59.9%. CONCLUSIONES: La cuantificación de IP-10 podría desarrollarse como una herramienta para identificar tanto AHI en individuos seronegativos febriles como fallo terapéutico en pacientes tratados mediante confirmación posterior por CV. La implementación de estos algoritmos en la práctica clínica facilitaría el diagnóstico de AHI y la monitorización del tratamiento en áreas de escasos recursos como el África sub-Sahariana, permitiendo así un mayor control de la pandemia del VIH.

The aim of this thesis was to monitor the Varroa destructor parasitic mite in correlation with the microclimatic conditions of the Carniolan honey bee (Apis mellifera carnica). The rate of infestation of selected bee colonies at different locations was assessed in three-day intervals. At the same time, the microclimate in the hives was observed. The monitoring took place from April to mid-October. Also, the effect of the microclimate on the mite fall count was evaluated. During the whole evaluation, the highest average daily fall count was 2.08 mites per day at honeybee colonies at location 1 and 2; 1.97 at location 3. There was no statistically significant difference (P > 0.05) between those locations. The comparison of fall count between the moths of observation revealed, that highest fall count was during September (3.03 mites per day) and the lowest fall count was in April (0.41 mites per day; P 0.001). The rates of dependence (assessed by correlation analysis) between the fall count and microclimatic conditions in individual colonies varied. The strongest correlation between hive temperature and fall count (r = -0.45, P 0.05) was found at location 2. A low correlation was found at location 1 (r = -0.17, P 0.05). On the other hand, location 3 showed an insignificant and inconclusive correlation between hive temperature and fall count (r = 0.003, P > 0.05). The aggregate data (without distinction of location or month) showed significant (P 0.05) correlation between fall count and hive temperature (r = -0.14). The correlation between relative air humidity in hive and the fall count was statistically insignificant and low (r = -0.02, P > 0.05). The results revealed that the degree of correlation between the hive microclimate and the development (fall count respectively) of the Varroa destructor population is different for each colony. The monitoring of the dead Varroa destructor females is an appropriate complementary tool to diagnose a colony's infestation. The statistical analysis confirmed that with the decreasing summer and end-of-summer temperatures the Varroa destructor population grows and it is necessary to take measures to suppress its growth due to the development of the honey bee long-term winter generation.

Monitoring the adherence of patients taking highly-active anti-retroviral therapy (HAART) and Pre-Exposure Prophylaxis (PrEP) is a key step in treating an HIV infection. For most regimens, when patients are not at least 95% adherent to their drug schedule there is a loss of effectiveness in treatment resulting in increases of health care costs, increases of the rate of transmission, and reduction of positive patient outcomes. Currently, subjective methods such as pill counting, electronic drug monitoring, and patient self-reporting are the only ways clinicians can track adherence and intervene in cases of non-compliance. We address this issue by developing colorimetric solutions to directly assay for the presence of common HIV drug metabolites in urine. First we developed a dipstick based point-of-care azide-alkyne click chemistry assay with colorimetric readout that directly tests for the presence of azidothymidine (AZT). An alkyne-modified dextran was synthesized and characterized by NMR and then used to colorimetrically report the presence of AZT in urine samples. The assay is specific to azide-containing molecules that are not naturally present in the urine and is sensitive to physiologically relevant urine concentrations as low as 750μM. Second we adapted the Wheeler and Johnson test, originally discovered for the determination of uracil and cytosine, for colorimetric readout of lamivudine (3TC) and emtricitabine (FTC). The cytosine base of these molecules is reacted with bromine and precipitated by barium hydroxide to give a purple color to the solution. The protocol was adapted to be performed easily with urine samples at physiological concentrations. Finally, an antibody-based lateral flow device has been designed for the detection of tenofovir (TFV). Direct application of urine to the lateral flow device gives fast, clear, and reliable readouts of TFV detection. All of these colorimetric assays, which can be done in resource-limited settings with minimal equipment, are all strong alternatives over current direct measurement techniques that are expensive and require trained users such as HPLC and NMR. In addition the detection of AZT and TFV can be deployed at the point-of-care for direct monitoring where the need is greatest.

In dieser Untersuchung wurde die praktische Bedeutung des Therapeutischen Drug Monitorings (TDM) in der HIV-Therapie an 2634 Plasmaproben von 1929 Patienten in mehrfacher Hinsicht gezeigt. Unterschiedliche Therapieumstände erfordern im Einzelfall sowohl für die Proteaseinhibitoren LPV, RTV, APV, SQV, NFV, IDV und ATV, als auch für die Nicht-Nukleosidalen Reverse-Transkriptase-Hemmer EFV und NVP ein Therapeutisches Drug Monitoring. Bei Begleitmedikation mit nicht-antiretroviralen Präparaten konnten die pharmakologischen Interaktionen größtenteils bestätigt werden. Als Beispiel sei die Komedikation mit Carbamazepin genannt, wodurch mit 5733,1±1768,9 ng/ml ein erniedrigter LPV-Plasmaspiegel im Vergleich zum Referenzwert von 6207,3±4110,0 ng/ml resultierte und die Wirkung von Carbamazepin als Induktor des Enzymsystems gezeigt werden konnte. Ein ähnliches Verhalten ergab sich bei Kombination von Carbamazepin mit RTV und mit NFV. Zum Erreichen optimaler Plasmaspiegel, die für die Therapie ausreichend effizient sind und die Toxizität nicht erhöhen, ist ein TDM für alle PI und NNRTI notwendig. Weiter konnte gezeigt werden, dass ein Therapeutisches Drug Monitoring ein wichtiges Instrument zum Aufdecken von Complianceproblemen sein kann, insbesondere gilt dies für LPV, RTV, SQV, IDV, EFV und NVP. Bei Therapieversagen ist die Interpretation des TDM häufig schwierig. Erniedrigte Spiegel konnten für LPV, APV, SQV, NFV, ATV und EFV gezeigt werden. Die Bedeutung des TDM liegt in der Vermeidung suboptimaler Konzentrationen. Die Notwendigkeit eines TDM bei Vorliegen von chronischen Lebererkrankungen konnte anhand von 301 Patienten gezeigt werden. Insbesondere für LPV, APV, SQV, NFV, IDV, EFV und NVP waren erhöhte Plasmaspiegel nachweisbar. Auch das Auftreten von Nebenwirkungen lässt ein TDM und eine darauf beruhende Dosisanpassung für alle untersuchten PI und NNRTI empfehlen. Bei ART-Kombinationen von PI und NNRTI ist ein TDM unbedingt erforderlich, da das Ausmaß der Interaktionen, die durch die antiretroviralen Medikamente verursacht werden, großen individuellen Veränderungen unterliegt. Die Notwendigkeit eines TDM konnte für alle untersuchten PI und NNRTI bestätigt werden. Insgesamt wurden in dieser retrospektiven Untersuchung die möglichen pharmakologischen Interaktionen der PI und NNRTI größtenteils bestätigt. Unterstrichen wird dadurch die Bedeutung des TDM bei der Betreuung HIV infizierter Patienten im klinischen Alltag
This is a retrospective study that includes 2634 plasma levels from 1929 patients. The importance of Therapeutic Drug Monitoring (TDM)could be shown for cases of combination of antiretroviral drug with non-antiretroviral drugs. For example reduced Carbamazepin the plasma level of LPV, RTV and NFV. The need of TDM could be shown for non-compliant patients especially for such who take LPV, RTV, SQV, IDV, EFV and NVP. The study also shows the need of TDM in cases of liver disease, failure of therapy and side effects. Because of interactions is in the case of combination of antiretroviral drugs with other antiretroviral drugs a special need for a TDM. This could be shown for all PI and NNRTI

Nevirapin ist ein Nicht-Nukleosidaler Reverse Transkriptase Inhibitor, welcher seit 1996 in der Therapie der HIV-Infektion eingesetzt wird. Im wissenschaftlichen Labor des Schwerpunktes Hepatologie/Infektiologie der Medizinischen Klinik und Poliklinik II des Universitätsklinikums Würzburg werden im Rahmen der therapiebegleitenden Diagnostik bei Patienten mit HIV-Infektion regelmäßig Nevirapin-Plasmakonzentrationen bestimmt. Anhand einer statistischen Auswertung der von 1996 bis 7/2002 gemesssenen Nevirapinspiegel werden in der vorliegenden Arbeit zunächst Einflussgrößen auf inter- und intraindividuelle Variabilität der Plasmakonzentrationen identifiziert. Den stärksten Einfluss auf die interindividuelle Streuung hat dabei das Patientengewicht, weitere Einflussfaktoren sind Rauchen und Compliance der Patienten. Auf Grundlage der Ergebnisse werden Kriterien für eine Dosisanpassung in bestimmten klinischen Situationen erarbeitet. Im zweiten Teil der Arbeit werden akute und langfristige Nebenwirkungen der Nevirapintherapie untersucht. Hautausschlag und Leberwerterhöhung treten vor allem in den ersten Wochen der Therapie auf. Weibliches Geschlecht und hohe CD 4-Zellzahl am Therapiebeginn können als Risikofaktoren für das Auftreten dieser Nebenwirkungen identifiziert werden. Eine Steroidtherapie erscheint aufgrund der vorliegenden Einzelfalldarstellungen vorteilhaft und damit indiziert. Im langfristigen Verlauf steigt die GGT-Aktivität auf etwa das doppelte des Ausgangswertes an, GOT- und GPT-Aktivitäten ändern sich kaum und bei der LDH und der AP kann ein Anstieg in den ersten acht Therapiewochen beobachtet werden. Hepatitis B- und C-Koinfetion haben in dieser Auswertung keinen Einfluss auf nevirapinbedingte Leberwerterhöhung. In Übereinstimmung mit Daten aus der Literatur wird ein deutlicher Anstieg des HDL unter der Nevirapintherapie gefunden. Schließlich wird im dritten Teil dieser Untersuchung die Wirksamkeit der NVP-Therapie anhand von Viruslast- und CD4-Veränderungen analysiert. Bei der Mehrzahl der Patienten kann eine gute Wirksamkeit mit anhaltender Suppression der Viruslast und kontinuierlichem Anstieg der CD4-Zellzahl beobachtet werden
Nevirapine is a Non-nucleosidic Reverse Transcriptase Inhibitor, currently in the therapy of the HIV-infection. Nevirapine plasma concentrations are regularly determined in patients with HIV-infection at the scientific laboratory of the Division of Infectiology at the Medical Policlinic of Würzburg. With help of a statistical evaluation of Nevirapine plasma levels taken between 1996 and 7/2002, reasons for intra-patient and inter-patient variability are identified. Differences in body weight turn out to be the most important reason for inter-patient variability. Other factors with influence on Nevirapine plasma levels are compliance of patients and smoking. On the basis of the results of this evaluation, a suggestion for dosage adjustment of Nevirapine in certain clinical situations is made. In the second part of this treatise, acute and long-term side-effects of Nevirapine therapy are investigated. Rash and enhancement of liver enzymes mainly appear during the first few weeks of therapy. Risk factors for the occurrence of these side effects are female gender and a high CD4 cell count at baseline. Therapy with steroids did have a positive effect in all reported case histories and therefore appears to be indicated for patients with acute side effects. Observed over a prolonged period, the activity of GGT increases to about double the amount of baseline, GOT and GPT do not change significantly, and for LDL and AP an increase during the first eight weeks of therapy could be observed. Coinfection with Hepatitis B and C do not influence Nevirapine-associated liver encyme enhancement in this evaluation. A significant increase of HDL during the time of Nevirapine therapy is found in accordance with results of earlier studies. Finally, the efficacy of Nevirapine therapy is analysed with help of viral load and CD 4 cell count parameters. A good efficacy of therapy with lasting depression of viral load and steady increase of CD 4 cell count could be observed in most patients