This thesis explores the dynamics of HIV/AIDS in the Venda region of South Africa through an exploration of post-apartheid traditionalism and the anthropology of knowledge at the juncture of planned AIDS interventions. It argues that current policies of peer education act to reinforce the patriarchal Venda aetiology through which men and older women explain sexually transmitted infections in terms of blood related taboos and the build up of pollution. This has resulted in a situation where many Venda men are more concerned with who they sleep with, rather than how "safe" the encounter may be, and has reinforced or even given rise to widely held idea that condoms cause AIDS. By looking at AIDS education through the political economy of traditional leadership in the region, the thesis locates concepts of AIDS, musical performance, power, generational authority, death and secrecy in the context of a post-apartheid struggle for the consolidation of political power between the royal houses of Mphephu and Tshivhase. This has exacerbated historical tensions between the rival centres of power, and encouraged the implementation of policies through which the ANC doctrine of African renaissance has taken centre stage. It argues that, in this context, official attempts to increase the frequency of female initiation schools have bolstered the generational authority of older women and increased the extent to which HIV/AIDS is understood through the "folk model" of blood taboos and pollution. Although peer education creates a space in which younger women - mostly through the singing of songs - promote biomedical notions of sexual health and healing, this space should not be conceptualised simply as a site of "resistance" against these structural forms of authority. It also provides them with a basis for securing positions of employment in health-related government programmes, and as such acts as a potential vehicle for upward mobility among the rural poor. Their desire to change the social/sexual health environment is thus matched by their desire to transcend and move away from it, given that it constructs them as vectors of the virus.

This thesis contributes to an understanding of how gender norms shape HIV / AIDS risk perception, but importantly, the responsive actions taken by men and women to reduce noted risks. Data was gathered in mid-2008 in Cabo Delgado Mozambique and consisted of 16 participatory group discussions to better understand local norms and HIV / AIDS risk determinants and 29 in-depth interviews to explore how gender views interface with risk reduction efforts. The theory of triadic influence and gender and power theory were used in the conceptual framework to guide the research in terms of the factors that influence risk across a multitude of levels. The findings are based on three key social situations where HIV / AIDS risk was deemed high by respondents and where the interplay of gender norms between men and women could be analysed in greater detail: 1) partner behaviour; 2) marriage and 3) the exchange of sex for resources. Men and women who actively take measures to decrease the threat of HIV / AIDS do so in a context of often repressive gender norms, however, the decision to engage in risk reduction behaviour is also based on other factors including an assessment of risk, various level of influence from family or peers, prior experience, relationship dynamics and a reflection of broader personal outcomes. The findings demonstrated that the move towards more gender balanced relationships and norms, while essential for reducing HIV / AIDS disparities in prevalence rates and risk, are not a precondition for the employment of HIV / AIDS risk reduction strategies. Efforts however, should continue to promote gender equality in its own right as well as to help reduce HIV / AIDS risk among men and women. Programmes should simultaneously build on local gender dynamics and norms and incorporate strategies already being used by men and women to reduce HIV / AIDS risk into interventions and policies.

Estimates of total prevalent human immunodeficiency virus (HIV) infections make an important contribution to public health planning. HIV test data has become increasingly important to the monitoring of the HIV epidemic, however a large proportion of HIV infections remain undiagnosed in the early stages of infection. This thesis aims to develop a method to estimate total HIV infections in men who have sex with men (MSM) in the United Kingdom (UK) using surveillance data on HIV testing. A conceptual framework for the relationship between HIV testing and risk of HIV infection was developed. A review of literature showed that HIV testing was associated with socio-demographic factors like increasing age and area of residence. HIV testing was also associated with higher-risk behaviours such as unprotected anal intercourse and increased numbers of sexual partners. This thesis identified and quantified factors associated with both HIV testing and risk of HIV infection in MSM in the UK through two studies. The first was an analysis of a national representative study and the second a cross-sectional unlinked anonymous HIV seroprevalence study of MSM attending a genitourinary medicine clinic (GUM) in inner London. An investigation of the National Survey of Sexual Attitudes and Lifestyles found that 36.6% of MSM had HIV tested in the past 5 years. HIV testing was associated with area of residence and increased numbers of sexual partners. The unlinked anonymous study found that MSM who had HIV tested were at higher risk of HIV infection compared to MSM who had not and that history of sexually transmitted infections was associated with HIV infection. A comparative analysis with a community-recruited study of MSM provided upper and lower behavioural bounds. Finally, a model based on the conceptual framework which extrapolated all diagnosed HIV infections in MSM to give reliable estimates of total HIV infections in the general MSM population, including undiagnosed HIV infections, was developed. This thesis has provided a unique methodology to estimate total HIV infections in MSM in the UK.

Introduction: The obesity epidemic is leading to wide-ranging public health problems and potentially reduced life expectancy. This thesis aims to characterise secular trends of anthropometric change among Singaporeans aged 6 to 18 and explore relationships of their latent body mass index (BMI) Z-score growth trajectories during childhood and adolescence on mental health status in later life. It also presents a systematic review of the evidence on the associations of weight change on later life health outcomes. Methods: The uniqueness of this research lies in the development of a new Singapore Longitudinal and Life Course Cohort (SLLCC), an extensive individual-level dataset of repeatedly measured anthropometric data, from about 2.7 million students born between 1973 to 2003, collected through routine annual school-based health screening programmes from 1990 to 2011. Life course growth models were used to model latent developmental trajectories in the SLLCC and age-period-cohort (APC) analyses were conducted to determine secular trends in BMI. Results: Cohorts of people born from 2000 to 2010 had successively higher body weights than cohorts born two decades earlier. These effects were attenuated when cohort influences were removed. Findings from piecewise linear regression and the Zivot-Andrews Unit Root test suggested an upward shift in obesity rates for children aged 6 to 12 years and a levelling off between ages 13 to 18, occurring around the year 2008. In a sub-sample of 519 members of the SLLCC cohort linked with the 2010 National Health Survey, results from latent class growth mixture modelling suggested that individuals who experienced a distinct developmental trajectory of an increasing rate of weight gain from age 10 resulting in obesity at age 16 was associated with a 37% increased risk of later poor mental health well-being, all else held constant. This is the first study to show that cumulative duration of obesity during childhood and adolescence is associated with significant risks of psychological distress later in life. Discussion: The findings from this thesis could lead to new evidence-informed public health imperatives for investments to monitor early childhood growth development so as to mitigate deleterious effects on health, social and economic outcomes in adulthood.

Within high HIV prevalence settings, the integration of HIV and SRH services has been widely regarded as beneficial in not only improving individual outcomes and reducing HIV transmission, but also improving the efficiency of service delivery. However, while ample evidence exists on the behavioural, health and social outcomes, evidence on the economic benefits of integrating these services remains scarce which is a barrier to creating effective policy. This thesis therefore aimed to contribute to the understanding of the optimal organisation of HIV and SRH services in high and medium HIV prevalence settings. To achieve this aim, data was collected from 40 health facilities providing integrated HIV and SRH services in Kenya and Swaziland. Costs of providing these integrated services were estimated and the impacts of integration (among other organizational and contextual factors) on the technical and cost efficiency explored using non-parametric and parametric methods respectively. This thesis presents the first study to analyse both technical and cost efficiency in this context. It further extends the literature on efficiency measurement in low and middle income settings by considering two particularly relevant aspects of health care provision: quality of care and the impact of organisational and contextual factors on the technical efficiency of health facilities. The findings from this thesis are especially relevant to the on-going discussions of the optimal organisation of HIV and SRH services in resource constrained settings. These findings not only show that inefficiencies exist in the provision of integrated HIV and SRH services but underscore the importance of investigating both technical and cost efficiency as the results differ depending on the type of efficiency analysed.

The integration of Antiretroviral Treatment (ART) for HIV in to South African primary health care (PHC) and task shifting are increasing nurses' role in ART and H/V care. There is evidence this role is motivating nurses to adopt more patient-centred care. This study explored this potential emergence of more patient centred care in PHC in the Free State province, South Africa. A multi-site, mixed-method observational approach was used, building on ethnographic principles. A purposive sample of four clinics, two providing ART and two not, were the focus for observation and interviews through four phases of data collection. Emerging findings were explored in an additional six clinics in later phases of data collection. 34 professional nurses, 6 members of clinic staff and 21 patients were interviewed. A thematic analysis that aimed to develop theory grounded in the study contexts through integrating existing theory with inductively identified themes was used. The study found care is patient centred and integrated to a limited extent, while ART and HIV care are more likely to be patient centred than other aspects of PHC. These care routines are then shown to emerge from nurses' agency mediating different levels of structure: the rules of clinic interaction and then the clinic context. Further analysis of nurses' agency explores how it is shaped by a complex identity and a health system context of constant change. The study provides in-depth understanding of a little explored health services issue, and is the basis for recommendations to support patient centred and integrated care. The analysis supports the reconceptualisation of patient centred care to consider Issues of convenience, as a response to the specific context of nurse-led PHC in South Africa. The study also introduces a structure-agency theoretical framework that can be applied to the context of nurse-led PHC.

Despite progress in increasing uptake of HIV testing and treatment, preventing new HIV infections remains a challenge for South Africa. Though in the last decade interest has grown in interventions using sport to promote health, rigorous evidence supporting the effectiveness of these interventions is limited. Also, although there is some evidence that SMS-based interventions can effectively promote healthy behaviour, few evaluations have been carried out. In 2012, a three-year cluster-randomised trial was launched to assess the effectiveness of a sport-based HIV prevention (SBHP) intervention and associated SMS campaign. The trial enrolled 46 schools in informal settlements in Cape Town and Port Elizabeth. Schools were randomised to receive the SBHP intervention or standard life-orientation classes only, with intervention schools randomised to receive (or not receive) biweekly SMS’s reinforcing the intervention. Self-administered questionnaires were completed on touchscreen mobile phones at baseline (n=4485) and midline (8-11 months post-intervention, n=3442) to assess the intervention’s effectiveness in reducing reported sexual risk behaviour and improving HIV-related knowledge and reported attitudes. Random-effects logistic and linear regression was used to assess differences between study groups at midline, adjusting for age, site, school-level clustering and baseline prevalences. Very strong evidence of a positive effect of the intervention was observed on HIV-related knowledge (β=0.39, 95%CI=0.25-0.53) among males and females and on reported HIV testing in the last year (OR=1.47, 95%CI=1.13-1.90) among males. There was, however, strong evidence of a negative effect on reported multiple partners in the last six months among males (OR=1.34, 95%CI=1.08-1.66) and on reported perpetration of intimate-partner violence by males (OR=1.27, 95%CI=1.00-1.60). There was strong evidence of that including SMS’s in the intervention reduced reported multiple partners in the last six months (OR=0.75, 95%CI=0.58-0.96). The midline results suggested the SBHP intervention was not effective in achieving its primary behavioural objectives but did improve HIV-related knowledge and HIV testing uptake among males. They provided further evidence that SMS’s may be an effective sexual health promotion tool. Further qualitative research is investigating why the intervention may have led to an increase in certain risk behaviours.

Background and objectives: Men who have sex with men (MSM) remain one of the groups with the highest HIV prevalence in the UK. The goal of this study is to help inform appropriate health policy by investigating the contribution to HIV transmission of various MSM subgroups and estimating the impacts of alternative HIV control measures. The future course of the epidemic is also projected. Methods: Research questions were addressed through the use of rigorous data analysis and a partnership-based HIV transmission model that takes into account key MSM and HIV heterogeneities and intervention effects. The model was fitted and validated against the observed data and reported estimates of various types. Sensitivity analyses were conducted throughout the study to assess the effects of parameter uncertainty. Results Without additional interventions, the estimated 44,000 UK MSM living with HIV in 2013 could increase to around 52,000 men by the end of the decade, with around 2,400 new infections each year. The key group sustaining HIV transmission was the higher-sexual activity MSM aged below 35 years living with undiagnosed asymptomatic HIV. Pre-exposure prophylaxis (PrEP) with 44% efficacy and 100% coverage would prevent approximately 10,000 cases (59% of total incidence) over 2014–2020. Simultaneously offering PrEP, expanding HIV testing, and initiating a test-and-treat programme in 25% of different target populations could save around 7,400 UK MSM from HIV. An extreme increase in unsafe sex and number of sexual partners would greatly reduce the incidence reduction but is unlikely to completely negate the prevention benefit. Conclusion: Increasing HIV testing uptake should remain the core of the national HIV/AIDS strategy, but a combination of HIV prevention interventions are also necessary to enhance the overall performance of HIV control measures. Combining a program to expand HIV testing with other novel interventions, such as test-and-treat and PrEP, has a great potential to save thousands of UK MSM from HIV and become the key HIV prevention initiatives in the UK.

In this thesis the problem of planning under uncertainty is examined. A classification of uncertainty is given with the purpose of identifying those areas where traditional methods for planning under uncertainty fail to prescribe suitable courses of action. Traditional planning methods have increasingly proved inadequate in their handling of the uncertainty inherent in complex and turbulent environments. Methodologies suitable to planning under uncertainty should attempt to preserve future flexibility, by keeping options open for later resolution. This thesis describes the development of Scenario-Robustness Methodology (SRM), a flexible methodology for planning under uncertainty. SRM uses scenario analysis to develop altemative futures, and robustness analysis to determine the most flexible options under those futures, for both the short and long term. A new criterion is proposed for evaluating the consequences of initial decisions in terms both of the positive options which are maintained and of the undesirable options still left open. This criterion is a composite measure which enables decision-makers to give relative weights to positive outcomes (robustness) or negative outcomes (debility), by varying a key parameter. A number of alternative measures of uncertainty which may be employed in a planning situation characterized by a set of initial decisions and a set of altemative future scenarios, are also examined. The coefficient of concordance W is found to be the most useful of such measures. An example is given of the application of SRM to an HIV/AIDS-related resource allocation problem. Planning for HIV/AIDS is selected as a suitable area of application because of the uncertainties surrounding the nature of the disease, the availability of treatments and their timing, and the size of the planned for population. SRM is used to assist in structuring the problem and to identify those initial commitments which are preferable in terms of flexibility. The problem structuring capability of SRM is of particular value since it initiates a process of reflection and negotiation which helps to incorporate in the analysis, in addition to flexibility, other relevant factors which will shape the final selection of an appropriate course of action.

Part I of this thesis, reviews research pertaining to quality of life and personality in HIV. Conceptual and methodological issues, which hinder research into quality of life and personality, are discussed. The review notes the lack of research into personality and HIV beyond prevention, and the need to investigate personality beyond neuroticism and extraversion. The review concludes that further replication of the reported associations between personality and quality of life in HIV is required. Studies that consider clinical directions and potential interventions are needed. The empirical paper presents a cross-sectional, questionnaire, study looking at the relationships between personality, quality of life, and cognitive schemas, in HIV positive gay men. The study found that HIV is associated with poorer quality of life. Higher levels of neuroticism, and lower levels of extraversion, were found in the HIV positive group compared with the HIV negative group. Neuroticism and extraversion significantly predicted quality of life, and significant correlations were found between cognitive schemas and quality of life. Factor analyses of the Schema Questionnaire suggest problems with the measure. Results of the study are discussed with regard to future studies, and clinical implications. The final part of the thesis is a reflective paper. It begins with a presentation of the processes leading to the conception of the research, and a discussion of clinical experiences that have informed and impacted on this process. An extended discussion of the strengths and weaknesses of the research is presented, followed by a consideration of the clinical and scientific implications of the research. In the final sections of the paper, the author reflects on how the research has shaped her clinical understanding, and the methodological lessons learned.