Background: HIV policy states that palliative care is required from diagnosis onward, but evidence of the prevalence, severity and duration of patient-centred problems at HIV diagnosis is very limited, particularly in Africa. This thesis aims to determine palliative carerelated problems reported by outpatients over three months from diagnosis, taking a patient-centred approach. Methods: A prospective observational cohort was conducted in Kenya and Uganda. Twelve HIV facilities each consecutively recruited 100 adults and those diagnosed within 14 days previously were selected. Outcomes were the seven patient-response items of the APCA African POS, a validated instrument completed at four monthly intervals. Cross-sectional analysis used ordinal logistic regression (cross-sectional multivariate), proportion of net change (longitudinal univariate) and population averaged fixed-effects conditional logistic regression (longitudinal multivariate). Results: Among 438 participants (aged 18-59, 67% women), problems are highly prevalent at diagnosis (47% received no help and advice, 11% severe worry, 6% severe pain). Problems decrease over time on average but many persist after three months (e.g. 28% unable to share feelings). Physical problems decrease most rapidly, psychosocial more slowly. Poverty is a risk factor for pain, symptoms and difficulty finding life worthwhile(OR=0.8-0.9). Five outcomes are exacerbated by limited physical function(OR=1.6-3.1) but none are associated with CD4 count. Uniquely, difficulty sharing feelings is more common over time for those with full physical function (OR=0.7) and the highest relative wealth(OR=1.2). Psychosocial and spiritual problems are more severe in Uganda (OR=2.7-3.3). Patients taking antiretroviral therapy have fewer symptoms, more peace, and more help/advice(OR=0.6=0.7). Conclusion: This thesis presents the highest quality evidence of patient-reported problems at HIV diagnosis. Physical, psychological, social and spiritual problems are common and severe, requiring holistic assessment and management. The findings are relevant to service development in the context of scaled-up testing services for access to antiretroviral therapy. Staff need palliative care training, with support from specialist centres for intractable problems. This research contributes longitudinal analysis techniques appropriate for resource-limited settings, helping overcome research barriers.

HIV/AIDS programmes have been running in the informal settlements around Rundu, a town in Northeast Namibia, for more than a decade. Yet in spite of concerted efforts by government agencies and civil society organisations to promote broad and deep participation in these programmes, residents still express little sense of ownership of them. Drawing on fourteen months of ethnographic fieldwork, this thesis describes how different groups of actors within the locale have experienced and interpreted the fight against HIV/AIDS, and in doing so explores the micro-social processes that have hindered the expansion of a sense of ownership of HIV/AIDS programmes beyond a relatively small cadre of actors: programme managers, AIDS activists and prominent volunteers. This thesis presents a thick description of the fight against HIV/AIDS as a tangle of practices, assumptions, affective structures and a system of commonsense reasoning that cohere around a network of loosely affiliated organisations situated within but at the same time often distinguished by respondents from the wider social milieu of Rundu. Drawing on Kleinman’s (1992) concept of local moral worlds, these intersubjectively constructed contexts of shared experience are referred to as the local moral world of the fight against HIV/AIDS in Rundu. The account of the local moral world of the fight against HIV/AIDS presented in this thesis enables the identification of socially embedded structures of conditionality that shape local understandings of where ownership of HIV/AIDS programmes lies. Three main issues are explored: local accounts of differentiated cultural orientation in relation to the local moral world of the fight against HIV/AIDS; the social construction of “legitimate” knowledge and the distribution of symbolic power in relation to HIV/AIDS programmes; and the challenge of building deep trust between actors at the centre and periphery of HIV/AIDS programmes who operate within what are often quite different local moral worlds.

This research focused on the service use of HIV-positive mothers. My aim was to explore service use from the perspective of users and potential users of voluntary and statutory social services for people with HIV infection. This approach was prompted by the assumption I thought to underlie much of the much of the literature on HIV services, namely, that once a need had been identified and a relevant service provided, and adequately publicised, it would be used. I decided to adopt a case study approach focused on Edinburgh. The city, with its relatively high prevalence of HIV infection and density of social services, provided an excellent location for a contextualised exploration of service use. To deepen my knowledge of this context, and prepare for interviews with HIV-positive mothers, I first interviewed ten service providers including funders and representatives of statutory and voluntary, child-centred and adult-focused services. My concern to explore the social processes, attitudes and experiences underlying the use and non-use of services informed my choice of qualitative methods. The study is primarily based on in-depth, semi-structured interviews with 12 women, who had lived with HIV infection for between seven and 12 years. To reflect the unpredictability of living with a chronic condition interspersed with acute episodes, I decided to interview the respondents twice over the course of some months. Drawing on the high level of intermediate analysis completed between the two interviews, the second interviews were also used to explore recurrent themes raised in the first interviews further, and to map the chronology of each respondent's service use against other important life events. My findings attest to the importance of exploring chronic illness and service use in the context of wider social, familial and caring relationships, as well as socioeconomic circumstances. I focus on the relationship between service use and a continuing process of post-diagnosis identity reconstruction. My analysis of this process relates not only to the diagnosis itself, but explores several other sources of, or influences on, post-diagnosis identity construction, and the inter-relationships between them. These include motherhood, work, intimate relationships, infonnal support and participation in service decision-making. The theoretical and policy implications of these findings for the development of services are also addressed.

During the 1990s, empowerment through collective action became widely referred to by feminist anthropologists and health behaviouralists as a potential approach towards reducing HIV and AIDS amongst African women. However, conflicting understandings of empowerment ultimately positions African women as too disempowered to protect themselves from HIV and AIDS, but empowered enough through collective participation to challenge structural and gender inequalities that facilitate HIV transmission. By the next decade, many prevention programmes around the world were said to have been unsuccessful. This thesis explores these issues; first, by examining different understandings of empowerment; second, by investigating a potentially alternative model of participation underpinned by post-modern, feminist post-colonial and social psychological theory; and finally, by analysing women's own narratives of empowerment. To do so, this thesis reviews life histories of forty-five women aged between their twenties and sixties, participating in one of five women's associations. The movements and individuals were selected in order to consider the diversity of experiences across age, ethnicity, sexual identity, social class and religion. This consideration of the realities of women's lives found that gender and social identities shape women's individual and collective responses to HIV and AIDS in ways that extend beyond employing traditional prevention methods which are said to police sexual behaviour. Nevertheless, their diverse experiences also suggest alternative notions and sites of power, thus enabling them to employ strategies and charter avenues of agency that facilitate AIDS prevention in some contexts, but hinder it in others. These alternative notions of power and agency have implications for reconfiguring and expanding HIV and AIDS prevention and, possibly, gender relations. The thesis considers the extent to which alternative empowerment strategies, executed between the contours of donor- driven programmes and everyday reality, contribute to disrupting dominant discourses as well as gender norms and expectations predicated on tensions around representations of respectability, 'African' sexuality, spirituality, health and illness, and AIDS citizenship.

The first substantive chapter (II) addresses the macroeconomic impact of HIV/AIDS, with reference to sub-Saharan Africa. The framework is designed to capture some interactions between the formal and the informal sector, and - reflecting open capital markets of many economies affected by HIV/AIDS - to address the implications of capital mobility. Additionally, our study is the first academic study of the growth impact of scaling up antiretroviral treatment. Allowing for capital mobility, our analysis returns a stronger impact of HIV/AIDS on output and income per capita than the corresponding closed-economy models. The estimated impact on the informal sector is more pronounced than for the formal sector, reflecting a stronger impact of HIV/AIDS on savings rates. GDP per capita is lower in the scenario with comprehensive scaling-up of antiretroviral treatment, as rising costs of care and treatment affect savings rates. Chapter III adapts a microeconomic framework with forward-looking agents to study the contributions of health, as well as income, to living standards, drawing on empirical work on the value of statistical life. For leading industrialized countries, the contribution of health over long periods of time has been of similar magnitude as rising incomes, but the contribution of health has slowed down since about 1950. For developing countries, the slowdown occurred somewhat later. HIV/AIDS has resulted in steep declines in living standards in a number of countries in sub-Saharan Africa. Chapter IV focuses on the impact of capital-deepening arising from falling relative prices of ICT equipment. The estimated impact of ICT-related capital deepening on growth in developing countries is substantial (about 0.3 percentage points), although lower than comparable estimates for leading industrialized countries. Unlike in some industrialized countries, the impact of ICT-related capital deepening has not slowed down after 2000, owing to growing absorption of communications equipment.

This thesis aims to investigate the use of prevention of mother-to-child transmission (PMTCT) of HIV services in rural Tanzania. Paper A, a systematic literature review of barriers and facilitating factors to the uptake of antiretroviral drugs for PMTCT in sub-Saharan Africa, identified many influencing factors at the level of individuals, their communities and health systems. Paper B discusses the challenges, including lack of unique identification numbers, associated with using routine clinic data for monitoring PMTCT programmes in Africa. Papers C and D use clinic data linked to community HIV cohort data to describe community-level access to PMTCT services among HIVpositive pregnant women. Paper C documented low, but increasing, coverage with PMTCT services in 2005-2012, with weaknesses throughout the PMTCT service continuum. Paper D identified women from remote areas, younger women, and unmarried women as less likely to access PMTCT services. Voluntary counselling and HIV testing before pregnancy, longer duration of HIV-infection, and more recent pregnancies were associated with improved PMTCT service use. Paper E critiques the use of a vignette within a qualitative investigation of barriers to PMTCT service uptake, suggesting that vignettes can be used successfully in rural Africa to draw out barriers to PMTCT service use. The qualitative analysis for paper F revealed a pivotal role for patient-provider interactions in PMTCT service use, through decision-making processes, trust, and features of care. The collective findings highlight the considerable barriers to uptake of PMTCT services that must be tackled in order to successfully eliminate new paediatric HIV infections. Potential positive impacts of ‘Option B+’ (initiating all HIV-positive pregnant women onto life-long antiretroviral therapy) may be limited by these barriers. Addressing health systems issues, particularly stock-outs of HIV test kits, drugs and delivery materials, and improving patient-provider relationships, may have the greatest immediate impact on PMTCT service use in this setting.

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.

This thesis concerns the clinical epidemiology of HIV infection in Zimbabwean adolescents. Without treatment, there is a very high risk of death in the early years of life in HIV-infected infants. However, in recent years increasing numbers of adolescents have been presenting to health care services with symptomatic HIV infection and with features suggesting longstanding disease. Population-based surveys in Southern Africa have shown HIV prevalence rates among older children and adolescents to be much higher than would be anticipated if HIV-infants were not surviving early childhood. The burden and spectrum of HIV-associated morbidity among adolescents was investigated with two studies at secondary and primary care level, respectively. The main finding was of an extremely high prevalence of HIV infection at both levels of the health system, with HIV infection being the single most common cause of hospital admission and death among adolescents. Mother-to-child transmission was the most likely source of HIV infection in the majority, suggesting a substantial epidemic of older survivors of vertical HIV infection. Other countries with severe HIV epidemics may be experiencing a similar trend as their HIV epidemics mature. The lack of awareness of the possibility of survival to older childhood and adolescence with maternally-acquired, untreated HIV infection results in many missed opportunities for diagnosis, with HIV infection frequently not diagnosed until presentation with a severe HIV-related illness. The median CD4 count in 3 HIV-infected adolescents in primary care was 350cells/µl compared to a median CD4 count of 151cells/µl among hospitalised adolescents, suggesting that HIV testing in primary care identifies HIV-infected adolescents at an earlier stage of infection. Provider-initiated HIV testing and counselling in primary care was highly acceptable to adolescents and guardians. Provision of care has been adversely affected by under-appreciation of the numbers of surviving adolescents living with HIV, and the special needs of this age-group have not been distinguished from those of younger children. Young people who have acquired HIV perinatally are stigmatised by society who assume they must have acquired it through "bad" behaviour themselves, since it is not widely appreciated that long-term survival following vertical infection is possible. Immediate priorities are earlier diagnosis of HIV infection and improved management of HIV-infected adolescents. Possible areas of intervention are discussed in the final chapter. Similar studies are needed in neighbouring countries to investigate the generalisability of these findings.

The links between HIV/AIDS and national security have played a major and under recognized role in impacting efforts to fight the pandemic. To date, critical studies of the HIV/AIDS - national security nexus have been limited. Using 27 semi-structured interview and extensive literature review, this thesis creates the first global history of the nexus, from 1985-2007. This long-timeframe analysis allows a novel examination of the risks and benefits of this politically potent linkage, an assessment of the role of global health actors in the nexus, and a testing of the published conceptual frameworks that seek to explain the relationship between global health and national security. This thesis examines the history of the HIV/AIDS - national security nexus in three parts. First, the early and beneficial securitizations of the epidemic in Uganda and Thailand are examined. Two other events, the U. S. and USSR intelligence community interest in HIV/AIDS and the likely spread of HIV/AIDS by the United Nations peacekeeping mission in Cambodia, illustrate hazards of the nexus and complete this section. Second, the factors and events that led to the securitization of HIV/AIDS at the United Nations Security Council and within the U. S. are evaluated. Third, the consequences of securitization are considered, including the impact on global priority and funding, Security Council Resolution 1308, the U. S. President's Emergency Plan for AIDS Relief, and military HIV/AIDS programs. This thesis finds that where policymakers have framed HIV/AIDS as a direct threat to national security and prioritized the disease, clear benefits in fighting the epidemic have resulted. However the role of global health actors in these political events has been limited, and hazards of the nexus include the classification of public health data and the divergent interests of the global health and national security communities

Background: The scale-up of HIV care and treatment services in sub-Saharan Africa has been accompanied by calls to address the broader health care needs of people living with HIV (PLWH), including their sexual and reproductive health (SRH) needs. The integration of HIV and SRH services has been proposed as an important means to achieve this. This thesis presents a comparative case study investigating health care structure, process and outcomes across four different models of HIV services in Swaziland: two integrated SRH-HIV clinics, one semi-specialist HIV outpatient unit at a hospital, and one stand-alone HIV clinic. Methods: Mixed methods were used including in-depth interviews with providers and clients, and an exit survey (N=611) with HIV clients. Qualitative data were analysed thematically. Quantitative data were compared across clinic models using chi-squared tests and analysis of variance. Selected outcomes were analysed with logistic regression modelling. Qualitative and quantitative data were triangulated and integrated in the presentation of results. Findings: A critical need for SRH services was identified across all four sites. Most clients relied on condoms alone for contraceptive protection, reflecting a service focus on reinfection rather than pregnancy risk. In multivariable analyses, integrated sites did perform better than the most stand-alone site in promoting access to family planning and pregnancy counselling, but were no better or worse in providing condoms, addressing unmet needs for family planning, achieving client satisfaction and reducing stigma. Provider capacity to move beyond HIV care was limited, even at integrated sites, by a range of contextual factors, including individual provider, interpersonal, infrastructural or systems, and institutional factors. In particular, heavy client loads and perceived needs for fast care inhibited exploration of clients’ holistic needs. Discussion & conclusions: While integrated services offer opportunities to promote service uptake, this capacity can only be translated into health outcomes when a range of contextual contingencies are addressed. Promoting more client-centred continuity care may help facilitate this. Widespread assumptions that integrated services are better than stand-alone models have been challenged by this study: a well-run stand-alone site can achieve positive outcomes, including impacts on family planning needs and client satisfaction. PLWH should be able to choose a model of care that suits their particular situation and needs best.