In this thesis I analyse paradigms for the conceptualisation of male-to-male sexuality as put forward in HIV/AIDS programming in India. This is an especially pertinent project; over the last decade, international and national HIV/AIDS agencies working in India have increasingly identified men who have sex with men as a ‘target population’ for community based intervention. By contrast, within the broader milieu of Indian society the notion of homosexual identity exercises little cognitive grip as a salient category for the constitution of specific persons. This is not withstanding ‘modern’, predominantly urban, middle class popularisations of ‘gay’ identity, nor the specification of various ‘indigenous’ categories of male-to-male sexuality, which have predominantly been outlined in policy oriented research. As a counterpoint to these concerns my research explores the experiences of men who have sex with men in Calcutta for whom categories of homosexual identity are either completely unfamiliar or, where used, inscribed within a far more subtle mesh of conflicting emotions and allegiances than current studies elucidate. Moreover, I argue that in many contemporary Indian contexts homosexuality is most often signified within relational tropes and social spaces made available within heteronormative parameters. Homosexuality therefore has an isomorphic correspondence to identity, meaning that policy and research needs better conceptions of the tacit conditions of sexual subjectivity. My thesis explores what this assertion means for the cross-cultural study of male-to-male sexuality and HIV/AIDS policy and programming.

Sport is increasingly being recognised for the contribution it can make to the Millennium Development Goals and, in particular, the response to the HIV/AIDS pandemic. This study is based on Zambia, a low-income country, heavily affected by the HIV/AIDS pandemic in sub-Saharan Africa. The study focuses on National Sports Associations (NSAs), which are quasi- autonomous organisations at meso level of policy analysis. Centring on three NSAs: Football Association of Zambia (FAZ), Zambia Basketball Association (ZBA) and Netball Association of Zambia (NAZ), this study critically analysed the organisational responses of each of the selected cases towards the HIV/AIDS multisectoral approach. The study adopted a case study approach which utilised semi-structured (face-to-face and telephone), interviews, focus group discussions and documentary analysis for data collection. Comparative analysis of all three cases revealed differences in how each case mainstreamed HIV/AIDS based on power, resources and forms of collaboration. Meso-level analysis was utilised to examine workplace HIV/AIDS policy formulation and implementation. In addition, meso-level analysis also helped reveal forms of health-related collaborations with both internal and external agencies. Macro-level theories of the state were useful in examining power relations between the Zambian state and civil society. The application of policy network theory, global health governance, multiple streams framework, and the top-down and bottom-up approaches to policy implementation proved useful in drawing attention to how each NSA case responded differently to the mainstreaming of HIV/AIDS. The political power of football as a national sport and the Association s access to foreign resources enabled FAZ to influence HIV/AIDS policy implementation and build of strong collaborative relationships with government than the ZBA and NAZ. The study concludes that lack of political steer from the top has re-introduced a new foreign top-down approach as those with resources from the Global North influenced policy formulation and implementation within all three cases. The conclusion also found useful the application of post-colonialism and development theories when examining international sport-for-development practices. This finding revealed the power imbalances between Global South practitioners and Global North funding partners.

Global statistics indicate that currently 35 million people are living with HIV of which 4, 634 are living in Scotland (out of a total population of 5 295 00) and the figure for Zimbabwe is estimated at 1, 400 000 (out of a total population of 14 149648). In this thesis, I have suggested a framework that goes beyond a limited analysis of the complexity of understanding the HIV/AIDS origins, its evolution and prevalence beyond the epidemiological mapping. The approach allows for the development of a more rational, inclusive, broader and sustainable HIV/AIDS Education (Wood 2014, Wood and Rolleri 2014). This approach is not only emancipatory but also empowers (Freire 2000, Freire 2004) both those affected and infected by the HIV/AIDS epidemic. I have chosen both Scotland and Zimbabwe as each of them has dealt with the epidemic in different ways. Scotland has had significant success in combating HIV/AIDS through various initiatives. Zimbabwe on the other hand, is an example of a developing country in sub-Saharan Africa with one of the highest levels of HIV/AIDS infected and affected people in the world (UNAIDS Country Report 2014). I used ‘selected’ documentary analysis that is, looking at selected documents that contain the major policy responses to the HIV/AIDS epidemic. I also conducted interviews with key informants using semi-structured interview questions and then analysed the resultant data using a range of heuristic tools. The main findings of this research included how a number of conspiracy theories were constructed in order to explain the origins and the evolution of HIV/AIDS. Examples of these conspiracy theories included the homosexual link to HIV/AIDS,witchcraft and biological warfare among others. Other issues discussed focused on conspiracy as the construction of otherness, moralising the epidemic, assessing the impact of culture, religion and politics on the epidemic as well as the implications of these issues on Sex Education. The thesis concluded with suggesting a framework for developing a transformative approach to HIV/AIDS and Sex Education.

This thesis centres on the lives of women who live in Khayelitsha and who receive AIDS biomedicines through South Africa's public health system. It is tiered across five ethnographic chapters to elucidate a single overarching argument: biopolitical precarity is networked into the permeable body. This argument is based on ethnographic research and seeks to challenge the discursive construction of distance that divorces women's lives and bodies from the governance of AIDS biomedicines as life-­giving technologies. The multi-­sited ethnography underpinning this thesis was configured to follow the networked threads that weave women's embodied precarity into the governance of technologies and the technologies of governance. To this end, fieldwork was conducted in South Africa from October 2010 – July 2011 in order to understand the embodied and political dimensions of access to AIDS biomedicine. Thereafter, fieldwork was conducted in Brazil from August 2011 – September 2011 to explore the networked connections spanning activist organisations, government coalitions and economic blocs to move out from the intimate spaces of women's lives and bodies to locate them in the regional and global spaces of biomedical developments and health policy dynamics. This thesis argues that although it is crucial to anchor technologies in people's lives, it is also analytically and politically necessary to link people's lives - and the technologies that sustain them - back into the global assemblage that is networked around the governance of medicine. Therefore, I locate biomedical technologies in social and political contexts of lives of the people with whom I worked in Khayelitsha, and I argue further that their lives also need to be understood as part of a complex network of actors (spanning international organisations, regional coalitions and national governments) and actants (HIV and ARVs) that assemble in dynamic configurations and that are woven into and through the body.

This thesis evaluates the cost-effectiveness of eight policies expanding human immunodeficiency virus (HIV) testing in South Africa. All policies entail provider-initiated test offers for primary healthcare users and one of two options across three policy components: (i) consent method, opt-in or opt-out; (ii) test protocol, rapid only or rapid plus acute infection testing; and (iii) linkage-to-care, standard or enhanced. This thesis highlights four methodological issues. First is the challenge of conducting a population-level analysis, projecting the cost-effectiveness of expanded testing for each member of South Africa’s adult African population. To this end, I conducted a retrospective, descriptive study to measure current population-level testing rates and epidemic descriptors in an African community near Cape Town, South Africa. Second, the effects of testing expansion on current testing uptake were estimated by distinguishing testing in the study community likely to cease after testing expansion (baseline testing) from that likely to continue (background testing). Third, because testing alone is an outcome of less interest than health benefits following treatment, study community linkage-to-care probabilities were estimated and models utilized to estimate the efficacy of treatment. Fourth, the methods to convert the study community testing data into inputs for these models’ parameters are outlined. The enhanced linkage-to-care policies proved the most cost-effective, with opt-in testing and a rapid-only test protocol the least expensive cost-effective option at $848 per life year gained (LYG). Adding an opt-out consent method or acute infection test protocol to this policy increased the LYGs, but at higher cost-effectiveness ratios.

This thesis contributes to debates on the role of civil society organizations (CSOs) in global governance by asking if their participation in the global response to HIV/AIDS has been transformative – with transformation conceptualized as change towards a more equitable order. Adopting a critical International Relations approach, and applying qualitative methods, it analyzes how CSOs used the initial failure of biomedical responses to the epidemic to advance a human rights frame, which justified their participation in global governance. This frame complemented conceptions of AIDS exceptionalism, and has recently shifted in response to an increased focus on key populations. CSOs continue to advance the rights frame in global institutions – the focus here being on how they have done so within UNAIDS and the Global Fund to Fight AIDS, Malaria and Tuberculosis. However, rigid bureaucracies and dominant power relationships limit CSOs’ ability to transform these institutions to be more responsive to and representative of those affected by the epidemic. CSOs have further struggled to influence the largest global donors of the HIV/AIDS response – the Global Fund and PEPFAR – to direct greater resources to rights-based initiatives, despite CSO participation in resource mobilization. Though CSO participation has been restricted by donor state power, bureaucratic structures, and changes in the political economy of global health, CSOs have continued to promote potentially transformative alternatives, and so have continued to represent the interests of those most affected by the epidemic. This allows potential for further transformative alternatives.

HIV-positive adolescents are an increasingly numerous and challenging population in the South African HIV/AIDS epidemic. Their access to, and retention in, ART care has become a pressing public health concern. Comprised of four journal articles, this thesis explores the practice of antiretroviral treatment (ART) among a cohort of HIV-positive adolescents (age 10-19) in South Africa's Eastern Cape. By 'practice', I mean the volatile, situated and relational 'work' that goes into young people's everyday achievement of ART - into consuming daily medication, regularly attending health appointments, and participating in HIV programmes. Through an exploration of the ways in which some HIV-positive adolescents use, appropriate, or reject ART care; this thesis contributes to a much-needed evidence-base on the needs and survival strategies of adolescent ART users. Data for this study was gathered through eight months of multi-method ethnographic fieldwork with 23 HIV-positive youth, their families, and local health workers. The findings elucidate adolescent ART as a complex (and often volatile) form of social incorporation, through which young people negotiate survival, care and moral connection in contemporary South Africa. Enrolling in ART meant being encompassed into a (often hierarchical) set of social relationships, through which adolescents sought belonging, recognition and protection, amid profound insecurity. Through ART and its associated programmes, adolescents and their families attempted to strengthen familial ties, appeal to powerful patrons, petition for care, and access basic resources. Yet these pursuits were often deeply ambivalent, as discipline, blame, and resentment often came encased in the terms of care. At the crux of each article is an attempt to understand how adolescents, often alongside their families, negotiated both the social stakes and possibilities of ART. Through these discussions, we might better be able to grasp the fragility and complexity of young people's retention in ART.

The thesis proposes a theory for the development of substantive representation among social movement organisations (SMOs). Substantive representation (SR) is the extent to which political institutions advance the policy interests of their constituents, in particular the most disenfranchised. Despite their noble proclamations, institutions of representative democracy often fail to advance the interests of groups who have been ignored and absent at the proverbial table. The thesis establishes a causal process to explain the divergence in SR outcomes among informal SMOs, or all-volunteer groups that disavow formal hierarchy in favour of egalitarian modes of decision-making. It utilises a case study of the AIDS Coalition to Unleash Power (ACT UP), an umbrella organisation dedicated to ending the HIV/AIDS crisis in the United States and worldwide. It explains an anomalous story of SR attainment through the ACT UP Philadelphia chapter, compared to sister groups in New York City and Boston. The analysis draws from 92 semi-structured interviews, 13 months of participant observation, periodical review, and archival databases. ACT UP Philadelphia translated common SMO intentions of inclusivity into the uncommon rituals of practice. It forged a deliberate pipeline to invest not only in the presence but also the power of disenfranchised people with HIV, people too dark and poor to interest counterpart groups in other cities. Through an analytic retelling of ACT UP's history, the thesis argues that the fulfilment of SR depends on the ability of SMOs to appeal to member self-interest. Critically, SMOs can offer material incentives and nurture feelings of debt and obligation: causal steps to recruitment and sustainability of a heterogeneous membership. In building a crucial if contentious core of dissimilar people and partnerships, SMOs can unleash an oft-unrealised power for collective action and SR, by and for disenfranchised peoples who had thought change to be impossible.

The aim of this study is to evaluate the supply of markers for the identification of syringes distributed by pharmacy needle exchanges and to determine if this product and service delivery offers a feasible method of marking syringes to promote the reduction of accidental sharing of syringes and needles amongst injecting drug users (IDU) and thereby reduce the risk of transmission of blood borne viruses (BBVs) and other related infections. This study involves the assessment, implementation and evaluation of syringe markers as a pilot study within three community pharmacy sites in Glasgow. The secondary aims of the study were to identify whether the supply of syringe markers from community pharmacy needle exchanges was acceptable to IDU and if it enabled them to mark their syringes. The literature review demonstrates that providing a means of identification of personal injecting equipment has been proposed as a viable option that should be promoted to prevent the inadvertent accidental sharing of syringes within a group setting. Needle exchanges (NEX) are important component parts of the harm reduction responses designed to reduce the physical health harms caused to individuals through injecting drug use. The literature is reviewed on BBV transmission and the historical, legal and policy context associated with the development of NEXs. Community pharmacies act as a source of health advice and can help to facilitate access to treatment services for those attending the NEX. However the specific aim of this study is not to investigate the totality of the benefits of a NEX but to examine the supply of a potential means of reducing accidental and unintentional sharing of all injecting equipment and thereby contribute to minimising some of the health harms linked to injecting drug use. Three established community pharmacies were identified as suitable sites to pilot the supply of syringe markers. A number of criteria were used to select the sites. These included an assessment of the geographic locations, staffing arrangements, NEX attendances and transactional activity and the availability of private consultation facilities. The health board central database which holds records on a range of factors including, the characteristics of those who attend NEX and detailed information on all transactions, was used to identify the most suitable sites to pilot the new intervention. This indicated that the characteristics of those who attended the three chosen sites were broadly similar to the wider NEX attending population. The evaluation was conducted in two separate periods. The first 4 week period was the supply phase where markers were distributed over this period to all patients receiving NEX packs from the 3 pharmacies. The second data collection phase was undertaken in the following 4 week period. Data was collected by means of a structured questionnaire. In order to reduce the potential interviewer bias it was decided to incorporate the use of peer researchers in the administration of the questionnaire. The Scottish Drugs Forum (SDF) was approached and agreement was reached to use members of the Service User Involvement Group (SUIG) to assist with the design and administration of the questionnaire. A submission was made to the health board Research Ethics Committee (REC) and approval was given to enable the study and the research evaluation to proceed. Before the start of the study, joint briefing and training sessions were held for pharmacy staff from the 3 sites and the 6 participating SUIG members. A total of 177 questionnaires were completed during the second data collection phase of the evaluation. Information was collected on personal details and injecting behaviours (including deliberate and accidental sharing), any current means of syringe identification, use of the markers and on the usefulness of the instruction card. Most individuals (75%, n=132) had been supplied with the markers to trial during the first supply phase of the study with 63% of the 132 (n=83) of those individuals reporting use of the markers. The results of the evaluation and subsequent analysis of the findings indicated that the syringe marker supply could be successfully implemented using pharmacy NEXs. The product and the supply method were acceptable to both staff and service users. Initial bivariate analysis was conducted using a number of dependent and independent variables identified within the questionnaire. These findings highlighted a number of areas worthy of further exploration, including emerging differences between male and female respondents, and indicated specific target groups for future developments in syringe identification. The contribution of the peer researchers was found to be a significant factor in successfully completing the evaluation. However it is not possible to make any definitive statements on how effective the intervention is in terms of reducing the transmission of BBVs and other related infections. The findings of the evaluation indicated a number of potential areas of work that could be usefully explored to investigate the effectiveness of the markers in reducing the transmission of infections. The limitations of the evaluation became apparent during the course of the study and the implications of these limitations are discussed.

With the advent of Highly Active Antiretroviral Therapy (HAART), people with the human immune deficiency virus (HIV) infection are increasingly enjoying longer and relatively healthy lives, particularly in developed countries. However, black Africans and African-Caribbean people in the United Kingdom and other developed countries are not yet enjoying the full benefits of HAART, essentially as a result of delayed diagnosis. Delayed diagnosis, in addition to affecting the health of infected individuals, also creates a community reservoir for the spread of the infection; thereby hampering prevention and control strategies by international and NHS guidelines. The delayed diagnosis may be grounded in individual, societal and health service factors that guide help-seeking behaviours of black African and African-Caribbean populations. This study set out to investigate the help-seeking behaviours to diagnose HIV and AIDS among UK based black African and African-Caribbean people, and to investigate the dynamics in those behaviours by place of origin (Africa vs. Caribbean) and by gender. A qualitative methodological approach involving semi-structured interviews was used to explore help-seeking behaviours to diagnose HIV and AIDS among black Africans and African-Caribbean populations in the UK and compared by gender. Thirty (30) purposively selected individuals from patients attending two sexual health clinics in the city of London were interviewed. These included 16 black Africans and 14 African-Caribbean people, and 16 men and 14 women. The symbolic interactionist perspective, and the concepts of broken narratives/silences, biographical disruption and biographical abruption guided the study and interpretation of findings. One main theme ‘Africanness’ and two sub-themes (“African way” and “African thing”) emerged from the findings. The “African way” embodies the risk factors involved in contracting or transmitting HIV and the “African thing” represents the HIV status itself. This is a cultural construction of HIV and AIDS within the acceptable context of participants which helped them to talk about HIV and AIDS without addressing it by the biomedical idiom. The notion of ‘Africanness’ provided a ‘marker’ for African identity. The “African thing” represented a new landscape for naming HIV without necessarily calling it by name and provided a comfortable platform for participants to seek help. The “African way” described the risk behaviours by participants that resulted in the “African thing”. Three sociological concepts; ‘broken narratives or silences, biographical disruption and biographical abruption were key issues in HIV and AIDS diagnosis at a late stage and have formed the basis for the development of a model of help-seeking for diagnosis by participants. Apparently, the main determinants of help-seeking for diagnosis of HIV and AIDS are dependent on cultural factors. Stigma is reinforced by the national health care system practices as well as health professionals themselves. This potentially increases the reluctance among black African and African-Caribbean populations to voluntarily test for HIV. An HIV diagnosis is seemingly a challenging experience because of the impending uncertainties associated with it. Seeking help for diagnosis may even be more difficult because of the anticipated and unpleasant experiences along the path to diagnosis. This may guide the individual to consider other alternatives outside the biomedical pathway, potentially; the biomedical path becomes the least likely choice, especially with black African and African-Caribbean populations. An insufficient cultural understanding is likely to result in inadequate recognition of alternative medical practices, insufficient attention to alternatives to biomedical health systems and potential distortion of the meaning of health messages linking them to practice.