From reflexive, theoretical, historical and fieldwork perspectives, this multidisciplinary work (using triangulated methodological approaches) challenges and interrogates current viewpoints on health promotion, in the context of HIV/AIDS, in Malawi. The thesis is presented in a number of steps, culminating in the explication of the dynamics of cultural socialisation among primary, secondary and tertiary school students, relevant to HIV/AIDS. First, a culturally based pre-colonial traditional framework of health promotion, medical service delivery and order maintenance is ‘reconstructed‘, using a number of markers, which are later used to show the colonial and postcolonial persistence and continuity of this framework. Second, it is argued that this culturally based medical framework survived and minimised conflict (and epistemological and pragmatic dialogue) with colonial power and medicine by largely retreating into localities. This created localised indigenous communal medicocultural and welfare traditions, which continued to offer services to most Ahcans. Third, it is suggested that the framework’ s postcolonial persistence reflects the limited colonial and postcolonial socio-economic change in Malawi, with elites now, as whites then, controlling limited western medical resources at the expense of the anthu wamba (peasantry). Fourth, a critical history of HIV/AIDS in Malawi shows how, having entered Malawi in this context, the HIV/AIDS epidemic was bound to be viewed through these vibrant localised traditional frameworks of beliefs. The localised beliefs affected the perceptions and responses to, as well as the extent of, the epidemic; some Malawians saw HIV/AIDS as mdulo or kanyela (wasting diseases caused by transgressing sexual taboos). Fifth, political, religious and economic factors also affected the explanations and interpretations of and strategies for dealing with HIV/AIDS, contributing to a donor-dependent National Aids Strategic Framework (2000 - 2004) predicated on assumptions of socio-economic, educational and developmental progress. Six, the fieldwork confirmed the vibrancy of and influential dynamic of indigenous culture towards health beliefs and practices among the general public, and school students in particular, despite a high level of awareness among school students (and the public) about the scientific aspects of HIV/AIDS. Seven, these high awareness levels, even in school contexts coexist with discourses, such as ufiti (witchcraft), which are influenced by localised cultural traditions. Eight, it is argued that, given the socio-economic constraints, these discourses may influence or dilute western HIV/AIDS awareness messages and influence the actual socialisation and social and sexual behaviour of students.

This thesis investigated perceptions of HIV/AIDS at the Walter Sisulu University (WSU), situated in the Eastern Cape, South Africa. The study focused on understanding opinions related to HIV/AIDS using data derived from interviews with twenty HIV/AIDS key role players from across the entire institution, and twenty students at the Institute for Advanced Tooling (IAT), a postgraduate section of the Mechanical Engineering Department in the Faculty of Science, Engineering and Technology (FSET) in Chiselhurst, East London. A key concern of the study was to examine the way in which local cultural beliefs and practices may shape understandings in relation to HIV/AIDS and to help inform more sensitive prevention campaigns in the future. The study, methodologically utilising Denzin’s concept of interpretative interactionism,and Giddens’ structuration theory, found that there was no single ‘cultural belief’ regarding health or related issues, but that cultural beliefs were always expressed in personal and contextual ways. The investigation into nutrition, health and general well-being and perceived causes of HIV/AIDS revealed that research informants subscribed to cultural beliefs for different reasons in personal constructs, and the study concluded that cultural issues surrounding these factors would need to be socially debated in intervention efforts. Perceptions of gender, as the most significant factor, were highly contested, with differing beliefs expressed regarding female sexual agency. It was further stated by research informants that the ABC approach lacked contextual consideration of environmental factors. The thesis therefore argues that for effective preventative action, there is a necessity, firstly, for a health-enabling environment to be created that includes strategies for alleviating nutritional deficiencies in a culturally contextual fashion. Second, based on the data, it was established that in relation to respondents’ orientation towards cultural beliefs, social HIV/AIDS debate programmes should be introduced in conjunction with health officials, the community and traditional healers in a peer-oriented approach. It was thirdly established that this approach should include addressing contextual factors from a ‘lived experience’ perspective, and that social positioning by the WSU should occur towards certain social issues (for example, constructions of gender) identified within this study.

Background: The global policy focus of today’s HIV efforts and strategies is to reverse the spread of HIV/AIDS and provide care, treatment and support. A key component of this strategy is to increase individual HIV status awareness through expansion of HIV testing and counselling (HTC). However, the numbers tested still remain low and evidence suggests that there are significant missed opportunities for HIV testing in clinical settings. One key strategy to expand HTC in clinical settings has been to implement a policy of ‘provider initiated counselling and testing’ (PITC) in which all patients accessing health facilities for treatment are routinely offered a HIV test. The introduction of PITC has brought with it a ‘dilution’ of the previously lengthy and stringent testing process by doing away with signed informed consent and extensive pre and post test counselling. The previous process was recognised as a barrier to public health gains of HIV testing expansion, particularly as it differentiated an HIV test from other routine medical tests resulting in a sense of HIV exceptionalism. In its place, the PITC policy recommends an opt-out approach and replaces the extensive pre test counselling with an information giving session placing more emphasis on post test counselling in cases where the result is positive. This change has given rise to debates about the potential for PITC to infringe patients’ rights to informed consent and counselling especially in developing countries. Emerging evidence from the exploration of the PITC process within antenatal settings in the Sub Saharan Africa has revealed some of the complexities of implementing PITC guidelines in different cultural and healthcare contexts. These studies suggest that information giving and consent are difficult to apply in contexts characterized by healthcare worker dominance, lack of sufficient resources and time constraints. This study aimed to specifically investigate how patients and counsellors co-construct informed consent and perform counselling during the PITC consultation. It examined ‘real time’ patient-counsellor interaction within hospital outpatient and inpatient settings in Kenya, explored the patient’s experience of a routine HIV test and evaluated how stigma and patient – provider interaction norms influence the PITC process in this context. Methods: In order to explore the context of the routine testing consultation and the way the interaction played out, a qualitative research approach was adopted, utilizing multiple data collection methods (interviews, observations and audio recording of consultations). The study was carried out in two government run health facilities in Kenya’s capital, Nairobi. The intention was to follow patients through the PITC process, i.e. before testing, during the HIV test and (whenever possible) after the HIV test. To get a broader picture of the events during the routine HIV testing consultation, additional interviews were conducted with five nurse-counsellors whose consultations had been observed. Ethical approval was obtained from the Kenya National Research Council, Kenya Medical Research Institute and the Aga Khan University Ethics Committee. The data were analysed using Charmaz’s constructivist grounded theory approach which allowed for a systematic yet flexible approach to analysis. This method facilitated immersion and engagement with the data, and provided a means of managing the different data sets in the study and undertaking a process of constant comparison within and between data sets. Findings: Results from the study suggest that HIV remains a highly stigmatised illness in Kenyan society and is associated with death and immorality. This is still the case in spite of years of health promotion and high profile media campaigns raising awareness about HIV and the availability and effectiveness of treatment. The context of stigma shaped the consultation so that both patients and counsellors worked together to help patients to maintain a ‘moral face’. Patients tended to withhold information on risky sexual behaviour whilst the counsellors avoided inquiring into this domain. The PITC consultation was characterised by a counsellor dominated approach to communication and health promotion. Counsellor inputs were generic, highly scripted and didactic rather than patient-centred. As a result, the counsellors’ style of communication allowed little space for personalised risk assessment or for patients to ask questions or to express concerns. The findings suggest that informed consent enabling explicit refusal of the test offer was difficult to achieve in an environment where the HIV test was not framed as a choice and patients came to the health facility expecting to be told what to do. Nevertheless, in spite of the obvious lack of explicit informed consent and the counsellor dominated interaction, post test interviews revealed that patients were satisfied with the nature of the interaction. The study concludes that there is a considerable distance between the policy recommendations and their implementation on the ground due to the complexity of real world practice. Lay constructions about HIV (HIV stigma) and the existing norms of patient-provider interaction that are characterised by a passive patient and a dominant health care provider shape the way the consultation unfolds. PITC training programs and manuals need to include skills and strategies that can support counsellors manage an uncomfortable interaction and emphasis the need to ensure an individualized post test counselling is carried out. The thesis makes several contributions to knowledge. The study pays attention to the operationalization of PITC recommendations thus illuminating how the PITC policy is translated into practice within a developing country like Kenya. It informs the existing debates on how informed consent and counselling should be implemented. The study findings suggest that in spite of the global debates on what constitutes ideal informed consent and counselling, in practice, sociocultural norms shape how these issues are translated and implemented. However, the study indicates that diversion from the PITC policy recommendations does not necessarily constitute a disregard for the recommendations but, rather, is an attempt to adapt to the prevailing environment. The study methodology enabled unique insights to be gained on how counselling and consent are constructed and managed in the PITC setting through the use of observations / audio recording to examine ‘real time’ interactions. The research study has been able to illuminate barriers that are posed by sociocultural and organisational structures in the real world implementation of the PITC policy. Therefore, my study suggests that the national PITC policy needs to consider the practical problems faced on the ground in developing contextually appropriate recommendations for the conduct of PITC and implementation of key guidelines.

HIV/AIDS is a major health problem for sub-Saharan Africa. There are identifiable prevention and treatment regimes which would greatly ameliorate the situation, but these are beyond the resources of the sub-Saharan countries themselves. The research focus of this thesis is an investigation of the responsibility that the developed world has towards supplying help to combat this disease process. A series of arguments are adduced in support of the contention that the developed world has responsibility in this area and that that legitimate responsibility is very demanding indeed. These arguments are drawn firstly from a consideration of beneficence, secondly, from considerations of distributive justice, and finally from a consideration of reparative justice and rights based arguments. With beneficence the accent was upon Singer and his child in the pond thought experiment. With distributive justice the focus was upon contractualism, primarily considering Rawls, but then extending this both into health and in a cosmopolitan direction. Where reparative justice and rights based arguments were concerned the arguments were constructed from Pogge, Shue and Ooms. Major objections to this position were considered and largely rejected arising from the question of over-demandingness, from libertarianism and from a consideration of Murphy and the question of fairness in a non-ideal situation. However it was accepted that there is a place for partiality in moral obligations and that there are reasonable moral duties and prerogatives with regards to self and the needs of those in close relationships with the moral agent involved. Major writers involved in these countervailing arguments included Scheffler and Cullity. The original extreme demand provisionally accepted was counterbalanced by a consideration of partialist obligations. Nonetheless the overall moral position would be such that the needs outlined in the Millennium Development Goals in regard to HIV/AIDS fall easily within the limits of moral obligations of the developed world.

More than 2 billion people live on less than 2 US dollars per day. People in these conditions often have inadequate access to basic sanitation, safe water, and medical services. These individuals, households and communities may be at high risk for a wide range of preventable and treatable infectious diseases. The aims of this study were to: 1) describe the prevalence of endemic helminth, protozoal, bacterial and viral infections of people in a small-holder farming community in western Kenya; 2) explore the spatial distribution of infection risk; 3) quantify associations between social and environmental conditions and individual- and household-level infection; 4) identify shared risk factors operating on multiple pathogens. All data were collected between July 2010 and July 2012 as part of a cross-sectional survey of 416 households and 2113 people. This sample was considered representative of a population of 1.4 million people living in an area of western Kenya characterised by high levels of poverty. Sampled individuals were tested for exposure to, or infection with, 21 infectious agents using a range of faecal, blood and serological tests. Extensive questionnaire-based data were also collected. Individual- and household-level risk factors for infection with prevalent pathogens were explored using multilevel logistic regression, with a particular focus on examining the impact of socioeconomic position (SEP). Hierarchical zero-inflated binomial (ZIB) regression was used to derive an estimate of household pathogen ‘species richness’ with correction for imperfect detection. This modelling framework allowed assessment of the relationship between household-level infection with each parasite and a range of social and environmental conditions and, uniquely for a single study setting, the average response of the ‘group’ of parasites to these conditions. This study found very high levels of parasitism in the community, particularly with hookworm (36.3% (95% CI 32.8 – 39.9)), Entamoeba histolytica/dispar (30.1% (27.5 – 32.8)), Plasmodium falciparum (29.4% (26.8 – 32.0)), and Taenia spp. (19.7% (16.7 – 22.7)). Some degree of within-household clustering was found for all pathogens, and this was particularly large for the helminth species and HIV. Most pathogens also showed spatial heterogeneity in infection risk, with evidence of spatial clustering in household-level infection, most notably for HIV, Schistosoma mansoni, P. falciparum and the soiltransmitted helminths. A socioeconomic gradient was identified, even in this predominantly poor community. Increasing socioeconomic position (SEP) resulted in significantly reduced risk of individual infection for E. histolytica/dispar, P. falciparum, and hookworm. By contrast, individuals living in the richest households were at significantly elevated risk of infection with Mycobacterium spp. Individuals living in the poorest households were least likely to report the recent use of medical treatments. The average pathogen species richness (out of 21 species) per household was 4.7 (range: 0 to 13). Following correction for detection error, the predicted average helminth species count (out of 6 species) was 3 (range: 0.94 to 5.96). While socioeconomic position had little effect on the probability that a household was infected with any of the helminth species of interest, domestic (within-household) transmission appeared to be greatest in the poorest households for hookworm, S. mansoni, Ascaris lumbricoides and Strongyloides stercoralis. Household size had a consistent effect on probably of household infection with each helminth species, so that the largest households were also the most pathogen diverse. Household-level helminth species richness was identified as a significant positive predictor of individual risk of HIV infection, raising potentially important questions about helminth-HIV interactions in the study area. This study integrates approaches from epidemiology and ecology to explore infectious disease risk and its determinants at a range of social and geographic scales in a small-holder farming community in western Kenya. Considering risk at both the individual and household level within the same community can contribute to better understanding of the factors that influence disease transmission in both domestic and public domains.

In countries like Nigeria and similar contexts in Sub-Saharan Africa and Asia, maternal deaths remain prevalent and the current political will and corresponding interventions remain insufficient to significantly address the problem. One way of generating the required political priority is through the mass media, which has been credited with the capacity to influence social and political conversations and set the policy agenda by raising the salience of an issue on its own agenda. This study investigates the processes and factors which influence the media agenda for maternal mortality and comparatively, HIV/AIDS in Nigeria. It utilizes content and frame analysis of newspaper coverage to establish the media agenda for both issues. It also utilises in-depth, semi-structured interviews: 1) with NGOs and other advocates to determine the factors which influence the state of maternal health and source strategies for media engagement; and 2) with senior reporters and health editors, to investigate the factors which influence the media agenda for health issues especially maternal mortality and HIV/AIDS. The results show that the state of maternal health in Nigeria has been influenced by epidemiological factors, cultural and religious factors, gender and socio economic class and strategic factors such as donor politics and priorities. Content analysis of newspaper coverage indicate that news coverage of maternal mortality is significantly low, when benchmarked against HIV/AIDS and that a wider range of framing approaches (including a political and multi-disciplinary approach) are employed in coverage of the latter, compared to the former. The study results also suggest that most maternal health advocates do not take a strategic approach to media engagement and that there is poor collaboration and lack of trust between NGOs and the media. Interviews with media personnel show that that the lack of trust and collaboration between the media and NGOs has resulted in a lack of stakeholding, and media engagement is largely at the level of events reporting. In addition to the above, the results show that the media agenda is predominantly driven by funding, political issue champions, celebrities, expert sources, epidemiology, global health days, events, and human interest stories.

Background: Human immunodeficiency virus (HIV) remains a global health problem. In sub-Saharan Africa, where the majority of HIV infected individuals live, 1.5 million HIV positive individuals die and 1.2 million become infected every year. Ensuring timely access to anti-retroviral therapy (ART) and efficacious HIV prevention strategies could potentially end the epidemic. To realise these benefits, individuals need access to frequent HIV testing and retesting. Facility-based HIV testing and counselling (HTC) is not popular in the region. HIV self-testing (HIVST), where individuals test in the privacy of their own homes, has been found to potentially achieve the required levels of HIV testing needed to achieve these goals. However no economic analysis of HIVST has been undertaken to inform policy makers whether it is a cost-effective option to scale-up in the region. Objective: To undertake a cost-utility analysis (CUA), from the health provider and societal perspectives, that estimates the incremental cost per quality-adjusted life year (QALY) gained by providing Malawian communities HIVST, in addition to routine provision of facility-based HTC. Methods: A decision-analytical model parameterised using primary cost and health-related quality of life (HRQoL) data collected from three observational studies: (1) a cross-sectional study recruiting individuals (n=1,241) who accessed HIVST and facility-based HTC; (2) a cohort study following up HIV positive individuals (n=330) accessing HIV treatment after HIVST or facility-based HTC; and (3) a cohort study of adults (n=822) admitted to the medical wards at Queen Elizabeth Central Hospital. In addition, evidence from the literature was synthesised to estimate epidemiological parameter inputs. Primary costing was undertaken to estimate health provider costs. Participants were asked about the direct non-medical and indirect costs they incurred, and their HRQoL measured using the EuroQol EQ-5D. Costs were adjusted to 2014 US and INT Dollars, and the primary cost-effectiveness outcome was expressed in terms of incremental cost per QALY gained. Results: The health provider cost per participant tested through HIVST (US$8.78) was comparable to that for facility-based HTC (US$7.53-US$10.57), although the mean societal costs of HTC were US$ 2.38 (95%CI: US$0.87-US$3.89) lower with HIVST. The mean total health provider (US$22.74 v US$28.33) and societal cost (US$25.56 v US$32.22) during the pre-ART period was lower for those who had accessed HIVST to learn their status than for those who accessed facility-based HTC. Mean total health provider and societal costs during the first year of accessing ART were comparable between those who had accessed HIVST and facility-HTC (mean total societal cost: US$251.14 v US$261.57). HIV positive individuals who had more advanced HIV disease, measured by the CD4 count, had lower EQ-5D utility scores. Health-related quality of life improved once individuals started ART, with the majority of participants reporting perfect health one year after starting ART. The mean cost of hospital admission was high, for example the mean health provider cost of managing Cryptococcal Meningitis and Pulmonary Tuberculosis was US$837.92 and US$473.11, respectively, and was associated with low EQ-5D utility scores. The CUA found the incremental cost-effectiveness ratio (ICER) of providing HIVST in addition routine facility-based HTC to be US$316.18 per QALY gained from the health provider perspective (societal perspective: US$332.05 per QALY gained). The sensitivity analysis found the ICER was comparable if the cost of HIVST was higher, if there were lower rates of linkage into HIV treatment after HIVST and if the HIV prevalence in the population was lower. Conclusion: HIVST was found to be an affordable and cost-effective option for Malawi based on International guidelines (ICER below three times the gross domestic product: US$250 in Malawi). Undertaking primary economic data collection in resource-constrained settings was feasible and provided robust estimates for use in decision-analytic models.

The recent promotion of male circumcision as a public health strategy in settings with low circumcision rates is based on research evidence suggesting that male circumcision provides heterosexual men with 50 to 60 per cent protective benefit against HIV infection. For the Kikuyu people in Kenya, male circumcision is a cultural ritual and a rite of passage from childhood to adulthood. The study explored the male circumcision ritual and practices in Muranga, Kenya and their implications on public health. A qualitative research design underpinned by an Interpretivist paradigm was employed. Focused ethnographic methodology was used to capture the cultural context of the ritual and its meanings. Participants were recruited through purposive sampling method. Data were collected through in-depth interviews with 13 circumcision mentors, participant observations in three churches and written narratives with 43 male students from six schools. Data were analysed using thematic analysis. The findings suggest a changing circumcision ritual with women as key agents of change in a ritual considered a male arena. The church, hospital and urbanisation emerged as the drivers of the changes which women effected with the aim of protecting their sons from institutional bullying and the culture of pain in the era of HIV and AIDS. The latest change in the ritual feature boys getting circumcised and recuperating in hospitals. The changes in male circumcision practices are of significance to public health. The changes in sexual practices are likely to increase the risk of HIV infection counteracting the protective effect expected of circumcision. The study recommends a revision of policies especially the WHO policy on male circumcision for the effective impact on HIV prevention among the circumcising communities. Women can be engaged in mobilising changes in the circumcision ritual that are significant to the health of young men through institutions such as hospitals and churches.

Mothers living with HIV (MLH) are the focus of this narrative study. HIV is increasingly seen as a chronic illness because of medical advances in its treatment. Much research with HIV positive mothers is situated within the dominant biomedical discourse focusing more on outcome rather than experience and, while valuable, it fails to provide insight into their subjective experiences. In Ireland, women represent a third of the newly diagnosed HIV population (O’Donnell, Moran and Igoe 2013), many of whom have children, and migrant African-origin women represent a significant percentage of these new diagnoses. However, no research has examined contemporary maternal HIV experiences within an Irish context. This is an important fact considering the changing nature of HIV and that most HIV positive women are prescribed Highly active antiretroviral treatment (HAART) during their pregnancies and so give birth to HIV negative babies. This study explores the HIV maternal experience as the psychosocial impact of being HIV positive persists even though it is increasingly seen as a chronic illness. The original contribution to knowledge of this thesis is to provide insight into the experiences of mothers living with HIV in Ireland. My study involved adopting a narrative approach to interviewing a purposive sample of eleven HIV positive mothers living in Ireland who were at different points on the motherhood trajectory, and were from both high and low HIV prevalence countries. The analysis of this study’s narratives drew on a combination of theoretical perspectives including HIV stigma frameworks (Campbell et al., 2007, Herek 2002), social capital theory (Putnam 1995), medicalisation and HIV normalisation. The interviews reveal the centrality of being a mother to the study participants and how being HIV positive affects mothering. Being an HIV positive mother means protecting children from HIV from the moment of diagnosis , during and after pregnancy; minimising the impact of HIV in everyday life; having an awareness of the persuasiveness of HIV stigma; and managing HIV disclosure. Peer support was a significant factor for these mothers and all were members of an HIV support organisation in Dublin. Linking the findings of this study to wider theoretical literature allows for a greater understanding of the lives of HIV positive mothers in the HIV normalisation era and accentuates the multidimensional impact of maternal HIV infection.

From 28 October 1999 to 26 September 2000 Mbeki publically endorsed the position of ‘denialist’ AIDS scientists – a marginal group who oppose the claim that HIV causes AIDS – and used their views as the basis for a policy of not providing ARVs (antiretrovirals – the treatment that prevents HIV from replicating) via the public health system. This policy persisted until 2004, with severe consequences – best estimates indicate that it resulted in 171,000 avoidable new infections and 343,000 deaths over the 1999 – 2002 period. I use this case to address two questions. First, is it reasonable for policy makers to consult non-mainstream scientists in the process of policy development? Second, can they be held personally morally responsible for the consequences of having done so when things go very badly wrong? I begin by providing a motivation for why philosophers should be interested in real-world cases. Having justified the philosophical “methodology” of this thesis, I move on to describing the specific case of South African AIDS denialism in the early 2000s. I then take a chronological step back in order to assess the rationality of accepting HIV as the sole cause of AIDS in 1984, when the virus was first identified. I argue that it was rational, but that some explanatory power was lost when other competing accounts of the disease’s aetiology were discarded. I argue that this explanatory loss can be accounted for by re-considering the way causation is understood in biomedicine and epidemiology. Having settled the scientific issues of the case, I then move on to the question of moral responsibility. I specifically look at when an agent can be held morally responsible for their ignorance, and the role of suppressed disagreement in the production of that ignorance.