Research in the field of HIV acknowledges the existence of social constructs, including the incongruity between HIV, motherhood and sexuality, which may add to the psychosocial burden of an HIV diagnosis (Blystad and Moland, 2009; Long, 2006; Stinon & Myer, 2012). However the research is fragmented, and addresses the concepts of motherhood and sexuality in the presence of HIV independently. There has been little consideration of how the opposing constructs may be simultaneously experienced and negotiated by positive woman. Additionally existing research focuses on pregnant women or mothers, it does not explore the impact of an HIV diagnosis before entering into motherhood. Despite adopting a philosophy of holism and valuing the creation of environments that sustain mental well-being, Counselling Psychology literature is relatively silent on women’s adaptation to HIV. This qualitative study explores how European, childless women who have been historically underrepresented in the literature experience sexuality, and feelings of motherhood following an HIV-diagnosis. Interpretative phenomenological analysis of five women’s experiences produced superordinate themes of, ‘The even worse than undateable woman’, ‘Nothing can spark my sexuality’ and ‘You have to adapt…I owe it something’. The women speak of experiencing a continued psychological impact of an HIV-diagnosis, despite the advances in medication, which precipitates multiple psychosocial crises related to sexuality, identity, femininity and concepts of motherhood. There is a dominant experience of distress, confirming previous research on HIV-trauma. However there are also experiences of resistance, successful negotiation, and personal growth. Clinical implications are discussed in light of counselling psychology’s multidisciplinary approach, including therapeutic recommendations to explore and challenge women’s definitions of sexuality, femininity and motherhood.

In this thesis, I argue for a move from the preoccupation with the obvious (crude and quantifiable impacts), towards critically examining the subtle (less than obvious impacts), which will allow us to deal with adversities (the likes of HIV and AIDS) in the most effective ways. The thesis adopts the summative governance framework to demonstrate how our preoccupation with the quantifiable impacts shrouds our intellectual and practical ability to deal with the subtle impacts of AIDS. Governance is hypothesised to emerge amidst turbulent, unpredictable, messy, complex and dynamic path conditions predicated upon certain orders of criticality, including but not limited to the process of knowledge formation, retention and transfer. The thesis suggests that the evolution of governance from nascent to fully institutionalised mechanisms of control is in itself a product of the evolution of knowledge. Notwithstanding, HIV and AIDS constrain the emergence of governance through impacting the process of knowledge formation, retention and transfer. Resultantly, these impacts are not merely additive and isolated to the sectoral governances, but are summative, intergenerational and structured, and potentially endanger the fundamental systems of governance. The pre and post independence induced vulnerabilities of Namibia are presented to demonstrate that the country is an engrossing, but yet a perilous mix of the past and the present. Whilst Namibia aspires for a democratic, non-racial, progressive society, the thesis demonstrates that due to constraints engendered by HIV and AIDS this proceeds on terms and conditions that by no means guarantee a happy outcome.

The Global Fund to Fight HIV/AIDS, Malaria and TB and U.S President’s Emergency Fund for AIDS Relief (PEPFAR) are global health initiatives (GHIs) that were established in the early 2000s with the mandates to increase global capacity to address HIV and AIDS rapidly. When the two GHIs were created, Namibia was one of the highest recipients of funding from both GHIs. A significant portion of their support to the country went to the Ministry of Health, which was the principal provider of treatment services in the country. Critics have argued, however, that the rise of financial support from the Global Fund and PEPFAR was associated with the creation of new administrative structures and procedures at the country level. This approach raises important questions about the degree to which Namibian health policymakers were able to exercise autonomy in the presence of GHI support. The aim of this thesis is to analyse the implications for institutional capacity and autonomy at the rise and fall of funding from the Global Fund and PEPFAR to the Ministry of Health concerning financial flows; human resources recruitment; and civil society engagement. With a focus on the changing relationship between the Ministry of Health and the two initiatives, the thesis examines the implications for country ownership and health systems capacity in the context of decreasing financial support from the Global Fund and PEPFAR. The field studies for this research was undertaken in 2011- 2012, when the two GHIs had indicated their intentions to scale-down the financial support made available to Namibia. This thesis uses multiple sources of data to qualitatively analyse the influences of Global Fund and PEPFAR support to Namibia from when the two initiatives were first established in 2002 and 2004, respectively, to 2012. A principal source of data was 43 semi-structured interviews conducted in Namibia during a placement with the Directorate of Special Programs in the Ministry of Health in early 2012. For financial flows, both the Global Fund and PEPFAR channelled and managed their funding through funder-specific structures and procedures that were developed and operated in parallel to existing Ministry of Health operations. Both for financial flows and human resources, initial structures and processes created difficulties for the Ministry of Health’s long-term objectives for HIV and AIDS. For civil society engagement, the thesis examined the Ministry of Health’s relationship with the Global Fund. At the rise of funding, the Global Fund required the establishment of a new multi-sector coordination structure for HIV and AIDS. This new structure operated at the same time as the existing national coordination structure and was perceived as having undermined the Ministry of Health’s role as the primary steward of Namibia's response. The Global Fund was also criticised for initially funding civil society organisations without making provisions for sustaining their capacity in the event of funding decline. The findings presented in this thesis indicate that at the rise of financing, the Ministry of Health’s engagement with the two HIV and AIDS GHIs initiatives was governed by the objectives of the two initiatives, rather than the long-term health systems goals of the Namibian Government. Their relationships with Namibia had an adverse impact on the Ministry of Health’s autonomy in making decisions on the national response to HIV and AIDS. The initial operations of the GHIs also had negative implications for Namibia's ability to sustain the health systems capacity they had helped to increase.

HIV/AIDS is a disease which emerged in the early 1980s and rapidly became a grave problem of global proportions. Millions of people fall victims to HIV/AIDS while its cause and remedy have not yet been discovered. This epidemic has captured the attention of politicians, economists, sociologists, clergy, lawyers, judges and police officers all over the world and mobilised them to curb or control it by finding solutions that limit the extent of its transmission. Through this research, I have investigated the possibility of criminalising the intentional or unintentional transmission of HIV in the United Arab Emirates. The importance of this research emanates from the fact that there is no stipulation in the UAE penal code which incriminates this act. The study also examines the impact of criminalisation and whether criminalisation is compatible with the Islamic teachings, drawing on the experiences of Arab states and other advanced countries, and finally whether it is in line with the views of human rights organisations.

Much has been written about the need to involve communities in efforts to reduce HIV stigma. However less is known about the psycho-social pathways between participation and stigma reduction or the most appropriate strategies for ensuring such participation. Drawing on Campbell’s social psychological conceptualisation of social capital and the ‘HIV competent community’, this study explores how community groups in eastern Zimbabwe, and in particular churches--the most established formal social network in the area--tackle HIV stigma, drawing on data collected between 2005 and 2009. The thesis explores four issues: the effect of participation in community groups on stigmatizing attitudes; the extent to which church groups perpetuate or reduce stigma; possible differences between the role played by the Protestant, Apostolic and Catholic churches in relation to stigma and the potential for using the ‘community conversations’ (CCs) approach to develop more effective responses to stigma amongst the three churches. The quantitative analysis from over 15,000 respondents used multivariable logistic regression modelling to explore relationships between participation and stigmatizing attitudes. Fewer of the individuals who participated in community groups than those who did not were found to report stigmatising attitudes towards people living with HIV (PLHIV). The qualitative research involved a total of 30 individual interviews and 24 CCs and explored how church groups respond to PLHIV. Participants discussed the strategies to combat HIV stigma and suggested that the church facilitated unhelpful attitudes, as well as helpful attitudes and actions. CCs workshops provided participants with opportunities to formulate a range of creative plans to tackle stigma in their communities. However over time it emerged that various obstacles stood in the way of putting these plans into action in their lives beyond the context of workshop discussions. l conclude that CCs have an important role to play in promoting reflection and action planning amongst participants. However, external constraints limit the extent to which people are able to turn this reflection and planning into action. To address these constraints I argue for the need to create sustainable bridges with external support agencies.

Nigeria is one of the countries most affected by the HIV/AIDS pandemic, third only to India and South Africa. With about 10% of the global HIV/AIDS cases estimated to be in the country, the public health and socio-economic implications are enormous. This thesis has two broad aims: the first is to develop statistical models which adequately describe the spatial distribution of the Nigerian HIV/AIDS epidemic and its associated ecological risk factors; the second, to develop models that could reconstruct the HIV incidence curve, obtain an estimate of the hidden HIV/AIDS population and a short term projection for AIDS incidence and a measure of precision of the estimates. To achieve these objectives, we first examined data from various sources and selected three sets of data based on national coverage and minimal reporting delay. The data sets are the outcome of the National HIV/AIDS Sentinel Surveillance Survey conducted in 1999, 2001, 2003 and 2005 by the Federal Ministry of Health; the outcome of the survey of 1057 health and laboratory facilities conducted by the Nigerian Institute of Medical Research in 2000; and case by case HIV screening data collected from an HIV/AIDS centre of excellence. A thorough review of methods used by WHO/UNAIDS to produce estimates of the Nigerian HIV/AIDS scenario was carried out. The Estimation and Projection Package (EPP) currently being used for modelling the epidemic partitions the population into at-risk, not-at-risk and infected sub-populations. It also requires some parameter input representing the force of infection and behaviour or high risk adjustment parameter. It may be difficult to precisely ascertain the size of these population groups and parameters in countries as large and diverse as Nigeria. Also, the accuracy of vital rates used in the EPP and Spectrum program is doubtful. Literature on ordinary back-calculation, nonparametric back-calculation, and modified back-calculation methods was reviewed in detail. Also, an indepth review of disease mapping techniques including multilevel models and geostatistical methods was conducted. The existence of spatial clusters was investigated using cluster analysis and some measure of spatial autocorrelation (Moran I and Geary c coefficients, semivariogram and kriging) applied to the National HIV/AIDS Surveillance data. Results revealed the existence of spatial clusters with significant positive spatial autocorrelation coefficients that tended to get stronger as the epidemic developed through time. GAM and local regression fit on the data revealed spatial trends on the north-south and east - west axis. Analysis of hierarchical, spatial and ecological factor effects on the geographical variation of HIV prevalence using variance component and spatial multilevel models was performed using restricted maximum likelihood implemented in R and empirical and full Bayesian methods in WinBUGS. Results confirmed significant spatial effects and some ecological factors were significant in explaining the variation. Also, variation due to various levels of aggregation was prominent. Estimates of cumulative HIV infection in Nigeria were obtained from both parametric and nonparametric back-calculation methods. Step and spline functions were assumed for the HIV infection curve in the parametric case. Parameter estimates obtained using 3-step and 4-step models were similar but the standard errors of these parameters were higher in the 4-step model. Estimates obtained using linear, quadratic, cubic and natural splines differed and also depended on the number and positions of the knots. Cumulative HIV infection estimates obtained using the step function models were comparable with those obtained using nonparametric back-calculation methods. Estimates from nonparametric back-calculation were obtained using the EMS algorithm. The modified nonparametric back-calculation method makes use of HIV data instead of the AIDS incidence data that are used in parametric and ordinary nonparametric back-calculation methods. In this approach, the hazard of undergoing HIV test is different for routine and symptom-related tests. The constant hazard of routine testing and the proportionality coefficient of symptom-related tests were estimated from the data and incorporated into the HIV induction distribution function. Estimates of HIV prevalence differ widely (about three times higher) from those obtained using parametric and ordinary nonparametric back-calculation methods. Nonparametric bootstrap procedure was used to obtain point-wise confidence interval and the uncertainty in estimating or predicting precisely the most recent incidence of AIDS or HIV infection was noticeable in the models but greater when AIDS data was used in the back-projection model. Analysis of case by case HIV screening data indicate that of 33349 patients who attended the HIV laboratory of a centre of excellence for the treatment of HIV/AIDS between October 2000 and August 2006, 7646 (23%) were HIV positive with females constituting about 61% of the positive cases. The bulk of infection was found in patients aged 15-49 years, about 86 percent of infected females and 78 percent of males were in this age group. Attendance at the laboratory and the proportion of HIV positive tests witnessed a remarkable increase when screening became free of charge. Logistic regression analysis indicated a 3-way interaction between time period, age and sex. Removing the effect of time by stratifying by time period left 2-way interactions between age and sex. A Correction factor for underreporting was ascertained by studying attendance at the laboratory facility over two time periods defined by the cost of HIV screening. Estimates of HIV prevalence obtained from corrected data using the modified nonparametric back-calculation are comparable with UN estimates obtained by a different method. The Nigerian HIV/AIDS pandemic is made up of multiple epidemics spatially located in different parts of the country with most of them having the potential of being sustained into the future given information on some risk factors. It is hoped that the findings of this research will be a ready tool in the hands of policy makers in the formulation of policy and design of programs to combat the epidemic in the country. Access to data on HIV/AIDS are highly restricted in the country and this hampers more in-depth modelling of the epidemic. Subject to data availability, we recommend that further work be done on the construction of stratification models based on sex, age and the geopolitical zones in order to estimate the infection intensity in each of the population groups. Uncertainties surrounding assumptions of infection intensity and incubation distribution can be minimized using Bayesian methods in back-projection.

This thesis discusses the impact of HIV in Edinburgh on infected individuals, professionals and the Scottish churches. It is grounded in contextual practical theology, offering reflexive responses to evidence gleaned from oral histories. The thesis documents the development of a local agency, Waverley Care, exploring the influences and pressures that contributed to its distinctive ethos. The author was employed as chaplain to people living with HIV from 2000 – 2016; the pastoral and professional relationships that emerged from that ministry form the foundation for the research. Unstructured interviews were conducted and Interpretative Phenomenological Analysis was used to analyse, interpret and reflect on the resultant material. Personal stories and perspectives were shared, both by people living with HIV and by professionals in the field. The impact of living with HIV is shown by discussing issues such as the ongoing impact of HIV-related stigma and the challenges associated with living long-term with the condition. Attention is paid to the challenges arising as a result of multiple bereavements and the resultant spiritual questions that emerge. The impact on physicians is also evidenced, in particular the transition from treating patients before the advent of effective medication, to the situation in 2016 when HIV has been re-classified as a chronic illness. Recommendations on areas of ongoing concern are made for decision makers in public health, the churches and Waverley Care. Deep reflective analysis is offered, using the Stations of the Cross and models from bereavement work to provide frameworks for understanding. The contribution of the Scottish churches to the establishment of support services is recognised; the churches’ influence, both positive and negative on discourse on human sexuality is discussed. The research evidences the impact of the provision of spiritual care within a secular agency, showing that it is possible to create sacred space and to deliver a sacramental ministry within a non-church setting.

Aim: To investigate how diversity within the African migrant population in Scotland affects their understandings of HIV and uptake of HIV testing and treatment, in order to improve HIV-related outcomes. Background: In the UK, Africans have the worst outcomes for HIV infection, primarily due to late diagnosis. Improvement requires better understanding of the barriers to healthcare engagement. This PhD study investigates how diversity among first generation African migrants in Scotland could affect engagement with general healthcare and HIV related interventions and services. Methods: I conducted qualitative research, involving participant observation at two sites (an African religious group and an asylum seeker/refugee drop-in centre) and interviews with African migrants attending these and three additional sites (two advocacy charities and a student association). Data were collected in two cities (Glasgow and Edinburgh) and two smaller towns (Paisley and Kirkcaldy). I interviewed 27 Africans, including economic migrants (n=8), students (n=9) and asylum seeker/refugees (n=10) and 14 representatives from organisations with high levels of African attendees (e.g., country associations, community organisations, advocacy groups, commercial establishments and religious based organisations). Thematic data analysis was carried out. Results: Diversity of the population and related issues of identity: Participants were highly diverse and reported considerable heterogeneity in the African diaspora in Scotland. The identity of “African” was bound with various negative stereotypes and appeals to this identity did not necessarily have relevance for participants. Nature of African affiliated organisations in Scotland: There were a wide range of organisations that advertised their remit as catering for the African diaspora. They varied in consistency and sustainability and contributed towards healthcare engagement to different degrees. Engagement with healthcare: There were multiple experiences and understandings of the healthcare system within the sample as a whole, and to an extent by migrant type. Whilst the majority reported successful and satisfactory service use, distinct barriers emerged. These included: understandings of rights and access to care based on African models of healthcare; the interplay of religious based understandings with ideas about access to healthcare; and assumptions and anxiety about the connections between visa status and health status. Knowledge of HIV and engagement with HIV related services: Participants had good knowledge about HIV, with some notable exceptions, but there was no patterning by migrant type. They had diverse views about risk of HIV infection, most of which did not align with the HIV epidemiology that identifies African migrants as an at risk group. Most of the sample did not think targeting African migrants for HIV interventions would be successful and were hostile to the proposal for various reasons, especially because they believed it would perpetuate stigma and prejudice towards the African diaspora. There were mixed experiences of HIV related services, and prompts to test for HIV had elicited a range of reactions, the majority negative. Conclusion: Diversity within the African diaspora in Scotland should be taken into account to improve the salience and relevance of future HIV interventions. Attitudes towards current HIV testing promotion suggest that a more cooperative approach could be taken with African communities to build on existing relationships of trust and understandings of HIV.

This thesis examines the underlying cause of social stigma towards people living with HIV, and the extent to which it discourages HIV testing and treatment. We use a discrete choice model to describe a person’s decision to seek treatment for HIV (antiretroviral therapy or ART), and estimate the social cost of seeking treatment using administrative health records from southern Malawi. We show that seeking ART at a clinic where many other community members are present carries a significant cost, even after taking into account clinic quality and location. We investigate the theoretical effects of policy interventions designed to reduce stigma and other barriers to care, and demonstrate important complementarities between such policies. We next evaluate a cluster-randomized information experiment in Zomba, Malawi designed to correct a common misconception: most do not know that ART drugs have a public benefit, that is, the medication prevents HIV transmission between sexual partners. We microfound HIV stigma as sexual discrimination between sexual partners, and model the decision to seek an HIV test (and then, if required, medical treatment) as a signal of infection. We show, theoretically and empirically, that the randomized information intervention reduces this type of stigma and significantly increases the rate of HIV testing. The results demonstrate that social stigma is an important barrier to HIV testing and treatment, that stigma can be due to rational behavior by a misinformed public, and that providing new information can be an effective way to mitigate its effects.

Background: Many HIV/AIDS patients experience pain. This is often associated with advanced HIV/AIDS infection and side effects of treatment. In sub-Saharan Africa, pain management for people with HIV/AIDS is suboptimal. With survival extended as a direct consequence of improved access to antiretroviral therapy, the prevalence of HIV/AIDS related pain is increasing. As most care is provided at home, the management of pain requires patient and family involvement. Pain education is an important aspect in the management of pain in HIV/AIDS patients. Aim: The aim of this study was to evaluate the effects of a pain educational intervention on pain severity and pain related outcomes among patients with HIV/AIDS and their family carers. Methods: Two systematic reviews were conducted: (1) to examine the evidence base of the effectiveness of educational interventions delivered to people living with HIV/AIDS on pain severity, pain interference, quality of life, knowledge of pain management, and (2) To examine the evidence base of the effectiveness of educational interventions delivered to their family carers on knowledge of pain management, quality of life and carer motivation. A randomised controlled trial was conducted at the HIV and palliative care clinics of two public hospitals in Malawi. To be eligible, patient participants had a diagnosis of HIV/AIDS (stage III or IV). Carer participants were individuals most involved in the patient’s unpaid care. Eligible participants were randomised to either: (1) a 30-minute face–to-face educational intervention covering pain assessment and management, augmented by a leaflet and follow-up telephone call at two weeks; or (2) usual care. Those allocated to the usual care group receive the educational intervention after follow-up assessments had been conducted (wait-list control group). The primary outcome was average pain severity measured by the Brief Pain Inventory. Secondary outcomes were pain interference, patient knowledge of pain management, patient quality of life. Carer outcomes were; carer knowledge of pain management, caregiver motivation and carer quality of life. Follow-up assessments were conducted eight weeks after randomisation by nurses’ blind to allocation. Results: Systematic review Eight published randomised controlled trials of educational interventions among patients with HIV/AIDS were identified. Only one study examined the effect on pain severity but the results were not statistically significant. Three studies reported positive effects in improving severity and frequency of symptoms, three reported improvement in quality of life and two studies found improvement in knowledge. Seven published studies of family carers of HIV/AIDS patients were identified. Only three of which were randomised controlled trials. Five of these reported that educational interventions were effective in reducing psychosocial outcomes. Two studies reported that the interventions improved knowledge outcomes among family carers of HIV/AIDS patients. Trial Of the 182 patients/carers dyads randomised; 167 patients and 157 carers completed the trial. At follow-up, patients in the intervention group experienced a greater decrease in average pain severity score 21.25 (mean difference 21.25, 95% confidence interval 16.7 to 25.8; P <0.001). Patients in the intervention group reported, less pain interference (mean difference 24.5, 95% confidence interval 19.61 to 29.38; P<0.001), had improved knowledge of pain management (mean difference 20.39, 95% confidence interval 17.51 to 23.27; P<0.001), and a better quality of life (mean difference 28.76, 95% confidence interval 24.62 to 32.91; P<0.001). At follow-up carers in the intervention group had improved knowledge (mean difference 20.32, 95% confidence interval 17.37 to 23.28; P<0.001), greater motivation (mean difference 7.64, 95% confidence interval 5.15 to 10.13; P<0.001) and better quality of life (mean difference 34.16, 95% confidence interval 30.15 to 38.17; P<0.001). Conclusion: Current evidence of educational interventions among HIV/AIDS and family carers on pain severity is inconclusive and based on a relatively small number of studies, many of which have methodological problems. A relatively simple form of pain education is effective in reducing pain and improving outcomes for patients with HIV/AIDS and their carers. Greater attention needs to be given to incorporating this into the routine care of people with HIV/AIDS in sub-Saharan Africa. Trial registration: Current Controlled Trials ISRCTN72861423.