Health systems in central Asia (the former Soviet Union) face challenges to control TB and HIV/AIDS epidemics. Integration of communicable disease control programmes with the broader health system has been recommended to ensure programmes' sustainability. An important constraint for studying sustainability and integration has been a lack of conceptual clarity. Drawing on a critical assessmenot f publishedl iterature, a novel conceptualf ramework for the analysis of sustainability and integration in health systems has been developed. A sustainablec ommunicabled iseasep rogrammei s defined as continuouslye ffective in reducinga disease problem, responsive and adaptive to changes in the nature of disease epidemics, population needs or the contextual environment. Sustainability of a programme is conceptualised as having five dimensions: leadership, capacity, interactions, flexibility (adaptability) and performance (effectiveness, efficiency, equity). Existing frameworks of integration and health systems have been extended; defining levels of formal interactions between the system components. The research applied a case study approach. The case study was conducted in Kyrgyzstan, and relied on documentary review, qualitative interviews with key informants, and framework analysis. This study revealed several inter-related factors that affect the potential for sustainability of TB and HIV/AIDS programmes in Kyrgyzstan. Among overarching challenges for sustainability of both programmes are overall weak capacity of the health system and the reliance on international assistance for implementing the efforts to control the epidemics. This thesis highlights the importance of health system's structural and functional arrangements in sustaining the programmes into the future. In Kyrgyzstan, the factors such as fragmentation of governance and financing impede the development of effective interactions at the level of service delivery. In turn, fragmentation of service delivery remains the key impediment for efficiency, effectiveness and equity of disease control interventions. The prospects for sustainability of both programmes are constrained by institutional interests of domestic and international actors, who rarely consider the central question for sustainability that is efficiency of resources allocation and use. Weak disease surveillance and M&E systems emerged as one of the key barrier for development of effective disease control policies in the country and efficient planning of resources. Because of weaknesses of surveillance, this study could not provide the answer whether disease control efforts have resulted in the reduction of mortality and morbidity associated with TB and/or HIV/AIDS.

This thesis argues that the cultural practices and productions associated with HIV I AIDS represent a major resource in the struggle to understand and combat the epidemic. Research into HIV / AIDS is dominated by biomedical scholarship, and yet in South Africa, the main drivers of the epidemic are social and economic. The cultural productions analysed in this thesis confront and illuminate many of the contradictory and unresolved questions facing HIV/AIDS research today. The primary materials analysed in this thesis are the cultural texts that explore representations and performances of HI VI AIDS in South Africa from 1995-2012. I locate experiences of HlV / AIDS in a range of theatrical, literary and visual artworks, including prose, drama and memoir, as well as film and critical work across an array of genres. More than simply surveying HIV I AIDS cultural artefacts, I offer socially and historically contextualised accounts of how stories from post-apartheid writers, performers, artists and subjects engage with HIV I AIDS within a climate hostile to their existence. In my analysis of the texts considered, I develop an argument that underlines the interventionist capacities of cultural production around HIV / AIDS. I investigate to what degree these texts aim to change consciousness and challenge the social behaviours that contribute to HIV prevalence. I argue that the most significant responses to HIV/AIDS in the last thirty years have been grassroots cultural practices that empower those who otherwise have had little agency in dictating their own circumstances and histories of the epidemic. These findings lead me to argue for a paradigm shift in HIV / AIDS research: from the widespread application of medical hegemony to the consideration of community-level cultural interventions in addressing the epidemic.

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This thesis aims at understanding the impact of HIV/AIDS and socioeconomic stressors in Sub-Saharan Africa. We present an agent-based simulation model of the social impacts of HIV/AIDS in villages in the Sekhukhune district of the Limpopo province in South Africa. AIDS in the Sub-Saharan region has not only affected individual's health but its prevalence has a long-term implication on the economic development of the society. The impact of the disease relates to other stresses, such as food insecurity, high climate variability, market fluctuations, and variations in support from government and non-government sources.

This study investigated the experiences of family caregivers of persons living with HIV/AIDS in two contexts of development - Kerala and Scotland. Although the study was primarily qualitative in nature, it incorporated some quantitative methodology in order to connect the findings to existing literature on stress, coping, and mental health. In-depth interviews were conducted with 23 respondents in Kerala and 5 in Scotland. Interview transcripts were analyzed for major themes, using elements of grounded theory. Quantitative measures included the Ways of Coping Questionnaire (Folkman & Lazarus, 1985) and the Self Report Questionnaire (Beusenberg & Orley, 1994). Results were analyzed for differences in coping style and mental health between the settings. Exploratory correlational and regression analyses were also conducted. The results indicated that caregivers from both contexts experienced significant burdens. The major experiences of the caregivers in Kerala consisted of poverty, stigmatization, discrimination, lack of support networks and adequate healthcare facilities. While the caregivers in Scotland shared some of these experiences at a lesser degree, their dominant experiences centred on caregiving stress, limited support, role stress, difficulty finding and maintaining a job, and lack of recognition of carers' needs. Quantitative findings indicated that carers in Scotland used a wider array of coping strategies and were more likely to rely on problem-focused coping than the Kerala respondents. Although the carers in both settings experienced significant indicators of psychological distress, the level of symptoms was higher for the carers in Kerala. Correlational and regression analyses explored relationships among setting, gender, coping, and mental health problems. The findings were discussed in terms of the existing literature related to familycaring in HIV/AIDS, coping, and mental health. Synthesis of the findings led to the emergence of three unifying concepts of struggle, commitment and resilience. A model was proposed that explained the relationship among the three unifying concepts.

Abstinence, being faithful to one partner and correct and consistent condom use (known as ABC) has been a widely discussed and utilised HIV/AIDS prevention strategy. In 2003, policy analysts predicted that Zambia would follow the Ugandan trajectory of HIV/AIDS incidence decline, because both countries were implementing ABC. However Zambia presently remains one of the countries with the highest HIV/AIDS prevalence rates. Limited policy research has been carried out to investigate why countries that have utilised ABC have experienced different HIV policy outcomes. This study investigates this issue by studying the extent to which poor policy design, content or implementation was to blame. The study employs a mixed methods approach and the analysis was guided by Knoepfel et al.'s (2007) framework which examines the policy processes though the interaction of policy actors, resources and institutional rules. The study found that ambivalence towards condom promotion, gender inequity and stigma towards HIV/AIDS negatively affected the development of a comprehensive ABC public policy in the 1990s. Negative views over teaching young children comprehensive sexual education and condom use appears to have affected both policy content and implementation. The study found that the decentralised and diversified nature of sexual health education is benefiting youth of higher social economic status. The study findings indicate that aid agencies utilised resources to propel the policy process towards a more comprehensive ABC public policy approach after 2000. Stigma continues to challenge programs delivered through the workplace. Information on prevention is still required in addition to information on treatment. Finally the study indicates that communities affect sexual behaviour choices as the study found that knowing someone living with HIV/AIDS was associated with positive behaviour change. The study confirms that Knoepfel et al.'s framework is a useful tool in the study of public policy. The findings contribute to an understanding of the process of policy determination and the analysis of policy content. The findings underscore the importance of engaging with socio-cultural, economic and political factors that influence ABC in order to reduce negative societal norms if policy is to be successful. The study also highlights that dependency on foreign aid can lead to a loss of autonomy. This consequently may lead to the adoption of policies and programs that are not locally accepted. The analysis also illustrates the need to utilise the right type of universal and targeted communications and programs to target the different components of ABC.

The research which this thesis reports and represents sought to explore, 'The experiences of students Living With or Affected by HIV/AIDS in Trinidad and Tobago". The focus is on the perceptions and experiences of thirteen primary and secondary school students. some of whom were in residential care whilst the others lived with relatives. These perceptions and experiences are also considered in the context of the views of care givers and key informants involved in HIVi AIDS education in Trinidad and Tobago. The primary questions the research addressed were: What had happened to the young people up to the time of the research'? What were their stories with relation to the ways in which HIV/AIDS had impacted their lives? How had they experienced schools and schooling as HIV/AIDS affected students? What were their experiences with regard to the health sector? and, What were their hopes and dreams for the future? The research took a qualitative. auto/biographical approach using interviews and participant observation as the key methods of data collection and narrative/storying and grounded theory as the form of representation and analysis. My own voice both as researcher and as an education professional concerned with young people is acknowledged throughout. My aim has been to present lived experiences - to give voice - and to explore how HIV/AIDS impacted on different aspects of the students' lives, on their health, education. human rights, personal social development, family dynamics and support systems. XI This thesis is an attempt to counter the silence which surrounds students living with or affected by HIV:AIDS as it explores what can be learnt from the perspectives of those students and their care-givers about the cultural significance of the disease, its capacity to alter how we know ourselves and what we can do in the midst of epidemic. Topics addressed within the thesis include: HIV/AIDS in the Caribbean generally and in Trinidad and Tobago specifically; the Medical Disease - transmission. treatment, responses, advocacy; Human Rights: the Social Disease; Local responses of Ministries of Education and Health, The Churches and The NACC; Regional responses - C ARICOM, CAREC, PANCAP; and global response through UNESCO's Commonwealth Chair.

Background: AIDS is the leading cause of preventable death in Malawi. Increasingly young people of primary school age are becoming infected with HIV due to a lack of basic knowledge about the disease and its prevention, compounded by socio-historical factors such as cultural norms about sex and the social position of girls and women. Education is considered therefore a key prevention strategy. This study investigated whether a specially designed AIDS education, delivered by specifically trained teachers, with active involvement and participation of adults and peers, would improve pupils' understanding of AIDS and help them to adopt positive attitudes towards sex and sexual practices and behaviours. Methods: Two rural and two urban primary schools were selected to be control or intervention schools. Teachers were recruited and specially trained. Pupils from classes 6, 7 and 8 participated. Parents and the wider community of the intervention schools were involved. Knowledge, attitudes, and self-reports of adopting protective sexual behaviours were tested pre- and post-intervention. Additional data was collected in interviews. Attendances at HIV clinic were monitored, and data were collected on marriage and pregnancy rates. Results: 366 pupils completed the study. The mean scores for all study groups significantly improved in the course of the study (p<O.OO 1). However, there were greater gains in the rural intervention school: early marriages and pregnancies among the intervention schools' girls reduced; many pupils attended HIV testing clinics. In addition, adults, parents and teachers reported more open discussion about sex and HIV / AIDS and they became more positive towards teaching young people these Subjects.

The purpose of this research was to explore the interactions between the perceived healthcare needs of people with HIV and the processes involved in their healthcare in order to inform future models of care. A grounded theory approach was adopted utilising semi-structured interviews with 13 HIV patients and 21 healthcare workers in 3 HIV facilities of different size and service specification. Constant comparative analyses of concepts that emerged from the data were undertaken and a dimensional analysis strategy applied to develop conceptual categories and the connections between them. HIV as a condition was conceptualised in different ways by patients and healthcare workers. Although most patients viewed their condition as stable, previous illness experience, uncertainty and the impact of HIV on social integration influenced their views on the role of HIV services. Patient-provider relationships, feeling accepted and participating in care was central to maintaining high levels of patient engagement within the HIV setting. This was in contrast to the felt or enacted stigma experienced by most patients either in other healthcare settings or in their communities and challenges current theory that advances in treatment have reduced the social stigma of HIV. The service user illness representations were not necessarily reflective of HIV service provider views on the health status of medically stable patients or of funding mechanisms for HIV healthcare. A theory of illness representation has been developed utilising the principles of Leventhal’s model adapted for service planning. While HIV clinics were actively adapting services, the pervasive experience of HIV for some stable patients suggests that representations of HIV span a healthy-illness spectrum comprising a complex range of cognitive and emotional processes. These representations influenced how HIV healthcare services were organised and utilised and may be a useful tool to inform healthcare delivery and sustain quality and public health outcomes.

There exists broad consensus as to the importance of HIV- and AIDS-related education in efforts to decrease young people’s vulnerability to the epidemic. As illustrated by the broad variety of HIV prevention education initiatives implemented around the world, less agreement exists as to the form such education should take. This thesis has developed a conceptual framework to support analysis of school-based HIV- and AIDS-related education and, specifically, to support efforts to increase understanding of this particular and diverse field of education. The specific objectives of the study were to: i. develop an overview of research into the quality of HIV- and AIDS-related education; ii. investigate the theoretical underpinnings of school-based HIV- and AIDS-related education a) overall, and b) in Mozambique; iii. examine conceptions of the aims of HIV- and AIDS-related education in relation to the broader aims of school education in Mozambique; and iv. investigate the potential for the conceptual framework, developed as part of the study, to support comparison of perspectives on HIV- and AIDS-related education in Mozambique. Addressing key gaps in available literature on HIV- and AIDS-related education, two analytical frameworks were developed. Based on an analysis of current programmes worldwide and a review of a multidisciplinary body of literature on HIV- and AIDS-related education, the first framework draws a distinction between three broad approaches to HIV- and AIDS-related education: those building on moral concerns, and those that might be understood as informed by notions of rights, or science. The second analytical framework developed in the study distinguishes three principal conceptions of the aims of education, namely the achievement of autonomy, (civil) enculturation or vocational preparation. This latter heuristic device was informed by an examination of key educational philosophical debates on the aims of education. A qualitative multi-method empirical study was subsequently undertaken, gathering data from young people, (peer) educators, policy makers and representatives of 3 international agencies in Maputo, Mozambique on their views regarding the aims of (HIV- and AIDS-related) education. The analysis revealed that participants drew on varying and strongly gendered understandings of what was considered (im)moral behaviour and a commitment to rights in efforts to reduce the spread and impact of the epidemic. Furthermore, in different ways, policy makers, educators and international agency staff identified both the causes of and solution for the epidemic as existing in various forms of modern and traditional ‘culture’. Policy makers and educators, for instance, stressed their concerns regarding the relationship between modernity and the spread of HIV and AIDS in Mozambican society, while staff members of international agencies identified the causes of the epidemic in inequitable - ‘traditional’ - interpersonal relationships. Young people were often found to appropriate dominant discourse, but also challenged opinions, particularly in relation to gendered perceptions of (im)moral behaviour. Building on the analysis, a fourth broad approach to HIV- and AIDS-related education was identified, namely that informed by notions of culture. The analysis illustrates that within HIV- and AIDS-related education, where concepts such as rights and culture are seen as central to many programmes, the different actors involved in the development, delivery and uptake of such education draw on a considerable variety of discourses. An important consequence is that within and across these various sets of actors, understandings of what issues should be addressed and how, can vary widely. At other times, such understandings may differ in more subtle but, nonetheless, crucial ways. A critical implication of the study, therefore, concerns the need for more meaningful dialogue across and between different actors. The thesis concludes by elucidating how dialogue about HIV- and AIDS-related education as well as HIV prevention education might be enhanced by drawing on a pragmatic epistemology of ‘knowing’, i.e. one whereby dialogue and education are acknowledged as ongoing processes of growth and, crucially, as ways to deal with uncertainty, rather than leading to closed-ended certainties.